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Digital culture and qualitative methodologies in education.

• Eliane Schlemmer Eliane Schlemmer Universidade do Vale do Rio dos Sinos - UNISOS
• https://doi.org/10.1093/acrefore/9780190264093.013.508
• Published online: 30 September 2019

From a digital culture perspective, this article has as main objective to assess two contemporary qualitative research methods in the field of education with distinct theoretical orientations: the cartographic method as a way of tracing trajectories in research-intervention with a theoretical basis in the biology of knowledge, enactive cognition and inventive cognition; and the cartographic method as a means of identifying and mapping the controversies linked to the different associations between human and non-human actors with a theoretical basis in actor-network theory (ANT). With their own specificities, both methods have been fruitful in the development of qualitative research in the field of education, in the context of digital culture, and more recently, in the hybrid culture of atopic habitation, mainly because they also relate to equally consistent theories and aspects of human cognition, making it possible to detect traces and clues in the fluid associations between actors enhanced by different digital technologies (DT), including data mining and learning analytics. From the Brazilian perspective on the topic, this article approaches the experience of the cartographic method of research intervention as well as the cartography of controversies as tools for developing qualitative research in education. These different forms of the cartographic method have inspired the construction of didactic-pedagogical experiences based on theoretical approaches linked to cognition, producing inventive methodologies and interventionist pedagogical practices. These methodologies and practices, which will be discussed at length in this article, have been developed and validated by the Research Group in Digital Education at Unisinos University at different levels and in varied educational settings.

• qualitative research
• cartography
• digital culture
• multimodality
• pervasiveness

Introduction

A version of this article in its original language.

A social group’s socialization is made visible by a distinctive way of acting, which develops rituals representing emotions, common values, and norms for coexistence, all of which contribute to constructing a culture. This makes it possible to refer, for example, to a pre-digital, digital, or gamer culture, and, more recently, a hybrid culture in atopic habitation.

Research itself is also embedded in a culture, which is evident in the understanding of what science is and how to do science in different areas of knowledge. This way of doing science, of researching, has faced new challenges and implications arising mainly from exponential digital technological growth.

The production of knowledge, as well as its almost instantaneous dissemination, produces broad access to ever greater amounts of information in a very short time, providing direct interaction with the researcher or research group responsible for a given discovery and/or innovation, as well as the constitution of research networks. This movement, so characteristic of contemporary scientific inquiry, instigates dialogue among fields, allowing distinct areas of knowledge to overlap and establish new research contexts. Thus we have seen the emergence of biomedicine, biotechnology, food engineering, and informatics in digital education/education, among many others, posing new methodological research challenges.

Lopes and Schlemmer ( 2017 ), point out that research in education in the context of digital culture has sought theoretical and methodological references that can support the complexity of knowledge production in this context, provoking dialogue and the problematization of the very theoretical and epistemological field that sustains it, in addition to the simple problematization related to the use of specific digital technologies (DT) and their effects on education. In this sense, theorists such as Pierre Lévy, Manuel Castells, Bruno Latour, Michel Maffesoli, Massimo Di Felice, Lúcia Santaella, and André Lemos, among others, problematize the sociocultural dimension of digital technological development, allowing us to broaden the focus of research into the contexts of emerging digital culture and, according to Schlemmer ( 2018 ), hybrid culture in atopic habitation, as well as to understand how this phenomenon relates to the field of education. It is therefore a matter of researching the broader meanings that these cultures produce in the field of teaching and learning, that is, the broader field of education.

With this context in mind, the following is a presentation of the research we have conducted as part of the Research Group in Digital Education, which highlights some of the concerns, strategies, and theoretical and methodological approaches that we have adopted in our research in the field of education in digital culture, and more recently in the hybrid culture in atopic habitation, which has enabled us to engage in broader and deeper dialogue. The objective is to consider the cartographic method of intervention research so as to highlight the research process, showing how we gradually adopted digital culture research methods before arriving at the cartographic method of intervention research and the cartography of controversies, which are discussed at length in this article.

From Digital Culture to Hybrid Culture in Atopic Habitation: Challenges for Qualitative Research in Education

In the field of research on education and digital culture in Brazil, Schlemmer, Lopes, and Molina ( 2012 ) outline some epistemological and methodological challenges on experiments in providing guidance by master’s and doctoral students in education. These challenges involve the construction of research objects and problems in the field of education and digital culture in DT contexts, including virtual learning environments, digital social media, and 3D digital virtual worlds. The authors propose rethinking the term virtual as a demarcation of an epistemological and methodological frontier in the ethnographic research of education and digital culture. They argue that the term digital would be more appropriate in distinguishing this border. They also suggest that the term netnography would be the most appropriate in a theoretical-methodological ethnographic research design in education and digital culture.

With this perspective, Lopes, Schlemmer, and Molina ( 2014b ) present some approaches to developing research and new procedures involving the use of applications (apps) and mobile devices (netbooks, tablets, and smartphones) in ethnographic research based on the project “Escola aumentada: Cartografia digital e mobilidade para a aprendizagem e a cidadania.” For the authors, the development of mobile technologies, geolocation (GPS and locative media), and distributed online databases (cloud computing) created new possibilities for the production of records and interactions in ethnographic research. While the diversity of digital records (text, photo, audio, and video) coupled with indexing and tagging mechanisms (tags, hashtags, geotags, etc.) opens up new possibilities for research, it also requires participants to understand the relevant syntax and new technological procedures for the production, recording, and sharing of information. Some programs and applications for desktop and mobile devices such as NVivo and Evernote, among others, can facilitate this process, contributing to the planning and organization of such production. The authors also refer to participatory research methodologies capable of involving researchers and subjects in the production and analysis of data. The current technological context, they note, can consolidate a new scenario in the field of research in which scholars and subjects act as co-producers of knowledge. In this sense, cartography mediated by digital devices emerges as a rich methodological possibility, involving social actors in the context of local problems. This engagement is a necessary condition for the production of meaning through the shared and mediated use of DT in the process of knowledge construction. This scenario can reconfigure both the research itself and the contract between researchers and subjects, since action and participation become instances of authorship from which all sides speak and produce.

Expanding their experimentation along with the discussion over the cartographic method, Lopes, Schlemmer, and Molina ( 2014a ) carried out an early attempt to map actions linked to a digital inclusion program—Província de São Pedro (PSP)—to distribute netbooks and tablets to teachers and students, initially prioritizing schools in cities participating in the Territories of Peace Program (Programa Territórios de Paz, PTP) to address the following research problem: What is the reasoning for linking an educational program of digital inclusion to a public safety program? The objective of the research was to understand the ties between such programs. Thus, the authors present digital cartography as a methodological proposition for online research and indicate the digital map of culture in Rio Grande do Sul (RS) and digital cartography as technological possibilities to promote greater connectivity between such programs.

Schlemmer and Lopes ( 2016 ) and Schlemmer ( 2016a ) also analyze the potential of the method to inspire new practices in line with the need to understand the phenomenon of learning in all its complexity—social, political, cognitive, affective, and technological—precisely because of its interventionist nature. In this context, the authors present a theoretical, methodological, and technological experiment developed in higher education and inspired by the cartographic method as a way of monitoring and evaluating learning in gamified processes and games from an interventionist perspective developed in a hybrid, multimodal, pervasive, and ubiquitous context.

Lopes and Schlemmer ( 2017 ) problematize the ethical, epistemological, and methodological aspects related to the field of education in digital culture, reflecting on how ethics can dialogue with the choices scholars make when conducting research. The authors present the paths adopted in two surveys conducted between 2010 and 2015 with a state public school in the metropolitan region of Porto Alegre participating in government programs for digital inclusion. Founded on the intervention research cartographic method, they present some of the results of discussions with teachers and students, based on the experience of producing and publishing information on the Internet. They problematize the ethical dilemma of research intervention based on the idea of technological appropriation, as a process that is established from the changes of practices that take place in contexts of analogical school culture and digital culture. They discuss and propose, based on the results of the research, overcoming the ethical dilemma of children and young students participating in surveys involving the publication of online content and the fears regarding media exposure—namely, the production and access to inappropriate content—and inattention in the classroom.

This research demonstrates that the cartographic method has been relevant, especially when the research tries to understand phenomena related to learning in the digital culture or, more recently, in the hybrid culture in an atopic habitation. Associated with this perspective, in the digital technological context are systems of data mining and learning analytics that make it possible to more effectively follow the tracks left by the subjects in the different spaces in which they interact.

Hybrid, in this context, refers to the mix between different elements resulting in a new element composed of the previous ones. For Latour ( 1994 ), the hybrid consists of multiple matrices, mixtures of nature and culture, which is therefore contrary to the separation between culture/nature, human/non human, among other things.

By atopic habitation, Di Felice ( 2009 ) refers to a relationship, a form of communication, characterized by the network interactions between different human and non human collectives, digital and territorial technologies. Atopic habitation “is thus the transient and fluid hybridization of bodies, technologies and landscapes, and as the advent of a new typology of ecosystem, neither organic, nor inorganic, nor static, nor delimitable, but informative and immaterial” (p. 291).

Thus, according to Schlemmer ( 2013 , 2014 , 2015 , 2016a , 2016b , 2016c , 2017 ), the hybrid is understood to be a mixture of space (geographic and digital), presence (physical and digital), technologies (analogue and digital), and culture (pre-digital and digital). It is in this context that the term multimodal is used, which includes the different imbricated educational modalities: the presential-physical modality and online modality and, while online, being able to combine elements of electronic learning, mobile learning, pervasive learning, ubiquitous learning, immersive learning, gamification learning, and game-based learning.

When scholars refer to hybridism in atopic habitation, in multimodality, pervasiveness, and ubiquity, they mean actions and interactions between human actors (HA) and non-human actors (NHA), in geographic and digital spaces, in interactions of different cultures (digital and pre-digital), constituting inseparable networks linking interconnected natures, techniques, and cultures. This suggests that a new understanding of culture and society may be emerging, one that embraces coexistence, co-engendering, mutual respect, solidarity, and the recognition of the other as a legitimate interlocutor. Thus, it is worth seeking to understand what these changes might mean in the area of education and, by extension, for research in education.

It is in this context that two contemporary methodological approaches are presented and discussed within the scope of qualitative research in education, linked to specific theoretical orientations.

The Cartographic Method of Research Intervention in Relation to Cognition Sciences

The cartographic method of intervention research is based on the cartographic method proposed by Deleuze and Guattari ( 1995 ). This method has been developed in Brazil by Kastrup ( 2007 , 2008 ), Passos, Kastrup, and Escóssia ( 2009 ), and Passos, Kastrup, and Tedesco ( 2014 ) as a means of interventionist research.

According to Passos et al. ( 2009 ), this approach originated from concerns about research methodology, which requires more open and, at the same time, inventive procedures. Thus, the theme of cartography emerged as a methodological issue in the face of impasses in cognition research, developed by the research group Cognição e Subjetividades. 1 The method began taking shape when the members of the research group questioned the assumption that knowledge means representing or recognizing reality by configuring the importance of the binomial cognition/creation and calling for a more detailed investigation process into the temporal dimension of knowledge production processes. Thus, the authors defined the concept of cognition as creative, autopoietic (Humberto Maturana and Francisco Varela, 2001 ), or enactive (Francisco Varela, 1988 ).

Maturana and Rezepka ( 2000 ) suggest that the way people attribute meaning and learn has a distinctly human quality, since people are autonomous and autopoietic, in congruence with the environment in which they are inserted. This congruence can cause disturbances in the structure of human beings, promoting learning processes insofar as the structure self-produces to compensate for the disturbance. Thus, for Maturana ( 1993a , 1993b ), learning is the act of transforming within a particular environment of recurrent interactions, and happens as the behavior of an organism varies during its ontogenesis in a manner congruent with the variations of the environment (Maturana, 1998 ). Therefore, when I refer to a medium or a hybrid, it means that the congruence of the subject with this environment causes disruptions in the structure of this subject, which allows him or her to attribute meanings that originate from the action and interaction in that space, thus promoting learning processes as the structure reproduces itself to compensate for the disturbance, and in so doing, compounds its ontogeny.

The process of cognition consists of creating a range of behaviors through conduct within a field of interactions. Knowledge, from this perspective, is not simply representation, but implies a permanent interpretation of action. For Varela ( 1990 ), interpretation and knowledge are emergent (in the sense of emerging) results of action or acting in the world. Thus, greater capacity for cognition consists, to a large extent, of asking the pertinent questions that arise at every moment of our life. These are not predefined but rather enactive: they emerge from action in the world, the relevant aspect being what our common sense deems appropriate within a given context. Thus, knower and what is known, subject and object, determine each other and arise simultaneously. The enactive orientation proposes an intermediate way of transcending both extremes: subject and object define each other and are correlative.

The central point of cognition for Maturana and Varela ( 1997 ) is its ability to elicit meaning: knowledge is not predetermined or established a priori, but implicit in regular processes of cognitive activities themselves. In this way, cognition is not the representation of a world that exists independently, but rather the “production” of a world through the process of living, the “continuous coincidence of our being, our doing and our knowing” (p. 20).

According to Passos ( 2015 ), “to know is to enter a structural coupling with the environment, to interact” (p. 85). However, the understanding of interaction changes in this perspective because it no longer assumes the preexistence of the two terms (organism and environment, subject and object) that interact. To interact in this perspective means to construct oneself and the environment, being, therefore, the “act of knowing reality, an act of affirmation of self, self-surrendering, of autopoiesis. By redefining the cognitive act, its representational sense disappears” (p. 86). In this way, transgression lies in imbuing knowledge with pragmatic value that makes it a performative act, in which to know is to do and vice versa. This delegitimizes the understanding of knowledge through transparency or indifference of the cognitive act: “The whole act of knowing is a form of engagement in the world, of commitment to the world that constitutes itself in this act” (p. 86).

An important element that marks the difference between the enactive approach and any form of biological constructivism or neo-Kantianism is the emphasis on codetermination. In this context, the understanding that conduct is potentially unpredictable marks a departure from the theoretical approach of Maturana and Varela, from other behaviorist and Piagetian approaches.

In this perspective, according to Passos et al. ( 2009 ), subject and object—the poles of cognoscence—are outcomes of cognitive activity rather than conditions. By broadening the concept of cognition and understanding it as linked to creation, the production of knowledge pragmatically and reciprocally shapes the self and the cognitive domain such that cognitive practice engenders subjectivity, overcoming an understanding of dependence of a cognitive subject and a given world, understood as invariant fundamentals. Understanding of cognition as an act of creation brings with it “the problem of the ethical commitment of the cognitive act to the created reality. Production of knowledge, production of subjectivity” (p. 13). The methodological problem is set as follows: “How to study the plane of reality production? What method allows us to follow these processes?” (p. 13). Instead of rules to be applied in the method, the authors offer clues to guide the researcher, since it is not always possible to predetermine every methodological procedure: “The clues that guide the cartographer are like references that contribute to maintaining an attitude of openness to what is happening and of calibrating the course of the research—the meta-hodos of research” (p. 13).

Initially, eight points were proposed to guide the practice of the cartographic method. These were not laid out in hierarchical order but as a rhizome (based on Deleuze & Guattari, 1995 ), referring to each other and forming a set of connections and references to order, develop, and collectivize the cartographer’s experience.

According to Passos et al. ( 2009 ), cartography is an intervention research method (point 1) that aims to track the process, through clues, guiding the course of the research, without establishing a linear path to an end. In this way, it considers the effects of the research process on the research object, the researcher, and the results, and does not simply represent an object: “Cartography seeks to ensure the accuracy of the method without giving up the unpredictability of the process of knowledge production, which is a positive requirement of the ad hoc investigation process” (Kastrup, 2007 , p. 19). What sets it apart from other approaches is the focus on the process and not the end result. With the aim of tracking the process (point 3), clues may arise, which might help to describe, discuss, and, above all, to collect the experience of the cartographer.

In this sense, the cartographer needs to keep in mind that the action of researching his object in motion constitutes a practice in which his path establishes links with the participants inserted into the context of what is being investigated. This composition of agency between heterogeneous actors is expressed by Barros and Kastrup ( 2009 ), drawing from Caiafa ( 2007 ). For these authors, agency implies a relationship of cooperation, a kind of sympathy, which, in addition to a simple feeling of esteem, refers to a composition of bodies implying mutual affection that enable the ethnographer to effectively “enter into relationship with the heterogeneous ones that surround it, to act with them, to write with them” (Barros & Kastrup, 2009 , p. 57).

According to Passos et al. ( 2009 ), cartography as a methodological orientation needs to be articulated using three ideas that make up a plan of action or a research plan: transversality, implication, and the dissolution of the observer’s point of view (point 6). In traditional third- and first-person methodologies, there is always the imposition of a point of view capable of representing or signifying the object at hand. There must be an observer, which implies the “subject–object separation or duality, as well as the imposition of an interpretative reference frame separate from experience” (Passos & Eirado, 2009 , p. 121). These authors discuss the work of Varela, Thompson, and Rosch ( 2003 ), who point out that third-person methodology does not work when studying cognition or the mind, because there is a circularity between knowledge and the known world that is fundamental but often overlooked. This is more evident in studies of cognition because it is not possible to separate the structure that is known from the experience of knowing. This understanding of cognitive experience as its own creation, that is, of both the known object and the subject it knows, which occurs in circular motion, is called “enactive action or approach, modulating the notion of autopoiesis formulated by Maturana and Varela in the 1970s” (Passos & Eirado, 2009 , p. 121).

For Passos and Eirado ( 2009 ), the biology of knowledge, autopoiesis, accepts the challenge of thinking without a foundation, since third-person methodology needs to be complemented by first-person methodology. Woven together, these make it possible to penetrate the circularity that arises in the experience of acquiring knowledge. The cartographer has to avoid merely seeking solutions and testing hypotheses, for “he does not take the self as an object, but the self-emergence processes as the destabilization of the points of view that collapse the experience in the (‘internal’) self” (p. 123). He must inhabit the experience without being bound by any point of view, his main task being to dissolve the observer’s point of view without neglecting observation. Enaction assumes that all experience emerges from experimentation, since it does not refer to what is already a given but rather the emergence of change. Data does not exist a priori, waiting to be gathered, instead, it is constituted in the experience itself. In this way, it is up to the cartographer to accompany this emergence of himself and the world in the experience, and for this it is imperative to be immersed and never immune to the process.

Kastrup and Barros ( 2009 ) argue that the method is not a research model developed through clues, strategies, and procedures. The procedures are embodied in apparatuses (dispositif) that perform important and distinct functions in the operation of cartography. 2 Grounded in Deleuze’s work, they understand apparatuses as “machines that make it possible to see and speak,” composed of lines of visibility, enunciation, force, and subjectification. These apparatuses are aligned with the process of creation, and the work of the researcher-cartographer is to unravel these lines and monitor their effects. The purpose of the apparatus involves three movement functions (point 4): reference (more or less regular apparatus, in which repetition and variation are articulated); explicitation (research territory to be explored, explicitation of the lines that participate in the ongoing production process, inseparable dimensions, research and intervention); and transformation production (“transformation of the relations between the elements/lines/affective, cognitive, institutional, micro and macropolitical vectors, activating movements and sustaining processes of production” [Kastrup & Barros, 2009 , p. 80]). Cartography can produce and transform the reality to be analyzed. In this way, mapping implies intervention.

The cartographer, the person using the cartographic method, does so through “cartographic attention.” Cartographic attention (point 2), according to Kastrup ( 2007 , p. 15), is based on Freud’s concept of “free-floating attention” and Bergson’s concept of “attentive recognition.” It is concentrated and open with four varieties (movements): tracing, touch, landing, and attentive recognition. The cartographer’s work begins with tracing , which involves scanning/sweeping the field, an overview with open and unfocused attention. It is a broader look at something that touches it, beyond the search for information. Touch triggers the selection process, the first meaning, the first analysis performed on the selection process. It is characterized by a quick sense of focus on attention, when something touches, it draws attention, causing it to become alert, but that does not yet define what the cartographer will focus on. The movement that refers to a defined point of attention and focus is the landing , which is to stop, zoom in, choose/define, and indicate that the selected element needs to be inspected more closely for analysis. That is, “the landing gesture indicates that the perception, whether it is visual, auditory or otherwise, makes a stop and the field closes in a kind of zoom. A new territory is formed, the field of observation is reconfigured” (Kastrup, 2009 , p. 43). The fourth and final movement is of Bergson’s attentive recognition , characterized by an investigative attitude about the landing, to which the cartographer’s attention is drawn. It represents analysis itself.

The cartographer’s objective is to map a territory that he/she did not previously inhabit (point 7), to understand the planes of power (point 5)—a moving plane of the reality of things at work in it—and to produce knowledge over the course of research, which involves attention and, with it, the very creation of the field of observation (Escóssia & Tedesco, 2009 ).

Because it is a form of intervention research, the analysis occurs in the process, in the movement of cartography, which makes it possible to carry out the intervention while the process is taking place. Thus, Escóssia and Tedesco ( 2009 ) point to the double direction of the nature of cartography: as a knowledge process that is not restricted to describing or classifying the formal contours of the objects of the world, but in tracing the movement itself that animates them, and as a practice of intervention, where access to the plane of power implies inhabiting it, so that the acts of the cartographer, also a collective of forces, participate and intervene in the changes and in the transformations that occur.

This inhabiting of an existential territory is significantly different from the “application of a theory or the execution of a prescriptive methodological planning, since it implies receiving and being welcomed in the difference that is expressed between the terms of the relation: subject and object, researcher and researched, I and the world” (Alvarez & Passos, 2009 , p. 148). In cartography, one does not “separate theory and practice, spaces of reflection and action. To know, to act and to inhabit a territory are no longer experiences distant from each other” (p. 149).

As far as the cartographic method of research intervention is concerned, where the data are produced Passos and Barros ( 2009 ) emphasize the question of narrativity, that is, it is always narratives that we deal with, being that sometimes the research participants also are cartographers. What each one says, what the situation says implies taking a position in a certain narrativity politics (point 8). 3 This narrative position (ethos of research) is embedded in other policies that are at stake, such as research policies, subjectivity, or cognitive policies. So all production of knowledge comes from an implicitly political position. According to the authors, narrativity politics refers to the position we take in facing the world and ourselves. In this way, “the knowledge we express about ourselves and the world is not only a theoretical problem, but a policy-related problem” (Passos & Barros, 2009 , p. 151).

According to Passos and Barros ( 2009 ), narrativity politics involves two methods and two ways of speaking—extensivism and intensivism—and also two narrative procedures: redundancy (“organizing what in this case is abundance, generating a circulation of meaning that reinforces the clarity of the case, its unity and identity” [p. 158]) and disassembly (“extracting from the larger case the agitation of microcases as microstruggles brought into the scene” [p.161]). In this dismantling process, three characteristics stand out: (1) the procedure to narrate the “case” is due to an increase in the coefficient of deterritorialization; (2) “everything is political”; and (3) everything acquires collective value.

Continuing their elaboration of the eight points of the cartographic method, Passos et al. ( 2014 ) cite thinkers besides Deleuze, Guattari, Maturana, and Varela, introducing Latour, among others, into the discussion regarding the research experience. According to Passos et al. ( 2014 ), the “importance of the research experience points to its inscription on the plane of powers, which constitutes the production plan of both knowledge and known reality” (p. 8). Researchers are immersed in the experience, which distances the cartographic method from other approaches guided by processes such as the “collection,” processing, and analysis of the data, taken as information. In this way, the cartographic method is based on inventive cognition and creative cognition, thus differentiating itself from the idea of the representation of a preexisting world. Therefore, “the cartographic method is not defined by the procedures it adopts, but it is an activity guided by a directive of a nature that is not strictly epistemological, but ethical-aesthetic-political” (p. 9).

Kastrup, Tedesco, and Passos ( 2015 ) point out that the cartographic method is compatible and can be used alongside different techniques, strategies, and research approaches, among them interviews, data analysis, and qualitative or quantitative strategies. In this way, the method is fluid, distinct from methodological models guided by the assumptions of representation. However, research that investigates the experience of research itself must make clear the “firm position of the cartographer with regard to the guideline of research: access/production of the plane of powers that responds to the creation/transformation of experience” (p. 9).

Inventive cognition emerges from the biology of knowledge (Maturana and Varela), of enunciative cognition (Varela), and includes elements of Bergson, Nietzsche, Foucault, Deleuze, and Guattari. According to Kastrup ( 2015 ), thinking stems from stimuli that make you think and does not happen spontaneously, from nothing. The stimuli are, therefore, forces of the present, of a world in movement and accelerated transformation constituting “the unique ground of emergence of thought and novelty” (p. 96). This understanding differs from that held by those who understand cognition from a perspective that Maturana and Varela ( 2001 ) call environmentalist (a realistic assumption of a given world), which “does not allow us to think about the invention of the world itself and above all the world in transformation” (p. 96). Thus, Kastrup ( 2015 ) seeks to understand the “shifts of cognition in the contemporary,” from the encounter of two intercessors for the psychology of cognition: (a) Maturana and Varela, who promote the idea of the biology of knowledge (autopoiesis), by refusing the model of representation and promoting the understanding of cognition as an invention of oneself and of the world; and (b) Deleuze and Guattari, who focus on the transformations currently taking place in cognition. To this understanding, the author adds that, in order to be able to understand the new ways of knowing and living emerging today, it is necessary to affirm the present as a movement of virtualization of currently constituted cognitive forms. The conditions of cognition have in themselves tension between constituted forms and forces of instability: “Forces of the present, which problematize the old forms, placing cognition on the route of experimentation” (Kastrup, 2015 , p. 97).

In this context, Kastrup ( 2015 ) refers to DTs, stating that they cannot be understood as mere objects or as solutions to old problems but as a basis “for creating new problems, new relationships with information, in time, with space, with oneself and with others” (p. 97). 4 Thus, the relation between the constituted forms and the present is not of rupture or of discontinuity, but of coexistence, the conditions of cognition being polytemporal and not invariant or historical. The problem of cognitive functioning is in how the present can provoke “cracks in historical strata, in old mental habits, in established structural couplings and produce novelty,” in addition to understanding it as historically produced. “It is the living gift that coexists with the history of structural couplings. Through this notion, Varela introduces in the studies of cognition the possibility of thinking it into becoming, becoming that makes the history bifurcate” (pp. 98–99).

In the biology of knowledge, with the concept of autopoiesis, Varela resignifies the understanding of learning by, in approaching the problem, placing the actor as the prototypical apprentice. Learning is not, as previous theories proposed, adapting to a given environment, or obtaining knowledge, but experimentation, invention of self and the world. The invention of a work of art is correlated with the production of the artist him or herself. As a novelty comes a theory of action, since for Maturana and Varela the living system is a constantly moving cognitive system in a process of permanent self-production, that is, autopoietic, which can be understood, according to Kastrup ( 2015 ), by the formula BE = DO = KNOW. 5 In this sense, the functioning of the living being is confused with the process of self-creation; according to Varela ( 1990 , p. 99), “doing is ontological.” Understanding cognition as action or practice leads to its permanent modification and not to invariant structures. In addition to the logic of action, cognition refers to flows in conduct (Maturana & Mpodozis, 1992 , p. 18).

Paradoxically, according to Kastrup ( 2015 ), what ensures the flow of the conduct is precisely the crack, the break, the notion of breakdown, described in Varela ( 1990 ) and Varela, Thompson, and Rosch ( 2003 ), as perturbation, a “problematization” of the structures of the living, ranging from engagements with the world, without it being possible to determine a principle that guides this drift toward the pursuit of a superior equilibrium. Breakdowns are the source of the autonomous and creative side of living cognition and arise as a theoretical-scientific formulation for an understanding of cognition that is not restricted to solving problems but is, first of all, the invention of problems. Thus, Varela ( 1990 ) explains the rooting of cognition in the “concrete,” dealing with earlier conceptions that approach cognition from the point of view of logic, general mechanisms, or representation, grouped under the denomination of “abstract” approaches to cognition (p. 102). The breakdown is a cognitive activity that happens in the immediate present and in that concrete actually lives. This “concrete” for Varela ( 1990 ) is not a step for something different, but how we arrived and where we are.

In the perspective of reconciling cognition with concrete Varela presents the notion of enaction (actuation), previously explained. For Kastrup ( 2015 ), this notion refers first to an embodied cognition distinct from the understanding of cognition as a mental process, for it is “tributary to action, resulting from experiences that are not mentally inscribed, but in the body” (p. 103). It is an action guided by local sensory processes and not by the perception of objects or forms. These sensorimotor attachments are not separate from the lived cognition (biological, psychological, and cultural couplings). Thus, the embodiment of knowledge implies social couplings, including linguistic ones, so that the body, in addition to a biological entity, is able to register and mark itself historically and culturally.

In order to exemplify the concept of enaction, linked to the embodiment of knowledge, Varela et al. ( 2003 ) refer to learning a musical instrument, where the musician is taken as a prototype of the learner. In this process of learning, initially the body functions are commanded by the mind, because the process begins with a representation, with symbolic instructions. However, to learn to play an instrument is not to follow rules, and learning truly only happens “when the symbolic relation is transformed into direct coupling of the body with the instrument, eliminating the intermediary of representation” (p. 103). That is, therein is the enaction, actuation, incarnation, or embodiment of knowledge. Thus, for the author, cognition begins to function outside the register of representation, in direct coupling with the matter that the world provides. To learn is not to adapt to the musical instrument, but to act with it. Thus, the notion of acting refers to a collective dimension that appears in the body, at the same time as it indicates the participation of the body in the configuration of the world that is shared by the collective.

This understanding of coupling as agency allows Kastrup ( 2015 ) to move forward in a second sense of the notion of acting— cognition as invention of a world—constructed in the interface between Varela’s cognitive studies and Deleuze and Guattari’s subjectivity production, from whom it takes the concept of agency as “direct communication, without mediation of representation” (p. 104). Communication without subordination, hierarchy, or determinism does not operate by causality, but by reciprocal implication between movements, processes, or heterogeneous flows, by double capture. According to the authors still referring to the learning of a musical instrument, agency refers to the production of a complex apprentice–instrument unit, which produces a process of reciprocal differentiation. The mechanical relationship occurs between previous elements (having the same elements and the same relationships, we will have the same product behavior repeated in the same way) whereas machinic agency, on the other hand, connects flows or processes and creates forms.

Kastrup ( 2015 ) uses again the example of learning a musical instrument to demonstrate that if we understand flute learning, for example, as a machinic agency, “learning is eliminating distances, because one learns between mouth and flute, learns in the middle, on the surface of its coupling, outside the field of representation” (p. 104). That is to say, in this adaptation with the medium, “the blowing motion is able to interact with the arrangement of the instrument and at the same time generate the sound and the apprentice” (p. 105). Thus, coupling should be thought of as a machinic agency or a product of learning, a creative activity always focused on becoming and not a mechanical representation or repetition. This understanding puts an end to the supposed determinism of the object or the environment. The best learner is the one who permanently creates a relationship with the instrument, incessantly reinventing himself as a musician.

The best student, for Kastrup ( 2015 ), is not the one who approaches the world through crystallized habits, but who can always remain in the process of learning, which can also be understood as permanent unlearning. That is, learn is to experience incessantly in order to evade the control of representation, preventing crystallized habits from forming, that is, be alert to continuous variations and rapid resonances, implying, at the same time, a certain lack of attention to the practical schemes of recognition.

Bergson ( 1934 ) theorizes this relation between certain attention and correlative inattention. For this author, there is a pragmatic, utilitarian life that assures learning while solving problems, but there is also an additional attention, which is attention to duration, which ensures learning as the invention of problems.

In this context, it is fundamental to consider that the contemporary world has provoked the emergence of new forms of subjectivity, mainly by the ceaseless and almost omnipresent presence of all kinds of DT, which has accelerated processes of transformation and innovation in the ways of living and engaging, which are more and more open and in flux. In this whirlwind of uncertainty, subjectivity is called upon to reconfigure itself and must learn to deal with breakdowns, with the disturbances that present themselves. On the other hand, this same reality, coupled with the online approach to the most diverse cultures, according to Kastrup ( 2015 ), reveals the precariousness of any supposed foundation that can be provided by the world (p. 108), that is, if we are affected on all sides by disturbances of all nature, solutions are not assured. Therefore, if we want to create new ways of knowing and living, we must invent a world, for learning to live in a world without fundamentals is to invent it by living, remembering that invention of self cannot be achieved without the invention of a related world.

If interpretation and knowledge are emergent results (in the sense of emerging) of action in the world or acting, when spaces are hybrid, multimodal, pervasive, and ubiquitous, and dwelling is atopical, what are the relevant issues that emerge concerning the action and performance of the subjects in these spaces? How do meanings emerge? What world do we produce and invent?

The Cartographic Method as a Means of Identifying and Mapping Controversies and Actor–Network Theory

Recently, actor–network theory (ANT), developed by Latour, Law, and Callon, also recognized subject–object codetermination by emphasizing the participation of non-humans—objects and quasi-objects—in social relations, thus presenting itself as an alternative to the binaries of modernity by eschewing a compartmentalized view of reality. 6

In this perspective, ANT (Latour, 2012 ) provides a new understanding of what is social, presenting the idea that humans establish a social network not only to interact with other people, but with non human elements as well. According to the author, the social is not simply made up of people, but also machines, animals, texts, money, architecture, laboratories, institutions, among other elements. By the principle of connectivity, everything is linked in a network, with multiple inputs, which is always in continuous movement and open to new elements. For the author, social refers to the network of HA and NHA, where the actor is any person, thing, (quasi-)object, or institution that produces agency, that is, something with the ability to produce effects on the network (although indirectly), of being actant. The understanding of agency, therefore, is related to the human and non human actors (actants), similarly, who participate in the actions and provoke transformations in the network, in movement. Thus, in ANT, or sociology of associations, the non human is no longer considered only as an artifact, whose meaning is attributed by the human, but as having agency, because it participates in actions in everyday situations and causes transformations. Non human actors also shape events in the creation of meanings, acting in the reflective and symbolic sphere.

In this context, network is understood from the perspective of a rhizome (based on Deleuze & Guattari, 1995 ), that is, seen as something alive, changeable—as flows, circulations, alliances, and movements of a series of animate and inanimate elements—and not as fixed to a set of actors. It refers to transformations, translations, displacements, therefore, quite distinct from the traditional understanding of a network as a form or structure. The network is the associative movement that forms the social, being rather an instrument of analysis or its object. The actor–network binomial perspective proposes that the actor never acts alone. In acting, it is influenced (constituted) by the networks in which it has connections and, at the same time, it can represent these networks, as well as influence them. In this way, it is never quite clear who is acting. The actor is, at the same time, the builder and receiver of the networks.

For Latour ( 2012 ), the social has no predefined locus, but is understood as provisional, performative, as processes of aggregations, associations, and reassociations between HA and NHA. In order to understand the social, which, therefore, is not what explains but rather what needs to be explained, the author recommends that the actors be followed in their associations and reassociations (cartography). I understand, therefore, that nowadays these associations and reassociations are increasingly constituted in nomadic movements, in an atopic habitation that takes place in hybrid, multimodal, pervasive, and ubiquitous spaces. 7

With regard to science, Latour ( 2016 ) says that every idea only proceeds from multiple deviations and compositions. It is the attribution of science to understand this process and not only the result. For this, it is necessary to retrace the entire chain of deviations and compositions, and what matters in this process is what emerges and forms in the course of the process of composition and deviations of courses of action. Linked to this question, Latour ( 2016 ) in the second letter of Cogitamus, raises the problem of method: How is it possible to analyze deviations and compositions if, in general, they are invisible?

In this context, the concept of proof becomes the protagonist, because, according to the author, it is at the moment of proof that the blunting of deviations and compositions is revealed. This evidence, although there are other forms of evidence, materializes in the panel: everything works well, until it stops working. This is more pedagogical form of expression of proof. The computer, initially understood as a technical object, is now presented as a sociotechnical project: “From simple, my computer has become multiple; of unified, has become disunited; it immediately became mediate; of fast, it became slow” (Latour, 2016 , p. 47). The network, or part of it, with the different elements that together kept it working, now fails, becoming visible. It is at this moment that it is necessary to analyze the links, the relationships, the networks that integrate it.

This perspective, presented by Latour ( 2016 ), although linked to the method he calls “cartography of controversies,” could also be linked to the cartographic method of intervention research, proposed by Kastrup ( 2007 , 2008 ), Passos et al. ( 2009 ), and Passos, Kastrup, and Tedesco ( 2014 ).

While Latour ( 2016 ) refers to pane and understood as a proof, bringing sociotechnical network analysis (HA and ANH) to the context; we could think from the point of view of the subject’s cognition (HA) as a cognitive imbalance (Piaget) or as a breakdown (Varela) understood as a proof, later assumed by Kastrup, Tedesco, and Passos ( 2015 ) from the perspective of the inventive cognition.

With regard to the interactions that take place in this sociotechnical network, the deviations and compositions are visible by the traces that the different actants produce in the movement of associations, which can be accompanied by “another” sociotechnical network formed by HA (teachers) and NHA (mining and data-based systems and learning analytics), providing elements that allow us to trace the cosmogram and understand the process under construction.

Turning to the question of the pane for Latour ( 2016 )—in the context of a sociotechnical network; cognitive imbalance for Piaget and breakdown for Varela—in the context of cognition; a process of investigation begins, so that the initial indetermination begins to be deciphered, the source of the disturbance is found, and a problem is revealed progressively. 8 Hypotheses and solutions are tested and verified, until the problem is solved.

In the case of the computer (NHA), in the context of sociotechnical network (formed by HA and NHA), the pane is repaired and put back to use. In the case of cognition, what in the comprehension of Varela ( 1990 ) and Kastrup, Tedesco, and Passos ( 2015 ) refers to an enactuated, self-engendered process of agency, caused by a breakdown, takes knowledge to a superior equilibrium, not in the perspective of problem-solving but, above all, in the invention of problems. It is not the result, but the process by which the result is achieved. In a way, this is related to the concept of debugging, a result of a metacognitive process (Piaget, 1976 , 1978a , 1978b , 1995 ) that is necessary for computational thinking, which was very present in research related to language programming in the 1980s and 1990s.

From the proof concept, Latour ( 2016 ), in his third letter in Cogitamus, goes on to discuss scientific controversies, stating that the statements pass between two poles: radical doubt and unquestionable certainty: “At the beginning of the exercise, the statement floats; in the end, one must find it solidly anchored in a precise landscape . . .” (p. 81). According to the author, this is where the importance of controversies lies.

The term controversy, according to Latour ( 2016 ), “designates all possible positions, ranging from absolute doubt . . . to indisputable certainty” (p. 79). The word “controversy” describes a shared uncertainty about aspects of science and/or technology that are not yet stabilized. It occurs when there is a disagreement between the actors, that is, “when actors discover that they cannot ignore each other and controversies end when actors manage to work out the solid commitment to live together” (Venturini, 2010 , p. 260). The cartography of controversies consists in mapping the actions of human and non human actors involved in contemporary sociotechnical questions, without, however, assuming an a priori frame or an order to be followed. In this context, according to Latour ( 2012 ), the Actor-Network Theory (ANT) achieves a better understanding of the order after the actors explain all the controversies in which they were involved, that is, “We [social scientists] will not try to discipline, to frame you [the actors] in our categories; we will allow them to stick to their own worlds and only then will we ask for their explanation of how they were established” (p. 44). It is not up to the analyst to define and order the social, but rather to the actors present in the context. If the goal is to restore order, it is best to go through the associations, tracing the connections between the controversies themselves. The pursuit of order, rigor, and pattern is by no means abandoned, just repositioned one step further in the form of abstraction, so that actors can unfold their own and various cosmos, no matter how irrational they may seem.

Latour ( 2012 ) notes that it is possible to trace stronger relationships and discover more revealing patterns when we find a way to record the links between unstable and mutable frames of reference rather than trying to stabilize one. What makes one expand, relate, compare, and organize is what one has to describe. The important thing is not to stop the flow of controversy, because if the actors do not act, they will leave no clues: “No clue, no information, no description—and therefore no conversation” (p. 217). It is in the flow of controversies that one has to find the “firm ground: on shifting sands. Contrary to what is commonly said, relativism is a way of floating in the data, not plunging into it” (p. 46).

The main idea is to give visibility to the different understandings about situations, movements, representativities, influences, and interests. For this, it is necessary to explore, visualize polemics, the movement of action and motion, that is, where mediation flows (Lemos, 2013 ). Controversies are those spaces of dialogue, conflict, negotiation, and action, which the actors reveal by leaving traces.

For Latour ( 2016 ), mapping a controversy is learning to locate all these movements. This implies following the statements from doubts permeated by intermediate states (rumor, opinion, idea, proposition), pros and cons, until they become the

final result, where clear and well-defined inscriptions are evident. However, with the condition of taking it in its motion, and not frozen in an object. Remembering that nothing is definitive, both techniques and sciences do not exist by the simple force of inertia. To exist is to always be in that front line. What we now understand as a certain statement is only the final stage of a controversy and in no way its beginning. (Latour, 2016 , pp. 80–81)

Latour ( 2016 ) states that the two extremes must be considered: fact and opinion, which correspond to two moments in the controversy. Accompanying the controversies is then to describe the ways in which the actors construct and modify the evidence.

Venturini ( 2012 , p. 800) proposes a script to subsidize the creation of cartographies of controversies, which is summarized by Lemos ( 2013 , p. 118): (1) to define the best possible controversy; (2) observe, describe, and maintain that the object is controversial; (3) identify whether the controversy is: cold/hot, present/past, secret/public, difficult to access/accessible, limited/unlimited; (4) apply the lenses to the collection of information (gather statements, opinions, read the specialized literature); (5) identify human and non human actants and sketch the network that connects them; (6) identify cosmogram, ideologies, and worldviews. The cartographer must then identify the representativity, influence, and interest of the actors in the networks.

If there is evidence, Latour ( 2016 ) proposes that two conditions are imposed on the analysis: (1) that it comes from the actors, and (2) that it results from joint activity, therefore, not more than a cogito, but a Cogitamus.

In this context, the author refers to the new passage from the infinite world (modern and post-scientific revolution) to the complicated multiverse or pluriverse, term coined by William James. Thus, if there is no radical discontinuity, the meaning of the word revolution changes. Latour ( 2016 ), based on Sloterdijk, stresses that it is not a matter of revolution or emancipation, but of explicitness, since “history never breaks with the past, but permanently makes more and more explicit with which we have to learn to live, elements that will be compatible or incompatible with existing ones” (p. 115). Thus, the author inaugurates a new “epistemological policy,” in which the researcher’s function is to describe “the agency of all beings that a particular culture links with practical forms of life” (p. 166). This refers to a movement of associations between the different parties participating in a controversy, which can be represented by what the author calls a cosmogram. In order to retract the different parties, Latour ( 2016 ) proposes the description of the associations of convenience, coexistence, opposition, and exclusion between HA and NHA, whose conditions of existence become explicit in the course of the trials submitted by the disputes: “to become sensitive to these lists of associations and logical duels without resorting to the distinction between the rational and the irrational, the modern and the archaic, the systematic and the unsystematic” (Latour, 2016 , pp. 116–117).

Mapping the cosmograms means working with the movement, with the agency distribution drawing of mobility, unlike the paradigm, which works with frames (stabilized theoretical framework). When designing a cosmogram, the analyst does not need to resort to structures, systems, or frames, which limit or even render unviable the monitoring of the connections in formation in the sociotechnical networks. He needs to go through the network, follow the actants in their associations, identifying the controversies, their different visions or world versions (multiverses or pluriverses), showing how the whole world (a complicated and complex pluriverse), a cosmos, reveals itself, emerges, and reconfigures itself in the confrontation of ontologies.

It is within the scope of interactions that occur in this sociotechnical network that the different actants (human and non human) produce traces in the movement of associations. These traces, in the scope of education research, can be accompanied by another sociotechnical network formed by HA (teachers-researchers) and NHA (diverse systems, including those based on mining and data and learning analytics) which, when mapped, provide elements that make it possible to draw the cosmogram (diagram of mediations, motion, mobility), a multiverse, and understand the process under construction—the movement of these associations happening. The aim is to map the controversies: “the study of innovations and controversies is one of the first privileged places where objects can be held longer as visible, disseminated and recognized mediators before they become invisible, non-social intermediaries” (Latour, 2012 , p. 120).

It is important to consider that for Latour ( 1994 ), the logic of thinking of the sciences is vitiated by a need for purification by division, which results in exclusion. According to Melo ( 2011 ), this logic, in a way, freezes the possibility of transformation, because it does not consider the continuous mixture, which produces hybrids incessantly and indefinitely. Instead of imposing one part(s) on another, replacing one or the other(s), as the modern project intended, the parts become the contact with heterogeneous versions, through the adjustment of hybrid practices and interests, through which these parties receive from each other the chance of mutual transformation (Despret, 2002 ). TAR presents the notion of hybrids and generalized symmetry.

It is possible to bring elements of this vision presented by Latour to reflect on the question of culture, since it is not a question of dividing, of classifying, into analogical (pre-digital) culture, digital culture, or cyberculture, or, but to consider the mixture, that is to say, the hybrids that are produced in that mixture, which is resignified and transformed in that coexistence.

Conclusion: Education Qualitative Research in the Hybrid and Multimodal Culture Context in an Atopic Dwelling

Both methods, the cartographic method of intervention research and the cartography of controversies, with their specificities, have proved robust for the development of qualitative research in the field of education, in the context of digital culture and hybrid culture in an atopic dwelling, mainly because they are also related to equally consistent and contemporary theories in terms of human cognition aspects, enabling us to track the traces and clues in the mobility of associations between actants, which are enhanced by different Digital Technologies (DT), including data mining and learning analytics.

These methods have been used in the research developed by the Grupo de Pesquisa Educação Digital (GPe-dU Unisinos/CNPq), in which I am involved at the Universidade do Vale do Rio dos Sinos (UNISINOS), since 2010 . In particular, the cartographic method of intervention research, as well as being appropriate as a research method, has been investigated for its potency with regard to the development of new methodologies and pedagogical practices, due to its interventionist characteristic in accompanying the process (along the course), aligned with the need to understand the phenomenon of learning in its complexity—social, political, cognitive, affective, and technological (Schlemmer, Lopes, & Molina, 2012 ), in contexts of hybridism, multimodality, pervasiveness, and ubiquity. Its power to accompany learning processes has also been investigated as well as the possibility of it being appropriated by teachers and students in their own learning pathways.

Among the research projects that have used the cartographic method of intervention research are: “Escola aumentada: Cartografias digitais para as aprendizagens e a cidadania,” “Gamificação em Espaços de Convivência Híbridos e Multimodais: Uma experiência no ensino superior,” and “Gamificação em Espaços de Convivência Híbridos e Multimodais: A educação na cultura digital.” Under different approaches and in varying contexts, research explores the perspectives of hybridism, multimodality, pervasiveness, and ubiquity, as well as cartographic attention. It was in the context of these projects that the cartographic method of intervention research began to become the object of study, inspiring studies carried out on the formation and qualification of teachers and students (Lopes & Schlemmer, 2017 ; Lopes & Valentini, 2012 ; Schlemmer, 2014 , 2015 ; Schlemmer & Lopes, 2016 ) in the scope of elementary education, graduation in pedagogy and digital games, post-graduation stricto sensu , and continuing teacher training. Our focus has been to explore some elements related to the hybrid, multimodal, pervasive, and ubiquitous culture and the new regimes of action, participation, and socialization of experience.

In the context of elementary education schools, we have outlined some experiences involving cartography with the support of digital media, geolocation, and digital marking (quick response [QR] codes), to provoke experiences of local mapping of people, objects, and places in the public space. In the undergraduate, and graduate continuing teacher education context, as well as in elementary school, we also designed inventive methodologies and pedagogical interventionist, aggregative, and gammatical practices with a cartographic bent, mainly the cartographer attention through the four movements (tracing, touching, landing and attentive recognition) , linked to elements of gamification, with the support of digital media, geolocation, digital coding (QR codes), and augmented reality, in order to provoke learning experiences in a hybrid, multimodal, pervasive, and ubiquitous context. According to Schlemmer and Lopes ( 2016 ), unlike classic cartography (mapping), the idea was to provoke aesthetic and/or informational experiences for the production of meanings about our environment in the case of schools, and on the concepts present in undergraduate and undergraduate academic activities in the case of higher education. The purpose of these experiments is to activate sensibility and cognition as functions of intelligence, as well as registration and sharing as functions of sociability.

Schlemmer ( 2018 ) states that inspiration in the cartographic method of intervention research to develop inventive methodologies and interventionist, aggregative, and gamified pedagogical practices comes from the following elements:

the intervention research perspective, and, during the development of games and gamified processes, at different times, both the teacher and the subjects themselves act as interventionist mediators

the idea of working with learning as an invention of problems (“supplementary” attention, duration, attentive recognition of a context), besides learning how to solve problems (attention to pragmatic utilitarian life)

the proposal to follow the course

the clue metaphor

movements of the cartographer’s attention (tracing, touching, landing, and attentive recognition).

In the context of tracks, according to Schlemmer ( 2018 ), the proposal is to work with the concept of geographic tracks (local/specific points in the community/city), live tracks (people from local community who hold certain knowledge necessary for the development of the missions), online tracks (specialists that do not belong to the local community, but that can appear in video), as characters in Mixed Reality (MR) or in Augmented Reality (AR) (iotized objects).

In the scope of a cartographer’s attention movements, tracing is characterized by the exploration/scanning of the field—in the case of this research, geographic and online spaces in search of clues (information) to understand the processes; the touch triggers the selection process which consists, in this case from Schlemmer ( 2016a , 2017 ), in the selection of geographic clues, online clues, and live clues, to direct the research; and landing refers to stopping, zooming in on lanes, choice/definition, and attentive recognition in the perception of the global context.

The metaphor of the clue, as well as the changing focus of the cartographer’s attention, can also serve as inspiration to understand the composition of tracks, as well as the progression itself in the context of a game or gamified process—gaining achievements—at the same time as achievements can be understood as skills for the own gameplay and sociability. 9

It is important to point out that as a result of this process the inventive methodology |Gamified Learning Processes (GLP) is created (Schlemmer, 2018 ).

The Grupo de Pesquisa em Educação Digital (GPe-dU) has also investigated and developed theoretical, methodological, and technological experiences inspired by the cartographic method of research, as methodology for the monitoring and evaluation of learning in games and gamified processes from an interventionist perspective and developed in a hybrid, multimodal, pervasive, and ubiquitous context. According to Schlemmer and Lopes ( 2016 ) and Schlemmer ( 2016a ) such contexts are more easily subject to the pulverization of the spaces of participation and registration and, therefore, can hinder the exercise of teaching and of the discourse regarding both pedagogical mediation and the evaluation. Thus, the proposal developed by the authors, inspired by the cartographic method of intervention research as a methodology of monitoring and evaluation, allows accompanying the subjects in their different learning pathways, involving analogue technologies and DT, physical and online face-to-face interactions to develop their own missions and projects that, from the perspective of bring your own device (BYOD), can extend beyond the time set for formal education. The fact that the subject possesses a mobile device and is connected creates conditions of possibility for him or her to remain engaged in the process, regardless of time and space. Thus, the processes of monitoring and evaluation can, at different times, be “situated” and still intertwined. By means of clues, designed and planned to provide the hybridization of analogue and digital spaces, it is possible to establish a multimodal context, which is desirable when talking about immersion, agency, and engagement.

More specifically, with regard to the movements proposed by Kastrup ( 2007 , 2008 ) and others in the cartographic method, the development of gamification and game experiments allowed us to evaluate the power of the method and the inadequacies we perceive in our own experience of building the game or gamification. The question that seemed to us most challenging was to guarantee the unpredictability and rhizomatic opening of the cartographic method and attention. If we work from a perspective of “use of” rather than inventiveness, the design of phases of a gamified game or process, for example, which was designed by someone to be “applied” in education or simply played by players, cannot always guarantee the rhizomatic opening that underlies the two proposals of methods previously carried out, because it has a limited context and whose control is not complete developed in the field reconfiguration of the students learning. The possible reconfigurations take place in the circular or linear dimension of success itself when completing the missions. In this sense, an a priori objective always seems limited from the point of view of cartography, but not limiting from the point of view of learning. What is learned opens possibilities, but in the dynamics of the game these are not necessarily unpredictable, since it is a condition that games advance in phases.

The clue metaphor to the tracks conception, according to Schlemmer and Lopes ( 2016 ), was inspiring for game designers or gamification, but, to become inspirational to gaming, we identified the need for players to leave “traces” which may become clues for other players. An interesting strategy would be to insert notebooks as an object/item that loads and can be left somewhere—as in some online and offline role-playing games—into the dynamics of the game or gamification. Another strategy would be to insert HA and/or bots equipped with AI to record and report events, producing clues for the route of the tracks to grow and insert, at continuously, new challenges based on the reconfiguration of the field of knowledge produced by the players themselves. This perspective of valuing, in the context of game or gamification, ways of recording and sharing personal narratives (dynamic clue production) would be an interesting possibility for both teachers and students to map their learning processes—after all, mapping, from the perspective here presented, is a means to track processes.

In this case, it seems important to consider that it is necessary to invest in game dynamics that strengthen and value the narratives of the players (as in the case of Role Playing Game [RPG] or, better still, to work at the level of inventiveness, in which the entire process of the conception and development of the game or gamification is co-constructed by the learning subjects themselves).

It is important to mention that, in the case of the researches we develop, because they are situated within the scope of enactive and inventive cognition, the creation of the game or process is a result of a co-creation process between and with the learning subjects themselves, where the teacher acts as an interventionist, conducting pedagogical mediation. Thus, everything that composes the game or gamified process—from the pre-concept, concept, and development; what is implied in the definition of mechanics and dynamics; to being able to include tracks and progression—are defined by the subjects themselves who, therefore, extrapolate the perspective of knowledge as representation and learning as problem-solving, working on the level of knowledge as interpretation and learning through the invention of problems, from the notion of the rhizome, which is at the base of the development of both the cartographic method of intervention research, as well as the cartography of the controversies. This approach is qualitatively different from the traditional approaches found in games or gamified processes, where the subjects are only users, players, whose learning is by solving problems and their evolution by linear stages or phases.

Most recently, the projects “The City as a Learning Space: Games and Gamification in the Constitution of Hybrid, Multimodal, Pervasive and Ubiquitous Spaces for the Development of Citizenship,” and “The City as a Learning Space: Education for Citizenship in Hybrid, Multimodal, Pervasive and Ubiquitous Contexts,” also developed on the basis of the cartographic method of intervention research, we have more appropriately called the cartography of controversies, in order to better understand, in addition to what occurs at the micro level (enative and inventive cognition), the associations that occur between HA and NHA, which may be due to convenience, coexistence, opposition, and exclusion. These associations also evidence planes of forces and, therefore, political expression of cognition, in the sense that “knowing involves a position in relation to the world and itself, an attitude, an ethos” (Kastrup, Tedesco, & Passos, 2015 , p. 12). These associations can be evidenced in a cosmogram, which makes it possible to draw the distribution of the agency, the diagram of the mediations, in short, the design of the movement, its formation. In this way, the cosmogram works with the empirical and in motion, unlike the paradigm that works with the frame, with the theoretical framework stabilized with the model as structure.

Schlemmer and Lopes ( 2016 ) and Schlemmer ( 2018 ) emphasize that the proposal does not consist in a transposition of the method or methods, but rather an experimentation with the logic behind them, as well as some of its elements, which are linked to others, in this case, present in games, gamification, and PAGs, allowing us to develop inventive methodologies and pedagogical interventionist, aggregative, and gamified practices in the educational context.

Thus, relating the cartographic method of controversies and, consequently, elements present in the ANT with the cartographic method of intervention research and with the perspective of enactive cognition, in its two senses of action—corporate cognition and inventive cognition—allows us to understand that the process of invention or innovation, both in development and research, advances from multiple breakdowns, deviations, compositions, associations, and reassociations that occur in the empirical movement. In this way, understanding an invention, an innovation, implies tracking the traces and retracing the whole network of deviations and compositions, associations and reassociations that constitute the path.

From this context questions that inspire future investigations arise:

How can Latour’s concept of symmetry or flat ontology, in which HA and NHA are on the same plane (which eliminates the anthropocentric view of cognition), contribute to research in education?

How can the Latour cosmogram contribute to the intervention research cartographic method as a means of understanding the paths made by the different actors, as well as the controversies established in a network?

How can the intervention research cartographic method, comprising cognition as the invention of problems, associated with the cartography of controversies, be part of the methodology to help us understand the place of the human in the context of intelligent cities?

To sum up, “we go, we hear, we learn, we practice, we become competent, we change our minds. Very simple indeed: this is called research. Good research always produces copious new descriptions . . . There is no in-formation, just trans-formation” (Latour, 2012 , pp. 212–216).

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1. A group composed of researchers from the Universidade Federal Fluminense and Universidade Federal do Rio de Janeiro.

2. The idea of an apparatus (dispositif) is based on Foucault ( 1979 ), who understood it as a decidedly heterogeneous agglomeration involving discourses, institutions, architectural organizations, regulatory decisions, laws, administrative measures, scientific statements, and philosophical, moral, and philanthropic propositions. In short, the apparatus is made up of that which is said and unsaid. The apparatus is the network that can be established among these elements (p. 244). The relationship among these elements indicates the existence of change of positions and modification of functions. An apparatus always responds to an urgent need, made clear by its strategic or dominant function.

3. Passos, Kastrup, and Escóssia ( 2009 ) understand politics in a broad sense as the form of human activity that, linked to power, relates to subjects, articulating them according to rules or norms that are not necessarily only legal in nature. Politics is also done through local arrangements, that is, micro relations, indicating this micropolitical dimension of power relations (Foucault, 1979 ).

4. See conception of non human actor, present in Latour’s ANT.

5. It is important to emphasize that the perspective of “doing and understanding” is also described as a theory in the work of Jean Piaget ( 1978a ). It is, however, necessary to establish differences and similarities.

6. ANT emerged from an interdisciplinary perspective, with contributions from different areas, and is still defining itself as a methodological tool.

7. The author of this article.

8. In the sense put forth by Dewey ( 1938 ) and taken up by Latour ( 2016 ).

9. In gamer lingo, achievements are goals that a subject can complete during the game. They can be explicit or secret, that is, that the subject discovers during the process of play.

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Qualitative Research in Early Childhood Education and Care Implementation

• Wendy K. Jarvie 1  

International Journal of Child Care and Education Policy volume  6 ,  pages 35–43 ( 2012 ) Cite this article

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Governments around the world have boosted their early childhood education and care (ECEC) engagement and investment on the basis of evidence from neurological studies and quantitative social science research. The role of qualitative research is less understood and under-valued. At the same time the hard evidence is only of limited use in helping public servants and governments design policies that work on the ground. The paper argues that some of the key challenges in ECEC today require a focus on implementation. For this a range of qualitative research is required, including knowledge of organisational and parent behaviour, and strategies for generating support for change. This is particularly true of policies and programs aimed at ethnic minority children. It concludes that there is a need for a more systematic approach to analysing and reporting ECEC implementation, along the lines of “implementation science” developed in the health area.

Introduction

Research conducted over the last 15 years has been fundamental to generating support for ECEC policy reform and has led to increased government investments and intervention in ECEC around the world. While neurological evidence has been a powerful influence on ECEC policy practitioners, quantitative research has also been persuasive, particularly randomised trials and longitudinal studies providing evidence (1) on the impact of early childhood development experiences to school success, and to adult income and productivity, and (2) that properly constructed government intervention, particularly for the most disadvantaged children, can make a significant difference to those adult outcomes. At the same time the increased focus on evidence-informed policy has meant experimental/quantitative design studies have become the “gold standard” for producing knowledge (Denzin & Lincoln, 2005 ), and pressures for improved reporting and accountability have meant systematic research effort by government has tended to focus more on data collection and monitoring, than on qualitative research (Bink, 2007 ). In this environment the role of qualitative research has been less valued by senior government officials.

Qualitative Research-WhatIs It?

The term qualitative research means different things to different people (Denzin & Lincoln, 2005 ). For some researchers it is a way of addressing social justice issues and thus is part of radical politics to give power to the marginalised. Others see it simply as another research method that complements quantitative methodologies, without any overt political function. Whatever the definition of qualitative research, or its role, a qualitative study usually:

Features an in depth analysis of an issue, event, entity, or process. This includes literature reviews and meta studies that draw together findings from a number of studies.

Is an attempt to explain a highly complex and/or dynamic issue or process that is unsuited to experimental or quantitative analysis.

Includes a record of the views and behaviours of the players — it studies the world from the perspective of the participating individual.

Cuts across disciplines, fields and subject matter.

Uses a range of methods in one study, such as participant observation; in depth interviewing of participants, key stakeholders, and focus groups; literature review; and document analysis.

High quality qualitative research requires high levels of skill and judgement. Sometimes it requires pulling together information from a mosaic of data sources and can include quantitative data (the latter is sometimes called mixed mode studies). From a public official perspective, the weaknesses of qualitative research can include (a) the cost-it can be very expensive to undertake case studies if there are a large number of participants and issues, (b) the complexity — the reports can be highly detailed, contextually specific examples of implementation experience that while useful for service delivery and front line officials are of limited use for national policy development, (c) difficultyin generalising from poor quality and liable to researcher bias, and (d) focus, at times, more on political agendas of child rights than the most cost-effective policies to support the economic and social development of a nation. It has proved hard for qualitative research to deliver conclusions that are as powerful as those from quantitative research. Educational research too, has suffered from the view that education academics have over-used qualitative research and expert judgement, with little rigorous or quantitative verification (Cook & Gorard, 2007 ).

Qualitative Research and Early Childhood Education and Care

In fact, the strengths of qualitative ECEC research are many, and their importance for government, considerable. Qualitative research has been done in all aspects of ECEC operations and policies, from coordinating mechanisms at a national level (OECD, 2006 ), curriculum frameworks (Office for Children and Early Childhood Development, 2008 ), and determining the critical elements of preschool quality (Siraj-Blatchford et al., 2003 ), to developing services at a community level including effective outreach practices and governance arrangements. Qualitative research underpins best practice guides and regulations (Bink, 2007 ). Cross country comparative studies on policies and programs rely heavily on qualitative research methods.

For public officials qualitative components of program evaluations are essential to understanding how a program has worked, and to what extent variation in outcomes and impacts from those expected, or between communities, are the result of local or national implementation issues or policy flaws. In addition, the public/participant engagement in qualitative components of evaluations can reinforce public trust in public officials and in government more broadly.

In many ways the contrast between quantitative and qualitative research is a false dichotomy and an unproductive comparison. Qualitative research complements quantitative research, for example, through provision of background material and identification of research questions. Much quantitative research relies on qualitative research to define terms, and to identify what needs to be measured. For example, the Effective Provision of PreSchool Education (EPPE) studies, which have been very influential and is a mine of information for policy makers, rely on initial qualitative work on what is quality in a kindergarten, and how can it be assessed systematically (Siraj-Blatchford et al., 2003 ). Qualitative research too can elucidate the “how” of a quantitative result. For example, quantitative research indicates that staff qualifications are strongly associated with better child outcomes, but it is qualitative work that shows that it is not the qualification per se that has an impact on child outcomes-rather it is the ability of staff to create a high quality pedagogic environment (OECD, 2012 ).

Challenges of Early Childhood Education and Care

Systematic qualitative research focused on the design and implementation of government programs is essential for governments today.

Consider some of the big challenges facing governments in early childhood development (note this is not a complete list):

Creating coordinated national agendas for early childhood development that bring together education, health, family and community policies and programs, at national, provincial and local levels (The Lancet, 2011 ).

Building parent and community engagement in ECEC/Early Childhood Development (ECD), including increasing parental awareness of the importance of early childhood services. In highly disadvantaged or dysfunctional communities this also includes increasing their skills and abilities to provide a healthy, stimulating and supportive environment for young children, through for example parenting programs (Naudeau, Kataoka, Valerio, Neuman & Elder, 2011 ; The Lancet, 2011 ; OECD, 2012 ).

Strategies and action focused on ethnic minority children, such as outreach, ethnic minority teachers and teaching assistants and informal as well as formal programs.

Enhancing workforce quality, including reducing turnover, and improved practice (OECD, 2012 ).

Building momentum and advocacy to persuade governments to invest in the more “invisible” components of quality such as workforce professional development and community liaison infrastructure; and to maintain investment over significant periods of time (Jarvie, 2011 ).

Driving a radical change in the way health/education/familyservicepro fessions and their agencies understand each other and to work together. Effectively integrated services focused on parents, children and communities can only be achieved when professions and agencies step outside their silos (Lancet, 2011 ). This would include redesign of initial training and professional development, and fostering collaborations in research, policy design and implementation.

There are also the ongoing needs for,

Identifying and developing effective parenting programs that work in tandem with formal ECEC provision.

Experiments to determine if there are lower cost ways of delivering quality and outcomes for disadvantaged children, including the merits of adding targeted services for these children on the base of universal services.

Figuring out how to scale up from successful trials (Grunewald & Rolnick, 2007 ; Engle et al., 2011 ).

Working out how to make more effective transitions between preschool and primary school.

Making research literature more accessible to public officials (OECD, 2012 ).

Indeed it can be argued that some of the most critical policy and program imperatives are in areas where quantitative research is of little help. In particular, qualitative research on effective strategies for ethnic minority children, their parents and their communities, is urgently needed. In most countries it is the ethnic minority children who are educationally and economically the most disadvantaged, and different strategies are required to engage their parents and communities. This is an area where governments struggle for effectiveness, and public officials have poor skills and capacities. This issue is common across many developed and developing countries, including countries with indigenous children such as Australia, China, Vietnam, Chile, Canada and European countries with migrant minorities (OECD, 2006 ; COAG, 2008 ; World Bank, 2011 ). Research that is systematic and persuasive to governments is needed on for example, the relative effectiveness of having bilingual environments and ethnic minority teachers and teaching assistants in ECEC centres, compared to the simpler community outreach strategies, and how to build parent and community leadership.

Many countries are acknowledging that parental and community engagement is a critical element of effective child development outcomes (OECD, 2012 ). Yet public officials, many siloed in education and child care ministries delivering formal ECEC services, are remote from research on raising parent awareness and parenting programs. They do not see raising parental skills and awareness as core to their policy and program responsibilities. Improving parenting skills is particularly important for very young children (say 0–3) where the impact on brain development is so critical. It has been argued there needs to be a more systematic approach to parenting coach/support programs, to develop a menu of options that we know will work, to explore how informal programs can work with formal programs, and how health programs aimed young mothers or pregnant women can be enriched with education messages (The Lancet, 2011 ).

Other areas where qualitative research could assist are shown in Table 1 (see p. 40).

Implementation Science in Early Childhood Education and Care

Much of the suggested qualitative research in Table 1 is around program design and implementation . It is well-known that policies often fail because program design has not foreseen implementation issues or implementation has inadequate risk management. Early childhood programs are a classic example of the “paradox of non-evidence-based implementation of evidence-based practice” (Drake, Gorman & Torrey, 2005). Governments recognise that implementation is a serious issue: there may be a lot of general knowledge about “what works”, but there is minimal systematic information about how things actually work . One difficulty is that there is a lack of a common language and conceptual framework to describe ECEC implementation. For example, the word “consult” can describe a number of different processes, from public officials holding a one hour meeting with available parents in alocation,to ongoing structures set up which ensureall communityelementsare involved and reflect thespectrum of community views, and tocontinue tobuild up community awareness and engagement over time.

There is a need to derive robust findingsof generic value to public officials, for program design. In the health sciences, there is a developing literature on implementation, including a National implementation Research Network based in the USA, and a Journal of Implementation Science (Fixsen, Naoom, Blasé, Friedman & Wallace, 2005 ). While much of the health science literature is focused on professional practice, some of the concepts they have developed are useful for other fields, such as the concept of “fidelity” of implementation which describes the extent to which a program or service has been implemented as designed. Education program implementation is sometimes included in these fora, however, there is no equivalent significant movement in early childhood education and care.

A priority in qualitative research for ECEC of value to public officials would then appear to be a systematic focus on implementation studies, which would include developing a conceptual framework and possibly a language for systematic description of implementation, as well as, meta-studies. This need not start from scratch-much of the implementation science literature in health is relevant, especially the components around how to influence practitioners to incorporate latest evidence-based research into their practice, and the notions of fidelity of implementation. It could provide an opportunity to engage providers and ECE professionals in research, where historically ECEC research has been weak.

Essential to this would be collaborative relationships between government agencies, providers and research institutions, so that there is a flow of information and findings between all parties.

Quantitative social science research, together with studies of brain development, has successfully made the case for greater investment in the early years.There has been less emphasis on investigating what works on the ground especially for the most disadvantaged groups, and bringing findings together to inform government action. Yet many of the ECEC challenges facing governments are in implementation, and in ensuring that interventions are high quality. This is particularly true of interventions to assist ethnic minority children, who in many countries are the most marginalised and disadvantaged. Without studies that can improve the quality of ECEC implementation, governments, and other bodies implementing ECEC strategies, are at risk of not delivering the expected returns on early childhood investment. This could, over time, undermine the case for sustained government support.

It is time for a rebalancing of government research activity towards qualitative research, complemented by scaled up collaborations with ECEC providers and research institutions. A significant element of this research activity could usefully be in developing a more systematic approach to analysing and reporting implementation, and linking implementation to outcomes. This has been done quite effectively in the health sciences. An investment in developing an ECEC ‘implementation science’ would thus appear to be a worthy of focus for future work.

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Siraj-Blatchford, I., Sylva, K., Taggart, B., Sammons, P., Melhuish, E., & Elliot, K. (2003). The Effective Provision of PreSchool Education (EPPE) Project: Intensive Case Studies of Practice across the Foundation Stage (Technical Paper 10). London: DfEE/Institute of Education, University of London.

The Lancet. (2011). The Debate: Why hasn’t the world embraced early childhood development? [Video Post] Retrieved from http://www.thelancet.com/series/child-development-in-developing-countries-2

The World Bank. (2011). Early Child Development in China: Breaking the Cycle of Poverty and Improving Future Competiveness (Report No. 53746-CN). Retrieved from https://openknowledge.worldbank.org/bitstream/handle/10986/9383/709830PUB0EPI0067926B09780821395646.pdf?sequence=1

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Qualitative research essentials for medical education

Sayra m cristancho.

1 Department of Surgery and Faculty of Education, Schulich School of Medicine and Dentistry, Western University, Canada

2 Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, Canada

Mark Goldszmidt

3 Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Canada

Lorelei Lingard

Christopher watling.

4 Postgraduate Medical Education, Schulich School of Medicine and Dentistry, Western University, Canada

This paper offers a selective overview of the increasingly popular paradigm of qualitative research. We consider the nature of qualitative research questions, describe common methodologies, discuss data collection and analysis methods, highlight recent innovations and outline principles of rigour. Examples are provided from our own and other authors’ published qualitative medical education research. Our aim is to provide both an introduction to some qualitative essentials for readers who are new to this research paradigm and a resource for more experienced readers, such as those who are currently engaged in a qualitative research project and would like a better sense of where their work sits within the broader paradigm.

INTRODUCTION

Are you a medical education researcher engaged in qualitative research and wondering if you are on the right track? Are you contemplating a qualitative research project and not sure how to get started? Are you reading qualitative manuscripts and making guesses about their quality? This paper offers a selective overview of the increasingly popular domain of qualitative research. We consider the nature of qualitative research questions, describe common methodologies, discuss data collection and analysis methods, highlight recent innovations, and outline principles of rigour. The aim of this paper is to educate newcomers through introductory explanations while stimulating more experienced researchers through attention to current innovations and emerging debates.

WHAT IS QUALITATIVE RESEARCH?

Qualitative research is naturalistic; the natural setting – not the laboratory – is the source of data. Researchers go where the action is; to collect data, they may talk with individuals or groups, observe their behaviour and their setting, or examine their artefacts.( 1 ) As defined by leading qualitative researchers Denzin and Lincoln, qualitative research studies social and human phenomena in their natural settings, attempting to make sense of or interpret these phenomena in terms of the meanings participants bring to them.( 2 )

Because qualitative research situates itself firmly in the world it studies, it cannot aim for generalisability. Its aim is to understand, rather than erase, the influence of context, culture and perspective. Good qualitative research produces descriptions, theory or conceptual understanding that may be usefully transferred to other contexts, but users of qualitative research must always carefully consider how the principles unearthed might unfold in their own distinct settings.

WHAT QUESTIONS ARE APPROPRIATE FOR QUALITATIVE RESEARCH?

Meaningful education research begins with compelling questions. Research methods translate curiosity into action, facilitating exploration of those questions. Methods must be chosen wisely; some questions lend themselves to certain methodological approaches and not to others.

In recent years, qualitative research methods have become increasingly prominent in medical education. The reason is simple: some of the most pressing questions in the field require qualitative approaches for meaningful answers to be found.

Qualitative research examines how things unfold in real world settings. While quantitative research approaches that dominate the basic and clinical sciences focus on testing hypotheses, qualitative research explores processes, phenomena and settings ( Box 1 ). For example, the question “Does the introduction of a mandatory rural clerkship increase the rate of graduates choosing to practise in rural areas? ” demands a quantitative approach. The question embeds a hypothesis – that a mandatory rural clerkship will increase the rate of graduates choosing to practise in rural areas – and so the research method must test whether or not that hypothesis is true. But the question “ How do graduating doctors make choices about their practice location? ” demands a qualitative approach. The question does not embed a hypothesis; rather, it explores a process of decision-making.

Qualitative research questions:

Many issues in medical education could be examined from either a quantitative or qualitative approach; one approach is not inherently superior. The questions that drive the research as well as the products that derive from it are, however, fundamentally different. Consider two approaches to studying the issue of online learning. A quantitative researcher might ask, “ What is the effect of an online learning module on medical students’ end-of-semester OSCE [objective structured clinical examination] scores? ”, while a qualitative researcher might ask “ How do medical students make choices about using online learning resources? ” Although the underlying issue is the same – the phenomenon of online learning in medical school – the studies launched by these questions and the products of those studies will look very different.

WHAT ARE QUALITATIVE METHODOLOGIES AND WHY ARE THEY IMPORTANT?

Executing rigorous qualitative research requires an understanding of methodology – the principles and procedures that define how the research is approached. Far from being monolithic, the world of qualitative research encompasses a range of methodologies, each with distinctive approaches to inquiry and characteristic products. Methodologies are informed by the researcher’s epistemology – that is, their theory of knowledge. Epistemology shapes how researchers approach the researcher’s role, the participant-researcher relationship, forms of data, analytical procedures, measures of research quality, and representation of results in analysis and writing.( 3 )

In medical education, published qualitative work includes methodologies such as grounded theory, phenomenology, ethnography, case study, discourse analysis, participatory action research and narrative inquiry, although the list is growing as the field embraces researchers with diverse disciplinary backgrounds. This paper neither seeks to exhaustively catalogue all qualitative methodologies nor comprehensively describe any of them. Rather, we present a subset, with the aim of familiarising readers with its fundamental goals. In this article, we briefly introduce four common methodologies used in medical education research ( Box 2 ). Using one topic, professionalism, we illustrate how each methodology might be applied and how its particular features would yield different insights into that topic.

Common qualitative methodologies in medical education:

Grounded theory

Arguably the most frequently used methodology in medical education research today, grounded theory seeks to understand social processes. Core features of grounded theory include iteration, in which data collection and analysis take place concurrently with each informing the other, and a reliance on theoretical sampling to explore patterns as they emerge.( 4 ) While many different schools of grounded theory exist, they share the aim of generating theory that is grounded in empirical data.( 5 ) Theory, in this type of research, can be thought of as a conceptual understanding of the process under study, ideally affording a useful explanatory power. For example, if one were interested in the development of professionalism among senior medical students during clerkship, one might design a grounded theory study around the following question: “ What aspects of clerkship support or challenge professional behaviour among senior medical students? ” The resulting product would be a conceptual rendering of how senior medical students navigate thorny professionalism issues, which might in turn be useful to curriculum planners.

Phenomenology

This methodology begins with a phenomenon of interest and seeks to understand the subjective lived experience of that phenomenon.( 6 ) Core features of phenomenology include a focus on the individual experience (typically pursued through in-depth interviewing and/or examinations of personal narratives), inductive analysis and a particular attention to reflexivity.( 7 ) Phenomenological researchers typically enumerate their own ideas and preconceptions about the phenomenon under study and consider how these perceptions might influence their interpretation of data.( 8 ) A phenomenological study around professionalism in senior medical students, for example, might involve interviewing several students who have experienced a professionalism lapse about that experience. The resulting product might be an enhanced understanding of the emotional, social and professional implications of this phenomenon from the student’s perspective, which might in turn inform wellness or resilience strategies.

Ethnography

Ethnography aims to understand people in their contexts, exploring the influence of culture, social organisation and shared values on how people behave – their routines and rituals. Core features of ethnography include reliance on direct observation as a data source, and the use of sustained immersive engagement in the setting of interest in order to understand social dynamics from within.( 9 , 10 ) An ethnographic approach to studying how professional attitudes develop in senior medical students might gather data through observations of ward rounds, team meetings and clinical teaching sessions over a period of time. The resulting product – called an ethnography – would describe how professional values are socialised in junior learners in clinical settings, which could assist educators in understanding how the clinical experiences they programme for their learners are influencing their professional development.

Case study research seeks an in-depth understanding of an individual case (or series of cases) that is illustrative of a problem of interest. Like clinical case studies, the goal is not generalisation but a thorough exploration of one case, in hopes that the fruits of that exploration may prove useful to others facing similar problems. Core features of case study research include: thoughtful bounding or defining of the scope of the case at the outset; collection of data from multiple sources, ranging from interviews with key players to written material in policy documents and websites; and careful attention to both the phenomenon of interest and its particular context.( 11 ) A specific professionalism challenge involving medical students could provide fodder for a productive case study. For example, if a medical school had to discipline several students for inappropriately sharing personal patient information on social media, a case study might be undertaken. The ‘case’ would be the incident of social media misuse at a single medical school, and the data gathered might include interviews with students and school officials, examination of relevant policy documents, examination of news media coverage of the event, and so on. The product of this research might trigger similar institutions to carefully consider how they might approach – or prevent – a similar problem.

As these four examples illustrate, methodology is the backbone of qualitative research. Methodology shapes the way the research question is asked, defines the characteristics of an appropriate sample, and governs the way the data collection and analysis procedures are organised. The researcher’s role is also distinctive in each methodology; for instance, in constructivist grounded theory, the researcher actively constructs the theory,( 12 ) while in phenomenology, the researcher attempts to manage his or her ‘pre-understandings’ through either bracketing them off or being reflexive about them.( 13 ) Interested readers may wish to consult the reference list for recently published examples of research using grounded theory,( 14 ) phenomenology,( 15 ) ethnography( 16 ) and case study approaches( 17 ) in order to appreciate how researchers deploy these methodologies to tackle compelling questions in contemporary medical education.

WHAT ARE SOME COMMON METHODS OF QUALITATIVE DATA COLLECTION?

The most common methods of qualitative data collection are interview – talking to participants about their experiences relevant to the research question, and observation – watching participants while they are having those experiences. Depending on the research questions explored, a research design might combine interviews and observations.

Interview-based methods

Interviews are typically used for situations where a guided conversation with relevant participants can help provide insight into their lived experiences and how they view and interpret the world around them. Interviews are also particularly useful for exploring past events that cannot be replicated or phenomena where direct observation is impossible or unfeasible.

Participants may be interviewed individually or in groups. Focus group interviews are used when the researcher’s topic of interest is best explored through a guided, interactive discussion among the participants themselves. Therefore, when focus groups are used, the sample is conceptualised at the level of the group – three focus groups of five people constitutes a sample of three interactive discussions, not 15 individual participants. Because they centre on the group discussion and dynamic, focus groups are less well-suited for topics that are sensitive, highly personal or perceived to be culturally inappropriate to discuss publicly.( 18 )

Unlike quantitative interviews, where a set of structured, closed-ended (e.g. yes/no) questions are asked in the same order with the same wording every time, qualitative interviews typically involve a semi-structured design where a list of open-ended questions serves to guide, but not constrain, the interview. Therefore, at the interviewer’s discretion, the questions and their sequence may vary from interview to interview. This judgement is made based on both the interviewer’s understanding of the phenomenon under exploration and the emerging dynamic between the interviewer and participant.

The primary goal of a qualitative interview is to get the participants to think carefully about their experience and relate it to the interviewer with rich detail. Getting good data from interviewing relies on using creative strategies to avoid the common trap of getting politically correct answers – often called ‘cover stories’– or answers that are superficial rather than deep and reflective.( 19 ) A common design error occurs when researchers are overly explicit in their questioning, such as asking “ What are the top five criteria you use to assess student professionalism? ” A better approach involves questions that ask participants to describe what they do in practice, with follow-up probes that extend beyond the specific experience described. For example, starting with “ Tell me about a recent experience where you assessed a student’s professionalism ” allows the participant to relay an experience, to which the interviewer can respond with probes such as “ What was tricky about that? ” or “ How typical is that experience? ”

Another common strategy for prompting participants to engage in rich reflection on their experience and perceptions is to use vignettes as discussion prompts. Vignettes are often artificial scenarios presented to participants to read or watch on video, about which they are then asked probing questions.( 20 ) However, vignettes can also be used to recreate an authentic situation for the participant to engage with.( 21 ) For instance, in one interview study, we presented participants with a vignette in the form of the research assistant reading aloud a standard patient admission presentation that the interviewees would typically hear from their students on morning ward rounds. We then asked the participants to interact with the interviewer as though he or she was a student who had presented this case on morning rounds. Recreating this interaction in the context of the interview served as a stepping stone to questions such as “ Why did you ask the student ‘x’? ” and “ How would your approach have differed with a different student presenter, e.g. a stronger or weaker one? ”

Direct observation

Observation-based research can involve a wide spectrum of activities, ranging from brief observations of specific tasks (e.g. handover, preoperative team briefings) to prolonged field observations such as those seen in ethnography. When used effectively, direct observation can provide the researcher with powerful insight into the routines of a group.

Getting good data from observational research relies on several key components. First, it is essential to define the scope of the project upfront: limited budgets, the massive amount of detail to be attended to, and the ability of any individual or group of observers to attend to these make this essential. Good observational research therefore relies on collaboration between knowledgeable insiders and those with both methodological and theoretical expertise. Sampling demands particular attention; an initial purposive sampling approach is often followed by more targeted, theoretical sampling that is guided by the developing analysis. Observational research also typically involves a mix of data sources, including observational field notes, field interviews and document analysis. Audio and video may be helpful when the studied phenomena is particularly complex or nuances of interaction may be missed without the ability to review data, or when precision of verbal and nonverbal interactions is necessary to answer the research question.( 22 )

Field notes are often the dominant data source used for subsequent analysis in observational research. As such, they must be created with great diligence. Usually researchers will jot down brief notes during an observation and afterwards elaborate in as much detail as they can recall. Field notes have an important reflective component. In addition to the factual descriptions, researchers include comments about their feelings, reactions, hunches, speculations and working theories or interpretations. The content of field notes, therefore, usually includes: descriptions of the setting, people and activities; direct quotations or paraphrasing of what people said; and the observer’s reflections.( 23 ) Field notes are time-consuming when done well – even a single hour of observation can lead to several hours of reflective documentation.

An important aspect to consider when designing observation-based research is the ‘observer effect’, also known as the Hawthorne effect, more recently reframed as ‘participant reactivity’ by health professions education researchers Paradis and Sutkin.( 24 ) The Hawthorne effect is conventionally defined as “ when observed participants act differently from how they would act if the observer were not present ”.( 25 ) Researchers have implemented a number of strategies to mitigate this effect, including prolonged embedding of the observer, efforts to ‘fit in’ through dress or comportment, and careful recording of explicit instances of the effect.( 24 ) However, Paradis and Sutkin found that instances of the Hawthorne effect, as conventionally defined, have never been described in qualitative research manuscripts in the health professions education field, perhaps because, as they speculate, healthcare workers and trainees are accustomed to being observed. Based on this, they argued that researchers should worry less about mitigating the Hawthorne effect and instead invest in interpersonal relationships at their study site to mitigate the effects of altered behaviour and draw on theory to make sense of participants’ altered behaviour.( 23 ) Combining interviewing and observation is also common in qualitative research ( Box 3 ).

Combining interviews and observations:

WHAT ARE THE COMMON METHODS OF QUALITATIVE DATA ANALYSIS?

Qualitative data almost invariably takes the form of text; an interview is turned into a transcript and an observation is rendered into a field note. Analysing these qualitative texts is about uncovering meaning, developing understanding and discovering insights relevant to the research question. Analysis is not separated from data collection in qualitative research, and begins with the first interview, the first observation or the first reading of a document. In fact, the iterative nature of data collection and analysis is a hallmark of qualitative research, because it allows the researcher’s emerging insights about the study phenomena to inform subsequent rounds of data collection ( Box 4 ).

The iterative process of analysis:

Data that has been analysed while being collected is both parsimonious and illuminating. However, this process can extend indefinitely. There will always be another person to interview or another observation to record. Deciding when to stop depends on both practical and theoretical concerns. Practical concerns include deadlines and funding. More importantly, the decision should be guided by the theoretical concern of sufficiency.( 26 ) Sufficiency occurs when new data does not produce new insights into the phenomenon, in other words, when you keep hearing and seeing the same things you have heard and seen before.

Qualitative data analysis is primarily inductive and comparative. The overall process of data analysis begins by identifying segments in the data that are responsive to the research question. The next step is to compare one segment with the next, looking for recurring patterns in the data set. During this step, the focus is on sorting the raw data into categories that progressively build a coherent description or explanation of the phenomenon under study. This process of identifying pieces of data and grouping them into categories is called coding.( 14 ) Once a tentative scheme of categories is derived, it is applied to new data to see whether those categories continue to exist or not, or whether new categories arise – this step determines whether sufficiency has been reached. The final step in the analysis is to think about how categories interrelate. At this point, the analysis moves to interpreting the meaning of these categories and their interrelations.( 12 )

The process for data analysis laid out in this section is a basic inductive and comparative analysis strategy that is suitable for analysing data for most interpretive qualitative research methodologies, including the four featured in this paper – phenomenology, grounded theory, ethnography and case study – as well as others such as narrative analysis and action research. While each methodology attends to specific procedures, they all share the use of this basic inductive/comparative strategy. Overall, analysis should be guided by methodology, but different analytical procedures can be creatively combined across methodologies, as long as this combining is explicit and intentional.( 27 )

WHAT ARE SOME CURRENT INNOVATIONS IN QUALITATIVE RESEARCH?

Understanding the complex factors that influence clinical practice and medical education is not an easy research task. Many important issues may be difficult for the insider to articulate during interviews and impossible for the outsider to ‘see’ during observation. Innovations to address these challenges include guided walks,( 28 ) photovoice( 29 ) and point-of-view filming.( 30 ) Our own research has drawn intensively on the innovation termed ‘rich pictures’ to explore the features and implications of complexity in medical education.( 31 ) In one study, we asked medical students to draw pictures of clinical cases that they found complex: an exciting case and a frustrating one.( 32 ) Participants were given 30–60 minutes on their own to reflect on the situation and draw their pictures. This was followed by an in-depth interview using the pictures as triggers to explore the phenomenon under study – in this case, students’ experiences of and responses to complexity during their training.

Such innovations hold great promise for qualitative research in medical education. For instance, rich pictures can reveal emotional and organisational dimensions of complex clinical experiences, which are less likely to be emphasised in participants’ traditional interview responses.( 33 ) Methodological innovations, however, bring new challenges: they can be time-intensive for participants and researchers; they require new analytical procedures to be developed; and they necessitate efforts to educate audiences about the rigour and credibility of unfamiliar approaches.

WHAT ARE THE PRINCIPLES OF RIGOUR IN QUALITATIVE RESEARCH?

Like quantitative research, qualitative research has principles of rigour that are used to judge the quality of the work.( 34 ) Here, we discuss principles that appear in most criteria for rigour in the field: reflexivity, adequacy, authenticity, trustworthiness and resonance ( Box 5 ).

Principles of rigour in qualitative research:

The main data collection tool in qualitative research is the researcher. We talk to participants, observe their practices and interpret their documents. Consequently, a critical feature of rigour in qualitative data collection is researcher reflexivity: the ability to consider our own orientations towards the studied phenomenon, acknowledge our assumptions and articulate regularly our impressions of the data.( 35 ) Only this way can we assure others that our subjectivity has been thoughtfully considered and afford them the ability to judge its influence on the work for themselves. Qualitative research does not seek to remove this subjectivity; it treats research perspective as unavoidable and enriching, not as a form of bias to purge.

Every qualitative dataset is an approximation of a complex phenomenon – no study can capture all dimensions and nuances of situated social experiences, such as medical students’ negotiations of professional dilemmas in the clinical workplace. Therefore, two other important criteria of rigour relate to the adequacy and authenticity of the sampled experiences. Did the research focus on the appropriate participants and/or situations? Was the size and scope of the sample adequate to represent the scope of the phenomenon?( 36 ) Was the data collected an authentic reflection of the phenomenon in question? Qualitative researchers should thoughtfully combine different perspectives, methods and data sources (a process called ‘triangulation’) to intensify the richness of their representation.( 37 ) We should endeavour to draw on data in our written reports such that we provide what sociologist Geertz has termed a sufficiently ‘thick’ description( 38 ) for readers to judge the authenticity of our portrayal of the studied phenomenon.

Qualitative analysis embraces subjectivity: what the researcher ‘sees’ in the data is a product both of what participants told or showed us and of what we were oriented to make of those stories and situations. To some degree, a rhetorician will always see rhetoric and a systems engineer will always see systems. To fulfil the rigour criteria of trustworthiness, qualitative analysis should also be systematic and held to a principle of trustworthiness, which dictates that we should clearly describe: (a) what was done by whom during the inductive, comparative analytical process; (b) how the perspectives of multiple coders were negotiated; (c) how and when theoretical lenses were brought to bear in the iterative process of data collection and analysis; and (d) how discrepant instances in the data – those that fell outside the dominant thematic patterns – were handled.

Finally, the ultimate measure of quality in qualitative research is the resonance of the final product to those who live the social experience under study.( 4 ) As qualitative researchers presenting our work at conferences, we know we have met this bar if our audiences laugh, nod or scowl at the right moments, and if their response at the end is “ You nailed it. That’s my world. But you’ve given me a new way to look at it ”. The situatedness of qualitative research means that its transferability to other contexts is always a matter of the listener/reader’s judgement, based on their consideration of the similarities and differences between the research context and their own. Thus, there is a necessity for qualitative research to sufficiently describe its context, so that consumers of the work have the necessary information to gauge transferability. Ultimately, though, transferability remains an open question, requiring further inquiry to explore the explanatory power of one study’s insights in a new setting.

WHAT ELSE IS THERE TO KNOW?

This overview of qualitative research in medical education is not exhaustive. We have been purposefully selective, discussing in depth some common methodologies and methods, and leaving aside others. We have also passed over important issues such as qualitative research ethics, sampling and writing. There is much, much more for readers to know! Our selectivity notwithstanding, we hope that this paper will provide an accessible introduction to some qualitative essentials for readers who are new to this research domain, and that it may serve as a useful resource for more experienced readers, particularly those who are doing a qualitative research project and would like a better sense of where their work sits within the broader field of qualitative approaches.

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• Published: 22 April 2024

The design and evaluation of gamified online role-play as a telehealth training strategy in dental education: an explanatory sequential mixed-methods study

• Chayanid Teerawongpairoj 1 ,
• Chanita Tantipoj 1 &
• Kawin Sipiyaruk 2  

Scientific Reports volume  14 , Article number:  9216 ( 2024 ) Cite this article

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To evaluate user perceptions and educational impact of gamified online role-play in teledentistry as well as to construct a conceptual framework highlighting how to design this interactive learning strategy, this research employed an explanatory sequential mixed-methods design. Participants were requested to complete self-perceived assessments toward confidence and awareness in teledentistry before and after participating in a gamified online role-play. They were also asked to complete a satisfaction questionnaire and participate in an in-depth interview to investigate their learning experience. The data were analyzed using descriptive statistics, paired sample t-test, one-way analysis of variance, and framework analysis. There were 18 participants who completed self-perceived assessments and satisfaction questionnaire, in which 12 of them participated in a semi-structured interview. There were statistically significant increases in self-perceived confidence and awareness after participating in the gamified online role-play ( P  < 0.001). In addition, the participants were likely to be satisfied with this learning strategy, where usefulness was perceived as the most positive aspect with a score of 4.44 out of 5, followed by ease of use (4.40) and enjoyment (4.03). The conceptual framework constructed from the qualitative findings has revealed five key elements in designing a gamified online role-play, including learner profile, learning settings, pedagogical components, interactive functions, and educational impact. The gamified online role-play has demonstrated its potential in improving self-perceived confidence and awareness in teledentistry. The conceptual framework developed in this research could be considered to design and implement a gamified online role-play in dental education. This research provides valuable evidence on the educational impact of gamified online role-play in teledentistry and how it could be designed and implemented in dental education. This information would be supportive for dental instructors or educators who are considering to implement teledentistry training in their practice.

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Introduction.

Telehealth has gained significant attention from various organization due to its potential to improve healthcare quality and accessibility 1 . It can be supportive in several aspects in healthcare, including medical and nursing services, to enhance continuous monitoring and follow-up 2 . Its adoption has increased substantially during the COVID-19 pandemic, aiming to provide convenient healthcare services 3 . Even though the COVID-19 outbreak has passed, many patients still perceive telehealth as an effective tool in reducing a number of visits and enhancing access to health care services 4 , 5 . This supports the use of telehealth in the post-COVID-19 era.

Teledentistry, a form of telehealth specific to dentistry, has been employed to improve access to dental services 6 . This system offers benefits ranging from online history taking, oral diagnosis, treatment monitoring, and interdisciplinary communication among dental professionals, enabling comprehensive and holistic treatment planning for patients 7 . Teledentistry can also reduce travel time and costs associated with dental appointments 8 , 9 , 10 . There is evidence that teledentistry serves as a valuable tool to enhance access to dental care for patients 11 . Additionally, in the context of long-term management in patients, telehealth has contributed to patient-centered care, by enhancing their surrounding environments 12 . Therefore, teledentistry should be emphasized as one of digital dentistry to enhance treatment quality.

Albeit the benefits of teledentistry, available evidence demonstrates challenges and concerns in the implementation of telehealth. Lack of awareness and knowledge in the use of telehealth can hinder the adoption of telehealth 13 . Legal issues and privacy concerns also emerge as significant challenges in telehealth use 14 . Moreover, online communication skills and technology literacy, including competency in using technological tools and applications, have been frequently reported as challenges in teledentistry 15 , 16 . Concerns regarding limitations stemming from the lack of physical examination are also significant 17 . These challenges and complexities may impact the accuracy of diagnosis and the security and confidentiality of patient information. Therefore, telehealth training for dental professionals emerges as essential prerequisites to effectively navigate the use of teledentistry, fostering confidence and competence in remote oral healthcare delivery.

The feasibility and practicality of telehealth in dental education present ongoing challenges and concerns. Given the limitations of teledentistry compared to face-to-face appointments, areas of training should encompass the telehealth system, online communication, technical issues, confidentiality concerns, and legal compliance 18 . However, there is currently no educational strategy that effectively demonstrates the importance and application of teledentistry 19 . A role-play can be considered as a teaching strategy where learners play a role that closely resembles real-life scenarios. A well-organized storytelling allows learner to manage problematic situations, leading to the development of problem-solving skill 20 , 21 . When compared to traditional lecture-based learning, learners can also enhance their communication skills through conversations with simulated patients 22 , 23 . In addition, they could express their thoughts and emotions during a role-play through experiential learning 20 , 24 , 25 . Role-play through video teleconference would be considered as a distance learning tool for training dental professionals to effectively use teledentistry.

While there have been studies supporting online role-play as an effective learning tool due to its impact of flexibility, engagement, and anonymity 26 , 27 , no evidence has been yet reported whether or not this learning strategy could have potential for training teledentistry. Given the complicated issues in telehealth, role-play for training teledentistry should incorporate different learning aspects compared to face-to-face communication with patients. In addition, game components have proved to be supportive in dental education 28 , 29 . Consequently, this research aimed to evaluate user perceptions and educational impact of gamified online role-play to enhance learner competence and awareness in using teledentistry as well as to construct a conceptual framework highlighting how to design and implement this interactive learning strategy. This research would introduce and promote the design and implementation of gamified online role-play as a learning tool for training teledentistry. To achieve the aim, specific objectives were established as follows:

1. To design a gamified online role-play for teledentistry training.

2. To investigate learner perceptions regarding their confidence and awareness in the use of teledentistry after completing the gamified online role-play.

3. To explore user satisfactions toward the use of gamified online role-play.

4. To develop a conceptual framework for designing and implementing a gamified online role-play for teledentistry training.

Materials and methods

Research design.

This research employed an explanatory sequential mixed-methods design, where a quantitative phase was firstly performed followed by a qualitative phase 30 , 31 . The quantitative phase was conducted based on pre-experimental research using one-group pretest–posttest design. Participants were requested to complete self-perceived assessments toward confidence and awareness in the use of teledentistry before and after participating in a gamified online role-play. They were also asked to complete a satisfaction questionnaire in using a gamified online role-play for training teledentistry. The qualitative phase was afterwards conducted to explore in-depth information through semi-structured interviews, in order to enhance an understanding of the quantitative phase, and to develop a conceptual framework for designing and implementing an online role-play for training teledentistry.

A gamified online role-play for training teledentistry

A gamified online role-play was designed and developed by the author team. To ensure its educational impact was significant, the expected learning outcomes were formulated based on insights gathered from a survey with experienced instructors from the Department of Advanced General Dentistry, Faculty of Dentistry, Mahidol University. These learning outcomes covered areas of online communication skill, technical issues, technology literacy of patients, limitations of physical examination, and privacy concerns of personal information. Learning scenario and instructional content were subsequently designed to support learners in achieving the expected learning outcomes, with their alignments validated by three experts in dental education. A professional actress underwent training to role-play a patient with a dental problem, requesting a virtual consultation or teledentistry. Before conducting data collection, the simulated patient was required to undergo a training and adjusting process with a pilot group under supervision of two experts in advanced general dentistry and dental education who had experience with teledentistry to ensure realism and completeness of learning content.

According to the role-play scenario, an actress was assigned to portray a 34-year-old female with chief complaints of pain around both ears, accompanied by difficulties in chewing food due to tooth loss. She was instructed to express her anxiety and nervousness about addressing these issues. Additionally, it was specified that she could not take a day off from work during this period. Despite this constraint, she required a dental consultation to receive advice for initial self-care, as her symptoms significantly impacted her daily life. Furthermore, she was designated to encounter difficulties with the technological use of the teledentistry platform.

The game components were implemented into the online role-play to enhance motivation and engagement. As challenge and randomness appear to be game elements 32 , 33 , five challenge cards were designed and embedded into the online role-play, where a participant was asked to randomly select one of them before interacting with the simulated patient. The challenging situations were potential technical concerns which could occur frequently during video conferencing, including network problems (e.g., internet disconnection and poor connection) and audiovisual quality issues. The participants were blinded to the selected card, while it was revealed to only the simulated patient. The challenging conditions were mimicked by the organizers and simulated patient, allowing learners to deal with difficulties. Therefore, both challenges and randomness were implemented into this learning intervention not only to create learning situations but also to enhance engagement.

A feedback system was carefully considered and implemented into the gamified online role-play. Immediate feedback appears to be a key feature of interactive learning environments 29 . Formative feedback was instantly delivered to learners through verbal and non-verbal communication, including words (content), tone of voice, facial expressions, and gestures of the simulated patient. This type of feedback allowed participants to reflect on whether or not their inputs were appropriate, enabling them to learn from their mistakes, or so-called the role of failure 34 . Summative feedback was also provided at the end of the role-play through a reflection from a simulated patient and suggestions from an instructor.

Learners were able to interact with the simulated patient using an online meeting room by Cisco WebEx. According to the research setting (Fig.  1 ), a learner was asked to participate in the role-play activity using a computer laptop in a soundproof room, while a simulated patient was arranged in a prepared location showing her residential environment. The researcher and instructor also joined the online meeting room and observed the interaction between the simulated patient and learners during the role-play activity whether or not all necessary information was accurately obtained. The role-play activity took around 30 minutes.

A diagram demonstrating the setting of gamified online role-play.

Research participants

Quantitative phase.

The participants in this research were postgraduate students from the Residency Training Program in Advanced General Dentistry at Mahidol University Faculty of Dentistry in academic year 2022, using a volunteer sampling. This program was selected because its objective was to develop graduates capable of integrating competencies from various dental disciplines to provide comprehensive dental care for both normal patients and those with special needs. Therefore, teledentistry should be a supportive component of their service. The recruitment procedure involved posting a recruiting text in the group chat of the residents. Those interested in participating in the research were informed to directly contact us to request more information, and they were subsequently allowed to decide whether they would like to participate. This approach ensured that participation was voluntary. Although there could be a non-response bias within this non-probability sampling technique 35 , it was considered as appropriate for this study, as participants were willing to have contribution in the learning activity, and therefore accurate and reliable research findings with no dropout could be achieved 36 .

The inclusion and exclusion criteria were established to determine the eligibility of prospective participants for this research. This study included postgraduate students from Years 1 to 3 in the Residency Training Program in Advanced General Dentistry at Mahidol University Faculty of Dentistry, enrolled during the academic year 2022. They were also required to at least complete the first semester to be eligible for this research to ensure familiarity with comprehensive dental care. However, they were excluded if they had previous involvement in the pilot testing of the gamified online role-play or if they were not fluent in the Thai language. The sample size was determined using a formula for two dependent samples (comparing means) 37 . To detect a difference in self-perceived confidence and awareness between pre- and post-assessments at a power of 90% and a level of statistical significance of 1%, five participants were required. With an assumed dropout rate of 20%, the number of residents per year (Year 1–3) was set to be 6. Therefore, 18 residents were required for this research.

Qualitative phase

The participants from the quantitative phase were selected for semi-structured interviews using a purposive sampling. This sampling method involved the selection of information-rich participants based on specific criteria deemed relevant to the research objective and to ensure a diverse representation of perspectives and experiences within the sample group 38 . In this research, the information considered for the purposive sampling included demographic data (e.g., sex and year of study), along with self-perceived assessment scores. By incorporating perceptions from a variety of participants, a broad spectrum of insights from different experiences in comprehensive dental practice and diverse improvement levels in self-perceived confidence and awareness could inform the design and implementation of the training program effectively. The sample size for this phase was determined based on data saturation, wherein interviews continued until no new information or emerging themes were retrieved. This method ensured thorough exploration of the research topic and maximized the richness of the qualitative data obtained.

Outcome assessments

To evaluate the gamified online role-play, a triangular design approach was employed, enabling the researchers to compare the research outcomes from different assessment methods. In this research, self-perceived assessments (confidence and awareness) in teledentistry, satisfactions toward gamified online role-play, and learner experience were assessed to assure the quality and feasibility of the gamified online role-play.

Self-perceived confidence and awareness toward teledentistry

All participants were requested to rate their perceptions of teledentistry before and after participating in the gamified online role-play (Supplementary material 1 ). The self-perceived assessment was developed based on previous literature 39 , 40 , 41 , 42 . The assessment scores would inform whether or not the participants could improve their self-perceived confidence and awareness through a learning activity. The assessment consisted of two parts, which were (1) self-perceived confidence and (2) self-perceived awareness. Each part contained six items, which were similar between the pre- and post-assessments. All items were designed using a 5-point Likert scale, where 1 being ‘strongly disagree’ and 5 being ‘strongly agree’.

Satisfactions toward the gamified online role-play

All participants were asked to complete the satisfaction questionnaire after participating in the gamified online role-play, to investigate whether or not they felt satisfied with their learning (Supplementary material 2 ). The questionnaire was developed based on previous literature regarding gamification and role-play 41 , 42 , 43 , 44 . Most of the items were designed using a 5-point Likert scale, where 1 being ‘very dissatisfied’ and 5 being ‘very satisfied’. They were grouped into three aspects, which were (1) Perceived usefulness, (2) Perceived ease of use, and (3) Perceived enjoyment.

Learner experiences within the gamified online role-play

Semi-structured interviews were conducted with the purposively selected participants to gather in-depth information regarding their learning experiences within the gamified online role-play. This technique allowed researchers to ask additional interesting topics raised from the responses of participants. A topic guide for interviews were constructed based on the findings of previous literature 45 , 46 , 47 . The interview was conducted in a private room by a researcher who was trained in conducting qualitative research including interviews. The interview sessions took approximately 45–60 minutes, where all responses from participants were recorded using a digital audio recorder with their permission. The recorded audios were transcribed using a verbatim technique by a transcription service under a confidential agreement.

Validity and reliability of data collection tools

To enhance the quality of self-perceived assessment and satisfaction questionnaire, they were piloted and revised to assure their validity and reliability. According to the content validity, three experts in advanced general dentistry were asked to evaluate the questionnaire, where problematic items were iteratively revised until they achieved the index of item-objective congruence (IOC) higher than 0.5. To perform a test–retest reliability, the validated versions of both self-perceived assessment and satisfaction questionnaire were afterwards piloted in residents from other programs, and the data were analyzed using an intraclass correlation coefficient (ICC), where the values of all items were 0.7 or greater. The data from the first pilot completion of both data collection tools were analyzed using Cronbach’s alpha to ensure the internal consistency of all constructs. The problematic items were deleted to achieve the coefficient alpha of 0.7 or greater for all constructs, which was considered as acceptable internal consistency.

Data analysis

The quantitative data retrieved from self-perceived assessment and satisfaction questionnaire were analyzed with the Statistical Package for Social Sciences software (SPSS, version 29, IBM Corp.). Descriptive statistics were performed to present an overview of the data. The scores from pre- and post-assessments were analyzed using a paired sample t-test to evaluate whether or not the participants would better self-perceive their confidence and awareness in teledentistry after participating in the gamified online role-play. One-way analysis of variance (ANOVA) was conducted to compare whether or not there were statistically significant differences in self-perceived assessment and satisfaction scores among the three academic years.

The qualitative data retrieved from semi-structured interviews were analyzed using a framework analysis, where its procedure involved transcription, familiarization with the interview data, coding, developing an analytical framework, indexing, charting, and data interpreting qualitative findings 48 . In this research, the initial codes had been pre-defined from previous literature and subsequently adjusted following the analysis of each transcript to develop an analytical framework (themes and subthemes), requiring several iterations until no additional codes emerged. Subsequently, the established categories and codes were applied consistently across all transcripts (indexing). The data from each transcript were then charted to develop a matrix, facilitating the management and summarization of qualitative findings. This method enabled the researchers to compare and contrast differences within the data and to identify connections between categories, thereby exploring their relationships and informing data interpretation.

The procedure of framework analysis necessitated a transparent process for data management and interpretation of emerging themes to ensure the robustness of research 49 . The transparency of this analytic approach enabled two researchers (C.Te. and K.S.) to independently analyze the qualitative data, and the emerging themes afterwards were discussed to obtain consensus among the researchers. This technique can be considered as a triangular approach to assure the intercoder reliability and internal validity of this research. The transparent process also allowed an external expert in dental education to verify the accuracy of the analysis. All emerging themes and the decision on data saturation were based on a discussion of all researchers until an agreement was made. NVivo (version 14, QSR International) was used to performed the qualitative data analysis. Subsequently, a conceptual framework was constructed to demonstrate emerging themes and subthemes together with their relationships.

Ethical consideration

The ethical approval for the study was approved by the Institutional Review Board of Faculty of Dentistry and Faculty of Pharmacy, Mahidol University on 29 th September 2022, the ethical approval number: MU-DT/PY-IRB 2022/049.2909. All methods were performed in accordance with the relevant guidelines and regulations. Although the data were not anonymous in nature as they contained identifiable data, they were coded prior to the analysis to assure confidentiality of participants.

Informed consent

Informed consent was obtained from all participants.

There were 18 residents from Year 1 to 3 of the Residency Training Program in Advanced General Dentistry who participated in this research (six from each year). Of these, there were 14 females and 4 males. There was no participant dropout, as all of them completed all required tasks, including the pre- and post-perceived assessments, gamified online role-play, and satisfaction questionnaire. According to the purposive sampling, the participants from the quantitative phase were selected for semi-structured interviews by considering sex, year of study, and self-perceived assessment scores. Twelve students (ten females and two males) participated in semi-structured interviews, where their characteristics are presented in Table 1 .

Internal consistency of all constructs

The data collected from the research participants, in addition to the pilot samples, were analyzed with Cronbach’s alpha to confirm the internal consistency. The coefficient alpha of all constructs demonstrated high internal consistency, as demonstrated in Table 2 .

Self-perceived assessments toward confidence and awareness of teledentistry

There were statistically significant increases in the assessment scores of self-perceived confidence and awareness after participating in the gamified online role-play ( P  < 0.001). According to Table 3 , there was an increase in self-perceived confidence from 3.38 (SD = 0.68) for the pre-assessment to 4.22 (SD = 0.59) for the post-assessment ( P  < 0.001). The findings of self-perceived awareness also showed score improvement from 4.16 (SD = 0.48) to 4.55 (SD = 0.38) after interacting with the simulated patient ( P  < 0.001).

According to Fig.  2 , participants demonstrated a higher level of self-perceived assessments for both self-confidence and awareness in all aspects after participating in the gamified online role-play for teledentistry training.

Self-perceived assessments toward confidence and awareness of teledentistry.

When comparing the self-perceived assessment scores toward confidence and awareness in the use of teledentistry among the three years of study (Year 1–3), there were no statistically significant differences in the pre-assessment, post-assessment score, and score difference (Table 4 ).

Satisfactions toward the use of gamified online role-play

According to Fig.  3 , participants exhibited high levels of satisfaction with the use of gamified online role-play across all three aspects. The aspect of usefulness received the highest satisfaction rating with a score of 4.44 (SD = 0.23) out of 5, followed by ease of use and enjoyment, scoring 4.40 (SD = 0.23) and 4.03 (SD = 0.21), respectively. Particularly, participants expressed the highest satisfaction levels regarding the usefulness of gamified online role-play for identifying their role (Mean = 4.72, SD = 0.46) and developing problem-solving skills associated with teledentistry (Mean = 4.61, SD = 0.50). Additionally, they reported satisfaction with the learning sequence presented in the gamified online role-play (Mean = 4.61, SD = 0.50). However, participants did not strongly perceive that the format of the gamified online role-play could engage them with the learning task for an extended period (Mean = 3.72, SD = 0.83).

Satisfactions toward the use of gamified online role-play.

When comparing the satisfaction levels perceived by participants from different academic years (Table 5 ), no statistically significant differences were observed among the three groups for all three aspects ( P  > 0.05).

Following the framework analysis of qualitative data, there were five emerging themes, including: (1) learner profile, (2) learning settings of the gamified online role-play, (3) pedagogical components, (4) interactive functions, and (5) educational impact.

Theme 1: Learner profile

Learner experience and preferences appeared to have impact on how the participants perceived the use of gamified online role-play for teledentistry training. When learners preferred role-play or realized benefits of teledentistry, they were likely to support this learning intervention. In addition, they could have seen an overall picture of the assigned tasks before participating in this research.

“I had experience with a role-play activity when I was dental undergraduates, and I like this kind of learning where someone role-plays a patient with specific personalities in various contexts. This could be a reason why I felt interested to participate in this task (the gamified online role-play). I also believed that it would be supportive for my clinical practice.” Participant 12, Year 1, Female “Actually, I' have seen in several videos (about teledentistry), where dentists were teaching patients to perform self-examinations, such as checking their own mouth and taking pictures for consultations. Therefore, I could have thought about what I would experience during the activity (within the gamified online role-play).” Participant 8, Year 2, Female

Theme 2: Learning settings of the gamified online role-play

Subtheme 2.1: location.

Participants had agreed that the location for conducting a gamified online role-play should be in a private room without any disturbances, enabling learners to focus on the simulated patient. This could allow them to effectively communicate and understand of the needs of patient, leading to a better grasp of lesson content. In addition, the environments of both learners and simulated patient should be authentic to the learning quality.

“The room should be a private space without any disturbances. This will make us feel confident and engage in conversations with the simulated patient.” Participant 10, Year 1, Female “… simulating a realistic environment can engage me to interact with the simulated patient more effectively ...” Participant 8, Year 2, Female

Subtheme 2.2: Time allocated for the gamified online role-play

The time allocated for the gamified online role-play in this research was considered as appropriate, as participants believed that a 30-minutes period should be suitable to take information and afterwards give some advice to their patient. In addition, a 10-minutes discussion on how they interact with the patient could be supportive for participants to enhance their competencies in the use of teledentistry.

“… it would probably take about 20 minutes because we would need to gather a lot of information … it might need some time to request and gather various information … maybe another 10-15 minutes to provide some advice.” Participant 7, Year 1, Female “I think during the class … we could allocate around 30 minutes for role-play, … we may have discussion of learner performance for 10-15 minutes ... I think it should not be longer than 45 minutes in total.” Participant 6, Year 2, Female

Subtheme 2.3: Learning consequence within a postgraduate curriculum

Most participants suggested that the gamified online role-play in teledentistry should be arranged in the first year of their postgraduate program. This could maximize the effectiveness of online role-play, as they would be able to implement teledentistry for their clinical practice since the beginning of their training. However, some participants suggested that this learning approach could be rearranged in either second or third year of the program. As they already had experience in clinical practice, the gamified online role-play would reinforce their competence in teledentistry.

"Actually, it would be great if this session could be scheduled in the first year … I would feel more comfortable when dealing with my patients through an online platform." Participant 11, Year 2, Male "I believe this approach should be implemented in the first year because it allows students to be trained in teledentistry before being exposed to real patients. However, if this approach is implemented in either the second or third year when they have already had experience in patient care, they would be able to better learn from conversations with simulated patients." Participant 4, Year 3, Male

Theme 3: Pedagogical components

Subtheme 3.1: learning content.

Learning content appeared to be an important component of pedagogical aspect, as it would inform what participants should learn from the gamified online role-play. Based on the interview data, participants reported they could learn how to use a video teleconference platform for teledentistry. The conditions of simulated patient embedded in an online role-play also allowed them to realize the advantages of teledentistry. In addition, dental problems assigned to the simulated patient could reveal the limitations of teledentistry for participants.

“The learning tasks (within the gamified online role-play) let me know how to manage patients through the teleconference.” Participant 5, Year 2, Female “… there seemed to be limitations (of teledentistry) … there could be a risk of misdiagnosis … the poor quality of video may lead to diagnostic errors … it is difficult for patients to capture their oral lesions.” Participant 3, Year 2, Female

Subtheme 3.2: Feedback

During the use of online role-play, the simulated patient can provide formative feedback to participants through facial expressions and tones of voice, enabling participants to observe and learn to adjust their inquiries more accurately. In addition, at the completion of the gamified online role-play, summative feedback provided by instructors could summarize the performance of participants leading to further improvements in the implementation of teledentistry.

“I knew (whether or not I interacted correctly) from the gestures and emotions of the simulated patient between the conversation. I could have learnt from feedback provided during the role-play, especially from the facial expressions of the patient.” Participant 11, Year 2, Male “The feedback provided at the end let me know how well I performed within the learning tasks.” Participant 2, Year 1, Female

Theme 4: Interactive functions

Subtheme 4.1: the authenticity of the simulated patient.

Most participants believed that a simulated patient with high acting performance could enhance the flow of role-play, allowing learners to experience real consequences. The appropriate level of authenticity could engage learners with the learning activity, as they would have less awareness of time passing in the state of flow. Therefore, they could learn better from the gamified online role-play.

"It was so realistic. ... This allowed me to talk with the simulated patient naturally ... At first, when we were talking, I was not sure how I should perform … but afterwards I no longer had any doubts and felt like I wanted to explain things to her even more." Participant 3, Year 2, Female "At first, I believed that if there was a factor that could influence learning, it would probably be a simulated patient. I was impressed by how this simulated patient could perform very well. It made the conversation flow smoothly and gradually." Participant 9, Year 3, Female

Subtheme 4.2: Entertaining features

Participants were likely to be satisfied with the entertaining features embedded in the gamified online role-play. They felt excited when they were being exposed to the unrevealed challenge which they had randomly selected. In addition, participants suggested to have more learning scenarios or simulated patients where they could randomly select to enhance randomness and excitement.

“It was a playful experience while communicating with the simulated patient. There are elements of surprise from the challenge cards that make the conversation more engaging, and I did not feel bored during the role-play.” Participant 4, Year 3, Male “I like the challenge card we randomly selected, as we had no idea what we would encounter … more scenarios like eight choices and we can randomly choose to be more excited. I think we do not need additional challenge cards, as some of them have already been embedded in patient conditions.” Participant 5, Year 2, Female

Subtheme 4.3: Level of difficulty

Participants suggested the gamified online role-play to have various levels of difficulty, so learners could have a chance to select a suitable level for their competence. The difficulties could be represented through patient conditions (e.g., systemic diseases or socioeconomic status), personal health literacy, and emotional tendencies. They also recommended to design the gamified online role-play to have different levels where learners could select an option that is suitable for them.

“The patient had hidden their information, and I needed to bring them out from the conversation.” Participant 12, Year 1, Female “Patients' emotions could be more sensitive to increase level of challenges. This can provide us with more opportunities to enhance our management skills in handling patient emotions.” Participant 11, Year 2, Male “… we can gradually increase the difficult level, similar to playing a game. These challenges could be related to the simulated patient, such as limited knowledge or difficulties in communication, which is likely to occur in our profession.” Participant 6, Year 2, Female

Theme 5: Educational impact

Subtheme 5.1: self-perceived confidence in teledentistry, communication skills.

Participants were likely to perceive that they could learn from the gamified online role-play and felt more confident in the use of teledentistry. This educational impact was mostly achieved from the online conversation within the role-play activity, where the participants could improve their communication skills through a video teleconference platform.

“I feel like the online role-play was a unique form of learning. I believe that I gained confidence from the online communication the simulated patient. I could develop skills to communicate effectively with real patients.” Participant 11, Year 2, Male “I believe it support us to train communication skills ... It allowed us to practice both listening and speaking skills more comprehensively.” Participant 4, Year 3, Male

Critical thinking and problem-solving skills

In addition to communication skills, participants reported that challenges embedded in the role-play allowed them to enhance critical thinking and problem-solving skills, which were a set of skills required to deal with potential problems in the use of teledentistry.

"It was a way of training before experiencing real situations … It allowed us to think critically whether or not what we performed with the simulated patients was appropriate." Participant 7, Year 1, Female “It allowed us to learn how to effectively solve the arranged problems in simulated situation. We needed to solve problems in order to gather required information from the patient and think about how to deliver dental advice through teledentistry.” Participant 11, Year 2, Male

Subtheme 5.2: Self perceived awareness in teledentistry

Participants believed that they could realize the necessity of teledentistry from the gamified online role-play. The storytelling or patient conditions allowed learners to understand how teledentistry could have both physical and psychological support for dental patients.

“From the activity, I would consider teledentistry as a convenient tool for communicating with patients, especially if a patient cannot go to a dental office”. Participant 5, Year 2, Female “I learned about the benefits of teledentistry, particularly in terms of follow-up. The video conference platform could support information sharing, such as drawing images or presenting treatment plans, to patients.” Participant 8, Year 2, Female

A conceptual framework of learning experience within a gamified online role-play

Based on the qualitative findings, a conceptual framework was developed in which a gamified online role-play was conceptualized as a learning strategy in supporting learners to be able to implement teledentistry in their clinical practice (Fig.  4 ).

The conceptual framework of key elements in designing a gamified online role-play.

The conceptual framework has revealed key elements to be considered in designing a gamified online role-play. Learner profile, learning settings, pedagogical components, and interactive functions are considered as influential factors toward user experience within the gamified online role-play. The well-designed learning activity will support learners to achieve expected learning outcomes, considered as educational impact of the gamified online role-play. The contributions of these five key elements to the design of gamified online role-play were interpreted, as follows:

Learner profile: This element tailors the design of gamified online role-plays for teledentistry training involves considering the background knowledge, skills, and experiences of target learners to ensure relevance and engagement.

Learning settings: The element focuses the planning for gamified online role-plays in teledentistry training involves selecting appropriate contexts, such as location and timing, to enhance accessibility and achieve learning outcomes effectively.

Pedagogical components: This element emphasizes the alignment between learning components and learning outcomes within gamified online role-plays, to ensure that the content together with effective feedback design can support learners in improving their competencies from their mistakes.

Interactive functions: This element highlights interactivity features integrated into gamified online role-plays, such as the authenticity and entertaining components to enhance immersion and engagement, together with game difficulty for optimal flow. All these features should engage learners with the learning activities until the achievement of learner outcomes.

Educational impact: This element represents the expected learning outcomes, which will inform the design of learning content and activities within gamified online role-plays. In addition, this element could be considered to evaluate the efficacy of gamified online role-plays, reflecting how well learning designs align with the learning outcomes.

A gamified online role-play can be considered as a learning strategy for teledentistry according to its educational impact. This pedagogical approach could mimic real-life practice, where dental learners could gain experience in the use of teledentistry in simulated situations before interacting with actual patients. Role-play could provide learners opportunities to develop their required competencies, especially communication and real-time decision-making skills, in a predictable and safe learning environment 20 , 23 , 46 . Potential obstacles could also be arranged for learners to deal with, leading to the enhancement of problem-solving skill 50 . In addition, the recognition of teledentistry benefits can enhance awareness and encourage its adoption and implementation, which could be explained by the technology acceptance model 51 . Therefore, a gamified online role-play with a robust design and implementation appeared to have potential in enhancing self-perceived confidence and awareness in the use of teledentistry.

The pedagogical components comprised learning content, which was complemented by assessment and feedback. Learners could develop their competence with engagement through the learning content, gamified by storytelling of the online role-play 52 , 53 . Immediate feedback provided through facial expression and voice tone of simulated patients allowed participants to learn from their failure, considered as a key feature of game-based learning 29 , 45 . The discussion of summative feedback provided from an instructor at the end of role-play activity could support a debriefing process enabling participants to reflect their learning experience, considered as important of simulation-based game 54 . These key considerations should be initially considered in the design of gamified online role-play.

The interactive functions can be considered as another key component for designing and evaluating the gamified online role-play 45 . Several participants enjoyed with a learning process within the gamified online role-play and suggested it to have more learning scenarios. In other words, this tool could engage learners with an instructional process, leading to the achievement of learning outcomes 29 , 45 . As challenge and randomness appear to be game elements 32 , 33 , this learning intervention assigned a set of cards with obstacle tasks for learners to randomly pick up before interacting with simulated patients, which was perceived by participants as a feature to make the role-play more challenging and engaging. This is consistent with previous research, where challenging content for simulated patients could make learners more engaged with a learning process 55 . However, the balance between task challenges and learner competencies is certainly required for the design of learning activities 56 , 57 . The authenticity of simulated patient and immediate feedback could also affect the game flow, leading to the enhancement of learner engagement 45 . These elements could engage participants with a learning process, leading to the enhancement of educational impact.

The educational settings for implementing gamified online role-play into dental curriculum should be another concern. This aspect has been recognized as significant in existing evidence 45 . As this research found no significant differences in all aspects among the three groups of learners, this learning intervention demonstrated the potential for its implementation at any time of postgraduate dental curriculum. This argument can be supported by previous evidence where a role-play could be adaptable for learning at any time, as it requires a short learning period but provides learners with valuable experience prior to being exposed in real-life scenarios 58 . This strategy also provides opportunities for learners who have any question or concern to seek advice or guidance from their instructors 59 . Although the gamified online role-play can be arranged in the program at any time, the first academic year should be considered, as dental learners would be confidence in implementing teledentistry for their clinical practice.

While a gamified online role-play demonstrated its strengths as an interactive learning strategy specifically for teledentistry, there are a couple of potential drawbacks that need to be addressed. The requirement for synchronous participation could limit the flexibility of access time for learners (synchronous interactivity limitation). With only one learner able to engage with a simulated patient at a time (limited participants), more simulated patients would be required if there are a number of learners, otherwise they would need to wait for their turn. Time and resources are significantly required for preparing simulated patients 60 . Despite the use of trained and calibrated professional actors/actresses, inauthenticity may be perceived during role-plays, requiring a significant amount of effort to achieve both interactional and clinical authenticities 46 . Future research could investigate asynchronous learning approaches utilizing non-player character (NPC) controlled by an artificial intelligence system as a simulated patient. This setup would enable multiple learners to have the flexibility to engage with the material at their own pace and at times convenient to them 29 . While there are potential concerns about using gamified online role-plays, this interactive learning intervention offers opportunities for dental professionals to enhance their teledentistry competency in a safe and engaging environment.

Albeit the robust design and data collection tools to assure reliability and validity as well as transparency of this study, a few limitations were raised leading to a potential of further research. While this research recruited only postgraduate students to evaluate the feasibility of gamified online role-play in teledentistry training, further research should include not only experienced dental practitioners but also undergraduate students to confirm its potential use in participants with different learner profiles. More learning scenarios in other dental specialties should also be included to validate its effectiveness, as different specialties could have different limitations and variations. Additional learning scenarios from various dental disciplines should be considered to validate the effectiveness of gamified online role-plays, as different specialties may present unique limitations and variations. A randomized controlled trial with robust design should be required to compare the effectiveness of gamified online role-play with different approaches in training the use of teledentistry.

Conclusions

This research supports the design and implementation of a gamified online role-play in dental education, as dental learners could develop self-perceived confidence and awareness with satisfaction. A well-designed gamified online role-play is necessary to support learners to achieve expected learning outcomes, and the conceptual framework developed in this research can serve as a guidance to design and implement this interactive learning strategy in dental education. However, further research with robust design should be required to validate and ensure the educational impact of gamified online role-play in dental education. Additionally, efforts should be made to develop gamified online role-play in asynchronous learning approaches to enhance the flexibility of learning activities.

Data availability

The data that support the findings of this study are available from the corresponding author, up-on reasonable request. The data are not publicly available due to information that could compromise the privacy of research participants.

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Acknowledgements

The authors would like to express our sincere gratitude to participants for their contributions in this research. We would also like to thank the experts who provided their helpful suggestions in the validation process of the data collection tools.

This research project was funded by the Faculty of Dentistry, Mahidol University. The APC was funded by Mahidol University.

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Teerawongpairoj, C., Tantipoj, C. & Sipiyaruk, K. The design and evaluation of gamified online role-play as a telehealth training strategy in dental education: an explanatory sequential mixed-methods study. Sci Rep 14 , 9216 (2024). https://doi.org/10.1038/s41598-024-58425-9

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Living with type 1 diabetes and schooling among young people in Ghana: a truism of health selection, inadequate support, or artefactual explanation of educational inequalities?

• Bernard Afriyie Owusu 1 &
• David Teye Doku 1  

BMC Public Health volume  24 , Article number:  1137 ( 2024 ) Cite this article

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Introduction

Type 1 diabetes mellitus (T1DM) is mostly diagnosed among young people. Despite the evidence that T1DM is disruptive, and affects individuals’ health and cognitive ability, there is dearth of knowledge on the impact of T1DM on schooling in LMICs including Ghana. In this research, we explored the impact of T1DM on the schooling of young people living with the disease, and discussed the results within health selection, social support, and artefactual perspectives of inequality.

Data were extracted from a qualitative project on T1DM lived experiences in southern Ghana. The study participants were young persons living with T1DM ( n  = 28) and their caregivers ( n  = 12). They were purposively recruited to participate in the study using maximum variation and snowball sampling techniques and interviewed in their support group centres, homes, or healthcare facilities using semi-structured interview guides. A computer-assisted qualitative data analysis was performed using QSR NVivo 14 software, and the results were categorised into themes.

Three themes were identified from the transcripts. These themes were school and classroom attendance , choice of school , and school/academic performance . T1DM was a major reason for patients’ limited contact hours with teachers, school drop-out, preference for day schools rather than boarding, opting for vocational training instead of continuation of formal education, limited concentration at school, and delayed educational progression.

T1DM impacted the schooling of young people living with the disease. The mechanisms of these impacts, and young peoples lived experiences are not artefactual, but rather support discourses on health selection and inadequate social support for young people living with the disease. The results call for the need to develop educational and social interventions to address these barriers. The full implementation of the Inclusive Education Policy (IEP) may contribute to reducing educational and social inequalities caused by ill-health.

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Across the globe, recent estimates show that about 8.4 million individuals are living with Type 1 Diabetes Mellitus (T1DM) [ 1 ]. A fifth of these individuals live in low-and-middle-income countries (LMICs) and about 18% of the global average are young people and children (aged below 20 years) [ 1 ]. In Ghana, about three thousand young people aged less than 20 years are living with T1DM [ 2 ] with a higher proportion that usually go unreported. For this latter group, the condition can be crippling. Associated T1DM health conditions such as Mauriac syndrome, thyroid disorders, and bone ill-health [ 3 , 4 ] negatively impact growth and development while reducing the probability of survival. Beyond physical growth impairment, the disease can impact cognitive development. Over the past decades, several scholars have provided evidence on the adverse impacts of T1DM on young people’s educational attainment [ 5 , 6 , 7 ]; strengthening the need to develop interventions to accommodate such warriors (a lay term used for young people living with T1DM in Ghana) [ 8 ] in educational settings. An educational intervention pertinent to students living with T1DM is the Inclusive Education Policy (IEP) which highlights concerns about learner diversities such as “persons with other health impairment and chronic diseases” [ 9 ].

There are two major pathways that explain the influence of T1DM on educational attainment among warriors. First, T1DM operates through impaired physical health. Young people living with T1DM require regular medical attention and this leaves them with little time and energy for school and other educational activities [ 5 ]. Yu and colleagues found that on average, children with T1DM missed 8.3 more days annually compared to their healthy counterparts [ 10 ]. Glaab, Brown and Daneman also attested to more missed days for diabetic children and reported that in Ontario, Toronto, it could be 2 or 3 days more [ 11 ]. Second, T1DM is associated with several neuropsychological conditions [ 7 ] such as hypoglycaemia, hyperglycaemia, and diabetes ketoacidosis. These conditions affect mental alertness [ 6 , 12 ] which results in poor overall final grades and delayed educational progression. Given the central role of education in future employment prospects, T1DM can, in the long term, affect their socio-economic positions in life via health selection.

Within the contexts of this study, the cornerstone of health selection is that students’ overall health dictates their social resources needed to excel in school, with those affected by ill health drifting down the educational ladder and those with good health drifting upwards the educational ladder (upward drift) [ 13 , 14 , 15 ]. Health selection can be tested using comparative data to examine associations between health and educational outcomes, but it is imperative to contextualise the interpretation of this synergy through subjective experiences. We find this theory important to advance our discussion on T1DM and schooling due to three main reasons. First, T1DM is a life-long condition with no cure and no days off management. Second, it mostly manifest among young people who may be in school and studying towards various socio-economic positions in society. Third, T1DM is a multidimensional condition that affects the cognitive and socio-economic participation of patients.

The Ghanaian education system has three levels of pre-tertiary education. They are the primary, junior high, and senior high school levels. Currently, the government funds public education on all three pre-tertiary levels as part of its “free education” agenda. This helps to reduce the financial burden for people, of which children and student warriors are inclusive. The first two levels operate the day-schooling module where children attend school and return home on a day-to-day basis. Day schools are usually located in communities or towns closer to their place of residence and in easy commute. At the senior high school level, two modules are adopted – day and boarding schooling. The latter requires students to stay in accommodation facilities (mostly referred to as “boarding houses” or “hostels”) within the schools’ premises. A senior high school may adopt either one of the approaches or both. Thus, for these warriors and their caregivers, decisions on the choice of school move beyond pursuing their programmes of study - the accommodation module that can make schooling convenient for them is crucial. At the tertiary level, the situation is further exacerbated by the limited number of public tertiary institutions, high priced private institutions, and the temptation to consider other vocational training options (e.g., apprenticeship) which may not necessarily be in the interest of warriors. There are high trade-offs for warriors in either choosing the best schools/educational institutions or those that are convenient given their health condition – an add-on to inequalities in educational choices and outcomes.

There is limited research on the impact of T1DM on schooling in LMICs including Ghana, and more deplete as discussed within health selection, social support, and artefactual perspectives globally. On one hand, this is partly due to the limited attention T1DM among young warriors has received and on the other hand, limitations in data availability to investigate the impact of T1DM on educational outcomes or perhaps, limited funding to explore such research interests in LMICs. The limitations in this area have implications for both present and future attempts to promote quality education for all, and reduce avoidable educational inequalities. Furthermore, existing studies, though useful, have provided little qualitative evidence to fill in the “how” and “why” and in most instances, the experiences of caregivers are left out. Since caregivers are involved in their children’s educational choices and considerations, their insights and experiences on these issues are indispensable and need to be featured in ongoing discourse.

Several large-scale studies have compared educational and school performance of young people living with T1DM with their non-diabetic counterparts and concluded that T1DM has an adverse impact on the schooling of young people with T1DM [ 16 , 17 , 18 ]. In this research, emphasis is placed on the lived experiences of warriors at the primary to tertiary levels of education and their caregivers to understand how T1DM influence educational outcomes. Using qualitative approaches, this research explores the educational experiences of young people living with T1DM to provide more contextualized, African, and diversified evidence on the impact of T1DM on educational outcomes, and highlight evidence which is critical to understanding the linkages between ill-health, education, inequality, and socio-economic development. The evidence from this research will be of great importance to guide educational programs, interventions, and policies that target young people with medical conditions in general, and those with T1DM in particular.

Materials and methods

The study was conducted in southern Ghana, specifically Greater Accra, Central, and Western regions where T1DM is most prevalent [ 19 ]. These regions represent a heterogeneous population due to the high migration of people from both the middle and northern belts of Ghana. This zone benefits from improved socio-economic infrastructure including major healthcare infrastructure. For instance, healthcare facilities such as the Korle-Bu Teaching Hospital, Greater Accra Regional Hospital (Ridge Hospital), and Cape Coast Teaching Hospitals are found in this zone and are major referral points for T1DM care [ 8 , 20 ].

Study design and participants selection

Data were drawn from a qualitative project on the lived experiences of young persons living with T1DM and their caregivers in southern Ghana. Amongst the participants studied were 28 young persons living with T1DM, and 12 caregivers. The warriors were identified at Diabetes Youth Care (DYC: an NGO that provides monthly psychosocial support to a diverse group of young persons living with T1DM across the regions) support group centres in the study area (n = 13), healthcare facilities (n = 6), and their homes (n = 9). They were purposively recruited to participate in the study using maximum variation, convenience, and snowball sampling techniques. The maximum variation selection techniques relied on the various DYC register, allowing participants with different socio-demographic characteristics such as age, sex, and educational levels to be interviewed. Using snow-ball approaches, participants who were non-members of the DYC/rarely went to the DYC monthly support meetings were followed up in their homes or healthcare centres and interviewed. The inclusion criteria were as follows:

The warrior must be aged 14–24 years and living in southern Ghana for not less than 24 months.

The warrior must either be a student at the time of the study or must have been a student within 24 months preceding the study.

The caregiver should be living with and providing care for the warrior for not less than 24 months. The 24 months were deemed as sufficient time to reduce recall biases. Participants’ selection and data analysis were ongoing, and this helped to gauge the point of saturation/information power.

Data collection procedure

Qualitative data were collected at the DYC support group centres, participants' homes, and healthcare facilities using a semi-structured interview guide. The interview guide was pre-tested and revised before it was used for data collection which lasted 40 days (1st August 2021 – 9th September 2021). The lead author negotiated access to the network of warriors through the organisation’s leadership across the regions. Three research assistants who have experience in qualitative methods, its philosophies and practices were trained on the issues covered in the interview guide. They visited and interviewed the warriors either during their monthly support group meetings, healthcare facility, or their usual place of abode. The data collection methods were both face-to-face (n = 17) and via telephone (n = 11). The interviews were mostly conducted in the morning and late afternoon, and at an appropriate location agreed upon by participants. A maximum of one interview was conducted in a day. All interviews were conducted in either English, Fanti, Twi, or a combination of these languages as best spoken and understood by participants. The average duration of the interviews was 48 min and were audio-recorded. All study participants received a compensation of a dollar (US$1) after data collection to cover transportation back home, and airtime costs.

The semi-structured interview guide covered four (4) sections (See Supplementary file ): Socio-demographic characteristics (Section A), T1DM management knowledge (Section B), effects of T1DM on health and education (Section C), challenges of managing T1DM and coping strategies (Section D). This study extracted data from Section A and C, specifically, the socio-demographic characteristics, and the effects of T1DM on education. In this section, the questions explored included “ What does it mean to be living with T1DM as a student? What have been some of the good and challenging moments you have faced as a student living with T1DM? Has T1DM affected your educational choices in any way, and are there any stories to share? The caregivers were asked similar questions including “How has T1DM affected your child’s education". The interviews were transcribed verbatim into the English language soon after data collection and password protected.

Quality assurance mechanisms were embedded in the planning, fieldwork, and analysis phases. We employed credibility methods such as observation, extensive engagement with participants, data triangulation, and participants re-checking of transcripts. Also, there were multiple field officers and coders, and the use of maximum variation sampling technique was important to collect data from different participants. We adopted a phenomenological study design and a chain of evidence to investigate the same issues. We present participants quote including discrepant information to allow readers to vicariously reflect on the data themselves. The semi-structured interview guides were guided by a systematic review of the literature, and the lead researchers' regular involvement with T1DM patients and carers.

Data processing, analysis, and presentation

The analytical technique was thematic analysis. The transcripts were coded independently by the field assistants. The Codebook was shared among the researchers, discussed and themes were generated from the codes. A computer-assisted qualitative data analysis was performed using QSR NVivo 14 software. This software facilitated the comparison of different codes via matrix coding. For instance, comparing participants’ age, sex, and place of residence with classroom attendance. Data analysis was ongoing, and codes were inductively identified from the transcripts. Data coders assigned a word or brief statement of description to depict significant statements that related to the study objectives. For instance, all issues such as “ sought permission out of the classroom to check my sugars, take my shots”, I was on admission while class was in session”, I didn’t go to school due to hospital reviews” were thematised as limited contact hours with teachers. In like manner, narratives such as “I went hypo during examinations, and I couldn’t concentrate during examinations” were thematised as reduced levels of concentration. These significant statements were categorised into themes. Participants’ information was anonymised using a shared in-vivo term they had chosen to call themselves [ warriors, meaning fighting against T1DM ].

Ethical consideration

Ethical clearance was obtained from the University of Cape Coast Institutional Review Board before the start of the data collection [Clearance ID: UCCIRB/CHLS/2021/19]. To accommodate the health and safety needs of participants amid the global Covid-19 pandemic, the study adhered to the Covid-19 protocols, including a 2-m social distance between interviewers and participants. The leadership of the DYC and caregivers consented for participants below age 18, and the assent of these minors was sought as well. Signed copies of informed consent forms as well as verbal consent were obtained or sought respectively prior to the commencement of data collection.

Background characteristics of participants

Forty (40) participants representing two target groups - patients (warriors) and caregivers were interviewed. Twenty-eight (28) of them were warriors. Within this group, there were equal representation of males and females. Ten of the warriors were aged below 19 years. The average duration of T1DM experience for the warriors was about 8 years. Twelve of them reported an immediate family history of diabetes [undifferentiated], and most ( n =19) warriors were students. For instance, 11 of the participants had attained Senior High School level education, eight had attained tertiary education, and two had attained primary education. Most of the warriors stayed with their caregivers—mostly their mothers and grandmothers (n = 11), compared with those who stayed with a non-relative (n = 2). All the warriors were actively covered under the national health insurance scheme (NHIS). A warrior was married, and two others were cohabiting. Three of them had newly joined the DYC, and 7 were irregular meeting attendees. The average age of the caregivers was 45 years, mostly with Basic education (JHS: n = 7), Senior High School (SHS: n = 3), and tertiary (n = 1) levels of education. Nine of the 12 caregivers were biological mothers of a warrior, amongst whom some confirmed they have DM including T1DM. Eight of the caregivers were married and mostly engaged in petty trading. The caregivers have been engaged in T1DM care for about 6 years. Table 1 summarises the socio-demographic characteristics of the study participants.

Themes on the effect of type 1 diabetes (T1DM) on patients’ schooling

Three themes were identified from the inductive analysis. These themes were school and classroom attendance, choice of school, and school/academic performance. The first theme [school and classroom attendance] was formed from sub-themes on limited contact hours with teachers and school drop-out. The second theme [choice of school] was formed from sub-themes on day versus boarding, and opting for vocational training. The final theme [school/academic performance] was formed from sub-themes on limited concentration and delayed educational progression.

School and classroom attendance

The first theme concerned school and classroom attendance of young persons living with T1DM. Type 1 diabetes affected young person’s school and classroom attendance. Concerning this theme, two main sub-themes were identified. These sub-themes were limited contact hours with schoolteachers and early school drop-out.

Limited contact hours with schoolteachers

Young people living with T1DM faced limited contact hours with teachers during school sessions. This sub-theme was formed from two main issues which were frequent permission out of the classroom, and absenteeism . Young persons living with T1DM sought permission outside the classroom to self-monitor their blood glucose, inject their insulin or urinate frequently while classes were in session. In explaining this issue, this was what was said:

“I will usually go out during class sections to urinate or seek permission to go and check my sugar or something” [a 20-year-old female warrior with 6 years of lived experience].

A 21-year-old male warrior with 10 years of lived experience corroborated this issue by sharing his experience while writing his final examination in high school. He revealed how T1DM disturbed his concentration while writing his examinations:

“My condition disturbed me a lot when I was writing my WASSCE [West African Senior School Certificate Examination]. I couldn’t concentrate especially when my sugars were going low, and I had to be getting out to urinate and check my sugars amidst the limited time pressure”.

Concerning absenteeism , most young persons living with T1DM revealed that they usually absented themselves from school or classroom because of T1DM-related hospital/school-based infirmary admissions, caregiver delays in preparing food for them early enough to go to school, sick days, and T1DM complications. Excerpts from participants support this finding:

“I had to miss days of school to get check-ups and medicines from the hospital which made my education a bit off the rail because by the time I would return from the hospital, school will almost be over” [a 21-year-old male warrior with 7 years of lived experience].

Assertions from some caregivers corroborate this finding. For instance, in the words of a 50-year-old mother with child who had 7 years of lived experience, this was what was said:

“Since 2014, there are several times that he was admitted to the hospital and therefore couldn’t write examination or didn’t have the time to study for it”.

Early school dropout

The second sub-theme on school and classroom attendance was early school drop-out due to T1DM and its complications. Some warriors dropped out of school due to T1DM complications and its related stigma. Specifically, eye and foot complications were common reasons for some patients dropping out of school. This was common amongst patients from poor socio-economic backgrounds. In explaining the issue of complications, this was what was said:

“I stopped school at class 6 because of my condition. I found it difficult to read from the board. The school’s food wasn’t good for my condition, and this wound [has an impaired wound healing] so it was stressful at school” [a 15-year-old female warrior with 5 years of lived experience].

Also, some young persons dropped out of school due to T1DM-related stigma. They experienced stigma concerning emaciation, insulin injection, and name-calling as always “ sick ”. Excerpts from participants support this finding.

“My friends tease me [starts to cry], they tease me and tell me that I am a sickler”. My … [same religion] friends who know that I inject myself don’t laugh at me, the other [religion] laugh at me. I couldn’t stay in the school, and my mother didn’t have money to change my school, so I stopped” [a 17-year-old female warrior with 5 years of lived experience] .

Choice of school

The second theme concerned the choice of school. This was found to be a major issue of concern for young persons living with T1DM and their caregivers. Issues pertinent to the choice of school were day versus boarding and opting for vocational training.

Day versus boarding

From the outset, caregivers selected secondary schools for their children living with T1DM to attend. These schools were either close-by their place of residence, or caregivers had personal contact with the school authorities intended for their children to attend. In explaining these issues of proximity and personal contacts at the school, this was what was said by a 55-year-old mother with 5 years of lived experience:

“She had admission at [mentions name of school] but due to her condition and distance, I obtained [mentions name of school] SHS for her because it is closer, and her sister went there and knows a woman who stays close to the school, so I took my child into her house to be under her care”.

Caregivers were hesitant about allowing their children living with T1DM to be in boarding schools due to concerns over limited T1DM support in school. Excerpts from caregivers and young people living with T1DM showed that the boarding house compromised their adequate management of T1DM. As such, these students living with T1DM commuted to and from school, rather than being in the boarding house unlike most of their colleagues without diabetes. In their narrations, this was what was said:

“Those I completed JHS with are in the boarding house. I couldn’t go to the boarding house due to my condition…I would have loved to go the boarding house also because of improved study time, but that would be difficult for me” . [a 17-year-old female warrior with 5 years of lived experience]. “I have not chosen the school [SHS] yet but my mother says I will go to a day school so that she can have time for me” [a 17-year-old male warrior with 4 years of lived experience].

In explaining this issue , a 41-year-old mother with 5 years of lived experience provided insights to corroborate this finding by revealing this:

“ One of my major concerns is that I can’t allow her to go to boarding school. She may sleep and something may happen to her, and no one will know”.

For some students whose caregivers were concerned about their inability to properly manage their condition while transitioning from SHS to the University, they preferred that their children spend the first year of their university education at the house to gather enough time to experience the university environment prior to transitioning fully to campus residence. In their revelation, a 21-year-old female warrior with 7 years of lived experience had this to say:

“In level 100, I was moving from home to school. They [parents] wanted to be sure that I will be able to cope and manage my condition in school before allowing me to move a year after. My daddy used to drop me off every day at school before going to work”.

Opting for vocational institutions

Due to the worries about the boarding house, a few young people living with T1DM shunned the Senior High School system, with its boarding provisions to enrol in vocational institutions. Concerning this, a 20-year-old female warrior with 5 years of lived experience had this to say:

“My uncle was like going to the boarding house was a whole lot so I enroled in a fashion school (vocational institute) where I am doing clothing for two years… I always wanted to be a journalist, but I think circumstances, so I was like okay, doing clothing is also a job”.

In buttressing this issue, a 53-year-old caregiver with 3 years of lived experience shared her plans about enrolling her warrior into a vocational institution. In her revelations, this was what was said:

I am taking care of her to finish her BECE [Basic Education Certificate Examination] and I plan of asking her to learn a trade or start some vocational school.

School/academic performance

There were concerns about the effect of T1DM on patients’ school performance (defined as meeting goals and objectives set for school). We found.

that, due to the effects of T1DM on school attendance, caregivers attributed the poor academic performance of their warriors to the demanding nature of T1DM management. They shared that T1DM affected their wards’ academic performance through polyuria and limited concentration during examinations. The sub-themes identified were limited concentration and delayed educational progression .

Limited concentration

Participants shared their experiences with living with T1DM while writing examinations, particularly the WASSCE (West African Senior School Certificate Examination). In their revelations, T1DM was the major reason for their lack of concentration due to severe low blood glucose and polyuria. In elucidating this issue, this was what was said:

Diabetes affected me in many ways, I remember I was so worried about my WASSCE. I remember I went hypo [hypoglycaemia] on the very first day we started WASSCE [a 24-year-old male warrior with 13 years of lived experience].

In buttressing this issue, a 48-year-old mother with 11 years of lived experience said this:

“When she sat for WASSCE, she didn’t do well because she was sick from her condition and said she couldn’t concentrate due to very low sugar levels” .

Delayed educational progression

There were concerns held by participants about their delayed educational progression. This concern was also shared by the parents/guardians of the young persons living with T1DM. Concerning educational progression, a 48-year-old mother with 11 years of lived experience had this to say:

“All her friends will be completing University this year, she’s the only one who just enroled”.

In buttressing this issue, a 56-year-old mother with 6 years of lived experience with two children living with T1DM said this:

“She is 19 years, but her brain is dull. It is now that she’s picking up some behaviours from time to time. Her junior brother is in SHS, and she is in JHS”.

We studied the influence of T1DM on schooling by exploring the experiences of young people living with T1DM and their caregivers in Ghana. The results show that T1DM impacted the schooling of young persons living with the disease in adverse ways. T1DM impacted young person’s schooling through absenteeism/limited classroom attendance, choice of school, and school/academic performance. These findings add new knowledge regarding how diabetes impacts on education among young people living with the disease – a critical pathway to socio-economic development. The results further provide a considerable amount of evidence to explain the various pathways to a downward drift in educational settings.

Concerning school and classroom attendance, the finding that T1DM contributes to students’ absenteeism due to increased hospitalisation or medical appointments has been confirmed in Australia [ 21 ] and Canada [ 11 ]. By its nature, the management of T1DM is complex and demanding [ 22 ]. It requires patients and their caregivers to make daily lifestyle modifications which can be overwhelming. Also, poor management of T1DM can lead to acute complications such as hypoglycaemia and diabetes coma which requires immediate hospitalisation [ 23 , 24 ]. As confirmed in a related study, the experience of T1DM-related stigma is a major reason for missing school days [ 22 ]. Due to polyuria, use of glucose monitoring devices and insulin injection outside of classroom, young people living with T1DM frequently miss class sessions [ 18 , 25 ]. These evidence demonstrates the impact of T1DM on school and classroom attendance and calls for the need to develop interventions to address these barriers of schooling.

The finding that T1DM influenced the choice of school for warriors has been reported in other studies. The fear of allowing children living with T1DM to be in boarding schools or stay close to caregivers was emphasised. This is consistent with the report by Kratzer that parents fear that their children’s diabetes will not be managed properly while away from home [ 26 ]. Caregivers, therefore, want to keep close relations with their children [ 27 , 28 ]. For warriors in Senior High and Tertiary levels of schooling, the prospects of transitioning to boarding school/higher education was a daunting panorama for many of the caregivers as it meant moving from a safer space [home] to an unsafe environment [school] for T1DM management. Although, some warriors felt the need to be in the boarding house largely due to reasons including improved study time , T1DM and the complexities of management constrained both patients and their caregivers to normalise avoiding the boarding school system, and opting for being a day student or apprenticeship. Shunning the boarding house was primarily a caregiver’s decision, informed by the constraints of group quarter housing - poor diet, supervision, and healthcare accessibility, and therefore geared towards providing safer spaces for the adequate management of T1DM.

Some previous quantitative studies illustrate that T1DM has implications on education and academic performance [ 29 , 30 ]. As found in this study, TIDM affected not only daily activities but also impinged on their academic performance, concentration on schoolwork, and school progression [ 31 ]. Ahmed et al. found similar results in Khartoum (Sudan) on the implications of T1DM on academic progression of diabetic school children [ 32 ]. In their meta-analysis, Brands et al., found that warriors have a significantly lower cognitive performance, and obtained significantly lower academic grades compared with their non-diabetic classmates [ 16 , 33 ]. In Sweden, Persson and colleagues reported that the mean final grades from compulsory school were lower for child warriors and only a handful were able to progress to upper secondary education [ 6 ]. In a related study, T1DM was reported to affect warriors’ choice of academic programmes - warriors choose academic programmes that may offer them insights into their T1DM including nutrition programmes[ 8 ]. Decisions on school, academic progression or career choices provides individuals with the requisite knowledge and skillset for the next level of employment [ 34 ]. Choice of school and career as evident in this study raises concerns about the career pathway, socio-economic participation, and satisfaction of warriors about their career prospects. Given that career choices explicitly train people for various employment prospects, there can be high trade-offs. Evidence from Scotland also revealed additional characteristics that underlie the low grades among young warriors. They include absenteeism, learning difficulties, and to a greater extent, school exclusion [ 5 ]. Thus, a drift hypothesis can occur among young people such that T1DM can compound health, academic, career, employment, and income constraints which can influence their socio-economic prospects and positions in life (Fig.  1 ).

Pathways through which T1DM may affect educational achievements and plausibly SES.  Source: Owusu B.A and Doku D.T., (2024)

Insofar as the health selection is true, this would imply that the social consequences of ill-health will need to be greater among young persons living with T1DM who suffer the brunt of their condition, and that they are more likely to be found amongst the lower socio-economic positions or groups. Despite the lack of a comparison group (young people without T1DM), the experiences of young persons living with T1DM with respect to the impact of T1DM on their schooling or education is not artefactual. Certainly, the analysis of different datasets and application of different measures produces different results, but further supports underlying concepts being tested. These theoretical insights (health selection or artefact) are rather speculative and therefore limited; none of them wholly provide a holistic explanation of inequality. For adolescents living with chronic T1DM, particularly those in senior and junior high schools, this “sick role” can be an “opportunity” to miss school days. Also, since students in boarding houses relatively enjoy stable study times, group studies, and adequate academic supervision, missing boarding schools can blur the academic achievement of warriors, and their progression to higher levels of education in the Ghanaian context. However, in some instances, educational inequalities such as those found in this study are structural and therefore preventable.

Education in Ghana is a basic human right for all citizens. The overarching goal of the Inclusive Education Policy (IEP) is to “ redefine and recast the delivery and management of educational services to respond to the diverse needs of all learners with special educational needs …” including “…those children who are failing in school because they experience barriers that prevent them from achieving optimal progress in their learning and development ” ([ 9 ], p3-4). T1DM is a barrier to adequate learning, progress, and development of warriors as it adversely affects their school attendance, performance, choice of school and cognitive abilities. The results of this study underscore the need to, as part of a wider educational reform, be aware of the different health needs of learners, especially, those suffering from disruptive health conditions such as T1DM, its implication on learners’ educational achievements, and equitably address them. This will entail all stakeholders, including teachers, school authorities, school nurses, kitchen staff, working together to respond to the peculiar needs of warriors that may arise/be pertinent in the school setting.

Strengths and limitations of the study

To the best of our knowledge, this is the first study in Ghana that focuses on the impact of T1DM on schooling by exploring the experiences of warriors and their caregivers. This study is therefore an add-on to T1DM studies which are limited in Ghana and LMICs. The results also highlight the voices of warriors and their caregivers, and make arguments towards a potential health selection - requiring a targeted, age-appropriate and systemic interventions to address these mechanisms of impact. These aside, there are some methodological limitations worth mentioning. First, there was no comparison group (either within group or young people without diabetes) to enhance deeper understanding of the observed differences in school outcomes. Also, the study could have benefited from comparing the school attendance and academic results of warriors to their classmates without T1DM. Thus, the discussion on inequality is rather speculative, and will require further quantitative studies, also to test Fig.  1 as a plausible pathway. Consequently, the conclusion of this study can be generalised only to sub-groups within our inclusion criteria.

T1DM was a major reason for warriors absenteeism, limited contact time with schoolteachers, choice of school, school drop-out, and limited concentration at school. These findings are not artefactual, but seem in support of health selection and inadequate social support perspectives. Addressing these barriers of schooling for young people with T1DM will require the implementation of the inclusive education policy in Ghana. Such targeted intervention in the life of young people would most likely break the continuous linkage between ill-health and social class. Also, comprehensive diabetes education programmes for young persons living with T1DM are essential to build upon their coping strategies, improve glycaemic control as it affects school outcomes, and improve caregivers' trust and confidence in teachers and school management’s capability to support their children with T1DM while in school.

Availability of data and materials

The transcribed data and/or analysed during the current study is available upon request from the Department of Population and Health, UCC at [email protected].

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Acknowledgements

The authors are grateful to all the young persons living with T1DM who participated in this research, including those who have since lost their lives to T1DM. We also acknowledge the review and editing support provided by Dr Kwamena Sekyi Dickson, Josephine Akua Ackah and Castro Ayebeng.

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Owusu, B.A., Doku, D.T. Living with type 1 diabetes and schooling among young people in Ghana: a truism of health selection, inadequate support, or artefactual explanation of educational inequalities?. BMC Public Health 24 , 1137 (2024). https://doi.org/10.1186/s12889-024-18590-y

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Barriers and facilitators to implementation of an exercise and education programme for osteoarthritis: a qualitative study using the consolidated framework for implementation research

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• Avantika Bhardwaj   ORCID: orcid.org/0000-0002-9482-5884 1 , 2 ,
• Christine FitzGerald   ORCID: orcid.org/0000-0002-2180-7431 1 , 2 ,
• Margaret Graham   ORCID: orcid.org/0000-0003-4705-0219 2 , 3 ,
• Anne MacFarlane   ORCID: orcid.org/0000-0002-9708-5025 4 , 5 ,
• Norelee Kennedy   ORCID: orcid.org/0000-0001-6047-1240 1 , 2 &
• Clodagh M. Toomey   ORCID: orcid.org/0000-0002-9373-100X 1 , 2 , 5  

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Targeted efforts to better understand the barriers and facilitators of stakeholders and healthcare settings to implementation of exercise and education self-management programmes for osteoarthritis (OA) are needed. This study aimed to explore the barriers and facilitators to the implementation of Good Life with osteoArthritis in Denmark (GLA:D), a supervised group guideline-based OA programme, across Irish public and private healthcare settings. Interviews with 10 physiotherapists (PTs; 8 public) and 9 people with hip and knee OA (PwOA; 4 public) were coded by the Consolidated Framework for Implementation Research (CFIR) constructs in a case memo (summary, rationale, quotes). The strong positive/negative implementation determinants were identified collaboratively by rating the valence and strength of CFIR constructs on implementation. Across public and private settings, PTs and PwOA strongly perceived GLA:D Ireland as evidence-based, with easily accessible education and modifiable marketing/training materials that meet participants’ needs, improve skills/confidence and address exercise beliefs/expectations. Despite difficulties in scheduling sessions (e.g., work/caring responsibilities), PTs in public and private settings perceived advantages to implementation over current clinical practice (e.g., shortens waiting lists). Only PTs in public settings reported limited availability of internal/external funding, inappropriate space, marketing/training tools, and inadequate staffing. Across public and private settings, PwOA reported adaptability, appropriate space/equipment and coaching/supervision, autonomy, and social support as facilitators. Flexible training and tailored education for stakeholders and healthcare settings on guideline-based OA management may promote implementation. Additional support on organising (e.g., scheduling clinical time), planning (e.g., securing appropriate space, marketing/training tools), and funding (e.g., accessing dedicated internal/external grants) may strengthen implementation across public settings.

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Introduction

Osteoarthritis (OA) is a major public health burden [ 1 ]. Several evidence-based guidelines for OA recommend exercise and education for self-management as first-line treatments [ 2 , 3 ]. However, less than 40% of people with hip and knee OA (PwOA) receive guideline-based first-line treatments [ 4 ]. Global inequities and challenges within healthcare settings and service delivery, ageing populations, and higher obesity and physical inactivity rates may contribute to this evidence-to-practice gap [ 5 , 6 , 7 ]. Targeted efforts to strengthen the implementation of guideline-based healthcare services that may alleviate the burden of OA must be encouraged.

Good Life with osteoArthritis in Denmark (GLA:D) is a supervised group education and neuromuscular exercise self-management programme for OA [ 8 ]. Findings from 28,370 PwOA in the GLA:D data collection registry (Denmark, Canada, Australia) suggest that participation reduces pain intensity by 26–33% and improves quality of life by 12–26% [ 9 ]. To optimise healthcare service delivery for OA, GLA:D was cross-culturally adapted for implementation in Irish public and private healthcare settings using a participatory health research approach [ 10 , 11 ]. In Ireland, a two-tiered healthcare system exists (closest to the UK and Australia), where cost and access to public services are associated with an individual’s circumstance (e.g., people with low incomes may be allocated medical cards granting access to some services for free) [ 12 ]. Approximately, 33% of the population have a medical card and 46% are covered by voluntary private health insurance, which may provide faster access to and better choice of providers/services [ 13 ]. Furthermore, rheumatologists are currently under-staffed in Ireland, with per capita numbers one of the lowest in Europe [ 14 ]. A better understanding of the multilevel factors of stakeholders and healthcare settings that influence the implementation of new healthcare services is needed to address the gap in guideline-based OA management.

Implementation science and the application of established theoretical frameworks consider multifactorial barriers and facilitators to programme implementation [ 15 , 16 ]. Previously, the implementation of GLA:D Canada and GLA:D Australia were evaluated using mixed methods [ 17 ] and surveys [ 18 ], respectively. Implementation determinants, such as costs and training, were reported using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. However, problems associated with applying RE-AIM have been highlighted regarding reporting of recruitment methods and/or costs and resources required [ 19 ]. The Consolidated Framework for Implementation Research (CFIR) is a comprehensive implementation science framework comprising of five domains: “Innovation”, “Outer Setting”, “Inner Setting”, “Individuals”, and “Implementation Process” [ 20 ]. Previously, CFIR has been used to identify the implementation barriers and facilitators of guideline-based programmes that may improve other healthcare services, including older adults with disabilities and frailty [ 21 , 22 ]. CFIR’s inclusion of a broad range of implementation determinants may be useful across different healthcare systems, services, stakeholders, and societies globally. Thus, this study aims to use CFIR to qualitatively explore the barriers and facilitators to the implementation of a supervised group neuromuscular exercise and education self-management programme for OA (GLA:D Ireland) across public and private healthcare settings. The implementation determinants associated with a strong positive/negative influence on stakeholders and healthcare settings will be identified.

GLA:D Ireland

This qualitative study, as part of a larger study (IMPACT: IMPlementation of osteoArthritis Clinical guidelines Together), was conducted between 2022 and 2023. A convenience sample of PTs from different Irish healthcare settings was invited to participate in GLA:D training, with additional courses advertised nationally, across networks and clinical interest groups [ 10 ]. These PTs participated in a training course, between October 2021 and May 2022, developing essential skills and knowledge on guideline-based OA management and GLA:D Ireland protocol (e.g., delivering education, supervising neuromuscular exercise, and using the online data collection registry) [ 10 ]. After completion of the course, GLA:D-trained PTs used existing/new referral sources to invite PwOA (≥ 18 years old) to participate. Criteria excluding participation were the non-OA cause of symptoms (e.g., tumour), or other symptoms that are more pronounced than OA (e.g., fibromyalgia) [ 10 ]. GLA:D Ireland consisted of face-to-face supervised group education sessions ( n  = 2) and neuromuscular exercise sessions ( n  = 12 (twice a week)).

Consolidated framework for implementation research

Implementation was assessed retrospectively, using CFIR as an evaluation framework. CFIR offers a structured approach developed from multiple implementation theories to promote effective implementation [ 20 ]. CFIR consists of 60 constructs sorted under five domains: “Innovation” “Outer Setting”, “Inner Setting”, “Individuals” and “Implementation Process”. Table 1 presents further details on the definitions and operalisation of CFIR domains.

Inclusion criteria were (1) PTs who have implemented GLA:D Ireland and (2) PwOA who have taken part in GLA:D Ireland. Participants were contacted by email and maximum variation sampling was applied to include a balance of gender, affected joint, duration of pain, and healthcare settings to collect data from the widest range of implementation experiences. The sampling of new participants continued until data saturation.

Data collection

A semi-structured interview guide including a range of open-ended questions/probes on participant experiences that were an implementation barrier and/or facilitator was developed using CFIR and prior literature [ 17 ] and is presented in Online Resource 1. The guide was tailored to gather specific information on GLA:D Ireland, with CFIR constructs informing operalisation. A pilot interview to test and refine the guide was undertaken. No revisions were necessary. Questions were related to programme delivery, logistics, fidelity, appropriateness and sustainability. Participant descriptions were probed to understand how implementation experiences related to each CFIR construct and the study aim. Interviews were conducted by a single investigator (AB) via a telephone call or online videoconferencing software Microsoft Teams (Microsoft Teams v.1.6, USA). AB is a PhD candidate evaluating the implementation of GLA:D Ireland, has trained in qualitative methodologies, and had no other interactions with participants. The interviews were audio-recorded and transcribed verbatim by AB, and personal identifiers were removed. Written consent was obtained from all participants prior to interviews. To minimise bias, AB reflexively assessed pre-existing perspectives using field notes to document decisions.

Data analysis

Demographic characteristics were analysed quantitatively using frequency distributions. Interview data were interpreted by at least two investigators using a deductive content analysis approach first, appropriate for analysing data using an existing framework (CFIR) [ 23 ]. Any additional themes identified using an inductive approach were labelled as appropriate. Firstly, investigators (AB, CF, MG) familiarised themselves with the data through multiple readings of transcripts. Following this, transcripts were transferred to and managed with NVivo10 (QSR International). An NVivo10 template, pre-populated with CFIR construct definitions, was used [ 24 ] to develop codes for each transcript [ 25 ]. Based on these codes, case memos for each transcript including summary statements with quotations were developed and organised by each CFIR construct. This was a highly iterative process and involved refining CFIR constructs continuously within the scope of the study until the case memo for each transcript was complete (i.e., until data saturation). Next, each CFIR construct within each case memo was subjected to a rating process using a consensus approach [ 24 , 25 ]. The ratings reflected the valence (positive/negative influence) and strength of each CFIR construct based on each case memo. CFIR constructs were rated as either: missing data (M), mixed positive and negative (X), strong negative (-2) or positive (+ 2), weak negative (-1) or positive (+ 1), or neutral/no influence on implementation (0). Table 2 presents further details on the criteria used to assign ratings. Once all CFIR constructs for all case memos were rated, we created a matrix that listed all the ratings using Microsoft Excel (Microsoft Excel v.16.59, USA). Once consensus on overall ratings for each CFIR construct was reached, we reviewed overall ratings to discern patterns that reflected participants’ descriptions. This allowed us to take a collaborative approach to identify implementation barriers and facilitators. During each step of the analysis, investigators continuously reviewed the codes and associated ratings to identify pre-existing biases or assumptions, to ensure they reflected participants’ descriptions of implementation barriers and facilitators, and to resolve any discrepancies.

Interviews were conducted between 2022 and 2023 (i.e., within six months of having completed their respective GLA:D Ireland programmes). In total, 20 PTs and 35 PwOA were invited and of these, 10 PTs (50.0%) and 9 PwOA (25.7%) responded and agreed to be interviewed. The PT interviews ranged in duration from 29 to 54 min (telephone call n  = 1), PwOA from 22 to 37 min (telephone call n  = 9), and no repeat interviews were conducted. The majority of participants were female (PTs: 60.0%; n  = 6 and PwOA: 77.8%; n  = 7), living in the province of Connacht (PTs: 40.0%, n  = 4) and Leinster (PwOA: 55.6%, n  = 5), and reported public (PTs: 80.0%, n  = 8) or private (PwOA: 55.6%, n  = 5) healthcare settings. Detailed participant demographic characteristics can be found in Table  3 .

CFIR domains

Of the total 60 CFIR constructs, PTs identified 11 as barriers ( – 2 or  – 1), 33 as facilitators (+ 2 or + 1), 4 as both barriers and facilitators (X), 2 as neutral (0), and 10 as missing too much data to discern an influence on implementation (M). PwOA identified 2 CFIR constructs as barriers, 28 as facilitators, 2 as neutral, and 28 as missing. More facilitators were identified than barriers for both PwOA and PTs in the CFIR domains of “Innovation”, “Inner Setting”, “Individuals” and “Implementation Process”. However, more barriers were identified in the CFIR domain of “Outer Setting” for PTs. For a complete list of barriers and facilitators with associated ratings, see Online Resource 2.

Tables 4 and 5 list illustrative quotes for CFIR constructs with a (1) strong positive/negative and (2) mixed positive and negative influence on implementation for PTs and PwOA, respectively. PTs identified nine CFIR constructs as strong positive, 1 as strong negative, and 4 as mixed positive and negative influences on implementation. PwOA identified 15 CFIR constructs as strong positive influences on implementation. No CFIR constructs were identified by PwOA as strong negative or mixed positive and negative influences on implementation.

“Innovation Evidence-Base” and “Innovation Design” were strong facilitators for all participants. PTs and PwOA believed that the programme was supported by peers/colleagues, up-to-date research, previous clinical/participant experience, and in line with current guidelines. Both reported that the programme marketing and training materials included high quality, effective resources that were designed to be easily accessible.

PT 9: “The quality of the programme is really good and it’s well-structured and evidence-based.” PwOA 6: “If you found a particular exercise didn’t suit you, they had an alternative one that you could do.”

Only PTs reported “Innovation Relative Advantage” as a strong facilitator citing a clear advantage to implementing the programme. They perceived that the programme offers an alternative treatment/care pathway for PwOA, shortens waiting lists and encourages first-line treatment success.

PT 10: “On average, these patients would be seen once a month for three months, whereas now you’re definitely getting a more kind of an intensive input granted over a shorter period of time.”

Only PwOA reported “Innovation Adaptability” as a strong facilitator acknowledging that the programme materials and equipment were easily modifiable, and the structure could be tailored to fit participant needs.

PwOA 7: “You didn’t have to go and buy special equipment; you could use your stairs for the steps.”

Outer setting

“Financing” was both a barrier and facilitator only for PTs. They perceived that while external funding (e.g., grants, reimbursements) is available to implement new healthcare services, access may be limited, and long-term sustainability is challenging.

PT 1: “Maybe I do one in the morning somewhere and one in the afternoon somewhere else, but probably just won’t work out more because of funding than anything else.”

Only PwOA reported “Local Attitudes” as a strong facilitator citing previous exercise beliefs/expectations and PTs encouragement to engage in the programme.

PwOA 4: “Exercise has always been a huge part of my life.”

Inner setting

“Access to Knowledge and Information” was a strong facilitator for all participants. PTs and PwOA perceived that guidance and training to implement the programme was accessible, timely, and informative.

PT 3: “The practical component of it and practicing on each other and practicing teaching it. Even though the exercises are simple, it’s just getting the confidence in doing them and getting a structure with doing them.” PwOA 4: “And X always was great at sending YouTube videos so you could actually watch, because I’ve been doing them religiously and consistently, I know how to do them, but that was handy at the start, so that you could just go back to them to refresh your memory on how to do the exercise.”

Only PTs found “Tension for Change” as a strong facilitator. They described first-hand experiences with PwOA that demonstrate a strong need for change in the healthcare setting.

PT 2: “Always see so much osteoarthritis, especially hip and knee. I think it could definitely help with our waiting list.”

“Information Technology and Work Infrastructure”, and “Available Funding” acted as both barriers and facilitators only for PTs. They found that while roles/responsibilities of individuals in the healthcare settings may be well-organised, technical systems, staffing levels, and lack of consistently available internal funding may not support day-to-day activities.

PT 2: “Management had been pretty good, just good timing that they had funding to buy stuff.”

Only PwOA reported “Physical Infrastructure”, “Recipient-Centredness”, and “Relative Priority” as strong facilitators. PwOA perceived that the features and layout of the healthcare setting supported functional performance as well as programme delivery. Additionally, they found that they received care that addressed their needs (e.g., supervision and autonomy). Further, supporting participation in the programme may be important.

PwOA 9: “I made up my mind that this is a chance to help me, to help myself, and that’s the way I looked at it, and that’s what worked out”

Individuals: roles

Only PwOA found “Implementation Leads” as a strong facilitator. PwOA believed that the programme was well-supported by individuals with expert knowledge.

PwOA 2: “The whole thing was conducted in a very professional manner.”

Individuals: characteristics

“Need” was a strong facilitator for PTs and PwOA. Both believed that the programme met the needs of participants including, functional improvements, pain reduction, increased strength and stamina and social engagement.

PT 8: “From a social point of view, they did so well. From a PT point of view, they did very well. From the exercise point of view, they did very well. And from functionally in their activities of daily living, they did very well.” PwOA 1: “I bought myself a step. So, I’ve been stepping on the step and stepping over the step.”

“Capability” and “Motivation” were strong facilitators only for PTs. They found that participants were highly committed to their role in the programme, understood the exercise and education self-management strategies, and had high confidence in their skills and knowledge.

PT 9: “I didn’t experience many challenges because I have done a lot of classes before.”

Only PTs found “Opportunity” as a strong barrier. PTs perceived a lack of time and resources to implement the programme. Further, work/family commitments and the logistics of recruiting participants and scheduling appointments were reported as barriers.

PT 5: “Time is a challenge because resources are finite and trying to establish the programme on top of my other role, which is in triage, I only have very limited PT time.”

Implementation process

“Engaging Innovation Deliverers” was a strong facilitator for PTs and PwOA. Participants believed that attracting participation from appropriate healthcare professionals (HCPs) is important for implementation. They described several activities that may promote engagement including education, training, research, data, social marketing and role modelling.

PT 3: “ You could use the argument with managers that you are clearing this cohort off the list and providing them with a service, which is easy to continue.” PwOA 2: “I think the first phone call would be the consultant.”

“Teaming”, “Assessing Context”, “Engaging Innovation Recipients” and “Reflecting and Evaluating on the Implementation” were strong facilitators only for PwOA. They perceived that building a good support network with other participants was important for continued engagement. Also, the proximity of the class to their location, self-management education and supervision were positive influences on participation. Attracting participation from other PwOA to the programme is important, with participants suggesting word-of-mouth, role modelling, education and peer-to-peer rapport building strategies. Participants also believed that formal assessments to capture outcomes may improve programme implementation.

PwOA 2: “If it was known in the different hospitals that do orthopaedic surgery to give people the option of participating in that, I think more people might take it up.”

Consistent with previous research, our findings within the CFIR domains of “Innovation”, “Outer Setting”, “Inner Setting”, “Individuals” and “Implementation Process” highlighted how characteristics and preferences of stakeholders and healthcare settings affect implementation. New healthcare services that are guideline-based and supported by colleagues/management are positively associated with implementation [ 26 ]. Gleadhill et al. [ 27 ] found that integration was crucial, with 77% of PTs ( n  = 57) rating their colleague’s treatment choices as ‘important’ or ‘very important’. This indicates the importance of developing appropriate care pathways and partnerships between stakeholders and healthcare settings. Participant-reported recommendations to encourage participation included early access to training and knowledge on components and benefits of the programme, social/role modelling, peer-to-peer marketing/word-of-mouth, and targeted education on up-to-date guidelines. Likewise, Parmar et al. [ 26 ] found that developing multidisciplinary teams, brainstorming potential implementation challenges and solutions, assigning responsibilities, and promoting HCP buy-in are critical steps to “intentional implementation planning”. Moreover, collecting feedback on implementation outcomes as an indicator of programme effectiveness may be used to improve stakeholder buy-in [ 28 ].

The use of new healthcare services is further promoted if participants perceive that programme marketing and training materials are easily accessible, and modifiable to meet specific needs [ 29 ]. Our participants believed that the programme may be tailored to suit their needs citing examples such as flexibility to use alternative equipment and the option to refine exercises to fit the home/outdoor environment. Also, the development of alternative online-delivered exercise and education self-management programmes may alleviate limitations imposed by work/caring responsibilities, location, or symptoms [ 30 ]. Further, training on how to implement the programme, and perceived confidence in capabilities to effectively execute the required steps are important positive determinants [ 26 , 31 ]. Similar to GLA:D trained PTs in Switzerland ( n  = 86) who reported limited time and lack of appropriate space in the healthcare setting [ 32 ], our participants emphasised the need for flexible training opportunities that may improve participation (e.g., fit clinical time, proximity of training centre). Interestingly, PwOA did not report a lack of appropriate space (physical/technical features) as an implementation barrier citing opposing experiences to PTs. Possible reasons for this contrast in our findings could be due to differences in participant healthcare settings; the majority of PwOA in our sample reported as “private” healthcare settings (55.6%, n  = 5), whereas majority of PTs reported “public” (80.0%, n  = 8). Ireland’s private system offers faster access to and better choice of providers/services for those who can afford voluntary health insurance or to pay out of pocket [ 12 ]. While the Irish Health Service Executive delivers direct and indirect services, access to public healthcare remains poor. Specifically, Irish PwOA are estimated to use healthcare services significantly more than those without OA, costing €13.6 million annually [ 33 ]. Notably, only PTs reported the availability of internal and external funding/grants or reimbursement models as important determinants of implementation success. They perceived that the availability of financial support to implement new healthcare services is limited, citing that long-term adoption of new programmes may be difficult. A systematic review of reviews also reported that the financial climate of healthcare settings (e.g., allocation of or grants from health authorities/government funds) affects the implementation of evidence-based guidelines and new responsibilities [ 34 ]. It is pertinent to note that PTs in private healthcare settings did not identify financial climate as an implementation barrier. This supports previous findings on inequities in healthcare financing between public and private healthcare settings [ 13 , 35 ]. Due to such inequities, it is possible participants in private healthcare settings are less likely to have experienced setting-level barriers to guideline-based clinical practice. Advocating for improved access to grants and reimbursement models and the development of programme guidelines/toolkits for logistics and financing may be effective. Likewise, future implementation efforts may find it helpful to define the necessary components of exercise and education self-management programmes for OA allowing healthcare settings to adapt services as relevant to their contexts.

Also, participation in GLA:D Ireland was perceived to be more beneficial than current clinical practice. While the perceived relative advantage of new healthcare services is an important factor in implementation success [ 36 ], it may be further compounded by dissatisfaction with current clinical practices. For example, challenges within healthcare settings are a barrier to implementation and may promote relative priority for testing new guideline-based programmes that aid global efforts to strengthen healthcare settings [ 7 ]. Additionally, implementation success may be influenced by how well the programme meets the needs of participants and is aligned with their beliefs/expectations. HCPs who were strongly interested in prevention also perceived a chronic disease prevention and screening programme to be a good fit with their role [ 37 ]. Similarly, in the implementation evaluation study on GLA:D Australia, PTs ( n  = 1064) reported that addressing participant beliefs about OA and treatment options was key to improving programme reach [ 18 ]. Our participants also described how PTs and healthcare settings addressed their needs including, receiving coaching/supervision, treatment choice and low costs. In the cross-cultural adaptation study on GLA:D Canada, PTs ( n  = 58) also described operational processes that may be patient-centred including, flexibility to schedule sessions and encouraging self-efficacy [ 17 ]. Future strategies may focus on promoting PwOA exercise behaviours and providing self-management education for stakeholders that highlights the benefits and advantages of exercise and education self-management programmes for OA.

Implications

Findings provide more specific knowledge on multilevel (programme, stakeholder and healthcare setting) implementation determinants of guideline-based healthcare services for OA. This comprehensive insight may guide research, policy, and practice towards the development of new healthcare strategies that are effective. Specifically, the identification of more strong implementation facilitators than barriers indicates that stakeholders and healthcare settings may acknowledge the importance of implementing guideline-based programmes for OA. It also suggests that future implementers must focus on addressing strong implementation barriers including, lack of time, unclear roles/responsibilities, limited internal and external financial support, and inappropriate space (physical and/or technical features). Further work on targeted strategies to address strong implementation determinants across varying geographical locations, healthcare settings, and stakeholders is needed. For example, a targeted strategy for a new healthcare service in the future may recommend an implementation checklist that requires implementers to develop multidisciplinary teams with designated responsibilities and/or to secure dedicated space/funding prior to the onset of the programme. Additionally, our findings on commonalities and differences between stakeholders (PTs vs PwOA) and healthcare settings (public vs private) may help provide evidence of the gap in the provision of guideline-based OA management. This is critical for supporting global priorities to shift healthcare policies and alleviate the OA burden. Specifically, future work must focus on advocating for equitable staffing levels, funding, and space to implement new guideline-based healthcare services. Also, our participants were offered GLA:D Ireland at no financial cost, and more work on the impact of limited public healthcare funding and out-of-pocket private healthcare costs on healthcare service utilisation is needed.

Strengths and limitations

A strength of this study is its focus on the combination of theoretical framework-based and explorative approaches to interpret the experiences of PTs and PwOA. Using CFIR allowed for both a context-specific (rating each construct for each participant) and variable-oriented (rating each construct across all participants) approach to identifying implementation barriers and facilitators [ 38 ]. Additionally, using the updated CFIR framework based on user feedback [ 20 ] ensured that a broad range of outcomes were examined to identify what works where and why, and our definitions/approach to operationalisation may help establish and strengthen validated measures, relationships, and boundaries within CFIR. Further, reflexive assessment of reviewers’ beliefs/experiences helped counteract potential bias. The study sample was mostly female, older age, reported knee pain and were evenly located in public and private healthcare settings [ 39 , 40 ]. Although reasons for non-response to interview requests were unclear, perhaps time constraints or lack of interest to continue participation may have contributed. While the robustness of the research approaches adds credence to the findings, at individual healthcare setting levels, the findings of this study must be contextualised in maximising generalisability.

To alleviate the public health burden of OA, global efforts to strengthen healthcare service delivery must address implementation barriers and facilitators of new guideline-based healthcare services. This study qualitatively identified the implementation determinants of PTs and PwOA for a supervised group neuromuscular exercise and education self-management programme for OA in public and private healthcare settings. Implementation may be strengthened by tailored training and education for stakeholders on the components and benefits of the programme, with more guidance needed for public healthcare settings on organising (e.g., scheduling clinic time, assigning responsibilities), planning (e.g., securing appropriate space, marketing/training tools), and funding (e.g., accessing dedicated internal/external grants). Future healthcare policy and practice may benefit from a framework-based approach to evaluating implementation determinants that may be applicable across broad contexts. Such contextualised research-driven strategies may support the future development of guideline-based healthcare services that encourage access to high-quality, equitable healthcare.

Data availability

The dataset supporting the conclusions of this article is available under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0) from Zenodo at: https://doi.org/10.5281/zenodo.10473852 .

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Avantika Bhardwaj, Christine FitzGerald, Norelee Kennedy & Clodagh M. Toomey

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Avantika Bhardwaj, Christine FitzGerald, Margaret Graham, Norelee Kennedy & Clodagh M. Toomey

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Bhardwaj A: Conceptualization, Formal Analysis, Visualization, Methodology, Writing – Original Draft Preparation; FitzGerald C: Methodology, Writing – Review & Editing; Graham M: Methodology, Writing – Review & Editing; MacFarlane A: Supervision, Writing – Review & Editing; Kennedy N: Conceptualization, Supervision, Writing – Review & Editing; Toomey CM: Conceptualization, Supervision, Writing – Review & Editing.

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The study was conducted in compliance with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained from all study participants. Ethical approval was obtained from the University of Limerick Faculty of Education & Health Sciences Research Ethics Committee (REC) (2020_12_13_EHS), Galway Clinical REC (C.A.2685), National Orthopaedic Hospital Cappagh REC (NOHC-2022-ETH-MB-CEO-331), Clinical REC of the Cork Teaching Hospitals (ECM 4 (v) 16/11/2021 & ECM 3 (cc) 22/02/2022), and the University of Limerick Hospitals Group Mid-West Region REC (051/2022).

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Data from the current study will be presented at one scientific meeting. Bhardwaj, A., FitzGerald, C., Graham, M., MacFarlane, A., Kennedy, N. and Toomey, CM. (in press). ‘Barriers and Facilitators to Implementation of an Exercise and Education Programme for Osteoarthritis: A Qualitative Study Using the Consolidated Framework for Implementation Research.’ Osteoarthr Cartil.

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Bhardwaj, A., FitzGerald, C., Graham, M. et al. Barriers and facilitators to implementation of an exercise and education programme for osteoarthritis: a qualitative study using the consolidated framework for implementation research. Rheumatol Int (2024). https://doi.org/10.1007/s00296-024-05590-9

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ORIGINAL RESEARCH article

Understanding health education needs of pregnant women in china during public health emergencies: a qualitative study amidst the covid-19 pandemic.

• 1 Department of Nursing, Quanzhou Medical College, Quanzhou, China
• 2 Quanzhou Women and Children’s Hospital, Quanzhou, Fujian Province, China
• 3 Department of Imaging, Anxi County Hospital，Quanzhou，Fujian 362400, China, Quanzhou, China
• 4 Fujian Maternity and Child Health Hospital, Fuzhou, Fujian Province, China

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Background: Public health emergencies impose unique challenges on pregnant women, affecting their physiological, psychological, and social well-being. This study, focusing on the context of COVID-19 pandemic in China, aims to comprehensively explore the experiences of pregnant women amidst diverse public health crises.Herein, we investigate the health education needs of pregnant Chinese women in regard to public health emergencies to provide a scientific foundation for the development of targeted health education strategies. Methods: Thirteen pregnant women were purposively selected, and the rationale for this sample size lies in the qualitative nature of the study, seeking in-depth insights rather than generalizability. Data collection involved semi-structured interviews, and the Colaizzi, which is a structured qualitative technique used to extract, interpret, and organize significant statements from participant descriptions into themes, providing a comprehensive understanding of their lived experiences. Results: The analysis yielded six prominent themes encompassing following six areas. Theme I:Personal protection and vaccine safety was analysed with 2 sub-themes( needs for personal protection knowledge, vaccine safety knowledge needs); Theme II:Knowledge of maternal health was analysed with 3 sub-themes( nutrition and diet, exercise and rest, sexual life)); Theme III:Knowledge of fetal health was analysed with 3 sub-themes( medications and hazardous substances, pregnancy check-ups, fetal movement monitoring); Theme IV:Knowledge of childbirth was analysed with 3 sub-themes( family accompaniment, analgesia in childbirth, choice of mode of delivery) ;Theme V:Knowledge of postpartum recovery was analysed with 1 sub-theme (knowledge of postnatal recovery); Theme VI:Knowledge sources of health education for pregnant women and their expectations of healthcare providers was analysed with 1 sub-theme( expectations of Healthcare providers). Sub-themes within each main theme were identified, offering a nuanced understanding of the multifaceted challenges faced by pregnant women during public health emergencies. The interrelation between sub-themes and main themes contributes to a holistic portrayal of their experiences. Conclusion: The study emphasizes the need for healthcare professionals to tailor health education for pregnant women during emergencies, highlighting the role of the Internet in improving information dissemination. It recommends actionable strategies for effective health communication, ensuring these women receive comprehensive support through digital platforms for better health outcomes during public health crises.

Keywords: Pregnant Women, Health Education, Public health emergencies, qualitative research, COVID-19 -

Received: 12 Sep 2023; Accepted: 22 Apr 2024.

Copyright: © 2024 Su, Zhang, Chen, Xu and Liu. 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) or licensor 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: Yuezhen Zhang, Department of Nursing, Quanzhou Medical College, Quanzhou, China Meide Chen, Quanzhou Women and Children’s Hospital, Quanzhou, Fujian Province, China Xiangyang Xu, Department of Imaging, Anxi County Hospital，Quanzhou，Fujian 362400, China, Quanzhou, China Guihua Liu, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian Province, China

Disclaimer: 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.

• Open access
• Published: 24 April 2024

Transcending technology boundaries and maintaining sense of community in virtual mental health peer support: a qualitative study with service providers and users

• Elmira Mirbahaeddin 1 &
• Samia Chreim 1  

BMC Health Services Research volume  24 , Article number:  510 ( 2024 ) Cite this article

Metrics details

This qualitative study explores the experiences of peer support workers (PSWs) and service users (or peers) during transition from in-person to virtual mental health services. During and following the COVID-19 pandemic, the need for accessible and community-based mental health support has become increasingly important. This research aims to understand how technological factors act as bridges and boundaries to mental health peer support services. In addition, the study explores whether and how a sense of community can be built or maintained among PSWs and peers in a virtual space when connections are mediated by technology. This research fills a gap in the literature by incorporating the perspectives of service users and underscores the potential of virtual peer support beyond pandemic conditions.

Data collection was conducted from a community organization that offers mental health peer support services. Semi-structured interviews were conducted with 13 employees and 27 service users. Thematic analysis was employed to identify key themes and synthesize a comprehensive understanding.

The findings highlight the mental health peer support needs that were met through virtual services, the manifestation of technology-based boundaries and the steps taken to remove some of these boundaries, and the strategies employed by the organization and its members to establish and maintain a sense of community in a virtual environment marked by physical distancing and technology-mediated interrelations. The findings also reveal the importance of providing hybrid services consisting of a mixture of in person and virtual mental health support to reach a broad spectrum of service users.

Conclusions

The study contributes to the ongoing efforts to enhance community mental health services and support in the virtual realm. It shows the importance of virtual peer support in situations where in-person support is not accessible. A hybrid model combining virtual and in-person mental health support services is recommended for better accessibility to mental health support services. Moreover, the importance of organizational support and of equitable resource allocation to overcome service boundaries are discussed.

Peer Review reports

There is growing awareness around the world of the need to improve mental health services, yet the response to the need has been constrained [ 1 ]. The World Health Organization (WHO) has pointed to the urgent need to invest in community-based mental health services that prioritize a person-centred, recovery approach. Among these services, the WHO highlights the importance of peer support [ 1 ]. Formal mental health peer support refers to emotional and social support (Mental Health Commission of Canada, https://mentalhealthcommission.ca/what-we-do/access/peer-support/ ) provided by an individual referred to as a peer support worker (PSW). A mental health PSW is a person who has lived experience of mental health issues, has paid employment in a mental health support or services organization– often after receiving training– and offers intentional support to clients with mental health challenges through empathetic understanding and encouragement of self-determined recovery [ 2 , 3 ].

Peer support is based on the belief that individuals who have navigated their own recovery experiences hold unique insights and lived practical knowledge that can be helpful in supporting others in their recovery (Mead, Hilton & Curtis, 2001). The notion of recovery in mental health refers to a multidimensional process that involves individuals actively engaging in their own well-being, making self-determined choices, fostering social connections, and pursuing a meaningful life despite the presence of mental health challenges (Mead, Hilton & Curtis, 2001). Peer support represents a political alternative to professionally led services and decision-making processes; it is an important approach for promoting the agency of individuals with mental health issues and reversing the power imbalances prevalent in the mental health system. Peer support can promote empowerment and self-efficacy, help enhance coping skills and strategies, and contribute to overall quality of life and emotional well-being [ 4 , 5 , 6 ]. It has been particularly helpful in situations where traditional professional mental health services might not fully address the needs of individuals or are not easily accessible [ 3 , 7 ].

The importance of peer support became particularly salient during the COVID-19 pandemic. The pandemic adversely affected access to in-person mental health services, especially in jurisdictions where lockdowns were enacted. Peer support services in an online format created an opportunity to maintain availability and accessibility to basic yet important community-based mental health support [ 8 ]. A number of jurisdictions increased their peer support capacities by offering PSW training on remote services during the COVID-19 crisis (e.g., the Digital Peer Support Certification for peer specialists in the US that provided Medicaid-reimbursable virtual health services) [ 9 ]. Virtual peer support services have been beneficial in various ways including overcoming geographical barriers, reducing regional inequalities in access to providers, and offering convenience for a wide range of vulnerable populations in communities [ 10 – 11 ]. Hence virtual peer support has created bridges allowing people in need of mental health support to access it. These bridges can be advantageous not only in crisis situations such as the pandemic but also in non-crisis contexts by offering expanded accessibility.

There has been growing use of technology for a variety of mental health and support services with an aim to improve accessibility [ 10 , 11 , 12 ]. However, the move to provide mental health services and support remotely, despite its many benefits, also comes with challenges. These challenges include, among others, the need for providers and service users to adapt to the utilization of diverse technologies including synchronous (e.g. video calls) and asynchronous (e.g. apps) modalities [ 11 ]. We view the technological challenges as setting boundaries to providing, accessing and utilizing virtual services.

Existing literature does not provide adequate insight into how individuals adapt when a sudden and major change occurs from in-person to remote mental health and support services. Makarius & Larson (2017) state that the role of individuals in virtual work has been overlooked by considering them as “passive actors” [ 13 , p.166] while portraying organizations as accountable for effective virtual work. They indicate that extant research on virtual work has tended to focus on virtual teams. Therefore, there is a need for a greater focus on individual experiences [ 14 – 15 ]. This applies in a general sense, but also, specifically to peer support. With the advent of COVID-19, PSWs became one of the forefront providers of mental health support [ 9 ]. Service users also had to adjust to virtual services. Yet limited knowledge exists about the individual experiences in the process of adapting and acclimating to using online mediums in virtual services in the context of peer support [ 16 ]. As virtual mental health services and supports are expected to continue to be used in the future, the experiences of individuals providing and receiving virtual peer support have become an important research topic.

Another issue of importance that needs to be considered when peer support is delivered virtually is whether technology-mediated connections allow peer support groups and individuals to maintain a sense of community. This sense of community is grounded in people’s relationship with a group that offers them membership, fulfillment of needs, and shared emotional connection [ 17 ], yet it is unclear whether the sense of community that is characteristic of in-person peer support is severed when services move online.

Earlier conceptualizations of communities emphasized the spatial dimension, defining communities as groups of people associated with a setting such as a neighbourhood or village [ 18 ]. McMillan and Chavis (1986) point to earlier work [ 19 ] that distinguished between the geographical notion of community (such as a neighbourhood or town) and the relational notion concerned with human relationships regardless of location [ 20 ]. McMillan and Chavis [ 20 , p. 9] propose a definition of sense of community that applies to both of these conceptualizations, and is as follows: “Sense of community is a feeling that members have of belonging, a feeling that members matter to one another and to the group, and a shared faith that members’ needs will be met through their commitment to be together.” These authors point to four elements in their definition: (a) membership (a feeling of belonging or personal relatedness), (b) influence (a sense of mattering to the group), (c) integration and fulfillment of needs (a feeling that needs will be met through membership in the group), and (d) shared emotional connection (a belief that members have shared history and similar experiences) [ 20 , p. 9].

In peer support communities, the principles of valuing individuals’ experiential knowledge of mental illnesses, determination for recovery, equality and reciprocity, and mutual agreement on what would be helpful for different individuals play a vital role [ 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. People benefit in different ways by having a sense of community. They experience less isolation and social exclusion, have a greater sense of well-being, can call on support when they need it and learn from the experiences of other members [ 22 – 23 ]. Cronenwett & Norris (2009) examined the role of social collectives in providing peer support services to individuals with co-occurring disorders and the benefits of social support and shared experiences in promoting recovery [ 24 ]. However, it is not clear yet how peer support sense of community is created or maintained in situations where peer support moves to a virtual space and relationships are mediated by technological tools. To our knowledge, this topic has not been addressed despite its importance.

Given the importance of peer support and the recent surge in virtual peer support service provision, our objective is to understand how technological factors can act as bridges and boundaries to services, and whether and how a peer sense of community can be built or maintained in a virtual space that relies extensively on the use of technological tools. We aim to understand these issues from the perspective of individuals affected directly by the changes from in-person to virtual services. Therefore, we focus on PSWs who provide support services, and on the service users or clients– also known as peers. Inclusion of peer voices is particularly important, given that this is a gap in the literature since much research on peer support is based on the views of managers and PSWs, and not on the views of the peers themselves [ 25 ]. This limitation in the literature applies to peer support specifically, but also more broadly. For example, a systematic review investigating the implementation and adoption of telemental health found that research studies involved fewer service users compared to the number of providers (only 9 out of 45 included papers involved service users), indicating that the point of view of service users has not been adequately researched and little is reported about their experiences [ 26 ].

Hence, we ask the following research questions: What mental health peer support needs were met with virtual services? How were technology-based boundaries manifested and what bridges were built to open boundaries? How, if at all, was a sense of community established or maintained in a virtual space? We researched these topics in the case of a peer support organization that transitioned from in-person to virtual services during the COVID-19 pandemic. While in the case we studied the move to a virtual space was a response to exacerbated mental health challenges during the pandemic, it also opened up opportunities to understand if and how peer support could be enacted virtually beyond pandemic conditions . The surging interest in providing mental health services and support virtually thus makes our study a timely endeavor, and our findings a valuable addition to the literature.

Study design and context

We adopted an exploratory case study approach [ 27 ] as it allows us to understand complex social phenomena and generate new insights [ 28 ]. We aimed to achieve a deep understanding of how members of a peer support organization viewed or experienced mental health needs within the broader social context of the pandemic, how they interacted with technological aspects of virtual services, and the strategies they used to create a sense of community in a virtual space.

Our primary data consisted of semi-structured interviews with employees (PSWs and/or managers) and service users (or peers) of a peer support organization based in a major city in Ontario, Canada. This organization had more than twenty compensated PSWs, some of whom held managerial positions in the organization. It served the needs of a large number of peers who sought its various services. Before the COVID-19 pandemic, this organization primarily offered in-person services that included, among others, various peer groups as well as recreational and social programs which were also intended to provide support. We initiated the data collection in the early stages of the pandemic when lockdown regulations were implemented in Ontario. The reason for selecting this particular case was the organization’s rapid transition to virtual platforms in response to increased demand for peer support during lockdowns and isolation.

Data collection

We collaborated with the organization in informing potential participants about the study. An email was sent by the organization to all its employees and service users informing them about the study, and inviting individuals interested in participating to contact the researchers. Thirteen PSWs and twenty-seven service users contacted the researchers. We interviewed all individuals who contacted us, thus our study included forty participants. Participants’ age ranged between being in their 20s and 60s, and the majority identified as female.

We conducted semi-structured interviews with participants. Different interview protocols were developed for each group of participants, and they were developed for this specific study. Based on the research questions and objectives, key themes were identified to guide the formulation of the interview questions. Moreover, the interview protocol was informed by existing literature on mental health peer support, the pandemic circumstances and concepts relating to boundary theory and sense of community. We adjusted the interview questions to account for feedback from the organization, whose approval we sought on the final interview protocols. A small group representing managers, PSWs and peers participated in providing feedback and validating the interview protocols. Overall, the questions were crafted to be clear and open-ended to encourage detailed responses and in-depth exploration of the subject matter. The interview protocols included questions on individuals’ mental health experiences during the pandemic, their experiences associated with opportunities and challenges of virtual services technology, the strategies that they and the organization used to capitalize on opportunities, remove difficulties, and build or maintain a sense of community. Open-ended questions enabled us to probe for additional details and allowed the participants to share beyond our questions, which provided us with rich and nuanced data [ 29 ]. The interviews were conducted via Zoom or phone, based on the participant’s preference. The interviews were conducted during the pandemic from February to November 2021. They were recorded and transcribed verbatim.

Data analysis

We conducted thematic analysis and used the N-Vivo software for data coding and retrieval. Specifically, we followed the steps outlined by Braun and Clarke (2006) [ 30 ]. Familiarization with the data started with both authors conducting a number of interviews conjointly, taking notes during this process and discussing the preliminary data. Familiarization was enhanced by the first author’s transcription of the interviews. We then generated initial codes by immersing ourselves in the data. The long list of initial codes– or descriptive codes [ 28 ]– was closely related to participants’ words. We then identified emergent themes by grouping similar codes together and reviewing that the coded extracts fit the themes. The process involved constant comparison and was iterative in that we reviewed the codes and themes and changed the theme names when we identified emergent ideas based on new data. Analysis was mostly inductive, but we had also been sensitized by extant literature. In the later stage of the analysis, we grouped the themes into more abstract categories, continuously reviewing and refining the categories. Our final descriptive codes and theme list is presented in Table  1 .

The first author performed the primary analysis and the second author reviewed the analysis on the basis of the data. When the authors’ interpretations differed, they returned to the data to find answers. This process offered confidence that the analysis was well anchored in the data from participants. We conducted member checking—explained in the next section— by seeking feedback from the participants on our analysis.

Establishing trustworthiness

We took several steps to establish the trustworthiness of the study [ 28 , 31 ]. Two researchers worked together on data analysis, returning to the data when disagreements emerged. This offered triangulation through the involvement of two researchers. We also report extensive quotes from our participants as evidence of our analysis. In addition, we conducted member checking to determine whether our findings captured well the experiences of participants and thus ensured the credibility of the results. This entailed sharing a draft of the manuscript with the participants and asking them to provide their feedback on the researchers’ interpretation and whether those aligned with their experiences. We received feedback from two PSWs and five peers, all of whom were in agreement with the results reported. One participant commented, “ I feel that the paper captured… challenges and victories peer supporters experienced during COVID ” and another participant stated, “ It is a good in-depth work/story showing the mental health challenges and how those were addressed during the pandemic, how people evolved from their experience and stood for each other when it mattered the most. ”

Research ethics

The study was approved by the Research Ethics Board (REB) of the University of Ottawa (Reference number S-11-20-6226). All study participants were fully informed about the project through both written and oral communication, and willingly gave their consent. The consent form included information about mental health resources available to them if needed, and participants were informed about their right to withdraw from the study. All procedures followed the appropriate guidelines and regulations.

We begin with the results showing the need for virtual mental health support during the pandemic and follow with the technology-based boundaries and bridges identified in virtual mental health support. In the last section of the results, we focus on the strategies that were used by the collective to maintain a sense of community despite the physical distances. It is important to note that we give attention to pandemic-related dynamics where pertinent, but also go beyond the pandemic context to address more general issues related to virtual peer support that were central in our participants’ accounts.

Need for virtual mental health support services

Boundaries related to accessing in-person services.

The pandemic amplified social issues that resulted in a surge in mental health challenges. Peers shared concerns regarding social vulnerabilities that became exacerbated during the pandemic. They told us about their challenges which included homelessness, domestic abuse, and struggles with addiction that were exacerbated during lockdowns. One peer referred to the “ downward spiral [of mental health] once the COVID-19 pandemic hit”. A peer pointed out that “literally everything shut down in the city…the needs of the community are just desperate ”, and a PSW stated that “with the pandemic, there was a lot of isolation, and it was really hard…also just the transition back as things started opening up. It’s really anxiety provoking for a lot of people. ”

There was also difficulty finding mental health services as there were lengthy wait times to see a mental health professional. A peer stated: “I think the most difficult thing was probably finding people to connect with…. There was a three-month waiting list to be able to even speak to anybody.” It is important to note that accessing mental health services in person was difficult for many people even before and regardless of the pandemic. The following quote by a peer illustrates one of many situations under which accessing in-person peer support can be difficult: “When you have a baby, it’s hard to be somewhere on time and remember to bring everything that you need and deal with the cranky baby… When your expectation is that you’re going to participate in these types of groups in-person, it can be very jarring ”.

Virtual peer support as a bridge

Virtual services can be a bridge connecting individuals to mental health peer support, especially when these individuals experience challenges with attending in-person peer activities. The peer who reflected above on the difficulties associated with accessing in-person peer support pointed out that “ when you can proceed in groups virtually, you can mute yourself, you can step away, your baby’s crib is right there…. So it was a really wonderful option.” A peer reflecting on the high cost of seeking “formal therapy” and the inconvenience of doing so, pointed out that virtual peer support was “a light in the tunnel” for them: “it was free, it was accessible, it was easier to find a peer support group during times that I could access it. During the pandemic, I accessed more groups than I did [in person].”

We also heard from peers whose anxieties had been exacerbated during the pandemic. A peer shared that seeking in-person mental health support was a major challenge. This person added that “ it was nice to be able to access things from Zoom”. Considering the risk of contracting the coronavirus, peers felt that not having to leave the house gave them a “sense of accomplishment” because accessing services remotely helped them remain engaged. A peer noted that virtual peer support had been “ the winter month survival ” for many individuals.

Peers also told us that virtual support was helpful for them in general, and not only because of the pandemic. Social anxieties, unrelated to the pandemic, were often mentioned by participants. A peer stated: I’m very timid to talk in a support group, and with Zoom, I feel I can raise my hand with the computer and I get to speak. Whereas in a peer support group in person, I don’t always get to do that. And… you get to see everybody’s facial reactions when you’re in the gallery view [on Zoom], whereas you can’t do that when you’re in the group because I’m very shy and very anxious.”

Anxieties were also related to driving. A peer stated, “I feel grateful I don’t have to drive far or pay for parking. Without the anxiety of driving and being on time too is very relaxing… (Virtual peer support) is a blessing.” For some individuals for whom transportation to in-person meetings could be difficult due to time or financial constraints, virtual services opened the possibility of receiving peer support.

Peers also told us how the virtual services facilitated receiving support in cases where struggles with depression kept them from seeking in-person services: “ If you’re so depressed, it’s hard to get out of bed… That’s another thing about Zoom, you don’t have to worry so much about your appearance. If you haven’t washed your hair that day, it’s fine… It makes it so much easier to attend .”. Virtual services were also very helpful for peers who felt they needed to seek support frequently: “ I’ve struggled with feeling alone and… feeling overwhelmed… If I had to go to a walk-in, I wouldn’t have done it. I wouldn’t have had access and that would have been bad for me .” Moreover, peers who felt self-conscious about their appearance, had experienced weight shaming, or physical differences found it more comfortable to attend virtual meetings because they “take away the self-consciousness” as a participant stated. By allowing participants to control what they reveal (e.g. by turning the camera on or off), virtual meetings may offer a certain sense of safety that in-person meetings may not provide.

Importantly, we were told that new members had joined virtual meetings who had not previously participated in in-person peer services. A manager pointed out that “a lot of new people who were not previous members have joined the community to get support or to get social interaction” and a PSW stated: “ we are supporting more people now. Our meetings are much larger. I’ve had people contact me from other provinces asking ‘Am I allowed to join?’ We’ve decided that as long as we have the capacity, anybody who wants can come .”

In sum, virtual services offered benefits for individuals who struggled with various issues including anxieties and depression, or whose life circumstances made it difficult for them to commute to in-person meetings. Although the pandemic (and the lockdowns associated with it) exacerbated some of the challenges that people had faced, the quotes above indicate that some challenges were not specifically pandemic-related, but rather pertained to more general mental states and life circumstances. The fact that virtual meetings drew in attendance from individuals who had never been to in-person meetings is a further indication that virtual platforms increase accessibility for peers.

Boundaries and bridges relating to telecommunication technology for virtual mental health support

Accessing virtual services offered peers opportunities to receive support, but accessing these services had its own challenges. A major challenge was technology, which manifested in terms of access to and compatibility of devices, access to internet connection, and basic technological skills. We report on these challenges and on how they were mitigated.

Virtual service technology boundaries

Technology-based challenges were associated with access to and use of equipment, access to internet connections, and limited technology-based skills. Some individuals from both groups (peers and PSWs) found it difficult to transition to virtual services due to the unprecedented complexities introduced by the new service environment: “ the hardest thing for people is the technology part of it .” The experience of change to virtual services was described as “ anxiety-provoking ” for people who were not familiar with the use of technology such as computers and smartphones in daily life.

Accessing virtual services required the use of the appropriate equipment such as smart phones, and for some peers, access to these devices was a challenge. A peer described: “ The devices that I had access to were lower-end devices… My cell phone was blocking out and freezing ”. Another peer stated: “ I would drop in occasionally using my phone. But I didn’t have a computer, and currently, I’m receiving disability benefits… As far as having money to burn, that’s not an option for me, it’s a very tight situation ”. In addition, lack of access to and reliable internet connection was another boundary. A participant described the lockdown situation: “ It was a big shock. It’s a big change. It’s forcing a lot of people who didn’t have the Internet to get Internet. So that caused a lot of stress and strain on a lot of people ”. Peers who shared an internet connection with multiple residents had to coordinate schedules since simultaneous Zoom calls could interrupt connections.

For some individuals, a lack of technology-based skills was a boundary. Some peers had difficulty navigating the nuances of the various platforms and their compatibility with the devices they were using: “ You had to figure out what platform was used and whether or not your technology was going to be compatible with it. ” Other peers experienced difficulties early on with logging in and accessing meetings: “[It was a] struggle with the process of getting signed up, to get the notifications, to get the information ”. Others reported difficulty navigating the programs’ options during the meetings (e.g., using the raise hand option). The challenges did not only pertain to peers. PSWs also faced difficulties with technology: “I did not have the technology needed to be able to do my job from home. I had a smartphone, but it’s still very challenging to host a Zoom group when I can only see 4 little faces on a screen.”

Virtual service bridges: supports provided by the organization and PSWs

When the lockdowns were mandated, concern about peers’ mental health needs drove the organization to create a variety of platforms through which peer support services could be accessed. Within a few weeks, the organization created remote services to maintain continuity in support for peers. A PSW pointed out “They were relying on us for their well-being.” This created a sense of urgency to adapt quickly in order to meet the needs of the community.

Efforts were quickly deployed to connect with peers by phone and to create accessibility through online options. As a peer stated, they were “ trying to make things just as accessible as they could be ”. To this end, the organization engaged in advocacy efforts with external partners to provide devices, data, and internet connection to those without technology. A manager stated: “Many people with mental health and addictions don’t even have access… We have been providing people with tech and tablets and smartphones and connectivity, and we’re a peer agency, we don’t have this kind of stuff!… I kept raising it at our (regional health authority) table with a lot of people who are very high up. And they said, ‘Let’s do it’! So we applied and put together a proposal… We now have contracts with [internet] providers, so [one company] provides the smartphones with sim cards and [another company] provides the tablets.”

PSWs walked peers step by step through the Zoom functions that they needed in order to attend and participate in virtual meetings. A PSW pointed out: “ We did a lot of one-on-one training and coaching and mentoring with people to help them get their virtual equipment set up. At first, it was a lot of, ‘this is how you set up Zoom, this is how you set up your camera’… and then more people got comfortable using it .”

PSWs also received training and support. Training included group and one-on-one sessions, and manuals were made available to provide instructions for an online environment: “In the beginning, we had training from a staff member who is a certified online facilitator… and it walked us through how to use Zoom. I also had one-on-one training… to walk me individually before doing any online groups… I asked my questions, and felt comfortable then to roll with it, [and] manuals were written with the policies of how we were gonna do this online.”

The social media team of the organization also became very active during the early days of the lockdowns. A manager who was part of this team described the role of the social media team: “We re-did all the posters we had for in-person, we switched them to virtual, giving new contact information, laying out the registration process…Every day we posted what groups we had going on, and all of that content had been created after the pandemic started. Again, a lot of that very quick adaptation to the needs.” We were also told that the organization added and adjusted online group activities and services as the lockdown policies and the needs of the peer community changed.

In sum, the findings show the challenges and solutions relating to using telecommunication technology for virtual mental health support during the COVID-19 pandemic. Accessing and providing these virtual services required access to and compatibility with devices, reliable internet connection, and technology-based skills, which could be challenging for some individuals. To address these challenging access boundaries, the organization arranged to provide devices, data, and internet connections, along with training and ongoing support to both peers and PSWs. Meanwhile, the organization also experienced a learning curve as it was adapting to the new circumstances and applied efforts to bridge the gaps in service access.

Maintaining a sense of community in virtual mental health support services

The peer support community already existed before the pandemic lockdowns. Peers would come to the organization locale for in-person services and programs, and many relied on these programs for mental health support. The lockdowns were disruptive of the in-person programs, which had to be halted, and as we elaborated earlier, the organization quickly responded by establishing services online. We were interested in whether and how a sense of community could be re-established and maintained in a virtual environment. Our findings point to five strategies in which the organization and the peers engaged, and which enabled maintaining a sense of community. We present these strategies next, and would like to point out that although we discuss them separately to facilitate the presentation, these strategies were not mutually exclusive.

Maintaining continuous presence and social interaction

In a context of increasing isolation, and to meet the needs of peers, the organization quickly began to offer phone services whereby peers and PSWs could connect by phone. Participants told us the phone support communicated a sense of caring and had a significant impact on individuals’ mental health during the pandemic. One of several volunteer peers who took on the task of checking on other peers regularly, indicated that for some individuals, their only connection to the outside world was through these phone calls: “ It could mean the difference between being stable and unstable… Being unstable for a long time could lead to something terrible .” Phone calls were not only about mental health topics, but could also include friendly conversations about daily living activities, which solidified relationships. The peers looked forward to these phone calls as a means of getting positive contact with someone who cared to listen. As one peer said, “They opened up a phone line and… I would call almost every day… I really needed [peer support]… So having that as a service was really, really good.” And another peer stated: “[It was great] knowing that they’re always there. It’s just the comfort of knowing there’s someone to reach out to. ”

It is important to note the speed with which the organization was able to adapt and to create programs that met the peers’ needs, thus maintaining a continuous presence. As a manager stated, “ [peer support] works well in a pandemic because we were able to be more flexible.” This is in contrast to institutional mental health services that were subject to various regulatory restrictions that would delay the introduction of online services. A PSW stated, “ we are extremely adaptable.”

In short order, the organization created a variety of online groups and activities in which peers could register and participate. These programs allowed the peers to continue interacting and engaging with one another. The sense of community was palpable even for peers who did not participate actively in the programs: “So for these people [like me], even though their videos and microphones are off, being immersed in the group, feeling like, hey, I’m not the only one, these are my people… and they look good and they’re talking and they’re feeling great. I feel good being there. And I may not want to say anything. It’s amazing. It’s a good feeling.”

Another peer commented on the relationships with the PSWs in the virtual meetings and said “… you can access [virtual support] anywhere and see the facilitators that you’re connected to. And that sometimes is enough to just make my spirit go fly. ” A similar sentiment was communicated by PSWs, one of whom stated: “We have things seven days a week that peers can come and join us. That has been really great; [it] helps keep the sense of community because we have that touchpoint with them. “

Establishing multiple points of connection

The organization was intent on meeting the diverse needs of peers, and to this end, created a variety of virtual programs and groups as well as phone services. In addition to the mental support groups, there were special activities such as yoga, crafting, and cooking, all of which instigated mutual support. These various activities could draw in diverse people who share similar interests, creating online communities. Peers stated that despite the lack of one-on-one eye contact, they found online groups were effective in offering valuable social activities related to wellness, nutrition, parenting, and gender-based support. One peer noted, “ They have a variety (of services)… Sometimes I’m in the mode of meeting [people], or joining arts and crafts. Sometimes I join the trivia online.” Another peer indicated that it was possible “to find the niche of the thing that you were looking for ” and a third peer stated: “ the trivia for me is very engaging… everybody can play. ”

The availability of multiple points of connection implied that the peers and PSWs could remain connected to each other on a regular basis. Another initiative by the organization to encourage this sense of community was the creation of a Facebook group. Due to the variety of points of contact, new members joined as they learned about the virtual services, expanding the community. However, the main aim of the organization remained to continue providing mental health support. A manager stated: “A lot of what people wanted was social connection, which we do offer in recreation. But we’re a support-based organization, and even our recreation has some support components to it. We came up with this private Facebook group which has helped a lot with that because people can stay in touch, not just with facilitators or with a group in a moment, but they can talk to each other whenever they want should they choose to join. “

Building on organizational and peer culture

Participants pointed out that peer culture is permeated by care and concern for members, and this was clear in various quotes we reported above from managers, PSWs and peers. In fact, managers and PSWs are also peers and they pointed this out continuously during our study. For example, a manager stated: “ It’s very helpful when peer support is informed by a community of people. And when peers can run some of their own services and see that peers are not only people who are recipients of services but actually are also managers ”. This manager also pointed out: “A peer-run community of peer supporters can help people meet different needs: their creative needs, their social needs, their support needs. There are physical needs, we’re doing some walking. We’re supporting people to get technology so they can not only take part in our Zoom meetings but also order their own groceries online or maybe they can talk to their doctor online now. Peer support has a lot of strengths.”

Another manager noted, “ It’s never just a job for people [at the organization]. It’s about how we can create something that is going to benefit the people who need it .” This focus on helping and supporting each other was integral to the organization’s mission and culture. This focus was shared by peers. Increased involvement of peer volunteers, who were not paid by the organization, in running services including the voluntary phone line was highlighted as an example of peer values and practices. A manager explained, “ One of the things that’s really important is to rely on the people who are actually DOING the thing, as opposed to me saying “well I know what’s good for this”, but actually leaning into our values .” Various participants mentioned that the implementation of online mental health support during the pandemic was an indication of resiliency in the peer support community. A peer stated “ We weren’t able to meet face to face. So people took it upon themselves to set up and organize these meetings and to learn how to use the technology to provide those services. ”

Acting collectively

The sense of community was also enabled by how decisions were made in the organization and with the help of peers. Deciding and acting collectively helped maintain a sense of community in the virtual space. This approach was especially effective during times of disruption that affected the organization and the peers. Overall, the organization’s collaborative approach to decision-making and focus on benefiting those in need were key components of its success.

The organization relied on discussion-based decision-making, with all staff members coming together weekly to discuss various issues and make decisions for the week. The management approach was collaborative and non-hierarchical. A manager said, “ We make decisions with the management collectively, and at times, when it’s appropriate, we make decisions with all staff .” Another manager described how “ the hierarchy felt a lot flatter” during the pandemic and the priority became “Who’s got what competencies? Who’s got what skills? Bring them in!” . Different members of the organization contributed their knowledge and skills to enhance the capacity to move services online. A PSW said: “We all bring our own perspectives. So I said my specialty is looking at the programming and the scheduling and what is feasible for us as staff… it was a lot of communication.”

Sharing lived experiences and learning together

Peer support is based on the shared lived experience of individuals. Sharing these experiences helps build bonds among peers. We were interested in how the virtual environment could have affected the sharing of experiences. Although some peers pointed out that they found it easier to share experiences in person, others– as we showed earlier– indicated that the online environment made it easier for them to participate. A PSW indicated: “We offer that space to just connect… Even though we’re saying “You gotta raise your hand before you talk”– that was an adjustment period. But now it’s the norm… That sense of belonging comes from connecting around shared lived experiences. So connecting around that shared lived experience is still happening. It’s just virtual, and a little more systematic.”

A peer described how the shared lived experience was helpful when using virtual services during the pandemic: “The ability to participate with other people who are struggling [was helpful], I just think that sharing those feelings and hearing that you’re not alone was worthwhile to me ”. Another peer reflected on the importance of the virtual services for connection around shared experiences of feeling “lost”: “It was a wonderful place to connect with people who were also struggling when everybody was sort of lost and in the same boat”.

Shared experiences were not limited to feelings of being lost and struggling. Members were also learning together, which solidified the sense of community. A peer pointed out: “[Relationships] became stronger in a sense, because we were all in the same boat… Sometimes the facilitators themselves were like I don’t know how to do that . We were all learning…and figuring things out. And I think that’s a good way to become closer to people. ”

In sum, various strategies were used by the organization and the collective (including PSWs and peers) to build and maintain a sense of community that was anchored in peer culture values.

Continuation of mental health support through a hybrid mode: importance of combining in-person and virtual services

Virtual peer services were “a lifeline” especially during the pandemic, as a peer noted. However, some peers also looked forward to returning to in-person services for various reasons. For some, the in-person services provided structure to their week and a chance to leave the house. A peer noted: “It forces me to get out of the house…I’m having difficulty leaving the house…half of me looks forward to it [the weekly support meeting], and half of me dreads it. But in the end, I get myself out of the door and I walk up to the center…I feel so much better afterwards.”

Naturally occurring conversations during coffee breaks or after the meetings, which contribute to supporting relationships, were missed. As one peer stated, “ A lot of it [peer support] is the action piece and when you’re connecting virtually, it’s just not the same as being in person ”. Some participants pointed out that in-person interactions offered a deeper level of connection through shared energy and physical space. A participant noted, “ When someone’s super upset, you can feel it. When people are in their own homes, it feels disconnected because there are so many other people there. I feel like we’re seeing less emotional distress, whereas in-person, it would be brought out– and not distress in the sense that they’re not coping, but that they’re bringing big feelings or things on their mind and they’re expressing them freely in person. I feel there’s a lot less of that since being virtual .” Additionally, some participants felt “strange” expressing strong emotions through a computer screen and pointed out that virtual settings offered less authentic connections compared to in-person interactions. Nonetheless, participants acknowledged that some people could still struggle regardless of the mode of interaction.

It was also pointed out that although virtual events drew in people who had never attended in person, some peers who used to attend in-person meetings did not join any virtual meetings, and it was not clear why this was the case or how they coped with the pandemic. Some of these individuals could not be found on online platforms to connect with. A participant stated, “… there’s a whole voice of those who can’t access virtual, those who have only been going in-person… So I think we definitely should try to cater to both [when designing mental health support services ]”.

Overall, peers expressed support for maintaining remote online mental health peer support services even as lockdowns were lifted, and pointed out that transitioning to a hybrid mode would offer efficiency in resource utilization and greater convenience for remote access. A peer emphasizing the need to continue the virtual services noted the importance of social integration for peers with disabilities: “ I think there’s a lot of people, especially with disabilities or just more issues who have a really hard time going in person. I feel like there’s a lot more people who were able to access services and I don’t think that they should just be cut off and done. ” Those living on the outskirts of the city or with other commitments had limited time to attend in-person support meetings, making hybrid services desirable after pandemic restrictions were lifted. Online meetings made mental health services more accessible, allowing individuals to manage their work-life domains more harmoniously. A peer said: “… People are always finding it a stress release and I like accessing it (peer support) from home sometimes instead of having to go to places…Sometimes I’m just not into seeing people, or going out and dealing with traffic.”

In sum, continuing with virtual services while also maintaining in-person services was seen as offering more access to peer support services to a broader population, and as providing more choice for individuals who sought peer support.

This study contributes to the literature in a number of ways. It emphasizes the importance of providing virtual peer support in situations where mental health in-person support and services are not possible or accessible. We have highlighted the technology-based challenges and opportunities that create boundaries and bridges respectively to peer support in a virtual space. We have shown that a hybrid model involving both virtual and in-person services offers better accessibility to individuals and groups in need of support, and have argued for the importance of maintaining both modalities. We have also shown that a sense of community can be established in a virtual space, and have highlighted the strategies that peer organizations and their members can utilize to maintain the community spirit. As importantly, we have contributed to the literature by including peer voices and highlighting their experiences in their own words. Researchers have pointed out that the experiences of service users have not been adequately researched [ 26 ] and this is particularly so in the case of peers [ 25 ]. Our research enhances understanding of service users’ lived experiences.

A hybrid model of peer support services

Our findings show, consistent with the literature, that each of virtual and in-person peer support service has its own advantages and disadvantages when used singularly, and that the joint operation of virtual and in-person services through a hybrid model provides more accessible service [ 32 ]. Using both approaches conjointly offers the opportunity to strengthen community-based mental health, and to reinforce recovery approaches that promote individual choice and self-determination. The importance and benefits of peer support and recovery approaches have been documented [ 33 ] and have been implemented increasingly across countries around the globe [ 1 ]. A hybrid model benefits service users in that during health system crises, such as a pandemic caused by an infectious disease when mental health needs are higher, access to mental health support can be maintained. Overall, this model offers promising potential as a vital resource to support the mental well-being of populations.

Using both models conjointly benefits not only service users and communities but also organizations that support mental health. By maintaining and strengthening both types of services, organizations that provide mental health services can build their capacities and be better prepared for sudden changes that might require suspending or limiting in-person services. This enhances flexibility and adaptability by maintaining a system that can dynamically switch between the two modalities.

Yet, despite the benefits of maintaining virtual services alongside in-person services, some PSWs and peers in our study reported a number of technology-related challenges that included difficulties obtaining internet connection or proper equipment, as well as limited skills with respect to the use of technology. Our findings are consistent with research which shows that providers and users of virtual mental health services report several limitations, such as difficulties with the adoption of the remote practice, and access and literacy challenges [ 11 , 34 , 35 , 36 , 37 ]. Our findings also show that to be effective, a mental health support system that utilizes a virtual mode of service delivery requires appropriate technological tools and infrastructure, as well as appropriate support. In the case we studied, the organization advocated for and obtained access to the internet and equipment for peers. Further, the organization allocated extensive time to the training of PSWs and peers. PSWs, once versed on the use of the technology, offered help to peers in group settings and one-on-one when necessary. This kind of assistance and collaboration is common in peer support communities, where principles of mutuality and cooperation prevail, but this also suggests the importance of providing adequate resources to peer support communities so they can achieve their full potential.

Another challenge associated with the virtual environment is that computer-mediated communications provide fewer social context cues; hence individuals who join an online community may experience less personal connection [ 23 ]. This challenge was identified by some of our participants, prompting us to ask how a sense of community may be established and maintained when peers connect virtually.

• Sense of community

Ilioudi et al. (2012) refer to virtual communities in health care as “a group of people using telecommunication with the purposes of delivering health care and education, and/or providing support” [ 38 , p.1]. These communities encompass a wide range of clinical services and technologies. During the COVID-19 pandemic, there was increasing attention to online recovery services and phone support, self-help and mental health self-management delivered virtually or in e-communities [ 39 ]. E-communities are critical for mental health support and have the potential to transform the philosophical approach to the provision of mental health services as they help bridge the gap between the high prevalence of mental health challenges and the relatively low capacity of mental health systems [ 40 ].

In peer support communities, individuals share experiential knowledge to encourage and pursue recovery as a mutual goal, showing common purpose and interdependence [ 41 , 42 ]. Despite many peer support e-communities having been set up and having flourished during the COVID-19 pandemic and thereafter, there has been limited research on how the sense of community can be established or maintained in these groups. In studies of groups and communities more generally (and not only in the case of peer support), there has been focus on applying quantitative measurements and scales for the assessment of the sense of community, e.g., the Brief Sense of Community Index [ 43 ], and the Brief Sense of Community Scale [ 44 ]. These scales have been applied to study academic communities of practice [ 18 ], online education programs for different groups [ 45 – 46 ] and for individuals with serious mental illness living in community settings [ 47 ]. However, less research applies qualitative methods to explore in more depth this sense of community.

Literature shows that a sense of community is important in mental health support, especially during crises such as the COVID-19 pandemic [ 48 ]. A better understanding of the sense of community in virtual services could uncover factors that contribute to a positive therapeutic environment [ 49 ]. Our results identified five strategies to maintain a sense of community amongst peers and providers in a virtual environment during the COVID-19 pandemic. These findings highlight the importance of having a holistic and multidimensional perspective where the organization, providers, and peers all play a role.

The strategies we identified resonate with McMillan and Chavis’ conceptualization of a sense of community [ 20 ]. Their conceptualization highlights four elements: (a) membership (a feeling of belonging), (b) influence (a sense of mattering to the group), (c) integration and fulfillment of needs (a feeling that needs will be met through membership in the group), and (d) shared emotional connection (a belief that members have shared history and similar experiences). By “ acting collectively” (as in our findings), individuals reinforce the notion that they belong to a community where their contributions matter and are valued. Acting collectively also allows the community to fulfill common needs. “ Building on organizational and peer culture ” involves recognizing the contributions of individual members that could reinforce the belief that each member has a meaningful impact on the community. This culture is inclusive and fosters integration and emotional connection among the members. “ Establishing multiple points of connection ” ensures that community members have diverse channels to interact, collaborate, and meet their needs. “ Maintaining a continuous presence and social interaction ” helps establish trust that membership in the community is a reliable path for meeting their needs. Finally, “ sharing lived experiences and learning together ” allows members to open up about their mental health (or other) challenges, contributing to an emerging collective narrative and shared history. Other organizations attempting to build or maintain a sense of community in a virtual space may find some of these strategies employed by the organization, the PSWs and the peers to be helpful.

Limitations and directions for future research

Our study has a number of limitations. Concerns regarding security and privacy in virtual health care communities have been highlighted in research [ 10 , 50 ]. Researchers have also pointed to potential conflicts within online communities set up for various purposes [ 51 , 52 ]. Our paper did not examine these privacy and social concerns, however, evidence regarding these topics is important to provide guidance on how to make virtual spaces safe for peers who participate. Future research on these topics would be useful.

In addition, our findings pointed to peer support users who did not access the mental health support services when these transitioned to virtual platforms. We did not have access to these individuals, and it is not clear what factors contributed to their absence. Future research may explore whether and how technology-based boundaries become an impediment to seeking mental health support for some individuals. We also need a better understanding of the mental health of individuals who stopped using peer support when services moved online.

Our study focused on an organization and its members (PSWs and peers) and did not include in-depth attention to macro system level influences on or implications of peer support in a virtual space. The socio-economic aspects of adopting virtual work and services require further exploration including the financial return on investment and social returns (e.g. recovery) associated with using hybrid mental health support services. Overall, future research may identify and address system level influences that can hinder or facilitate mental health virtual services within community organizations, and how the needs of and services provided by these organizations may influence the allocation of resources and mental health indicators at a systems level.

Implications for policy and practice

Our findings highlight the organization’s efforts to provide accessibility and support for both peers and PSWs and demonstrate the value of a proactive and responsive approach to addressing major change. Organizational and management support has been identified as a central factor in employees’ readiness when change occurs in an organization [ 53 ]. In fact, the COVID-19 pandemic situation highlighted the adaptability and resilience of peer support services and communities. As a manager in our study pointed out, the peer support organization was able to quickly and flexibly respond to the sudden surge in need for mental health support at a time when more institutionalized and strongly professionalized services were struggling to adapt. The resilience and adaptability of peer support organizations and programs are strengths in mental health care systems that are struggling to meet the needs of populations [ 1 ], yet these organizations and programs often receive a relatively small share of health care resources. Future policy may consider a more equitable allocation of resources to peer support services.

Another policy-related implication pertains to technology infrastructure and more specifically to who gets access to devices (such as smart phones and computers) and internet connections. Our study highlighted that lack of access to these resources was a boundary that challenged some peers seeking virtual support services. The peer support organization stepped in to create bridges by advocating with funders and tech providers. However, this leaves unsolved an issue that needs to be addressed at a higher societal level, namely the limited, yet necessary, resources available to some segments of the population (typically homeless individuals, people with disabilities, refugees and other groups). This issue should be an important consideration in future policy.

Finally, our study pointed to several practical implications based on the experience of the case we studied. For example, we pointed to the various strategies that peer organizations can use to maintain a sense of community in a virtual space. Further, in anticipation of the growth of virtual peer support services, organizations may consider the need for renewed training modules that integrate necessary skills relating to using technology for recovery support. Peer support organizations may also consider building their capacity to respond quickly to crises and major changes, as it is during these situations that their services may be in most demand.

The important role of mental health community services and the changing drivers in mental health systems have been noted by researchers. Norton (2023) points out that “ mental health services are currently undergoing immense cultural, philosophical, and organizational change. One such mechanism involved in this change has been the recognition of lived experience as a knowledge subset in its own right ” [ 54 , p.1]. The trends of peer support gaining in importance and being delivered in virtual as well as in-person spaces are poised to continue in the future. It is incumbent on researchers to continue studying the challenges and opportunities of peer support in its various models. Our study has been a step in this direction.

Data availability

The dataset used in this research is not publicly available as set out by the research ethics approval from the University of Ottawa and the consent forms signed by the participants. Further information is available from the corresponding author upon request.

Abbreviations

Peer Support Worker

United Kingdom

United States

World Health Organization

Research Ethics Board

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Acknowledgements

The authors would like to thank the peer support organization, the peer support workers and the peers who kindly shared their experiences with us.

This research was financially supported by the Partnership Engage Grants COVID-19 Special Initiative from the Social Sciences and Humanities Research Council (SSHRC), Fund # 1008-2020-1020.

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This article is part of EM’s doctoral thesis. EM and SC contributed to the study conception and design. Data collection was done in collaboration, and analysis and manuscript drafting were performed by EM, and were thoroughly reviewed by SC. Both authors critically revised the drafts until finalized.

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Mirbahaeddin, E., Chreim, S. Transcending technology boundaries and maintaining sense of community in virtual mental health peer support: a qualitative study with service providers and users. BMC Health Serv Res 24 , 510 (2024). https://doi.org/10.1186/s12913-024-10943-y

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What It Means To Be Asian in America

The lived experiences and perspectives of asian americans in their own words.

Asians are the fastest growing racial and ethnic group in the United States. More than 24 million Americans in the U.S. trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent.

The majority of Asian Americans are immigrants, coming to understand what they left behind and building their lives in the United States. At the same time, there is a fast growing, U.S.-born generation of Asian Americans who are navigating their own connections to familial heritage and their own experiences growing up in the U.S.

In a new Pew Research Center analysis based on dozens of focus groups, Asian American participants described the challenges of navigating their own identity in a nation where the label “Asian” brings expectations about their origins, behavior and physical self. Read on to see, in their own words, what it means to be Asian in America.

Table of Contents

Introduction, this is how i view my identity, this is how others see and treat me, this is what it means to be home in america, about this project, methodological note, acknowledgments.

No single experience defines what it means to be Asian in the United States today. Instead, Asian Americans’ lived experiences are in part shaped by where they were born, how connected they are to their family’s ethnic origins, and how others – both Asians and non-Asians – see and engage with them in their daily lives. Yet despite diverse experiences, backgrounds and origins, shared experiences and common themes emerged when we asked: “What does it mean to be Asian in America?”

In the fall of 2021, Pew Research Center undertook the largest focus group study it had ever conducted – 66 focus groups with 264 total participants – to hear Asian Americans talk about their lived experiences in America. The focus groups were organized into 18 distinct Asian ethnic origin groups, fielded in 18 languages and moderated by members of their own ethnic groups. Because of the pandemic, the focus groups were conducted virtually, allowing us to recruit participants from all parts of the United States. This approach allowed us to hear a diverse set of voices – especially from less populous Asian ethnic groups whose views, attitudes and opinions are seldom presented in traditional polling. The approach also allowed us to explore the reasons behind people’s opinions and choices about what it means to belong in America, beyond the preset response options of a traditional survey.

The terms “Asian,” “Asians living in the United States” and “Asian American” are used interchangeably throughout this essay to refer to U.S. adults who self-identify as Asian, either alone or in combination with other races or Hispanic identity.

“The United States” and “the U.S.” are used interchangeably with “America” for variations in the writing.

Multiracial participants are those who indicate they are of two or more racial backgrounds (one of which is Asian). Multiethnic participants are those who indicate they are of two or more ethnicities, including those identified as Asian with Hispanic background.

U.S. born refers to people born in the 50 U.S. states or the District of Columbia, Puerto Rico, or other U.S. territories.

Immigrant refers to people who were not U.S. citizens at birth – in other words, those born outside the U.S., Puerto Rico or other U.S. territories to parents who were not U.S. citizens. The terms “immigrant,” “first generation” and “foreign born” are used interchangeably in this report.  

Second generation refers to people born in the 50 states or the District of Columbia with at least one first-generation, or immigrant, parent.

The pan-ethnic term “Asian American” describes the population of about 22 million people living in the United States who trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent. The term was popularized by U.S. student activists in the 1960s and was eventually adopted by the U.S. Census Bureau. However, the “Asian” label masks the diverse demographics and wide economic disparities across the largest national origin groups (such as Chinese, Indian, Filipino) and the less populous ones (such as Bhutanese, Hmong and Nepalese) living in America. It also hides the varied circumstances of groups immigrated to the U.S. and how they started their lives there. The population’s diversity often presents challenges . Conventional survey methods typically reflect the voices of larger groups without fully capturing the broad range of views, attitudes, life starting points and perspectives experienced by Asian Americans. They can also limit understanding of the shared experiences across this diverse population.

Across all focus groups, some common findings emerged. Participants highlighted how the pan-ethnic “Asian” label used in the U.S. represented only one part of how they think of themselves. For example, recently arrived Asian immigrant participants told us they are drawn more to their ethnic identity than to the more general, U.S.-created pan-ethnic Asian American identity. Meanwhile, U.S.-born Asian participants shared how they identified, at times, as Asian but also, at other times, by their ethnic origin and as Americans.

Another common finding among focus group participants is the disconnect they noted between how they see themselves and how others view them. Sometimes this led to maltreatment of them or their families, especially at heightened moments in American history such as during Japanese incarceration during World War II, the aftermath of 9/11 and, more recently, the COVID-19 pandemic. Beyond these specific moments, many in the focus groups offered their own experiences that had revealed other people’s assumptions or misconceptions about their identity.

Another shared finding is the multiple ways in which participants take and express pride in their cultural and ethnic backgrounds while also feeling at home in America, celebrating and blending their unique cultural traditions and practices with those of other Americans.

This focus group project is part of a broader research agenda about Asians living in the United States. The findings presented here offer a small glimpse of what participants told us, in their own words, about how they identify themselves, how others see and treat them, and more generally, what it means to be Asian in America.

Illustrations by Jing Li

Publications from the Being Asian in America project

• Read the data essay: What It Means to Be Asian in America
• Watch the documentary: Being Asian in America
• Explore the interactive: In Their Own Words: The Diverse Perspectives of Being Asian in America
• View expanded interviews: Extended Interviews: Being Asian in America
• About this research project: More on the Being Asian in America project
• Q&A: Why and how Pew Research Center conducted 66 focus groups with Asian Americans

One of the topics covered in each focus group was how participants viewed their own racial or ethnic identity. Moderators asked them how they viewed themselves, and what experiences informed their views about their identity. These discussions not only highlighted differences in how participants thought about their own racial or ethnic background, but they also revealed how different settings can influence how they would choose to identify themselves. Across all focus groups, the general theme emerged that being Asian was only one part of how participants viewed themselves.

The pan-ethnic label ‘Asian’ is often used more in formal settings

“I think when I think of the Asian Americans, I think that we’re all unique and different. We come from different cultures and backgrounds. We come from unique stories, not just as a group, but just as individual humans.” Mali , documentary participant

Many participants described a complicated relationship with the pan-ethnic labels “Asian” or “Asian American.” For some, using the term was less of an active choice and more of an imposed one, with participants discussing the disconnect between how they would like to identify themselves and the available choices often found in formal settings. For example, an immigrant Pakistani woman remarked how she typically sees “Asian American” on forms, but not more specific options. Similarly, an immigrant Burmese woman described her experience of applying for jobs and having to identify as “Asian,” as opposed to identifying by her ethnic background, because no other options were available. These experiences highlight the challenges organizations like government agencies and employers have in developing surveys or forms that ask respondents about their identity. A common sentiment is one like this:

“I guess … I feel like I just kind of check off ‘Asian’ [for] an application or the test forms. That’s the only time I would identify as Asian. But Asian is too broad. Asia is a big continent. Yeah, I feel like it’s just too broad. To specify things, you’re Taiwanese American, that’s exactly where you came from.”

–U.S.-born woman of Taiwanese origin in early 20s

Smaller ethnic groups default to ‘Asian’ since their groups are less recognizable

Other participants shared how their experiences in explaining the geographic location and culture of their origin country led them to prefer “Asian” when talking about themselves with others. This theme was especially prominent among those belonging to smaller origin groups such as Bangladeshis and Bhutanese. A Lao participant remarked she would initially say “Asian American” because people might not be familiar with “Lao.”

“​​[When I fill out] forms, I select ‘Asian American,’ and that’s why I consider myself as an Asian American. [It is difficult to identify as] Nepali American [since] there are no such options in forms. That’s why, Asian American is fine to me.”

–Immigrant woman of Nepalese origin in late 20s

“Coming to a big country like [the United States], when people ask where we are from … there are some people who have no idea about Bhutan, so we end up introducing ourselves as being Asian.”

–Immigrant woman of Bhutanese origin in late 40s

But for many, ‘Asian’ as a label or identity just doesn’t fit

Many participants felt that neither “Asian” nor “Asian American” truly captures how they view themselves and their identity. They argue that these labels are too broad or too ambiguous, as there are so many different groups included within these labels. For example, a U.S.-born Pakistani man remarked on how “Asian” lumps many groups together – that the term is not limited to South Asian groups such as Indian and Pakistani, but also includes East Asian groups. Similarly, an immigrant Nepalese man described how “Asian” often means Chinese for many Americans. A Filipino woman summed it up this way:

“Now I consider myself to be both Filipino and Asian American, but growing up in [Southern California] … I didn’t start to identify as Asian American until college because in [the Los Angeles suburb where I lived], it’s a big mix of everything – Black, Latino, Pacific Islander and Asian … when I would go into spaces where there were a lot of other Asians, especially East Asians, I didn’t feel like I belonged. … In media, right, like people still associate Asian with being East Asian.”

–U.S.-born woman of Filipino origin in mid-20s

Participants also noted they have encountered confusion or the tendency for others to view Asian Americans as people from mostly East Asian countries, such as China, Japan and Korea. For some, this confusion even extends to interactions with other Asian American groups. A Pakistani man remarked on how he rarely finds Pakistani or Indian brands when he visits Asian stores. Instead, he recalled mostly finding Vietnamese, Korean and Chinese items.

Among participants of South Asian descent, some identified with the label “South Asian” more than just “Asian.” There were other nuances, too, when it comes to the labels people choose. Some Indian participants, for example, said people sometimes group them with Native Americans who are also referred to as Indians in the United States. This Indian woman shared her experience at school:

“I love South Asian or ‘Desi’ only because up until recently … it’s fairly new to say South Asian. I’ve always said ‘Desi’ because growing up … I’ve had to say I’m the red dot Indian, not the feather Indian. So annoying, you know? … Always a distinction that I’ve had to make.”

–U.S.-born woman of Indian origin in late 20s

Participants with multiethnic or multiracial backgrounds described their own unique experiences with their identity. Rather than choosing one racial or ethnic group over the other, some participants described identifying with both groups, since this more accurately describes how they see themselves. In some cases, this choice reflected the history of the Asian diaspora. For example, an immigrant Cambodian man described being both Khmer/Cambodian and Chinese, since his grandparents came from China. Some other participants recalled going through an “identity crisis” as they navigated between multiple identities. As one woman explained:

“I would say I went through an identity crisis. … It’s because of being multicultural. … There’s also French in the mix within my family, too. Because I don’t identify, speak or understand the language, I really can’t connect to the French roots … I’m in between like Cambodian and Thai, and then Chinese and then French … I finally lumped it up. I’m just an Asian American and proud of all my roots.”

–U.S.-born woman of Cambodian origin in mid-30s

In other cases, the choice reflected U.S. patterns of intermarriage. Asian newlyweds have the highest intermarriage rate of any racial or ethnic group in the country. One Japanese-origin man with Hispanic roots noted:

“So I would like to see myself as a Hispanic Asian American. I want to say Hispanic first because I have more of my mom’s culture in me than my dad’s culture. In fact, I actually have more American culture than my dad’s culture for what I do normally. So I guess, Hispanic American Asian.”

–U.S.-born man of Hispanic and Japanese origin in early 40s

Other identities beyond race or ethnicity are also important

Focus group participants also talked about their identity beyond the racial or ethnic dimension. For example, one Chinese woman noted that the best term to describe her would be “immigrant.” Faith and religious ties were also important to some. One immigrant participant talked about his love of Pakistani values and how religion is intermingled into Pakistani culture. Another woman explained:

“[Japanese language and culture] are very important to me and ingrained in me because they were always part of my life, and I felt them when I was growing up. Even the word itadakimasu reflects Japanese culture or the tradition. Shinto religion is a part of the culture. They are part of my identity, and they are very important to me.”

–Immigrant woman of Japanese origin in mid-30s

For some, gender is another important aspect of identity. One Korean participant emphasized that being a woman is an important part of her identity. For others, sexual orientation is an essential part of their overall identity. One U.S.-born Filipino participant described herself as “queer Asian American.” Another participant put it this way:

“I belong to the [LGBTQ] community … before, what we only know is gay and lesbian. We don’t know about being queer, nonbinary. [Here], my horizon of knowing what genders and gender roles is also expanded … in the Philippines, if you’ll be with same sex, you’re considered gay or lesbian. But here … what’s happening is so broad, on how you identify yourself.”

–Immigrant woman of Filipino origin in early 20s

Immigrant identity is tied to their ethnic heritage

Participants born outside the United States tended to link their identity with their ethnic heritage. Some felt strongly connected with their ethnic ties due to their citizenship status. For others, the lack of permanent residency or citizenship meant they have stronger ties to their ethnicity and birthplace. And in some cases, participants said they held on to their ethnic identity even after they became U.S. citizens. One woman emphasized that she will always be Taiwanese because she was born there, despite now living in the U.S.

For other participants, family origin played a central role in their identity, regardless of their status in the U.S. According to some of them, this attitude was heavily influenced by their memories and experiences in early childhood when they were still living in their countries of origin. These influences are so profound that even after decades of living in the U.S., some still feel the strong connection to their ethnic roots. And those with U.S.-born children talked about sending their kids to special educational programs in the U.S. to learn about their ethnic heritage.

“Yes, as for me, I hold that I am Khmer because our nationality cannot be deleted, our identity is Khmer as I hold that I am Khmer … so I try, even [with] my children today, I try to learn Khmer through Zoom through the so-called Khmer Parent Association.”

–Immigrant man of Cambodian origin in late 50s

Navigating life in America is an adjustment

Many participants pointed to cultural differences they have noticed between their ethnic culture and U.S. culture. One of the most distinct differences is in food. For some participants, their strong attachment to the unique dishes of their families and their countries of origin helps them maintain strong ties to their ethnic identity. One Sri Lankan participant shared that her roots are still in Sri Lanka, since she still follows Sri Lankan traditions in the U.S. such as preparing kiribath (rice with coconut milk) and celebrating Ramadan.

For other participants, interactions in social settings with those outside their own ethnic group circles highlighted cultural differences. One Bangladeshi woman talked about how Bengalis share personal stories and challenges with each other, while others in the U.S. like to have “small talk” about TV series or clothes.

Many immigrants in the focus groups have found it is easier to socialize when they are around others belonging to their ethnicity. When interacting with others who don’t share the same ethnicity, participants noted they must be more self-aware about cultural differences to avoid making mistakes in social interactions. Here, participants described the importance of learning to “fit in,” to avoid feeling left out or excluded. One Korean woman said:

“Every time I go to a party, I feel unwelcome. … In Korea, when I invite guests to my house and one person sits without talking, I come over and talk and treat them as a host. But in the United States, I have to go and mingle. I hate mingling so much. I have to talk and keep going through unimportant stories. In Korea, I am assigned to a dinner or gathering. I have a party with a sense of security. In America, I have nowhere to sit, and I don’t know where to go and who to talk to.”

–Immigrant woman of Korean origin in mid-40s

And a Bhutanese immigrant explained:

“In my case, I am not an American. I consider myself a Bhutanese. … I am a Bhutanese because I do not know American culture to consider myself as an American. It is very difficult to understand the sense of humor in America. So, we are pure Bhutanese in America.”

–Immigrant man of Bhutanese origin in early 40s

Language was also a key aspect of identity for the participants. Many immigrants in the focus groups said they speak a language other than English at home and in their daily lives. One Vietnamese man considered himself Vietnamese since his Vietnamese is better than his English. Others emphasized their English skills. A Bangladeshi participant felt that she was more accepted in the workplace when she does more “American” things and speaks fluent English, rather than sharing things from Bangladeshi culture. She felt that others in her workplace correlate her English fluency with her ability to do her job. For others born in the U.S., the language they speak at home influences their connection to their ethnic roots.

“Now if I go to my work and do show my Bengali culture and Asian culture, they are not going to take anything out of it. So, basically, I have to show something that they are interested in. I have to show that I am American, [that] I can speak English fluently. I can do whatever you give me as a responsibility. So, in those cases I can’t show anything about my culture.”

–Immigrant woman of Bangladeshi origin in late 20s

“Being bi-ethnic and tri-cultural creates so many unique dynamics, and … one of the dynamics has to do with … what it is to be Americanized. … One of the things that played a role into how I associate the identity is language. Now, my father never spoke Spanish to me … because he wanted me to develop a fluency in English, because for him, he struggled with English. What happened was three out of the four people that raised me were Khmer … they spoke to me in Khmer. We’d eat breakfast, lunch and dinner speaking Khmer. We’d go to the temple in Khmer with the language and we’d also watch videos and movies in Khmer. … Looking into why I strongly identify with the heritage, one of the reasons is [that] speaking that language connects to the home I used to have [as my families have passed away].”

–U.S.-born man of Cambodian origin in early 30s

Balancing between individualistic and collective thinking

For some immigrant participants, the main differences between themselves and others who are seen as “truly American” were less about cultural differences, or how people behave, and more about differences in “mindset,” or how people think . Those who identified strongly with their ethnicity discussed how their way of thinking is different from a “typical American.” To some, the “American mentality” is more individualistic, with less judgment on what one should do or how they should act . One immigrant Japanese man, for example, talked about how other Japanese-origin co-workers in the U.S. would work without taking breaks because it’s culturally inconsiderate to take a break while others continued working. However, he would speak up for himself and other workers when they are not taking any work breaks. He attributed this to his “American” way of thinking, which encourages people to stand up for themselves.

Some U.S.-born participants who grew up in an immigrant family described the cultural clashes that happened between themselves and their immigrant parents. Participants talked about how the second generation (children of immigrant parents) struggles to pursue their own dreams while still living up to the traditional expectations of their immigrant parents.

“I feel like one of the biggest things I’ve seen, just like [my] Asian American friends overall, is the kind of family-individualistic clash … like wanting to do your own thing is like, is kind of instilled in you as an American, like go and … follow your dream. But then you just grow up with such a sense of like also wanting to be there for your family and to live up to those expectations, and I feel like that’s something that’s very pronounced in Asian cultures.”

–U.S.-born man of Indian origin in mid-20s

Discussions also highlighted differences about gender roles between growing up in America compared with elsewhere.

“As a woman or being a girl, because of your gender, you have to keep your mouth shut [and] wait so that they call on you for you to speak up. … I do respect our elders and I do respect hearing their guidance but I also want them to learn to hear from the younger person … because we have things to share that they might not know and that [are] important … so I like to challenge gender roles or traditional roles because it is something that [because] I was born and raised here [in America], I learn that we all have the equal rights to be able to speak and share our thoughts and ideas.”

U.S. born have mixed ties to their family’s heritage

“I think being Hmong is somewhat of being free, but being free of others’ perceptions of you or of others’ attempts to assimilate you or attempts to put pressure on you. I feel like being Hmong is to resist, really.” Pa Houa , documentary participant

How U.S.-born participants identify themselves depends on their familiarity with their own heritage, whom they are talking with, where they are when asked about their identity and what the answer is used for. Some mentioned that they have stronger ethnic ties because they are very familiar with their family’s ethnic heritage. Others talked about how their eating habits and preferred dishes made them feel closer to their ethnic identity. For example, one Korean participant shared his journey of getting closer to his Korean heritage because of Korean food and customs. When some participants shared their reasons for feeling closer to their ethnic identity, they also expressed a strong sense of pride with their unique cultural and ethnic heritage.

“I definitely consider myself Japanese American. I mean I’m Japanese and American. Really, ever since I’ve grown up, I’ve really admired Japanese culture. I grew up watching a lot of anime and Japanese black and white films. Just learning about [it], I would hear about Japanese stuff from my grandparents … myself, and my family having blended Japanese culture and American culture together.”

–U.S.-born man of Japanese origin in late 20s

Meanwhile, participants who were not familiar with their family’s heritage showed less connection with their ethnic ties. One U.S.-born woman said she has a hard time calling herself Cambodian, as she is “not close to the Cambodian community.” Participants with stronger ethnic ties talked about relating to their specific ethnic group more than the broader Asian group. Another woman noted that being Vietnamese is “more specific and unique than just being Asian” and said that she didn’t feel she belonged with other Asians. Some participants also disliked being seen as or called “Asian,” in part because they want to distinguish themselves from other Asian groups. For example, one Taiwanese woman introduces herself as Taiwanese when she can, because she had frequently been seen as Chinese.

Some in the focus groups described how their views of their own identities shifted as they grew older. For example, some U.S.-born and immigrant participants who came to the U.S. at younger ages described how their experiences in high school and the need to “fit in” were important in shaping their own identities. A Chinese woman put it this way:

“So basically, all I know is that I was born in the United States. Again, when I came back, I didn’t feel any barrier with my other friends who are White or Black. … Then I got a little confused in high school when I had trouble self-identifying if I am Asian, Chinese American, like who am I. … Should I completely immerse myself in the American culture? Should I also keep my Chinese identity and stuff like that? So yeah, that was like the middle of that mist. Now, I’m pretty clear about myself. I think I am Chinese American, Asian American, whatever people want.”

–U.S.-born woman of Chinese origin in early 20s

Identity is influenced by birthplace

“I identified myself first and foremost as American. Even on the forms that you fill out that says, you know, ‘Asian’ or ‘Chinese’ or ‘other,’ I would check the ‘other’ box, and I would put ‘American Chinese’ instead of ‘Chinese American.’” Brent , documentary participant

When talking about what it means to be “American,” participants offered their own definitions. For some, “American” is associated with acquiring a distinct identity alongside their ethnic or racial backgrounds, rather than replacing them. One Indian participant put it this way:

“I would also say [that I am] Indian American just because I find myself always bouncing between the two … it’s not even like dual identity, it just is one whole identity for me, like there’s not this separation. … I’m doing [both] Indian things [and] American things. … They use that term like ABCD … ‘American Born Confused Desi’ … I don’t feel that way anymore, although there are those moments … but I would say [that I am] Indian American for sure.”

–U.S.-born woman of Indian origin in early 30s

Meanwhile, some U.S.-born participants view being American as central to their identity while also valuing the culture of their family’s heritage.

Many immigrant participants associated the term “American” with immigration status or citizenship. One Taiwanese woman said she can’t call herself American since she doesn’t have a U.S. passport. Notably, U.S. citizenship is an important milestone for many immigrant participants, giving them a stronger sense of belonging and ultimately calling themselves American. A Bangladeshi participant shared that she hasn’t received U.S. citizenship yet, and she would call herself American after she receives her U.S. passport.

Other participants gave an even narrower definition, saying only those born and raised in the United States are truly American. One Taiwanese woman mentioned that her son would be American since he was born, raised and educated in the U.S. She added that while she has U.S. citizenship, she didn’t consider herself American since she didn’t grow up in the U.S. This narrower definition has implications for belonging. Some immigrants in the groups said they could never become truly American since the way they express themselves is so different from those who were born and raised in the U.S. A Japanese woman pointed out that Japanese people “are still very intimidated by authorities,” while those born and raised in America give their opinions without hesitation.

“As soon as I arrived, I called myself a Burmese immigrant. I had a green card, but I still wasn’t an American citizen. … Now I have become a U.S. citizen, so now I am a Burmese American.”

–Immigrant man of Burmese origin in mid-30s

“Since I was born … and raised here, I kind of always view myself as American first who just happened to be Asian or Chinese. So I actually don’t like the term Chinese American or Asian American. I’m American Asian or American Chinese. I view myself as American first.”

–U.S.-born man of Chinese origin in early 60s

“[I used to think of myself as] Filipino, but recently I started saying ‘Filipino American’ because I got [U.S.] citizenship. And it just sounds weird to say Filipino American, but I’m trying to … I want to accept it. I feel like it’s now marry-able to my identity.”

–Immigrant woman of Filipino origin in early 30s

For others, American identity is about the process of ‘becoming’ culturally American

Immigrant participants also emphasized how their experiences and time living in America inform their views of being an “American.” As a result, some started to see themselves as Americans after spending more than a decade in the U.S. One Taiwanese man considered himself an American since he knows more about the U.S. than Taiwan after living in the U.S. for over 52 years.

But for other immigrant participants, the process of “becoming” American is not about how long they have lived in the U.S., but rather how familiar they are with American culture and their ability to speak English with little to no accent. This is especially true for those whose first language is not English, as learning and speaking it without an accent can be a big challenge for some. One Bangladeshi participant shared that his pronunciation of “hot water” was very different from American English, resulting in confusions in communication. By contrast, those who were more confident in their English skills felt they can better understand American culture and values as a result, leading them to a stronger connection with an American identity.

“[My friends and family tease me for being Americanized when I go back to Japan.] I think I seem a little different to people who live in Japan. I don’t think they mean anything bad, and they [were] just joking, because I already know that I seem a little different to people who live in Japan.”

–Immigrant man of Japanese origin in mid-40s

“I value my Hmong culture, and language, and ethnicity, but I also do acknowledge, again, that I was born here in America and I’m grateful that I was born here, and I was given opportunities that my parents weren’t given opportunities for.”

–U.S.-born woman of Hmong origin in early 30s

During the focus group discussions about identity, a recurring theme emerged about the difference between how participants saw themselves and how others see them. When asked to elaborate on their experiences and their points of view, some participants shared experiences they had with people misidentifying their race or ethnicity. Others talked about their frustration with being labeled the “model minority.” In all these discussions, participants shed light on the negative impacts that mistaken assumptions and labels had on their lives.

All people see is ‘Asian’

For many, interactions with others (non-Asians and Asians alike) often required explaining their backgrounds, reacting to stereotypes, and for those from smaller origin groups in particular, correcting the misconception that being “Asian” means you come from one of the larger Asian ethnic groups. Several participants remarked that in their own experiences, when others think about Asians, they tend to think of someone who is Chinese. As one immigrant Filipino woman put it, “Interacting with [non-Asians in the U.S.], it’s hard. … Well, first, I look Spanish. I mean, I don’t look Asian, so would you guess – it’s like they have a vision of what an Asian [should] look like.” Similarly, an immigrant Indonesian man remarked how Americans tended to see Asians primarily through their physical features, which not all Asian groups share.

Several participants also described how the tendency to view Asians as a monolithic group can be even more common in the wake of the COVID-19 pandemic.

“The first [thing people think of me as] is just Chinese. ‘You guys are just Chinese.’ I’m not the only one who felt [this] after the COVID-19 outbreak. ‘Whether you’re Japanese, Korean, or Southeast Asian, you’re just Chinese [to Americans]. I should avoid you.’ I’ve felt this way before, but I think I’ve felt it a bit more after the COVID-19 outbreak.”

–Immigrant woman of Korean origin in early 30s

At the same time, other participants described their own experiences trying to convince others that they are Asian or Asian American. This was a common experience among Southeast Asian participants.

“I have to convince people I’m Asian, not Middle Eastern. … If you type in Asian or you say Asian, most people associate it with Chinese food, Japanese food, karate, and like all these things but then they don’t associate it with you.”

–U.S.-born man of Pakistani origin in early 30s

The model minority myth and its impact

“I’ve never really done the best academically, compared to all my other Asian peers too. I never really excelled. I wasn’t in honors. … Those stereotypes, I think really [have] taken a toll on my self-esteem.” Diane , documentary participant

Across focus groups, immigrant and U.S.-born participants described the challenges of the seemingly positive stereotypes of Asians as intelligent, gifted in technical roles and hardworking. Participants often referred to this as the “model minority myth.”

The label “model minority” was coined in the 1960s and has been used to characterize Asian Americans as financially and educationally successful and hardworking when compared with other groups. However, for many Asians living in the United States, these characterizations do not align with their lived experiences or reflect their socioeconomic backgrounds. Indeed, among Asian origin groups in the U.S., there are wide differences in economic and social experiences. 

Academic research on the model minority myth has pointed to its impact beyond Asian Americans and towards other racial and ethnic groups, especially Black Americans, in the U.S. Some argue that the model minority myth has been used to justify policies that overlook the historical circumstances and impacts of colonialism, slavery, discrimination and segregation on other non-White racial and ethnic groups.

Many participants noted ways in which the model minority myth has been harmful. For some, expectations based on the myth didn’t match their own experiences of coming from impoverished communities. Some also recalled experiences at school when they struggled to meet their teachers’ expectations in math and science.

“As an Asian person, I feel like there’s that stereotype that Asian students are high achievers academically. They’re good at math and science. … I was a pretty mediocre student, and math and science were actually my weakest subjects, so I feel like it’s either way you lose. Teachers expect you to fit a certain stereotype and if you’re not, then you’re a disappointment, but at the same time, even if you are good at math and science, that just means that you’re fitting a stereotype. It’s [actually] your own achievement, but your teachers might think, ‘Oh, it’s because they’re Asian,’ and that diminishes your achievement.”

–U.S.-born woman of Korean origin in late 20s

Some participants felt that even when being Asian worked in their favor in the job market, they encountered stereotypes that “Asians can do quality work with less compensation” or that “Asians would not complain about anything at work.”

“There is a joke from foreigners and even Asian Americans that says, ‘No matter what you do, Asians always do the best.’ You need to get A, not just B-plus. Otherwise, you’ll be a disgrace to the family. … Even Silicon Valley hires Asian because [an] Asian’s wage is cheaper but [they] can work better. When [work] visa overflow happens, they hire Asians like Chinese and Indian to work in IT fields because we are good at this and do not complain about anything.”

–Immigrant man of Thai origin in early 40s

Others expressed frustration that people were placing them in the model minority box. One Indian woman put it this way:

“Indian people and Asian people, like … our parents or grandparents are the ones who immigrated here … against all odds. … A lot of Indian and Asian people have succeeded and have done really well for themselves because they’ve worked themselves to the bone. So now the expectations [of] the newer generations who were born here are incredibly unrealistic and high. And you get that not only from your family and the Indian community, but you’re also getting it from all of the American people around you, expecting you to be … insanely good at math, play an instrument, you know how to do this, you know how to do that, but it’s not true. And it’s just living with those expectations, it’s difficult.”

–U.S.-born woman of Indian origin in early 20s

Whether U.S. born or immigrants, Asians are often seen by others as foreigners

“Being only not quite 10 years old, it was kind of exciting to ride on a bus to go someplace. But when we went to Pomona, the assembly center, we were stuck in one of the stalls they used for the animals.” Tokiko , documentary participant

Across all focus groups, participants highlighted a common question they are asked in America when meeting people for the first time: “Where are you really from?” For participants, this question implied that people think they are “foreigners,” even though they may be longtime residents or citizens of the United States or were born in the country. One man of Vietnamese origin shared his experience with strangers who assumed that he and his friends are North Korean. Perhaps even more hurtful, participants mentioned that this meant people had a preconceived notion of what an “American” is supposed to look like, sound like or act like. One Chinese woman said that White Americans treated people like herself as outsiders based on her skin color and appearance, even though she was raised in the U.S.

Many focus group participants also acknowledged the common stereotype of treating Asians as “forever foreigners.” Some immigrant participants said they felt exhausted from constantly being asked this question by people even when they speak perfect English with no accent. During the discussion, a Korean immigrant man recalled that someone had said to him, “You speak English well, but where are you from?” One Filipino participant shared her experience during the first six months in the U.S.:

“You know, I spoke English fine. But there were certain things that, you know, people constantly questioning you like, oh, where are you from? When did you come here? You know, just asking about your experience to the point where … you become fed up with it after a while.”

–Immigrant woman of Filipino origin in mid-30s

U.S.-born participants also talked about experiences when others asked where they are from. Many shared that they would not talk about their ethnic origin right away when answering such a question because it often led to misunderstandings and assumptions that they are immigrants.

“I always get that question of, you know, ‘Where are you from?’ and I’m like, ‘I’m from America.’ And then they’re like, ‘No. Where are you from-from ?’ and I’m like, ‘Yeah, my family is from Pakistan,’ so it’s like I always had like that dual identity even though it’s never attached to me because I am like, of Pakistani descent.”

–U.S.-born man of Pakistani origin in early 20s

One Korean woman born in the U.S. said that once people know she is Korean, they ask even more offensive questions such as “Are you from North or South Korea?” or “Do you still eat dogs?”

In a similar situation, this U.S.-born Indian woman shared her responses:

“I find that there’s a, ‘So but where are you from?’ Like even in professional settings when they feel comfortable enough to ask you. ‘So – so where are you from?’ ‘Oh, I was born in [names city], Colorado. Like at [the hospital], down the street.’ ‘No, but like where are you from?’ ‘My mother’s womb?’”

–U.S.-born woman of Indian origin in early 40s

Ignorance and misinformation about Asian identity can lead to contentious encounters

“I have dealt with kids who just gave up on their Sikh identity, cut their hair and groomed their beard and everything. They just wanted to fit in and not have to deal with it, especially [those] who are victim or bullied in any incident.” Surinder , documentary participant

In some cases, ignorance and misinformation about Asians in the U.S. lead to inappropriate comments or questions and uncomfortable or dangerous situations. Participants shared their frustration when others asked about their country of origin, and they then had to explain their identity or correct misunderstandings or stereotypes about their background. At other times, some participants faced ignorant comments about their ethnicity, which sometimes led to more contentious encounters. For example, some Indian or Pakistani participants talked about the attacks or verbal abuse they experienced from others blaming them for the 9/11 terrorist attacks. Others discussed the racial slurs directed toward them since the COVID-19 pandemic in 2020. Some Japanese participants recalled their families losing everything and being incarcerated during World War II and the long-term effect it had on their lives.

“I think like right now with the coronavirus, I think we’re just Chinese, Chinese American, well, just Asian American or Asians in general, you’re just going through the same struggles right now. Like everyone is just blaming whoever looks Asian about the virus. You don’t feel safe.”

–U.S.-born man of Chinese origin in early 30s

“At the beginning of the pandemic, a friend and I went to celebrate her birthday at a club and like these guys just kept calling us COVID.”

–U.S.-born woman of Korean origin in early 20s

“There [were] a lot of instances after 9/11. One day, somebody put a poster about 9/11 [in front of] my business. He was wearing a gun. … On the poster, it was written ‘you Arabs, go back to your country.’ And then someone came inside. He pointed his gun at me and said ‘Go back to your country.’”

–Immigrant man of Pakistani origin in mid-60s

“[My parents went through the] internment camps during World War II. And my dad, he was in high school, so he was – they were building the camps and then he was put into the Santa Anita horse track place, the stables there. And then they were sent – all the Japanese Americans were sent to different camps, right, during World War II and – in California. Yeah, and they lost everything, yeah.”

–U.S.-born woman of Japanese origin in mid-60s

As focus group participants contemplated their identity during the discussions, many talked about their sense of belonging in America. Although some felt frustrated with people misunderstanding their ethnic heritage, they didn’t take a negative view of life in America. Instead, many participants – both immigrant and U.S. born – took pride in their unique cultural and ethnic backgrounds. In these discussions, people gave their own definitions of America as a place with a diverse set of cultures, with their ethnic heritage being a part of it.

Taking pride in their unique cultures

“Being a Pakistani American, I’m proud. … Because I work hard, and I make true my dreams from here.” Shahid , documentary participant

Despite the challenges of adapting to life in America for immigrant participants or of navigating their dual cultural identity for U.S.-born ones, focus group participants called America their home. And while participants talked about their identities in different ways – ethnic identity, racial (Asian) identity, and being American – they take pride in their unique cultures. Many also expressed a strong sense of responsibility to give back or support their community, sharing their cultural heritage with others on their own terms.

“Right now it has been a little difficult. I think it has been for all Asians because of the COVID issue … but I’m glad that we’re all here [in America]. I think we should be proud to be here. I’m glad that our families have traveled here, and we can help make life better for communities, our families and ourselves. I think that’s really a wonderful thing. We can be those role models for a lot of the future, the younger folks. I hope that something I did in the last years will have impacted either my family, friends or students that I taught in other community things that I’ve done. So you hope that it helps someplace along the line.”

“I am very proud of my culture. … There is not a single Bengali at my workplace, but people know the name of my country. Maybe many years [later] – educated people know all about the country. So, I don’t have to explain that there is a small country next to India and Nepal. It’s beyond saying. People after all know Bangladesh. And there are so many Bengali present here as well. So, I am very proud to be a Bangladeshi.”

Where home is

When asked about the definition of home, some immigrant participants said home is where their families are located. Immigrants in the focus groups came to the United States by various paths, whether through work opportunities, reuniting with family or seeking a safe haven as refugees. Along their journey, some received support from family members, their local community or other individuals, while others overcame challenges by themselves. Either way, they take pride in establishing their home in America and can feel hurt when someone tells them to “go back to your country.” In response, one Laotian woman in her mid-40s said, “This is my home. My country. Go away.”

“If you ask me personally, I view my home as my house … then I would say my house is with my family because wherever I go, I cannot marry if I do not have my family so that is how I would answer.”

–Immigrant man of Hmong origin in late 30s

“[If somebody yelled at me ‘go back to your country’] I’d feel angry because this is my country! I live here. America is my country. I grew up here and worked here … I’d say, ‘This is my country! You go back to your country! … I will not go anywhere. This is my home. I will live here.’ That’s what I’d say.”

–Immigrant woman of Laotian origin in early 50s

‘American’ means to blend their unique cultural and ethnic heritage with that in the U.S.

“I want to teach my children two traditions – one American and one Vietnamese – so they can compare and choose for themselves the best route in life.” Helen , documentary participant (translated from Vietnamese)

Both U.S.-born and immigrant participants in the focus groups shared their experiences of navigating a dual cultural environment between their ethnic heritage and American culture. A common thread that emerged was that being Asian in America is a process of blending two or more identities as one.

“Yeah, I want to say that’s how I feel – because like thinking about it, I would call my dad Lao but I would call myself Laotian American because I think I’m a little more integrated in the American society and I’ve also been a little more Americanized, compared to my dad. So that’s how I would see it.”

–U.S.-born man of Laotian origin in late 20s

“I mean, Bangladeshi Americans who are here, we are carrying Bangladeshi culture, religion, food. I am also trying to be Americanized like the Americans. Regarding language, eating habits.”

–Immigrant man of Bangladeshi origin in mid-50s

“Just like there is Chinese American, Mexican American, Japanese American, Italian American, so there is Indian American. I don’t want to give up Indianness. I am American by nationality, but I am Indian by birth. So whenever I talk, I try to show both the flags as well, both Indian and American flags. Just because you make new relatives but don’t forget the old relatives.”

–Immigrant man of Indian origin in late 40s

Pew Research Center designed these focus groups to better understand how members of an ethnically diverse Asian population think about their place in America and life here. By including participants of different languages, immigration or refugee experiences, educational backgrounds, and income levels, this focus group study aimed to capture in people’s own words what it means to be Asian in America. The discussions in these groups may or may not resonate with all Asians living in the United States. Browse excerpts from our focus groups with the interactive quote sorter below, view a video documentary focused on the topics discussed in the focus groups, or tell us your story of belonging in America via social media. The focus group project is part of a broader research project studying the diverse experiences of Asians living in the U.S.

Read sortable quotes from our focus groups

Browse excerpts in the interactive quote sorter from focus group participants in response to the question “What does it mean to be [Vietnamese, Thai, Sri Lankan, Hmong, etc.] like yourself in America?” This interactive allows you to sort quotes from focus group participants by ethnic origin, nativity (U.S. born or born in another country), gender and age.

Video documentary

Videos throughout the data essay illustrate what focus group participants discussed. Those recorded in these videos did not participate in the focus groups but were sampled to have similar demographic characteristics and thematically relevant stories.

Watch the full video documentary and watch additional shorter video clips related to the themes of this data essay.

Share the story of your family and your identity

Did the voices in this data essay resonate? Share your story of what it means to be Asian in America with @pewresearch. Tell us your story by using the hashtag #BeingAsianInAmerica and @pewidentity on Twitter, as well as #BeingAsianInAmerica and @pewresearch on Instagram.

This cross-ethnic, comparative qualitative research project explores the identity, economic mobility, representation, and experiences of immigration and discrimination among the Asian population in the United States. The analysis is based on 66 focus groups we conducted virtually in the fall of 2021 and included 264 participants from across the U.S. More information about the groups and analysis can be found in this appendix .

Pew Research Center is a subsidiary of The Pew Charitable Trusts, its primary funder. This data essay was funded by The Pew Charitable Trusts, with generous support from the Chan Zuckerberg Initiative DAF, an advised fund of the Silicon Valley Community Foundation; the Robert Wood Johnson Foundation; the Henry Luce Foundation; The Wallace H. Coulter Foundation; The Dirk and Charlene Kabcenell Foundation; The Long Family Foundation; Lu-Hebert Fund; Gee Family Foundation; Joseph Cotchett; the Julian Abdey and Sabrina Moyle Charitable Fund; and Nanci Nishimura.

The accompanying video clips and video documentary were made possible by The Pew Charitable Trusts, with generous support from The Sobrato Family Foundation and The Long Family Foundation.

We would also like to thank the Leaders Forum for its thought leadership and valuable assistance in helping make this study possible. This is a collaborative effort based on the input and analysis of a number of individuals and experts at Pew Research Center and outside experts.

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