AME: COREQ mainly covers the qualitative studies using interviews and focus groups. But we know that qualitative research has some other common methods, such as participant observation, documentary approaches and action research. Why COREQ mainly focus on interviews and focus groups?

Jane Noyes: COREQ was published in 2007, so it’s quite old now. Qualitative research has taken longer to become a mainstream health service research methodology and I think that the methods have evolved over the last 20 years but the COREQ guideline hasn’t kept up with evolving methods so it needs updating and revising. Similarly, you’ll notice that the CONSORT guidelines for trials have been updated and had regular extensions for different types of quantitative evaluations but this hasn’t happened on the qualitative side and it’s a shame. COREQ does need to be updated as it doesn’t specifically take account of ethnographic observational qualitative research or art-based research. That’s qualitative research where you get people to express how they feel through art.

As a journal editor and a qualitative researcher, I just use COREQ as a guide and I use the principles that you can apply to different types of qualitative research. I think all of us would like to see a new version and extensions for the more ethnographic type of research. COREQ has its limitations but it’s a useful guide.

I think the other thing to say is that we encourage qualitative researchers not to use it as a checklist, but to use it as a way of engaging with reporting of the paper to make sure that everything that should be reported is there. We don’t want researchers to just tick the boxes, as we want them to really think about what needs to be reported in their paper and why. The key principle is transparency and that authors are making clear to readers, their research question and methodology, the rationale for doing the research and all the elements of reporting that need to be there in order for somebody to understand the study and to assess its rigor.

I do a lot of systematic reviews and qualitative evidence synthesis and I do a lot of work for Cochrane who produce qualitative evidence syntheses. I therefore also work on the other side of things to quality appraise qualitative research reports and they have actually improved in quality over the last 20 years but there’s still a long way to go.

AME: Among all the items, do you have any prioritized items?

Jane Noyes: That’s an interesting question because their priority is not all the same. It’s really clear that you have to establish the rationale, that you need to articulate your research question, and you need to report your methodology and your methods. One of the things that I find in qualitative reports is people only talk about the methods that they use and not an overarching methodology, e.g. whether there’s been a specific methodology used, or a theoretical perspective or a conceptual framework etc. A methodological and theoretical perspective helps explain how participants have been sampled and why or whether that sample is sufficient to address the research questions. How data were recorded or observed and documented and how data were analyzed and by whom is really important as well because qualitative researchers do a lot of the analysis in their heads. Therefore, the qualitative researchers themselves will have their inherent biases, so these issues of reflexivity are really important as to who’s on the team, what their prior beliefs are and what biases they bring to the study. And an example of that might be something like a belief. For example, you get qualitative research undertaken by lots of organizations who provide services or who lobby. For example, in the United Kingdom, there’s a real move to include all disabled children in mainstream schools. So if you’re doing qualitative research about the inclusion of the children in mainstream schools who have disabilities, if that research is being conducted by an organization who is lobbying for this, the authors must declare that they are actually starting off from a position of belief that it’s a positive thing. So it’s this whole thing about equipoise. Whether you can actually maintain an open interpretation if the evidence goes either way and whether the evidence does or doesn’t support your position. And then in terms of the findings, I think that the findings need to be reported in a really clear way.

I think what COREQ lacks at the moment is a differentiation between the sort of more descriptive level findings and the more theoretical level findings that you would see in methodologies such as grounded theory and ethnography which involve the production of new theory. COREQ remains a very basic checklist and authors need to interpret it for the application and reporting of their specific qualitative methodology and methods. I think there’s no particular priority of one domain over another. You would want to see all of these things in a qualitative report but some things are more important for some methodologies than others. For example, whether you use software or not. I don’t particularly mind whether people are still using paper and pencil to analyze qualitative research. When using software, you may still do lots of drawing of diagrams on a white board during team meetings to understand the evidence, so analysis is not all done with a software product. There’s lots of thinking and articulating and mapping out on paper or mapping out on computer, so I don’t particularly mind if there isn’t a software product that’s used as long as the process of analysis is articulated clearly.

In addition, there are lots of ways of assessing rigor in a qualitative study other than participant checking. The COREQ checklist does not include all the things that you might do to assess rigor, but other than that I think it’s important to put sufficient data in your report to establish that your themes are appropriate and are appropriately interpreted and evidenced so participant quotes and how you evidence those quotes are very important. I think the basic principles are there, but I would like to see COREQ now revised and some extensions for the different types of research are developed. The majority of qualitative research does include interviews or focus groups and there is an implied assumption that if you go and interview somebody and you do it in person that you are also observing their context, you would write some fields notes about their context such as what their accommodation was like their living circumstances etc and then you would annotate those notes, which can be coded in the same way as the interview. Experienced qualitative researchers would know to do that. Whereas, I think that inexperienced qualitative researchers just use COREQ as a checklist of what’s in and what’s out and what’s the minimum that needs to be reported.

AME: How is the status of COREQ's endorsement by journals?

Jane Noyes: COREQ is endorsed by journals and there is also another qualitative reporting guideline very similar to COREQ (SRQR). It’s endorsed by journals because it provides a template for transparent reporting even though it has some limitations. As I said the vast majority of qualitative studies tend to include interviews and focus groups. We are seeing more ethnographic types of research reports coming through now. For mixed methods studies, there’s always a question about which reporting tool to use. We’ve just written some guidance on how you report a mixed methods study that has a qualitative component and a quantitative component. There’s no specific reporting guideline for mixed-method studies that incorporate a qualitative component at the moment. There are just some principles that you can use around the data integration and we’ve written some guidance on that. But it would be nice to have a COREQ extension for mixed method studies that have a qualitative component.

AME: How compliant are relevant articles with COREQ?

Jane Noyes: We ask our peer reviewers to use it. I’m one of the editors of the Journal of Advanced Nursing and we ask all peer reviewers and authors to submit a COREQ or SRQR checklist with a qualitative study and we do ask peer reviewers to check that all the main things are covered. We need to pick up that everything has been appropriately reported. I’m sure some things still slip through the net and we do see that. For example, as a systematic reviewer of qualitative studies, we search for the primary qualitative studies and then we do an appraisal of their quality. One of the factors that caused lots of problems in appraising qualitative studies is poor reporting. Reporting is getting better in recent years and a number of factors have come together to make it easier for qualitative researchers with open access publications. In the past, the word limit has been a hinderance to report really in-depth rich qualitative studies within the journal word limits. In the United Kingdom, we aspire to publishing qualitative studies in the really high-ranking journals like the British Medical Journal (BMJ), though BMJ stopped publishing qualitative studies now. BMJ has a word limit of 3700 words, so one had to truncate everything, to condense everything and the reports lost their richness and it was very difficult to meet all the COREQ reporting guidelines given the low word limit. Now with open access reporting and even with the hybrid journals (my own journal – the Journal of Advanced Nursing -is a hybrid one and we allow up to 8000 words to report a study and additional online files which don’t count towards the word count), it’s much easier now to write a comprehensive report of a qualitative study that has all the required details.

AME: Compared with other guidelines for qualitative studies (e.g. SRQR, ENTREQ, etc.), what do you think are the most prominent characteristics and advantages of COREQ? What is the main reason why it can be recommended by the EQUATOR Network on the home page?

Jane Noyes: COREQ came first. The one that is first often gains ascendancy and the others all spin off from that. SRQR came later and encourages authors to think about methodology and methods, but otherwise is very similar to COREQ. Some of the reporting guidelines are designed for specific purposes. For example, ENTREQ is for reporting generic qualitative evidence syntheses. I think that we probably need a new updated COREQ guideline as 2007 is a long time ago and it does need updating now. We’ve got far more sophisticated approaches to conduct qualitative research now.

COREQ as the first guideline of its kind, it is more commonly used as it is generic and cover all types of qualitative research though it actually focuses on reporting of those studies with interviews and focus groups, which the majority of qualitative research feature. This is the reason why it gained ascendancy but this is not to say that you can’t use other guidelines. We encourage authors to select the most appropriate reporting guideline for their manuscript.

AME: Would you like to share with us if there is any specific plan for the update of the COREQ in the coming future?

Jane Noyes: Not that I know of. After COREQ, ENTREQ was developed which was created for qualitative evidence synthesis, but we already find that it isn’t a good fit for all qualitative evidence synthesis types. In Cochrane we’re just about to develop a set of methodological standards for reporting a qualitative evidence synthesis. Anybody who does a qualitative evidence synthesis in Cochrane will need to think about the methodological standards that we develop when they’re reporting. But for Cochrane we are responsible for qualitative evidence synthesis and not the reporting of primary studies so it’s something that really does need to be addressed. What we can do now is to nudge and get people to think about updating COREQ.

Acknowledgments
We would like to express our sincerest gratitude to Dr. Jane Noyes for sharing her insights and opinions with us.