More value and less waste in research on primary cam morphology and its natural history: a qualitative interview study of stakeholders' perspectives

Aim

This study aimed to explore research quality on primary cam morphology and its natural history through the perspectives of athletes, patients, parents and coaches, clinicians, and researchers. Exploring stakeholders’ diverse perspectives on high-quality research through the lens of an existing research quality framework (INQUIRE) could pave the way for authentic collaboration to enhance research quality on primary cam morphology and its natural history.

Ontological and epistemological orientation, and study design

This was a descriptive qualitative study,^15,16 situated within a pragmatism-informed interpretive description research paradigm.^17–19 By ‘pragmatism-informed’ in this context, we mean drawing on the practical wisdom of practitioners and oriented to informing their practice in concrete situations. An interpretative orientation acknowledges that human experience is both constructed and contextual.

While some qualitative methodologies have a primary aim of developing theory, interpretive description emphasises the need for ‘informed action’:

Interpretative description, responding to the needs within applied health sciences to address pragmatic questions,²¹ seeks to describe and understand a process or phenomenon (in this case, research on primary cam morphology and its natural history) through the subjective perspectives of research participants and, importantly, intends to use this knowledge to inform practice.^22,23

This study’s pragmatic orientation manifests at different stages of the research process. For example, the research team’s expert clinical knowledge is seen as solid grounding for research design. It is this practical knowledge, tested and validated in the clinic, which is emphasised in interpretive description and used as a way to provide answers to solve real-world problems.²³ Particularly in areas where there is little prior research or empirical data about a health phenomenon, such foreknowledge and expertise are viewed as a useful starting place for orienting research.²¹

Alongside the foreknowledge that the researcher brings to the study, interpretative description aims to explore the subjective experiences of participants relevant to this study: the experiences and perspectives of doing research on primary cam morphology and its natural history. Participants should therefore be a purposive sample representing the full breadth of different kinds of knowledge and experience of the topic being researched.^24,25 Within interpretive description research, this knowledge and understanding is constantly revised in a continuous process of (re) negotiating, where both researchers and participants co-construct a coherent narrative that can inform clinical—and research—practice.²⁶

In summary, interpretive description suits the research question for this study. It facilitates straightforward and pragmatic answers to questions that are relevant to researchers, clinicians, patients, and policy makers^15,16 and helps to improve understanding of what works (or might work) best to promote high-quality research in the field of primary cam morphology and its natural history.

Ethical approval was received from the University of Oxford’s Medical Sciences Interdivisional Research Ethics Committee (Project ID R66281) and Qatar University Institutional Review Board (QU-IRB 1239-EA/20) prior to conducting the study. We followed the ‘Standards for Reporting Qualitative Research: A Synthesis of Recommendations’ for this report.²⁷

Instrument development

We developed, piloted, and adapted an interview guide based on the INQUIRE framework to explore participants’ perspectives of research quality on primary cam morphology and its natural history. The INQUIRE framework provides a guide for the practical assessment of clinical research quality at all stages of a research project, and for developing quality enhancement initiatives (Figure 1).¹⁴

Figure 1. Framework for INcreasing QUality In patient-orientated academic clinical Research (INQUIRE) (reproduced and minimally adapted from Ref. 14 under Creative Commons Attribution 4.0 International (CC BY) license).

This framework was a useful scaffold for developing quality enhancement initiatives (Figure 1), addressing five study stages (concept, planning and feasibility, conduct, analysis and interpretation, and reporting and knowledge translation), and six dimensions: (1) protection of patient safety and rights, (2) relevance/patient centredness and involvement, (3) minimisation of bias [1] (internal validity), (4) precision, (5) transparency/access to data, and (6) generalisability [2] (external validity) of the study results.

The six dimensions interact with two promoters, a set of factors that may enhance all quality dimensions at a research institution: (1) an established research infrastructure (e.g. well-trained personnel and functional facilities on-site: 3T MRI with trained radiographer and radiologist for serial hip joint imaging), and (2) sustainability through education (the structures and systems to support young researchers and build capacity through mentoring and developing the next generation, and continuous education of all study personnel to secure a long term productive clinical research environment). The Interview Protocol Refinement (IPR) Framework²⁸ was then used to develop and refine the interview guide (Figure 2).

Figure 2. Study's conceptual framework and interview guide development.

Sample

A purposive and structured variation approach was used to select the sample for this study. This method allowed us to select a sample of stakeholders representing a wide range of expertise and experience. Participants were purposively identified. Most were clinician-researchers who have published in the field between 2010 and 2021; (n=9). Other participants (n=6) were identified from the first author’s collegial, athlete and patient networks, and that of co-researcher Dr Sean McAuliffe (SMA) with oversight by the first author’s DPhil supervisors: Professors Trisha Greenhalgh (TG), Siôn Glyn-Jones (SGJ), Karim Khan (KK) and Mike Clarke (MC). The professional background of the research team allowed us to reach a large population of primary cam morphology research stakeholders, guarding against over-representation of one group. We invited all potential participants through e-mail. This sampling strategy is common in interpretive description and rests on the premise that researchers’ knowledge of the topic area enables them to identify participants who are especially knowledgeable about or experienced with the topic of interest.^{17,18,22,26,29} Potential participants included clinicians, researchers, patients, athletes, sports coaches, and parents of competitive adolescent athletes. Most participants had more than one role, ‘researcher, clinician, and parent’, for example. This often allowed the first author to explore a multiplicity of perspectives in each individual interview.

The sampling strategy, aimed at maximum variation in stakeholder background and expertise, was informed by literature and the ‘closeness continuum’ model.³⁰ According to this model, participants can have different types of expertise, based on closeness to the topic of interest. Some individuals have a degree of ‘subjective closeness’ to a topic, which involves deep experiential knowledge or real-life experiences. Patients may have this kind of subjective closeness. Participants with professional and/or legal (ethical) responsibility represent a ‘mandated closeness’. Finally, individuals can have a degree of ‘objective closeness’ to a topic, because of their profession or occupation.³⁰ To represent a wide range of experience and expertise in our sample, we purposively included participants from all three categories.

Data collection

Fifteen individuals participated: six physiotherapists, five physicians, a sport scientist, and three athletes/patients (Table 1). Two physiotherapists were also patients, four participants had adolescent children playing competitive sport, while three were sports coaches. The lead author conducted semi-structured online interviews during the Covid-19 pandemic between June 2020 and February 2022. The interviews lasted on average 60 minutes (range 44:32 to 68:08 minutes).

Using video conferencing technology (Zoom^®), all interviews were audio-recorded with permission. Informed oral consent was recorded during the first part of each interview after confirming that participants understood the research project and their rights. Co-researcher (SMA) attended 14 of 15 interviews and kept field notes that provided further interview context for analysis.³¹ Audio-recorded interviews were transcribed by a third member of the research team, Ms Jolanda Boersma (JB), a research assistant experienced in conducting and transcribing qualitative research, before being imported to qualitative data analysis software NVivo^® (QRS international Pty Ltd, Burlington, Massachusetts, United States). To protect their privacy, we assigned a unique number to each participant and deleted identifying information from the transcript.

Given the semi-structured nature of the interview guide, we had the flexibility to invite participants to elaborate on their responses; they could discuss their perspectives in whatever direction, and in as much depth as they wished. We were therefore able to probe beyond the specific questions of the interview guide, exploring participants’ unique personal experiences, practices, and preferences, which shaped their perspective on primary cam morphology research.³² These included, for example, concerns about the morphology that competitive athletes, who were worried about their future sporting careers, might have. We also asked parents and coaches of adolescent athletes how they perceived high load training and competition that might put young athletes at risk of primary cam morphology and future hip disease (Figure 2).

Analysis

Consistent with interpretive description, we used thematic analysis to analyse the data.^33–35 Thematic analysis is an approach that seeks to develop themes across cases, through reading, re-reading, and charting of data.³⁴ It is a form of pattern recognition where identified themes become the categories for analysis.³² Often misunderstood as a single method with one set of procedures, thematic analysis is best thought of as a continuum of methods—from types that place prominent emphasis on developing codes and categories and demonstrating their reliability (both within and between different coders), to more reflexive approaches which place more emphasis on a single researcher developing a plausible and coherent account of the data.^34,35

In this study, we chose not to prioritise ‘coding reliability’ since this notion rests to some extent on positivist philosophical assumptions (e.g. that the data are ‘out there’ waiting to be collected and that every researcher analysing the same data should get identical findings). Rather, we sought to use a structured coding framework to support and inform reflexive thematic analysis.³⁴

The analysis therefore incorporated both a deductive coding approach (based on a priori codes generated from the quality dimensions and promoters of the INQUIRE framework¹⁴) and a data-driven inductive approach. Early analysis of the transcripts was guided but not constrained by the preliminary codes derived from the INQUIRE framework: we populated codes according to the coding framework, but we also flagged instances in the data that did not fit. Consistent with thematic analysis, two co-researchers (SMA and JB) and the lead author immersed themselves in the data to become familiar with the depth and breadth of the content. We read interview transcripts several times. Based on the INQUIRE framework, JB and the lead author independently coded all interviews and SMA coded half of the interviews. The lead author regularly met with both co-researchers to discuss and reflect on our perspectives that shaped how we identified primary patterns in the data. Once initial coding was complete, discussions among the research team and further analytic work allowed us to identify underlying patterns of shared meaning that drew together several of the initial ‘domain summary’ codes into richer and more complex themes (more ‘fully realised themes’) that revealed multiple facets of a particular meaning or experience.^34,35

For example, the initial coding framework emphasised ‘Protection of patient safety & rights’ and ‘Relevance/Patient centeredness and involvement’ as possible ‘domain summary’ themes. This evolved into ‘Research communities should partner with patients/athletes’ to better represent authentic involvement—athletes/patients co-driving research. The process of coding and theme development had both descriptive and interpretive elements, representing what participants said and subjective considerations by the research team of patterns that were not directly evident. Here we aligned with the notion that themes are not ‘discovered’ nor do they represent pre-existing forms of knowledge waiting to ‘emerge’.^33–35 Thematic analysis is seen as an active process of knowledge production by the researcher—themes are patterns that a researcher identifies through their perspective of the data.

Research team and reflexivity

Interpretive description also draws attention to researchers’ disciplinary orientations and subjectivity. To account for their perspectives, researchers should engage in reflexivity. Reflexivity involves recognising that researchers are part of the process of producing data and their meanings—a ‘sensitivity to the ways in which the researcher and the research process have shaped the collected data, including the role of prior assumptions and experience …’(Ref. 36, p51). The researcher is a ‘valuable instrument’ of the research in interpretive description; their technical knowledge, research background and personal experience are ‘major sources of insight’.²² Findings do not ‘emerge’ from the data, nor do data ‘speak for themselves’. The researcher ultimately determines what constitutes data, which data are relevant, how the final dataset will be presented and structured, and how and to whom the findings will be disseminated—no matter how participatory and collaborative the method.³⁷ Therefore, although we acknowledge the influence of our preconceptions, we perceived our subjective clinical experience and prior knowledge (particularly HPD, SMA) to be a resource in this study.³⁸

This study’s research team consisted of the following: HPD, lead researcher, a practising sport and exercise medicine physician, director of medical education, and DPhil candidate responsible for the overall design of the study, participant recruitment, data collection and analysis; SMA, a practising sports physiotherapist, and PhD-trained qualitative researcher, acted as Qatar-based co-principal investigator, attended 14 of 15 online interviews as an observer and contributed to the analysis; JB, a medical anthropologist with experience in qualitative research (sociology and anthropology) but no clinical experience or prior knowledge of the topic, aided in transcribing and analysing data; TG, a professor of primary healthcare with extensive experience in qualitative and mixed-method research, supervised on all aspects of the study as DPhil supervisor to HPD; SGJ, a practicing orthopaedic surgeon, professor of orthopaedic surgery and experienced researcher, oversaw all aspects of the study as principal investigator and DPhil supervisor to HPD; MC, experienced researcher and DPhil supervisor to HPD, provided oversight to all aspects of the study; KK, sport and exercise medicine physician, and previous journal editor, provided oversight to all aspects of the study as an experienced researcher and DPhil supervisor to HPD. HPD and SMA, SGJ and KK had working relationships with some of the participants.

The research team’s diverse academic training and experiences set the foundations for interdisciplinary dialogue and helped to promote reflexivity throughout the project.²⁵ Olmos-Vega and colleagues (2022, p6) put it thus: ‘… assumptions become most evident when viewed from the point of view of others who do not share them’.³⁹ Several discussions, for example, brought together an anthropological, non-clinical perspective (JB) to theme development with that of a physician with intimate knowledge of the field (HPD), and a PhD physiotherapist working in research and elite sport (SMA). In addition, TG, with vast clinical and (qualitative) research experience, shaped how the lead author approached the complicated deductive-inductive coding dance. An excerpt from his research and DPhil supervision diary provides nuance: ‘Don’t get boxed-in by your (INQUIRE-informed) coding framework. Dive deeper and search for meanings and insightful, new patterns/themes to inform future (research) practice’.

Methodological reflections

It is important to consider how professional identity and positionality might have influenced aspects of this study, including the research topic, research design, context and process, participants, data collection and analysis.^40,41

When selecting a sample, we recruited participants who could contribute meaningfully to the aims of the study, either through their research experience, professional involvement, or personal experience with primary cam morphology. Participants were purposively identified, including from the lead author’s collegial network (research and clinical), as described. Although diverse to a certain extent (clinicians, researchers, athletes, patients, parents), the ten men and five women participants were all white and from the Global North. Participants representing research teams and athletes from the Global South could have shared different perspectives on research quality.

It is important to reflect on the prior relationship with some interviewees, as this ultimately shaped the data collected during this study. Garton and Copland refer to such interviews as ‘acquaintance interviews’.⁴² Data are generated in a particular way because participants may invoke prior relationships (most often implicitly, but at times explicitly) in these interviews.⁴²

‘Insider status’ offers affordances and challenges. Insider status can often lead to valuable and even unique insights.⁴³ A certain social or professional proximity often allows researchers access to resources that are not always available in more traditional interviews and might not be available to researchers who do not share this familiarity with their participants.⁴² Thus, some participants could have regarded the lead author as a professional or social proximate rather than an outsider; they might therefore have been more comfortable sharing their perspectives. In keeping with interpretive description, it is through this deep involvement with a small number of individuals familiar with the researcher and willing to share their experiences that it is possible to build trust and gather valuable data.²³

Cognisant of the fact that insider status could also be a challenge—participants might feel obliged to assist the researcher because of their prior relationship—we ensured participants knew their rights, including the right to change consent or retract completely.⁴⁴ Participants received an email explaining the study, their rights, and the informed consent process. They were able to ask questions or raise concerns at any time before or during the interview. Before starting the formal interview, the lead author briefly explained the aim and background of the study again, including participants’ rights. As mentioned earlier, the interview started after verbal consent was recorded and documented in the presence of a second member of the research team (SMA).

Theme 1: Research communities should partner with athletes/patients

This theme combines and extends two INQUIRE dimensions: protection of patient safety and rights and relevance/patient centeredness and involvement. Our interviewees reported that athlete/patient-centred research is important and multifaceted. The athlete/patient distinction is important—most athletes with primary cam morphology will never become patients. Athletes are at risk of developing primary cam morphology but ‘we know that obviously only a small percentage of people, even if they have primary cam morphology, develop symptoms’. (P5)

More than just being involved, athletes/patients should co-drive research as equal partners. Athletes/patients in this study expressed keenness to get involved in research. This was especially true ‘if patients are aware that the ultimate goal is to help people to get better and to utilise the information in a way that’s going to help people’. (P8 – physiotherapist, athlete, patient) She continued to explain:

Involvement, however, could be therapeutic at more than one level. Another athlete-patient (P10), discussing how involvement helped her ‘own learning about the condition’, also felt proud to contribute to research (Table 2, quote 1). Educating research teams and other stakeholders ‘can provide valuable input that other people might not be able to give’. (P10)

Discussing his ‘passion to try and create change’ and ‘to try and educate’ (especially parents of young athletes) about the morphology and its hip-disease consequences, another athlete (P9) shared how his ‘whole life was changed because of [his] hips’:

Our interviewees gave several examples of how a partnership approach could facilitate more value and less waste in research. First, engagement pivots on and promotes the relevance of research:

Second, athletes/patients (including adolescents, their parents, and coaches) could enlighten, not only researchers, but also the research process by illuminating blind spots in their research plans (Table 2, quote 2). In addition to gaining such insight to ‘the practicalities of what is realistic’, professionals also learned that patients ascribe importance to different things than researchers do (Table 2, quote 3). Additionally, patients can help in planning research; ‘they give us ideas that we wouldn’t have if we just think with our research hat on’. (P14)

Third, athlete/patient partnerships change how research communities communicate about research and research findings. A recurring theme in our interviews was the need to avoid jargon and use a language that everyone understands. The way to achieve this, they felt, was to involve all stakeholders from the outset, as illustrated by quote 4 (Table 2). Clinician-researchers and parents of competitive adolescent athletes, in particular, stressed the importance of avoiding alarming and inflammatory language (Table 2, quote 5). A former elite athlete and now sports coach warned that ‘things like “abnormality” perhaps trigger a lay person to automatically think that this is something damaging and negative, and will be inhibiting: so, “lesion”, when you say to me “lesion”, I’m thinking of something more like a scar or an abrasion’. (P12) Although femoroacetabular impingement (FAI) syndrome is the agreed term, ‘syndrome is a negative thing’ (Table 2, quote 6).

Sharing their experiences, several participants were concerned that language and communication style—in research and in the clinic—could create the need for (unnecessary) interventions. A clinician-researcher shared how a patient’s expectations had been shaped by an older footballer-brother who had bilateral hip surgery. The older brother framed the problem based on his own surgical experience (Table 2, quote 7). An athlete-patient and clinician shared her experience as a patient—how the language used and framing of the condition by a surgeon in a position of power left her vulnerable, confused, and distressed:

Fourth, our participants, including parents of young competitive athletes, raised the importance of safe research, particularly when children, female athletes, and competitive athletes are involved. Research communities should guard against breaches of confidentiality (Table 2, quote 8), and protect, especially children, from unnecessary exposure to imaging-related radiation (Table 2, quote 9). Protecting athletes’ health, including those participating in long-term research, and the influence of power-dynamics in competitive sport—especially when ‘juggling’ several managers at the same time—was raised as a safety concern by participant 9. Medical teams, particularly those involved in long-term research, must be empowered to protect athletes, and should, with club managers, be accountable to a higher management (Table 2, quote 10).

Finally, engagement could also be a challenge for athletes/patients, given that it requires them to share knowledge of living with primary cam morphology, which, in most, is an asymptomatic, benign morphology—unlike, for example, knee osteoarthritis (OA) (Table 2, quote 11).

In sum, when athletes/patients are equal partners in research—when they share their experiences and expertise—research would likely be more relevant, safer, and more ethical. Athlete/patient partners, as people who have a voice, could help to shape clearer and less threatening communication in research and in the clinic, and expressed eagerness to share their stories and struggles—to get involved in research and education to help others. Healthcare professionals and researchers seemed equally keen to involve and learn from athlete/patient partners.

Theme 2: Research communities should collaborate with one another

This theme combines and extends elements from several INQUIRE dimensions and promotors, including minimisation of bias (internal validity), precision, infrastructure, and sustainability.

Interviewees discussed the need for coordinated efforts to plan and deliver multi-centre and multidisciplinary research on, for example, primary cam morphology aetiology and prognosis (Table 3, quote 12). To strengthen large-scale multi-centre research collaborations—‘helping each other’—research teams should agree on research questions (Table 3, quote 13). Such studies should use the same methodology and capitalise on transparent research centre-specific expertise to facilitate high quality data sharing (Table 3, quote 14).

To reduce attrition and measurement bias, research centre-specific expertise is particularly important when performing and analysing imaging. Long-term prospective studies (with serial hip imaging over time—every five years, for example) could benefit from an international network of collaborating imaging units to accommodate elite athletes who are often contracted to live and play around the world. They could be accommodated at an imaging centre close to them. Imaging collaboration could include shared (online) infrastructure like Digital Imaging and Communications in Medicine (DICOM) (Table 3, quotes 15 and 16).

International collaboration on a registry or large database could have a ‘really big impact’ on this field, benefitting research teams, patients, and healthcare systems (Table 3, quote 17). Collaboration could be bolstered when—with a ‘we need each other’-approach—coordinated by global sporting bodies like the International Olympic Committee (IOC) or FIFA (Table 3, quote 18). Participants commented on data sharing, including their frustration with it. Meaningful data sharing was acknowledged as ‘my biggest problem’ (P4). However, if done well, for example through the 11 IOC Research Centres [3], such data sharing could improve small sample bias and result in large datasets ‘that could be interrogated with better techniques, and with better statistical knowledge’ (Table 3, quote 19).

A common theme was also multidisciplinary team approach to intra-team collaboration, including with academic partners. Multidisciplinary team collaboration should involve athletes, coaches, different medical specialties and topic experts, researchers, and methodologists, for example (Table 3, quote 20 and 21). Some participants described their perspectives and experiences on multi-stakeholder collaboration to facilitate research buy-in. Buy-in could make or break research in this field. How researchers frame their research question, especially in elite sport, is key for engaging with management, big stakeholders, and decision-makers, including finance decision-makers (Table 3, quote 22).

Effective research collaboration among academia and professional sports clubs is important in this field.^4,45–47 Researchers working with football clubs benefit when clubs, especially the coaches in the clubs, determine the research questions before engaging ‘the right university’ (Table 3, quote 23). However, such a collaboration could often be a slog, and someone needs to ‘kind of steer the university’ on what is possible and what is not impossible (Table 3, quote 24).

In sum, participants discussed how ‘we are stronger together’ when aligning to pursue large-scale, multi-centre and international collaborations to answer research questions that matter to all. Effective multidisciplinary intra-team collaboration resonated with our interviewees too.

Theme 3: Research communities should pursue open science

This theme includes and extends the INQUIRE dimension, transparency/access to data. Access—for everyone—to as much information as possible, and translated to lay people’s language, resonated with our interviewees (Table 4, quotes 25 and 26). All stakeholders, including athlete/patients and coaches, should have access to research—in ‘plain language’:

An athlete/patient participant warned that financial and career benefits for researchers should not trump end users’ access to research —‘it’s silly and very naïve in this day and age that it’s happening’! (P9):

Peer reviewed publications buried behind paywalls are problematic for young scholars and clinicians alike (Table 4, quote 27). Access should be easy—‘simply click on a button’—and include study protocols to reduce research waste (Table 4, quote 28) and data (Table 4, quote 29). Although open access to data resonated with our interviewees—even if it becomes a future journal requirement for new studies—there are important considerations, including informed consent from participants for anonymised patient data to be shared among research groups (Table 4, quote 30).

Some participants felt that prioritising open access was easier said than done. For example, particularly for early career researchers, impact factor might trump open access; an approach that could disrupt effective dissemination of results (Table 4, quote 31).

Researchers should think carefully when sharing test results with individual research participants (and, in the professional football club context, their sports club medical teams and managers): they should have an agreed protocol for this (Table 4, quote 32) and be comfortable to say: ‘there’s nothing to share’. Particularly when sharing, for example, ‘normal’ imaging results of ‘frankly, probably a pretty typical development [primary cam morphology]’ in athletes (Table 4, quote 33). Research teams should also give athletes/patients ownership of the decision to share, or not to share, their results with club medical staff (Table 4, quote 34).

Finally, participants also expressed concern about, or questioned the need for, open access. They discussed: the high (‘extortionate’) cost of open access publication (Table 4, quote 35); the ‘completely crazy’ academic publication system—paying to sign away copyright (Table 4, quote 36); the problem of predatory or low-quality open access journals (Table 4, quote 37); and their perspective that open access papers are ‘not that important’ as the average clinician ‘don’t really read research papers’—the cost of open access publication ‘pull money away’ from research (Table 4, quote 38).

In sum, our study participants discussed how research communities could pursue open science to improve research quality. Clinicians, researchers, and athletes/patients need to have easy access to important findings. There are perverse incentives (e.g. researchers seeking publication in a high impact factor journal that is only available to readers via a paywall). Finally, the cost of making publications open access could be prohibitive.

Theme 4: Research communities should champion equity, diversity, and inclusion

This theme includes and extends the INQUIRE dimensions: generalisability (external validity), and relevance/patient centredness & involvement. Our interviewees highlighted several equity, diversity, and inclusion (EDI) elements of high-quality research relevant to the steps of a research project in the hip-and-groin research field.

First, as described in theme 1, research communities should partner with athletes/patients. Such partnerships, to inform research questions, for example, should focus on racial/ethnic and sex/gender minoritised individuals and groups in the EDI context of this research field (e.g. girls, women, Black people, and people from the Global South).

Second, considering study populations, the primary cam morphology research field is largely void of research involving girls and women, and people from the Global South—particularly athletes. This was emphasised by our interviewees too (Table 5, quote 39). To engage more diverse populations, research should not only consider the different impact on males and females, but also involve people of different ages, people with disabilities, and people with different ethnicities (P12). To date, very little research in this field is done in the Global South, for example. A clinician-researcher and patient warned that ‘to understand the injury or morphology well’ it is important not to ‘shut out certain geographical areas’ (P13). Participant 7 confirmed this perspective, discussing research that involved diverse populations with ‘genetic variation’ and different athletic backgrounds (Table 5, quote 40).

Third, research team-specific EDI considerations include fostering an inclusive and equitable research climate within teams and their collaborative networks. Our interviewees discussed: (1) team diversity (e.g. female research participants might feel uncomfortable when male researchers perform a groin evaluation, as illustrated in quote 41 (Table 5)); (2) access for team members who live remotely (e.g. accessible and inclusive online meetings, as illustrated in quote 42 (Table 5)); (3) building capacity (e.g. team member compensation and mentoring ensuring socioeconomic status and knowledge about the research topic do not exclude certain team members, as illustrated in quote 43 (Table 5)).

Finally, EDI in knowledge translation include, as discussed above, easy access to research reports written in lay language, ideally with patient partners (Table 4, quote 26).

Theme 5: Research communities should nurture young scholars

This theme includes and extends the INQUIRE promotor: sustainability/education. Mentoring seems to be key for scholarly growth and has been defined as ‘a dynamic, reciprocal relationship in a work environment between and advanced career incumbent (mentor) and a beginner (protégé) aimed at promoting the career development of both.’ (Ref. 48, p17). Four archetypes of mentorship have been proposed: the traditional mentor, the coach, the sponsor, and the connector.⁴⁹

Interviewees illuminated how research communities could nurture young scholars through mentoring, deconstructed here using the four archetypes above. First, through careful mentoring by humble mentors. Humble mentors model imperfection—they are willing to say, ‘I don’t know’.⁵⁰ They seem to carefully guide young scholars to pursue relevant research questions ‘as part of something bigger’, as quote 44 (Table 6) illustrates. Second, through mentors that challenge mentees in safe spaces (the coach or supervisor-type mentorship), as quote 45 (Table 6) illustrates. Third, through mentors that create opportunities – the sponsor-type mentorship. Scholars should not be ‘dumped’ into research with a ‘good luck, my friend’ approach (P2). Rather, research teams—especially senior researchers and mentors—should create opportunities for young scholars to lead (Table 6, quote 46). Finally, through mentors that empower. Clinician-researcher (P3) described his role (as a connector-type mentor) in creating a stable and sustainable environment for young scholars, connecting them with a professional sporting organisation (football club) as employer and a university for academic training:

A clinician-researcher and young scholar (P2) stressed the importance of ‘insight in the ethical way of things’ when creating opportunities for young scholars, and warned against research for the sake of research:

Several participants mentioned lack of sustainable employment and funding as a problem, creating ‘considerable stress and lack of certainty about the long-term job and continuity’ (P1), as quote 47 (Table 6) illustrates. Research in this field (‘arthritis’) seems to struggle for funding compared to other fields like cancer (Table 6, quote 48). However, protected employment seems not enough; financial and collegial support for relevant research, with continued access to data after employment, should be cemented in employment contracts (Table 6, quote 49).

In addition to mentoring, participants discussed personal growth when well-organised research teams created opportunities for structured education, for discussing ideas (Table 6, quote 50), and for sharing the struggles of being a young scholar (Table 6, quote 51). Participants emphasised structured education programmes for young scholars. One participant urged education on ‘the rules and the processes of research.’ (P4). Although important, this element is often missing in education; ‘that a lot of people, despite the fact that they have PhDs, still don’t understand the research process, is fascinating to me.’ (P4). Participant 2 agreed, advocating for a structured education programme: ‘We had like a course of two weeks on biomedical statistics, but to be honest, how can you learn biomedical statistics in two weeks?’ (P2). Another participant advocated for ‘having the right people in the right positions to educate the team’ on more field-specific knowledge and skills (P5).

In sum, creating opportunities for young scholars to learn, teach, and lead even large-scale studies in well-supported teams, resonated with participants. Participants agreed that stable and sustainable research environments are key for supporting young scholars’ development into independent researchers.

Summary of findings and implications for research and practice

Our first theme echoed that authentic patient and public involvement (PPI) in research—partnering with athletes/patients—could facilitate more relevant, safer, and more ethical research.⁵¹ Patient-centred research could help to identify unmet needs and gaps for research communities to prioritise—research questions that are relevant to athletes/patients with primary cam morphology or a related hip disease. These include qualitative research to explore experiences, preferences, and perspectives. It goes without saying that athlete/patient-centred research must be safe and ethical. In the context of primary cam morphology and its natural history, this means, for example, avoiding radiographs when researching aetiology in maturing athletes, protecting participants’ personal information, prioritising general and research-specific ethics and integrity, and valuing methodological rigour.

A haphazard approach to language (including terminology and definitions) could confuse patients.⁵² This gap was addressed when the research community agreed on primary cam morphology terminology, definitions, taxonomy, and imaging outcomes for research.¹² The YAHiR Collaborative and others are working to implement this agreement and to address areas of tension and dissent. This will take time; many clinicians and researchers still use cam ‘lesion’, ‘deformity’ or ‘impingement’ instead of the agreed ‘morphology’.^5,12 With athletes/patients as partners, research communities would likely be more inclined to prioritise clear and non-threatening language when stakeholders communicate about the morphology and its hip-disease consequences.

Second, high-performing research teams should collaborate with one another—a key INQUIRE element of high-quality research.¹⁴ Such collaborations could catalyse, among other benefits, larger data sets (through well-planned multi-centre research projects on primary cam morphology aetiology and prognosis, for example), increased methodological rigour (by involving, for example, methodologists and specialist radiologists from the outset), and better framing of research questions to secure wider buy-in (of football club managers, for example). Professor Trish Greenhalgh shared ‘3 tips for authentic research collaboration from interdisciplinary health research’ in Session 4 of the 2022 Oxford Young Athlete’s Hip Symposium: ‘build relationships and trust’, ‘foster tolerance of uncertainty’, and ‘harness conflict productively’.⁵³

Third, the research community should pursue open science. Participants emphasised access for everyone to as much information as possible—including protocols, datasets, and summaries of results in non-scientific language. Several participants discussed ‘extortionate’ costs of open access publishing and warned against predatory and low-quality open access journals. These problems are not unique to the hip-and-groin research field. With an estimated annual turnover of $2 billion, the open access publishing model has become the ‘mainstream approach to delivering scientific knowledge with Article Processing Charges as driving force’.⁵⁴ Predatory journals and publishers, a problem in all research fields,⁵⁵ were defined as ‘entities that prioritize self-interest at the expense of scholarship and are characterized by false or misleading information, deviation from best editorial and publication practices, a lack of transparency, and/or the use of aggressive and indiscriminate solicitation practices’.⁵⁶ This consensus definition is likely to contribute to a coordinated strategy aimed at eradicating the plague of predatory journal and publishers.

Fourth, high-quality research on primary cam morphology champions EDI. An EDI-conscious research community at each stage of the research process, would be more aware of possible blind spots, including a tokenistic, tick-box approach to EDI.⁵⁷ Similar to other research fields, there is a lack of diversity and inclusion in sport and exercise medicine, science and rehabilitation in general, but specifically Black female athletes.^58–60 Other fields have prioritised efforts to improve EDI, including in academia⁶¹ and nursing.⁶² An EDI lens should not only inform research populations but also research teams. Our findings suggest such a research community would likely (1) prioritise more diverse research populations and research teams with an immediate focus on girls and women, and the Global South (diversity); (2) secure access to equal and fair opportunities to minoritised individuals and populations (equity); and (3) emphasise inclusion as ‘a sense of belonging: feeling respected, valued, and seen for who we are as individuals’.⁶³

Finally, participants in this study emphasised young scholars, in high-quality research, should be nurtured. This echoed the move away from an ‘unhealthy reliance on impact factors’ to assessing scientific research quality,⁶⁴ to rather focus on nurturing and mentoring the next generation of scholars.⁶⁵ They are carefully mentored, share, and learn together, benefit from opportunities created by their mentors and seniors, and thrive when employed with funding—creating a stable and sustainable research environment.

Comparison to the research quality literature

The findings of this study, informed by the six dimensions and two promotors of the INQUIRE framework, are consistent with current trends in assessing research. However, what research quality in health care is, also depends on context and research type. The INQUIRE framework’s dimensions—minimisation of bias, precision, and generalisability—illuminate a predominantly positivist lens to assessing research quality. For example, we don’t trust results of cohort studies plagued by researcher bias and imprecision. ‘Confirmability’, ‘credibility’, and ‘transferability’, on the other hand, are concepts for defining and investigating rigorous qualitative research.^66–68 A carefully constructed conceptual framework for research quality in health care can inform efforts to improve research in a specific field. A new, more inclusive framework could, for example, be the catalyst to moving a field beyond the ‘impact-factor-is-king’ approach to assessing research quality, to embracing a more contemporary approach. In this study, our analysis started with the INQUIRE framework but also explored research quality beyond the positivist frame of enquiry.

Despite worldwide quests, a uniform approach to describing and assessing research quality and impact is still contested. The 2014 ‘Increasing Value, Reducing Waste’ series in The Lancet^69–74 spotlighted waste in biomedical research and made 17 recommendations to increase research value, addressed to five main stakeholders—funders, regulators, journals, academic institutions, and researchers. The authors of this series formed an alliance (the Reduced Research Waste and Reward Diligence [REWARD] campaign),⁷⁵ emphasising five principles—several echoed in our findings—to maximise research potential, including (1) the right research priorities; (2) robust research design, conduct and analysis; (3) regulation and management that are proportionate to risks; (4) access to all information on research methods and findings; and (5) complete and usable reports of research. However, a follow-up article in 2016, providing an overview of the effects of The Lancet’s Series and REWARD campaign, concluded that, overall, and despite early corrective actions by some stakeholder groups, further work was needed to increase research value.¹¹ Six years later, the tide continues to turn against research waste and, importantly, the narrow notion that high quality research and impact can only be ‘measured with a number’.^65,76

The findings of this study resonate with the key quality concepts of the Agreement on Reforming Research Assessment [4]. This agreement emphasises research (quality) assessment based primarily on qualitative judgement and more-inclusive assessment systems.⁷⁶ Commendably, this agreement was co-produced ‘bottom-up’ by research stakeholders from 350 research organisations and 40 countries as ‘an exercise of consensus’, based on a ‘common vision, and shared responsibility and direction.’.⁷⁷ This inclusive approach is a foundation to collaborate—a call for collective action. To date (31 July 2023) and supported by the Coalition for Advancing Research Assessment initiative,⁷⁸ 608 organisations worldwide have signed the agreement.⁷⁹ Others have paved the way for this approach, notedly in the transdisciplinary research context,⁸⁰ and patient-orientated academic clinical research’ (the INQUIRE framework described earlier).¹⁴

Belcher et al. (2016) proposed a framework of four main principles when assessing research quality in transdisciplinary research.⁸⁰ These principles are (1) relevance (the importance, significance, and usefulness of the research problem, objectives, processes, and findings to the problem context); (2) credibility (the research findings are robust, and the sources of knowledge are dependable. This includes a clear demonstration of the adequacy of the data and the methods used to procure the data including clearly presented and logical interpretation of findings); (3) legitimacy (the research process is perceived as fair and ethical, including ethical and fair representation of all involved, and the appropriate and genuine inclusion and consideration of diverse participants, values, interests, and perspectives); and (4) effectiveness (the research generates knowledge and stimulates actions that address the problem and contribute to solutions and innovations).

In sum, there are no shortage of research quality frameworks; however, how these frameworks are applied to inform research practice depends on several factors, including context. Nevertheless, there seems to be a world-wide movement towards a more qualitative assessment of research quality.

Strengths and limitations

To our knowledge, this is the first study in the hip-and-groin research field exploring research stakeholders’ perspectives on research quality. In light of these efforts to articulate research quality, limitations of this study deserve particular attention. Although our aim was to explore (describe and understand) perspectives on research quality of a diverse stakeholder group (rather than a deep case-by-case phenomenological analysis of a smaller homogenous group) the study population could have been even more diverse—we did not, for example, recruit any participants from the Global South or Black female athletes. This was perhaps a blind spot – patients, particularly in this research field, are not only middle-aged white males. Participants from the Global South at the intersection of race and gender, compared to their white Global North counterparts, would likely have different perspectives on participation and access to three-dimensional imaging, for example.

Although the data in this study provided a rich and complex picture of a diverse group of participants’ experiences and perspectives on research in the field of primary cam morphology and its natural history, it did not aim to completely capture the phenomenon under scrutiny.⁸¹ Our interviewees emphasised language and communication about the morphology, referring to ‘inflammatory’ language, for example. What ‘inflammatory’ is, however, depends on the hearer. Research communities might therefore choose to adopt a more flexible approach to defining ‘inflammatory’ language. We need more research on the perspectives and needs of subgroups living with primary cam morphology and its hip disease consequences, focussing on women, adolescents and the Global South. Village-born Kenyan long-distance runners who pad 25 miles a day barefoot, for example, or youngsters playing football for many hours per week in rural villages in South Africa: do they develop primary cam morphology or its hip disease consequences? what are their challenges, priorities and concerns? These and other gaps in current research should be addressed by the YAHiR Collaborative and collaborators.

The research team reflected on two aspects of our sampling strategy. First, the structured variation approach to sampling (informed by the ‘closeness continuum’) resulted in breadth, rather than individual depth, of perspectives. However, our purpose was not an in-depth phenomenological analysis; we were interested in multiple perspectives on research quality from a diverse stakeholder group. Second, the role of prior relationships between researchers and some participants. The familiar nature of some ‘acquaintance interviews’ might have shaped the data gathered during this study.⁴² For example:

Starting the sentence with ‘you know better than anyone’, the participant aligned himself with the lead investigator and interviewer, drawing upon their shared knowledge. The participant was still the interviewee, but it could be seen that he also invoked the professional relationship with the lead investigator.⁴² Some participants might have assumed the lead investigator knew the answer anyway, limiting the extent to which the interviewee elaborated on their responses. For that reason, we had a third person (SMA) present during the interview allowing the lead investigator the opportunity to ask, for example: ‘For SMA’s benefit, could you just explain why?’

Finally, we briefly mention critical orientations like power and equity. Epistemologically, were our orientation more ‘critical theory’ than pragmatism-informed interpretivist, we would have paused to unpack these constructs more.