example of introduction in qualitative research

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How to Write a Research Paper Introduction (with Examples)

The research paper introduction section, along with the Title and Abstract, can be considered the face of any research paper. The following article is intended to guide you in organizing and writing the research paper introduction for a quality academic article or dissertation.

The research paper introduction aims to present the topic to the reader. A study will only be accepted for publishing if you can ascertain that the available literature cannot answer your research question. So it is important to ensure that you have read important studies on that particular topic, especially those within the last five to ten years, and that they are properly referenced in this section. 1 What should be included in the research paper introduction is decided by what you want to tell readers about the reason behind the research and how you plan to fill the knowledge gap. The best research paper introduction provides a systemic review of existing work and demonstrates additional work that needs to be done. It needs to be brief, captivating, and well-referenced; a well-drafted research paper introduction will help the researcher win half the battle.

The introduction for a research paper is where you set up your topic and approach for the reader. It has several key goals:

• Present your research topic
• Capture reader interest
• Summarize existing research
• Position your own approach
• Define your specific research problem and problem statement
• Highlight the novelty and contributions of the study
• Give an overview of the paper’s structure

The research paper introduction can vary in size and structure depending on whether your paper presents the results of original empirical research or is a review paper. Some research paper introduction examples are only half a page while others are a few pages long. In many cases, the introduction will be shorter than all of the other sections of your paper; its length depends on the size of your paper as a whole.

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Table of Contents

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The introduction in a research paper is placed at the beginning to guide the reader from a broad subject area to the specific topic that your research addresses. They present the following information to the reader

• Scope: The topic covered in the research paper
• Context: Background of your topic
• Importance: Why your research matters in that particular area of research and the industry problem that can be targeted

The research paper introduction conveys a lot of information and can be considered an essential roadmap for the rest of your paper. A good introduction for a research paper is important for the following reasons:

• It stimulates your reader’s interest: A good introduction section can make your readers want to read your paper by capturing their interest. It informs the reader what they are going to learn and helps determine if the topic is of interest to them.
• It helps the reader understand the research background: Without a clear introduction, your readers may feel confused and even struggle when reading your paper. A good research paper introduction will prepare them for the in-depth research to come. It provides you the opportunity to engage with the readers and demonstrate your knowledge and authority on the specific topic.
• It explains why your research paper is worth reading: Your introduction can convey a lot of information to your readers. It introduces the topic, why the topic is important, and how you plan to proceed with your research.
• It helps guide the reader through the rest of the paper: The research paper introduction gives the reader a sense of the nature of the information that will support your arguments and the general organization of the paragraphs that will follow. It offers an overview of what to expect when reading the main body of your paper.

What are the parts of introduction in the research?

A good research paper introduction section should comprise three main elements: 2

• What is known: This sets the stage for your research. It informs the readers of what is known on the subject.
• What is lacking: This is aimed at justifying the reason for carrying out your research. This could involve investigating a new concept or method or building upon previous research.
• What you aim to do: This part briefly states the objectives of your research and its major contributions. Your detailed hypothesis will also form a part of this section.

How to write a research paper introduction?

The first step in writing the research paper introduction is to inform the reader what your topic is and why it’s interesting or important. This is generally accomplished with a strong opening statement. The second step involves establishing the kinds of research that have been done and ending with limitations or gaps in the research that you intend to address. Finally, the research paper introduction clarifies how your own research fits in and what problem it addresses. If your research involved testing hypotheses, these should be stated along with your research question. The hypothesis should be presented in the past tense since it will have been tested by the time you are writing the research paper introduction.

The following key points, with examples, can guide you when writing the research paper introduction section:

• Highlight the importance of the research field or topic
• Describe the background of the topic
• Present an overview of current research on the topic

Example: The inclusion of experiential and competency-based learning has benefitted electronics engineering education. Industry partnerships provide an excellent alternative for students wanting to engage in solving real-world challenges. Industry-academia participation has grown in recent years due to the need for skilled engineers with practical training and specialized expertise. However, from the educational perspective, many activities are needed to incorporate sustainable development goals into the university curricula and consolidate learning innovation in universities.

• Reveal a gap in existing research or oppose an existing assumption
• Formulate the research question

Example: There have been plausible efforts to integrate educational activities in higher education electronics engineering programs. However, very few studies have considered using educational research methods for performance evaluation of competency-based higher engineering education, with a focus on technical and or transversal skills. To remedy the current need for evaluating competencies in STEM fields and providing sustainable development goals in engineering education, in this study, a comparison was drawn between study groups without and with industry partners.

• State the purpose of your study
• Highlight the key characteristics of your study
• Describe important results
• Highlight the novelty of the study.
• Offer a brief overview of the structure of the paper.

Example: The study evaluates the main competency needed in the applied electronics course, which is a fundamental core subject for many electronics engineering undergraduate programs. We compared two groups, without and with an industrial partner, that offered real-world projects to solve during the semester. This comparison can help determine significant differences in both groups in terms of developing subject competency and achieving sustainable development goals.

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The purpose of the research paper introduction is to introduce the reader to the problem definition, justify the need for the study, and describe the main theme of the study. The aim is to gain the reader’s attention by providing them with necessary background information and establishing the main purpose and direction of the research.

The length of the research paper introduction can vary across journals and disciplines. While there are no strict word limits for writing the research paper introduction, an ideal length would be one page, with a maximum of 400 words over 1-4 paragraphs. Generally, it is one of the shorter sections of the paper as the reader is assumed to have at least a reasonable knowledge about the topic. 2 For example, for a study evaluating the role of building design in ensuring fire safety, there is no need to discuss definitions and nature of fire in the introduction; you could start by commenting upon the existing practices for fire safety and how your study will add to the existing knowledge and practice.

When deciding what to include in the research paper introduction, the rest of the paper should also be considered. The aim is to introduce the reader smoothly to the topic and facilitate an easy read without much dependency on external sources. 3 Below is a list of elements you can include to prepare a research paper introduction outline and follow it when you are writing the research paper introduction. Topic introduction: This can include key definitions and a brief history of the topic. Research context and background: Offer the readers some general information and then narrow it down to specific aspects. Details of the research you conducted: A brief literature review can be included to support your arguments or line of thought. Rationale for the study: This establishes the relevance of your study and establishes its importance. Importance of your research: The main contributions are highlighted to help establish the novelty of your study Research hypothesis: Introduce your research question and propose an expected outcome. Organization of the paper: Include a short paragraph of 3-4 sentences that highlights your plan for the entire paper

Cite only works that are most relevant to your topic; as a general rule, you can include one to three. Note that readers want to see evidence of original thinking. So it is better to avoid using too many references as it does not leave much room for your personal standpoint to shine through. Citations in your research paper introduction support the key points, and the number of citations depend on the subject matter and the point discussed. If the research paper introduction is too long or overflowing with citations, it is better to cite a few review articles rather than the individual articles summarized in the review. A good point to remember when citing research papers in the introduction section is to include at least one-third of the references in the introduction.

The literature review plays a significant role in the research paper introduction section. A good literature review accomplishes the following: Introduces the topic – Establishes the study’s significance – Provides an overview of the relevant literature – Provides context for the study using literature – Identifies knowledge gaps However, remember to avoid making the following mistakes when writing a research paper introduction: Do not use studies from the literature review to aggressively support your research Avoid direct quoting Do not allow literature review to be the focus of this section. Instead, the literature review should only aid in setting a foundation for the manuscript.

Remember the following key points for writing a good research paper introduction: 4

• Avoid stuffing too much general information: Avoid including what an average reader would know and include only that information related to the problem being addressed in the research paper introduction. For example, when describing a comparative study of non-traditional methods for mechanical design optimization, information related to the traditional methods and differences between traditional and non-traditional methods would not be relevant. In this case, the introduction for the research paper should begin with the state-of-the-art non-traditional methods and methods to evaluate the efficiency of newly developed algorithms.
• Avoid packing too many references: Cite only the required works in your research paper introduction. The other works can be included in the discussion section to strengthen your findings.
• Avoid extensive criticism of previous studies: Avoid being overly critical of earlier studies while setting the rationale for your study. A better place for this would be the Discussion section, where you can highlight the advantages of your method.
• Avoid describing conclusions of the study: When writing a research paper introduction remember not to include the findings of your study. The aim is to let the readers know what question is being answered. The actual answer should only be given in the Results and Discussion section.

To summarize, the research paper introduction section should be brief yet informative. It should convince the reader the need to conduct the study and motivate him to read further. If you’re feeling stuck or unsure, choose trusted AI academic writing assistants like Paperpal to effortlessly craft your research paper introduction and other sections of your research article.

1. Jawaid, S. A., & Jawaid, M. (2019). How to write introduction and discussion. Saudi Journal of Anaesthesia, 13(Suppl 1), S18.

2. Dewan, P., & Gupta, P. (2016). Writing the title, abstract and introduction: Looks matter!. Indian pediatrics, 53, 235-241.

3. Cetin, S., & Hackam, D. J. (2005). An approach to the writing of a scientific Manuscript1. Journal of Surgical Research, 128(2), 165-167.

4. Bavdekar, S. B. (2015). Writing introduction: Laying the foundations of a research paper. Journal of the Association of Physicians of India, 63(7), 44-6.

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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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Last Update: September 18, 2022 .

• Introduction

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. [1] Instead of collecting numerical data points or intervening or introducing treatments just like in quantitative research, qualitative research helps generate hypothenar to further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a standalone study, purely relying on qualitative data, or part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and applications of qualitative research.

Qualitative research, at its core, asks open-ended questions whose answers are not easily put into numbers, such as "how" and "why." [2] Due to the open-ended nature of the research questions, qualitative research design is often not linear like quantitative design. [2] One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. [3] Phenomena such as experiences, attitudes, and behaviors can be complex to capture accurately and quantitatively. In contrast, a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a particular time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify, and it is essential to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore "compete" against each other and the philosophical paradigms associated with each other, qualitative and quantitative work are neither necessarily opposites, nor are they incompatible. [4] While qualitative and quantitative approaches are different, they are not necessarily opposites and certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated.

Qualitative Research Approaches

Ethnography

Ethnography as a research design originates in social and cultural anthropology and involves the researcher being directly immersed in the participant’s environment. [2] Through this immersion, the ethnographer can use a variety of data collection techniques to produce a comprehensive account of the social phenomena that occurred during the research period. [2] That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc, through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded theory

Grounded Theory is the "generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior." [5] Unlike quantitative research, which is deductive and tests or verifies an existing theory, grounded theory research is inductive and, therefore, lends itself to research aimed at social interactions or experiences. [3] [2] In essence, Grounded Theory’s goal is to explain how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is the "study of the meaning of phenomena or the study of the particular.” [5] At first glance, it might seem that Grounded Theory and Phenomenology are pretty similar, but the differences can be seen upon careful examination. At its core, phenomenology looks to investigate experiences from the individual's perspective. [2] Phenomenology is essentially looking into the "lived experiences" of the participants and aims to examine how and why participants behaved a certain way from their perspective. Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources. In contrast, Phenomenology focuses on describing and explaining an event or phenomenon from the perspective of those who have experienced it.

Narrative research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called a "thick" or "rich" description and is a strength of qualitative research. Narrative research is rife with the possibilities of "thick" description as this approach weaves together a sequence of events, usually from just one or two individuals, hoping to create a cohesive story or narrative. [2] While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be "opportunities for innovation." [2]

Research Paradigm

Research paradigms are the assumptions, norms, and standards underpinning different research approaches. Essentially, research paradigms are the "worldviews" that inform research. [4] It is valuable for qualitative and quantitative researchers to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontologies and epistemologies. Ontology is defined as the "assumptions about the nature of reality,” whereas epistemology is defined as the "assumptions about the nature of knowledge" that inform researchers' work. [2] It is essential to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a complete understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, researchers must understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist versus postpositivist

To further understand qualitative research, we must discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social and natural sciences. [4] Essentially, positivist thinking insists that the social sciences should use natural science methods in their research. It stems from positivist ontology, that there is an objective reality that exists that is wholly independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained, but could be approximated. [4] Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world,” and therefore, postpositivist philosophy is often associated with qualitative research. [4] An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are also constructivist, meaning they think there is no objective external reality that exists but instead that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. "Constructivism contends that individuals' views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality.” [6]  constructivist thought focuses on how "reality" is not a fixed certainty and how experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike positivist views, that there is not necessarily an "objective"reality we all experience. This is the ‘relativist’ ontological view that reality and our world are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.” [4]

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have. It can even change the role of the researchers. [2] For example, is the researcher an "objective" observer, such as in positivist quantitative work? Or is the researcher an active participant in the research, as in postpositivist qualitative work? Understanding the philosophical base of the study undertaken allows researchers to fully understand the implications of their work and their role within the research and reflect on their positionality and bias as it pertains to the research they are conducting.

Data Sampling 

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors. The following are examples of participant sampling and selection: [7]

• Purposive sampling- selection based on the researcher’s rationale for being the most informative.
• Criterion sampling selection based on pre-identified factors.
• Convenience sampling- selection based on availability.
• Snowball sampling- the selection is by referral from other participants or people who know potential participants.
• Extreme case sampling- targeted selection of rare cases.
• Typical case sampling selection based on regular or average participants. 

Data Collection and Analysis

Qualitative research uses several techniques, including interviews, focus groups, and observation. [1] [2] [3] Interviews may be unstructured, with open-ended questions on a topic, and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one-on-one and appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be participant-observers to share the experiences of the subject or non-participants or detached observers.

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or the participants' environment, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed, which may then be coded manually or using computer-assisted qualitative data analysis software or CAQDAS such as ATLAS.ti or NVivo. [8] [9] [10]

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. [11] Results could also be in the form of themes and theory or model development.

Dissemination

The healthcare team can use two reporting standards to standardize and facilitate the dissemination of qualitative research outcomes. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. [12] The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a more comprehensive range of qualitative research. [13]

Applications

Many times, a research question will start with qualitative research. The qualitative research will help generate the research hypothesis, which can be tested with quantitative methods. After the data is collected and analyzed with quantitative methods, a set of qualitative methods can be used to dive deeper into the data to better understand what the numbers truly mean and their implications. The qualitative techniques can then help clarify the quantitative data and also help refine the hypothesis for future research. Furthermore, with qualitative research, researchers can explore poorly studied subjects with quantitative methods. These include opinions, individual actions, and social science research.

An excellent qualitative study design starts with a goal or objective. This should be clearly defined or stated. The target population needs to be specified. A method for obtaining information from the study population must be carefully detailed to ensure no omissions of part of the target population. A proper collection method should be selected that will help obtain the desired information without overly limiting the collected data because, often, the information sought is not well categorized or obtained. Finally, the design should ensure adequate methods for analyzing the data. An example may help better clarify some of the various aspects of qualitative research.

A researcher wants to decrease the number of teenagers who smoke in their community. The researcher could begin by asking current teen smokers why they started smoking through structured or unstructured interviews (qualitative research). The researcher can also get together a group of current teenage smokers and conduct a focus group to help brainstorm factors that may have prevented them from starting to smoke (qualitative research).

In this example, the researcher has used qualitative research methods (interviews and focus groups) to generate a list of ideas of why teens start to smoke and factors that may have prevented them from starting to smoke. Next, the researcher compiles this data. The research found that, hypothetically, peer pressure, health issues, cost, being considered "cool," and rebellious behavior all might increase or decrease the likelihood of teens starting to smoke.

The researcher creates a survey asking teen participants to rank how important each of the above factors is in either starting smoking (for current smokers) or not smoking (for current nonsmokers). This survey provides specific numbers (ranked importance of each factor) and is thus a quantitative research tool.

The researcher can use the survey results to focus efforts on the one or two highest-ranked factors. Let us say the researcher found that health was the primary factor that keeps teens from starting to smoke, and peer pressure was the primary factor that contributed to teens starting smoking. The researcher can go back to qualitative research methods to dive deeper into these for more information. The researcher wants to focus on keeping teens from starting to smoke, so they focus on the peer pressure aspect.

The researcher can conduct interviews and focus groups (qualitative research) about what types and forms of peer pressure are commonly encountered, where the peer pressure comes from, and where smoking starts. The researcher hypothetically finds that peer pressure often occurs after school at the local teen hangouts, mostly in the local park. The researcher also hypothetically finds that peer pressure comes from older, current smokers who provide the cigarettes.

The researcher could further explore this observation made at the local teen hangouts (qualitative research) and take notes regarding who is smoking, who is not, and what observable factors are at play for peer pressure to smoke. The researcher finds a local park where many local teenagers hang out and sees that the smokers tend to hang out in a shady, overgrown area of the park. The researcher notes that smoking teenagers buy their cigarettes from a local convenience store adjacent to the park, where the clerk does not check identification before selling cigarettes. These observations fall under qualitative research.

If the researcher returns to the park and counts how many individuals smoke in each region, this numerical data would be quantitative research. Based on the researcher's efforts thus far, they conclude that local teen smoking and teenagers who start to smoke may decrease if there are fewer overgrown areas of the park and the local convenience store does not sell cigarettes to underage individuals.

The researcher could try to have the parks department reassess the shady areas to make them less conducive to smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk populations their perceptions of the changes and what factors are still at play, and quantitative research that includes teen smoking rates in the community and the incidence of new teen smokers, among others. [14] [15]

Qualitative research functions as a standalone research design or combined with quantitative research to enhance our understanding of the world. Qualitative research uses techniques including structured and unstructured interviews, focus groups, and participant observation not only to help generate hypotheses that can be more rigorously tested with quantitative research but also to help researchers delve deeper into the quantitative research numbers, understand what they mean, and understand what the implications are. Qualitative research allows researchers to understand what is going on, especially when things are not easily categorized. [16]

• Issues of Concern

As discussed in the sections above, quantitative and qualitative work differ in many ways, including the evaluation criteria. There are four well-established criteria for evaluating quantitative data: internal validity, external validity, reliability, and objectivity. Credibility, transferability, dependability, and confirmability are the correlating concepts in qualitative research. [4] [11] The corresponding quantitative and qualitative concepts can be seen below, with the quantitative concept on the left and the qualitative concept on the right:

• Internal validity: Credibility
• External validity: Transferability
• Reliability: Dependability
• Objectivity: Confirmability

In conducting qualitative research, ensuring these concepts are satisfied and well thought out can mitigate potential issues from arising. For example, just as a researcher will ensure that their quantitative study is internally valid, qualitative researchers should ensure that their work has credibility. 

Indicators such as triangulation and peer examination can help evaluate the credibility of qualitative work.

• Triangulation: Triangulation involves using multiple data collection methods to increase the likelihood of getting a reliable and accurate result. In our above magic example, the result would be more reliable if we interviewed the magician, backstage hand, and the person who "vanished." In qualitative research, triangulation can include telephone surveys, in-person surveys, focus groups, and interviews and surveying an adequate cross-section of the target demographic.
• Peer examination: A peer can review results to ensure the data is consistent with the findings.

A "thick" or "rich" description can be used to evaluate the transferability of qualitative research, whereas an indicator such as an audit trail might help evaluate the dependability and confirmability.

• Thick or rich description:  This is a detailed and thorough description of details, the setting, and quotes from participants in the research. [5] Thick descriptions will include a detailed explanation of how the study was conducted. Thick descriptions are detailed enough to allow readers to draw conclusions and interpret the data, which can help with transferability and replicability.
• Audit trail: An audit trail provides a documented set of steps of how the participants were selected and the data was collected. The original information records should also be kept (eg, surveys, notes, recordings).

One issue of concern that qualitative researchers should consider is observation bias. Here are a few examples:

• Hawthorne effect: The effect is the change in participant behavior when they know they are being observed. Suppose a researcher wanted to identify factors that contribute to employee theft and tell the employees they will watch them to see what factors affect employee theft. In that case, one would suspect employee behavior would change when they know they are being protected.
• Observer-expectancy effect: Some participants change their behavior or responses to satisfy the researcher's desired effect. This happens unconsciously for the participant, so it is essential to eliminate or limit the transmission of the researcher's views.
• Artificial scenario effect: Some qualitative research occurs in contrived scenarios with preset goals. In such situations, the information may not be accurate because of the artificial nature of the scenario. The preset goals may limit the qualitative information obtained.
• Clinical Significance

Qualitative or quantitative research helps healthcare providers understand patients and the impact and challenges of the care they deliver. Qualitative research provides an opportunity to generate and refine hypotheses and delve deeper into the data generated by quantitative research. Qualitative research is not an island apart from quantitative research but an integral part of research methods to understand the world around us. [17]

• Enhancing Healthcare Team Outcomes

Qualitative research is essential for all healthcare team members as all are affected by qualitative research. Qualitative research may help develop a theory or a model for health research that can be further explored by quantitative research. Much of the qualitative research data acquisition is completed by numerous team members, including social workers, scientists, nurses, etc. Within each area of the medical field, there is copious ongoing qualitative research, including physician-patient interactions, nursing-patient interactions, patient-environment interactions, healthcare team function, patient information delivery, etc. 

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Qualitative research — when you first heard the term, your initial thought might have been, ‘What do qualitative researchers actually do?’ It may come as a surprise to you that you are already familiar with many of their activities, and you actually do them yourself — every day — as you watch and listen to what happens around you, and ask questions about what you have seen and heard.

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Croker, R.A. (2009). An Introduction to Qualitative Research. In: Heigham, J., Croker, R.A. (eds) Qualitative Research in Applied Linguistics. Palgrave Macmillan, London. https://doi.org/10.1057/9780230239517_1

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Introduction to Research Methods

6 qualitative research and interviews.

So we’ve described doing a survey and collecting quantitative data. But not all questions can best be answered by a survey. A survey is great for understanding what people think (for example), but not why they think what they do. If your research is intending to understand the underlying motivations or reasons behind peoples actions, or to build a deeper understanding on the background of a subject, an interview may be the more appropriate data collection method.

Interviews are a method of data collection that consist of two or more people exchanging information through a structured process of questions and answers. Questions are designed by the researcher to thoughtfully collect in-depth information on a topic or set of topics as related to the central research question. Interviews typically occur in-person, although good interviews can also be conducted remotely via the phone or video conferencing. Unlike surveys, interviews give the opportunity to ask follow-up questions and thoughtfully engage with participants on the spot (rather than the anonymous and impartial format of survey research).

And surveys can be used in qualitative or quantitative research – though they’re more typically a qualitative technique. In-depth interviews , containing open-ended questions and structured by an interview guide . One can also do a standardized interview with closed-ended questions (i.e. answer options) that are structured by an interview schedule as part of quantitative research. While these are called interviews they’re far closer to surveys, so we wont cover them again in this chapter. The terms used for in-depth interviews we’ll cover in the next section.

6.1 Interviews

In-depth interviews allow participants to describe experiences in their own words (a primary strength of the interview format). Strong in-depth interviews will include many open-ended questions that allow participants to respond in their own words, share new ideas, and lead the conversation in different directions. The purpose of open-ended questions and in-depth interviews is to hear as much as possible in the person’s own voice, to collect new information and ideas, and to achieve a level of depth not possible in surveys or most other forms of data collection.

Typically, an interview guide is used to create a soft structure for the conversation and is an important preparation tool for the researcher. You can not go into an interview unprepared and just “wing it”; what the interview guide allows you to do is map out a framework, order of topics, and may include specific questions to use during the interview. Generally, the interview guide is thought of as just that — a guide to use in order to keep the interview focused. It is not set in stone and a skilled researcher can change the order of questions or topics in an interviews based on the organic conversation flow.

Depending on the experience and skill level of the researcher, an interview guide can be as simple as a list of topics to cover. However, for consistency and quality of research, the interviewer may want to take the time to at least practice writing out questions in advance to ensure that phrasing and word choices are as clear, objective, and focused as possible. It’s worth remembering that working out the wording of questions in advance allows researchers to ensure more consistency across interview. The interview guide below, taken from the wonderful and free textbook Principles of Sociological Inquiry , shows an interview guide that just has topics.

Alternatively, you can use a more detailed guide that lists out possible questions, as shown below. A more detailed guide is probably better for an interviewer that has less experience, or is just beginning to work on a given topic.

The purpose of an interview guide is to help ask effective questions and to support the process of acquiring the best possible data for your research. Topics and questions should be organized thematically, and in a natural progression that will allow the conversation to flow and deepen throughout the course of the interview. Often, researchers will attempt to memorize or partially memorize the interview guide, in order to be more fully present with the participant during the conversation.

6.2 Asking good Questions

Remember, the purposes of interviews is to go more in-depth with an individual than is possible with a generalized survey. For this reason, it is important to use the guide as a starting point but not to be overly tethered to it during the actual interview process. You may get stuck when respondents give you shorter answers than you expect, or don’t provide the type of depth that you need for your research. Often, you may want to probe for more specifics. Think about using follow up questions like “How does/did that affect you?” or “How does X make you feel?” and “Tell me about a time where X…”

For example, if I was researching the relationship between pets and mental health, some strong open-ended questions might be: * How does your pet typically make you feel when you wake up in the morning? * How does your pet generally affect your mood when you arrive home in the evening? * Tell me about a time when your pet had a significant impact on your emotional state.

Questions framed in this manner leave plenty of room for the respondent to answer in their own words, as opposed to leading and/or truncated questions, such as: * Does being with your pet make you happy? * After a bad day, how much does seeing your pet improve your mood? * Tell me about how important your pet is to your mental health.

These questions assume outcomes and will not result in high quality research. Researchers should always avoid asking leading questions that give away an expected answer or suggest particular responses. For instance, if I ask “we need to spend more on public schools, don’t you think?” the respondent is more likely to agree regardless of their own thoughts. Some wont, but humans generally have a strong natural desire to be agreeable. That’s why leaving your questions neutral and open so that respondents can speak to their experiences and views is critical.

6.3 Analyzing Interview Data

Writing good questions and interviewing respondents are just the first steps of the interview process. After these stages, the researcher still has a lot of work to do to collect usable data from the interview. The researcher must spend time coding and analyzing the interview to retrieve this data. Just doing an interview wont produce data. Think about how many conversations you have everyday, and none of those are leaving you swimming in data.

Hopefully you can record your interviews. Recording your interviews will allow you the opportunity to transcribe them word for word later. If you can’t record the interview you’ll need to take detailed notes so that you can reconstruct what you heard later. Do not trust yourself to “just remember” the conversation. You’re collecting data, precious data that you’re spending time and energy to collect. Treat it as important and valuable. Remember our description of the methodology section from Chapter 2, you need to maintain a chain of custody on your data. If you just remembered the interview, you could be accused of making up the results. Your interview notes and the recording become part of that chain of custody to prove to others that your interviews were real and that your results are accurate.

Assuming you recorded your interview, the first step in the analysis process is transcribing the interview. A transcription is a written record of every word in an interview. Transcriptions can either be completed by the researcher or by a hired worker, though it is good practice for the researcher to transcribe the interview him or herself. Researchers should keep the following points in mind regarding transcriptions: * The interview should take place in a quiet location with minimal background noise to produce a clear recording; * Transcribing interviews is a time-consuming process and may take two to three times longer than the actual interview; * Transcriptions provide a more precise record of the interview than hand written notes and allow the interviewer to focus during the interview.

After transcribing the interview, the next step is to analyze the responses. Coding is the main form of analysis used for interviews and involves studying a transcription to identify important themes. These themes are categorized into codes, which are words or phrases that denote an idea.

You’ll typically being with several codes in mind that are generated by key ideas you week seeking in the questions, but you can also being by using open coding to understand the results. An open coding process involves reading through the transcript multiple times and paying close attention to each line of the text to discover noteworthy concepts. During the open coding process, the researcher keeps an open mind to find any codes that may be relevant to the research topic.

After the open coding process is complete, focused coding can begin. Focused coding takes a closer look at the notes compiled during the open coding stage to merge common codes and define what the codes mean in the context of the research project.

Imagine a researcher is conducting interviews to learn about various people’s experiences of childhood in New Orleans. The following example shows several codes that this researcher extrapolated from an interview with one of their subjects.

6.4 Using interview data

The next chapter will address ways to identify people to interview, but most of the remainder of the book will address how to analyze quantitative data. That shouldn’t be taken as a sign that quantitative data is better, or that it’s easier to use interview data. Because in an interview the researcher must interpret the words of others it is often more challenging to identify your findings and clearly answer your research question. However, quantitative data is more common, and there are more different things you can do with it, so we spend a lot of the textbook focusing on it.

I’ll work through one more example of using interview data though. It takes a lot of practice to be a good and skilled interviewer. What I show below is a brief excerpt of an interview I did, and how that data was used in a resulting paper I wrote. These aren’t the only way you can use interview data, but it’s an example of what the intermediary and final product might look like.

The overall project these are drawn from was concerned with minor league baseball stadiums, but the specific part I’m pulling from here was studying the decline and rejuvenation of downtown around those stadiums in several cities. You’ll see that I’m using the words of the respondent fairly directly, because that’s my data. But I’m not just relying on one respondent and trusting them, I did a few dozen interviews in order to understand the commonalities in people’s perspectives to build a narrative around my research question.

Excerpt from Notes

Excerpt from Resulting Paper

How many interviews are necessary? It actually doesn’t take many. What you want to observe in your interviews is theoretical saturation , where the codes you use in the transcript begin to appear across conversations and groups. If different people disagree that’s fine, but what you want to understand is the commonalities across peoples perspectives. Most research on the subject says that with 8 interviews you’ll typically start to see a decline in new information gathered. That doesn’t mean you won’t get new words , but you’ll stop hearing completely unique perspectives or gain novel insights. At that point, where you’ve ‘heard it all before’ you can stop, because you’ve probably identified the answer to the questions you were trying to research.

6.5 Ensuring Anonymity

One significant ethical concern with interviews, that also applies to surveys, is making sure that respondents maintain anonymity. In either form of data collection you may be asking respondents deeply personal questions, that if exposed may cause legal, personal, or professional harm. Notice that in the excerpt of the paper above the respondents are only identified by an id I assigned (Louisville D) and their career, rather than their name. I can only include the excerpt of the interview notes above because there are no details that might lead to them being identified.

You may want to report details about a person to contextualize the data you gathered, but you should always ensure that no one can be identified from your research. For instance, if you were doing research on racism at large companies, you may want to preface people’s comments by their race, as there is a good chance that white and minority employees would feel differently about the issues. However, if you preface someones comments by saying they’re a minority manager, that may violate their anonymity. Even if you don’t state what company you did interviews with, that may be enough detail for their co-workers to identify them if there are few minority managers at the company. As such, always think long and hard about whether there is any way that the participation of respondents may be exposed.

6.6 Why not both?

We’ve discussed surveys and interviews as different methods the last two chapters, but they can also complement each other.

For instance, let’s say you’re curious to study people who change opinions on abortion, either going from support to opposition or vice versa. You could use a survey to understand the prevalence of changing opinions, i.e. what percentage of people in your city have changed their views. That would help to establish whether this is a prominent issue, or whether it’s a rare phenomenon. But it would be difficult to understand from the survey what makes people change their views. You could add an open ended question for anyone that said they changed their opinion, but many people won’t respond and few will provide the level of detail necessary to understand their motivations. Interviews with people that have changed their opinions would give you an opportunity to explore how their experiences and beliefs have changed in combination with their views towards abortion.

6.7 Summary

In the last two chapters we’ve discussed the two most prominent methods of data collection in the social sciences: surveys and interviews. What we haven’t discussed though is how to identify the people you’ll collect data from; that’s called a sampling strategy. In the next chapter

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Original research article, exploring cambodian adolescents' perceptions on sex: a qualitative investigation.

• 1 School of Nursing, Research Institute of Nursing Science, Sustainable Development Center, Jeonbuk National University, Jeonju, Republic of Korea
• 2 Seoul Samsung Medical Center, Seoul, Republic of Korea
• 3 St. David’s School of Nursing, Texas State University, Round Rock, TX, United States
• 4 Jersey City Medical Center, Jersey City, NJ, United States

Introduction: Involvement in sexual activities increases during adolescence in many countries, including Cambodia. The objective of this study is to explore the perspectives and interpretations of sex held by Cambodian adolescents within the context of their social norms and culture.

Methods: A qualitative research design was used to conduct in-depth interviews with a purposive sample of 91 Cambodian adolescents aged between 15 and 19 years. Participants were recruited from rural areas, and data was collected through face-to-face interviews using semi-structured interview guides. Thematic analysis was used to analyze the data.

Results: Four themes as perspectives of sex were identified: (1) Desire: Releasing sexual desire and stress; (2) relationship: an emotional connection and demonstration of love; (3) roles: responsibilities within a woman's marital duties; and (4) values: the value of virginity and future engagement. Cambodian adolescents' perspectives and interpretations of sex were deeply influenced by their social norms and cultural values. Men typically perceived sex through the lens of instinct and pleasure, while women often emphasized a deep sense of familial duty and held premarital sex to be morally unacceptable.

Discussion: The findings suggest that interventions aimed at improving the sexual health of Cambodian adolescents should be designed with an understanding of the social norms and cultural values that shape their perspectives and interpretations of sex. Such interventions should focus on promoting safe sex practices and providing accurate and comprehensive sexual education.

1 Introduction

Adolescence is the period between 10 and 19 years of age that marks the transition from childhood to adulthood ( 1 ). Adolescents experience rapid changes not only in their physical growth but also in cognitive, emotional, and psychosocial development while pursuing sex and intimate relationships ( 1 ). Adolescence is considered a healthy period of life; however, negative sexual and reproductive health (SRH) outcomes can threaten the well-being of adolescents, especially in low- and middle-income countries ( 2 ). Young people typically engage in sexual activities as they reach adolescence, with limited knowledge about SRH, leading to the highest rates of sexually transmitted infections (STIs) and HIV infections ( 2 ).

The global adolescent population has increased, with the majority of adolescents living in Southeast Asia ( 3 ). Cambodia has the largest adolescent and young adult population in Southeast Asia, with two-thirds of its 14.7 million people under the age of 30 ( 4 ). However, Cambodia lags behind its neighboring countries in implementing effective strategies to improve SRH. Cambodian youth face numerous obstacles to sustainable SRH, including lack of SRH literacy and limited access to modern contraceptives ( 4 ). Only 6.7% of Cambodian youth reported having visited a local health center, hospital, or clinic to seek reproductive health care ( 3 ). Furthermore, the rate of condom use among young Cambodian men decreased from 26% in 2010 to 18% in 2014 ( 5 ). This means that challenges, such as unexpected pregnancies and STIs, are on the rise.

However, essential health services are expensive, particularly in rural areas, due to user fees and transportation, as well as food and accommodation costs. Geographical factors, including the time required to travel to facilities and transportation availability, are barriers to health care access ( 6 ). Therefore, eliminating financial and geographical barriers is critical to increasing health care utilization. In addition, sex education must be taught among adolescents, particularly on how to practice safe sex. Since mid-1997, the Reproductive Health Association of Cambodia has used peer educators, group discussions, one-on-one discussions, local theaters or quiz shows, various educational materials, and youth centers to convey reproductive health messages and information to young people. In 2007, the project distributed condoms and offered STI services to youth under the age of 25 ( 7 ). However, condom use declined over the following four years ( 5 ). This implies that the program must be revised the program to boost its effectivity.

Sex is often linked to the concept of marriage, with some regarding it as conditional on marriage, especially in rural areas. Young, unmarried individuals in urban Cambodia are 60% more likely to engage in pre-marital sexual intercourse compared with those who live in rural areas ( 5 ). Our study also supports this finding, stating that many of the respondents from rural Cambodia oppose premarital sex. After marriage, the purposive act of having a child has emerged as another primary reason for sex. Most rural households depend on agriculture and related subsectors to survive. Since launching its official rice export policy in 2010, Cambodia has emerged as a major player in the international rice commodity trade ( 8 ). Therefore, agricultural human resources are necessary for survival, and children are a form of accessible and inexpensive labor.

Cambodia's traditional wedding culture welcomes forced marriages and teenage pregnancies. For many Cambodians, marriage enhances their social and economic status ( 9 ). In addition to robbing a girl of her childhood, education, and future independence, child marriage also exposes her to the risk of fatal health complications associated with early childbearing. Additionally, forced child marriage exposes girls to repeated sexual and physical violence, which can have devastating effects on their mental and physical health and undermine gender equality ( 10 ). This practice deprives Cambodian women of sexual agency after marriage.

Most of the social norms underpinning this marriage system are patriarchal. For young girls, early marriage signifies an early transition to adulthood, socially imposed sexual norms, mandatory obedience, filial piety, and lack of economic freedom ( 11 ). In Cambodia, women are constantly exposed to sexual violence as a result of their subordinate status in a patriarchal society. This system renders women vulnerable to exploitation at the hands of their husbands, fathers, neighbors, authorities, and other male figures ( 12 ). Furthermore, social and cultural practices prevent women from exercising their rights to self-determination. These social norms are linked to Cambodia's early and forced marriage systems ( 5 ), as well as the Khmer cultural principle known as Chbab Srey ( 13 ). Cambodian culture encourages marriage at a young age, when women are typically unable to decide for themselves. Chbab Srey is considered crucial in Khmer culture and is taught in schools and Khmer literature. It codifies women's status at home and conveys the idea that married women should be respectful and submissive toward their husbands ( 13 ). Failure to comply with Chbab Srey results in social sanctions and exclusions ( 14 ). Moreover, most women are dependent (financially or otherwise) on their husbands, especially if they have children. In this social system, women have no option but to obey men ( 12 ).

Essentially, having children means preparing for old age. In Cambodia, filial piety means that most residents believe their children should devote themselves to their parents' welfare.

Many Asian cultures view sexuality as taboo and forbid sexual activities outside of marriage. However, increased access to media access has strengthened permissive attitudes toward dating and premarital sex among adolescents ( 2 ). In Cambodia, men enjoy more freedom than women. Women in Cambodia often repress their potential, whereas men enjoy the innate privileges afforded by their gender ( 5 ). A famous Cambodian Khmer proverb, “fruits should not ripen before they change color,” advises young women to maintain their virginity until marriage ( 15 ). In Cambodia, a woman's virginity is considered a sacred virtue reserved for their future spouses. Furthermore, a girl who loses virginity is a disgrace to her family, regardless of whether it was caused by sexual abuse, and will remain a loss of “virtue” ( 9 ). Cambodian society also disapproves of children born outside of wedlock, compelling young pregnant girls to marry ( 12 ). The 1975–1979 Cambodian Civil War disrupted social and family norms and precipitated rapid lifestyle changes. This period saw a decline in traditional monogamy and increased sexual promiscuity, often resulting from increased access to sex workers, who are individuals receiving monetary compensation in exchange for consensual sexual services ( 16 ). Almost half of the participants (45.0%) had their first sexual experience with a sex worker, and over half (58.3%) had engaged in sexual intercourse with multiple sex partners, including their wives ( 16 ). In Phnom Penh, Cambodia, the prevalence of HIV among sex workers ranged from 9.2% to 23% ( 17 ). Alarming statistics revealed that over 40% of new HIV infections are identified among adolescents ( 18 ). Furthermore, most Cambodian men engage in unprotected sex, such as not wearing a condom, with their wives, despite being uncertain about their HIV status ( 19 ). Some reasons for not practicing safe sex were poor sexual sensitivity, lack of prophylactic knowledge, and the belief that condom use indicates a lack of spousal trust ( 19 ). A recent study in Cambodia revealed that 68% of young males aged 16–24 years old were sexually active, and 27% of them had sexual contact with sex workers within the previous year, placing them at a high risk of contracting HIV ( 20 ).

In a qualitative study among Cambodian adults, sex was perceived as a woman's obligation but a man's personal pleasure ( 21 ). However, the sexual behaviors and perceptions of Cambodian adolescents are gradually changing and are influenced by cultural perceptions and subjective factors. As such, the patriarchal culture practiced in Cambodia may have substantially influenced these perceptions and behaviors. The purpose and meaning of sex in adolescents may be associated with early sexual initiation and practice of unprotected sex. This may also be related to efforts to maintain virginity, all of which can help develop programs to prevent STIs and improve reproductive health. This study was conducted to explore the perceptions of Cambodian adolescents toward sex to understand the cultural influence on sexual behaviors.

2 Materials and methods

2.1 study design, participants, and setting.

A descriptive qualitative approach was used to investigate the significance of sex to Cambodian adolescents. Three rural provinces in Cambodia, Kandal, Kompong Speu, and Kampong Chhnang, were selected through convenience sampling. This study was conducted between July and August 2017 in the high schools of these provinces. To be included in this study, participants must be (a) Cambodian residents, (b) third-year high school students, (c) aged 17–19 years, and (d) unmarried. The study aims, research processes, and interview questions were approved by the Cambodian Ministry of Education, Youth, and Sports. Furthermore, the respective high school principals approved the study after they were informed of its purpose, eligibility criteria, participation process, and student recruitment. The schools provided a private room to ensure confidentiality. The interviews were digitally audio recorded with participants' permission. Ethical permission for the study was obtained from the Jeonbuk National University Institutional Human Subjects Review Committee (2017-06-014-002) and Cambodia National Ethics Committee for Health Research of the Ministry of Health.

2.2 Data collection

The study team included two non-Cambodian (two females) and two Cambodian (one male and one female) researchers. Third-year students were briefly introduced to the study and its purpose. The participants were informed of their right to information privacy, confidentiality, and withdrawal at any time. Only those who agreed to participate were given a date and time for the interview. Informed consent was obtained from the participants, and interviews were conducted in Khmer using an in-depth interview guide and open-ended questions, such as “Can you explain your understanding of the concept of sex?” to explore the general perception of ex among adolescents. Additional probing questions were used to elicit rich and detailed perspectives from the participant, such as (1) “Tell me more about that …”, (2) “Tell me what you meant by…”, and (3) “How did that make you feel?” Two non-Cambodian investigators completed the data collection, while the Cambodian investigator assisted as a bilingual Khmer/English interpreter throughout the process. A male interpreter assisted the male participants, whereas a female interpreter assisted the female participants. So as to reduce bias between the researchers, the primary investigator participated in the male and female interviews. The gender identity of the primary investigator (PI) was female, and she participated in interviews while maintaining a neutral stance. To mitigate potential gender-related biases in the interviews, the PI adhered to the principles of qualitative research and research ethics, ensuring transparency throughout the process. These deliberate efforts were undertaken to uphold rigorous and unbiased research practices. Given that the research team conducted the interviews while traveling together, after each daily interview, the research team gathered to share the interview progress and monitor the follow-up. Each interview lasted between 40 and 80 min, and data were collected until data saturation. As a token of appreciation, each participant was given 20,000 Cambodian riels (equivalent to US$5) in a sealed envelope upon completing the interview. A total of 48 male and 43 female students participated in the interviews.

2.3 Data analysis

Each participant was assigned a pseudonym to ensure their privacy and confidentiality. The digitally recorded interviews were transcribed by a native Khmer speaker and translated into English. The interviews were then analyzed using thematic qualitative analysis ( 22 ). First, data familiarity was achieved by repeatedly reading the English transcripts. The initial concepts that represented the most critical features of the data were then coded to produce themes. The codes relevant to each theme were classified into subthemes. Next, a thematic “map” was created on the basis of whether the potential themes worked with the extracted codes and entire dataset. Themes were then assigned definitions and names to refine their characteristics. Finally, a written analysis was conducted after reviewing themes related to the literature and interview questions. Thereafter, the transcripts were read and reviewed to ensure that the codes adequately represented the aims of the study in the Cambodian context. The ATlas.ti software (version 6.0) was used to mark the code.

2.4 Ensuring research rigor

In order to enhance the rigor of our qualitative research, we maintained a high degree of transparency and reflexivity throughout the study. Transparency was achieved by meticulously documenting and reporting our research process, allowing for the scrutiny of our methods and decision-making. This documentation included detailed notes on data collection, coding processes, and analytical decisions. Reflexivity was a critical component of our study, as we recognized the potential impact of our own perspectives and experiences on the research process. To address this, we consistently engaged in self-reflection and acknowledged our positionalities, which were used to inform our interpretation of the data. This reflexive approach helped ensure that our findings were as objective as possible.

The average age of the participants was 17.9 and 18.7 years for females and males, respectively. Most participants identified as Buddhists. Their average monthly spending money was US$89 for females, whereas US$113 for males. Most participants lived with their parents ( Table 1 ). Regarding what sex meant to them, the following themes emerged from the data analysis: (1) desire: Releasing sexual desire and stress; (2) relationship: an emotional connection and demonstration of love; (3) roles: responsibilities within a woman's marital duties; and (4) values: the value of virginity and future engagement. Table 2 displays the themes, sub-themes, and corresponding codes.

Table 1 . Characteristics of the participants.

Table 2 . The results of the analysis: theme, sub-themes, codes.

3.1.1 Releasing sexual desire and stress

Many participants, including females, agreed that they found sex enjoyable. One male student mentioned that humans, similar to animals, naturally desire fulfilling their sexual needs. Sex is also regarded as a form of stress relief or evening entertainment.

“And maybe it is our desire. It is normal for men and women to desire sex.” (Soren, female, aged 18)

“For general people, some just want to have fun for a while, and they need to fulfill their desire.” (Nita, female, aged 19)

“The purpose of sex is to fulfill our sexual desires, and humans have similar feelings as animals. We want to have fun, so we do it to satisfy our desires.” (Kosal, male, aged 19)

3.2 Relationships

Male and female participants expressed that sex was a way to strengthen relationships and that the act of sex became a medium for expressing love toward one another. This theme was used to examine the romantic responses of students to sexual encounters.

3.2.1 A way to connect with one another

One female student believes that sex is a ritual in which two people accepted each other as life partners. She noted that sex serves as a physical promise to their partners, signifying their romantic bond that would endure for the rest of their lives. One male student provided a similar answer, stating that sex evokes feelings of love and happiness. He added that he felt at ease after engaging in sexual activity with his significant other.

“The meaning of sex is the accepting of a person into my life and us becoming one.” (Chanthavy, female, aged 18)

“We need sex to feel happy, in love, and connected with a partner, and able to sleep.” (Khemera, male, aged 18)

3.2.2 A way to show love

Many female students claimed that they express their affection through sex. To them, the act represents love, trust, honesty, faith, and the commitment to never betray their partners. Furthermore, many were willing to have sex with someone they genuinely loved.

“I am aware that sometimes it is the display of love. If we are just friends, I will not allow touching or having intimate relationships. However, for the person I love, I will allow it. I will be willing to sacrifice my body to fulfill his desires. This is the meaning of the love that I have shown him. Love is shown through sexual intercourse.” (Bopha, female, aged 18)

“I want to show him my faithfulness and sincerity that I will never betray him.” (Chenda, female, aged 17)

3.3.1 Conditional acts: after marriage

As provisions of sexual intercourse have been frequently discussed, this theme focuses specifically on marital sex. Some female participants believe that marriage authorizes them to give their husbands something they had previously protected and treasured. Despite the fact that modern norms indicate an increase in the prevalence of premarital sex, many still regard sex as an act of love between husband and wife, such that they should not hesitate to give themselves in such a physical manner in a marital context.

“It’s meaningful when both of them decide to get married and they can wait till the last night.” (Kiry, male, aged 18)

“[Sex is] to show the love and at that time we should not be afraid of anything because we are already husband and wife. So, what I have kept I will give to my husband.” (Deavy, female, aged 16)

3.3.2 Purposive acts: reproductive means

Many participants mentioned children on this theme. They believe that the purpose of marriage is to have children, which requires sexual intercourse. For these participants, children are the result of their love and an investment in their old age. Some participants claimed that children unite a couple and serve as a means to continue their lineage. One participant felt that he needed someone to care for him as he aged. He regarded the child as a resource to support him during old age.

“The meaning of sex… is the desire of a man who wants to be with a woman and to have a baby.” (Kunthea, female, aged 18)

“I think after marriage we have sex because we want to have children to protect our lineage and receive the result of our love.” (Chantou, female, aged 18)

“I think, [the purpose of sex is] to have kids for the next generation. When I get older, they can take care of me.” (Mony, female, aged 18)

3.3.3 Dutiful acts: wifely responsibilities

Some female students felt that sex would be their duty, as husbands took their wives for that purpose. Some women claimed that marriage was the act of giving life to their husbands. These participants believe that they are willing to sacrifice everything for their husbands after marriage because these men would provide for them for the rest of their lives. As part of this sacrifice, their husbands' sexual desires must be fulfilled.

“Because it is his desire, I will fulfill it, as we mentioned earlier, whatever he likes and we serve him, something like that.” (Bopha, female, aged 18)

“The wife should fulfill her duty as a wife because the husband gets a wife to fulfill his needs.” (Kanya, female, aged 18)

Additional questions were posed to the female participants. They were asked what they would do if their husbands asked for sex several times a day. While many female participants regarded sex as their duty, they generally responded negatively to the prospect of excessive demand for sex. They felt that excessive sexual intercourse would lead health problems in their reproductive system. Others thought that this would hinder their ability to complete daytime tasks. Many female respondents claimed that unlike previous generations, most modern women participated in economic activities. These obligations, in conjunction with familial duties, meant that they cannot comply with the frequent demands for sex.

“It is because I cannot have sex with him more than once a day. Sometimes, it exhausts me, and my health deteriorates. My health is more important, so I have to think of it.” (Maly, female, aged 18)

“The woman in this present day is not like before, [and] most women now also work outside to earn money. In the olden times she was just a housewife, and had to stay at home, but now it is different.” (Neary, female, aged 19)

This theme explains the different perceptions of sexual relationships, as they pertain to sex with a wife, sex worker, or girlfriend. A few male students were pleased with the prospect of sexual intimacy with pure and virgin wives. However, they felt psychologically burdened by engaging in premarital sex with a girlfriend due to unclear responsibilities and uncertain future. Furthermore, they were not sufficiently satisfied when engaging in sexual activities with workers.

3.4.1 Wife vs. sex worker: the value of virginity

Several male students clearly distinguished between potential wives and sex workers. However, they focused on virginity as the key factor. According to them, being a virgin is synonymous with having a clean body, which makes sex more pleasurable. These male participants claimed that while their wives would be pure, sex workers would not. Thus, sexual experiences with sex workers are less gratifying. One participant said:

“Having sex with the sex worker is not romantic because all of them have already lost their virginity and have less sexual pleasure, which is unlike wives or girlfriends who have a clean body because they allow sex only with the person they love. I can say it is more romantic.” (Dara, male, aged 19)

A few female students mentioned virginity. They believe that they had to offer pure bodies to their future husbands as a bond to unite them.

“I think he believes in me, [that] I have never done bad things before. And my virginity will be given to him so that he knows his baby is really his and understands that the baby that comes from his blood that belongs to him.” (Sothy, female, aged 18)

3.4.2 Girlfriend or wife: the burden of future engagement

While discussing their girlfriends, a few of the male students focused on the possibility of marriage. They expressed anxiety about having premarital sex due to the uncertainty of the relationship in the future. These male participants explained that engaging in sexual activities with a girlfriend may lead to unexpected pregnancies or STIs. Furthermore, they described it as being out of wedlock; thus, less meaningful to them.

“Having sex with a girlfriend, we are not sure if we can be responsible or marry her. Unlike having sex with a wife, which is to have children and create a family together.” (Manndy, male, aged 19)

4 Discussion

This study investigated the social and cultural perspectives on sex among adolescents in Cambodia. The influence of Cambodian culture on adolescents' sexual concepts and behaviors is a key outcome of this research. This study demonstrated differences and similarities in attitudes and perspectives of young men and women regarding sex.

Our study found males and females agreed that sexual intercourse grants them happiness and satisfaction, whereas for women, it is a marital obligation. Most of the respondents who focused on sex for physical pleasure were male. Men often focus on the physical aspects of sex, whereas women focus on the emotional aspects. Some male students acknowledged the emotional exchanges involved in sexual intercourse. These participants agreed that sex strengthened their relationship with their partners, allowing them to express their love for one another and feel connected.

Previous study reported that sex was considered a women's obligation ( 21 ). Our study result also revealed some female adolescents expressed that wives were obligated to have sex with their husbands. Others felt a strong sense of duty toward their role as wives, particularly concerning sexual matters. These beliefs are driven by societal and cultural norms that encourage acquiescence toward a husband's sexual desires ( 23 ).Some male participants ascribed different values to sex, depending on their sexual partner (wife, girlfriend, or sex worker). In Cambodian culture, a girl's values vary on the basis of her purity ( 24 ), and women are taught that a wife should retain her vaginal purity until marriage. Our study found many believed that a “pure” woman is dedicated entirely to her husband, which increases sexual gratification. Male adolescents expressed that they would feel more comfortable having sex with a future wife than with their girlfriends. Among the various sexual services, paid services for sex workers were the only ones available to experience sexual release. Interestingly, not all women view sex workers negatively. Previous literature reported that some wives believe they are incapable of sexually pleasing their husbands; thus, they encourage their husbands to have sexual relations with other women to avoid divorce ( 23 ). Additionally, men often perceive sex as innate and vital for personal happiness. In Cambodia, engaging with sex workers is a prevalent cultural norm, and Cambodian society does not view it negatively ( 19 ). However, sex workers, of which there are an estimated 40,000 nationwide, are considered a high-risk group for STIs ( 25 ). Recently, the prevalence of STIs in Cambodia has significantly decreased as a result of the government's national efforts to protect sex workers from STIs ( 26 ). However, despite those efforts, men often spread STIs to their wives when they do not use condoms during sexual intercourse ( 19 ).

To prevent STI transmission in Cambodia, the perception of sexual labor must be altered. The fulfillment of masculine needs is often used to justify engaging with sex workers; however, these men must be made aware of the dangers of STIs. Furthermore, those at risk of spreading STIs should be educated on the essential use of condoms during intercourse, even with their wives, to prevent transmission. Thus, rather than demonizing sex workers, STI cross-infection must be minimized.

Cambodia has a unique culture that includes sexual behavior among adolescents and young adults. Although Cambodian society has changed under the influence of Western culture, this study revealed that some Cambodian adolescents retain traditional attitudes toward sexual behavior. Furthermore, Cambodian men have more sexual and general freedom, whereas women are expected to retain their “purity” for their future husbands. Additionally, male sex before marriage is widely accepted by male and female adolescents.

The level of sexual concept varies depending on the meaning and purpose of sex, and in some cases, the risk of exposure to early sexual experience, lack of condom use, and maintenance of multiple sex partners may increase. Indiscriminate sex, caused by low-level sexual concepts, can be a shortcut to facing uncomfortable situations (e.g., STIs, unexpected pregnancies, and so on.) Adolescents and young adults should be taught that seeking sexual health care is necessary and normal to protect their health and that of their loved ones. Systems should also be established wherein adolescents can access regular check-ups. As in many developing countries, access to health care in Cambodia is constrained by poverty. By understanding Cambodian youth's perspective on sex, we can better understand the prevalence of STIs and the causes of unexpected pregnancies among adolescents in Cambodia. Several educational programs and resources are available to inform Cambodian citizens about safe sex practices and encourage the use of health services. However, STIs continue to spread from husbands to wives. Therefore, revised and culturally accepted sex education and intervention programs must be implemented to prevent the spread of STIs. Ultimately, adolescents in Cambodia must be taught appropriate SRH education.

5 Strengths and limitation of the study

A notable strength of this study is its adherence to rigorous qualitative research methodology, conducted across three regions capturing the perspectives of approximately 100 high school seniors. They eloquently expressed their thoughts and viewpoints, allowing for a comprehensive understanding of perspectives within Cambodia's unique culture and societal context. This can be considered a pioneering study in this regard. However, this study interviewed adolescents in rural areas only. Therefore, future study should include adolescents in urban areas to capture any changes in perception on sex among Cambodian adolescents nowadays. While language limitations may arise due to the principal investigator being a non-Cambodian researcher, over five years of residence in Cambodia and extensive research conducted within the country contribute to overcoming this challenge, supported by knowledgeable and skillful local scholars.

6 Conclusion

This study was conducted to comprehend the perspectives on sexuality among Cambodian adolescents. The research findings revealed differences between the viewpoints of males and females, but they were not significantly different from those of adults. To prevent HIV, STIs, and teenage pregnancy, there is a need for comprehensive sexual education promoting healthy attitudes towards sexuality and practicing protected sex. As the internet and social media continue to advance, contemporary adolescents exposed to these mediums require ICT-based educational resources and content. To support this, various research initiatives and policies should be in place.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Jeonbuk National University Institutional Human Subjects Review Committee (2017-06-014-002) and Cambodia National Ethics Committee for Health Research of the Ministry of Health. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

Author contributions

YY: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. JK: Writing – original draft, Writing – review & editing. GP: Writing – original draft, Writing – review & editing. RT: Writing – original draft, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article.

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (2016S1A2A2912566).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: adolescents, cambodia, HIV, sexual health, STIs

Citation: Yang Y, Kim J, Park G and Thapa R (2024) Exploring Cambodian adolescents' perceptions on sex: a qualitative investigation. Front. Reprod. Health 6:1275941. doi: 10.3389/frph.2024.1275941

Received: 10 August 2023; Accepted: 8 May 2024; Published: 16 May 2024.

Reviewed by:

© 2024 Yang, Kim, Park and Thapa. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gloria Park, [email protected]

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Reproductive Health and Mental Health in LMICs: Adolescent Health

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• Published: 17 May 2024

Risk factors and incidence of central venous access device-related thrombosis in hospitalized children: a systematic review and meta-analysis

• Maoling Fu 1 , 2 ,
• Quan Yuan 2 ,
• Qiaoyue Yang 1 , 2 ,
• Yaqi Yu 1 , 2 ,
• Wenshuai Song 1 , 2 ,
• Xiuli Qin 1 ,
• Ying Luo 1 ,
• Xiaoju Xiong 1 &
• Genzhen Yu 1  

Pediatric Research ( 2024 ) Cite this article

Metrics details

The risk factors for central venous access device-related thrombosis (CRT) in children are not fully understood. We used evidence-based medicine to find the risk factors for CRT by pooling current studies reporting risk factors of CRT, aiming to guide clinical diagnosis and treatment.

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang databases was conducted. RevMan 5.4 was employed for data analysis.

The review included 47 studies evaluating 262,587 children with CVAD placement. Qualitative synthesis and quantitative meta-analysis identified D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection as the most critical risk factors for CRT. Primarily due to observational design, the quality of evidence was regarded as low certainty for these risk factors according to the GRADE approach.

Because fewer high-quality studies are available, larger sample sizes and well-designed prospective studies are still needed to clarify the risk factors affecting CRT. In the future, developing pediatric-specific CRT risk assessment tools is important. Appropriate stratified preventive strategies for CRT according to risk assessment level will help improve clinical efficiency, avoid the occurrence of CRT, and alleviate unnecessary suffering of children.

This is the latest systematic review of risk factors and incidence of CRT in children.

A total of 47 studies involving 262,587 patients were included in our meta-analysis, according to which the pooled prevalence of CRT was 9.1%.

This study identified several of the most critical risk factors affecting CRT in children, including D-dimer, insertion location, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection (CLABSI).

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Introduction.

Central venous access device (CVAD) is an infusion device inserted through different parts to make the tip of the catheter to the vena cava. In the clinic, CVAD is mainly divided into the following four categories: tunneled central venous catheter (CVC), nontunneled CVC, peripherally inserted central catheter (PICC), and totally implantable venous access port (TIVAP). 1 Pediatric patients often require stable, multifunctional, and comfortable long-term vascular access due to factors such as poor puncture cooperation, small vessel diameter, poor peripheral venous visibility and tolerance, high water content in the body leading to easy dehydration, and easy changes in condition after diseases. 2 The application of CVAD can significantly reduce the frequency of venipuncture, relieve the stimulation of drugs on the venous blood vessels, alleviate the pain and fear of the children, improve their medication compliance, ensure the effectiveness of intravenous infusion, and improve the quality of disease treatment. 3 , 4 , 5 Therefore, CVAD is widely used in pediatric clinics and has become an indispensable aspect of complex medical care for children with severe and chronic diseases.

Although CVAD has become an important tool in the pediatric treatment and nursing process, there are also risks of complications related to it, including CVAD-related thrombosis (CRT), phlebitis, fluid and blood leakage at the puncture point, catheter displacement, catheter obstruction, central line-associated bloodstream infection (CLABSI) and so on. 6 , 7 Among these, CRT is one of the most common and serious complications. The prevalence of CRT in children varies significantly by country, age, disease, and medical institution, ranging from 2 to 81%, 4 , 8 , 9 , 10 while in Chinese children without prophylactic treatment ranges from 20 to 66%. 11 , 12 CRT has no obvious clinical symptoms in the early stage, but it may still cause serious side effects, not only increasing the patient pain and medical costs but also delaying treatment timing, affecting prognosis and quality of life, and in severe cases, may even lead to thromboembolism, endangering life. 13 , 14 , 15

Identifying risk factors and incidence of CRT facilitates clinical practitioners in the early identification of high-risk patients, designing specific preventive strategies, treatment regimens, and management plans, thereby effectively reducing the incidence of CRT in hospitalized children and alleviating unnecessary patient suffering. However, most current research on CRT involves only small-scale groups in isolated nursing units or specific disease types. To date, no up-to-date systematic review provides pooled estimates of the risk factors and prevalence of CRT in children. Therefore, this study had a dual purpose: 1. to explore potential risk factors for CRT in children and to determine a pooled level of CRT prevalence; and 2. to provide evidence-based recommendations to improve the recognition, control, and treatment of CRT in children, as well as better nursing management for CRT.

This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 16 The detailed research protocol can be accessed on the PROSPERO website (registration number: CRD42023421353).

Search strategy

Eight electronic databases were utilized to conduct a thorough literature search: PubMed, Web of Science, Embase, Cochrane Library, Scopus, China National Knowledge Infrastructure (CNKI), Sinomed, and Wanfang. The search in these databases was conducted from the earliest records available up to January 31st, 2024. The search strategy used a combination of Mesh terms and free words. The following Mesh terms and free words were mainly used: “child,” “children,” “adolescent,” “infant,” “pediatrics,” “central venous access device-related thrombosis,” “CRT,” “catheter-related thrombosis,” “catheter-related venous thrombosis,” “CVC-related thrombosis,” “risk factors,” “protective factors,” “predictors,” “causality,” “influencing factors”. The full search strategy for each database is available in the Supplementary Materials. In addition, we screened the reference lists of all included studies for relevant studies that met the criteria. Grey literature was searched as well. Some authors were contacted through email to gather more information or clarify any uncertainties.

Inclusion criteria

The study population was hospitalized children aged ≤18 years.

The primary research objective was to explore the risk factors for CRT.

The study results have at least one statistically significant predictor.

Case-control studies or cohort studies.

Published in English or Chinese.

Exclusion criteria

Catheter-related infection, catheter dysfunction, or other catheter complications as the primary outcome indicators.

Repeated published research.

Case reports, study designs, or clinical trials.

Reviews, editorials, letters, and conference abstracts.

In vitro or animal research.

Data were incomplete and could not be extracted.

Unable to find the original article.

Data extraction

Data from each eligible study were independently extracted by two reviewers using a pre-designed data collection form. Any disagreements were resolved by discussions among all authors. Data on the following characteristics were obtained from all included studies (see Supplementary Table S 1 for details):

Basic information: first author, country, year of publication, study duration, and study design.

Demographic characteristics: study population, sample size, number of CRT, and CRT rate.

Catheter-related features: catheter type, CRT type, and diagnostic method.

Potential risk factors for CRT: odds ratios (OR) or relative risks (RR) values and 95% confidence interval (CI) were extracted for each risk factor. If the study did not provide specific values, it was calculated by constructing a 2 × 2 contingency table.

Quality assessment

Two reviewers evaluated the quality of each study independently using the Risk of Bias Assessment for Nonrandomized Studies tool, 17 with any differences settled via group discussion. The tool assessed six domains of risk of bias: participant selection, confounding variables, exposure measurement, blinding of outcome assessment, incomplete outcome data, and selective outcome reporting. If all six domains were rated as low risk, the overall risk of bias for the study was low. The overall risk of bias was moderate if at least one domain was rated as unclear risk, and no domain was rated as high risk, and high if one or more domains were rated as high risk.

To ensure the accuracy of the assessment results, a third reviewer randomly selected five studies to check the data extraction and quality assessment.

Qualitative synthesis and quantitative meta-analysis

Qualitatively classify each risk factor as definite, likely, unclear, or not a risk factor based on the total number of studies with low and moderate bias risks and the proportion of studies demonstrating positive association (Box 1 in the supplementary material). If a risk factor was reported by more than two studies with low or moderate risk of bias, and the definition and reference range were sufficiently consistent, a quantitative meta-analysis was performed to estimate the combined OR.

Data were analyzed using Revman 5.4 software. In the meta-analysis of risk factors and CRT rate, the generic inverse variance method was applied, which only required effect estimate and standard error (SE). 18 The SE was obtained by inverse transforming the 95% CI applying the standard normal distribution. Heterogeneity tests were performed on the studies included in the Meta-analysis to examine for the combinability of the results of each independent study. P  ≥ 0.05 and I-squared ( I 2 ) < 50% considered less heterogeneity between studies and therefore a fixed-effects model was chosen for the analysis, conversely, P  < 0.05 or I 2  ≥ 50% considered greater heterogeneity, and a random-effects model was chosen.

Certainty of the evidence

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method was used to assess the certainty of the evidence. In this method, observational studies were initially classified as low-quality evidence and then downgraded and upgraded according to five downgrading and three upgrading principles. The 5 downgrading factors included risk of bias, inconsistency, indirectness, imprecision, and publication bias, and the 3 upgrading factors included the magnitude of an effect, dose-response gradient, and effect of plausible residual confounding. Based on these considerations, the overall certainty of each piece of evidence was rated as one of four levels: high, moderate, low, or very low.

The initial search of the databases extracted a total of 4193 articles, of which 1656 were duplicates and removed. The titles and abstracts of the remaining 2537 articles were screened according to the inclusion criteria and 142 were selected for full-text search. After a rigorous eligibility review, 45 articles met the inclusion criteria. In addition, two articles were found to meet the eligibility criteria in a search of the reference lists of the selected articles and grey literature. In the end, a total of 47 articles were included in this review, of which 43 contributed to the qualitative synthesis and quantitative meta-analysis (Fig.  1 ).

Demonstrate the screening and inclusion process for systematic literature search.

Of the 47 studies, 19 were prospective 4 , 13 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 and the rest were retrospective, 9 , 12 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 of which 10 were multicenter 4 , 9 , 13 , 21 , 23 , 26 , 27 , 28 , 49 , 59 and 37 were single-center. 12 , 19 , 20 , 22 , 24 , 25 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 60 , 61 The sample sizes ranged from 47 to 158,299, with the two largest being 71,782 13 and 158,299, 59 respectively. In addition, three studies constructed clinical prediction models. 22 , 28 , 47 Table  1 lists the summary characteristics of the included studies.

Study populations and CRT rates in included studies

These studies investigated a series of hospitalized children of different ages and departments, of which 12 studies with all hospitalized children as the study population, 12 studies with PICU hospitalized children as the study population, six studies with NICU hospitalized children as the study population, one study with all ICU hospitalized children as the study population, four studies with leukemia children as the study population, two studies with infants under 1-year-old as the study population, and the other ten studies with children with a specific disease as the study population.

The combined CRT rate was 9.1% (95% CI : 5.7–14.5%) with a high degree of heterogeneity ( I 2  = 100%). The combined CRT rate was 11.5% (95% CI : 5.7–23.1%; I 2  = 99%) in both male and female children. The frequency of CRT in PICU and NICU was available from 13 articles with 234,464 children and 7 articles with 6093 infants, which combined CRT rates were 10.7% (95% CI : 3.8–23.7%; I 2  = 100%), 2.9% (95% CI : 1.0–6.5%; I 2  = 96%), respectively. The combined CRT rate of children with leukemia was 13.0% (95% CI : 2.9–38.3%; I 2  = 98%) (Supplementary Material Figs. S 1 – 6 )

Quality of the CRT studies

The methodological quality of the included studies varied (Fig.  2 and Supplementary Material Fig. S 7 ). Nine studies had a low overall risk of bias, as all six domains were categorized as low risk. Four studies had a high overall risk of bias, three of which were associated with confounding variables and one to participant selection. The remaining 34 studies had a moderate overall risk of bias, with at least one of the six domains having an unclear risk.

A summary presentation of the assessment results of risk of bias for the 47 studies.

Risk factors of CRT in included studies

The 47 included studies reported 61 statistically significant risk factors for CRT (Table  1 ). These factors were classified into three categories: patient-related risk factors (37.7%, 23/61); CVAD-related risk factors (34.4%, 21/61), and treatment-related risk factors (27.9%, 17/61).

Based on the qualitative synthesis, six variables were considered to be definite risk factors for CRT, including D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time, and CLABSI. Eleven variables were considered likely associated with CRT, including gastrointestinal diseases, history of catheterization, thrombophilia, geographic location of line placement, catheter dysfunction, number of catheters, insertion length (cm), catheter to vein ratio, dialysis, hypertonic liquid, and cardiac catheterization. For 42 variables, the relationship with CRT was deemed unclear due to conflicting results from studies assessed as having low and moderate risk of bias, or because they were positively associated in only one study. Additionally, birth weight and gestational age were considered non-risk factors (Table  2 ).

Meta-analyses were implemented for risk factors that were reported by at least two low or moderate risk of bias studies with a consistent definition and reference range (Table  3 and Figs.  3 – 6 ).

Forest plots of odds ratios (OR) that were included in the quantitative meta-analysis and the associated overall OR. For each OR, the size of the red square region is proportional to the corresponding study weight. Diamond shape intervals represent the overall OR. I 2 represents the fraction of variability among the individual OR that cannot be explained by sampling variability.

Forest plots of odds ratios (OR) that were included in the quantitative meta-analysis and the associated overall OR. For each OR, the size of the red square region is proportional to the corresponding study weight. Diamond shape intervals represent the overall OR. I 2 represents the fraction of variability among the individual OR that cannot be explained by sampling variability.

GRADE assessment of evidence

Supplementary Table S 2 shows GRADE assessments for the certainty of evidence. Due to the design of the observational studies, all evidence was initially rated as low certainty. Based on five downgrading and three upgrading principles, 17 pieces of evidence were still rated as low certainty, and the remaining 44 pieces of evidence were downgraded to very low certainty for serious inconsistency and imprecision.

Our study is the latest systematic review of risk factors and the incidence of CRT in hospitalized children. Based on 47 studies included in the current meta-analysis, which involved a total of 262,587 patients, the pooled prevalence of CRT is 9.1%. We conducted a qualitative synthesis analysis of 61 predictive factors and a quantitative meta-analysis of 38 factors, identifying six definite factors, 11 likely factors, and 42 unclear factors associated with CRT. Definite predictors included being of D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time and CLABSI. The findings of our systematic review provide the latest comprehensive evidence summary that can inform the early identification of children at risk for CRT and the development of intervention measures to prevent and reduce CRT.

Implantable and temporary medical devices such as CVAD are exposed to blood for weeks to years depending on the type of CVAD in place. Since CVAD is an artificial surface and lacks an endothelial layer that inhibits platelet coagulation and adhesion, it is thought to potentially activate the contact pathways, ultimately leading to thrombosis. Assembly of artificial surface contact systems might be part of the host defense mechanism against foreign substances, but it can lead to kinin and thrombin generation, and complement activation. 62 This eventually promotes thrombosis and inflammation. The presence of CVAD is the most common risk factor for venous thromboembolism (VTE). CRT accounts for 10% of deep vein thrombosis (DVT) in adults and 50–80% in children. 10 , 55 , 63 The incidence of CRT in hospitalized children has increased significantly by 30–70% over the past 20 years, 64 , 65 which may cause serious medical complications besides increasing healthcare expenditures and length of stay.

We discover that a higher level of D-dimer is an independent risk factor for CRT in hospitalized children, consistent with the results of adult studies. 66 D-dimer is a soluble fibrin degradation product deriving from the plasmin-mediated degradation of cross-linked fibrin that is increased or positive in secondary hyperfibrinolysis, such as hypercoagulable states, disseminated intravascular coagulation, and thrombolytic therapy. 67 , 68 Increased D-dimer suggests an association with thrombotic disorders in the body of various origins and an increase in fibrinolytic activity. D-dimer has been extensively investigated for excluding the diagnosis of VTE and is used routinely for this indication. 67 , 69 Therefore, for early recognition and to reduce the incidence of CRT, D-dimer levels should be closely monitored before and after catheterization. However, the elevated D-dimer test results cannot fully explain the cause and location of CRT formation and must be analyzed in conjunction with clinical and other test results. Inherited thrombophilia, caused by genetic defects leading to a deficiency or abnormality in associated proteins, including protein C, protein S, antithrombin, the coagulation factor V Leiden mutation, and factor II mutation G20210A, 70 is considered a potential risk factor for CRT. The prevalence of thrombophilia varies widely among different populations, with a reported prevalence of 10% to 59% in pediatric VTE patients. 71 Children with gastrointestinal diseases like short bowel syndrome (SBS) and inflammatory bowel disease (IBD) have an increased risk of developing CRT during hospitalization. The precise mechanism behind this association is still uncertain according to current research. It may be attributed to the heightened inflammation levels during catheterization, particularly in patients with active IBD episodes or admissions during surgery, which leads to a period of increased inactivity. 55 This suggests that delaying placement during the most active period of inflammation may reduce the rate of thrombosis.

A narrative review pointed out that age is one of the most significant risk factors for VTE. In children, CRT shows a bimodal distribution, with the highest incidence rate in infancy and adolescence. 10 The higher incidence in infancy may be due in part to the smaller diameter of the vein, making insertion difficult and requiring multiple attempts. However, whether age is a risk factor for CRT is still highly controversial. The study by Chojnacka et al. did not find a statistically significant difference, 39 although a trend toward a similar bimodal distribution was found in the study population. Cancer, cardiovascular disease, sepsis, asphyxia, and neurological diseases are also considered unclear factors for CRT. Pediatric patients diagnosed with leukemia have multiple risk factors for VTE formation, such as the presence of hypercoagulable blast cells, the pro-thrombotic nature of the cancer itself, and treatment with steroids and L-asparaginase. Chen et al. 38 and Jaffray et al. 4 concluded that children with leukemia are more likely to develop CRT. Sepsis causes the coagulation mechanism to become fragile, which in turn activates the coagulation system and creates thrombosis. 72 However, a study by Onyeama et al. 52 showed that sepsis was significantly associated with a reduced incidence of CRT, and the exact mechanism is currently unknown.

The location of insertion and type of catheter are critical risk factors for CRT. The incidence of CRT is higher in femoral vein catheterizations compared to subclavian and jugular vein catheterizations in children, which is contrary to findings in adult patients. 73 The femoral location is a larger vessel and allows placement of a larger size catheter. Femoral CVAD is prioritized in urgent and emergency situations. In such cases, the patients tend to be more critically ill and often immobilized, further exacerbating the low-flow state. In addition, there may be vein compression and kinking beneath the inguinal ligament with leg movement, which may increase the risk of CRT. 27 PICC catheters provide a reliable medium to long-term route to intravenous therapy for children, but compared with other types of catheters, the risk of CRT is higher. We speculate that the long tunnel length and relatively large lumen size of the PICC, compared to the diameter of the vessel at the insertion site, may lead to increased blood flow obstruction. 52 Additionally, patients with PICC may be more likely to be diagnosed with symptomatic VTE than tunneled lines (TLs) because PICC is often placed in smaller vessels and journeys through the arm or leg causing limb pain and swelling, whereas TLs are located in the chest.

The risk of CRT increases with the number of lumens. A possible explanation for this finding is that multilumen catheters tend to have larger catheter sizes and thus occupy more area within the vessel lumen, leading to obstruction of normal blood flow within the veins. The relationship between CRT and CLABSI is bidirectional. Following catheter insertion, a fibrin sheath forms around the catheter. Microorganisms, especially staphylococcus aureus, easily adhere to the fibrin sheaths, and may lead to CLABSI. 74 Conversely, CLABSI can trigger inflammatory reactions, leading to further progression of thrombosis. CVAD duration is positively associated with the risk of CRT. Catheter placement may cause mechanical injury to the vein. As the indwelling duration increases, many damaged smooth muscle and endothelial cells become embedded within the fibrin, resulting in thrombus formation. In addition, prolonged indwelling increases the chance of platelet contact with the vessel lining, activating coagulation factors and thrombin, increasing the risk of thrombosis. 22 Therefore, nurses should perform routine maintenance of the catheter in children who require long-term CVAD indwelling. The duration of CVAD should be monitored, the necessity of its indwelling should be assessed daily, and the catheter should be removed as early as possible while ensuring treatment.

As obstruction of venous blood flow from the CVAD is considered an essential causative mechanism for the development of VTE, a high ratio between catheter size and vein diameter could be a risk factor for CRT. The 2012 international guidelines on pediatric CVC insertion recommend that the ratio between the catheter’s external diameter and the cannulated vein’s diameter should not exceed 0.33. 75 However, this suggestion is only based on expert opinions and currently lacks relevant clinical data support. Therefore, further research is still needed to verify it. Catheter dysfunction is mainly caused by small clots or fibrous sheaths wrapping around the tip of the catheter. Prolonged accumulation may lead to incomplete or complete blockage of blood vessels, becoming a gathering point for thrombosis. 74 Journeycake et al. observed that the risk of VTE was highest in pediatric cancer patients with multiple episodes of catheter dysfunction. 76 A study of pediatric brain tumor patients reported that VTE was more common in patients with catheter dysfunction. 77 Thus, these studies and the current data support the need to consider catheter dysfunction as a possible risk factor for CRT and to design further screening and intervention studies for early identification and prevention of catheter dysfunction.

The rationale for studying the relationship between the insertion side of CVAD and the risk of CRT is based on the anatomy of the upper body venous system. The left brachiocephalic vein is longer and courses more horizontally than the right side, thus entering the superior vena cava at a sharper angle. The right jugular vein is the most direct and shortest route for the CVAD to enter the heart. By contrast, the CVAD located in the left jugular vein has a greater distance to the heart and passes through 2 angles in the venous system, which may cause endothelial damage and increase the likelihood of blood flow obstruction and venous wall adhesion. 26 However, our meta-analysis did not find a statistically significant increase in the risk of CRT with left-sided placement compared to right-sided placement. The ideal location for the catheter tip is the junction of the superior vena cava and the right atrium. This location is preferred because of the higher blood flow rate, which may be protective against thrombosis. 43 Currently, the pediatric literature on the effect of optimal tip position on CRT is scarce and inconclusive. In addition, catheter tips do not always remain in that position after initial placement. Therefore, tip movement should be a significant concern in pediatric patients, especially active, growing, and requiring long-term catheter use.

Providing renal replacement therapy is a lifelong task for pediatric end-stage renal disease (ESRD) patients. Although successful transplantation can be achieved even in young patients, the lifespan of the graft is limited. Consequently, many transplant recipients may be put back on dialysis as part of their ESRD treatment. 78 CVC remains the main vascular access for hemodialysis in children. Long-term reliance on CVC is related to a high incidence of catheter dysfunction and failure. The frequent need for recurrent CVC placement in such patients leads to an elevated risk of central vein stenosis and CRT. Cardiac catheterization is also a possible risk factor for CRT. Appropriate anticoagulation is required during catheterization, without which the risk of thrombosis is up to 40%. However, the use of unfractionated heparin in pediatric patients is challenging because the coagulation system and heparin response are different from that of adults. 79 There’s a need for further research to determine if children are receiving adequate doses of heparin during cardiac catheterization to prevent thrombosis without increasing the risk of bleeding complications. The incidence of VTE in adult patients who are chronically bedridden and braked is 3.59 times higher than in patients with normal activity levels. 80 In critically ill or surgical children, mechanical ventilation is often performed in the early stages, requiring continuous use of multiple sedative or inotropic drugs to reduce cardiac load and protect pulmonary function. During sedation, the child is in a braked state, limb activity is reduced or even inactive, blood flow slows down, and blood stagnates in the veins, increasing the chance of platelet adhesion to the endothelium, which may increase the risk of CRT. Therefore, passive movements such as limb abduction, internal rotation, elbow flexion and elbow extension should be performed appropriately when the child’s condition permits.

Nutritional support is an important part of critical illness treatment, including enteral and parenteral nutrition (PN). CVAD is the supply channel for total parenteral nutrition (TPN), and some children may even need this method to provide calories for a long time. High glucose and calcium concentrations in PN are both possible triggers of CRT, and PN has been shown to upregulate the extrinsic coagulation cascade, especially with long-term use. 60 Diamanti et al. reported that the incidence rate of TPN complicated with CRT was 20%. 81 Mannitol or glycerol fructose are widely used as hypertonic drugs in clinical practice, which can increase plasma osmolality to dehydrate tissues after entering the body. At the same time, it may cause a cellular stress response, induce apoptosis, and can activate inflammatory cytokines and coagulation pathways to induce thrombosis. Jiang et al. 22 found vasoactive drugs to be a risk factor for CRT. The possible reason is that vasoactive drugs can cause strong vasoconstriction, endothelial function damage or impairment, and promote fibrinogen synthesis. However, this is contrary to the findings of Marquez et al. 28 and Faustino et al. 21 Therefore, larger prospective studies are still needed to assess this risk factor more precisely.

The strengths of this study include the systematic identification of all relevant studies of risk factors for CRT in hospitalized children and the classification of risk factors into three categories, patient-related risk factors, CVAD-related risk factors, and treatment-related risk factors, to offer a logical progression of the possible causes of CRT in children. However, several limitations of this systematic review should be stated. Firstly, as most of the studies originate from Western countries, extrapolating these results to Eastern populations is questionable. Second, significant heterogeneity was encountered in our analysis, potentially stemming from variations in regimen, duration, population enrolled, and center setting, among other factors. This diversity necessitates a cautious interpretation of the results. In addition, only a few high-quality studies with a low risk of bias, and many of the studies suffer from significant sources of bias. Furthermore, the effect in many occasions was assessed by very few studies. Therefore, the evidence to support it is low, which needs to be validated in future studies. Finally, risk factors for CRT could not be made causal assertions since the majority of studies were retrospective.

Conclusions

In conclusion, we have identified several critical factors that affect CRT, including D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time, and CLABSI. Nevertheless, none of the included studies considered the impact of socio-demographic factors on CRT, such as parental education level, occupation, and family economic status. Therefore, larger sample sizes and well-designed prospective studies are still needed to clarify the predictors affecting CRT in the future. In addition, there is a lack of pediatric-specific CRT risk assessment tools, which need to be further developed and validated. Machine learning (ML), as a method for designing risk assessment models that help to efficiently explore and mine useful information, has been widely used in recent years to solve a variety of challenging medical problems. Likewise, the application of ML in CRT risk diagnosis may contribute to a more precise assessment. In clinical practice, it is necessary to take appropriate stratified preventive measures according to the level of CRT risk assessment of children, to improve the efficiency of clinical work, reduce the burden of clinical work, and minimize the occurrence of CRT under the premise of ensuring the safety of children.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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This study was supported by the Fundamental Research Funds for the Central Universities [grant numbers YCJJ20230244] and Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Research Fund [grant numbers 2022C09].

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Maoling Fu, Qiaoyue Yang, Yaqi Yu, Wenshuai Song, Xiuli Qin, Ying Luo, Xiaoju Xiong & Genzhen Yu

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Maoling Fu, Quan Yuan, Qiaoyue Yang, Yaqi Yu & Wenshuai Song

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GY and YL framed the review questions on the basis of input from MF and QY. YY and XQ conducted the literature search. MF, WS, and QY screened and evaluated the identified papers. GY and YY performed data extraction and analysis. MF, WS, XQ and QY prepared the initial manuscript with revisions and comments from GY, YL, and XX. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

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Fu, M., Yuan, Q., Yang, Q. et al. Risk factors and incidence of central venous access device-related thrombosis in hospitalized children: a systematic review and meta-analysis. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03225-0

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Received : 06 October 2023

Revised : 18 March 2024

Accepted : 25 March 2024

Published : 17 May 2024

DOI : https://doi.org/10.1038/s41390-024-03225-0

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