In two prior papers in our series on qualitative research [Frankel & Devers (2000a, 2000b) Qualitative research: a consumer's guide, Education for Health, 13, 113–123; Frankel & Devers (2000) Study design in qualitative research—1: developing research questions and assessing research needs, Education for Health, 13, 251–261], we examine two critical issues in qualitative research design: sampling, including identifying and negotiating access to research sites and subjects, and data collection and management. We describe these two key steps in the qualitative research design process, discuss challenges that often emerge when pursuing these steps, and provide guidelines for addressing them. Qualitative research most often uses "purposive," rather than random, sampling strategies. A good understanding of these sampling strategies and why they are used is central to designing a credible qualitative study. In addition, given the real-world context in which most qualitative research is carried out, identifying and negotiating access to research sites and subjects are critical parts of the process. We also provide suggestions for developing and maintaining productive and mutually satisfying research relationships with sites and subjects. Finally, data collection and management are often neglected subjects in qualitative research. We offer practical advice on how to collect and manage qualitative data, including factors to consider when deciding how structured the data collection process should be, the pros and cons of audio- and/or videotaping compared with note-taking, and tips for writing up . eld notes and document management. A forthcoming, final paper in the series will focus on qualitative data analysis and the publication of qualitative research results.

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This is the second in a series of four papers on understanding and doing qualitative research [Frankel & Devers (2000) Qualitative research: a consumer's guide, Education for Health, 13, 113–123; Devers & Frankel (2000) Study design in qualitative research—2: sampling and data collection strategies, Education for Health, 13, 263–271]. Here, we focus on problems of study design, including question development, literature review, identifying a target audience and resource needs assessment. We provide a step-by-step description of major issues and choice points in the process. There are three key differences between qualitative and quantitative research designs. First, the logic of qualitative research is often inductive, rather than deductive, and consists of describing people's and groups' particular situations, meanings and experiences. Second, qualitative research designs are often emergent and exible, and the research itself is quite dynamic. Third, the qualitative research process is non-linear and non-sequential. There is agreement that good qualitative studies answer clearly stated, important research questions. How qualitative research questions are formulated has implications for conducting a literature review. Some scholars believe that literature should be reviewed prior to beginning a study; others argue that this may impede the researcher from truly listening, observing and remaining open to new concepts and ideas. We offer suggestions about formulating research questions and how and when to conduct a literature review. Another important issue in conducting qualitative research is determining the resources that will be needed to conduct a study. These include internal resources, such as research skills, and external resources, such as personnel (expertise and time), equipment, supplies and travel. A description of typical resource and management issues in conducting a qualitative research study is included.

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Background: During the 20th century medical education has been largely preoccupied with discussions of the venues and methods for teaching. Little attention has been paid to what should be learned about the scientific paradigm underlying research and practice. A 17th century model has gradually produced an increasingly narrow, monocausal , reductionistic view of health and disease. Much good has resulted, but this "belief system" fails to accommodate or explain the meaning and impact on patients' health of diverse internal and external experiences and in uences. During this period quantum mechanics and its ever-expanding capacity to accommodate new information and enhance understanding have superseded Newtonian physics in much scientific thinking. Methods: A broad range of historical and contemporary scientific literature is examined in support of four central questions in this three-part series: (1) Are there reasons to examine these matters now? (2) How is medical scientific thinking in uenced by the general reorientation of science during the 20th century? (3) Are there reasons now to examine the impact of these changes on medicine? (4) Will a change of paradigm affect medical practice, research, and education? Results: The extraordinarily productive contemporary biomedical model should be expanded beyond the physical and biological to incorporate meaningful information about how each patient's experiences impinge on health status. Conclusions: Family and other primary care physicians together with collaborators in the biological and behavioral sciences and other health professions should undertake rigorous research to establish the validity of the expanded paradigm espoused. Its impact on practice, research, education, and policies could be profound.

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Background: During the 20th century medical education has been largely preoccupied with discussions of the venues and methods for teaching. Little attention has been paid to what should be learned about the scientific paradigm underlying research and practice. A 17th century model has gradually produced an increasingly narrow, monocausal , reductionistic view of health and disease. Much good has resulted, but this "belief system" fails to accommodate or explain the meaning and impact on patients' health of diverse internal and external experiences and in uences. During this period quantum mechanics and its ever-expanding capacity to accommodate new information and enhance understanding have superseded Newtonian physics in much scientific thinking. Methods: A broad range of historical and contemporary scientific literature is examined in support of four central questions in this three-part series: (1) Are there reasons to examine these matters now? (2) How is medical scientific thinking in uenced by the general reorientation of science during the 20th century? (3) Are there reasons now to examine the impact of these changes on medicine? (4) Will a change of paradigm affect medical practice, research, and education? Results: The extraordinarily productive contemporary biomedical model should be expanded beyond the physical and biological to incorporate meaningful information about how each patient's experiences impinge on health status. Conclusions: Family and other primary care physicians together with collaborators in the biological and behavioral sciences and other health professions should undertake rigorous research to establish the validity of the expanded paradigm espoused. Its impact on practice, research, education, and policies could be profound.

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Context: Interdisciplinary teams of graduate health professions students and faculty were provided with experiential learning opportunities while assisting a small rural community address critical health-related issues. Project objectives: To establish an effective partnership with community leaders and area residents to assist in determining the feasibility of a new primary care clinic and to remediate a water borne disease threat. To create interdisciplinary clinical learning experiences and to develop future longitudinal learning opportunities, emphasizing primary prevention. To create a community– campus partnership with control originating in and sustained by the community. Partnership development: An interdisciplinary team of health professions students and faculty worked with community leaders and residents to develop leadership skills, enhance infrastructure and coordinate efforts to address health concerns. A health marketing analysis and a series of year-long environmental assessments of surface and ground water were completed. The community was assisted with reaching consensus for future actions, emphasizing local control, enhanced county-based ownership, and sustainability of intervention efforts. Outcomes and implications: The Del Rio and East Tennessee State University partnership was instrumental in accomplishing its short-term objectives with the remediation of two major health issues. The more important long-term objectives of enhancing citizen leadership skills and developing a more action-oriented community infrastructure were also met. Using an experiential learning model, students practiced community organization skills, conflict resolution and problem-solving strategies. The campus–community partnership illustrated the advantages of experiential, multidisciplinary education and accentuated the positive aspects of collaborative planning and action. The partnership continues to provide expanded learning opportunities for students and contributes to the empowerment and self-sufficiency of the community. The ripple effects of the model have become evident, with dramatic increases in university-wide efforts to increase partnership opportunities and enhanced support for service learning throughout the region.

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This study compares students' evaluation of a traditional and an innovative undergraduate family medicine (FM) courses. The old curriculum was traditional and teacher-centered. Changes in-line with the innovative learning concepts were introduced. While innovative course (IC) students had signi. cant improvement in both their attitude towards innovative learning methods and self-assessment of knowledge, traditional course students had improvement only in self-assessment of knowledge. Students in both courses did not show post-cycle improvement in perception of their own skills and were dissatis. ed with the Health Center (HC) tutors' training. The need to recruit trained family physicians at the af. liated HC became evident. IC students valued the exercise of adding their generated learning needs as part of the curriculum. Other lessons learned were presented. We hope that . ndings of this study would encourage medical colleges in the region to critically review their FM courses.

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Objective: To ascertain whether undergraduate medical students could acquire the basic competence needed to design, analyze and use a computer-ompatible database in an epidemiologically meaningful way. Setting: Since 1998 the Manipal College of Medical Sciences (MCOMS) of Kathmandu University (KU), Nepal has included in its undergraduate medical curriculum a training module that incorporates knowledge and skills in doing computer-assisted data analyses of epidemiological questions. The present study was designed around the implementation of this module. Subjects: All 96 students of the seventh semester (first six months of the fourth year) of the MBBS course at the MCOMS. Methods: The teaching-learning activities for the module were carried out mainly in six 2-hour sessions, for groups of 16 students at a time. The software used was EPI-INFO. Main outcome measures: Knowledge and skills of computer-assisted data analyses were assessed. In addition, feedback was obtained from the students and scored on seven dimensions. Findings: The pre-test/post-test questionnaire score difference, which evaluated the knowledge component, was highly significant (t 5 51.3, p , 0.001). In the skills assessment session, 83% were successful. The students gave high average scores on the satisfaction, small group learning environment, curricular relevance and evaluation dimensions; but the scores were relatively low on the time, other resources and confidence dimensions. Conclusion: The module was successful in achieving its objectives and can be implemented even under tight resource constraints. Our plans for improving upon this first run of the module are outlined in the paper.

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Context: Despite a mission statement and curriculum that are unique in our country in proposing to direct physicians to primary care (PC), the proportion of doctors graduating from Ben Gurion University (BGU) who choose PC is similar to that of other Israeli medical schools. Objectives, methods and study population: To investigate factors underlying our graduates' career choices we sent a questionnaire to six consecutive classes that had graduated from this medical school. We hypothesized that medical school was not the decisive factor in uencing career choice. Results: Returns were received from 135 graduates (54%). The nature of a specialty was the most important factor in choosing a career and in rejecting PC. Differences between primary care physicians (PCPs) and non-primary care physicians (NPCPs) were identified. PCPs emphasized factors relating to their personal lives. NPCPs emphasized the nature of a specialty in career choice. The most important factor in choosing PC was the physician– patient relationship and human aspects of medicine. Medical school was viewed as playing a minor role in career choice. Proposed interventions: Graduates proposed methods to increase the proportion of doctors choosing PC. These included: economic incentives; changing work conditions; strengthening contact with tertiary care; continuing medical education; and changing PC clerkships in medical school. Conclusion: The inherent nature of a specialty is central to career choice. In PC, the patient– physician relationship is central to physicians' career choice.

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Context: B.P. Koirala Institute of Health Sciences (BPKIHS), a new Health Sciences University in Nepal has taken several steps to respond to the societal needs and has adopted an integrated, partially problem based and community oriented curriculum. Objective: The objective of this study was to measure the school's achievements in responding to societal needs. Methodology: A descriptive cross sectional questionnaire survey (N = 46) of the administrators, faculty, students/residents and the community. The questionnaire included statements on relevance, quality, cost effectiveness and equity in the education, service and research domains of a medical school. The data were analyzed by using WINKS 4.5, a statistical package for Windows. Results: The responders satisfactorily rated BPKIHS. The mean rating (mean 3.11, SD = 1.06) was more than the satisfactory score (3). The responders were satis. ed with the education (Mean = 3.26, SD = 1.06) and research (Mean = 3.12, SD = 1.10) but were less satis. ed with the service domain (Mean = 2.94, SD = 0.98). The majority believed that the service is based on health care priorities (72%), and includes primary care (80%). A fair proportion felt the need for improvements in quality of care (50%) and cost effectiveness of care (46%). In general the faculty and administrators groups were more satis. ed than the community and students/residents groups. Conclusion: The study was useful in identifying the school's strengths as well as weaknesses in responding to the societal needs.

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