148 Chapter 7 Strength and weakness of the study The assurance of trustworthiness is an important construct in conducting qualitative research, which can be compared to validity and reliability in quantitative research. The strengths of this study are related to the three components of trustworthiness: credibility, transferability and dependability.31 First, we feel that we ensured credibility in this study by using the TDF and COM-B model as part of the BCW, whose suitability for PROM implementation has been previously demonstrated.3,5 Moreover, we aimed to enhance the credibility of this study by using the concept of triangulation through the process. This is evidenced by the inclusion of both user groups of the OQUA (ENT professionals and patients of one tertiary referral hospital and two regional hospitals), the consideration of the characteristics of both groups in choosing data collection methodologies and the involvement of two researchers and one independent moderator in the data collection and analysis. Second, we attempted to ensure the transferability of this study by providing a representative quotes for the identified barriers and enablers. We believe that this may provide sufficient detail for the reader to assess whether the results of this study can be related to similar contexts. Third, in order to ensure the dependability of this study, we used the four-phase content analysis technique of Atkins.15 We aimed to capture the analysis process as accurately as possible, by documenting all research steps and providing the used supporting information. Data saturation was not reached in the group of ENT-professionals. Due to the limited availability of professionals with a specialization in otology, we were unable to organize more focus groups. Therefore, some barriers and enablers may have been missed. However, there was a large overlap in identified factors among the focus groups, which suggests that the lack of data saturation may be restricted. Due to logistical and organizational restrictions, it was not possible to reflect the heterogeneity within characteristics of otology patients from NWZ and Deventer hospital. As a result, patient groups with external or inner ear diseases and patients who did not complete the OQUA were underrepresented. This may explain the previously achieved theoretical saturation at both hospitals. This implies that some barriers or factors may have been overlooked, or that the effect of the identified factor may not be adequately recognized. Applying frequency counts in a qualitative study can be debated, given there was no representative sample size. However, the determination of key domains was necessary for developing an implementation strategy, considering the large
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