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Quick answers, qualitative research glossary.

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Comparing wording of questions used in qualitative and quantitative research

For research questions in qualitative research, the use of open words such as “how” or “what” allow for greater exploration of issues, as opposed to words such as “why” which imply exploration of cause and effect, which is more characteristic of quantitative research. Suggested verbs to use in qualitative research questions are: discover, understand, describe, explore. Suggested verbs to use in quantitative research questions are those which convey the idea of cause and effect i.e. they indicate the link between variables: compare, relate, cause and influence. However it should be noted that this is only a guide and there are many examples of research questions that do not fit these ‘rules’.

Making your questions researchable

Research questions should be researchable , that is, they should allow you to do research in relation to them (Cresswell 2011). That means that they should not be formulated in terms that are so abstract that they cannot be translated into practice (Bryman 2008). Also the wording of research questions should be as simple as possible so that it can be easily understood. There should be no terms that are ambiguous, therefore it is important to think through the terminology used and ensure that the best possible choice of wording has been selected.

This example research question illustrates the need to change an ambiguous term:

Do children with behaviour problems benefit from the use of concrete materials in mathematics?

The term ‘benefit’ needs to be more specific as it is not possible to take the research forward without first considering what type of benefit is to be investigated, for example:

Do children with behaviour problems show increased levels of engagement when concrete materials are used in mathematics?

Questions that are too ‘wordy’

Also it is important that research questions should be written as concisely as possible. The next example shows how by rewording a research question to make it more concise, the meaning can be made clearer:

Do children learn more effectively in science in practical sessions compared to lessons using worksheets and textbooks?

This question is too wordy and as a consequence of this the main focus of the research is not clear. Below the reworked research question carries the same meaning, but is more concise and easier to understand:

Possible reworked question:

Does scientific enquiry improve children’s learning in science?

Avoiding bias and assumptions

The way a question is worded can reflect biased views or assumptions held by the researcher. It is often very difficult for you to identify your own bias or assumptions that you have made and it is necessary to consider your wording carefully. Also it may be helpful to run questions by a colleague to identify these. It is important to realise that an operational definition of a concept is context –specific and that if you were to research the same issue in a different context e.g. psychology rather than education, the definition may be need to change (Punch, 1998, cited in Robson, 2002).

Below is an example of a question which illustrates how researcher bias can impact on the research design

Do teachers use worksheets in science more than practical activities because they lack confidence in performing investigations in a classroom?

The wording of this question indicates that the researcher strongly believes that lack of teacher confidence is the root cause of a high incidence of use of worksheets rather than carrying out practical activities in science. If this is not addressed at an early stage it will impact on all aspects of the research design including how questions are phrased in the research tools, which will impact on the validity of the research. Also it could limit the potential findings because the researcher does not ask questions that could identify other issues contributing to lack of practical activities.

Key points to consider when developing research questions:

The process of developing your research questions is the foundation of all your subsequent research.

The wording of the central research question needs to be particularly carefully thought through as it will directly influence your choice of methods.

Throughout the early stages of planning your research, reading will form an integral part of the process as it will inform your thinking and help direct the development of your research questions and research design.  

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on 4 April 2022 by Pritha Bhandari . Revised on 30 January 2023.

Qualitative research involves collecting and analysing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analysing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, and history.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organisation?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography, action research, phenomenological research, and narrative research. They share some similarities, but emphasise different aims and perspectives.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves ‘instruments’ in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analysing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organise your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorise your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analysing qualitative data. Although these methods share similar processes, they emphasise different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Researchers must consider practical and theoretical limitations in analysing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analysing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalisability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalisable conclusions because the data may be biased and unrepresentative of the wider population .

• Labour-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to test a hypothesis by systematically collecting and analysing data, while qualitative methods allow you to explore ideas and experiences in depth.

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organisation to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organisations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organise your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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Qualitative Research : Definition

Qualitative research is the naturalistic study of social meanings and processes, using interviews, observations, and the analysis of texts and images.  In contrast to quantitative researchers, whose statistical methods enable broad generalizations about populations (for example, comparisons of the percentages of U.S. demographic groups who vote in particular ways), qualitative researchers use in-depth studies of the social world to analyze how and why groups think and act in particular ways (for instance, case studies of the experiences that shape political views).   

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Criteria for Good Qualitative Research: A Comprehensive Review

• Regular Article
• Open access
• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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• Drishti Yadav   ORCID: orcid.org/0000-0002-2974-0323 1  

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Good Qualitative Research: Opening up the Debate

Beyond qualitative/quantitative structuralism: the positivist qualitative research and the paradigmatic disclaimer.

What is Qualitative in Research

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Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

Amin, M. E. K., Nørgaard, L. S., Cavaco, A. M., Witry, M. J., Hillman, L., Cernasev, A., & Desselle, S. P. (2020). Establishing trustworthiness and authenticity in qualitative pharmacy research. Research in Social and Administrative Pharmacy, 16 (10), 1472–1482.

Article   Google Scholar  

Barker, C., & Pistrang, N. (2005). Quality criteria under methodological pluralism: Implications for conducting and evaluating research. American Journal of Community Psychology, 35 (3–4), 201–212.

Bryman, A., Becker, S., & Sempik, J. (2008). Quality criteria for quantitative, qualitative and mixed methods research: A view from social policy. International Journal of Social Research Methodology, 11 (4), 261–276.

Caelli, K., Ray, L., & Mill, J. (2003). ‘Clear as mud’: Toward greater clarity in generic qualitative research. International Journal of Qualitative Methods, 2 (2), 1–13.

CASP (2021). CASP checklists. Retrieved May 2021 from https://casp-uk.net/casp-tools-checklists/

Cohen, D. J., & Crabtree, B. F. (2008). Evaluative criteria for qualitative research in health care: Controversies and recommendations. The Annals of Family Medicine, 6 (4), 331–339.

Denzin, N. K., & Lincoln, Y. S. (2005). Introduction: The discipline and practice of qualitative research. In N. K. Denzin & Y. S. Lincoln (Eds.), The sage handbook of qualitative research (pp. 1–32). Sage Publications Ltd.

Google Scholar  

Elliott, R., Fischer, C. T., & Rennie, D. L. (1999). Evolving guidelines for publication of qualitative research studies in psychology and related fields. British Journal of Clinical Psychology, 38 (3), 215–229.

Epp, A. M., & Otnes, C. C. (2021). High-quality qualitative research: Getting into gear. Journal of Service Research . https://doi.org/10.1177/1094670520961445

Guba, E. G. (1990). The paradigm dialog. In Alternative paradigms conference, mar, 1989, Indiana u, school of education, San Francisco, ca, us . Sage Publications, Inc.

Hammersley, M. (2007). The issue of quality in qualitative research. International Journal of Research and Method in Education, 30 (3), 287–305.

Haven, T. L., Errington, T. M., Gleditsch, K. S., van Grootel, L., Jacobs, A. M., Kern, F. G., & Mokkink, L. B. (2020). Preregistering qualitative research: A Delphi study. International Journal of Qualitative Methods, 19 , 1609406920976417.

Hays, D. G., & McKibben, W. B. (2021). Promoting rigorous research: Generalizability and qualitative research. Journal of Counseling and Development, 99 (2), 178–188.

Horsburgh, D. (2003). Evaluation of qualitative research. Journal of Clinical Nursing, 12 (2), 307–312.

Howe, K. R. (2004). A critique of experimentalism. Qualitative Inquiry, 10 (1), 42–46.

Johnson, J. L., Adkins, D., & Chauvin, S. (2020). A review of the quality indicators of rigor in qualitative research. American Journal of Pharmaceutical Education, 84 (1), 7120.

Johnson, P., Buehring, A., Cassell, C., & Symon, G. (2006). Evaluating qualitative management research: Towards a contingent criteriology. International Journal of Management Reviews, 8 (3), 131–156.

Klein, H. K., & Myers, M. D. (1999). A set of principles for conducting and evaluating interpretive field studies in information systems. MIS Quarterly, 23 (1), 67–93.

Lather, P. (2004). This is your father’s paradigm: Government intrusion and the case of qualitative research in education. Qualitative Inquiry, 10 (1), 15–34.

Levitt, H. M., Morrill, Z., Collins, K. M., & Rizo, J. L. (2021). The methodological integrity of critical qualitative research: Principles to support design and research review. Journal of Counseling Psychology, 68 (3), 357.

Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Directions for Program Evaluation, 1986 (30), 73–84.

Lincoln, Y. S., & Guba, E. G. (2000). Paradigmatic controversies, contradictions and emerging confluences. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (2nd ed., pp. 163–188). Sage Publications.

Madill, A., Jordan, A., & Shirley, C. (2000). Objectivity and reliability in qualitative analysis: Realist, contextualist and radical constructionist epistemologies. British Journal of Psychology, 91 (1), 1–20.

Mays, N., & Pope, C. (2020). Quality in qualitative research. Qualitative Research in Health Care . https://doi.org/10.1002/9781119410867.ch15

McGinley, S., Wei, W., Zhang, L., & Zheng, Y. (2021). The state of qualitative research in hospitality: A 5-year review 2014 to 2019. Cornell Hospitality Quarterly, 62 (1), 8–20.

Merriam, S., & Tisdell, E. (2016). Qualitative research: A guide to design and implementation. San Francisco, US.

Meyer, M., & Dykes, J. (2019). Criteria for rigor in visualization design study. IEEE Transactions on Visualization and Computer Graphics, 26 (1), 87–97.

Monrouxe, L. V., & Rees, C. E. (2020). When I say… quantification in qualitative research. Medical Education, 54 (3), 186–187.

Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52 (2), 250.

Morse, J. M. (2003). A review committee’s guide for evaluating qualitative proposals. Qualitative Health Research, 13 (6), 833–851.

Nassaji, H. (2020). Good qualitative research. Language Teaching Research, 24 (4), 427–431.

O’Brien, B. C., Harris, I. B., Beckman, T. J., Reed, D. A., & Cook, D. A. (2014). Standards for reporting qualitative research: A synthesis of recommendations. Academic Medicine, 89 (9), 1245–1251.

O’Connor, C., & Joffe, H. (2020). Intercoder reliability in qualitative research: Debates and practical guidelines. International Journal of Qualitative Methods, 19 , 1609406919899220.

Reid, A., & Gough, S. (2000). Guidelines for reporting and evaluating qualitative research: What are the alternatives? Environmental Education Research, 6 (1), 59–91.

Rocco, T. S. (2010). Criteria for evaluating qualitative studies. Human Resource Development International . https://doi.org/10.1080/13678868.2010.501959

Sandberg, J. (2000). Understanding human competence at work: An interpretative approach. Academy of Management Journal, 43 (1), 9–25.

Schwandt, T. A. (1996). Farewell to criteriology. Qualitative Inquiry, 2 (1), 58–72.

Seale, C. (1999). Quality in qualitative research. Qualitative Inquiry, 5 (4), 465–478.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22 (2), 63–75.

Sparkes, A. C. (2001). Myth 94: Qualitative health researchers will agree about validity. Qualitative Health Research, 11 (4), 538–552.

Spencer, L., Ritchie, J., Lewis, J., & Dillon, L. (2004). Quality in qualitative evaluation: A framework for assessing research evidence.

Stenfors, T., Kajamaa, A., & Bennett, D. (2020). How to assess the quality of qualitative research. The Clinical Teacher, 17 (6), 596–599.

Taylor, E. W., Beck, J., & Ainsworth, E. (2001). Publishing qualitative adult education research: A peer review perspective. Studies in the Education of Adults, 33 (2), 163–179.

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19 (6), 349–357.

Tracy, S. J. (2010). Qualitative quality: Eight “big-tent” criteria for excellent qualitative research. Qualitative Inquiry, 16 (10), 837–851.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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Qualitative and Quantitative Research: Glossary of Key Terms

This glossary provides definitions of many of the terms used in the guides to conducting qualitative and quantitative research. The definitions were developed by members of the research methods seminar (E600) taught by Mike Palmquist in the 1990s and 2000s.

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500+ Qualitative Research Titles and Topics

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Qualitative research is a methodological approach that involves gathering and analyzing non-numerical data to understand and interpret social phenomena. Unlike quantitative research , which emphasizes the collection of numerical data through surveys and experiments, qualitative research is concerned with exploring the subjective experiences, perspectives, and meanings of individuals and groups. As such, qualitative research topics can be diverse and encompass a wide range of social issues and phenomena. From exploring the impact of culture on identity formation to examining the experiences of marginalized communities, qualitative research offers a rich and nuanced perspective on complex social issues. In this post, we will explore some of the most compelling qualitative research topics and provide some tips on how to conduct effective qualitative research.

Qualitative Research Titles

Qualitative research titles often reflect the study’s focus on understanding the depth and complexity of human behavior, experiences, or social phenomena. Here are some examples across various fields:

• “Understanding the Impact of Project-Based Learning on Student Engagement in High School Classrooms: A Qualitative Study”
• “Navigating the Transition: Experiences of International Students in American Universities”
• “The Role of Parental Involvement in Early Childhood Education: Perspectives from Teachers and Parents”
• “Exploring the Effects of Teacher Feedback on Student Motivation and Self-Efficacy in Middle Schools”
• “Digital Literacy in the Classroom: Teacher Strategies for Integrating Technology in Elementary Education”
• “Culturally Responsive Teaching Practices: A Case Study in Diverse Urban Schools”
• “The Influence of Extracurricular Activities on Academic Achievement: Student Perspectives”
• “Barriers to Implementing Inclusive Education in Public Schools: A Qualitative Inquiry”
• “Teacher Professional Development and Its Impact on Classroom Practice: A Qualitative Exploration”
• “Student-Centered Learning Environments: A Qualitative Study of Classroom Dynamics and Outcomes”
• “The Experience of First-Year Teachers: Challenges, Support Systems, and Professional Growth”
• “Exploring the Role of School Leadership in Fostering a Positive School Culture”
• “Peer Relationships and Learning Outcomes in Cooperative Learning Settings: A Qualitative Analysis”
• “The Impact of Social Media on Student Learning and Engagement: Teacher and Student Perspectives”
• “Understanding Special Education Needs: Parent and Teacher Perceptions of Support Services in Schools

Health Science

• “Living with Chronic Pain: Patient Narratives and Coping Strategies in Managing Daily Life”
• “Healthcare Professionals’ Perspectives on the Challenges of Rural Healthcare Delivery”
• “Exploring the Mental Health Impacts of COVID-19 on Frontline Healthcare Workers: A Qualitative Study”
• “Patient and Family Experiences of Palliative Care: Understanding Needs and Preferences”
• “The Role of Community Health Workers in Improving Access to Maternal Healthcare in Rural Areas”
• “Barriers to Mental Health Services Among Ethnic Minorities: A Qualitative Exploration”
• “Understanding Patient Satisfaction in Telemedicine Services: A Qualitative Study of User Experiences”
• “The Impact of Cultural Competence Training on Healthcare Provider-Patient Communication”
• “Navigating the Transition to Adult Healthcare Services: Experiences of Adolescents with Chronic Conditions”
• “Exploring the Use of Alternative Medicine Among Patients with Chronic Diseases: A Qualitative Inquiry”
• “The Role of Social Support in the Rehabilitation Process of Stroke Survivors”
• “Healthcare Decision-Making Among Elderly Patients: A Qualitative Study of Preferences and Influences”
• “Nurse Perceptions of Patient Safety Culture in Hospital Settings: A Qualitative Analysis”
• “Experiences of Women with Postpartum Depression: Barriers to Seeking Help”
• “The Impact of Nutrition Education on Eating Behaviors Among College Students: A Qualitative Approach”
• “Understanding Resilience in Survivors of Childhood Trauma: A Narrative Inquiry”
• “The Role of Mindfulness in Managing Work-Related Stress Among Corporate Employees: A Qualitative Study”
• “Coping Mechanisms Among Parents of Children with Autism Spectrum Disorder”
• “Exploring the Psychological Impact of Social Isolation in the Elderly: A Phenomenological Study”
• “Identity Formation in Adolescence: The Influence of Social Media and Peer Groups”
• “The Experience of Forgiveness in Interpersonal Relationships: A Qualitative Exploration”
• “Perceptions of Happiness and Well-Being Among University Students: A Cultural Perspective”
• “The Impact of Art Therapy on Anxiety and Depression in Adult Cancer Patients”
• “Narratives of Recovery: A Qualitative Study on the Journey Through Addiction Rehabilitation”
• “Exploring the Psychological Effects of Long-Term Unemployment: A Grounded Theory Approach”
• “Attachment Styles and Their Influence on Adult Romantic Relationships: A Qualitative Analysis”
• “The Role of Personal Values in Career Decision-Making Among Young Adults”
• “Understanding the Stigma of Mental Illness in Rural Communities: A Qualitative Inquiry”
• “Exploring the Use of Digital Mental Health Interventions Among Adolescents: A Qualitative Study”
• “The Psychological Impact of Climate Change on Young Adults: An Exploration of Anxiety and Action”
• “Navigating Identity: The Role of Social Media in Shaping Youth Culture and Self-Perception”
• “Community Resilience in the Face of Urban Gentrification: A Case Study of Neighborhood Change”
• “The Dynamics of Intergenerational Relationships in Immigrant Families: A Qualitative Analysis”
• “Social Capital and Economic Mobility in Low-Income Neighborhoods: An Ethnographic Approach”
• “Gender Roles and Career Aspirations Among Young Adults in Conservative Societies”
• “The Stigma of Mental Health in the Workplace: Employee Narratives and Organizational Culture”
• “Exploring the Intersection of Race, Class, and Education in Urban School Systems”
• “The Impact of Digital Divide on Access to Healthcare Information in Rural Communities”
• “Social Movements and Political Engagement Among Millennials: A Qualitative Study”
• “Cultural Adaptation and Identity Among Second-Generation Immigrants: A Phenomenological Inquiry”
• “The Role of Religious Institutions in Providing Community Support and Social Services”
• “Negotiating Public Space: Experiences of LGBTQ+ Individuals in Urban Environments”
• “The Sociology of Food: Exploring Eating Habits and Food Practices Across Cultures”
• “Work-Life Balance Challenges Among Dual-Career Couples: A Qualitative Exploration”
• “The Influence of Peer Networks on Substance Use Among Adolescents: A Community Study”

Business and Management

• “Navigating Organizational Change: Employee Perceptions and Adaptation Strategies in Mergers and Acquisitions”
• “Corporate Social Responsibility: Consumer Perceptions and Brand Loyalty in the Retail Sector”
• “Leadership Styles and Organizational Culture: A Comparative Study of Tech Startups”
• “Workplace Diversity and Inclusion: Best Practices and Challenges in Multinational Corporations”
• “Consumer Trust in E-commerce: A Qualitative Study of Online Shopping Behaviors”
• “The Gig Economy and Worker Satisfaction: Exploring the Experiences of Freelance Professionals”
• “Entrepreneurial Resilience: Success Stories and Lessons Learned from Failed Startups”
• “Employee Engagement and Productivity in Remote Work Settings: A Post-Pandemic Analysis”
• “Brand Storytelling: How Narrative Strategies Influence Consumer Engagement”
• “Sustainable Business Practices: Stakeholder Perspectives in the Fashion Industry”
• “Cross-Cultural Communication Challenges in Global Teams: Strategies for Effective Collaboration”
• “Innovative Workspaces: The Impact of Office Design on Creativity and Collaboration”
• “Consumer Perceptions of Artificial Intelligence in Customer Service: A Qualitative Exploration”
• “The Role of Mentoring in Career Development: Insights from Women in Leadership Positions”
• “Agile Management Practices: Adoption and Impact in Traditional Industries”

Environmental Studies

• “Community-Based Conservation Efforts in Tropical Rainforests: A Qualitative Study of Local Perspectives and Practices”
• “Urban Sustainability Initiatives: Exploring Resident Participation and Impact in Green City Projects”
• “Perceptions of Climate Change Among Indigenous Populations: Insights from Traditional Ecological Knowledge”
• “Environmental Justice and Industrial Pollution: A Case Study of Community Advocacy and Response”
• “The Role of Eco-Tourism in Promoting Conservation Awareness: Perspectives from Tour Operators and Visitors”
• “Sustainable Agriculture Practices Among Smallholder Farmers: Challenges and Opportunities”
• “Youth Engagement in Climate Action Movements: Motivations, Perceptions, and Outcomes”
• “Corporate Environmental Responsibility: A Qualitative Analysis of Stakeholder Expectations and Company Practices”
• “The Impact of Plastic Pollution on Marine Ecosystems: Community Awareness and Behavioral Change”
• “Renewable Energy Adoption in Rural Communities: Barriers, Facilitators, and Social Implications”
• “Water Scarcity and Community Adaptation Strategies in Arid Regions: A Grounded Theory Approach”
• “Urban Green Spaces: Public Perceptions and Use Patterns in Megacities”
• “Environmental Education in Schools: Teachers’ Perspectives on Integrating Sustainability into Curricula”
• “The Influence of Environmental Activism on Policy Change: Case Studies of Grassroots Campaigns”
• “Cultural Practices and Natural Resource Management: A Qualitative Study of Indigenous Stewardship Models”

Anthropology

• “Kinship and Social Organization in Matrilineal Societies: An Ethnographic Study”
• “Rituals and Beliefs Surrounding Death and Mourning in Diverse Cultures: A Comparative Analysis”
• “The Impact of Globalization on Indigenous Languages and Cultural Identity”
• “Food Sovereignty and Traditional Agricultural Practices Among Indigenous Communities”
• “Navigating Modernity: The Integration of Traditional Healing Practices in Contemporary Healthcare Systems”
• “Gender Roles and Equality in Hunter-Gatherer Societies: An Anthropological Perspective”
• “Sacred Spaces and Religious Practices: An Ethnographic Study of Pilgrimage Sites”
• “Youth Subcultures and Resistance: An Exploration of Identity and Expression in Urban Environments”
• “Cultural Constructions of Disability and Inclusion: A Cross-Cultural Analysis”
• “Interethnic Marriages and Cultural Syncretism: Case Studies from Multicultural Societies”
• “The Role of Folklore and Storytelling in Preserving Cultural Heritage”
• “Economic Anthropology of Gift-Giving and Reciprocity in Tribal Communities”
• “Digital Anthropology: The Role of Social Media in Shaping Political Movements”
• “Migration and Diaspora: Maintaining Cultural Identity in Transnational Communities”
• “Cultural Adaptations to Climate Change Among Coastal Fishing Communities”

Communication Studies

• “The Dynamics of Family Communication in the Digital Age: A Qualitative Inquiry”
• “Narratives of Identity and Belonging in Diaspora Communities Through Social Media”
• “Organizational Communication and Employee Engagement: A Case Study in the Non-Profit Sector”
• “Cultural Influences on Communication Styles in Multinational Teams: An Ethnographic Approach”
• “Media Representation of Women in Politics: A Content Analysis and Audience Perception Study”
• “The Role of Communication in Building Sustainable Community Development Projects”
• “Interpersonal Communication in Online Dating: Strategies, Challenges, and Outcomes”
• “Public Health Messaging During Pandemics: A Qualitative Study of Community Responses”
• “The Impact of Mobile Technology on Parent-Child Communication in the Digital Era”
• “Crisis Communication Strategies in the Hospitality Industry: A Case Study of Reputation Management”
• “Narrative Analysis of Personal Stories Shared on Mental Health Blogs”
• “The Influence of Podcasts on Political Engagement Among Young Adults”
• “Visual Communication and Brand Identity: A Qualitative Study of Consumer Interpretations”
• “Communication Barriers in Cross-Cultural Healthcare Settings: Patient and Provider Perspectives”
• “The Role of Internal Communication in Managing Organizational Change: Employee Experiences”

Information Technology

• “User Experience Design in Augmented Reality Applications: A Qualitative Study of Best Practices”
• “The Human Factor in Cybersecurity: Understanding Employee Behaviors and Attitudes Towards Phishing”
• “Adoption of Cloud Computing in Small and Medium Enterprises: Challenges and Success Factors”
• “Blockchain Technology in Supply Chain Management: A Qualitative Exploration of Potential Impacts”
• “The Role of Artificial Intelligence in Personalizing User Experiences on E-commerce Platforms”
• “Digital Transformation in Traditional Industries: A Case Study of Technology Adoption Challenges”
• “Ethical Considerations in the Development of Smart Home Technologies: A Stakeholder Analysis”
• “The Impact of Social Media Algorithms on News Consumption and Public Opinion”
• “Collaborative Software Development: Practices and Challenges in Open Source Projects”
• “Understanding the Digital Divide: Access to Information Technology in Rural Communities”
• “Data Privacy Concerns and User Trust in Internet of Things (IoT) Devices”
• “The Effectiveness of Gamification in Educational Software: A Qualitative Study of Engagement and Motivation”
• “Virtual Teams and Remote Work: Communication Strategies and Tools for Effectiveness”
• “User-Centered Design in Mobile Health Applications: Evaluating Usability and Accessibility”
• “The Influence of Technology on Work-Life Balance: Perspectives from IT Professionals”

Tourism and Hospitality

• “Exploring the Authenticity of Cultural Heritage Tourism in Indigenous Communities”
• “Sustainable Tourism Practices: Perceptions and Implementations in Small Island Destinations”
• “The Impact of Social Media Influencers on Destination Choice Among Millennials”
• “Gastronomy Tourism: Exploring the Culinary Experiences of International Visitors in Rural Regions”
• “Eco-Tourism and Conservation: Stakeholder Perspectives on Balancing Tourism and Environmental Protection”
• “The Role of Hospitality in Enhancing the Cultural Exchange Experience of Exchange Students”
• “Dark Tourism: Visitor Motivations and Experiences at Historical Conflict Sites”
• “Customer Satisfaction in Luxury Hotels: A Qualitative Study of Service Excellence and Personalization”
• “Adventure Tourism: Understanding the Risk Perception and Safety Measures Among Thrill-Seekers”
• “The Influence of Local Communities on Tourist Experiences in Ecotourism Sites”
• “Event Tourism: Economic Impacts and Community Perspectives on Large-Scale Music Festivals”
• “Heritage Tourism and Identity: Exploring the Connections Between Historic Sites and National Identity”
• “Tourist Perceptions of Sustainable Accommodation Practices: A Study of Green Hotels”
• “The Role of Language in Shaping the Tourist Experience in Multilingual Destinations”
• “Health and Wellness Tourism: Motivations and Experiences of Visitors to Spa and Retreat Centers”

Qualitative Research Topics

Qualitative Research Topics are as follows:

• Understanding the lived experiences of first-generation college students
• Exploring the impact of social media on self-esteem among adolescents
• Investigating the effects of mindfulness meditation on stress reduction
• Analyzing the perceptions of employees regarding organizational culture
• Examining the impact of parental involvement on academic achievement of elementary school students
• Investigating the role of music therapy in managing symptoms of depression
• Understanding the experience of women in male-dominated industries
• Exploring the factors that contribute to successful leadership in non-profit organizations
• Analyzing the effects of peer pressure on substance abuse among adolescents
• Investigating the experiences of individuals with disabilities in the workplace
• Understanding the factors that contribute to burnout among healthcare professionals
• Examining the impact of social support on mental health outcomes
• Analyzing the perceptions of parents regarding sex education in schools
• Investigating the experiences of immigrant families in the education system
• Understanding the impact of trauma on mental health outcomes
• Exploring the effectiveness of animal-assisted therapy for individuals with anxiety
• Analyzing the factors that contribute to successful intergenerational relationships
• Investigating the experiences of LGBTQ+ individuals in the workplace
• Understanding the impact of online gaming on social skills development among adolescents
• Examining the perceptions of teachers regarding technology integration in the classroom
• Analyzing the experiences of women in leadership positions
• Investigating the factors that contribute to successful marriage and long-term relationships
• Understanding the impact of social media on political participation
• Exploring the experiences of individuals with mental health disorders in the criminal justice system
• Analyzing the factors that contribute to successful community-based programs for youth development
• Investigating the experiences of veterans in accessing mental health services
• Understanding the impact of the COVID-19 pandemic on mental health outcomes
• Examining the perceptions of parents regarding childhood obesity prevention
• Analyzing the factors that contribute to successful multicultural education programs
• Investigating the experiences of individuals with chronic illnesses in the workplace
• Understanding the impact of poverty on academic achievement
• Exploring the experiences of individuals with autism spectrum disorder in the workplace
• Analyzing the factors that contribute to successful employee retention strategies
• Investigating the experiences of caregivers of individuals with Alzheimer’s disease
• Understanding the impact of parent-child communication on adolescent sexual behavior
• Examining the perceptions of college students regarding mental health services on campus
• Analyzing the factors that contribute to successful team building in the workplace
• Investigating the experiences of individuals with eating disorders in treatment programs
• Understanding the impact of mentorship on career success
• Exploring the experiences of individuals with physical disabilities in the workplace
• Analyzing the factors that contribute to successful community-based programs for mental health
• Investigating the experiences of individuals with substance use disorders in treatment programs
• Understanding the impact of social media on romantic relationships
• Examining the perceptions of parents regarding child discipline strategies
• Analyzing the factors that contribute to successful cross-cultural communication in the workplace
• Investigating the experiences of individuals with anxiety disorders in treatment programs
• Understanding the impact of cultural differences on healthcare delivery
• Exploring the experiences of individuals with hearing loss in the workplace
• Analyzing the factors that contribute to successful parent-teacher communication
• Investigating the experiences of individuals with depression in treatment programs
• Understanding the impact of childhood trauma on adult mental health outcomes
• Examining the perceptions of college students regarding alcohol and drug use on campus
• Analyzing the factors that contribute to successful mentor-mentee relationships
• Investigating the experiences of individuals with intellectual disabilities in the workplace
• Understanding the impact of work-family balance on employee satisfaction and well-being
• Exploring the experiences of individuals with autism spectrum disorder in vocational rehabilitation programs
• Analyzing the factors that contribute to successful project management in the construction industry
• Investigating the experiences of individuals with substance use disorders in peer support groups
• Understanding the impact of mindfulness meditation on stress reduction and mental health
• Examining the perceptions of parents regarding childhood nutrition
• Analyzing the factors that contribute to successful environmental sustainability initiatives in organizations
• Investigating the experiences of individuals with bipolar disorder in treatment programs
• Understanding the impact of job stress on employee burnout and turnover
• Exploring the experiences of individuals with physical disabilities in recreational activities
• Analyzing the factors that contribute to successful strategic planning in nonprofit organizations
• Investigating the experiences of individuals with hoarding disorder in treatment programs
• Understanding the impact of culture on leadership styles and effectiveness
• Examining the perceptions of college students regarding sexual health education on campus
• Analyzing the factors that contribute to successful supply chain management in the retail industry
• Investigating the experiences of individuals with personality disorders in treatment programs
• Understanding the impact of multiculturalism on group dynamics in the workplace
• Exploring the experiences of individuals with chronic pain in mindfulness-based pain management programs
• Analyzing the factors that contribute to successful employee engagement strategies in organizations
• Investigating the experiences of individuals with internet addiction disorder in treatment programs
• Understanding the impact of social comparison on body dissatisfaction and self-esteem
• Examining the perceptions of parents regarding childhood sleep habits
• Analyzing the factors that contribute to successful diversity and inclusion initiatives in organizations
• Investigating the experiences of individuals with schizophrenia in treatment programs
• Understanding the impact of job crafting on employee motivation and job satisfaction
• Exploring the experiences of individuals with vision impairments in navigating public spaces
• Analyzing the factors that contribute to successful customer relationship management strategies in the service industry
• Investigating the experiences of individuals with dissociative amnesia in treatment programs
• Understanding the impact of cultural intelligence on intercultural communication and collaboration
• Examining the perceptions of college students regarding campus diversity and inclusion efforts
• Analyzing the factors that contribute to successful supply chain sustainability initiatives in organizations
• Investigating the experiences of individuals with obsessive-compulsive disorder in treatment programs
• Understanding the impact of transformational leadership on organizational performance and employee well-being
• Exploring the experiences of individuals with mobility impairments in public transportation
• Analyzing the factors that contribute to successful talent management strategies in organizations
• Investigating the experiences of individuals with substance use disorders in harm reduction programs
• Understanding the impact of gratitude practices on well-being and resilience
• Examining the perceptions of parents regarding childhood mental health and well-being
• Analyzing the factors that contribute to successful corporate social responsibility initiatives in organizations
• Investigating the experiences of individuals with borderline personality disorder in treatment programs
• Understanding the impact of emotional labor on job stress and burnout
• Exploring the experiences of individuals with hearing impairments in healthcare settings
• Analyzing the factors that contribute to successful customer experience strategies in the hospitality industry
• Investigating the experiences of individuals with gender dysphoria in gender-affirming healthcare
• Understanding the impact of cultural differences on cross-cultural negotiation in the global marketplace
• Examining the perceptions of college students regarding academic stress and mental health
• Analyzing the factors that contribute to successful supply chain agility in organizations
• Understanding the impact of music therapy on mental health and well-being
• Exploring the experiences of individuals with dyslexia in educational settings
• Analyzing the factors that contribute to successful leadership in nonprofit organizations
• Investigating the experiences of individuals with chronic illnesses in online support groups
• Understanding the impact of exercise on mental health and well-being
• Examining the perceptions of parents regarding childhood screen time
• Analyzing the factors that contribute to successful change management strategies in organizations
• Understanding the impact of cultural differences on international business negotiations
• Exploring the experiences of individuals with hearing impairments in the workplace
• Analyzing the factors that contribute to successful team building in corporate settings
• Understanding the impact of technology on communication in romantic relationships
• Analyzing the factors that contribute to successful community engagement strategies for local governments
• Investigating the experiences of individuals with attention deficit hyperactivity disorder (ADHD) in treatment programs
• Understanding the impact of financial stress on mental health and well-being
• Analyzing the factors that contribute to successful mentorship programs in organizations
• Investigating the experiences of individuals with gambling addictions in treatment programs
• Understanding the impact of social media on body image and self-esteem
• Examining the perceptions of parents regarding childhood education
• Analyzing the factors that contribute to successful virtual team management strategies
• Investigating the experiences of individuals with dissociative identity disorder in treatment programs
• Understanding the impact of cultural differences on cross-cultural communication in healthcare settings
• Exploring the experiences of individuals with chronic pain in cognitive-behavioral therapy programs
• Analyzing the factors that contribute to successful community-building strategies in urban neighborhoods
• Investigating the experiences of individuals with alcohol use disorders in treatment programs
• Understanding the impact of personality traits on romantic relationships
• Examining the perceptions of college students regarding mental health stigma on campus
• Analyzing the factors that contribute to successful fundraising strategies for political campaigns
• Investigating the experiences of individuals with traumatic brain injuries in rehabilitation programs
• Understanding the impact of social support on mental health and well-being among the elderly
• Exploring the experiences of individuals with chronic illnesses in medical treatment decision-making processes
• Analyzing the factors that contribute to successful innovation strategies in organizations
• Investigating the experiences of individuals with dissociative disorders in treatment programs
• Understanding the impact of cultural differences on cross-cultural communication in education settings
• Examining the perceptions of parents regarding childhood physical activity
• Analyzing the factors that contribute to successful conflict resolution in family relationships
• Investigating the experiences of individuals with opioid use disorders in treatment programs
• Understanding the impact of emotional intelligence on leadership effectiveness
• Exploring the experiences of individuals with learning disabilities in the workplace
• Analyzing the factors that contribute to successful change management in educational institutions
• Investigating the experiences of individuals with eating disorders in recovery support groups
• Understanding the impact of self-compassion on mental health and well-being
• Examining the perceptions of college students regarding campus safety and security measures
• Analyzing the factors that contribute to successful marketing strategies for nonprofit organizations
• Investigating the experiences of individuals with postpartum depression in treatment programs
• Understanding the impact of ageism in the workplace
• Exploring the experiences of individuals with dyslexia in the education system
• Investigating the experiences of individuals with anxiety disorders in cognitive-behavioral therapy programs
• Understanding the impact of socioeconomic status on access to healthcare
• Examining the perceptions of parents regarding childhood screen time usage
• Analyzing the factors that contribute to successful supply chain management strategies
• Understanding the impact of parenting styles on child development
• Exploring the experiences of individuals with addiction in harm reduction programs
• Analyzing the factors that contribute to successful crisis management strategies in organizations
• Investigating the experiences of individuals with trauma in trauma-focused therapy programs
• Examining the perceptions of healthcare providers regarding patient-centered care
• Analyzing the factors that contribute to successful product development strategies
• Investigating the experiences of individuals with autism spectrum disorder in employment programs
• Understanding the impact of cultural competence on healthcare outcomes
• Exploring the experiences of individuals with chronic illnesses in healthcare navigation
• Analyzing the factors that contribute to successful community engagement strategies for non-profit organizations
• Investigating the experiences of individuals with physical disabilities in the workplace
• Understanding the impact of childhood trauma on adult mental health
• Analyzing the factors that contribute to successful supply chain sustainability strategies
• Investigating the experiences of individuals with personality disorders in dialectical behavior therapy programs
• Understanding the impact of gender identity on mental health treatment seeking behaviors
• Exploring the experiences of individuals with schizophrenia in community-based treatment programs
• Analyzing the factors that contribute to successful project team management strategies
• Investigating the experiences of individuals with obsessive-compulsive disorder in exposure and response prevention therapy programs
• Understanding the impact of cultural competence on academic achievement and success
• Examining the perceptions of college students regarding academic integrity
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• Open access
• Published: 27 May 2020

How to use and assess qualitative research methods

• Loraine Busetto   ORCID: orcid.org/0000-0002-9228-7875 1 ,
• Wolfgang Wick 1 , 2 &
• Christoph Gumbinger 1  

Neurological Research and Practice volume  2 , Article number:  14 ( 2020 ) Cite this article

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This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 , 8 , 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

From data collection to data analysis

Attributions for icons: see Fig. 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 , 32 , 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Availability of data and materials

Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

Philipsen, H., & Vernooij-Dassen, M. (2007). Kwalitatief onderzoek: nuttig, onmisbaar en uitdagend. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Qualitative research: useful, indispensable and challenging. In: Qualitative research: Practical methods for medical practice (pp. 5–12). Houten: Bohn Stafleu van Loghum.

Chapter   Google Scholar  

Punch, K. F. (2013). Introduction to social research: Quantitative and qualitative approaches . London: Sage.

Kelly, J., Dwyer, J., Willis, E., & Pekarsky, B. (2014). Travelling to the city for hospital care: Access factors in country aboriginal patient journeys. Australian Journal of Rural Health, 22 (3), 109–113.

Article   Google Scholar  

Nilsen, P., Ståhl, C., Roback, K., & Cairney, P. (2013). Never the twain shall meet? - a comparison of implementation science and policy implementation research. Implementation Science, 8 (1), 1–12.

Howick J, Chalmers I, Glasziou, P., Greenhalgh, T., Heneghan, C., Liberati, A., Moschetti, I., Phillips, B., & Thornton, H. (2011). The 2011 Oxford CEBM evidence levels of evidence (introductory document) . Oxford Center for Evidence Based Medicine. https://www.cebm.net/2011/06/2011-oxford-cebm-levels-evidence-introductory-document/ .

Eakin, J. M. (2016). Educating critical qualitative health researchers in the land of the randomized controlled trial. Qualitative Inquiry, 22 (2), 107–118.

May, A., & Mathijssen, J. (2015). Alternatieven voor RCT bij de evaluatie van effectiviteit van interventies!? Eindrapportage. In Alternatives for RCTs in the evaluation of effectiveness of interventions!? Final report .

Google Scholar  

Berwick, D. M. (2008). The science of improvement. Journal of the American Medical Association, 299 (10), 1182–1184.

Article   CAS   Google Scholar  

Christ, T. W. (2014). Scientific-based research and randomized controlled trials, the “gold” standard? Alternative paradigms and mixed methodologies. Qualitative Inquiry, 20 (1), 72–80.

Lamont, T., Barber, N., Jd, P., Fulop, N., Garfield-Birkbeck, S., Lilford, R., Mear, L., Raine, R., & Fitzpatrick, R. (2016). New approaches to evaluating complex health and care systems. BMJ, 352:i154.

Drabble, S. J., & O’Cathain, A. (2015). Moving from Randomized Controlled Trials to Mixed Methods Intervention Evaluation. In S. Hesse-Biber & R. B. Johnson (Eds.), The Oxford Handbook of Multimethod and Mixed Methods Research Inquiry (pp. 406–425). London: Oxford University Press.

Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013). The dynamic sustainability framework: Addressing the paradox of sustainment amid ongoing change. Implementation Science : IS, 8 , 117.

Hak, T. (2007). Waarnemingsmethoden in kwalitatief onderzoek. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Observation methods in qualitative research] (pp. 13–25). Houten: Bohn Stafleu van Loghum.

Russell, C. K., & Gregory, D. M. (2003). Evaluation of qualitative research studies. Evidence Based Nursing, 6 (2), 36–40.

Fossey, E., Harvey, C., McDermott, F., & Davidson, L. (2002). Understanding and evaluating qualitative research. Australian and New Zealand Journal of Psychiatry, 36 , 717–732.

Yanow, D. (2000). Conducting interpretive policy analysis (Vol. 47). Thousand Oaks: Sage University Papers Series on Qualitative Research Methods.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22 , 63–75.

van der Geest, S. (2006). Participeren in ziekte en zorg: meer over kwalitatief onderzoek. Huisarts en Wetenschap, 49 (4), 283–287.

Hijmans, E., & Kuyper, M. (2007). Het halfopen interview als onderzoeksmethode. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [The half-open interview as research method (pp. 43–51). Houten: Bohn Stafleu van Loghum.

Jansen, H. (2007). Systematiek en toepassing van de kwalitatieve survey. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Systematics and implementation of the qualitative survey (pp. 27–41). Houten: Bohn Stafleu van Loghum.

Pv, R., & Peremans, L. (2007). Exploreren met focusgroepgesprekken: de ‘stem’ van de groep onder de loep. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Exploring with focus group conversations: the “voice” of the group under the magnifying glass (pp. 53–64). Houten: Bohn Stafleu van Loghum.

Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of triangulation in qualitative research. Oncology Nursing Forum, 41 (5), 545–547.

Boeije H: Analyseren in kwalitatief onderzoek: Denken en doen, [Analysis in qualitative research: Thinking and doing] vol. Den Haag Boom Lemma uitgevers; 2012.

Hunter, A., & Brewer, J. (2015). Designing Multimethod Research. In S. Hesse-Biber & R. B. Johnson (Eds.), The Oxford Handbook of Multimethod and Mixed Methods Research Inquiry (pp. 185–205). London: Oxford University Press.

Archibald, M. M., Radil, A. I., Zhang, X., & Hanson, W. E. (2015). Current mixed methods practices in qualitative research: A content analysis of leading journals. International Journal of Qualitative Methods, 14 (2), 5–33.

Creswell, J. W., & Plano Clark, V. L. (2011). Choosing a Mixed Methods Design. In Designing and Conducting Mixed Methods Research . Thousand Oaks: SAGE Publications.

Mays, N., & Pope, C. (2000). Assessing quality in qualitative research. BMJ, 320 (7226), 50–52.

O'Brien, B. C., Harris, I. B., Beckman, T. J., Reed, D. A., & Cook, D. A. (2014). Standards for reporting qualitative research: A synthesis of recommendations. Academic Medicine : Journal of the Association of American Medical Colleges, 89 (9), 1245–1251.

Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., & Jinks, C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality and Quantity, 52 (4), 1893–1907.

Moser, A., & Korstjens, I. (2018). Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. European Journal of General Practice, 24 (1), 9–18.

Marlett, N., Shklarov, S., Marshall, D., Santana, M. J., & Wasylak, T. (2015). Building new roles and relationships in research: A model of patient engagement research. Quality of Life Research : an international journal of quality of life aspects of treatment, care and rehabilitation, 24 (5), 1057–1067.

Demian, M. N., Lam, N. N., Mac-Way, F., Sapir-Pichhadze, R., & Fernandez, N. (2017). Opportunities for engaging patients in kidney research. Canadian Journal of Kidney Health and Disease, 4 , 2054358117703070–2054358117703070.

Noyes, J., McLaughlin, L., Morgan, K., Roberts, A., Stephens, M., Bourne, J., Houlston, M., Houlston, J., Thomas, S., Rhys, R. G., et al. (2019). Designing a co-productive study to overcome known methodological challenges in organ donation research with bereaved family members. Health Expectations . 22(4):824–35.

Piil, K., Jarden, M., & Pii, K. H. (2019). Research agenda for life-threatening cancer. European Journal Cancer Care (Engl), 28 (1), e12935.

Hofmann, D., Ibrahim, F., Rose, D., Scott, D. L., Cope, A., Wykes, T., & Lempp, H. (2015). Expectations of new treatment in rheumatoid arthritis: Developing a patient-generated questionnaire. Health Expectations : an international journal of public participation in health care and health policy, 18 (5), 995–1008.

Jun, M., Manns, B., Laupacis, A., Manns, L., Rehal, B., Crowe, S., & Hemmelgarn, B. R. (2015). Assessing the extent to which current clinical research is consistent with patient priorities: A scoping review using a case study in patients on or nearing dialysis. Canadian Journal of Kidney Health and Disease, 2 , 35.

Elsie Baker, S., & Edwards, R. (2012). How many qualitative interviews is enough? In National Centre for Research Methods Review Paper . National Centre for Research Methods. http://eprints.ncrm.ac.uk/2273/4/how_many_interviews.pdf .

Sandelowski, M. (1995). Sample size in qualitative research. Research in Nursing & Health, 18 (2), 179–183.

Sim, J., Saunders, B., Waterfield, J., & Kingstone, T. (2018). Can sample size in qualitative research be determined a priori? International Journal of Social Research Methodology, 21 (5), 619–634.

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Loraine Busetto, Wolfgang Wick & Christoph Gumbinger

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Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z

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Chapter 1. Introduction

“Science is in danger, and for that reason it is becoming dangerous” -Pierre Bourdieu, Science of Science and Reflexivity

Why an Open Access Textbook on Qualitative Research Methods?

I have been teaching qualitative research methods to both undergraduates and graduate students for many years.  Although there are some excellent textbooks out there, they are often costly, and none of them, to my mind, properly introduces qualitative research methods to the beginning student (whether undergraduate or graduate student).  In contrast, this open-access textbook is designed as a (free) true introduction to the subject, with helpful, practical pointers on how to conduct research and how to access more advanced instruction.  

Textbooks are typically arranged in one of two ways: (1) by technique (each chapter covers one method used in qualitative research); or (2) by process (chapters advance from research design through publication).  But both of these approaches are necessary for the beginner student.  This textbook will have sections dedicated to the process as well as the techniques of qualitative research.  This is a true “comprehensive” book for the beginning student.  In addition to covering techniques of data collection and data analysis, it provides a road map of how to get started and how to keep going and where to go for advanced instruction.  It covers aspects of research design and research communication as well as methods employed.  Along the way, it includes examples from many different disciplines in the social sciences.

The primary goal has been to create a useful, accessible, engaging textbook for use across many disciplines.  And, let’s face it.  Textbooks can be boring.  I hope readers find this to be a little different.  I have tried to write in a practical and forthright manner, with many lively examples and references to good and intellectually creative qualitative research.  Woven throughout the text are short textual asides (in colored textboxes) by professional (academic) qualitative researchers in various disciplines.  These short accounts by practitioners should help inspire students.  So, let’s begin!

What is Research?

When we use the word research , what exactly do we mean by that?  This is one of those words that everyone thinks they understand, but it is worth beginning this textbook with a short explanation.  We use the term to refer to “empirical research,” which is actually a historically specific approach to understanding the world around us.  Think about how you know things about the world. [1] You might know your mother loves you because she’s told you she does.  Or because that is what “mothers” do by tradition.  Or you might know because you’ve looked for evidence that she does, like taking care of you when you are sick or reading to you in bed or working two jobs so you can have the things you need to do OK in life.  Maybe it seems churlish to look for evidence; you just take it “on faith” that you are loved.

Only one of the above comes close to what we mean by research.  Empirical research is research (investigation) based on evidence.  Conclusions can then be drawn from observable data.  This observable data can also be “tested” or checked.  If the data cannot be tested, that is a good indication that we are not doing research.  Note that we can never “prove” conclusively, through observable data, that our mothers love us.  We might have some “disconfirming evidence” (that time she didn’t show up to your graduation, for example) that could push you to question an original hypothesis , but no amount of “confirming evidence” will ever allow us to say with 100% certainty, “my mother loves me.”  Faith and tradition and authority work differently.  Our knowledge can be 100% certain using each of those alternative methods of knowledge, but our certainty in those cases will not be based on facts or evidence.

For many periods of history, those in power have been nervous about “science” because it uses evidence and facts as the primary source of understanding the world, and facts can be at odds with what power or authority or tradition want you to believe.  That is why I say that scientific empirical research is a historically specific approach to understand the world.  You are in college or university now partly to learn how to engage in this historically specific approach.

In the sixteenth and seventeenth centuries in Europe, there was a newfound respect for empirical research, some of which was seriously challenging to the established church.  Using observations and testing them, scientists found that the earth was not at the center of the universe, for example, but rather that it was but one planet of many which circled the sun. [2]   For the next two centuries, the science of astronomy, physics, biology, and chemistry emerged and became disciplines taught in universities.  All used the scientific method of observation and testing to advance knowledge.  Knowledge about people , however, and social institutions, however, was still left to faith, tradition, and authority.  Historians and philosophers and poets wrote about the human condition, but none of them used research to do so. [3]

It was not until the nineteenth century that “social science” really emerged, using the scientific method (empirical observation) to understand people and social institutions.  New fields of sociology, economics, political science, and anthropology emerged.  The first sociologists, people like Auguste Comte and Karl Marx, sought specifically to apply the scientific method of research to understand society, Engels famously claiming that Marx had done for the social world what Darwin did for the natural world, tracings its laws of development.  Today we tend to take for granted the naturalness of science here, but it is actually a pretty recent and radical development.

To return to the question, “does your mother love you?”  Well, this is actually not really how a researcher would frame the question, as it is too specific to your case.  It doesn’t tell us much about the world at large, even if it does tell us something about you and your relationship with your mother.  A social science researcher might ask, “do mothers love their children?”  Or maybe they would be more interested in how this loving relationship might change over time (e.g., “do mothers love their children more now than they did in the 18th century when so many children died before reaching adulthood?”) or perhaps they might be interested in measuring quality of love across cultures or time periods, or even establishing “what love looks like” using the mother/child relationship as a site of exploration.  All of these make good research questions because we can use observable data to answer them.

What is Qualitative Research?

“All we know is how to learn. How to study, how to listen, how to talk, how to tell.  If we don’t tell the world, we don’t know the world.  We’re lost in it, we die.” -Ursula LeGuin, The Telling

At its simplest, qualitative research is research about the social world that does not use numbers in its analyses.  All those who fear statistics can breathe a sigh of relief – there are no mathematical formulae or regression models in this book! But this definition is less about what qualitative research can be and more about what it is not.  To be honest, any simple statement will fail to capture the power and depth of qualitative research.  One way of contrasting qualitative research to quantitative research is to note that the focus of qualitative research is less about explaining and predicting relationships between variables and more about understanding the social world.  To use our mother love example, the question about “what love looks like” is a good question for the qualitative researcher while all questions measuring love or comparing incidences of love (both of which require measurement) are good questions for quantitative researchers. Patton writes,

Qualitative data describe.  They take us, as readers, into the time and place of the observation so that we know what it was like to have been there.  They capture and communicate someone else’s experience of the world in his or her own words.  Qualitative data tell a story. ( Patton 2002:47 )

Qualitative researchers are asking different questions about the world than their quantitative colleagues.  Even when researchers are employed in “mixed methods” research ( both quantitative and qualitative), they are using different methods to address different questions of the study.  I do a lot of research about first-generation and working-college college students.  Where a quantitative researcher might ask, how many first-generation college students graduate from college within four years? Or does first-generation college status predict high student debt loads?  A qualitative researcher might ask, how does the college experience differ for first-generation college students?  What is it like to carry a lot of debt, and how does this impact the ability to complete college on time?  Both sets of questions are important, but they can only be answered using specific tools tailored to those questions.  For the former, you need large numbers to make adequate comparisons.  For the latter, you need to talk to people, find out what they are thinking and feeling, and try to inhabit their shoes for a little while so you can make sense of their experiences and beliefs.

Examples of Qualitative Research

You have probably seen examples of qualitative research before, but you might not have paid particular attention to how they were produced or realized that the accounts you were reading were the result of hours, months, even years of research “in the field.”  A good qualitative researcher will present the product of their hours of work in such a way that it seems natural, even obvious, to the reader.  Because we are trying to convey what it is like answers, qualitative research is often presented as stories – stories about how people live their lives, go to work, raise their children, interact with one another.  In some ways, this can seem like reading particularly insightful novels.  But, unlike novels, there are very specific rules and guidelines that qualitative researchers follow to ensure that the “story” they are telling is accurate , a truthful rendition of what life is like for the people being studied.  Most of this textbook will be spent conveying those rules and guidelines.  Let’s take a look, first, however, at three examples of what the end product looks like.  I have chosen these three examples to showcase very different approaches to qualitative research, and I will return to these five examples throughout the book.  They were all published as whole books (not chapters or articles), and they are worth the long read, if you have the time.  I will also provide some information on how these books came to be and the length of time it takes to get them into book version.  It is important you know about this process, and the rest of this textbook will help explain why it takes so long to conduct good qualitative research!

Example 1 : The End Game (ethnography + interviews)

Corey Abramson is a sociologist who teaches at the University of Arizona.   In 2015 he published The End Game: How Inequality Shapes our Final Years ( 2015 ). This book was based on the research he did for his dissertation at the University of California-Berkeley in 2012.  Actually, the dissertation was completed in 2012 but the work that was produced that took several years.  The dissertation was entitled, “This is How We Live, This is How We Die: Social Stratification, Aging, and Health in Urban America” ( 2012 ).  You can see how the book version, which was written for a more general audience, has a more engaging sound to it, but that the dissertation version, which is what academic faculty read and evaluate, has a more descriptive title.  You can read the title and know that this is a study about aging and health and that the focus is going to be inequality and that the context (place) is going to be “urban America.”  It’s a study about “how” people do something – in this case, how they deal with aging and death.  This is the very first sentence of the dissertation, “From our first breath in the hospital to the day we die, we live in a society characterized by unequal opportunities for maintaining health and taking care of ourselves when ill.  These disparities reflect persistent racial, socio-economic, and gender-based inequalities and contribute to their persistence over time” ( 1 ).  What follows is a truthful account of how that is so.

Cory Abramson spent three years conducting his research in four different urban neighborhoods.  We call the type of research he conducted “comparative ethnographic” because he designed his study to compare groups of seniors as they went about their everyday business.  It’s comparative because he is comparing different groups (based on race, class, gender) and ethnographic because he is studying the culture/way of life of a group. [4]   He had an educated guess, rooted in what previous research had shown and what social theory would suggest, that people’s experiences of aging differ by race, class, and gender.  So, he set up a research design that would allow him to observe differences.  He chose two primarily middle-class (one was racially diverse and the other was predominantly White) and two primarily poor neighborhoods (one was racially diverse and the other was predominantly African American).  He hung out in senior centers and other places seniors congregated, watched them as they took the bus to get prescriptions filled, sat in doctor’s offices with them, and listened to their conversations with each other.  He also conducted more formal conversations, what we call in-depth interviews, with sixty seniors from each of the four neighborhoods.  As with a lot of fieldwork , as he got closer to the people involved, he both expanded and deepened his reach –

By the end of the project, I expanded my pool of general observations to include various settings frequented by seniors: apartment building common rooms, doctors’ offices, emergency rooms, pharmacies, senior centers, bars, parks, corner stores, shopping centers, pool halls, hair salons, coffee shops, and discount stores. Over the course of the three years of fieldwork, I observed hundreds of elders, and developed close relationships with a number of them. ( 2012:10 )

When Abramson rewrote the dissertation for a general audience and published his book in 2015, it got a lot of attention.  It is a beautifully written book and it provided insight into a common human experience that we surprisingly know very little about.  It won the Outstanding Publication Award by the American Sociological Association Section on Aging and the Life Course and was featured in the New York Times .  The book was about aging, and specifically how inequality shapes the aging process, but it was also about much more than that.  It helped show how inequality affects people’s everyday lives.  For example, by observing the difficulties the poor had in setting up appointments and getting to them using public transportation and then being made to wait to see a doctor, sometimes in standing-room-only situations, when they are unwell, and then being treated dismissively by hospital staff, Abramson allowed readers to feel the material reality of being poor in the US.  Comparing these examples with seniors with adequate supplemental insurance who have the resources to hire car services or have others assist them in arranging care when they need it, jolts the reader to understand and appreciate the difference money makes in the lives and circumstances of us all, and in a way that is different than simply reading a statistic (“80% of the poor do not keep regular doctor’s appointments”) does.  Qualitative research can reach into spaces and places that often go unexamined and then reports back to the rest of us what it is like in those spaces and places.

Example 2: Racing for Innocence (Interviews + Content Analysis + Fictional Stories)

Jennifer Pierce is a Professor of American Studies at the University of Minnesota.  Trained as a sociologist, she has written a number of books about gender, race, and power.  Her very first book, Gender Trials: Emotional Lives in Contemporary Law Firms, published in 1995, is a brilliant look at gender dynamics within two law firms.  Pierce was a participant observer, working as a paralegal, and she observed how female lawyers and female paralegals struggled to obtain parity with their male colleagues.

Fifteen years later, she reexamined the context of the law firm to include an examination of racial dynamics, particularly how elite white men working in these spaces created and maintained a culture that made it difficult for both female attorneys and attorneys of color to thrive. Her book, Racing for Innocence: Whiteness, Gender, and the Backlash Against Affirmative Action , published in 2012, is an interesting and creative blending of interviews with attorneys, content analyses of popular films during this period, and fictional accounts of racial discrimination and sexual harassment.  The law firm she chose to study had come under an affirmative action order and was in the process of implementing equitable policies and programs.  She wanted to understand how recipients of white privilege (the elite white male attorneys) come to deny the role they play in reproducing inequality.  Through interviews with attorneys who were present both before and during the affirmative action order, she creates a historical record of the “bad behavior” that necessitated new policies and procedures, but also, and more importantly , probed the participants ’ understanding of this behavior.  It should come as no surprise that most (but not all) of the white male attorneys saw little need for change, and that almost everyone else had accounts that were different if not sometimes downright harrowing.

I’ve used Pierce’s book in my qualitative research methods courses as an example of an interesting blend of techniques and presentation styles.  My students often have a very difficult time with the fictional accounts she includes.  But they serve an important communicative purpose here.  They are her attempts at presenting “both sides” to an objective reality – something happens (Pierce writes this something so it is very clear what it is), and the two participants to the thing that happened have very different understandings of what this means.  By including these stories, Pierce presents one of her key findings – people remember things differently and these different memories tend to support their own ideological positions.  I wonder what Pierce would have written had she studied the murder of George Floyd or the storming of the US Capitol on January 6 or any number of other historic events whose observers and participants record very different happenings.

This is not to say that qualitative researchers write fictional accounts.  In fact, the use of fiction in our work remains controversial.  When used, it must be clearly identified as a presentation device, as Pierce did.  I include Racing for Innocence here as an example of the multiple uses of methods and techniques and the way that these work together to produce better understandings by us, the readers, of what Pierce studied.  We readers come away with a better grasp of how and why advantaged people understate their own involvement in situations and structures that advantage them.  This is normal human behavior , in other words.  This case may have been about elite white men in law firms, but the general insights here can be transposed to other settings.  Indeed, Pierce argues that more research needs to be done about the role elites play in the reproduction of inequality in the workplace in general.

Example 3: Amplified Advantage (Mixed Methods: Survey Interviews + Focus Groups + Archives)

The final example comes from my own work with college students, particularly the ways in which class background affects the experience of college and outcomes for graduates.  I include it here as an example of mixed methods, and for the use of supplementary archival research.  I’ve done a lot of research over the years on first-generation, low-income, and working-class college students.  I am curious (and skeptical) about the possibility of social mobility today, particularly with the rising cost of college and growing inequality in general.  As one of the few people in my family to go to college, I didn’t grow up with a lot of examples of what college was like or how to make the most of it.  And when I entered graduate school, I realized with dismay that there were very few people like me there.  I worried about becoming too different from my family and friends back home.  And I wasn’t at all sure that I would ever be able to pay back the huge load of debt I was taking on.  And so I wrote my dissertation and first two books about working-class college students.  These books focused on experiences in college and the difficulties of navigating between family and school ( Hurst 2010a, 2012 ).  But even after all that research, I kept coming back to wondering if working-class students who made it through college had an equal chance at finding good jobs and happy lives,

What happens to students after college?  Do working-class students fare as well as their peers?  I knew from my own experience that barriers continued through graduate school and beyond, and that my debtload was higher than that of my peers, constraining some of the choices I made when I graduated.  To answer these questions, I designed a study of students attending small liberal arts colleges, the type of college that tried to equalize the experience of students by requiring all students to live on campus and offering small classes with lots of interaction with faculty.  These private colleges tend to have more money and resources so they can provide financial aid to low-income students.  They also attract some very wealthy students.  Because they enroll students across the class spectrum, I would be able to draw comparisons.  I ended up spending about four years collecting data, both a survey of more than 2000 students (which formed the basis for quantitative analyses) and qualitative data collection (interviews, focus groups, archival research, and participant observation).  This is what we call a “mixed methods” approach because we use both quantitative and qualitative data.  The survey gave me a large enough number of students that I could make comparisons of the how many kind, and to be able to say with some authority that there were in fact significant differences in experience and outcome by class (e.g., wealthier students earned more money and had little debt; working-class students often found jobs that were not in their chosen careers and were very affected by debt, upper-middle-class students were more likely to go to graduate school).  But the survey analyses could not explain why these differences existed.  For that, I needed to talk to people and ask them about their motivations and aspirations.  I needed to understand their perceptions of the world, and it is very hard to do this through a survey.

By interviewing students and recent graduates, I was able to discern particular patterns and pathways through college and beyond.  Specifically, I identified three versions of gameplay.  Upper-middle-class students, whose parents were themselves professionals (academics, lawyers, managers of non-profits), saw college as the first stage of their education and took classes and declared majors that would prepare them for graduate school.  They also spent a lot of time building their resumes, taking advantage of opportunities to help professors with their research, or study abroad.  This helped them gain admission to highly-ranked graduate schools and interesting jobs in the public sector.  In contrast, upper-class students, whose parents were wealthy and more likely to be engaged in business (as CEOs or other high-level directors), prioritized building social capital.  They did this by joining fraternities and sororities and playing club sports.  This helped them when they graduated as they called on friends and parents of friends to find them well-paying jobs.  Finally, low-income, first-generation, and working-class students were often adrift.  They took the classes that were recommended to them but without the knowledge of how to connect them to life beyond college.  They spent time working and studying rather than partying or building their resumes.  All three sets of students thought they were “doing college” the right way, the way that one was supposed to do college.   But these three versions of gameplay led to distinct outcomes that advantaged some students over others.  I titled my work “Amplified Advantage” to highlight this process.

These three examples, Cory Abramson’s The End Game , Jennifer Peirce’s Racing for Innocence, and my own Amplified Advantage, demonstrate the range of approaches and tools available to the qualitative researcher.  They also help explain why qualitative research is so important.  Numbers can tell us some things about the world, but they cannot get at the hearts and minds, motivations and beliefs of the people who make up the social worlds we inhabit.  For that, we need tools that allow us to listen and make sense of what people tell us and show us.  That is what good qualitative research offers us.

How Is This Book Organized?

This textbook is organized as a comprehensive introduction to the use of qualitative research methods.  The first half covers general topics (e.g., approaches to qualitative research, ethics) and research design (necessary steps for building a successful qualitative research study).  The second half reviews various data collection and data analysis techniques.  Of course, building a successful qualitative research study requires some knowledge of data collection and data analysis so the chapters in the first half and the chapters in the second half should be read in conversation with each other.  That said, each chapter can be read on its own for assistance with a particular narrow topic.  In addition to the chapters, a helpful glossary can be found in the back of the book.  Rummage around in the text as needed.

Chapter Descriptions

Chapter 2 provides an overview of the Research Design Process.  How does one begin a study? What is an appropriate research question?  How is the study to be done – with what methods ?  Involving what people and sites?  Although qualitative research studies can and often do change and develop over the course of data collection, it is important to have a good idea of what the aims and goals of your study are at the outset and a good plan of how to achieve those aims and goals.  Chapter 2 provides a road map of the process.

Chapter 3 describes and explains various ways of knowing the (social) world.  What is it possible for us to know about how other people think or why they behave the way they do?  What does it mean to say something is a “fact” or that it is “well-known” and understood?  Qualitative researchers are particularly interested in these questions because of the types of research questions we are interested in answering (the how questions rather than the how many questions of quantitative research).  Qualitative researchers have adopted various epistemological approaches.  Chapter 3 will explore these approaches, highlighting interpretivist approaches that acknowledge the subjective aspect of reality – in other words, reality and knowledge are not objective but rather influenced by (interpreted through) people.

Chapter 4 focuses on the practical matter of developing a research question and finding the right approach to data collection.  In any given study (think of Cory Abramson’s study of aging, for example), there may be years of collected data, thousands of observations , hundreds of pages of notes to read and review and make sense of.  If all you had was a general interest area (“aging”), it would be very difficult, nearly impossible, to make sense of all of that data.  The research question provides a helpful lens to refine and clarify (and simplify) everything you find and collect.  For that reason, it is important to pull out that lens (articulate the research question) before you get started.  In the case of the aging study, Cory Abramson was interested in how inequalities affected understandings and responses to aging.  It is for this reason he designed a study that would allow him to compare different groups of seniors (some middle-class, some poor).  Inevitably, he saw much more in the three years in the field than what made it into his book (or dissertation), but he was able to narrow down the complexity of the social world to provide us with this rich account linked to the original research question.  Developing a good research question is thus crucial to effective design and a successful outcome.  Chapter 4 will provide pointers on how to do this.  Chapter 4 also provides an overview of general approaches taken to doing qualitative research and various “traditions of inquiry.”

Chapter 5 explores sampling .  After you have developed a research question and have a general idea of how you will collect data (Observations?  Interviews?), how do you go about actually finding people and sites to study?  Although there is no “correct number” of people to interview , the sample should follow the research question and research design.  Unlike quantitative research, qualitative research involves nonprobability sampling.  Chapter 5 explains why this is so and what qualities instead make a good sample for qualitative research.

Chapter 6 addresses the importance of reflexivity in qualitative research.  Related to epistemological issues of how we know anything about the social world, qualitative researchers understand that we the researchers can never be truly neutral or outside the study we are conducting.  As observers, we see things that make sense to us and may entirely miss what is either too obvious to note or too different to comprehend.  As interviewers, as much as we would like to ask questions neutrally and remain in the background, interviews are a form of conversation, and the persons we interview are responding to us .  Therefore, it is important to reflect upon our social positions and the knowledges and expectations we bring to our work and to work through any blind spots that we may have.  Chapter 6 provides some examples of reflexivity in practice and exercises for thinking through one’s own biases.

Chapter 7 is a very important chapter and should not be overlooked.  As a practical matter, it should also be read closely with chapters 6 and 8.  Because qualitative researchers deal with people and the social world, it is imperative they develop and adhere to a strong ethical code for conducting research in a way that does not harm.  There are legal requirements and guidelines for doing so (see chapter 8), but these requirements should not be considered synonymous with the ethical code required of us.   Each researcher must constantly interrogate every aspect of their research, from research question to design to sample through analysis and presentation, to ensure that a minimum of harm (ideally, zero harm) is caused.  Because each research project is unique, the standards of care for each study are unique.  Part of being a professional researcher is carrying this code in one’s heart, being constantly attentive to what is required under particular circumstances.  Chapter 7 provides various research scenarios and asks readers to weigh in on the suitability and appropriateness of the research.  If done in a class setting, it will become obvious fairly quickly that there are often no absolutely correct answers, as different people find different aspects of the scenarios of greatest importance.  Minimizing the harm in one area may require possible harm in another.  Being attentive to all the ethical aspects of one’s research and making the best judgments one can, clearly and consciously, is an integral part of being a good researcher.

Chapter 8 , best to be read in conjunction with chapter 7, explains the role and importance of Institutional Review Boards (IRBs) .  Under federal guidelines, an IRB is an appropriately constituted group that has been formally designated to review and monitor research involving human subjects .  Every institution that receives funding from the federal government has an IRB.  IRBs have the authority to approve, require modifications to (to secure approval), or disapprove research.  This group review serves an important role in the protection of the rights and welfare of human research subjects.  Chapter 8 reviews the history of IRBs and the work they do but also argues that IRBs’ review of qualitative research is often both over-inclusive and under-inclusive.  Some aspects of qualitative research are not well understood by IRBs, given that they were developed to prevent abuses in biomedical research.  Thus, it is important not to rely on IRBs to identify all the potential ethical issues that emerge in our research (see chapter 7).

Chapter 9 provides help for getting started on formulating a research question based on gaps in the pre-existing literature.  Research is conducted as part of a community, even if particular studies are done by single individuals (or small teams).  What any of us finds and reports back becomes part of a much larger body of knowledge.  Thus, it is important that we look at the larger body of knowledge before we actually start our bit to see how we can best contribute.  When I first began interviewing working-class college students, there was only one other similar study I could find, and it hadn’t been published (it was a dissertation of students from poor backgrounds).  But there had been a lot published by professors who had grown up working class and made it through college despite the odds.  These accounts by “working-class academics” became an important inspiration for my study and helped me frame the questions I asked the students I interviewed.  Chapter 9 will provide some pointers on how to search for relevant literature and how to use this to refine your research question.

Chapter 10 serves as a bridge between the two parts of the textbook, by introducing techniques of data collection.  Qualitative research is often characterized by the form of data collection – for example, an ethnographic study is one that employs primarily observational data collection for the purpose of documenting and presenting a particular culture or ethnos.  Techniques can be effectively combined, depending on the research question and the aims and goals of the study.   Chapter 10 provides a general overview of all the various techniques and how they can be combined.

The second part of the textbook moves into the doing part of qualitative research once the research question has been articulated and the study designed.  Chapters 11 through 17 cover various data collection techniques and approaches.  Chapters 18 and 19 provide a very simple overview of basic data analysis.  Chapter 20 covers communication of the data to various audiences, and in various formats.

Chapter 11 begins our overview of data collection techniques with a focus on interviewing , the true heart of qualitative research.  This technique can serve as the primary and exclusive form of data collection, or it can be used to supplement other forms (observation, archival).  An interview is distinct from a survey, where questions are asked in a specific order and often with a range of predetermined responses available.  Interviews can be conversational and unstructured or, more conventionally, semistructured , where a general set of interview questions “guides” the conversation.  Chapter 11 covers the basics of interviews: how to create interview guides, how many people to interview, where to conduct the interview, what to watch out for (how to prepare against things going wrong), and how to get the most out of your interviews.

Chapter 12 covers an important variant of interviewing, the focus group.  Focus groups are semistructured interviews with a group of people moderated by a facilitator (the researcher or researcher’s assistant).  Focus groups explicitly use group interaction to assist in the data collection.  They are best used to collect data on a specific topic that is non-personal and shared among the group.  For example, asking a group of college students about a common experience such as taking classes by remote delivery during the pandemic year of 2020.  Chapter 12 covers the basics of focus groups: when to use them, how to create interview guides for them, and how to run them effectively.

Chapter 13 moves away from interviewing to the second major form of data collection unique to qualitative researchers – observation .  Qualitative research that employs observation can best be understood as falling on a continuum of “fly on the wall” observation (e.g., observing how strangers interact in a doctor’s waiting room) to “participant” observation, where the researcher is also an active participant of the activity being observed.  For example, an activist in the Black Lives Matter movement might want to study the movement, using her inside position to gain access to observe key meetings and interactions.  Chapter  13 covers the basics of participant observation studies: advantages and disadvantages, gaining access, ethical concerns related to insider/outsider status and entanglement, and recording techniques.

Chapter 14 takes a closer look at “deep ethnography” – immersion in the field of a particularly long duration for the purpose of gaining a deeper understanding and appreciation of a particular culture or social world.  Clifford Geertz called this “deep hanging out.”  Whereas participant observation is often combined with semistructured interview techniques, deep ethnography’s commitment to “living the life” or experiencing the situation as it really is demands more conversational and natural interactions with people.  These interactions and conversations may take place over months or even years.  As can be expected, there are some costs to this technique, as well as some very large rewards when done competently.  Chapter 14 provides some examples of deep ethnographies that will inspire some beginning researchers and intimidate others.

Chapter 15 moves in the opposite direction of deep ethnography, a technique that is the least positivist of all those discussed here, to mixed methods , a set of techniques that is arguably the most positivist .  A mixed methods approach combines both qualitative data collection and quantitative data collection, commonly by combining a survey that is analyzed statistically (e.g., cross-tabs or regression analyses of large number probability samples) with semi-structured interviews.  Although it is somewhat unconventional to discuss mixed methods in textbooks on qualitative research, I think it is important to recognize this often-employed approach here.  There are several advantages and some disadvantages to taking this route.  Chapter 16 will describe those advantages and disadvantages and provide some particular guidance on how to design a mixed methods study for maximum effectiveness.

Chapter 16 covers data collection that does not involve live human subjects at all – archival and historical research (chapter 17 will also cover data that does not involve interacting with human subjects).  Sometimes people are unavailable to us, either because they do not wish to be interviewed or observed (as is the case with many “elites”) or because they are too far away, in both place and time.  Fortunately, humans leave many traces and we can often answer questions we have by examining those traces.  Special collections and archives can be goldmines for social science research.  This chapter will explain how to access these places, for what purposes, and how to begin to make sense of what you find.

Chapter 17 covers another data collection area that does not involve face-to-face interaction with humans: content analysis .  Although content analysis may be understood more properly as a data analysis technique, the term is often used for the entire approach, which will be the case here.  Content analysis involves interpreting meaning from a body of text.  This body of text might be something found in historical records (see chapter 16) or something collected by the researcher, as in the case of comment posts on a popular blog post.  I once used the stories told by student loan debtors on the website studentloanjustice.org as the content I analyzed.  Content analysis is particularly useful when attempting to define and understand prevalent stories or communication about a topic of interest.  In other words, when we are less interested in what particular people (our defined sample) are doing or believing and more interested in what general narratives exist about a particular topic or issue.  This chapter will explore different approaches to content analysis and provide helpful tips on how to collect data, how to turn that data into codes for analysis, and how to go about presenting what is found through analysis.

Where chapter 17 has pushed us towards data analysis, chapters 18 and 19 are all about what to do with the data collected, whether that data be in the form of interview transcripts or fieldnotes from observations.  Chapter 18 introduces the basics of coding , the iterative process of assigning meaning to the data in order to both simplify and identify patterns.  What is a code and how does it work?  What are the different ways of coding data, and when should you use them?  What is a codebook, and why do you need one?  What does the process of data analysis look like?

Chapter 19 goes further into detail on codes and how to use them, particularly the later stages of coding in which our codes are refined, simplified, combined, and organized.  These later rounds of coding are essential to getting the most out of the data we’ve collected.  As students are often overwhelmed with the amount of data (a corpus of interview transcripts typically runs into the hundreds of pages; fieldnotes can easily top that), this chapter will also address time management and provide suggestions for dealing with chaos and reminders that feeling overwhelmed at the analysis stage is part of the process.  By the end of the chapter, you should understand how “findings” are actually found.

The book concludes with a chapter dedicated to the effective presentation of data results.  Chapter 20 covers the many ways that researchers communicate their studies to various audiences (academic, personal, political), what elements must be included in these various publications, and the hallmarks of excellent qualitative research that various audiences will be expecting.  Because qualitative researchers are motivated by understanding and conveying meaning , effective communication is not only an essential skill but a fundamental facet of the entire research project.  Ethnographers must be able to convey a certain sense of verisimilitude , the appearance of true reality.  Those employing interviews must faithfully depict the key meanings of the people they interviewed in a way that rings true to those people, even if the end result surprises them.  And all researchers must strive for clarity in their publications so that various audiences can understand what was found and why it is important.

The book concludes with a short chapter ( chapter 21 ) discussing the value of qualitative research. At the very end of this book, you will find a glossary of terms. I recommend you make frequent use of the glossary and add to each entry as you find examples. Although the entries are meant to be simple and clear, you may also want to paraphrase the definition—make it “make sense” to you, in other words. In addition to the standard reference list (all works cited here), you will find various recommendations for further reading at the end of many chapters. Some of these recommendations will be examples of excellent qualitative research, indicated with an asterisk (*) at the end of the entry. As they say, a picture is worth a thousand words. A good example of qualitative research can teach you more about conducting research than any textbook can (this one included). I highly recommend you select one to three examples from these lists and read them along with the textbook.

A final note on the choice of examples – you will note that many of the examples used in the text come from research on college students.  This is for two reasons.  First, as most of my research falls in this area, I am most familiar with this literature and have contacts with those who do research here and can call upon them to share their stories with you.  Second, and more importantly, my hope is that this textbook reaches a wide audience of beginning researchers who study widely and deeply across the range of what can be known about the social world (from marine resources management to public policy to nursing to political science to sexuality studies and beyond).  It is sometimes difficult to find examples that speak to all those research interests, however. A focus on college students is something that all readers can understand and, hopefully, appreciate, as we are all now or have been at some point a college student.

Recommended Reading: Other Qualitative Research Textbooks

I’ve included a brief list of some of my favorite qualitative research textbooks and guidebooks if you need more than what you will find in this introductory text.  For each, I’ve also indicated if these are for “beginning” or “advanced” (graduate-level) readers.  Many of these books have several editions that do not significantly vary; the edition recommended is merely the edition I have used in teaching and to whose page numbers any specific references made in the text agree.

Barbour, Rosaline. 2014. Introducing Qualitative Research: A Student’s Guide. Thousand Oaks, CA: SAGE.  A good introduction to qualitative research, with abundant examples (often from the discipline of health care) and clear definitions.  Includes quick summaries at the ends of each chapter.  However, some US students might find the British context distracting and can be a bit advanced in some places.  Beginning .

Bloomberg, Linda Dale, and Marie F. Volpe. 2012. Completing Your Qualitative Dissertation . 2nd ed. Thousand Oaks, CA: SAGE.  Specifically designed to guide graduate students through the research process. Advanced .

Creswell, John W., and Cheryl Poth. 2018 Qualitative Inquiry and Research Design: Choosing among Five Traditions .  4th ed. Thousand Oaks, CA: SAGE.  This is a classic and one of the go-to books I used myself as a graduate student.  One of the best things about this text is its clear presentation of five distinct traditions in qualitative research.  Despite the title, this reasonably sized book is about more than research design, including both data analysis and how to write about qualitative research.  Advanced .

Lareau, Annette. 2021. Listening to People: A Practical Guide to Interviewing, Participant Observation, Data Analysis, and Writing It All Up .  Chicago: University of Chicago Press. A readable and personal account of conducting qualitative research by an eminent sociologist, with a heavy emphasis on the kinds of participant-observation research conducted by the author.  Despite its reader-friendliness, this is really a book targeted to graduate students learning the craft.  Advanced .

Lune, Howard, and Bruce L. Berg. 2018. 9th edition.  Qualitative Research Methods for the Social Sciences.  Pearson . Although a good introduction to qualitative methods, the authors favor symbolic interactionist and dramaturgical approaches, which limits the appeal primarily to sociologists.  Beginning .

Marshall, Catherine, and Gretchen B. Rossman. 2016. 6th edition. Designing Qualitative Research. Thousand Oaks, CA: SAGE.  Very readable and accessible guide to research design by two educational scholars.  Although the presentation is sometimes fairly dry, personal vignettes and illustrations enliven the text.  Beginning .

Maxwell, Joseph A. 2013. Qualitative Research Design: An Interactive Approach .  3rd ed. Thousand Oaks, CA: SAGE. A short and accessible introduction to qualitative research design, particularly helpful for graduate students contemplating theses and dissertations. This has been a standard textbook in my graduate-level courses for years.  Advanced .

Patton, Michael Quinn. 2002. Qualitative Research and Evaluation Methods . Thousand Oaks, CA: SAGE.  This is a comprehensive text that served as my “go-to” reference when I was a graduate student.  It is particularly helpful for those involved in program evaluation and other forms of evaluation studies and uses examples from a wide range of disciplines.  Advanced .

Rubin, Ashley T. 2021. Rocking Qualitative Social Science: An Irreverent Guide to Rigorous Research. Stanford : Stanford University Press.  A delightful and personal read.  Rubin uses rock climbing as an extended metaphor for learning how to conduct qualitative research.  A bit slanted toward ethnographic and archival methods of data collection, with frequent examples from her own studies in criminology. Beginning .

Weis, Lois, and Michelle Fine. 2000. Speed Bumps: A Student-Friendly Guide to Qualitative Research . New York: Teachers College Press.  Readable and accessibly written in a quasi-conversational style.  Particularly strong in its discussion of ethical issues throughout the qualitative research process.  Not comprehensive, however, and very much tied to ethnographic research.  Although designed for graduate students, this is a recommended read for students of all levels.  Beginning .

Patton’s Ten Suggestions for Doing Qualitative Research

The following ten suggestions were made by Michael Quinn Patton in his massive textbooks Qualitative Research and Evaluations Methods . This book is highly recommended for those of you who want more than an introduction to qualitative methods. It is the book I relied on heavily when I was a graduate student, although it is much easier to “dip into” when necessary than to read through as a whole. Patton is asked for “just one bit of advice” for a graduate student considering using qualitative research methods for their dissertation.  Here are his top ten responses, in short form, heavily paraphrased, and with additional comments and emphases from me:

• Make sure that a qualitative approach fits the research question. The following are the kinds of questions that call out for qualitative methods or where qualitative methods are particularly appropriate: questions about people’s experiences or how they make sense of those experiences; studying a person in their natural environment; researching a phenomenon so unknown that it would be impossible to study it with standardized instruments or other forms of quantitative data collection.
• Study qualitative research by going to the original sources for the design and analysis appropriate to the particular approach you want to take (e.g., read Glaser and Straus if you are using grounded theory )
• Find a dissertation adviser who understands or at least who will support your use of qualitative research methods. You are asking for trouble if your entire committee is populated by quantitative researchers, even if they are all very knowledgeable about the subject or focus of your study (maybe even more so if they are!)
• Really work on design. Doing qualitative research effectively takes a lot of planning.  Even if things are more flexible than in quantitative research, a good design is absolutely essential when starting out.
• Practice data collection techniques, particularly interviewing and observing. There is definitely a set of learned skills here!  Do not expect your first interview to be perfect.  You will continue to grow as a researcher the more interviews you conduct, and you will probably come to understand yourself a bit more in the process, too.  This is not easy, despite what others who don’t work with qualitative methods may assume (and tell you!)
• Have a plan for analysis before you begin data collection. This is often a requirement in IRB protocols , although you can get away with writing something fairly simple.  And even if you are taking an approach, such as grounded theory, that pushes you to remain fairly open-minded during the data collection process, you still want to know what you will be doing with all the data collected – creating a codebook? Writing analytical memos? Comparing cases?  Having a plan in hand will also help prevent you from collecting too much extraneous data.
• Be prepared to confront controversies both within the qualitative research community and between qualitative research and quantitative research. Don’t be naïve about this – qualitative research, particularly some approaches, will be derided by many more “positivist” researchers and audiences.  For example, is an “n” of 1 really sufficient?  Yes!  But not everyone will agree.
• Do not make the mistake of using qualitative research methods because someone told you it was easier, or because you are intimidated by the math required of statistical analyses. Qualitative research is difficult in its own way (and many would claim much more time-consuming than quantitative research).  Do it because you are convinced it is right for your goals, aims, and research questions.
• Find a good support network. This could be a research mentor, or it could be a group of friends or colleagues who are also using qualitative research, or it could be just someone who will listen to you work through all of the issues you will confront out in the field and during the writing process.  Even though qualitative research often involves human subjects, it can be pretty lonely.  A lot of times you will feel like you are working without a net.  You have to create one for yourself.  Take care of yourself.
• And, finally, in the words of Patton, “Prepare to be changed. Looking deeply at other people’s lives will force you to look deeply at yourself.”
• We will actually spend an entire chapter ( chapter 3 ) looking at this question in much more detail! ↵
• Note that this might have been news to Europeans at the time, but many other societies around the world had also come to this conclusion through observation.  There is often a tendency to equate “the scientific revolution” with the European world in which it took place, but this is somewhat misleading. ↵
• Historians are a special case here.  Historians have scrupulously and rigorously investigated the social world, but not for the purpose of understanding general laws about how things work, which is the point of scientific empirical research.  History is often referred to as an idiographic field of study, meaning that it studies things that happened or are happening in themselves and not for general observations or conclusions. ↵
• Don’t worry, we’ll spend more time later in this book unpacking the meaning of ethnography and other terms that are important here.  Note the available glossary ↵

An approach to research that is “multimethod in focus, involving an interpretative, naturalistic approach to its subject matter.  This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them.  Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives." ( Denzin and Lincoln 2005:2 ). Contrast with quantitative research .

In contrast to methodology, methods are more simply the practices and tools used to collect and analyze data.  Examples of common methods in qualitative research are interviews , observations , and documentary analysis .  One’s methodology should connect to one’s choice of methods, of course, but they are distinguishable terms.  See also methodology .

A proposed explanation for an observation, phenomenon, or scientific problem that can be tested by further investigation.  The positing of a hypothesis is often the first step in quantitative research but not in qualitative research.  Even when qualitative researchers offer possible explanations in advance of conducting research, they will tend to not use the word “hypothesis” as it conjures up the kind of positivist research they are not conducting.

The foundational question to be addressed by the research study.  This will form the anchor of the research design, collection, and analysis.  Note that in qualitative research, the research question may, and probably will, alter or develop during the course of the research.

An approach to research that collects and analyzes numerical data for the purpose of finding patterns and averages, making predictions, testing causal relationships, and generalizing results to wider populations.  Contrast with qualitative research .

Data collection that takes place in real-world settings, referred to as “the field;” a key component of much Grounded Theory and ethnographic research.  Patton ( 2002 ) calls fieldwork “the central activity of qualitative inquiry” where “‘going into the field’ means having direct and personal contact with people under study in their own environments – getting close to people and situations being studied to personally understand the realities of minutiae of daily life” (48).

The people who are the subjects of a qualitative study.  In interview-based studies, they may be the respondents to the interviewer; for purposes of IRBs, they are often referred to as the human subjects of the research.

The branch of philosophy concerned with knowledge.  For researchers, it is important to recognize and adopt one of the many distinguishing epistemological perspectives as part of our understanding of what questions research can address or fully answer.  See, e.g., constructivism , subjectivism, and  objectivism .

An approach that refutes the possibility of neutrality in social science research.  All research is “guided by a set of beliefs and feelings about the world and how it should be understood and studied” (Denzin and Lincoln 2005: 13).  In contrast to positivism , interpretivism recognizes the social constructedness of reality, and researchers adopting this approach focus on capturing interpretations and understandings people have about the world rather than “the world” as it is (which is a chimera).

The cluster of data-collection tools and techniques that involve observing interactions between people, the behaviors, and practices of individuals (sometimes in contrast to what they say about how they act and behave), and cultures in context.  Observational methods are the key tools employed by ethnographers and Grounded Theory .

Research based on data collected and analyzed by the research (in contrast to secondary “library” research).

The process of selecting people or other units of analysis to represent a larger population. In quantitative research, this representation is taken quite literally, as statistically representative.  In qualitative research, in contrast, sample selection is often made based on potential to generate insight about a particular topic or phenomenon.

A method of data collection in which the researcher asks the participant questions; the answers to these questions are often recorded and transcribed verbatim. There are many different kinds of interviews - see also semistructured interview , structured interview , and unstructured interview .

The specific group of individuals that you will collect data from.  Contrast population.

The practice of being conscious of and reflective upon one’s own social location and presence when conducting research.  Because qualitative research often requires interaction with live humans, failing to take into account how one’s presence and prior expectations and social location affect the data collected and how analyzed may limit the reliability of the findings.  This remains true even when dealing with historical archives and other content.  Who we are matters when asking questions about how people experience the world because we, too, are a part of that world.

The science and practice of right conduct; in research, it is also the delineation of moral obligations towards research participants, communities to which we belong, and communities in which we conduct our research.

An administrative body established to protect the rights and welfare of human research subjects recruited to participate in research activities conducted under the auspices of the institution with which it is affiliated. The IRB is charged with the responsibility of reviewing all research involving human participants. The IRB is concerned with protecting the welfare, rights, and privacy of human subjects. The IRB has the authority to approve, disapprove, monitor, and require modifications in all research activities that fall within its jurisdiction as specified by both the federal regulations and institutional policy.

Research, according to US federal guidelines, that involves “a living individual about whom an investigator (whether professional or student) conducting research:  (1) Obtains information or biospecimens through intervention or interaction with the individual, and uses, studies, or analyzes the information or biospecimens; or  (2) Obtains, uses, studies, analyzes, or generates identifiable private information or identifiable biospecimens.”

One of the primary methodological traditions of inquiry in qualitative research, ethnography is the study of a group or group culture, largely through observational fieldwork supplemented by interviews. It is a form of fieldwork that may include participant-observation data collection. See chapter 14 for a discussion of deep ethnography. 

A form of interview that follows a standard guide of questions asked, although the order of the questions may change to match the particular needs of each individual interview subject, and probing “follow-up” questions are often added during the course of the interview.  The semi-structured interview is the primary form of interviewing used by qualitative researchers in the social sciences.  It is sometimes referred to as an “in-depth” interview.  See also interview and  interview guide .

A method of observational data collection taking place in a natural setting; a form of fieldwork .  The term encompasses a continuum of relative participation by the researcher (from full participant to “fly-on-the-wall” observer).  This is also sometimes referred to as ethnography , although the latter is characterized by a greater focus on the culture under observation.

A research design that employs both quantitative and qualitative methods, as in the case of a survey supplemented by interviews.

An epistemological perspective that posits the existence of reality through sensory experience similar to empiricism but goes further in denying any non-sensory basis of thought or consciousness.  In the social sciences, the term has roots in the proto-sociologist August Comte, who believed he could discern “laws” of society similar to the laws of natural science (e.g., gravity).  The term has come to mean the kinds of measurable and verifiable science conducted by quantitative researchers and is thus used pejoratively by some qualitative researchers interested in interpretation, consciousness, and human understanding.  Calling someone a “positivist” is often intended as an insult.  See also empiricism and objectivism.

A place or collection containing records, documents, or other materials of historical interest; most universities have an archive of material related to the university’s history, as well as other “special collections” that may be of interest to members of the community.

A method of both data collection and data analysis in which a given content (textual, visual, graphic) is examined systematically and rigorously to identify meanings, themes, patterns and assumptions.  Qualitative content analysis (QCA) is concerned with gathering and interpreting an existing body of material.    

A word or short phrase that symbolically assigns a summative, salient, essence-capturing, and/or evocative attribute for a portion of language-based or visual data (Saldaña 2021:5).

Usually a verbatim written record of an interview or focus group discussion.

The primary form of data for fieldwork , participant observation , and ethnography .  These notes, taken by the researcher either during the course of fieldwork or at day’s end, should include as many details as possible on what was observed and what was said.  They should include clear identifiers of date, time, setting, and names (or identifying characteristics) of participants.

The process of labeling and organizing qualitative data to identify different themes and the relationships between them; a way of simplifying data to allow better management and retrieval of key themes and illustrative passages.  See coding frame and  codebook.

A methodological tradition of inquiry and approach to analyzing qualitative data in which theories emerge from a rigorous and systematic process of induction.  This approach was pioneered by the sociologists Glaser and Strauss (1967).  The elements of theory generated from comparative analysis of data are, first, conceptual categories and their properties and, second, hypotheses or generalized relations among the categories and their properties – “The constant comparing of many groups draws the [researcher’s] attention to their many similarities and differences.  Considering these leads [the researcher] to generate abstract categories and their properties, which, since they emerge from the data, will clearly be important to a theory explaining the kind of behavior under observation.” (36).

A detailed description of any proposed research that involves human subjects for review by IRB.  The protocol serves as the recipe for the conduct of the research activity.  It includes the scientific rationale to justify the conduct of the study, the information necessary to conduct the study, the plan for managing and analyzing the data, and a discussion of the research ethical issues relevant to the research.  Protocols for qualitative research often include interview guides, all documents related to recruitment, informed consent forms, very clear guidelines on the safekeeping of materials collected, and plans for de-identifying transcripts or other data that include personal identifying information.

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

• Open access
• Published: 16 May 2024

Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts

• Jeremy Segrott   ORCID: orcid.org/0000-0001-6215-0870 1 ,
• Sue Channon 2 ,
• Amy Lloyd 4 ,
• Eleni Glarou 2 , 3 ,
• Josie Henley 5 ,
• Jacqueline Hughes 2 ,
• Nina Jacob 2 ,
• Sarah Milosevic 2 ,
• Yvonne Moriarty 2 ,
• Bethan Pell 6 ,
• Mike Robling 2 ,
• Heather Strange 2 ,
• Julia Townson 2 ,
• Qualitative Research Group &
• Lucy Brookes-Howell 2  

Trials volume  25 , Article number:  323 ( 2024 ) Cite this article

Metrics details

Background/aims

The value of using qualitative methods within clinical trials is widely recognised. How qualitative research is integrated within trials units to achieve this is less clear. This paper describes the process through which qualitative research has been integrated within Cardiff University’s Centre for Trials Research (CTR) in Wales, UK. We highlight facilitators of, and challenges to, integration.

We held group discussions on the work of the Qualitative Research Group (QRG) within CTR. The content of these discussions, materials for a presentation in CTR, and documents relating to the development of the QRG were interpreted at a workshop attended by group members. Normalisation Process Theory (NPT) was used to structure analysis. A writing group prepared a document for input from members of CTR, forming the basis of this paper.

Actions to integrate qualitative research comprised: its inclusion in Centre strategies; formation of a QRG with dedicated funding/roles; embedding of qualitative research within operating systems; capacity building/training; monitoring opportunities to include qualitative methods in studies; maximising the quality of qualitative research and developing methodological innovation. Facilitators of these actions included: the influence of the broader methodological landscape within trial/study design and its promotion of the value of qualitative research; and close physical proximity of CTR qualitative staff/students allowing sharing of methodological approaches. Introduction of innovative qualitative methods generated interest among other staff groups. Challenges included: pressure to under-resource qualitative components of research, preference for a statistical stance historically in some research areas and funding structures, and difficulties faced by qualitative researchers carving out individual academic profiles when working across trials/studies.

Conclusions

Given that CTUs are pivotal to the design and conduct of RCTs and related study types across multiple disciplines, integrating qualitative research into trials units is crucial if its contribution is to be fully realised. We have made explicit one trials unit’s experience of embedding qualitative research and present this to open dialogue on ways to operationalise and optimise qualitative research in trials. NPT provides a valuable framework with which to theorise these processes, including the importance of sense-making and legitimisation when introducing new practices within organisations.

Peer Review reports

The value of using qualitative methods within randomised control trials (RCTs) is widely recognised [ 1 , 2 , 3 ]. Qualitative research generates important evidence on factors affecting trial recruitment/retention [ 4 ] and implementation, aiding interpretation of quantitative data [ 5 ]. Though RCTs have traditionally been viewed as sitting within a positivist paradigm, recent methodological innovations have developed new trial designs that draw explicitly on both quantitative and qualitative methods. For instance, in the field of complex public health interventions, realist RCTs seek to understand the mechanisms through which interventions generate hypothesised impacts, and how interactions across different implementation contexts form part of these mechanisms. Proponents of realist RCTs—which integrate experimental and realist paradigms—highlight the importance of using quantitative and qualitative methods to fully realise these aims and to generate an understanding of intervention mechanisms and how context shapes them [ 6 ].

A need for guidance on how to conduct good quality qualitative research is being addressed, particularly in relation to feasibility studies for RCTs [ 7 ] and process evaluations embedded within trials of complex interventions [ 5 ]. There is also guidance on the conduct of qualitative research within trials at different points in the research cycle, including development, conduct and reporting [ 8 , 9 ].

A high proportion of trials are based within or involve clinical trials units (CTUs). In the UK the UKCRC Registered CTU Network describes them as:

… specialist units which have been set up with a specific remit to design, conduct, analyse and publish clinical trials and other well-designed studies. They have the capability to provide specialist expert statistical, epidemiological, and other methodological advice and coordination to undertake successful clinical trials. In addition, most CTUs will have expertise in the coordination of trials involving investigational medicinal products which must be conducted in compliance with the UK Regulations governing the conduct of clinical trials resulting from the EU Directive for Clinical Trials.

Thus, CTUs provide the specialist methodological expertise needed for the conduct of trials, and in the case of trials of investigational medicinal products, their involvement may be mandated to ensure compliance with relevant regulations. As the definition above suggests, CTUs also conduct and support other types of study apart from RCTs, providing a range of methodological and subject-based expertise.

However, despite their central role in the conduct and design of trials, (and other evaluation designs) little has been written about how CTUs have integrated qualitative work within their organisation at a time when such methods are, as stated above, now recognised as an important aspect of RCTs and evaluation studies more generally. This is a significant gap, since integration at the organisational level arguably shapes how qualitative research is integrated within individual studies, and thus it is valuable to understand how CTUs have approached the task. There are different ways of involving qualitative work in trials units, such as partnering with other departments (e.g. social science) or employing qualitative researchers directly. Qualitative research can be imagined and configured in different ways—as a method that generates data to inform future trial and intervention design, as an embedded component within an RCT or other evaluation type, or as a parallel strand of research focusing on lived experiences of illness, for instance. Understanding how trials units have integrated qualitative research is valuable, as it can shed light on which strategies show promise, and in which contexts, and how qualitative research is positioned within the field of trials research, foregrounding the value of qualitative research. However, although much has been written about its use within trials, few accounts exist of how trials units have integrated qualitative research within their systems and structures.

This paper discusses the process of embedding qualitative research within the work of one CTU—Cardiff University’s Centre for Trials Research (CTR). It highlights facilitators of this process and identifies challenges to integration. We use the Normalisation Process Theory (NPT) as a framework to structure our experience and approach. The key gap addressed by this paper is the implementation of strategies to integrate qualitative research (a relatively newly adopted set of practices and processes) within CTU systems and structures. We acknowledge from the outset that there are multiple ways of approaching this task. What follows therefore is not a set of recommendations for a preferred or best way to integrate qualitative research, as this will comprise diverse actions according to specific contexts. Rather, we examine the processes through which integration occurred in our own setting and highlight the potential value of these insights for others engaged in the work of promoting qualitative research within trials units.

Background to the integration of qualitative research within CTR

The CTR was formed in 2015 [ 10 ]. It brought together three existing trials units at Cardiff University: the South East Wales Trials Unit, the Wales Cancer Trials Unit, and the Haematology Clinical Trials Unit. From its inception, the CTR had a stated aim of developing a programme of qualitative research and integrating it within trials and other studies. In the sections below, we map these approaches onto the framework offered by Normalisation Process Theory to understand the processes through which they helped achieve embedding and integration of qualitative research.

CTR’s aims (including those relating to the development of qualitative research) were included within its strategy documents and communicated to others through infrastructure funding applications, annual reports and its website. A Qualitative Research Group (QRG), which had previously existed within the South East Wales Trials Unit, with dedicated funding for methodological specialists and group lead academics, was a key mechanism through which the development of a qualitative portfolio was put into action. Integration of qualitative research within Centre systems and processes occurred through the inclusion of qualitative research in study adoption processes and representation on committees. The CTR’s study portfolio provided a basis to track qualitative methods in new and existing studies, identify opportunities to embed qualitative methods within recently adopted studies (at the funding application stage) and to manage staff resources. Capacity building and training were an important focus of the QRG’s work, including training courses, mentoring, creation of an academic network open to university staff and practitioners working in the field of healthcare, presentations at CTR staff meetings and securing of PhD studentships. Standard operating procedures and methodological guidance on the design and conduct of qualitative research (e.g. templates for developing analysis plans) aimed to create a shared understanding of how to undertake high-quality research, and a means to monitor the implementation of rigorous approaches. As the QRG expanded its expertise it sought to develop innovative approaches, including the use of visual [ 11 ] and ethnographic methods [ 12 ].

Understanding implementation—Normalisation Process Theory (NPT)

Normalisation Process Theory (NPT) provides a model with which to understand the implementation of new sets of practices and their normalisation within organisational settings. The term ‘normalisation’ refers to how new practices become routinised (part of the everyday work of an organisation) through embedding and integration [ 13 , 14 ]. NPT defines implementation as ‘the social organisation of work’ and is concerned with the social processes that take place as new practices are introduced. Embedding involves ‘making practices routine elements of everyday life’ within an organisation. Integration takes the form of ‘sustaining embedded practices in social contexts’, and how these processes lead to the practices becoming (or not becoming) ‘normal and routine’ [ 14 ]. NPT is concerned with the factors which promote or ‘inhibit’ attempts to embed and integrate the operationalisation of new practices [ 13 , 14 , 15 ].

Embedding new practices is therefore achieved through implementation—which takes the form of interactions in specific contexts. Implementation is operationalised through four ‘generative mechanisms’— coherence , cognitive participation , collective action and reflexive monitoring [ 14 ]. Each mechanism is characterised by components comprising immediate and organisational work, with actions of individuals and organisations (or groups of individuals) interdependent. The mechanisms operate partly through forms of investment (i.e. meaning, commitment, effort, and comprehension) [ 14 ].

Coherence refers to how individuals/groups make sense of, and give meaning to, new practices. Sense-making concerns the coherence of a practice—whether it ‘holds together’, and its differentiation from existing activities [ 15 ]. Communal and individual specification involve understanding new practices and their potential benefits for oneself or an organisation. Individuals consider what new practices mean for them in terms of tasks and responsibilities ( internalisation ) [ 14 ].

NPT frames the second mechanism, cognitive participation , as the building of a ‘community of practice’. For a new practice to be initiated, individuals and groups within an organisation must commit to it [ 14 , 15 ]. Cognitive participation occurs through enrolment —how people relate to the new practice; legitimation —the belief that it is right for them to be involved; and activation —defining which actions are necessary to sustain the practice and their involvement [ 14 ]. Making the new practices work may require changes to roles (new responsibilities, altered procedures) and reconfiguring how colleagues work together (changed relationships).

Third, Collective Action refers to ‘the operational work that people do to enact a set of practices’ [ 14 ]. Individuals engage with the new practices ( interactional workability ) reshaping how members of an organisation interact with each other, through creation of new roles and expectations ( relational interaction ) [ 15 ]. Skill set workability concerns how the work of implementing a new set of practices is distributed and the necessary roles and skillsets defined [ 14 ]. Contextual integration draws attention to the incorporation of a practice within social contexts, and the potential for aspects of these contexts, such as systems and procedures, to be modified as a result [ 15 ].

Reflexive monitoring is the final implementation mechanism. Collective and individual appraisal evaluate the value of a set of practices, which depends on the collection of information—formally and informally ( systematisation ). Appraisal may lead to reconfiguration in which procedures of the practice are redefined or reshaped [ 14 , 15 ].

We sought to map the following: (1) the strategies used to embed qualitative research within the Centre, (2) key facilitators, and (3) barriers to their implementation. Through focused group discussions during the monthly meetings of the CTR QRG and in discussion with the CTR senior management team throughout 2019–2020 we identified nine types of documents (22 individual documents in total) produced within the CTR which had relevant information about the integration of qualitative research within its work (Table  1 ). The QRG had an ‘open door’ policy to membership and welcomed all staff/students with an interest in qualitative research. It included researchers who were employed specifically to undertake qualitative research and other staff with a range of study roles, including trial managers, statisticians, and data managers. There was also diversity in terms of career stage, including PhD students, mid-career researchers and members of the Centre’s Executive team. Membership was therefore largely self-selected, and comprised of individuals with a role related to, or an interest in, embedding qualitative research within trials. However, the group brought together diverse methodological perspectives and was not solely comprised of methodological ‘champions’ whose job it was to promote the development of qualitative research within the centre. Thus whilst the group (and by extension, the authors of this paper) had a shared appreciation of the value of qualitative research within a trials centre, they also brought varied methodological perspectives and ways of engaging with it.

All members of the QRG ( n  = 26) were invited to take part in a face-to-face, day-long workshop in February 2019 on ‘How to optimise and operationalise qualitative research in trials: reflections on CTR structure’. The workshop was attended by 12 members of staff and PhD students, including members of the QRG and the CTR’s senior management team. Recruitment to the workshop was therefore inclusive, and to some extent opportunistic, but all members of the QRG were able to contribute to discussions during regular monthly group meetings and the drafting of the current paper.

The aim of the workshop was to bring together information from the documents in Table  1 to generate discussion around the key strategies (and their component activities) that had been adopted to integrate qualitative research into CTR, as well as barriers to, and facilitators of, their implementation. The agenda for the workshop involved four key areas: development and history of the CTR model; mapping the current model within CTR; discussing the structure of other CTUs; and exploring the advantages and disadvantages of the CTR model.

During the workshop, we discussed the use of NPT to conceptualise how qualitative research had been embedded within CTR’s systems and practices. The group produced spider diagrams to map strategies and actions on to the four key domains (or ‘generative mechanisms’ of NPT) summarised above, to aid the understanding of how they had functioned, and the utility of NPT as a framework. This is summarised in Table  2 .

Detailed notes were made during the workshop. A core writing group then used these notes and the documents in Table  1 to develop a draft of the current paper. This was circulated to all members of the CTR QRG ( n  = 26) and stored within a central repository accessible to them to allow involvement and incorporate the views of those who were not able to attend the workshop. This draft was again presented for comments in the monthly CTR QRG meeting in February 2021 attended by n  = 10. The Standards for QUality Improvement Reporting Excellence 2.0 (SQUIRE) guidelines were used to inform the structure and content of the paper (see supplementary material) [ 16 ].

In the following sections, we describe the strategies CTR adopted to integrate qualitative research. These are mapped against NPT’s four generative mechanisms to explore the processes through which the strategies promoted integration, and facilitators of and barriers to their implementation. A summary of the strategies and their functioning in terms of the generative mechanisms is provided in Table  2 .

Coherence—making sense of qualitative research

In CTR, many of the actions taken to build a portfolio of qualitative research were aimed at enabling colleagues, and external actors, to make sense of this set of methodologies. Centre-level strategies and grant applications for infrastructure funding highlighted the value of qualitative research, the added benefits it would bring, and positioned it as a legitimate set of practices alongside existing methods. For example, a 2014 application for renewal of trials unit infrastructure funding stated:

We are currently in the process of undertaking […] restructuring for our qualitative research team and are planning similar for trial management next year. The aim of this restructuring is to establish greater hierarchical management and opportunities for staff development and also provide a structure that can accommodate continuing growth.

Within the CTR, various forms of communication on the development of qualitative research were designed to enable staff and students to make sense of it, and to think through its potential value for them, and ways in which they might engage with it. These included presentations at staff meetings, informal meetings between project teams and the qualitative group lead, and the visibility of qualitative research on the public-facing Centre website and Centre committees and systems. For instance, qualitative methods were included (and framed as a distinct set of practices) within study adoption forms and committee agendas. Information for colleagues described how qualitative methods could be incorporated within funding applications for RCTs and other evaluation studies to generate new insights into questions research teams were already keen to answer, such as influences on intervention implementation fidelity. Where externally based chief investigators approached the Centre to be involved in new grant applications, the existence of the qualitative team and group lead enabled the inclusion of qualitative research to be actively promoted at an early stage, and such opportunities were highlighted in the Centre’s brochure for new collaborators. Monthly qualitative research network meetings—advertised across CTR and to external research collaborators, were also designed to create a shared understanding of qualitative research methods and their utility within trials and other study types (e.g. intervention development, feasibility studies, and observational studies). Training events (discussed in more detail below) also aided sense-making.

Several factors facilitated the promotion of qualitative research as a distinctive and valuable entity. Among these was the influence of the broader methodological landscape within trial design which was promoting the value of qualitative research, such as guidance on the evaluation of complex interventions by the Medical Research Council [ 17 ], and the growing emphasis placed on process evaluations within trials (with qualitative methods important in understanding participant experience and influences on implementation) [ 5 ]. The attention given to lived experience (both through process evaluations and the move to embed public involvement in trials) helped to frame qualitative research within the Centre as something that was appropriate, legitimate, and of value. Recognition by research funders of the value of qualitative research within studies was also helpful in normalising and legitimising its adoption within grant applications.

The inclusion of qualitative methods within influential methodological guidance helped CTR researchers to develop a ‘shared language’ around these methods, and a way that a common understanding of the role of qualitative research could be generated. One barrier to such sense-making work was the varying extent to which staff and teams had existing knowledge or experience of qualitative research. This varied across methodological and subject groups within the Centre and reflected the history of the individual trials units which had merged to form the Centre.

Cognitive participation—legitimising qualitative research

Senior CTR leaders promoted the value and legitimacy of qualitative research. Its inclusion in centre strategies, infrastructure funding applications, and in public-facing materials (e.g. website, investigator brochures), signalled that it was appropriate for individuals to conduct qualitative research within their roles, or to support others in doing so. Legitimisation also took place through informal channels, such as senior leadership support for qualitative research methods in staff meetings and participation in QRG seminars. Continued development of the QRG (with dedicated infrastructure funding) provided a visible identity and equivalence with other methodological groups (e.g. trial managers, statisticians).

Staff were asked to engage with qualitative research in two main ways. First, there was an expansion in the number of staff for whom qualitative research formed part of their formal role and responsibilities. One of the three trials units that merged to form CTR brought with it a qualitative team comprising methodological specialists and a group lead. CTR continued the expansion of this group with the creation of new roles and an enlarged nucleus of researchers for whom qualitative research was the sole focus of their work. In part, this was linked to the successful award of projects that included a large qualitative component, and that were coordinated by CTR (see Table  3 which describes the PUMA study).

Members of the QRG were encouraged to develop their own research ideas and to gain experience as principal investigators, and group seminars were used to explore new ideas and provide peer support. This was communicated through line management, appraisal, and informal peer interaction. Boundaries were not strictly demarcated (i.e. staff located outside the qualitative team were already using qualitative methods), but the new team became a central focus for developing a growing programme of work.

Second, individuals and studies were called upon to engage in new ways with qualitative research, and with the qualitative team. A key goal for the Centre was that groups developing new research ideas should give more consideration in general to the potential value and inclusion of qualitative research within their funding applications. Specifically, they were asked to do this by thinking about qualitative research at an early point in their application’s development (rather than ‘bolting it on’ after other elements had been designed) and to draw upon the expertise and input of the qualitative team. An example was the inclusion of questions on qualitative methods within the Centre’s study adoption form and representation from the qualitative team at the committee which reviewed new adoption requests. Where adoption requests indicated the inclusion of qualitative methods, colleagues were encouraged to liaise with the qualitative team, facilitating the integration of its expertise from an early stage. Qualitative seminars offered an informal and supportive space in which researchers could share initial ideas and refine their methodological approach. The benefits of this included the provision of sufficient time for methodological specialists to be involved in the design of the proposed qualitative component and ensuring adequate costings had been drawn up. At study adoption group meetings, scrutiny of new proposals included consideration of whether new research proposals might be strengthened through the use of qualitative methods where these had not initially been included. Meetings of the QRG—which reviewed the Centre’s portfolio of new studies and gathered intelligence on new ideas—also helped to identify, early on, opportunities to integrate qualitative methods. Communication across teams was useful in identifying new research ideas and embedding qualitative researchers within emerging study development groups.

Actions to promote greater use of qualitative methods in funding applications fed through into a growing number of studies with a qualitative component. This helped to increase the visibility and legitimacy of qualitative methods within the Centre. For example, the PUMA study [ 12 ], which brought together a large multidisciplinary team to develop and evaluate a Paediatric early warning system, drew heavily on qualitative methods, with the qualitative research located within the QRG. The project introduced an extensive network of collaborators and clinical colleagues to qualitative methods and how they could be used during intervention development and the generation of case studies. Further information about the PUMA study is provided in Table  3 .

Increasing the legitimacy of qualitative work across an extensive network of staff, students and collaborators was a complex process. Set within the continuing dominance of quantitative methods with clinical trials, there were variations in the extent to which clinicians and other collaborators embraced the value of qualitative methods. Research funding schemes, which often continued to emphasise the quantitative element of randomised controlled trials, inevitably fed through into the focus of new research proposals. Staff and external collaborators were sometimes uncertain about the added value that qualitative methods would bring to their trials. Across the CTR there were variations in the speed at which qualitative research methods gained legitimacy, partly based on disciplinary traditions and their influences. For instance, population health trials, often located within non-health settings such as schools or community settings, frequently involved collaboration with social scientists who brought with them experience in qualitative methods. Methodological guidance in this field, such as MRC guidance on process evaluations, highlighted the value of qualitative methods and alternatives to the positivist paradigm, such as the value of realist RCTs. In other, more clinical areas, positivist paradigms had greater dominance. Established practices and methodological traditions across different funders also influenced the ease of obtaining funding to include qualitative research within studies. For drugs trials (CTIMPs), the influence of regulatory frameworks on study design, data collection and the allocation of staff resources may have played a role. Over time, teams gained repeated experience of embedding qualitative research (and researchers) within their work and took this learning with them to subsequent studies. For example, the senior clinician quoted within the PUMA case study (Table  3 below) described how they had gained an appreciation of the rigour of qualitative research and an understanding of its language. Through these repeated interactions, embedding of qualitative research within studies started to become the norm rather than the exception.

Collective action—operationalising qualitative research

Collective action concerns the operationalisation of new practices within organisations—the allocation and management of the work, how individuals interact with each other, and the work itself. In CTR the formation of a Qualitative Research Group helped to allocate and organise the work of building a portfolio of studies. Researchers across the Centre were called upon to interact with qualitative research in new ways. Presentations at staff meetings and the inclusion of qualitative research methods in portfolio study adoption forms were examples of this ( interactive workability ). It was operationalised by encouraging study teams to liaise with the qualitative research lead. Development of standard operating procedures, templates for costing qualitative research and methodological guidance (e.g. on analysis plans) also helped encourage researchers to interact with these methods in new ways. For some qualitative researchers who had been trained in the social sciences, working within a trials unit meant that they needed to interact in new and sometimes unfamiliar ways with standard operating procedures, risk assessments, and other trial-based systems. Thus, training needs and capacity-building efforts were multidirectional.

Whereas there had been a tendency for qualitative research to be ‘bolted on’ to proposals for RCTs, the systems described above were designed to embed thinking about the value and design of the qualitative component from the outset. They were also intended to integrate members of the qualitative team with trial teams from an early stage to promote effective integration of qualitative methods within larger trials and build relationships over time.

Standard Operating Procedures (SOPs), formal and informal training, and interaction between the qualitative team and other researchers increased the relational workability of qualitative methods within the Centre—the confidence individuals felt in including these methods within their studies, and their accountability for doing so. For instance, study adoption forms prompted researchers to interact routinely with the qualitative team at an early stage, whilst guidance on costing grants provided clear expectations about the resources needed to deliver a proposed set of qualitative data collection.

Formation of the Qualitative Research Group—comprised of methodological specialists, created new roles and skillsets ( skill set workability ). Research teams were encouraged to draw on these when writing funding applications for projects that included a qualitative component. Capacity-building initiatives were used to increase the number of researchers with the skills needed to undertake qualitative research, and for these individuals to develop their expertise over time. This was achieved through formal training courses, academic seminars, mentoring from experienced colleagues, and informal knowledge exchange. Links with external collaborators and centres engaged in building qualitative research supported these efforts. Within the Centre, the co-location of qualitative researchers with other methodological and trial teams facilitated knowledge exchange and building of collaborative relationships, whilst grouping of the qualitative team within a dedicated office space supported a collective identity and opportunities for informal peer support.

Some aspects of the context in which qualitative research was being developed created challenges to operationalisation. Dependence on project grants to fund qualitative methodologists meant that there was a continuing need to write further grant applications whilst limiting the amount of time available to do so. Similarly, researchers within the team whose role was funded largely by specific research projects could sometimes find it hard to create sufficient time to develop their personal methodological interests. However, the cultivation of a methodologically varied portfolio of work enabled members of the team to build significant expertise in different approaches (e.g. ethnography, discourse analysis) that connected individual studies.

Reflexive monitoring—evaluating the impact of qualitative research

Inclusion of questions/fields relating to qualitative research within the Centre’s study portfolio database was a key way in which information was collected ( systematisation ). It captured numbers of funding applications and funded studies, research design, and income generation. Alongside this database, a qualitative resource planner spreadsheet was used to link individual members of the qualitative team with projects and facilitate resource planning, further reinforcing the core responsibilities and roles of qualitative researchers within CTR. As with all staff in the Centre, members of the qualitative team were placed on ongoing rather than fixed-term contracts, reflecting their core role within CTR. Planning and strategy meetings used the database and resource planner to assess the integration of qualitative research within Centre research, identify opportunities for increasing involvement, and manage staff recruitment and sustainability of researcher posts. Academic meetings and day-to-day interaction fulfilled informal appraisal of the development of the group, and its position within the Centre. Individual appraisal was also important, with members of the qualitative team given opportunities to shape their role, reflect on progress, identify training needs, and further develop their skillset, particularly through line management systems.

These forms of systematisation and appraisal were used to reconfigure the development of qualitative research and its integration within the Centre. For example, group strategies considered how to achieve long-term integration of qualitative research from its initial embedding through further promoting the belief that it formed a core part of the Centre’s business. The visibility and legitimacy of qualitative research were promoted through initiatives such as greater prominence on the Centre’s website. Ongoing review of the qualitative portfolio and discussion at academic meetings enabled the identification of areas where increased capacity would be helpful, both for qualitative staff, and more broadly within the Centre. This prompted the qualitative group to develop an introductory course to qualitative methods open to all Centre staff and PhD students, aimed at increasing understanding and awareness. As the qualitative team built its expertise and experience it also sought to develop new and innovative approaches to conducting qualitative research. This included the use of visual and diary-based methods [ 11 ] and the adoption of ethnography to evaluate system-level clinical interventions [ 12 ]. Restrictions on conventional face-to-face qualitative data collection due to the COVID-19 pandemic prompted rapid adoption of virtual/online methods for interviews, observation, and use of new internet platforms such as Padlet—a form of digital note board.

In this paper, we have described the work undertaken by one CTU to integrate qualitative research within its studies and organisational culture. The parallel efforts of many trials units to achieve these goals arguably come at an opportune time. The traditional designs of RCTs have been challenged and re-imagined by the increasing influence of realist evaluation [ 6 , 18 ] and the widespread acceptance that trials need to understand implementation and intervention theory as well as assess outcomes [ 17 ]. Hence the widespread adoption of embedded mixed methods process evaluations within RCTs. These broad shifts in methodological orthodoxies, the production of high-profile methodological guidance, and the expectations of research funders all create fertile ground for the continued expansion of qualitative methods within trials units. However, whilst much has been written about the importance of developing qualitative research and the possible approaches to integrating qualitative and quantitative methods within studies, much less has been published on how to operationalise this within trials units. Filling this lacuna is important. Our paper highlights how the integration of a new set of practices within an organisation can become embedded as part of its ‘normal’ everyday work whilst also shaping the practices being integrated. In the case of CTR, it could be argued that the integration of qualitative research helped shape how this work was done (e.g. systems to assess progress and innovation).

In our trials unit, the presence of a dedicated research group of methodological specialists was a key action that helped realise the development of a portfolio of qualitative research and was perhaps the most visible evidence of a commitment to do so. However, our experience demonstrates that to fully realise the goal of developing qualitative research, much work focuses on the interaction between this ‘new’ set of methods and the organisation into which it is introduced. Whilst the team of methodological specialists was tasked with, and ‘able’ to do the work, the ‘work’ itself needed to be integrated and embedded within the existing system. Thus, alongside the creation of a team and methodological capacity, promoting the legitimacy of qualitative research was important to communicate to others that it was both a distinctive and different entity, yet similar and equivalent to more established groups and practices (e.g. trial management, statistics, data management). The framing of qualitative research within strategies, the messages given out by senior leaders (formally and informally) and the general visibility of qualitative research within the system all helped to achieve this.

Normalisation Process Theory draws our attention to the concepts of embedding (making a new practice routine, normal within an organisation) and integration —the long-term sustaining of these processes. An important process through which embedding took place in our centre concerned the creation of messages and systems that called upon individuals and research teams to interact with qualitative research. Research teams were encouraged to think about qualitative research and consider its potential value for their studies. Critically, they were asked to do so at specific points, and in particular ways. Early consideration of qualitative methods to maximise and optimise their inclusion within studies was emphasised, with timely input from the qualitative team. Study adoption systems, centre-level processes for managing financial and human resources, creation of a qualitative resource planner, and awareness raising among staff, helped to reinforce this. These processes of embedding and integration were complex and they varied in intensity and speed across different areas of the Centre’s work. In part this depended on existing research traditions, the extent of prior experience of working with qualitative researchers and methods, and the priorities of subject areas and funders. Centre-wide systems, sometimes linked to CTR’s operation as a CTU, also helped to legitimise and embed qualitative research, lending it equivalence with other research activity. For example, like all CTUs, CTR was required to conform with the principles of Good Clinical Practice, necessitating the creation of a quality management system, operationalised through standard operating procedures for all areas of its work. Qualitative research was included, and became embedded, within these systems, with SOPs produced to guide activities such as qualitative analysis.

NPT provides a helpful way of understanding how trials units might integrate qualitative research within their work. It highlights how new practices interact with existing organisational systems and the work needed to promote effective interaction. That is, alongside the creation of a team or programme of qualitative research, much of the work concerns how members of an organisation understand it, engage with it, and create systems to sustain it. Embedding a new set of practices may be just as important as the quality or characteristics of the practices themselves. High-quality qualitative research is of little value if it is not recognised and drawn upon within new studies for instance. NPT also offers a helpful lens with which to understand how integration and embedding occur, and the mechanisms through which they operate. For example, promoting the legitimacy of a new set of practices, or creating systems that embed it, can help sustain these practices by creating an organisational ambition and encouraging (or requiring) individuals to interact with them in certain ways, redefining their roles accordingly. NPT highlights the ways in which integration of new practices involves bi-directional exchanges with the organisation’s existing practices, with each having the potential to re-shape the other as interaction takes place. For instance, in CTR, qualitative researchers needed to integrate and apply their methods within the quality management and other systems of a CTU, such as the formalisation of key processes within standard operating procedures, something less likely to occur outside trials units. Equally, project teams (including those led by externally based chief investigators) increased the integration of qualitative methods within their overall study design, providing opportunities for new insights on intervention theory, implementation and the experiences of practitioners and participants.

We note two aspects of the normalisation processes within CTR that are slightly less well conceptualised by NPT. The first concerns the emphasis within coherence on identifying the distinctiveness of new practices, and how they differ from existing activities. Whilst differentiation was an important aspect of the integration of qualitative research in CTR, such integration could be seen as operating partly through processes of de-differentiation, or at least equivalence. That is, part of the integration of qualitative research was to see it as similar in terms of rigour, coherence, and importance to other forms of research within the Centre. To be viewed as similar, or at least comparable to existing practices, was to be legitimised.

Second, whilst NPT focuses mainly on the interaction between a new set of practices and the organisational context into which it is introduced, our own experience of introducing qualitative research into a trials unit was shaped by broader organisational and methodological contexts. For example, the increasing emphasis placed upon understanding implementation processes and the experiences of research participants in the field of clinical trials (e.g. by funders), created an environment conducive to the development of qualitative research methods within our Centre. Attempts to integrate qualitative research within studies were also cross-organisational, given that many of the studies managed within the CTR drew together multi-institutional teams. This provided important opportunities to integrate qualitative research within a portfolio of studies that extended beyond CTR and build a network of collaborators who increasingly included qualitative methods within their funding proposals. The work of growing and integrating qualitative research within a trials unit is an ongoing one in which ever-shifting macro-level influences can help or hinder, and where the organisations within which we work are never static in terms of barriers and facilitators.

The importance of utilising qualitative methods within RCTs is now widely recognised. Increased emphasis on the evaluation of complex interventions, the influence of realist methods directing greater attention to complexity and the widespread adoption of mixed methods process evaluations are key drivers of this shift. The inclusion of qualitative methods within individual trials is important and previous research has explored approaches to their incorporation and some of the challenges encountered. Our paper highlights that the integration of qualitative methods at the organisational level of the CTU can shape how they are taken up by individual trials. Within CTR, it can be argued that qualitative research achieved high levels of integration, as conceptualised by Normalisation Process Theory. Thus, qualitative research became recognised as a coherent and valuable set of practices, secured legitimisation as an appropriate focus of individual and organisational activity and benefitted from forms of collective action which operationalised these organisational processes. Crucially, the routinisation of qualitative research appeared to be sustained, something which NPT suggests helps define integration (as opposed to initial embedding). However, our analysis suggested that the degree of integration varied by trial area. This variation reflected a complex mix of factors including disciplinary traditions, methodological guidance, existing (un)familiarity with qualitative research, and the influence of regulatory frameworks for certain clinical trials.

NPT provides a valuable framework with which to understand how these processes of embedding and integration occur. Our use of NPT draws attention to the importance of sense-making and legitimisation as important steps in introducing a new set of practices within the work of an organisation. Integration also depends, across each mechanism of NPT, on the building of effective relationships, which allow individuals and teams to work together in new ways. By reflecting on our experiences and the decisions taken within CTR we have made explicit one such process for embedding qualitative research within a trials unit, whilst acknowledging that approaches may differ across trials units. Mindful of this fact, and the focus of the current paper on one trials unit’s experience, we do not propose a set of recommendations for others who are working to achieve similar goals. Rather, we offer three overarching reflections (framed by NPT) which may act as a useful starting point for trials units (and other infrastructures) seeking to promote the adoption of qualitative research.

First, whilst research organisations such as trials units are highly heterogenous, processes of embedding and integration, which we have foregrounded in this paper, are likely to be important across different contexts in sustaining the use of qualitative research. Second, developing a plan for the integration of qualitative research will benefit from mapping out the characteristics of the extant system. For example, it is valuable to know how familiar staff are with qualitative research and any variations across teams within an organisation. Thirdly, NPT frames integration as a process of implementation which operates through key generative mechanisms— coherence , cognitive participation , collective action and reflexive monitoring . These mechanisms can help guide understanding of which actions help achieve embedding and integration. Importantly, they span multiple aspects of how organisations, and the individuals within them, work. The ways in which people make sense of a new set of practices ( coherence ), their commitment towards it ( cognitive participation ), how it is operationalised ( collective action ) and the evaluation of its introduction ( reflexive monitoring ) are all important. Thus, for example, qualitative research, even when well organised and operationalised within an organisation, is unlikely to be sustained if appreciation of its value is limited, or people are not committed to it.

We present our experience of engaging with the processes described above to open dialogue with other trials units on ways to operationalise and optimise qualitative research in trials. Understanding how best to integrate qualitative research within these settings may help to fully realise the significant contribution which it makes the design and conduct of trials.

Availability of data and materials

Some documents cited in this paper are either freely available from the Centre for Trials Research website or can be requested from the author for correspondence.

O’Cathain A, Thomas KJ, Drabble SJ, Rudolph A, Hewison J. What can qualitative research do for randomised controlled trials? A systematic mapping review. BMJ Open. 2013;3(6):e002889.

Article   PubMed   PubMed Central   Google Scholar  

O’Cathain A, Thomas KJ, Drabble SJ, Rudolph A, Goode J, Hewison J. Maximising the value of combining qualitative research and randomised controlled trials in health research: the QUAlitative Research in Trials (QUART) study – a mixed methods study. Health Technol Assess. 2014;18(38):1–197.

Clement C, Edwards SL, Rapport F, Russell IT, Hutchings HA. Exploring qualitative methods reported in registered trials and their yields (EQUITY): systematic review. Trials. 2018;19(1):589.

Hennessy M, Hunter A, Healy P, Galvin S, Houghton C. Improving trial recruitment processes: how qualitative methodologies can be used to address the top 10 research priorities identified within the PRioRiTy study. Trials. 2018;19:584.

Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350(mar19 6):h1258.

Bonell C, Fletcher A, Morton M, Lorenc T, Moore L. Realist randomised controlled trials: a new approach to evaluating complex public health interventions. Soc Sci Med. 2012;75(12):2299–306.

Article   PubMed   Google Scholar  

O’Cathain A, Hoddinott P, Lewin S, Thomas KJ, Young B, Adamson J, et al. Maximising the impact of qualitative research in feasibility studies for randomised controlled trials: guidance for researchers. Pilot Feasibility Stud. 2015;1:32.

Cooper C, O’Cathain A, Hind D, Adamson J, Lawton J, Baird W. Conducting qualitative research within Clinical Trials Units: avoiding potential pitfalls. Contemp Clin Trials. 2014;38(2):338–43.

Rapport F, Storey M, Porter A, Snooks H, Jones K, Peconi J, et al. Qualitative research within trials: developing a standard operating procedure for a clinical trials unit. Trials. 2013;14:54.

Cardiff University. Centre for Trials Research. Available from: https://www.cardiff.ac.uk/centre-for-trials-research . Accessed 10 May 2024.

Pell B, Williams D, Phillips R, Sanders J, Edwards A, Choy E, et al. Using visual timelines in telephone interviews: reflections and lessons learned from the star family study. Int J Qual Methods. 2020;19:160940692091367.

Thomas-Jones E, Lloyd A, Roland D, Sefton G, Tume L, Hood K, et al. A prospective, mixed-methods, before and after study to identify the evidence base for the core components of an effective Paediatric Early Warning System and the development of an implementation package containing those core recommendations for use in th. BMC Pediatr. 2018;18:244.

May C, Finch T, Mair F, Ballini L, Dowrick C, Eccles M, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res. 2007;7:148.

May C, Finch T. Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology. 2009;43(3):535–54.

Article   Google Scholar  

May CR, Mair F, Finch T, Macfarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: normalization process theory. Implement Sci. 2009;4:29.

Ogrinc G, Davies L, Goodman D, Batalden PB, Davidoff F, Stevens D. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality and Safety. 2016;25:986-92.

Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.

Jamal F, Fletcher A, Shackleton N, Elbourne D, Viner R, Bonell C. The three stages of building and testing mid-level theories in a realist RCT: a theoretical and methodological case-example. Trials. 2015;16(1):466.

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Acknowledgements

Members of the Centre for Trials Research (CTR) Qualitative Research Group were collaborating authors: C Drew (Senior Research Fellow—Senior Trial Manager, Brain Health and Mental Wellbeing Division), D Gillespie (Director, Infection, Inflammation and Immunity Trials, Principal Research Fellow), R Hale (now Research Associate, School of Social Sciences, Cardiff University), J Latchem-Hastings (now Lecturer and Postdoctoral Fellow, School of Healthcare Sciences, Cardiff University), R Milton (Research Associate—Trial Manager), B Pell (now PhD student, DECIPHer Centre, Cardiff University), H Prout (Research Associate—Qualitative), V Shepherd (Senior Research Fellow), K Smallman (Research Associate), H Stanton (Research Associate—Senior Data Manager). Thanks are due to Kerry Hood and Aimee Grant for their involvement in developing processes and systems for qualitative research within CTR.

No specific grant was received to support the writing of this paper.

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JS contributed to the design of the work and interpretation of data and was responsible for leading the drafting and revision of the paper. SC contributed to the design of the work, the acquisition of data and the drafting and revision of the paper. AL contributed to the design of the work, the acquisition of data and the drafting and revision of the paper. EG contributed to a critical review of the manuscript and provided additional relevant references. JH provided feedback on initial drafts of the paper and contributed to subsequent revisions. JHu provided feedback on initial drafts of the paper and contributed to subsequent revisions. NG provided feedback on initial drafts of the paper and contributed to subsequent revisions. SM was involved in the acquisition and analysis of data and provided a critical review of the manuscript. YM was involved in the acquisition and analysis of data and provided a critical review of the manuscript. MR was involved in the interpretation of data and critical review and revision of the paper. HS contributed to the conception and design of the work, the acquisition and analysis of data, and the revision of the manuscript. JT provided feedback on initial drafts of the paper and contributed to subsequent revisions. LB-H made a substantial contribution to the design and conception of the work, led the acquisition and analysis of data, and contributed to the drafting and revision of the paper.

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Segrott, J., Channon, S., Lloyd, A. et al. Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts. Trials 25 , 323 (2024). https://doi.org/10.1186/s13063-024-08124-7

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Choosing a Qualitative Research Approach

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Editor's Note: The online version of this article contains a list of further reading resources and the authors' professional information .

The Challenge

Educators often pose questions about qualitative research. For example, a program director might say: “I collect data from my residents about their learning experiences in a new longitudinal clinical rotation. If I want to know about their learning experiences, should I use qualitative methods? I have been told that there are many approaches from which to choose. Someone suggested that I use grounded theory, but how do I know this is the best approach? Are there others?”

What Is Known

Qualitative research is the systematic inquiry into social phenomena in natural settings. These phenomena can include, but are not limited to, how people experience aspects of their lives, how individuals and/or groups behave, how organizations function, and how interactions shape relationships. In qualitative research, the researcher is the main data collection instrument. The researcher examines why events occur, what happens, and what those events mean to the participants studied. 1 , 2

Qualitative research starts from a fundamentally different set of beliefs—or paradigms—than those that underpin quantitative research. Quantitative research is based on positivist beliefs that there is a singular reality that can be discovered with the appropriate experimental methods. Post-positivist researchers agree with the positivist paradigm, but believe that environmental and individual differences, such as the learning culture or the learners' capacity to learn, influence this reality, and that these differences are important. Constructivist researchers believe that there is no single reality, but that the researcher elicits participants' views of reality. 3 Qualitative research generally draws on post-positivist or constructivist beliefs.

Qualitative scholars develop their work from these beliefs—usually post-positivist or constructivist—using different approaches to conduct their research. In this Rip Out, we describe 3 different qualitative research approaches commonly used in medical education: grounded theory, ethnography, and phenomenology. Each acts as a pivotal frame that shapes the research question(s), the method(s) of data collection, and how data are analyzed. 4 , 5

Choosing a Qualitative Approach

Before engaging in any qualitative study, consider how your views about what is possible to study will affect your approach. Then select an appropriate approach within which to work. Alignment between the belief system underpinning the research approach, the research question, and the research approach itself is a prerequisite for rigorous qualitative research. To enhance the understanding of how different approaches frame qualitative research, we use this introductory challenge as an illustrative example.

The clinic rotation in a program director's training program was recently redesigned as a longitudinal clinical experience. Resident satisfaction with this rotation improved significantly following implementation of the new longitudinal experience. The program director wants to understand how the changes made in the clinic rotation translated into changes in learning experiences for the residents.

Qualitative research can support this program director's efforts. Qualitative research focuses on the events that transpire and on outcomes of those events from the perspectives of those involved. In this case, the program director can use qualitative research to understand the impact of the new clinic rotation on the learning experiences of residents. The next step is to decide which approach to use as a frame for the study.

The table lists the purpose of 3 commonly used approaches to frame qualitative research. For each frame, we provide an example of a research question that could direct the study and delineate what outcomes might be gained by using that particular approach.

Methodology Overview

How You Can Start TODAY

• 1 Examine the foundations of the existing literature: As part of the literature review, make note of what is known about the topic and which approaches have been used in prior studies. A decision should be made to determine the extent to which the new study is exploratory and the extent to which findings will advance what is already known about the topic.
• 2 Find a qualitatively skilled collaborator: If you are interested in doing qualitative research, you should consult with a qualitative expert. Be prepared to talk to the qualitative scholar about what you would like to study and why . Furthermore, be ready to describe the literature to date on the topic (remember, you are asking for this person's expertise regarding qualitative approaches—he or she won't necessarily have content expertise). Qualitative research must be designed and conducted with rigor (rigor will be discussed in Rip Out No. 8 of this series). Input from a qualitative expert will ensure that rigor is employed from the study's inception.
• 3 Consider the approach: With a literature review completed and a qualitatively skilled collaborator secured, it is time to decide which approach would be best suited to answering the research question. Questions to consider when weighing approaches might include the following:
• • Will my findings contribute to the creation of a theoretical model to better understand the area of study? ( grounded theory )
• • Will I need to spend an extended amount of time trying to understand the culture and process of a particular group of learners in their natural context? ( ethnography )
• • Is there a particular phenomenon I want to better understand/describe? ( phenomenology )

What You Can Do LONG TERM

• 1 Develop your qualitative research knowledge and skills : A basic qualitative research textbook is a valuable investment to learn about qualitative research (further reading is provided as online supplemental material). A novice qualitative researcher will also benefit from participating in a massive online open course or a mini-course (often offered by professional organizations or conferences) that provides an introduction to qualitative research. Most of all, collaborating with a qualitative researcher can provide the support necessary to design, execute, and report on the study.
• 2 Undertake a pilot study: After learning about qualitative methodology, the next best way to gain expertise in qualitative research is to try it in a small scale pilot study with the support of a qualitative expert. Such application provides an appreciation for the thought processes that go into designing a study, analyzing the data, and reporting on the findings. Alternatively, if you have the opportunity to work on a study led by a qualitative expert, take it! The experience will provide invaluable opportunities for learning how to engage in qualitative research.

Supplementary Material

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of the Navy, the Department of Defense, or the US government.

References and Resources for Further Reading

• Open access
• Published: 11 May 2024

Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

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Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

Almarwani AM. The effect of integrating a nursing licensure examination preparation course into a nursing program curriculum: a quasi-experimental study. Saudi J Health Sci. 2022;11:184–9.

Article   Google Scholar  

Horntvedt MT, Nordsteien A, Fermann T, Severinsson E. Strategies for teaching evidence-based practice in nursing education: a thematic literature review. BMC Med Educ. 2018;18:172.

Article   PubMed   PubMed Central   Google Scholar  

Larsson M, Sundler AJ, Blomberg K, Bisholt B. The clinical learning environment during clinical practice in postgraduate district nursing students’ education: a cross-sectional study. Nurs Open. 2023;10:879–88.

Article   PubMed   Google Scholar  

Sellberg M, Palmgren PJ, Möller R. A cross-sectional study of clinical learning environments across four undergraduate programs using the undergraduate clinical education environment measure. BMC Med Educ. 2021;21:258.

Saifan A, Devadas B, Mekkawi M, Amoor H, Matizha P, James J, et al. Managing the theory-practice gap in nursing education and practice: hearing the voices of nursing students in the United Arab Emirates. J Nurs Manag. 2021;29:1869–79.

Flott EA, Linden L. The clinical learning environment in nursing education: a concept analysis. J Adv Nurs. 2016;72:501–13.

Kalyani MN, Jamshidi N, Molazem Z, Torabizadeh C, Sharif F. How do nursing students experience the clinical learning environment and respond to their experiences? A qualitative study. BMJ Open. 2019;9:e028052.

Mahasneh D, Shoqirat N, Alsaraireh A, Singh C, Thorpe L. From learning on mannequins to practicing on patients: nursing students’ first-time experience of clinical placement in Jordan. SAGE Open Nurs. 2021;7:23779608211004298.

PubMed   PubMed Central   Google Scholar  

Stubin C. Clinical stress among undergraduate nursing students: perceptions of clinical nursing faculty. Int J Nurs Educ Scholarsh. 2020;17:20190111.

Ahmed WAM. Anxiety and related symptoms among critical care nurses in Albaha, Kingdom of Saudi Arabia. AIMS Med Sci. 2015;2:303–9.

Alhassan. Duke Phillips. 2024.

Ekstedt M, Lindblad M, Löfmark A. Nursing students’ perception of the clinical learning environment and supervision in relation to two different supervision models - a comparative cross-sectional study. BMC Nurs. 2019;18:49.

Bradshaw C, Murphy Tighe S, Doody O. Midwifery students’ experiences of their clinical internship: a qualitative descriptive study. Nurse Educ Today. 2018;68:213–7.

McCarthy B, Trace A, O’Donovan M, O’Regan P, Brady-Nevin C, O’Shea M, et al. Coping with stressful events: a pre-post-test of a psycho-educational intervention for undergraduate nursing and midwifery students. Nurse Educ Today. 2018;61:273–80.

Chaabane S, Chaabna K, Bhagat S, Abraham A, Doraiswamy S, Mamtani R, et al. Perceived stress, stressors, and coping strategies among nursing students in the Middle East and North Africa: an overview of systematic reviews. Syst Rev. 2021;10:136.

Pines EW, Rauschhuber ML, Norgan GH, Cook JD, Canchola L, Richardson C, et al. Stress resiliency, psychological empowerment and conflict management styles among baccalaureate nursing students. J Adv Nurs. 2012;68:1482–93.

Lazarus RS. Coping theory and research: past, present, and future. Psychosom Med. 1993;55:234–47.

Article   CAS   PubMed   Google Scholar  

Boyd MA. Essentials of psychiatric nursing. Philadelphia, PA: Wolters Kluwer; 2017.

Google Scholar  

Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26:471–80.

Ni C, Lo D, Liu X, Ma J, Xu S, Li L. Chinese female nursing students’ coping strategies, self-esteem and related factors in different years of school. J Nurs Educ Pract. 2012;2:33–41.

Jan LK, Popescu L. Israel’s nursing students’ stress sources and coping strategies during their first clinical experience in hospital wards-a qualitative research. Soc Work Rev / Rev Asistenta Soc. 2014;13:163–88.

Tung YJ, Lo KKH, Ho RCM, Tam WSW. Prevalence of depression among nursing students: a systematic review and meta-analysis. Nurse Educ Today. 2018;63:119–29.

Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–12.

Bryman A. Integrating quantitative and qualitative research: how is it done? Qual Res. 2006;6:97–113.

Holloway I, Wheeler S. Qualitative research in nursing and healthcare. New York, NY: Wiley; 2013.

Richards L, Morse J. A user’s guide to qualitative methods. London, UK: Sage; 2007.

Lincoln Y, Guba EG. The SAGE handbook of qualitative research. Newbury Park, CA: SAGE Publications Inc; 2017.

Park S, Park KS. Family stigma: a concept analysis. Asian Nurs Res. 2014;8:165–71.

Onieva-Zafra MD, Fernández-Muñoz JJ, Fernández-Martínez E, García-Sánchez FJ, Abreu-Sánchez A, Parra-Fernández ML. Anxiety, perceived stress and coping strategies in nursing students: a cross-sectional, correlational, descriptive study. BMC Med Educ. 2020;20:370.

Albloushi M, Ferguson L, Stamler L, Bassendowski S, Hellsten L, Kent-Wilkinson A. Saudi female nursing students experiences of sense of belonging in the clinical settings: a qualitative study. Nurse Educ Pract. 2019;35:69–74.

Arkan B, Ordin Y, Yılmaz D. Undergraduate nursing students’ experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract. 2018;29:127–32.

Bhurtun HD, Azimirad M, Saaranen T, Turunen H. Stress and coping among nursing students during clinical training: an integrative review. J Nurs Educ. 2019;58:266–72.

Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Kalyani MN. The challenges of nursing students in the clinical learning environment: a qualitative study. ScientificWorldJournal. 2016;2016:1846178.

Porter SL. First year nursing students’ perceptions of stress and resilience during their initial clinical placement and the introduction of a stress management app: a mixed methods approach. A thesis submitted in partial fulfilment of the requirements of Edinburgh Napier University, for the award of Doctor of Philosophy. 2019. https://www.napier.ac.uk/~/media/worktribe/output-2086663/first-year-nursing-students-perceptions-of-stress-and-resilience-during-their-initial.pdf

Panda S, Dash M, John J, Rath K, Debata A, Swain D, et al. Challenges faced by student nurses and midwives in clinical learning environment - A systematic review and meta-synthesis. Nurse Educ Today. 2021;101:104875.

Ahmadi G, Shahriari M, Keyvanara M, Kohan S. Midwifery students’ experiences of learning clinical skills in Iran: a qualitative study. Int J Med Educ. 2018;9:64–71.

Harrison-White K, Owens J. Nurse link lecturers’ perceptions of the challenges facing student nurses in clinical learning environments: a qualitative study. Nurse Educ Pract. 2018;32:78–83.

Grobecker PA. A sense of belonging and perceived stress among baccalaureate nursing students in clinical placements. Nurse Educ Today. 2016;36:178–83.

Msiska G, Kamanga M, Chilemba E, Msosa A, Munkhondya TE. Sources of stress among undergraduate nursing students during clinical practice: a Malawian perspective. Open J Nurs. 2019;9:1.

Joolaee S, Amiri SRJ, Farahani MA, Varaei S. Iranian nursing students’ preparedness for clinical training: a qualitative study. Nurse Educ Today. 2015;35:e13–7.

Günay U, Kılınç G. The transfer of theoretical knowledge to clinical practice by nursing students and the difficulties they experience: a qualitative study. Nurse Educ Today. 2018;65:81–6.

Farzi S, Shahriari M, Farzi S. Exploring the challenges of clinical education in nursing and strategies to improve it: a qualitative study. J Educ Health Promot. 2018;7:115.

Hamaideh SH, Al-Omari H, Al-Modallal H. Nursing students’ perceived stress and coping behaviors in clinical training in Saudi Arabia. J Ment Health. 2017;26:197–203.

Yaghoobi A, Mohagheghi H, Zade MY, Ganji K, Olfatii N. The effect of time management training on test anxiety and academic achievement motivation among high school students. J Sch Psychol. 2014;3:131–44.

Kebriaei A, Bidgoli MS, Saeedi A. Relationship between use of time management skills and satisfaction with spending time among students of Zahedan University of Medical Sciences. J Med Educ Dev. 2014;6:79–88.

Chen YW, Hung CH. Predictors of Taiwanese baccalaureate nursing students’ physio-psycho-social responses during clinical practicum. Nurse Educ Today. 2014;34:73–7.

Ab Latif R, Mat Nor MZ. Stressors and coping strategies during clinical practice among diploma nursing students. Malays J Med Sci. 2019;26:88–98.

Al-Yateem N, Almarzouqi A, Dias JM, Saifan A, Timmins F. Nursing in the United Arab Emirates: current challenges and opportunities. J Nurs Manag. 2021;29:109–12.

Baraz-Pordanjani S, Memarian R, Vanaki Z. Damaged professional identity as a barrier to Iranian nursing students’ clinical learning: a qualitative study. J Clin Nurs Midwifery. 2014;3:1–15.

Labrague LJ, McEnroe-Petitte DM, Papathanasiou IV, Edet OB, Tsaras K, Leocadio MC, et al. Stress and coping strategies among nursing students: an international study. J Ment Health. 2018;27:402–8.

Madian AAEM, Abdelaziz MM, Ahmed HAE. Level of stress and coping strategies among nursing students at Damanhour University, Egypt. Am J Nurs Res. 2019;7:684–96.

Wu CS, Rong JR, Huang MZ. Factors associated with perceived stress of clinical practice among associate degree nursing students in Taiwan. BMC Nurs. 2021;20:89.

Zhao FF, Lei XL, He W, Gu YH, Li DW. The study of perceived stress, coping strategy and self-efficacy of Chinese undergraduate nursing students in clinical practice. Int J Nurs Pract. 2015;21:401–9.

Bektaş H, Terkes N, Özer Z. Stress and ways of coping among first year nursing students: a Turkish perspective. J Hum Sci. 2018;15:319–30.

John B, Al-Sawad M. Perceived stress in clinical areas and emotional intelligence among baccalaureate nursing students. J Indian Acad Appl Psychol. 2015;41:76–85.

Mapfumo JS, Chitsiko N, Chireshe R. Teaching practice generated stressors and coping mechanisms among student teachers in Zimbabwe. S Afr J Educ. 2012;32:155–66.

Timmins F, Corroon AM, Byrne G, Mooney B. The challenge of contemporary nurse education programmes. Perceived stressors of nursing students: mental health and related lifestyle issues. J Psychiatr Ment Health Nurs. 2011;18:758–66.

Hegberg NJ, Tone EB. Physical activity and stress resilience: considering those at-risk for developing mental health problems. Ment Health Phys Act. 2015;8:1–7.

Shudifat RM, Al-Husban RY. Perceived sources of stress among first-year nursing students in Jordan. J Psychosoc Nurs Ment Health Serv. 2015;53:37–43.

El Ansari W, Adetunji H, Oskrochi R. Food and mental health: relationship between food and perceived stress and depressive symptoms among university students in the United Kingdom. Cent Eur J Public Health. 2014;22:90–7.

Dias JM, Aderibigbe SA, Abraham MS. Undergraduate nursing students’ mentoring experiences in the clinical practicum: the United Arab Emirates (UAE) perspective. J Nurs Manag. 2022;30:4304–13.

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The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Barriers to equitable healthcare services for under-five children in Ethiopia: a qualitative exploratory study

• Hailu Fekadu 1 ,
• Wubegzier Mekonnen 2 ,
• Aynalem Adugna 3 ,
• Helmut Kloos 4 &
• Damen Hailemariam 2  

BMC Health Services Research volume  24 , Article number:  613 ( 2024 ) Cite this article

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Metrics details

Disparities in child healthcare service utilization are unacceptably high in Ethiopia. Nevertheless, little is known about underlying barriers to accessing child health services, especially among low socioeconomic subgroups and in remote areas. This study aims to identify barriers to equity in the use of child healthcare services in Ethiopia.

Data were obtained from 20 key- informant interviews (KII) and 6 focus group discussions (FGD) with mothers and care givers. This study was conducted in Oromia Region, Arsi Zone, Zuway Dugda District from June 1–30, 2023. The study participants for this research were selected purposively. The information was collected based on the principle of saturation after sixteen consecutives interview were conducted. Both KII and FGD were audio-recorded and complementary notes were taken to record observations about the participants’ comments and their interactions. Each interview and FGD data were transcribed word-for-word in the local Afaan Oromo and Amaharic languages and then translated to English language. Finally, the data were analyzed thematically using NVivo 14 software and narrated in the linked pattern of child health service utilization.

This study identified six major themes which emerged as barriers to healthcare utilization equity for caregivers and their -under-five children. Barriers related to equity in low level of awareness regarding need, low socioeconomic status, geographical inaccessibility, barriers related to deficient healthcare system, community perception and cultural restrictions, and barriers of equity related to political instability and conflict . The most commonly recognized barriers of equity at the community level were political instability, conflict, and a tremendous distance to a health facility. Transportation challenges, poor functional services, closure of the health facility in working hours, and lack of proper planning to address the marginalized populations were identified barriers of equity at organizational or policy level.

This study showed that inequity in child healthcare utilization is an important challenge confronting Ethiopia. To achieve equity, policy makers and planners need to change health policy and structure to be pro-poor. It is also necessary to improve the healthcare system to increase service utilization and access for impoverished women, individuals with lower levels of education, and residents of isolated rural areas. Furthermore, context specific information pertaining to cultural barriers and political ecology are required.

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Over the last few decades, the issue of equitable distribution and utilization of healthcare services has captured the attention of scholars, governments, and policy makers. While some countries have made much improvement in this regard, others have lagged behind. Child healthcare service use is no exception, and it has recently become a global concern [ 1 ].

Equity in health and health service utilization is a focus in the global health discourse as one of the cornerstones of primary health care (PHC) [ 2 ]. The United Nations has set a goal to reduce global neonatal deaths from 25 per 1,000 live births to 12 per 1,000 by the year 2030 [ 3 ]. Achieving this target will require strong commitment from both service providers as well as financiers of the health sector, including government and community leaders [ 3 ]. Among the World Health Organization’s main focus areas for under-five health, is the reduction of inequities in accordance with the universal health coverage principles. This includes addressing the health needs of children in poor and remote communities. Many countries have implemented various programs aimed at minimizing unnecessary disparities in health service utilization [ 4 ]. Community based health services in particular have been found to be effective in minimizing inequities in health status and health service utilization [ 4 ]. For instance, the Ethiopian government is committed to improve equity through the health extension program and other initiatives [ 5 ]. Moreover, Ethiopia included the equity objective in its health sector transformation plan [ 6 ]. Nevertheless, inequities in service coverage and difference in maternal and child health outcomes remain a challenge [ 7 , 8 ]. The coverage of child health services and basic child immunizations has favored wealthier, more educated, and urban populations. [ 9 ]. For instance, despite significant decline is observed in under five mortality from 123 per 1,000 live births in 2005 to 59 in 2019, still there exists a disparity between different population groups [ 9 ].

Ethiopia met the MDGS for child mortality rate (CMR) in 2013 [ 10 ]. However, the gains made between 1990 and 2013 were not uniformly distributed among Ethiopians; inequity indicators of mortality by wealth had not significantly decreased. During this 23-year period, the mortality among the poorest was unchanged. Even though child health services are supposed to be provided free of charge at public facilities, the disparity in access to or utilization of the services is high in Ethiopia. Like mortality disparity, there is a considerable disparity in coverage of life-saving interventions by wealth status and place of residence [ 11 ].

Addressing equity is a significant challenge in healthcare delivery in Ethiopia. The barriers that were reported to be significantly associated with service utilization included geographical access as a function of distance; financial barriers; and socio-cultural factors such as language, cultural norms, health beliefs and perceptions, maternal education and decision making power and lack of knowledge and awareness, which in the aggregate can lead to low demand for and use of services, particularly by the poor [ 12 , 13 ]. Long distances and extended travel times remain key barriers to access health facilities in many rural communities in Ethiopia [ 11 , 14 ]. For instance, in Indonesia proximity to healthcare facilities significantly decreases child mortality [ 15 ]. Furthermore, according to a study from Uganda, Nigeria and Ethiopia long distances to health care facilities cause delays seeking care [ 16 , 17 , 18 ]. Even where health care services are available, the cost of seeking care may delay or prevent poor households from accessing them. This problem is particularly discriminating in rural areas where the density of modern health care facilities is low and in settings where transportation systems and road infrastructures are poor [ 18 ]. Furthermore, over the last five years, Ethiopia has faced internal conflict and political instability which exacerbated inequity in the utilization of child health services among the poor and in rural communities. Both insecurity and scarce resources are critical issues in child healthcare accessibility for women living in conflict zones and socioeconomically unstable settings [ 19 ].

Political instability disrupts electricity, water, and food supplies, destabilizes social and welfare systems, including the health and transportation systems, and increases unemployment, homelessness, and poverty—all of which have a negative impact on the use of maternal and child health services [ 20 ]. Hence, these issues did not addressed in any of the studies done so far.

Thus, while many studies have been conducted on the utilization of healthcare services, there is insufficient comprehensive evidence on the barriers of equity in accessing and in utilization of healthcare services for under-five children from policy makers and community level perspective. Therefore, the objective of this study is to examine the context of specific barriers to achieving equity in child health-care services utilization in Ethiopia.

Inequity in child health care service is a major public health problem in developing countries, including Ethiopia. Accordingly, the study explored barriers to equitable healthcare services for under-five children, their health seeking behavior, geographical variation, their awareness, perceptions, attitude and political impact and policy contents of the country. The findings will benefit program leaders, policy makers on health inequality reduction and serve as an input to policy documents related to the new health sector strategic plan. Moreover, mothers and under-five children’s are directly benefited from the finding. Conceptual framework shows how different barriers affect equity in utilization of child health services (Fig.  1 ).

Modified Andersen and WHO conceptual framework, on social determinants of health inequity

The study setting and approach

This study was conducted in Oromia Region, Arsi Zone, Zuway Dugda District from June 1–30, 2023. The Ethiopian healthcare system is three-tiered, comprising primary, secondary, and tertiary care [Fig.  2 ]. The primary level healthcare system is responsible for providing child health services, such as immunizations, and the treatment of sick children. The primary care unit includes primary hospitals, health centers, and health posts which are responsible for providing services to rural communities ([ 17 ]; Arsi Zone Health Department report, Unpublished data, 2022). Women's development armies (WDAs) provide support to health extension workers (HEWs) by organizing and connecting women and their children with healthcare facilities. Based on 2022, the Arsi Zone report, Zuway Dugda district was low in utilization of child healthcare services and the population is low in socioeconomic status and mostly depends on the Safety Net program for nutritional and financial needs (Arsi Zone Health Department report, Unpublished data, 2022). The goal of the Safety Net program is to preserve family assets while generating new ones for the community. To achieve this, the program offers food or cash incentives in exchange for public works projects that improve the environment or create local infrastructure, like roads (e.g. terracing).

Ethiopian health care system [ 17 ]

Participant selection

The study includes 20 in-depth interviews of key informants (KII) and six focus group discussions (FGD). By taking into account various factors that contribute to variations in the use of child healthcare services, study participants were selected from a variety of demographic subgroups. The study participants were drawn from different segments of the population by considering different dimensions that explain disparities in utilization of child healthcare services. The selection of participants was based on their experience of child healthcare services as well as the information they possessed. For the purposes of this research, to ensure representativeness, and to understand the multifaceted levels of the study framework within society and how individuals and the environment interact within a social system, we used maximum variations sampling technique and we classified the participants into four groups. They were “mothers or caregivers who have under- five children”, “males who have under-five children”, “healthcare leaders at different levels” and “healthcare providers at different health facility”. The first group,, “women” refers to mothers who were gave birth prior to the study period and currently having under-five children. The second group were “males or husbands of the women who have under-five children”. The third groups, “healthcare leaders” like; heads of the health centers, district health office, expertise working on child health programs in district, Zonal, regional or national level. The fourth group, “health-care providers”, refers to health professionals, including doctors, health officers, nurses, midwives, and health extension workers working at different health facilities in Arsi Zone and having direct relation with child healthcare services.

Participants in the focus group discussions (FGDs) could be women and their partners who had under-five children at the time of the study. The participant mothers or caregivers were recruited by the HEWs and kebe le (neighborhood associations) leaders. They were identified on a purposive basis with the help of health extension workers and were contacted a few days before the planned FGD to explain the objectives of the study and request their participation. For the key informant interviews, the study participants were contacted by the principal investigator two weeks before the interviews. The information was collected based on the principle of saturation; for our case at least 16 interviewees were needed to reach information saturation principles. Then, data collection was terminated when no new information was generated.

An interview guide was prepared for both the key informant interviews (KII) and FGDs. First, the guides were prepared in English language and then translated into the local language [ 21 ]. Then, the guides were pre-tested and problems relating to the sequence of questions, conceptually similar questions, and sensitive wording were corrected. The data collectors for the KII and FGD were professionals with the background in health and health related fields with master and who are experienced in collecting qualitative data. Moreover, they are fluent in the local language and familiar with the culture of the local community. Key informant interviews were conducted at the office or at the health facility where the interviewee worked and FGDs were conducted in community halls or public rooms. Both key informant-interviews and focus group discussions were audio-recorded. Additionally, complementary observations and notes regarding the remarks made by the participants and their interactions were made.

Data analysis

The principal investigator and the moderator transcribed each interview and FGD word-for-word in the local Afaan Oromo and Amaharic languages and then translated the transcripts back into English. The translations were verified by listening to the recordings while re-reading the transcripts. The data were analyzed thematically using NVivo 12 software and narrated in the pattern linked to child health service utilization. Major themes representing the FGD participants and in-depth interviews are presented in the findings section, with illustrative quotes included to support the main findings.

Trustworthiness

In qualitative research, trustworthiness is determined by credibility, dependability, conformability and transferability. Establishing credibility involved the primary researcher spending a considerable amount of time at the study site to get a feel for the environment, receiving ongoing feedback from peers during peer debriefing, and applying negative case analysis. Dependability was demonstrated by providing an in-depth explanation of the techniques employed, keeping careful interview records, and recording the analytical procedure. All events that took place in the field, the researchers' personal reflections on the study, any phenomena that emerged during the investigation, and pertinent details of their personal histories were documented in order to verify that the interpretations of the findings were derived from the data and were not the product of their imagination. The investigators attempted to build rapport and trust with the informants by developing a long-term attachment because they were skeptical or doubtful if the information felt off. Triangulation of data sources was also employed. A thorough description that includes explaining each step of the research process was employed to aid in the transferability of research findings. At the end of each qualitative data collection session, the data collectors rephrased the collected information by summarizing major points and obtained approval from the participants for the corrected summary.

Characteristics of the study participants

A total of six focus group discussions (FGD)- three with mothers and three with fathers of under five children were conducted. And 20 key informant interview (KII) were held. The number of FGD participants ranged from 8 -12 in each groups. The majorities of women’s participating in FGDs were housewives and had at least one child under the age of 5 years in their care at the time of the FGD. The key informant interviews were conducted with leaders and policy makers at different levels of the health care system and a healthcare worker, including FMoH child health directors, Regional Health bureaus experts, Zonal Health office child health experts, woreda health office heads, Health center heads and health extension workers at health posts were involved. In all, 28 men and 30 women took part in the FGDs. In contrast, six HEW, three heads of health centers, one head of the district health office and with ten experts participated in the key informant interview. Each FGD took on average 42 min (38–52 min), while the key informant interviews took about 36 min (19 to 55 min) (Tables 1 and 2 ).

Barriers to equitable healthcare services for under-five children

Six major themes emerged from the findings.

These include; barriers related to low awareness, low socioeconomic status, geographical inaccessibility, barriers related to deficient healthcare system, cultural and behavioral constraints, and political instability and conflict, all of which lead to unmet healthcare needs such as delay in receiving appropriate care and inability to obtain healthcare services (Table  3 ).

Lack of awareness about benefits of the services

Lack of awareness and misconceptions were one of the top reasons raised by KII and FGD participants for not using healthcare services for under-five children especially in rural communities. Recognition of illness and the potential benefits of treatment are pre-requisites for health care demand. Communities who lived in remote areas and are undereducated tend to have little knowledge concerning health issues. Rural people have insufficient exposure to the media, attending low level of schooling to grasp and understand health related information. The key-informant interviewees and FGD discussants reported that because of low health literacy, rural community and the poor households have less access to health facilities to get treatment for childhood diseases, and for immunization services. One of the key informants mentioned that there are variation or differences among urban and rural rich and poor, literate and uneducated people in child health care service utilization.

“… . Children who visited our health center with malnutrition were from remote and far to reach areas and were brought to our health facility only after these cases were seriously complicated. So there is great variation among urban and rural, rich and poor, literate and illiterate communities in child health care service utilization in our district .” Male , KII, age 34years

One FGD discussant from women group added her experience and her awareness of immunization and availability of free service in health post in such ways;

“Yes, if I had been aware of the benefit of immunization and informed that they were given free of charge, I would have used these services for my sick child from health posts, not from traditional healers” Female FGD discussant, age 35 years, Seeking care from traditional healer

The health extension workers at health posts also approved the lack of awareness among mothers and caregivers on the availability of health service which jeopardizes health- seeking and utilization of health service for their under-five children. One worker said that.

“Most of the women’s and care givers did not know about the availability of treatment at the health post, especially for diarrhea and pneumonia. Those women’s who live near a health facility, are educated and young have more awareness about childhood illnesses and seek care from health posts than uneducated mothers; this may result in inequitable utilization of health services by illiterate care givers ” KII, Female 35 years

In some areas there is a mix of knowledge about utilization of healthcare services for under-five children. Health professionals used abbaa gadaa, or hadha sinqee (male and female cultural leaders) and members of the female development army (FDA) to raise the level of awareness in the community. One key informant interviewee shared the experience of his districts in utilizing women’s development army and these cultural leaders to increase the knowledge of the community as follows;

“We improve the awareness of our community on child healthcare utilization through women’s development army and cultural leaders, we trained these women about early recognition of maternal and child health danger sign. we provide them local COC for them. By now in our district, women’s development armies have equivalent knowledge with HEW and, we used them to teach the community”. Male, Key informant, age 42 year.

Socioeconomic barriers

Lack of sufficient income at household level and low level of maternal and paternal education were identified as major barriers for equity in utilization of healthcare services for under-five children. As part of its HSDP II strategic objectives, the Ethiopian Government intends to address equity in maternal and child health, particularly for the impoverished and rural communities, by providing free health services to these subgroups and allocating a sufficient budget. However, the actual and perceived cost of seeking care keeps some people from traveling to medical facilities. Out-of- pocket costs of health care, cost of transportation and living cost may prevent poor people from using services, leading to untreated childhood illness.

For instance after they reached to health facility, they obligated to pay for medical treatment or drugs they used to treat their children. In this case some advanced diagnosis and treatment is not available in governmental health facilities.. For example, CT scan and MRI to diagnose severe childhood diseases and some essential drugs to treat pneumonia, sepsis and diarrhea were not available in health centers and in health posts. They were advised to get this treatment from private clinics and to buy the drugs from private pharmacies. However, or mothers could not afford to purchase them from private clinic.

A woman from FGD discussant explained her experience of an availability of certain services in Government health facility and high cost of services in private clinic as follows:

“Yes, nowadays, the cost of drugs and treatment for childhood illness is increasing, when I used to get treatment for my sick child from a health center or health post the health professional referred me to a private clinic to be seen or diagnosed by a highly expensive machine; I am unable to afford for this machine. Moreover there were no drugs at the health post and the health center. They told us to purchase them from private clinics. So, how can the poor people get treatment from Governmental health facility?” Female FGD discussant age, 34 years, with low income.

Another FGD discussant described this problem as follows:

“Yes, getting treatment in this health facility is good but sometimes you go here and there to get examined and prescribed for drugs and you need money for those drugs. If you don’t have money, then you remain with the illness” Female FGD discussant, age 29 years.

The study participants suggested that, socioeconomic healthcare inequity must be addressed by healthcare system revisions such as the provision of health insurance, fee retention; waiving and exemptions from fees for poor people, and subsiding the cost of the transportation were considered as solution to reduce inequity in health care services.

Geographical barriers

Distance of health facilities from home and unavailability of motorized transportation were another major barrier to health services utilization. Pit the fact that availability of some community based services should increase health service utilization to caregivers, distance from homes to health facilities, poor roads and unavailability of motorized transport were major barriers for many people. Distance from health centers and health posts and lack of transportation and cost of transportation were cited as barberries of equity for child health service utilization by rural and the poor communities. Long distances, shoddy road construction, and a shortage of ambulances make it difficult for residents of remote communities and low-income families to get to medical facilities and thus have fewer opportunities to vaccinate their children. One key informant said that.

“…the primary issue facing this district is the lack of transportation and the distance between the residential area and the medical facilities . The caregivers were unable to get transportation service easily. In some areas the distance between health facilities and residential areas of the community is too far, besides there is no road to get access to health facility. We need more vehicles at health center level; moreover, the transportation issue cannot be solved unless quality roads will be constructed for the community.”Male, key-informant interview, age 40 years.

Another FGD discussant said that.

“ Yaa, we move more than 30 km on foot to access health facilities, especially health centers, there is no road for cars., we carry our sick child on our backs to get treatment from this health facility” FGD, Male, age 44 years.

One FGD described the transportation problem a follows:

“…even though roads were constructed, there is no reliable transportation system in our area. Ambulance service is not available in our area, no mobile network to call to ambulance service. Moreover, if we were hardly access the ambulance, we are requested to pay 1000 Birr for fuel. Therefore, the Government and concerned body has to understand and solve our situation related to distance and transportation problem.” Male, FGD discussant, Age 49 year.

The study participant also suggested that geographical and financial accessibility barriers have to be addressed by bringing services closer to homes or residential areas.

Healthcare system barriers

Certain aspects of healthcare system were identified as barriers to equitable healthcare services for under-five children. In Ethiopia, important deterrents include unavailability, unaffordability of the service, and closure of health posts during working hours and issues related to behaviors of the health professionals were the emerged theme from this study.

One of the important barriers of equity in utilization of child healthcare services especially by poor were unavailability of child care services at health posts. Even though the health posts are supposed to give services for the rural and poor populations, it was closed on many working days and at weekends. In addition, absence of health extension workers from the duty during working hours, services inconsistently and unavailability of drugs in the health posts were barberries of equity raised by KII and FGD discussants. One of key informant interviewees explained his observations as follows;

“Even though, the health posts are expected to give maternal and child health services for the rural community free of charge, how the poor and the rural community get these services, the health posts were closed during working hours, most of the time the HEW workers are in another duty, they were assigned to collect taxes and insurance from the community, so the richest household will get these services from private health institution but the poor and the rural community is in problem in accessing these services” Key-informant interview, Male, 45 years.

Besides giving health services, in some rural areas the health extension workers are assigned to other administrative and political activities. A health extension worker in health post acknowledged the absence of health services during working hour in such ways;

“ How can we give health services for the poor community, we are assigned to collect insurance, taxes and to register member for the political parties, if we say no we will be fired, most of the time the health posts were closed, all services were intercepted, mothers from rural area repeatedly came for immunization, but they did not get us in the health post, those mothers who were educated and have the money for transportation may went to health centers and Hospitals to get immunization service, but the poor mother were waiting us till the health post is opened” Female, Age 39 year.

One woman from FGD participant also explains her experience as follows;

“One day my 3 years old child was sick and I came to consult the HEW, but, the door is closed and she was not around” Female, FGD discussant, Age 38year, rural community

Another important finding from this qualitative study was issue of marginalized populations. The health services do not cover marginalized and poor people, like, beggars, around churches, mosques and along roads on child health services especially immunization . Key informant participants from the one woreda health office described this issue as follows;

“Here is the gap, now the health facilities have no plan and willing to give immunization services to marginalized poor people like; beggars around the mosque, church, and on roads. These poor people are totally forgotten, the motivation of health workers to serve this community is almost zero or near to nil. All vaccination mandates are given to HEW, but now health centers and health posts are not connected to these people and their children’s are not vaccinated at all. There is no supervision or support from higher officials, no accountability among HEW “KII M ale, 45yer.

Lack of adequate supply of medicines and other medical supplies emerged as a recurring theme in FGDs and KII at both the policy and service delivery levels. The health posts do not have all basic medicines available and end up giving inadequate drugs, no separate budget is allocated for child health by Ministry of Health or the regional health bureaus. Donors, NGO,s and partners have reduced their budgets and support of child health programs.

One KII participant shared his perceived cause of inadequate supplies and budgeting for health facility as follows:

“…Currently only limited budgets are allocated to the health sector, especially for maternal and child health. There are no donors and partners who support the healthcare system; this is probably linked to the current Ethiopian political upheavals. This creates problems for free services for maternal and child care. In my opinion this is the cause of an availability of materials and some drugs at health facility” key-informant-interview, age 44 year.

Disrespectful care and treatment was the issue raised as barriers to equity by caregivers for their under-five children. Ethiopian communities pay attention to respectful and quality of care, therefore giving preference to urban health centers, which generally meet patient expectation. But urban health facilities also discriminate against poor people. A female FGD discussant raised the issue of non-compassionate and disrespectful care given to her at an urban health facility, as follows:

“Yes, we looked unclean and came from rural areas, the health professionals treated us as not as humans and gave us poor care. They did not touch us by their hands or used apparatus to examine our problem. They simply asked us about our illness and gave us prescription to buy drugs” Female, FGD, 42 years.

Respondents suggest that, the government need to ensure the availability of adequate essential vaccines, drugs and supplies in health facilities. The FGD discussants further emphasized that, both central and local healthcare systems need to allocate adequate financial resources and procure adequate logistic and material supplies towards effective implementation of quality healthcare services.

Cultural and behavioral barriers

Low demand and utilization of modern health interventions often derives from deep-rooted attitudes that reflect culture, social norms and traditions of the community. Few FGD participants mentioned that cultural barriers such as using traditional medicines at home and taking the children to traditional healers were barriers to using child health services, especially in rural areas. In some areas peoples believed that the cause of the illness is caused by supernatural agents, exposure to cold, wind or the devil eye. Therefore they do not bring their children to health facilities. Many poor mothers and care givers in rural areas use traditional medicine or religious interventions such as payer as the first treatment for childhood illness because of their ready accessibility and low cost, as stated by one father:

“I have encountered people in some districts who delayed treatment because of traditional beliefs. One of them said … If my child gets sick, I will not bring it to a health facility immediately, I will wait until the disease matures and shows full blown sign can l be observed or till it will resolved by itself” key-informant interview, Male 42 years.

There are also other traditions, customs and beliefs among some rural communities which are barriers to equity of child health services. For instance haamachisaa is a kind of blessing used as the first treatment by traditional healers for neonates aged less than 3 months before seeking care services from health facilities. They believe that haamachisaa prevent malicious birds or the evil eye to inflict illness on neonates, as described by one mother:

“ in our area some of the rural communities will not send their “ children below three months of age” to get immunization services from health facilities before they practice haamchisaa or blessing services from a traditional healer because a bird or the evil eye may see the neonate “ Female, key- informant, 39 years.

In some rural districts, obstacles to child health care service utilization include the use of traditional uvulectomy, getting treatment for measles from traditional healers and using holy water (tsebel) at churches when children fall ill.

“In our area, when their child develops measles some of them refuse to take their children to health facility because they believe that the treatment there will cause girsha, the dissemination of the rash to different organ systems” Male, key-informant, 30 years head of HC.

Another FGD discussant described her preference of traditional healers for her sick child because of cost of the drug as follows;

“I visited a traditional healer for my child when he had tonsil, because drugs and repeated treatment from a health facility are expensive; After the tonsils are removed by a traditional healer there is no recurrence, so it is less costly for me” Female, FG, Age 40 year.

In another way less attention was given for morbidity and mortality of the child by rural community, especially to the neonate (if a neonate died) the funeral ceremony will not be practice in the church or mosque. The burial or funeral ceremony is accomplished at near house of the parents; the dead body is not brought to church or mosque. The community did not consider a neonatal death as a death of human being or adult death but, is concealed, as described by a male key-informant:

“ Here in the community less attention is given to child health, especially for the newborns; if the newborn dies the dead body will not brought to a church or mosque but it will be buried around the home. Nobody will go to that home to morn with the parents” Male key-informant, 42 years.

In many Ethiopian communities, women’s have low autonomy to decide for her own and their children’s health in Ethiopia. They need the permission of their husbands to seek care for their children, because of economic, psychological and material dependence. The norms and values of the community also reinforce this behavior.

One of the important finding of this study was inequity related to ethnicity. Almost all KII and FGD participants stated that there is no disparity in healthcare service utilization because of ethnicity.

“…..Even though Ethiopia is having a diversified ethnic group still there is no marginalization or inequity in utilization of child health services from health facility because of ethnicity; rather they encounter barriers related to language in understanding and to get consultation from service providers” Key-informant, Male, Age 39 year.

The study participants further suggested that barriers related to health illiteracy or mistrust of the healthcare system have to be addressed by involving different stakeholders such as community leaders, traditional healers and religious leaders .

Politics, conflict and security issues

Over the last few years, Ethiopia is suffering from different types of military conflicts between the Ethiopian government and insurgent forces in most regions and administrative areas. This protracted conflict hinders maternal and child health service delivery affected communities, especially in isolated rural areas. As a result, health services could not operate safely in the war zone, Increasing the incidence of vaccine-preventable diseases and malnutrition. A male FGD discussant explained the effects of conflict on maternal and children service utilization as follows:

“ In our district there is continuous military conflict between the government and rebel forces; most of the time the health facilities were closed, there is diversion of supplies for maternal and child health services to the armed forces, no immunization services was given to the community during this conflict period, roads were closed, the health professionals fled health facilities because they felt insecure, even ambulances assigned to MCH services were used for military purposes;, the rich may get the service from private clinic, the poor did not get anything, simply waiting an interventions from God,, or simply wait to die or migrate to other places” Male, FGD, age 45 years.

One key-informant interview participant reported his observation of security problem on child health services in his district as follows:

“Regarding the issue of security problem, currently in our area there is a military conflict between government and rebellions. Due to this there is no maternal and child healthcare services, 24 h ambulance was served for political purposes, as a result mothers and children are dying from severe anemia and severe pneumonia at their home, therefore, politically instability and conflict among Government and armed rebellion force exacerbate the existed disparity in utilization of healthcare services for mothers and children in our district”. Key –informant, male, age 41 years.

The research participant added that communication between opposing groups is necessary to resolve political unrest and conflict which has direct impact on child healthcare utilization.

This study aimed at exploring barriers of equity that mothers and their children face in accessing and utilization of healthcare services for under-five children. The findings point out multiple dynamics of barriers of equity to care-seeking and utilization of healthcare services in Ethiopia.

In this study the barriers and challenges linked with access and utilization of equitable healthcare services for under-five children were found to fall under six themes ; lack of awareness about availability of the service, socioeconomic barriers, geographic barriers, health system related barriers, cultural and behavioral barriers and political instability and military conflict related barriers. These barriers are inter-related and complex in nature. As key-informants and FGD discussants reported that lack of awareness was one of the top barriers for not using healthcare services for under-five children, especially in rural communities. Populations who have settled in far to reach areas and uneducated have no equal awareness about health related issues compared to urban and well educated populations. Their reasons are people leave in rural area has insufficient exposure to media, attending low level of schooling to grasp and understand health related information. Most studies reported that because of low health related literacy, rural community and the poor household had delayed to access health facility to get treatment for most of childhood illnesses, and vaccination services [ 22 ]. In this study having participants confirm that there is a gap in knowledge regarding the causes of childhood illness and regarding the availability of treatments at health posts, it is clear that a campaign to educate and mobilize community members will be necessary. The need for transmission of information about the availability of services was also highlighted by several other studies [ 23 ]. Studies in Ethiopia reported that, HEW home visits were reportedly valuable for increasing awareness and use of services and mothers of under-fives who received health information [ 24 ]. Different studies suggest that community education and mobilization campaigns may increase level of awareness of communities. One study also reported that HEWs and HDA were credible sources of health-related information [ 25 , 26 ]. For example, the HEW increased the awareness of communities during pregnant woman conferences, vaccination campaigns, and other community meetings.

This study further highlights that, socioeconomic barriers to health care utilization are strong deterrents that increase under-five mortality in Ethiopia. Limited financial resources for medical treatment and low educational level of parents are barriers to the use of healthcare services for children among disadvantaged populations. In this regard, the Ethiopian government plans to provide free health services for women and under-five children, through the HSTP. II but our finding revealed that low household income, low level of maternal education, and out-of- pocket payments for health care prevent poorer people from using services for under-five children. Furthermore it should be noted that the government of Ethiopia has adopted a waiver fee policy for the vulnerable groups. However, cost of services still play a major role in access to service since the exemption from paying for the services is unevenly applied.

Several studies corroborate our findings of the socioeconomic impact on health service utilization [ 27 , 28 ]. A study conducted by Daniel et al. confirmed that the levels of household income and health literacy affect access to healthcare services [ 27 ]. Moreover, indirect costs such as loss of work time, loss of income and transportation cost have a significant economic impact on poorer families [ 28 ]. Implementing health insurance scheme and waiving user fees may shield the poor from these charges and weaken household health budget constraints.

Our findings of the negative impact of low education of parents is corroborated by several studies. [ 29 , 30 ]. Pregnant mothers with higher education are more aware of the significance of good nutrition and child care as well as the prerequisites for being healthy [ 31 ]. Education plays a vital role in shaping attitudes, opinions, customs, and norms and also promotes the adoption of new ideas and values.

The result of our study revealed that, distance from health facility, lack of transportation and uncomfortable road topography especially in summer were mentioned as an important barriers of equity in healthcare service utilization for under –five children. Previous studies in Ethiopia confirmed that far to reach regions, districts and areas often face special issues and problems compared to non-far to reach areas [ 32 , 33 ]. Several studies in other countries also showed that travelling to a health center was challenging for caregivers of children residing in far to reach areas and cost of transportation, unreliability and its unavailability of services were the main impairments of equity in accessing healthcare services [ 34 , 35 , 36 , 37 , 38 ]. For example, a study of measles vaccination coverage in various African countries found that distance was a key factor in determining the level of immunization coverage [ 39 , 40 , 41 ]. In addition to the inverse relationship between distance and health services utilization, geographical location of health facilities in isolated rural areas also jeopardizes the staffing of health facilities. Doctors, midwifes and nurses are less eager to serve in such areas than in urban communities and vaccines and flooding may prevent the delivery of vaccines and drugs to distant mountain communities during the rainy season.

Respondents highlighted the need to ensure reliable availability of HEWs at the health post during opening hours and extending the hours of the health post so that services would be available working hours and on weekends. Such closures have been shown to be a major challenge in previous studies [ 42 ]. HEWs travel for activities such as collecting taxes registering political membership from the residential and payment for health insurance from the community should be stunned by the community and so that there is at least one HEW in each health post to give services for the community . Another important finding from this study was issue of marginalized populations. Some key-informant and FGD discussant cited that, the health facility is not have especial plan to address the services to marginalized poor people, like, baggers around the church, mosques and around roads on child health services especially for immunization services. Hence this may create critical inequity in child healthcare service utilization among the poor.

Barriers to equity in access and utilization of services extend beyond accessibility and availability issues, disrespectful care and negative attitude acts as a barrier to accessing health care services. Negative attitude of health workers in the form of verbal expression, represented a theme of recurrence as a barrier of equity in utilization of the services. Female FGD discussant raised the issue of non-compassionate and disrespectful care given to them by health professionals at health facility and they were receiving poor quality of care, and there is no companionate care for the poor. Improving quality and outcomes at health centers offers an incentive for the utilization of a service. In many African countries, low quality of health services has been identified as a hindrance to equitable access of services [ 43 ]. In the current study, few participants mentioned that cultural factors like home remedies taking the children to traditional healers were obstacles to utilization equity. Other studies from Sub-Saharan Africa show similar results [ 44 ]. This shows that, traditional beliefs and norms of the community impede from seeking-care modern healthcare and utilization of the services from health facility.

One of the promising finding in this study was, even though Ethiopia have a diversified ethnic group there is no report related disparity or inequity in utilization of child health services because of his/her ethnicity, rather they encounter barrier related to language in understanding and to get consultation from service provider.

Our finding revealed that, war and political instability disrupt health services accessibility and utilization. There was also reported from several other countries, including Afghanistan, the Democratic Republic of Congo, Pakistan, and Somalia [ 45 ]. Key impacts include disrupted infrastructure and supply chain; violence against health workers; difficulties retaining health workers; delivery service interruptions; and displacement and migration [ 46 ]. For populations affected by military conflict, adopting flexibility surrounding age and eligibility criteria can increase immunization coverage.

Strength and limitation of this study

Strengths of this study include the collection of data by experienced interviewers, efforts made to increase trustworthiness of the study, checking transcripts against audio-records and field notes by two independent experts, and use of the participants’ own language for data collection. In addition, inclusion of participants from all levels of the healthcare system and caregivers (both mothers and father) of the children broadened the range of experiences and opinions on inequity in child health services accessibility and utilization. The major limitation of this qualitative study is that its findings are may not be generalized to other settings. Furthermore, since the study was only conducted in one district, it might not be representative of the entire nation.

Conclusions and recommendations

We conclude that inequity in child healthcare utilization continues to be an important challenge confronting Ethiopia. Constraints such as poor community awareness of the availability of curative healthcare services, geographic inaccessibility, inadequate healthcare resources, socioeconomic barriers, and constraints related to the functioning of the healthcare system and political instability and military conflict were the most cited barriers to equity.

To achieve equity, Ethiopian policymakers and partners need to invest in health infrastructure, including bringing services closer to people by constructing new health posts, health centers and roads in rural areas, and increasing the quality of services. In addition, context-specific cultural barriers such as the use of traditional medicines and illness beliefs need to be addressed through health promotion and military conflict needs to be solved through dialog between opposing bodies.

Availability of data and materials

The data that support the finding of this study are available and attached as related files.

Abbreviations

Certificate of competency

Compassionate respectful care

Focus group discussion

Federal Ministry of Health

Health care workers

Health extension workers

Key-informant interview

Maternal and child health

Millennium developmental goals

Oromia Regional Health Bureau

Primary health care

United Nations

Berndt DJ, Fisher JW, Rajendrababu RV, Studnicki J. Measuring healthcare inequities using the Gini index. In: System Sciences, Proceedings of the 36th Annual Hawaii International Conference on IEEE. 2003. p. 10.

Google Scholar  

Hosseinpoor AR, Bergen N, Schlotheuber A, Williams JS. Monitoring health determinants with an equity focus, promoting health equity: WHO health inequality monitoring at global and national levels. Glob Health Action. 2015;8:1–8. https://doi.org/10.3402/gha.v8.29034 .

Article   Google Scholar  

United Nations. Transforming our world: the 2030 agenda for sustainable development. In: A new era in global health. 2018. https://doi.org/10.1891/9780826190123.ap02 .

Chapter   Google Scholar  

Houweling TAJ, Looman CWN, Azad K, et al. Neonatal and child mortality: the equity impact of community women’s groups to reduce neonatal mortality: a meta- analysis of four cluster randomized trials. Int J Epidemiol. 2019;48(1):168–82. https://doi.org/10.1093/ije/dyx160 .

Article   PubMed   Google Scholar  

Assefa Y, Gelaw YA, Hill PS, Taye BW, Damme W. Van community health extension program of Ethiopia, 2003–2018:successes and challenges toward universal coverage for primary healthcare services. Glob Health. 2019;15:24.

Federal Ministry of Health of Ethiopia. Health sector transformation plan (2015/16–2019/20). Addis Ababa: Ministry of Health of Ethiopia; 2015. p. 1–118.

Dhaliwal LK. Health equity and sustainable development goals: role and the complexity. In: Filho WL, editor. Good health and well-being. Cham: Springer Nature Switzerland AG; 2019. p. 316–24.

Boerma T, Requejo J, Victora CG, Amouzou A, George A, Agyepong I, Barroso C, Barros AJD, Bhutta ZA, Black RE, et al. Countdown to 2030 collaboration review countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Lancet. 2018;391:1538–48.

Ethiopian Public Health Institute (EPHI) [Ethiopia]; ICF. Ethiopia mini demographic and health survey 2019: key indicators. Rockville: EPHI;ICF; 2019.

Bergen N, Zhu G, Yedenekal SA, Mamo A, Abebe Gebretsadik L, Morankar S, Labonté R. Promoting equity in maternal, newborn and child health–how does gender factor in? Perceptions of public servants in the Ethiopian health sector. Glob Health Action. 2020;13: 1704530.

Article   PubMed   PubMed Central   Google Scholar  

Okwaraji YB, Cousens S, Berhane Y, Mulholland K, Edmond K. Effect of geographical access to health facilities on child mortality in Rural Ethiopia: a community based cross sectional study. PLoS One. 2012;7(3):e33564. https://doi.org/10.1371/journal.pone.0033564 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Wuneh AD, Medhanyie AA, Bezabih AM, Persson LÅ, Schellenberg J, Okwaraji YB. Wealth-based equity in maternal, neonatal, and child health services utilization: a cross-sectional study from Ethiopia. Int J Equity Health. 2019;18(1):1–9.

Tiruneh FN, Chuang K, Chuang Y. Women ’ s autonomy and maternal healthcare service utilization in Ethiopia. BMC Health Serv Res. 2017;17(718):1–12.

UNICEF. 2014, Level and trends in child mortality. New York: UNICEF; 2014.

Frankenberg E. The effects of access to health care on infant mortality in Indonesia. Health Transit Rev. 1995;5:14363.

Amooti-Kaguna B, Nuwaha F. Factors influencing choice of delivery sites in Rakai district of Uganda. Soc Sci Med. 2000;50:20313.

Federal Ministry of Health of Ethiopia. Essential health services package of Ethiopia. Addis Ababa: Ministry of Health of Ethiopia; 2019.

Stock R. Distance and the utilization of health facilities in rural Nigeria. Soc Sci Med. 1983;17:56370.

Bulage P, Urdal H, Sundby J. A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda. BMC Pregnancy Childbirth. 2015;15:18.

Murray CJL, King G, Lopez AD, Tomijima N, Krug EG. Armed conflict as a public health problem. BMJ. 2002;324(7333):346–9. https://doi.org/10.1136/bmj.324.7333.346 . PMID: 11834565.

Key-informant and focus group guiding tools.

Tesfaye G, Chojenta C, Smith R, Loxton D. Delaying factors for maternal health service utilization in eastern Ethiopia: a qualitative exploratory study. Women Birth. 2020;33(3):e216–226. https://doi.org/10.1016/j.wombi.2019.04.006 .

Shaw B, Amouzou A, Miller NP, et al. Determinants of utilization of health extension workers in the context of scale-up of integrated community case management of childhood illnesses in Ethiopia. Am J Trop Med Hyg. 2015;93:636–47.

Yitayal M, Berhane Y, Worku A, Kebede Y. Health extension program factors, frequency of household visits and being model households, improved utilization of basic health services in Ethiopia. BMC Health Serv Res. 2014;14:156.

Save the children report, Rapid Assessment of Determinants, Factors and Opportunities to Early Pregnancy Identification, Focused Antenatal Care, Skilled Birth Attendance and Postnatal Care Service Utilization in Gurage and Sidama Zones of SNNPR. Addis Ababa; 2015.

Central Statistical Agency [Ethiopia] and ICF International. Ethiopia demographic and health survey. 2016.

Daniel H, Bornstein SS, Kane GC, Health and Public Policy Committee of the American College of Physicians*. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med. 2018;168(8):577–8.

Eide AH, Mannan H, Khogali M, et al. Perceived barriers for accessing health services among individuals with disability in four African countries. PLoS One. 2015;10(5):e0125915.

Mirowsky J, Ross CE. Education, social status, and health. Routledge; 2017.

Book   Google Scholar  

Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97–107.

Sayakhot P, Carolan-Olah M. Internet use by pregnant women seeking pregnancy-related information: a systematic review. BMC Pregnancy Childbirth. 2016;16:65.

Defar A, Okwaraji YB, Tigabu Z, et al. Geographic differences in maternal and child health care utilization in four Ethiopian regions; a cross-sectional study. Int J Equity Health. 2019;18:173. https://doi.org/10.1186/s12939-019-1079-y .

Geremew TT, Gezie LD, Abejie AN. Geographical variation and associated factors of childhood measles vaccination in Ethiopia: a spatial and multilevel analysis. BMC Public Health. 2019;19:1194. https://doi.org/10.1186/s12889-019-7529-z .

Sritart H, Tuntiwong K, Miyazaki H, Taertulakarn S. Disparities in healthcare services and spatial assessments of mobile health clinics in the border regions of Thailand. Int J Environ Res Public Health. 2021;18(20):10782.

Gazzeh K, Abubakar IR. Regional disparity in access to basic public services in Saudi Arabia: a sustainability challenge. Utilities Policy. 2018;52:70–80.

Yourkavitch J, Burgert-Brucker C, Assaf S, Delgado S. Using geographical analysis to identify child health inequality in sub-saharan Africa. PLoS One. 2018;13(8):e0201870.

Bright T, Felix L, Kuper H, et al. A systematic review of strategies to increase access to health services among children in low and middle income countries. BMC Health Serv Res. 2017;17:252. https://doi.org/10.1186/s12913-017-2180-9 .

Tefera W, Tesfaye H, Bekele A, Kayessa E, Waltensperger KZ, Marsh DR. Factors influencing the low utilization of curative child health services in Shebedino District, Sidama Zone, Ethiopia. Ethiop Med J. 2014;52 Suppl 3:109–17.

PubMed   Google Scholar  

Metcalf CJE, Tatem A, Bjornstad ON, Lessler J, O’Reilly K, Takahashi S, et al. Transport networks and inequities in vaccination: remoteness shapes measles vaccine coverage and prospects for elimination across Africa. Epidemiol Infect. 2015;143(7):1457–66.

Article   CAS   PubMed   Google Scholar  

Levine O, Lemango ET, Bernson J, Gurley N, Rowley E, McIlvaine B. ERG Discussion paper No. 8. Tackling inequities in immunization outcomes in remote rural contexts. Equity Reference Group for Immunization; 2018. https://sites.google.com/view/erg4immunisation/discussion-papers . Accessed 6 Sept 2019.

Colvin CJ, Smith HJ, Swartz A, Ahs JW, De Heer J, Opiyo N, Kim JC, Marraccini T, George A. Understanding careseeking for child illness in sub-saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria. Soc Sci Med. 2013;86:66–78.

Shaw B, Amouzou A, Miller NP, Tafesse M, Bryce J, Surkan PJ. Access to integrated community case management of childhood illnesses services in rural Ethiopia: a qualitative study of the perspectives and experiences of caregivers. Health Policy and Planning. 2016;31(5):656–66. https://doi.org/10.1093/heapol/czv115 .

Kuwana MR. Barriers to accessing health care services for children with disabilities in Southern Africa: The case of Namibia. 2014. https://api.semanticscholar.org/CorpusID:68841196 .

Konje ET, Hatfield J, Kuhn S, Sauve RS, Magoma M, Dewey D. Is it home delivery or health facility? Community perceptions on place of childbirth in rural Northwest Tanzania using a qualitative approach. BMC Pregnancy Childbirth. 2020;20:270.

Nnadi C, Etsano A, Uba B, Ohuabunwo C, Melton M, Wa Nganda G, et al. Approaches to vaccination among populations in areas of conflict. J Infect Dis. 2017;216:S368–72.

Okwo-Bele JM, Conner R, McIlvaine B, Rowley E, Bernson J. ERG Discussion paper No. 6. Tackling inequities in immunization outcomes in conflict contexts. Equity Reference Group for Immunization; 2018. https://sites.google.com/view/erg4immunisation/discussion-papers . Accessed 6 Sept 2019.

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Acknowledgements

The authors would like to thank the study participants, the Federal Ministry of Health, regional health bureaus, and zonal and district level health leaders. We also acknowledge Addis Ababa University and Professor Helmut Kloos for funding this study.

Addis Ababa University School of Public Health, and support from Professor Helmut Kloos.

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Hailu Fekadu

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Wubegzier Mekonnen & Damen Hailemariam

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Contributions

H.F and D.H contributed to the design and conception of the study and analyzed and interpreted the data. W.M, H.K, and A.A participated in data analysis, interpretation and revision of the manuscript. All authors read and revised the draft of this manuscript and approved the final version.

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A written ethical approval for the study was obtained from the Institutional Review Board (IRB) of the College of Health Sciences at Addis Ababa University (Ref. No. 046/22/SPH). In addition a verbal informed consent was obtained from all interviewees and focus group discussion participants. All of the respondents were informed that their participation in the study was voluntary, and that the data would be stored safely, without identifiers, and would only be accessed by the involved researchers. All methods were carried out in accordance with relevant institutional guidelines and regulations.

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Fekadu, H., Mekonnen, W., Adugna, A. et al. Barriers to equitable healthcare services for under-five children in Ethiopia: a qualitative exploratory study. BMC Health Serv Res 24 , 613 (2024). https://doi.org/10.1186/s12913-024-11074-0

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Kutscher E , Arshed A , Greene RE , Kladney M. Exploring Anabolic Androgenic Steroid Use Among Cisgender Gay, Bisexual, and Queer Men. JAMA Netw Open. 2024;7(5):e2411088. doi:10.1001/jamanetworkopen.2024.11088

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Exploring Anabolic Androgenic Steroid Use Among Cisgender Gay, Bisexual, and Queer Men

• 1 Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
• 2 NYU Grossman School of Medicine, New York, New York
• 3 Bellevue Hospital Center, New York, New York

Question   How and why do cisgender gay, bisexual, and queer men use anabolic androgenic steroids (AAS), and what are their unique health care needs?

Findings   In this qualitative study of 12 men, AAS use was secondary to multifactorial motivators, including a likely AAS use disorder and muscle dysmorphia. Despite all participants experiencing harms from use, men seeking medical assistance found practitioners to be insistent on AAS cessation and, thus, developed their own harm reduction techniques.

Meaning   Cisgender gay, bisexual, and queer men using AAS reported insufficient medical support, suggesting that further research is warranted on the utility of practitioner education, the safety and efficacy of community-developed harm reduction methods, and the impact of AAS decriminalization on health care outcomes for this patient population.

Importance   Anabolic androgenic steroids (AAS) are disproportionately used by sexual minority men, with the physical and mental health implications of AAS use incompletely understood.

Objective   To understand the reasons for use and health care needs of gay, bisexual, and queer cisgender men using AAS.

Design, Setting, and Participants   This qualitative study was conducted from November 2021 to May 2023 using self-administered questionnaires and semistructured interviews that were transcribed and coded using reflexive thematic analysis. Participants were recruited through convenience and snowball sampling from lesbian, gay, bisexual, transgender, and queer clinical centers in New York, New York, as well as through online platforms. All patients self-identified as cisgender and gay, bisexual, or queer.

Exposures   History of nonprescribed AAS use for a minimum of 8 consecutive weeks was required.

Main Outcomes and Measures   The primary outcomes were reasons for and health implications of AAS use and interactions with health care practitioners, as determined through interviews. Interview transcripts were collected and analyzed.

Results   Thematic saturation was reached after interviews with 12 male participants (mean [SD] age, 44 [11] years), with the majority of participants identifying as gay (10 participants [83%]), White non-Hispanic (9 participants [75%]), being in their 30s and 40s (9 participants [75%]), holding a bachelor’s degree or higher (11 participants [92%]), and having used steroids for a mean (SD) of 7.5 (7.1) years. One participant (8%) self-identified as Black, and 2 (17%) identified as Hispanic. Seven men (58%) met the criteria for muscle dysmorphia on screening. Nine overarching themes were found, including internal and external motivators for initial use, continued use because of effectiveness or fear of losses, intensive personal research, physical and emotional harms experienced from use, using community-based harm reduction techniques, frustration with interactions with the medical community focused on AAS cessation, and concerns around the illegality of AAS.

Conclusions and Relevance   In this qualitative study, AAS use among cisgender gay, bisexual, and queer men was found to be associated with multifactorial motivators, including a likely AAS use disorder and muscle dysmorphia. Despite all participants experiencing harms from use, men seeking medical help found insufficient support with practitioners insistent on AAS cessation and, thus, developed their own harm reduction techniques. Further research is needed to assess the utility of practitioner education efforts, the safety and efficacy of community-developed harm reduction methods, and the impact of AAS decriminalization on health care outcomes for this patient population.

Anabolic androgenic steroids (AAS) are synthetic testosterones used by approximately 2.9 to 4.0 million US residents at least once, with 1 million developing AAS dependence. 1 AAS use disproportionately impacts gay, bisexual, and queer (GBQ) men, with 5.0% to 13.5% of gay and bisexual men reporting use, and up to 25.0% considering use. 2 , 3 Although many motivations exist for AAS use, improving physical appearance and gaining muscle and strength are the most common. 4 Among GBQ men, the history of HIV and prescriptions for AAS for HIV wasting syndrome, 5 views on masculinity, 6 gender role strain and internalized homophobia, 7 increased pressures to obtain an ideal male physique, and overemphasis on appearance and desirability 8 , 9 are cited as additional factors.

Despite widespread use, the health impacts of AAS remain incompletely understood. Although AAS is associated with increased risk of acquiring hepatitis B and C viruses, 10 its role in coronary artery disease, 11 , 12 stroke, 13 , 14 and the risk of developing prostate cancer remain poorly characterized. 15 Remarkably, gay men using AAS have a prevalence of HIV 39 times greater than that of the general population, although many acquire the virus before initiating AAS. 10 GBQ men using AAS have higher self-reported rates of male-male condomless anal sex in the past year, as well as increased use of ecstasy and methamphetamines. 16

The mental health implications of AAS are also unclear. Although a diagnosis of AAS use disorder was excluded in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5 ), multiple studies have found an addiction model, including loss of control, social impairment, risky use, and pharmacologic dependence, in up to 24% of individuals using AAS. 17 - 23 AAS use has also been closely associated with muscle dysmorphia (a subtype of body dysmorphic disorder), including among cisgender sexual minority men. 24 , 25

Despite these concerns, most individuals using AAS have declined to disclose their use to a medical practitioner, and general practitioners themselves often feel underprepared when caring for patients using AAS. 26 The majority of individuals who disclose AAS use have felt discriminated against after disclosure. 4 Treatment for AAS dependence is controversial, with accepted practice ranging from psychotherapy to harm reduction to prescribed testosterone, with the unique treatment needs of GBQ men unknown. 27 - 29 Although facilitators to care for individuals using AAS have been investigated, the particular needs of GBQ men remain poorly defined. 30 This project seeks to understand the lived experiences of GBQ cisgender men using AAS in the US, with a particular focus on motivations and patterns of use, knowledge-seeking behaviors, perceived benefits and harms of use, interactions with health care practitioners, and community perspectives on how practitioners can best care for patients using AAS.

This qualitative study used semistructured interviews and self-administered questionnaires administered between November 2021 through May 2023. Inclusion criteria included cisgender adult men who self-identified as GBQ and had used AAS for at least 8 consecutive weeks at any point of their life. Exclusion criteria included active psychotic or manic symptoms, exclusive use of prescription AAS by a practitioner with use only as prescribed, and past or current prostate cancer. Participants were recruited through convenience and snowball sampling from lesbian, gay, bisexual, transgender, and queer clinical centers in New York, New York, using posters and social media platforms. Recruitment occurred until theoretical saturation was reached. 31

This study was approved by the NYU Langone Health and Bellevue Hospital Center Independent Review Boards. Participants gave written consent after reading a participant information form and were given a chance to ask questions before participation. In this article, identifying attributes are avoided. Data reporting followed Consolidated Criteria for Reporting Qualitative Research ( COREQ ) reporting guidelines. 32

Participants self-administered a demographics questionnaire and a screening questionnaire testing for muscle dysmorphia, the Muscle Dysmorphic Disorder Inventory, 33 , 34 using REDCap. 35 , 36 One of 2 authors with no prior patient relationship (E.K., a cisgender gay White man, or A.A., a cisgender gay South Asian man) conducted interviews either in person or through a Health Insurance Portability and Accountability Act–secured videoconferencing platform. Interviews were approximately 1 hour long, with 1 participant requesting a brief follow-up interview, and were audio recorded and transcribed using a computer-based transcription system (Otter.ai; Otter). Authors wrote field notes after each interview. All participants were compensated with $100 gift card. Participants’ race and ethnicity were self-identified and were included in this study to assess for the generalizability of our findings.

The authors developed an interview guide using concept elicitation questioning, highlighting topics found to be important in prior research. Two preliminary interviews were conducted with this guide, after which modifications were made to enhance the flow and clarity of interviews.

Interviews were evaluated through the reflexive thematic analysis approach, as described by Braun et al, 37 following inductive reasoning. Two reviewing authors (E.K. and M.K.) familiarized themselves with the transcripts and developed coding for all interviews independently using Atlas.ti version 22 (ATLAS.ti Scientific Software Development GmbH) to categorize responses, then harmonizing their categorization to create consensus themes. The 2 reviewing authors then developed and reviewed these themes, followed by refining, defining, and naming themes. Both authors acknowledged their identity as cisgender White gay men, critically evaluating their analyses to assess for bias. Finally, themes were woven together with data extracts and shared among the entire research team for consensus. Questionnaires were reviewed, with a Muscle Dysmorphic Disorder Inventory score of 39 points considered meeting the criteria for muscle dysmorphia. 33 , 38 , 39 Participants were not provided with interview transcripts or analysis before publication.

Twelve male participants (mean [SD] age, 44 [11] years) completed semistructured interviews until thematic saturation was reached, with the majority identifying as gay (10 participants [83%]) and White non-Hispanic (9 participants [75%]), being in their 30s and 40s (9 participants [75%]), and holding a bachelor’s degree or higher (11 participants [92%]). Of our sample, 1 participant (8%) self-identified as Black, and 2 (17%) identified as Hispanic. Participants had used steroids for a mean (SD) of 7.5 (7.1) years. During recruitment, an additional 2 participants declined to partake in the study after screening, 3 participants completed screening but were then lost to follow-up, 6 did not follow up after initially reaching out to study team, and 7 did not meet inclusion criteria; possible differences in demographics between cohort participants and those lost to follow-up are unknown. Table 1 outlines the demographics of participants. Seven of the 12 participants (58%) met the criteria for muscle dysmorphia ( Table 2 ). Nine overarching themes with additional subthemes were found ( Table 3 ).

Participants reported internal and external motivations for AAS initiation. As internal motivators, some men identified childhood obesity or thinness as reasons to pursue a more muscular body in adulthood. For others, underlying body dysmorphia predated and/or motivated AAS use. Some men noted the importance of unrealistic body ideals for GBQ men and a desire to try and achieve them. Insecurities around sexual orientation and an attempt to compensate for perceived deficits in masculinity were also reported.

As external motivators, partners and peers were frequently cited as instigators for AAS use. The pressure to obtain an ideal body was most frequently reported around preparing for event in which men anticipated being shirtless around other GBQ men (such as circuit parties and gay cruises or vacation destinations). Participants repeatedly described a community that normalized and sometimes explicitly encouraged AAS use. Multiple men highlighted their work in the adult entertainment industry as practically requiring them to use AAS to be successful.

After starting AAS, most participants noticed gains and changes in their physique along with increased energy and libido that positively reinforced continued use. These gains were described by both participants who felt that AAS were working as intended and those who felt that higher doses or more intense AAS regimens were needed to obtain their goals.

Some participants felt that AAS use improved self-image sufficiently to combat preexisting muscle dysmorphia and body dissatisfaction, whereas others felt that AAS use made the dysmorphia worse by placing the power of easily changing body shape within their control. Most participants found increased external validation to be an important motivator for continued use and felt that AAS use allowed them to climb the social ladder within the GBQ community.

Multiple men expressed a need to continue AAS out of fear of discontinuation. Some felt ready to stop AAS but were scared to lose muscle gains, whereas others continued using to avoid confronting what their body looked like when not enhanced with AAS. When considering cessation of AAS, many reported a fear of a crash or withdrawal when stopping and thus continued use, whereas others noticed an unpleasant and unmanageable period of decreased energy from secondary hypogonadism that ultimately motivated them to reinitiate use.

Access to evidence-based and reliable information was almost universally desired, with most men conducting substantial amounts of research on AAS. However, data sources were often informal with information sourced from nonmedical websites, social media postings, and blogs. Peers, coaches, and suppliers were often relied on for guidance on effective regimens and methods to mitigate adverse effects. Notably, multiple men searched medical journals and peer reviewed research, extrapolating from these materials information that felt relevant to their own lives and AAS practices. These interpretations were often insightful, with participants able to explain biological mechanisms of action. Participant research was occasionally made possible from working as a health care practitioner, or more frequently from being close to a health care practitioner who used AAS and would provide friends with guidance and support. Overall, men desired more streamlined and reputable methods for information gathering.

Every participant reported at least one instance of harm they attributed to AAS use. Most commonly noted harms were cardiovascular, including hyperlipidemia, hypertension, hypertrophic cardiomyopathy, and atrial fibrillation. One man reported needing a cardioversion, which he attributed to AAS use, whereas another reported developing symptoms concerning for heart failure. Two men reported tendon ruptures requiring surgery, with an additional 3 developing tendinitis requiring physical therapy. Two participants developed cellulitis at an injection site. Multiple men reported balding, acne, testicular shrinkage, and night sweats as adverse effects.

Aside from physical harms, emotional harms were reported frequently, including difficulty with anger management, emotional instability, and worsening muscle dysmorphia. One participant reported that steroids were the root cause of his recent divorce. Men reported a concern about AAS use being perceived as cheating to obtain results and insisted that hard work at the gym was the primary reason for muscle gains. Participants frequently kept their AAS use secret out of fear of judgment or embarrassment. A sense of moral distress and self-judgment was notable, with men wondering whether their use showed an overvaluing of aesthetics and superficiality.

Men universally attempted to avoid or minimize AAS-related harms through harm reduction methods. Participants prioritized obtaining AAS from seemingly reliable sources, inspecting labels for any evidence of tampering or low-quality manufacturing. Men learned sterile injection techniques, obtaining supplies for injecting from health care supply warehouses, online, or through needle exchange programs. Men regularly planned schedules with cycling, or having discrete periods of steroid use followed by abstinence. At the end of a cycle, men reported using postcycle therapy (often clomiphene) to induce endogenous testosterone production and minimize the risk of secondary hypogonadism. All men routinely checked bloodwork, monitoring blood counts, kidney and liver function, prostate-specific antigen levels, and cholesterol levels. A few reported daily checks of their blood pressure or blood glucose levels. Cardiovascular exercise was often considered protective. A minority of participants hired nonmedical coaches to monitor their cycles to optimize overall safety. Most participants noted that steroid use had increased their libido and the number of sexual encounters. However, participants used preexposure prophylaxis (PrEP) for HIV prevention and attributed an increase in condomless sexual activity and increased number of sexual partners more to PrEP than to AAS use.

Participants commonly used additional nonprescribed medications to mitigate the effects of steroid use. For example, some men reported taking aromatase inhibitors and selective estrogen receptor modulators to decrease gynecomastia. Aspirin was thought to decrease the risk of blood clots and strokes from polycythemia, with participants also opting to donate blood to decrease blood counts. Many took prescribed or nonprescribed statins to decrease cholesterol. One participant purchased nonprescribed telmisartan to decrease his risk of developing hypertrophic cardiomyopathy.

Study participants reported discontentment and distrust of the medical system, with real and perceived stigma preventing multiple participants from disclosing steroid use. For participants who did disclose, there was a sense of dissatisfaction with practitioner knowledge about the risks and benefits of steroid use and a discomfort with clinicians focusing exclusively on abstinence from AAS. For the participant who required a cardioversion, he withheld information on AAS use until moments before the procedure because of fear of judgment.

Facilitators to participant disclosure to health care practitioners were reported. First, men overall felt most comfortable talking about steroid use with doctors who themselves identified as GBQ or who had a large GBQ patient panel. Men perceived these clinicians as less judgmental and less likely to focus on AAS cessation or abstinence only. Participants also embraced online clinics where testosterone could be prescribed by a practitioner in a direct-to-consumer model.

When discussing how to optimize the care for individuals using AAS, the legal status of AAS as a Schedule III drug was perceived as one of the biggest barriers to care. Men were concerned that the illegality of their substance use required them to purchase from unregulated markets and to hide their use from their doctors. Participants often felt that there was an arbitrary distinction between use of AAS at physiologic vs supraphysiologic doses and that AAS use itself was more aligned with plastic surgery than with many other recreational drugs. The illegality of AAS resulted in a fear of documentation of use, with men concerned that disclosure could result in denial of disability and life insurance, refusal to prescribe AAS for secondary hypogonadism in the future, and employment consequences.

Overall, the themes from this qualitative study were similar to those found in previous research among cisgender men regardless of sexual orientation. 30 Individuals start and continue AAS for many reasons, not always for underlying body and/or muscle dysmorphia. The importance of masculinity discussed by participants overlaps with machismo views on masculinity and self-confidence, as described elsewhere. 40 - 42

Our work contributes to the literature describing the existence of an AAS use disorder, because many participants continued use despite harm owing to the efficacy of AAS and the fear of losing muscle mass if abstinent. 21 , 23 , 43 , 44 This bias toward an addictive nature may be the result of our inclusion criteria requiring a minimum of 8 weeks of use yet supports the inclusion of AAS use disorder within future iterations of the DSM .

Our study participants did not associate their AAS use with any increase in risk of acquiring HIV. Unlike Ip et al, 10 , 16 men in our study reported an increase in number of sexual partners from increased libido with steroid use, but reported consistent use of PrEP predating their AAS use, with no change in the likelihood of unprotected sex from AAS use.

Individuals using AAS desired accurate, scientifically reviewed, and comprehensive information on AAS use, with high-quality and evidence-based resources thought to be highly beneficial. The interim need to rely on peers for information instead of medical practitioners was similar to findings from other studies. 45 - 47

Participants perceived that disclosure to health care practitioners could be more harmful to their care than therapeutic given the lack of knowledge of most health care practitioners and the repercussions of medical record documentation, thus highlighting the urgent need for enhanced practitioner education and use of empathetic approaches to care for sexual minority men using AAS. 9 Abstinence-focused models of care for individuals using AAS did not appear to be efficacious for participants in our study, because all men experienced harm from AAS but continued to use nonetheless. Participants who disclosed AAS use often perceived messages focused on cessation as bias and discrimination, leading to decisions to forgo future medical care. Further research can assess the acceptability of more nuanced discussions about abstinence focused on the specific AAS most associated with harm, such as trenbolone. 48

In the absence of medical harm reduction guidance, participants described community-developed harm reduction techniques, with some techniques similar to those proposed as treatments for AAS dependence. 49 , 50 Community-led medical interventions have a historical role within the GBQ community, as demonstrated through the inventions of PrEP and doxycycline postexposure prophylaxis. Yet, many harm reduction techniques in our study are newly reported and require further research on their safety and efficacy.

Finally, illegality around AAS use complicates the ability for patients to obtain medical care, as similarly demonstrated by Piatkowski et al. 51 To optimize health care outcomes, future work should revisit the risks and benefits of the scheduling of AAS, as well as test methods to prevent AAS use disclosure from the electronic medical record to life and disability insurance companies.

This study has limitations that should be mentioned. We had great difficulty recruiting for our study. Although 30 individuals contacted our research team with interest in enrollment, 18 participants ultimately were not included in the study owing to ineligibility, loss to follow-up, or declining to participate after initial screening. The final cohort of participants was predominantly White, college-educated gay men, despite outreach and recruitment in areas where traditionally marginalized individuals seek care. This is consistent with prior research showing that men in the US using AAS were typically White, highly educated, and with an above-average income. 52 It is unknown whether this cohort reflects the demographics of the GBQ population using AAS given the substantial cost and knowledge that participants relied on to use AAS, or whether our results are subject to a sampling bias.

In this qualitative study, AAS use among GBQ men was found to be the result of multifactorial motivators, including a likely AAS use disorder and muscle dysmorphia. Despite all participants experiencing harms from use, men seeking help found insufficient health care support from practitioners insistent on AAS cessation and, thus, developed their own harm reduction techniques. Further research is warranted to assess for the utility of physician education efforts, the efficacy and safety of community-developed harm reduction methods, and the impact of AAS decriminalization on health care outcomes for this patient population.

Accepted for Publication: March 12, 2024.

Published: May 14, 2024. doi:10.1001/jamanetworkopen.2024.11088

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Kutscher E et al. JAMA Network Open .

Corresponding Author: Eric Kutscher, MD, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, 17 E 102nd St, 6th Floor, New York, NY 10029 ( [email protected] ).

Author Contributions: Drs Kutscher and Kladney had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kutscher, Arshed.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Arshed, Greene, Kladney.

Obtained funding: Kutscher.

Administrative, technical, or material support: Kutscher, Greene, Kladney.

Supervision: Arshed, Greene, Kladney.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was supported with funding from the TULA Health Research Fellowship. Additional support for the project was provided through mentorship in the Research in Addiction Medicine Scholars Program (National Institute on Drug Abuse grant R25DA033211), the NYU Clinical and Translational Sciences Institute (National Institutes of Health grant UL 1TR001445), and tuition support through the Health Resources and Services Administration (grant T25HP37605).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See the Supplement .

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