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What is qualitative research.

Qualitative research methodologies seek to capture information that often can't be expressed numerically. These methodologies often include some level of interpretation from researchers as they collect information via observation, coded survey or interview responses, and so on. Researchers may use multiple qualitative methods in one study, as well as a theoretical or critical framework to help them interpret their data.

Qualitative research methods can be used to study:

• How are political and social attitudes formed? 
• How do people make decisions?
• What teaching or training methods are most effective?  

Qualitative Research Approaches

Action research.

In this type of study, researchers will actively pursue some kind of intervention, resolve a problem, or affect some kind of change. They will not only analyze the results but will also examine the challenges encountered through the process. 

Ethnography

Ethnographies are an in-depth, holistic type of research used to capture cultural practices, beliefs, traditions, and so on. Here, the researcher observes and interviews members of a culture — an ethnic group, a clique, members of a religion, etc. — and then analyzes their findings. 

Grounded Theory

Researchers will create and test a hypothesis using qualitative data. Often, researchers use grounded theory to understand decision-making, problem-solving, and other types of behavior.

Narrative Research

Researchers use this type of framework to understand different aspects of the human experience and how their subjects assign meaning to their experiences. Researchers use interviews to collect data from a small group of subjects, then discuss those results in the form of a narrative or story.

Phenomenology

This type of research attempts to understand the lived experiences of a group and/or how members of that group find meaning in their experiences. Researchers use interviews, observation, and other qualitative methods to collect data. 

Often used to share novel or unique information, case studies consist of a detailed, in-depth description of a single subject, pilot project, specific events, and so on. 

• Hossain, M.S., Runa, F., & Al Mosabbir, A. (2021). Impact of COVID-19 pandemic on rare diseases: A case study on thalassaemia patients in Bangladesh. Public Health in Practice, 2(100150), 1-3.
• Nožina, M. (2021). The Czech Rhino connection: A case study of Vietnamese wildlife trafficking networks’ operations across central Europe. European Journal on Criminal Policy and Research, 27(2), 265-283.

Focus Groups

Researchers will recruit people to answer questions in small group settings. Focus group members may share similar demographics or be diverse, depending on the researchers' needs. Group members will then be asked a series of questions and have their responses recorded. While these responses may be coded and discussed numerically (e.g., 50% of group members responded negatively to a question), researchers will also use responses to provide context, nuance, and other details. 

• Dichabeng, P., Merat, N., & Markkula, G. (2021). Factors that influence the acceptance of future shared automated vehicles – A focus group study with United Kingdom drivers. Transportation Research: Part F, 82, 121–140.
• Maynard, E., Barton, S., Rivett, K., Maynard, O., & Davies, W. (2021). Because ‘grown-ups don’t always get it right’: Allyship with children in research—From research question to authorship. Qualitative Research in Psychology, 18(4), 518–536.

Observational Study

Researchers will arrange to observe (usually in an unobtrusive way) a set of subjects in specific conditions. For example, researchers might visit a school cafeteria to learn about the food choices students make or set up trail cameras to collect information about animal behavior in the area. 

• He, J. Y., Chan, P. W., Li, Q. S., Li, L., Zhang, L., & Yang, H. L. (2022). Observations of wind and turbulence structures of Super Typhoons Hato and Mangkhut over land from a 356 m high meteorological tower. Atmospheric Research, 265(105910), 1-18.
• Zerovnik Spela, Kos Mitja, & Locatelli Igor. (2022). Initiation of insulin therapy in patients with type 2 diabetes: An observational study. Acta Pharmaceutica, 72(1), 147–157.

Open-Ended Surveys

Unlike quantitative surveys, open-ended surveys require respondents to answer the questions in their own words. 

• Mujcic, A., Blankers, M., Yildirim, D., Boon, B., & Engels, R. (2021). Cancer survivors’ views on digital support for smoking cessation and alcohol moderation: a survey and qualitative study. BMC Public Health, 21(1), 1-13.
• Smith, S. D., Hall, J. P., & Kurth, N. K. (2021). Perspectives on health policy from people with disabilities. Journal of Disability Policy Studies, 32(3), 224–232.

Structured or Semi-Structured Interviews

Researchers will recruit a small number of people who fit pre-determined criteria (e.g., people in a certain profession) and ask each the same set of questions, one-on-one. Semi-structured interviews will include opportunities for the interviewee to provide additional information they weren't asked about by the researcher.

• Gibbs, D., Haven-Tang, C., & Ritchie, C. (2021). Harmless flirtations or co-creation? Exploring flirtatious encounters in hospitable experiences. Tourism & Hospitality Research, 21(4), 473–486.
• Hongying Dai, Ramos, A., Tamrakar, N., Cheney, M., Samson, K., & Grimm, B. (2021). School personnel’s responses to school-based vaping prevention program: A qualitative study. Health Behavior & Policy Review, 8(2), 130–147.
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Home » Qualitative Research – Methods, Analysis Types and Guide

Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

Qualitative research is a type of research methodology that focuses on exploring and understanding people’s beliefs, attitudes, behaviors, and experiences through the collection and analysis of non-numerical data. It seeks to answer research questions through the examination of subjective data, such as interviews, focus groups, observations, and textual analysis.

Qualitative research aims to uncover the meaning and significance of social phenomena, and it typically involves a more flexible and iterative approach to data collection and analysis compared to quantitative research. Qualitative research is often used in fields such as sociology, anthropology, psychology, and education.

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

This method involves conducting an interview with a single participant to gain a detailed understanding of their experiences, attitudes, and beliefs. One-to-one interviews can be conducted in-person, over the phone, or through video conferencing. The interviewer typically uses open-ended questions to encourage the participant to share their thoughts and feelings. One-to-one interviews are useful for gaining detailed insights into individual experiences.

Focus Groups

This method involves bringing together a group of people to discuss a specific topic in a structured setting. The focus group is led by a moderator who guides the discussion and encourages participants to share their thoughts and opinions. Focus groups are useful for generating ideas and insights, exploring social norms and attitudes, and understanding group dynamics.

Ethnographic Studies

This method involves immersing oneself in a culture or community to gain a deep understanding of its norms, beliefs, and practices. Ethnographic studies typically involve long-term fieldwork and observation, as well as interviews and document analysis. Ethnographic studies are useful for understanding the cultural context of social phenomena and for gaining a holistic understanding of complex social processes.

Text Analysis

This method involves analyzing written or spoken language to identify patterns and themes. Text analysis can be quantitative or qualitative. Qualitative text analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Text analysis is useful for understanding media messages, public discourse, and cultural trends.

This method involves an in-depth examination of a single person, group, or event to gain an understanding of complex phenomena. Case studies typically involve a combination of data collection methods, such as interviews, observations, and document analysis, to provide a comprehensive understanding of the case. Case studies are useful for exploring unique or rare cases, and for generating hypotheses for further research.

Process of Observation

This method involves systematically observing and recording behaviors and interactions in natural settings. The observer may take notes, use audio or video recordings, or use other methods to document what they see. Process of observation is useful for understanding social interactions, cultural practices, and the context in which behaviors occur.

Record Keeping

This method involves keeping detailed records of observations, interviews, and other data collected during the research process. Record keeping is essential for ensuring the accuracy and reliability of the data, and for providing a basis for analysis and interpretation.

This method involves collecting data from a large sample of participants through a structured questionnaire. Surveys can be conducted in person, over the phone, through mail, or online. Surveys are useful for collecting data on attitudes, beliefs, and behaviors, and for identifying patterns and trends in a population.

Qualitative data analysis is a process of turning unstructured data into meaningful insights. It involves extracting and organizing information from sources like interviews, focus groups, and surveys. The goal is to understand people’s attitudes, behaviors, and motivations

Qualitative Research Analysis Methods

Qualitative Research analysis methods involve a systematic approach to interpreting and making sense of the data collected in qualitative research. Here are some common qualitative data analysis methods:

Thematic Analysis

This method involves identifying patterns or themes in the data that are relevant to the research question. The researcher reviews the data, identifies keywords or phrases, and groups them into categories or themes. Thematic analysis is useful for identifying patterns across multiple data sources and for generating new insights into the research topic.

Content Analysis

This method involves analyzing the content of written or spoken language to identify key themes or concepts. Content analysis can be quantitative or qualitative. Qualitative content analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Content analysis is useful for identifying patterns in media messages, public discourse, and cultural trends.

Discourse Analysis

This method involves analyzing language to understand how it constructs meaning and shapes social interactions. Discourse analysis can involve a variety of methods, such as conversation analysis, critical discourse analysis, and narrative analysis. Discourse analysis is useful for understanding how language shapes social interactions, cultural norms, and power relationships.

Grounded Theory Analysis

This method involves developing a theory or explanation based on the data collected. Grounded theory analysis starts with the data and uses an iterative process of coding and analysis to identify patterns and themes in the data. The theory or explanation that emerges is grounded in the data, rather than preconceived hypotheses. Grounded theory analysis is useful for understanding complex social phenomena and for generating new theoretical insights.

Narrative Analysis

This method involves analyzing the stories or narratives that participants share to gain insights into their experiences, attitudes, and beliefs. Narrative analysis can involve a variety of methods, such as structural analysis, thematic analysis, and discourse analysis. Narrative analysis is useful for understanding how individuals construct their identities, make sense of their experiences, and communicate their values and beliefs.

Phenomenological Analysis

This method involves analyzing how individuals make sense of their experiences and the meanings they attach to them. Phenomenological analysis typically involves in-depth interviews with participants to explore their experiences in detail. Phenomenological analysis is useful for understanding subjective experiences and for developing a rich understanding of human consciousness.

Comparative Analysis

This method involves comparing and contrasting data across different cases or groups to identify similarities and differences. Comparative analysis can be used to identify patterns or themes that are common across multiple cases, as well as to identify unique or distinctive features of individual cases. Comparative analysis is useful for understanding how social phenomena vary across different contexts and groups.

Applications of Qualitative Research

Qualitative research has many applications across different fields and industries. Here are some examples of how qualitative research is used:

• Market Research: Qualitative research is often used in market research to understand consumer attitudes, behaviors, and preferences. Researchers conduct focus groups and one-on-one interviews with consumers to gather insights into their experiences and perceptions of products and services.
• Health Care: Qualitative research is used in health care to explore patient experiences and perspectives on health and illness. Researchers conduct in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education: Qualitative research is used in education to understand student experiences and to develop effective teaching strategies. Researchers conduct classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work : Qualitative research is used in social work to explore social problems and to develop interventions to address them. Researchers conduct in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : Qualitative research is used in anthropology to understand different cultures and societies. Researchers conduct ethnographic studies and observe and interview members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : Qualitative research is used in psychology to understand human behavior and mental processes. Researchers conduct in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy : Qualitative research is used in public policy to explore public attitudes and to inform policy decisions. Researchers conduct focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

• Identify your research question: Qualitative research starts with a research question or set of questions that you want to explore. This question should be focused and specific, but also broad enough to allow for exploration and discovery.
• Select your research design: There are different types of qualitative research designs, including ethnography, case study, grounded theory, and phenomenology. You should select a design that aligns with your research question and that will allow you to gather the data you need to answer your research question.
• Recruit participants: Once you have your research question and design, you need to recruit participants. The number of participants you need will depend on your research design and the scope of your research. You can recruit participants through advertisements, social media, or through personal networks.
• Collect data: There are different methods for collecting qualitative data, including interviews, focus groups, observation, and document analysis. You should select the method or methods that align with your research design and that will allow you to gather the data you need to answer your research question.
• Analyze data: Once you have collected your data, you need to analyze it. This involves reviewing your data, identifying patterns and themes, and developing codes to organize your data. You can use different software programs to help you analyze your data, or you can do it manually.
• Interpret data: Once you have analyzed your data, you need to interpret it. This involves making sense of the patterns and themes you have identified, and developing insights and conclusions that answer your research question. You should be guided by your research question and use your data to support your conclusions.
• Communicate results: Once you have interpreted your data, you need to communicate your results. This can be done through academic papers, presentations, or reports. You should be clear and concise in your communication, and use examples and quotes from your data to support your findings.

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

• Customer Feedback: A company may conduct qualitative research to understand the feedback and experiences of its customers. This may involve conducting focus groups or one-on-one interviews with customers to gather insights into their attitudes, behaviors, and preferences.
• Healthcare : A healthcare provider may conduct qualitative research to explore patient experiences and perspectives on health and illness. This may involve conducting in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education : An educational institution may conduct qualitative research to understand student experiences and to develop effective teaching strategies. This may involve conducting classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work: A social worker may conduct qualitative research to explore social problems and to develop interventions to address them. This may involve conducting in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : An anthropologist may conduct qualitative research to understand different cultures and societies. This may involve conducting ethnographic studies and observing and interviewing members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : A psychologist may conduct qualitative research to understand human behavior and mental processes. This may involve conducting in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy: A government agency or non-profit organization may conduct qualitative research to explore public attitudes and to inform policy decisions. This may involve conducting focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

Purpose of Qualitative Research

The purpose of qualitative research is to explore and understand the subjective experiences, behaviors, and perspectives of individuals or groups in a particular context. Unlike quantitative research, which focuses on numerical data and statistical analysis, qualitative research aims to provide in-depth, descriptive information that can help researchers develop insights and theories about complex social phenomena.

Qualitative research can serve multiple purposes, including:

• Exploring new or emerging phenomena : Qualitative research can be useful for exploring new or emerging phenomena, such as new technologies or social trends. This type of research can help researchers develop a deeper understanding of these phenomena and identify potential areas for further study.
• Understanding complex social phenomena : Qualitative research can be useful for exploring complex social phenomena, such as cultural beliefs, social norms, or political processes. This type of research can help researchers develop a more nuanced understanding of these phenomena and identify factors that may influence them.
• Generating new theories or hypotheses: Qualitative research can be useful for generating new theories or hypotheses about social phenomena. By gathering rich, detailed data about individuals’ experiences and perspectives, researchers can develop insights that may challenge existing theories or lead to new lines of inquiry.
• Providing context for quantitative data: Qualitative research can be useful for providing context for quantitative data. By gathering qualitative data alongside quantitative data, researchers can develop a more complete understanding of complex social phenomena and identify potential explanations for quantitative findings.

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

• Exploring a new area: If little is known about a particular topic, qualitative research can help to identify key issues, generate hypotheses, and develop new theories.
• Understanding complex phenomena: Qualitative research can be used to investigate complex social, cultural, or organizational phenomena that are difficult to measure quantitatively.
• Investigating subjective experiences: Qualitative research is particularly useful for investigating the subjective experiences of individuals or groups, such as their attitudes, beliefs, values, or emotions.
• Conducting formative research: Qualitative research can be used in the early stages of a research project to develop research questions, identify potential research participants, and refine research methods.
• Evaluating interventions or programs: Qualitative research can be used to evaluate the effectiveness of interventions or programs by collecting data on participants’ experiences, attitudes, and behaviors.

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

• Focus on subjective experience: Qualitative research is concerned with understanding the subjective experiences, beliefs, and perspectives of individuals or groups in a particular context. Researchers aim to explore the meanings that people attach to their experiences and to understand the social and cultural factors that shape these meanings.
• Use of open-ended questions: Qualitative research relies on open-ended questions that allow participants to provide detailed, in-depth responses. Researchers seek to elicit rich, descriptive data that can provide insights into participants’ experiences and perspectives.
• Sampling-based on purpose and diversity: Qualitative research often involves purposive sampling, in which participants are selected based on specific criteria related to the research question. Researchers may also seek to include participants with diverse experiences and perspectives to capture a range of viewpoints.
• Data collection through multiple methods: Qualitative research typically involves the use of multiple data collection methods, such as in-depth interviews, focus groups, and observation. This allows researchers to gather rich, detailed data from multiple sources, which can provide a more complete picture of participants’ experiences and perspectives.
• Inductive data analysis: Qualitative research relies on inductive data analysis, in which researchers develop theories and insights based on the data rather than testing pre-existing hypotheses. Researchers use coding and thematic analysis to identify patterns and themes in the data and to develop theories and explanations based on these patterns.
• Emphasis on researcher reflexivity: Qualitative research recognizes the importance of the researcher’s role in shaping the research process and outcomes. Researchers are encouraged to reflect on their own biases and assumptions and to be transparent about their role in the research process.

Advantages of Qualitative Research

Qualitative research offers several advantages over other research methods, including:

• Depth and detail: Qualitative research allows researchers to gather rich, detailed data that provides a deeper understanding of complex social phenomena. Through in-depth interviews, focus groups, and observation, researchers can gather detailed information about participants’ experiences and perspectives that may be missed by other research methods.
• Flexibility : Qualitative research is a flexible approach that allows researchers to adapt their methods to the research question and context. Researchers can adjust their research methods in real-time to gather more information or explore unexpected findings.
• Contextual understanding: Qualitative research is well-suited to exploring the social and cultural context in which individuals or groups are situated. Researchers can gather information about cultural norms, social structures, and historical events that may influence participants’ experiences and perspectives.
• Participant perspective : Qualitative research prioritizes the perspective of participants, allowing researchers to explore subjective experiences and understand the meanings that participants attach to their experiences.
• Theory development: Qualitative research can contribute to the development of new theories and insights about complex social phenomena. By gathering rich, detailed data and using inductive data analysis, researchers can develop new theories and explanations that may challenge existing understandings.
• Validity : Qualitative research can offer high validity by using multiple data collection methods, purposive and diverse sampling, and researcher reflexivity. This can help ensure that findings are credible and trustworthy.

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

• Subjectivity : Qualitative research relies on the subjective interpretation of researchers, which can introduce bias into the research process. The researcher’s perspective, beliefs, and experiences can influence the way data is collected, analyzed, and interpreted.
• Limited generalizability: Qualitative research typically involves small, purposive samples that may not be representative of larger populations. This limits the generalizability of findings to other contexts or populations.
• Time-consuming: Qualitative research can be a time-consuming process, requiring significant resources for data collection, analysis, and interpretation.
• Resource-intensive: Qualitative research may require more resources than other research methods, including specialized training for researchers, specialized software for data analysis, and transcription services.
• Limited reliability: Qualitative research may be less reliable than quantitative research, as it relies on the subjective interpretation of researchers. This can make it difficult to replicate findings or compare results across different studies.
• Ethics and confidentiality: Qualitative research involves collecting sensitive information from participants, which raises ethical concerns about confidentiality and informed consent. Researchers must take care to protect the privacy and confidentiality of participants and obtain informed consent.

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• Open access
• Published: 27 May 2020

How to use and assess qualitative research methods

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

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

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

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Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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

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The word qualitative implies an emphasis on the qualities of entities and on processes and meanings that are not experimentally examined or measured [if measured at all] in terms of quantity, amount, intensity, or frequency. Qualitative researchers stress the socially constructed nature of reality, the intimate relationship between the researcher and what is studied, and the situational constraints that shape inquiry. Such researchers emphasize the value-laden nature of inquiry. They seek answers to questions that stress how social experience is created and given meaning. In contrast, quantitative studies emphasize the measurement and analysis of causal relationships between variables, not processes. Qualitative forms of inquiry are considered by many social and behavioral scientists to be as much a perspective on how to approach investigating a research problem as it is a method.

Denzin, Norman. K. and Yvonna S. Lincoln. “Introduction: The Discipline and Practice of Qualitative Research.” In The Sage Handbook of Qualitative Research . Norman. K. Denzin and Yvonna S. Lincoln, eds. 3 rd edition. (Thousand Oaks, CA: Sage, 2005), p. 10.

Characteristics of Qualitative Research

Below are the three key elements that define a qualitative research study and the applied forms each take in the investigation of a research problem.

• Naturalistic -- refers to studying real-world situations as they unfold naturally; non-manipulative and non-controlling; the researcher is open to whatever emerges [i.e., there is a lack of predetermined constraints on findings].
• Emergent -- acceptance of adapting inquiry as understanding deepens and/or situations change; the researcher avoids rigid designs that eliminate responding to opportunities to pursue new paths of discovery as they emerge.
• Purposeful -- cases for study [e.g., people, organizations, communities, cultures, events, critical incidences] are selected because they are “information rich” and illuminative. That is, they offer useful manifestations of the phenomenon of interest; sampling is aimed at insight about the phenomenon, not empirical generalization derived from a sample and applied to a population.

The Collection of Data

• Data -- observations yield a detailed, "thick description" [in-depth understanding]; interviews capture direct quotations about people’s personal perspectives and lived experiences; often derived from carefully conducted case studies and review of material culture.
• Personal experience and engagement -- researcher has direct contact with and gets close to the people, situation, and phenomenon under investigation; the researcher’s personal experiences and insights are an important part of the inquiry and critical to understanding the phenomenon.
• Empathic neutrality -- an empathic stance in working with study respondents seeks vicarious understanding without judgment [neutrality] by showing openness, sensitivity, respect, awareness, and responsiveness; in observation, it means being fully present [mindfulness].
• Dynamic systems -- there is attention to process; assumes change is ongoing, whether the focus is on an individual, an organization, a community, or an entire culture, therefore, the researcher is mindful of and attentive to system and situational dynamics.

The Analysis

• Unique case orientation -- assumes that each case is special and unique; the first level of analysis is being true to, respecting, and capturing the details of the individual cases being studied; cross-case analysis follows from and depends upon the quality of individual case studies.
• Inductive analysis -- immersion in the details and specifics of the data to discover important patterns, themes, and inter-relationships; begins by exploring, then confirming findings, guided by analytical principles rather than rules.
• Holistic perspective -- the whole phenomenon under study is understood as a complex system that is more than the sum of its parts; the focus is on complex interdependencies and system dynamics that cannot be reduced in any meaningful way to linear, cause and effect relationships and/or a few discrete variables.
• Context sensitive -- places findings in a social, historical, and temporal context; researcher is careful about [even dubious of] the possibility or meaningfulness of generalizations across time and space; emphasizes careful comparative case study analysis and extrapolating patterns for possible transferability and adaptation in new settings.
• Voice, perspective, and reflexivity -- the qualitative methodologist owns and is reflective about her or his own voice and perspective; a credible voice conveys authenticity and trustworthiness; complete objectivity being impossible and pure subjectivity undermining credibility, the researcher's focus reflects a balance between understanding and depicting the world authentically in all its complexity and of being self-analytical, politically aware, and reflexive in consciousness.

Berg, Bruce Lawrence. Qualitative Research Methods for the Social Sciences . 8th edition. Boston, MA: Allyn and Bacon, 2012; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 2nd ed. Thousand Oaks, CA: Sage Publications, 1995; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Basic Research Design for Qualitative Studies

Unlike positivist or experimental research that utilizes a linear and one-directional sequence of design steps, there is considerable variation in how a qualitative research study is organized. In general, qualitative researchers attempt to describe and interpret human behavior based primarily on the words of selected individuals [a.k.a., “informants” or “respondents”] and/or through the interpretation of their material culture or occupied space. There is a reflexive process underpinning every stage of a qualitative study to ensure that researcher biases, presuppositions, and interpretations are clearly evident, thus ensuring that the reader is better able to interpret the overall validity of the research. According to Maxwell (2009), there are five, not necessarily ordered or sequential, components in qualitative research designs. How they are presented depends upon the research philosophy and theoretical framework of the study, the methods chosen, and the general assumptions underpinning the study. Goals Describe the central research problem being addressed but avoid describing any anticipated outcomes. Questions to ask yourself are: Why is your study worth doing? What issues do you want to clarify, and what practices and policies do you want it to influence? Why do you want to conduct this study, and why should the reader care about the results? Conceptual Framework Questions to ask yourself are: What do you think is going on with the issues, settings, or people you plan to study? What theories, beliefs, and prior research findings will guide or inform your research, and what literature, preliminary studies, and personal experiences will you draw upon for understanding the people or issues you are studying? Note to not only report the results of other studies in your review of the literature, but note the methods used as well. If appropriate, describe why earlier studies using quantitative methods were inadequate in addressing the research problem. Research Questions Usually there is a research problem that frames your qualitative study and that influences your decision about what methods to use, but qualitative designs generally lack an accompanying hypothesis or set of assumptions because the findings are emergent and unpredictable. In this context, more specific research questions are generally the result of an interactive design process rather than the starting point for that process. Questions to ask yourself are: What do you specifically want to learn or understand by conducting this study? What do you not know about the things you are studying that you want to learn? What questions will your research attempt to answer, and how are these questions related to one another? Methods Structured approaches to applying a method or methods to your study help to ensure that there is comparability of data across sources and researchers and, thus, they can be useful in answering questions that deal with differences between phenomena and the explanation for these differences [variance questions]. An unstructured approach allows the researcher to focus on the particular phenomena studied. This facilitates an understanding of the processes that led to specific outcomes, trading generalizability and comparability for internal validity and contextual and evaluative understanding. Questions to ask yourself are: What will you actually do in conducting this study? What approaches and techniques will you use to collect and analyze your data, and how do these constitute an integrated strategy? Validity In contrast to quantitative studies where the goal is to design, in advance, “controls” such as formal comparisons, sampling strategies, or statistical manipulations to address anticipated and unanticipated threats to validity, qualitative researchers must attempt to rule out most threats to validity after the research has begun by relying on evidence collected during the research process itself in order to effectively argue that any alternative explanations for a phenomenon are implausible. Questions to ask yourself are: How might your results and conclusions be wrong? What are the plausible alternative interpretations and validity threats to these, and how will you deal with these? How can the data that you have, or that you could potentially collect, support or challenge your ideas about what’s going on? Why should we believe your results? Conclusion Although Maxwell does not mention a conclusion as one of the components of a qualitative research design, you should formally conclude your study. Briefly reiterate the goals of your study and the ways in which your research addressed them. Discuss the benefits of your study and how stakeholders can use your results. Also, note the limitations of your study and, if appropriate, place them in the context of areas in need of further research.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Heath, A. W. The Proposal in Qualitative Research. The Qualitative Report 3 (March 1997); Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 3rd edition. Thousand Oaks, CA: Sage, 1999; Maxwell, Joseph A. "Designing a Qualitative Study." In The SAGE Handbook of Applied Social Research Methods . Leonard Bickman and Debra J. Rog, eds. 2nd ed. (Thousand Oaks, CA: Sage, 2009), p. 214-253; Qualitative Research Methods. Writing@CSU. Colorado State University; Yin, Robert K. Qualitative Research from Start to Finish . 2nd edition. New York: Guilford, 2015.

Strengths of Using Qualitative Methods

The advantage of using qualitative methods is that they generate rich, detailed data that leave the participants' perspectives intact and provide multiple contexts for understanding the phenomenon under study. In this way, qualitative research can be used to vividly demonstrate phenomena or to conduct cross-case comparisons and analysis of individuals or groups.

Among the specific strengths of using qualitative methods to study social science research problems is the ability to:

• Obtain a more realistic view of the lived world that cannot be understood or experienced in numerical data and statistical analysis;
• Provide the researcher with the perspective of the participants of the study through immersion in a culture or situation and as a result of direct interaction with them;
• Allow the researcher to describe existing phenomena and current situations;
• Develop flexible ways to perform data collection, subsequent analysis, and interpretation of collected information;
• Yield results that can be helpful in pioneering new ways of understanding;
• Respond to changes that occur while conducting the study ]e.g., extended fieldwork or observation] and offer the flexibility to shift the focus of the research as a result;
• Provide a holistic view of the phenomena under investigation;
• Respond to local situations, conditions, and needs of participants;
• Interact with the research subjects in their own language and on their own terms; and,
• Create a descriptive capability based on primary and unstructured data.

Anderson, Claire. “Presenting and Evaluating Qualitative Research.” American Journal of Pharmaceutical Education 74 (2010): 1-7; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Limitations of Using Qualitative Methods

It is very much true that most of the limitations you find in using qualitative research techniques also reflect their inherent strengths . For example, small sample sizes help you investigate research problems in a comprehensive and in-depth manner. However, small sample sizes undermine opportunities to draw useful generalizations from, or to make broad policy recommendations based upon, the findings. Additionally, as the primary instrument of investigation, qualitative researchers are often embedded in the cultures and experiences of others. However, cultural embeddedness increases the opportunity for bias generated from conscious or unconscious assumptions about the study setting to enter into how data is gathered, interpreted, and reported.

Some specific limitations associated with using qualitative methods to study research problems in the social sciences include the following:

• Drifting away from the original objectives of the study in response to the changing nature of the context under which the research is conducted;
• Arriving at different conclusions based on the same information depending on the personal characteristics of the researcher;
• Replication of a study is very difficult;
• Research using human subjects increases the chance of ethical dilemmas that undermine the overall validity of the study;
• An inability to investigate causality between different research phenomena;
• Difficulty in explaining differences in the quality and quantity of information obtained from different respondents and arriving at different, non-consistent conclusions;
• Data gathering and analysis is often time consuming and/or expensive;
• Requires a high level of experience from the researcher to obtain the targeted information from the respondent;
• May lack consistency and reliability because the researcher can employ different probing techniques and the respondent can choose to tell some particular stories and ignore others; and,
• Generation of a significant amount of data that cannot be randomized into manageable parts for analysis.

Research Tip

Human Subject Research and Institutional Review Board Approval

Almost every socio-behavioral study requires you to submit your proposed research plan to an Institutional Review Board. The role of the Board is to evaluate your research proposal and determine whether it will be conducted ethically and under the regulations, institutional polices, and Code of Ethics set forth by the university. The purpose of the review is to protect the rights and welfare of individuals participating in your study. The review is intended to ensure equitable selection of respondents, that you have met the requirements for obtaining informed consent , that there is clear assessment and minimization of risks to participants and to the university [read: no lawsuits!], and that privacy and confidentiality are maintained throughout the research process and beyond. Go to the USC IRB website for detailed information and templates of forms you need to submit before you can proceed. If you are  unsure whether your study is subject to IRB review, consult with your professor or academic advisor.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Labaree, Robert V. "Working Successfully with Your Institutional Review Board: Practical Advice for Academic Librarians." College and Research Libraries News 71 (April 2010): 190-193.

Another Research Tip

Finding Examples of How to Apply Different Types of Research Methods

SAGE publications is a major publisher of studies about how to design and conduct research in the social and behavioral sciences. Their SAGE Research Methods Online and Cases database includes contents from books, articles, encyclopedias, handbooks, and videos covering social science research design and methods including the complete Little Green Book Series of Quantitative Applications in the Social Sciences and the Little Blue Book Series of Qualitative Research techniques. The database also includes case studies outlining the research methods used in real research projects. This is an excellent source for finding definitions of key terms and descriptions of research design and practice, techniques of data gathering, analysis, and reporting, and information about theories of research [e.g., grounded theory]. The database covers both qualitative and quantitative research methods as well as mixed methods approaches to conducting research.

SAGE Research Methods Online and Cases

NOTE :  For a list of online communities, research centers, indispensable learning resources, and personal websites of leading qualitative researchers, GO HERE .

For a list of scholarly journals devoted to the study and application of qualitative research methods, GO HERE .

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An Overview of Qualitative Research Methods

Direct Observation, Interviews, Participation, Immersion, Focus Groups

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Qualitative research is a type of social science research that collects and works with non-numerical data and that seeks to interpret meaning from these data that help understand social life through the study of targeted populations or places.

People often frame it in opposition to quantitative research , which uses numerical data to identify large-scale trends and employs statistical operations to determine causal and correlative relationships between variables.

Within sociology, qualitative research is typically focused on the micro-level of social interaction that composes everyday life, whereas quantitative research typically focuses on macro-level trends and phenomena.

Key Takeaways

Methods of qualitative research include:

• observation and immersion
• open-ended surveys
• focus groups
• content analysis of visual and textual materials
• oral history

Qualitative research has a long history in sociology and has been used within it for as long as the field has existed.

This type of research has long appealed to social scientists because it allows the researchers to investigate the meanings people attribute to their behavior, actions, and interactions with others.

While quantitative research is useful for identifying relationships between variables, like, for example, the connection between poverty and racial hate, it is qualitative research that can illuminate why this connection exists by going directly to the source—the people themselves.

Qualitative research is designed to reveal the meaning that informs the action or outcomes that are typically measured by quantitative research. So qualitative researchers investigate meanings, interpretations, symbols, and the processes and relations of social life.

What this type of research produces is descriptive data that the researcher must then interpret using rigorous and systematic methods of transcribing, coding, and analysis of trends and themes.

Because its focus is everyday life and people's experiences, qualitative research lends itself well to creating new theories using the inductive method , which can then be tested with further research.

Qualitative researchers use their own eyes, ears, and intelligence to collect in-depth perceptions and descriptions of targeted populations, places, and events.

Their findings are collected through a variety of methods, and often a researcher will use at least two or several of the following while conducting a qualitative study:

• Direct observation : With direct observation, a researcher studies people as they go about their daily lives without participating or interfering. This type of research is often unknown to those under study, and as such, must be conducted in public settings where people do not have a reasonable expectation of privacy. For example, a researcher might observe the ways in which strangers interact in public as they gather to watch a street performer.
• Open-ended surveys : While many surveys are designed to generate quantitative data, many are also designed with open-ended questions that allow for the generation and analysis of qualitative data. For example, a survey might be used to investigate not just which political candidates voters chose, but why they chose them, in their own words.
• Focus group : In a focus group, a researcher engages a small group of participants in a conversation designed to generate data relevant to the research question. Focus groups can contain anywhere from 5 to 15 participants. Social scientists often use them in studies that examine an event or trend that occurs within a specific community. They are common in market research, too.
• In-depth interviews : Researchers conduct in-depth interviews by speaking with participants in a one-on-one setting. Sometimes a researcher approaches the interview with a predetermined list of questions or topics for discussion but allows the conversation to evolve based on how the participant responds. Other times, the researcher has identified certain topics of interest but does not have a formal guide for the conversation, but allows the participant to guide it.
• Oral history : The oral history method is used to create a historical account of an event, group, or community, and typically involves a series of in-depth interviews conducted with one or multiple participants over an extended period.
• Participant observation : This method is similar to observation, however with this one, the researcher also participates in the action or events to not only observe others but to gain the first-hand experience in the setting.
• Ethnographic observation : Ethnographic observation is the most intensive and in-depth observational method. Originating in anthropology, with this method, a researcher fully immerses themselves into the research setting and lives among the participants as one of them for anywhere from months to years. By doing this, the researcher attempts to experience day-to-day existence from the viewpoints of those studied to develop in-depth and long-term accounts of the community, events, or trends under observation.
• Content analysis : This method is used by sociologists to analyze social life by interpreting words and images from documents, film, art, music, and other cultural products and media. The researchers look at how the words and images are used, and the context in which they are used to draw inferences about the underlying culture. Content analysis of digital material, especially that generated by social media users, has become a popular technique within the social sciences.

While much of the data generated by qualitative research is coded and analyzed using just the researcher's eyes and brain, the use of computer software to do these processes is increasingly popular within the social sciences.

Such software analysis works well when the data is too large for humans to handle, though the lack of a human interpreter is a common criticism of the use of computer software.

Pros and Cons

Qualitative research has both benefits and drawbacks.

On the plus side, it creates an in-depth understanding of the attitudes, behaviors, interactions, events, and social processes that comprise everyday life. In doing so, it helps social scientists understand how everyday life is influenced by society-wide things like social structure , social order , and all kinds of social forces.

This set of methods also has the benefit of being flexible and easily adaptable to changes in the research environment and can be conducted with minimal cost in many cases.

Among the downsides of qualitative research is that its scope is fairly limited so its findings are not always widely able to be generalized.

Researchers also have to use caution with these methods to ensure that they do not influence the data in ways that significantly change it and that they do not bring undue personal bias to their interpretation of the findings.

Fortunately, qualitative researchers receive rigorous training designed to eliminate or reduce these types of research bias.

• How to Conduct a Sociology Research Interview
• Definition of Idiographic and Nomothetic
• What Is Participant Observation Research?
• Pilot Study in Research
• Conducting Case Study Research in Sociology
• How to Understand Interpretive Sociology
• What Is Ethnography?
• Understanding Secondary Data and How to Use It in Research
• Social Surveys: Questionnaires, Interviews, and Telephone Polls
• Research in Essays and Reports
• What Is Naturalistic Observation? Definition and Examples
• Definition and Overview of Grounded Theory
• A Review of Software Tools for Quantitative Data Analysis
• Content Analysis: Method to Analyze Social Life Through Words, Images
• The Sociology of the Internet and Digital Sociology
• Immersion Definition: Cultural, Language, and Virtual

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Home Market Research

Qualitative Research Methods: Types, Analysis + Examples

Qualitative research is based on the disciplines of social sciences like psychology, sociology, and anthropology. Therefore, the qualitative research methods allow for in-depth and further probing and questioning of respondents based on their responses. The interviewer/researcher also tries to understand their motivation and feelings. Understanding how your audience makes decisions can help derive conclusions in market research.

What is qualitative research?

Qualitative research is defined as a market research method that focuses on obtaining data through open-ended and conversational communication .

This method is about “what” people think and “why” they think so. For example, consider a convenience store looking to improve its patronage. A systematic observation concludes that more men are visiting this store. One good method to determine why women were not visiting the store is conducting an in-depth interview method with potential customers.

For example, after successfully interviewing female customers and visiting nearby stores and malls, the researchers selected participants through random sampling . As a result, it was discovered that the store didn’t have enough items for women.

So fewer women were visiting the store, which was understood only by personally interacting with them and understanding why they didn’t visit the store because there were more male products than female ones.

Gather research insights

Types of qualitative research methods with examples

Qualitative research methods are designed in a manner that helps reveal the behavior and perception of a target audience with reference to a particular topic. There are different types of qualitative research methods, such as in-depth interviews, focus groups, ethnographic research, content analysis, and case study research that are usually used.

The results of qualitative methods are more descriptive, and the inferences can be drawn quite easily from the obtained data .

Qualitative research methods originated in the social and behavioral research sciences. Today, our world is more complicated, and it is difficult to understand what people think and perceive. Online research methods make it easier to understand that as it is a more communicative and descriptive analysis .

The following are the qualitative research methods that are frequently used. Also, read about qualitative research examples :

1. One-on-one interview

Conducting in-depth interviews is one of the most common qualitative research methods. It is a personal interview that is carried out with one respondent at a time. This is purely a conversational method and invites opportunities to get details in depth from the respondent.

One of the advantages of this method is that it provides a great opportunity to gather precise data about what people believe and their motivations . If the researcher is well experienced, asking the right questions can help him/her collect meaningful data. If they should need more information, the researchers should ask such follow-up questions that will help them collect more information.

These interviews can be performed face-to-face or on the phone and usually can last between half an hour to two hours or even more. When the in-depth interview is conducted face to face, it gives a better opportunity to read the respondents’ body language and match the responses.

2. Focus groups

A focus group is also a commonly used qualitative research method used in data collection. A focus group usually includes a limited number of respondents (6-10) from within your target market.

The main aim of the focus group is to find answers to the “why, ” “what,” and “how” questions. One advantage of focus groups is you don’t necessarily need to interact with the group in person. Nowadays, focus groups can be sent an online survey on various devices, and responses can be collected at the click of a button.

Focus groups are an expensive method as compared to other online qualitative research methods. Typically, they are used to explain complex processes. This method is very useful for market research on new products and testing new concepts.

3. Ethnographic research

Ethnographic research is the most in-depth observational research method that studies people in their naturally occurring environment.

This method requires the researchers to adapt to the target audiences’ environments, which could be anywhere from an organization to a city or any remote location. Here, geographical constraints can be an issue while collecting data.

This research design aims to understand the cultures, challenges, motivations, and settings that occur. Instead of relying on interviews and discussions, you experience the natural settings firsthand.

This type of research method can last from a few days to a few years, as it involves in-depth observation and collecting data on those grounds. It’s a challenging and time-consuming method and solely depends on the researcher’s expertise to analyze, observe, and infer the data.

4. Case study research

T he case study method has evolved over the past few years and developed into a valuable quality research method. As the name suggests, it is used for explaining an organization or an entity.

This type of research method is used within a number of areas like education, social sciences, and similar. This method may look difficult to operate; however , it is one of the simplest ways of conducting research as it involves a deep dive and thorough understanding of the data collection methods and inferring the data.

5. Record keeping

This method makes use of the already existing reliable documents and similar sources of information as the data source. This data can be used in new research. This is similar to going to a library. There, one can go over books and other reference material to collect relevant data that can likely be used in the research.

6. Process of observation

Qualitative Observation is a process of research that uses subjective methodologies to gather systematic information or data. Since the focus on qualitative observation is the research process of using subjective methodologies to gather information or data. Qualitative observation is primarily used to equate quality differences.

Qualitative observation deals with the 5 major sensory organs and their functioning – sight, smell, touch, taste, and hearing. This doesn’t involve measurements or numbers but instead characteristics.

Explore Insightfully Contextual Inquiry in Qualitative Research

Qualitative research: data collection and analysis

A. qualitative data collection.

Qualitative data collection allows collecting data that is non-numeric and helps us to explore how decisions are made and provide us with detailed insight. For reaching such conclusions the data that is collected should be holistic, rich, and nuanced and findings to emerge through careful analysis.

• Whatever method a researcher chooses for collecting qualitative data, one aspect is very clear the process will generate a large amount of data. In addition to the variety of methods available, there are also different methods of collecting and recording the data.

For example, if the qualitative data is collected through a focus group or one-to-one discussion, there will be handwritten notes or video recorded tapes. If there are recording they should be transcribed and before the process of data analysis can begin.

• As a rough guide, it can take a seasoned researcher 8-10 hours to transcribe the recordings of an interview, which can generate roughly 20-30 pages of dialogues. Many researchers also like to maintain separate folders to maintain the recording collected from the different focus group. This helps them compartmentalize the data collected.
• In case there are running notes taken, which are also known as field notes, they are helpful in maintaining comments, environmental contexts, environmental analysis , nonverbal cues etc. These filed notes are helpful and can be compared while transcribing audio recorded data. Such notes are usually informal but should be secured in a similar manner as the video recordings or the audio tapes.

B. Qualitative data analysis

Qualitative data analysis such as notes, videos, audio recordings images, and text documents. One of the most used methods for qualitative data analysis is text analysis.

Text analysis is a  data analysis method that is distinctly different from all other qualitative research methods, where researchers analyze the social life of the participants in the research study and decode the words, actions, etc. 

There are images also that are used in this research study and the researchers analyze the context in which the images are used and draw inferences from them. In the last decade, text analysis through what is shared on social media platforms has gained supreme popularity.

Characteristics of qualitative research methods

• Qualitative research methods usually collect data at the sight, where the participants are experiencing issues or research problems . These are real-time data and rarely bring the participants out of the geographic locations to collect information.
• Qualitative researchers typically gather multiple forms of data, such as interviews, observations, and documents, rather than rely on a single data source .
• This type of research method works towards solving complex issues by breaking down into meaningful inferences, that is easily readable and understood by all.
• Since it’s a more communicative method, people can build their trust on the researcher and the information thus obtained is raw and unadulterated.

Qualitative research method case study

Let’s take the example of a bookstore owner who is looking for ways to improve their sales and customer outreach. An online community of members who were loyal patrons of the bookstore were interviewed and related questions were asked and the questions were answered by them.

At the end of the interview, it was realized that most of the books in the stores were suitable for adults and there were not enough options for children or teenagers.

By conducting this qualitative research the bookstore owner realized what the shortcomings were and what were the feelings of the readers. Through this research now the bookstore owner can now keep books for different age categories and can improve his sales and customer outreach.

Such qualitative research method examples can serve as the basis to indulge in further quantitative research , which provides remedies.

When to use qualitative research

Researchers make use of qualitative research techniques when they need to capture accurate, in-depth insights. It is very useful to capture “factual data”. Here are some examples of when to use qualitative research.

• Developing a new product or generating an idea.
• Studying your product/brand or service to strengthen your marketing strategy.
• To understand your strengths and weaknesses.
• Understanding purchase behavior.
• To study the reactions of your audience to marketing campaigns and other communications.
• Exploring market demographics, segments, and customer care groups.
• Gathering perception data of a brand, company, or product.

LEARN ABOUT: Steps in Qualitative Research

Qualitative research methods vs quantitative research methods

The basic differences between qualitative research methods and quantitative research methods are simple and straightforward. They differ in:

• Their analytical objectives
• Types of questions asked
• Types of data collection instruments
• Forms of data they produce
• Degree of flexibility

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Article Contents

Introduction, when to use qualitative research, how to judge qualitative research, conclusions, authors' roles, conflict of interest.

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Qualitative research methods: when to use them and how to judge them

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K. Hammarberg, M. Kirkman, S. de Lacey, Qualitative research methods: when to use them and how to judge them, Human Reproduction , Volume 31, Issue 3, March 2016, Pages 498–501, https://doi.org/10.1093/humrep/dev334

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In March 2015, an impressive set of guidelines for best practice on how to incorporate psychosocial care in routine infertility care was published by the ESHRE Psychology and Counselling Guideline Development Group ( ESHRE Psychology and Counselling Guideline Development Group, 2015 ). The authors report that the guidelines are based on a comprehensive review of the literature and we congratulate them on their meticulous compilation of evidence into a clinically useful document. However, when we read the methodology section, we were baffled and disappointed to find that evidence from research using qualitative methods was not included in the formulation of the guidelines. Despite stating that ‘qualitative research has significant value to assess the lived experience of infertility and fertility treatment’, the group excluded this body of evidence because qualitative research is ‘not generally hypothesis-driven and not objective/neutral, as the researcher puts him/herself in the position of the participant to understand how the world is from the person's perspective’.

Qualitative and quantitative research methods are often juxtaposed as representing two different world views. In quantitative circles, qualitative research is commonly viewed with suspicion and considered lightweight because it involves small samples which may not be representative of the broader population, it is seen as not objective, and the results are assessed as biased by the researchers' own experiences or opinions. In qualitative circles, quantitative research can be dismissed as over-simplifying individual experience in the cause of generalisation, failing to acknowledge researcher biases and expectations in research design, and requiring guesswork to understand the human meaning of aggregate data.

As social scientists who investigate psychosocial aspects of human reproduction, we use qualitative and quantitative methods, separately or together, depending on the research question. The crucial part is to know when to use what method.

The peer-review process is a pillar of scientific publishing. One of the important roles of reviewers is to assess the scientific rigour of the studies from which authors draw their conclusions. If rigour is lacking, the paper should not be published. As with research using quantitative methods, research using qualitative methods is home to the good, the bad and the ugly. It is essential that reviewers know the difference. Rejection letters are hard to take but more often than not they are based on legitimate critique. However, from time to time it is obvious that the reviewer has little grasp of what constitutes rigour or quality in qualitative research. The first author (K.H.) recently submitted a paper that reported findings from a qualitative study about fertility-related knowledge and information-seeking behaviour among people of reproductive age. In the rejection letter one of the reviewers (not from Human Reproduction ) lamented, ‘Even for a qualitative study, I would expect that some form of confidence interval and paired t-tables analysis, etc. be used to analyse the significance of results'. This comment reveals the reviewer's inappropriate application to qualitative research of criteria relevant only to quantitative research.

In this commentary, we give illustrative examples of questions most appropriately answered using qualitative methods and provide general advice about how to appraise the scientific rigour of qualitative studies. We hope this will help the journal's reviewers and readers appreciate the legitimate place of qualitative research and ensure we do not throw the baby out with the bath water by excluding or rejecting papers simply because they report the results of qualitative studies.

In psychosocial research, ‘quantitative’ research methods are appropriate when ‘factual’ data are required to answer the research question; when general or probability information is sought on opinions, attitudes, views, beliefs or preferences; when variables can be isolated and defined; when variables can be linked to form hypotheses before data collection; and when the question or problem is known, clear and unambiguous. Quantitative methods can reveal, for example, what percentage of the population supports assisted conception, their distribution by age, marital status, residential area and so on, as well as changes from one survey to the next ( Kovacs et al. , 2012 ); the number of donors and donor siblings located by parents of donor-conceived children ( Freeman et al. , 2009 ); and the relationship between the attitude of donor-conceived people to learning of their donor insemination conception and their family ‘type’ (one or two parents, lesbian or heterosexual parents; Beeson et al. , 2011 ).

In contrast, ‘qualitative’ methods are used to answer questions about experience, meaning and perspective, most often from the standpoint of the participant. These data are usually not amenable to counting or measuring. Qualitative research techniques include ‘small-group discussions’ for investigating beliefs, attitudes and concepts of normative behaviour; ‘semi-structured interviews’, to seek views on a focused topic or, with key informants, for background information or an institutional perspective; ‘in-depth interviews’ to understand a condition, experience, or event from a personal perspective; and ‘analysis of texts and documents’, such as government reports, media articles, websites or diaries, to learn about distributed or private knowledge.

Qualitative methods have been used to reveal, for example, potential problems in implementing a proposed trial of elective single embryo transfer, where small-group discussions enabled staff to explain their own resistance, leading to an amended approach ( Porter and Bhattacharya, 2005 ). Small-group discussions among assisted reproductive technology (ART) counsellors were used to investigate how the welfare principle is interpreted and practised by health professionals who must apply it in ART ( de Lacey et al. , 2015 ). When legislative change meant that gamete donors could seek identifying details of people conceived from their gametes, parents needed advice on how best to tell their children. Small-group discussions were convened to ask adolescents (not known to be donor-conceived) to reflect on how they would prefer to be told ( Kirkman et al. , 2007 ).

When a population cannot be identified, such as anonymous sperm donors from the 1980s, a qualitative approach with wide publicity can reach people who do not usually volunteer for research and reveal (for example) their attitudes to proposed legislation to remove anonymity with retrospective effect ( Hammarberg et al. , 2014 ). When researchers invite people to talk about their reflections on experience, they can sometimes learn more than they set out to discover. In describing their responses to proposed legislative change, participants also talked about people conceived as a result of their donations, demonstrating various constructions and expectations of relationships ( Kirkman et al. , 2014 ).

Interviews with parents in lesbian-parented families generated insight into the diverse meanings of the sperm donor in the creation and life of the family ( Wyverkens et al. , 2014 ). Oral and written interviews also revealed the embarrassment and ambivalence surrounding sperm donors evident in participants in donor-assisted conception ( Kirkman, 2004 ). The way in which parents conceptualise unused embryos and why they discard rather than donate was explored and understood via in-depth interviews, showing how and why the meaning of those embryos changed with parenthood ( de Lacey, 2005 ). In-depth interviews were also used to establish the intricate understanding by embryo donors and recipients of the meaning of embryo donation and the families built as a result ( Goedeke et al. , 2015 ).

It is possible to combine quantitative and qualitative methods, although great care should be taken to ensure that the theory behind each method is compatible and that the methods are being used for appropriate reasons. The two methods can be used sequentially (first a quantitative then a qualitative study or vice versa), where the first approach is used to facilitate the design of the second; they can be used in parallel as different approaches to the same question; or a dominant method may be enriched with a small component of an alternative method (such as qualitative interviews ‘nested’ in a large survey). It is important to note that free text in surveys represents qualitative data but does not constitute qualitative research. Qualitative and quantitative methods may be used together for corroboration (hoping for similar outcomes from both methods), elaboration (using qualitative data to explain or interpret quantitative data, or to demonstrate how the quantitative findings apply in particular cases), complementarity (where the qualitative and quantitative results differ but generate complementary insights) or contradiction (where qualitative and quantitative data lead to different conclusions). Each has its advantages and challenges ( Brannen, 2005 ).

Qualitative research is gaining increased momentum in the clinical setting and carries different criteria for evaluating its rigour or quality. Quantitative studies generally involve the systematic collection of data about a phenomenon, using standardized measures and statistical analysis. In contrast, qualitative studies involve the systematic collection, organization, description and interpretation of textual, verbal or visual data. The particular approach taken determines to a certain extent the criteria used for judging the quality of the report. However, research using qualitative methods can be evaluated ( Dixon-Woods et al. , 2006 ; Young et al. , 2014 ) and there are some generic guidelines for assessing qualitative research ( Kitto et al. , 2008 ).

Although the terms ‘reliability’ and ‘validity’ are contentious among qualitative researchers ( Lincoln and Guba, 1985 ) with some preferring ‘verification’, research integrity and robustness are as important in qualitative studies as they are in other forms of research. It is widely accepted that qualitative research should be ethical, important, intelligibly described, and use appropriate and rigorous methods ( Cohen and Crabtree, 2008 ). In research investigating data that can be counted or measured, replicability is essential. When other kinds of data are gathered in order to answer questions of personal or social meaning, we need to be able to capture real-life experiences, which cannot be identical from one person to the next. Furthermore, meaning is culturally determined and subject to evolutionary change. The way of explaining a phenomenon—such as what it means to use donated gametes—will vary, for example, according to the cultural significance of ‘blood’ or genes, interpretations of marital infidelity and religious constructs of sexual relationships and families. Culture may apply to a country, a community, or other actual or virtual group, and a person may be engaged at various levels of culture. In identifying meaning for members of a particular group, consistency may indeed be found from one research project to another. However, individuals within a cultural group may present different experiences and perceptions or transgress cultural expectations. That does not make them ‘wrong’ or invalidate the research. Rather, it offers insight into diversity and adds a piece to the puzzle to which other researchers also contribute.

In qualitative research the objective stance is obsolete, the researcher is the instrument, and ‘subjects’ become ‘participants’ who may contribute to data interpretation and analysis ( Denzin and Lincoln, 1998 ). Qualitative researchers defend the integrity of their work by different means: trustworthiness, credibility, applicability and consistency are the evaluative criteria ( Leininger, 1994 ).

Trustworthiness

A report of a qualitative study should contain the same robust procedural description as any other study. The purpose of the research, how it was conducted, procedural decisions, and details of data generation and management should be transparent and explicit. A reviewer should be able to follow the progression of events and decisions and understand their logic because there is adequate description, explanation and justification of the methodology and methods ( Kitto et al. , 2008 )

Credibility

Credibility is the criterion for evaluating the truth value or internal validity of qualitative research. A qualitative study is credible when its results, presented with adequate descriptions of context, are recognizable to people who share the experience and those who care for or treat them. As the instrument in qualitative research, the researcher defends its credibility through practices such as reflexivity (reflection on the influence of the researcher on the research), triangulation (where appropriate, answering the research question in several ways, such as through interviews, observation and documentary analysis) and substantial description of the interpretation process; verbatim quotations from the data are supplied to illustrate and support their interpretations ( Sandelowski, 1986 ). Where excerpts of data and interpretations are incongruent, the credibility of the study is in doubt.

Applicability

Applicability, or transferability of the research findings, is the criterion for evaluating external validity. A study is considered to meet the criterion of applicability when its findings can fit into contexts outside the study situation and when clinicians and researchers view the findings as meaningful and applicable in their own experiences.

Larger sample sizes do not produce greater applicability. Depth may be sacrificed to breadth or there may be too much data for adequate analysis. Sample sizes in qualitative research are typically small. The term ‘saturation’ is often used in reference to decisions about sample size in research using qualitative methods. Emerging from grounded theory, where filling theoretical categories is considered essential to the robustness of the developing theory, data saturation has been expanded to describe a situation where data tend towards repetition or where data cease to offer new directions and raise new questions ( Charmaz, 2005 ). However, the legitimacy of saturation as a generic marker of sampling adequacy has been questioned ( O'Reilly and Parker, 2013 ). Caution must be exercised to ensure that a commitment to saturation does not assume an ‘essence’ of an experience in which limited diversity is anticipated; each account is likely to be subtly different and each ‘sample’ will contribute to knowledge without telling the whole story. Increasingly, it is expected that researchers will report the kind of saturation they have applied and their criteria for recognising its achievement; an assessor will need to judge whether the choice is appropriate and consistent with the theoretical context within which the research has been conducted.

Sampling strategies are usually purposive, convenient, theoretical or snowballed. Maximum variation sampling may be used to seek representation of diverse perspectives on the topic. Homogeneous sampling may be used to recruit a group of participants with specified criteria. The threat of bias is irrelevant; participants are recruited and selected specifically because they can illuminate the phenomenon being studied. Rather than being predetermined by statistical power analysis, qualitative study samples are dependent on the nature of the data, the availability of participants and where those data take the investigator. Multiple data collections may also take place to obtain maximum insight into sensitive topics. For instance, the question of how decisions are made for embryo disposition may involve sampling within the patient group as well as from scientists, clinicians, counsellors and clinic administrators.

Consistency

Consistency, or dependability of the results, is the criterion for assessing reliability. This does not mean that the same result would necessarily be found in other contexts but that, given the same data, other researchers would find similar patterns. Researchers often seek maximum variation in the experience of a phenomenon, not only to illuminate it but also to discourage fulfilment of limited researcher expectations (for example, negative cases or instances that do not fit the emerging interpretation or theory should be actively sought and explored). Qualitative researchers sometimes describe the processes by which verification of the theoretical findings by another team member takes place ( Morse and Richards, 2002 ).

Research that uses qualitative methods is not, as it seems sometimes to be represented, the easy option, nor is it a collation of anecdotes. It usually involves a complex theoretical or philosophical framework. Rigorous analysis is conducted without the aid of straightforward mathematical rules. Researchers must demonstrate the validity of their analysis and conclusions, resulting in longer papers and occasional frustration with the word limits of appropriate journals. Nevertheless, we need the different kinds of evidence that is generated by qualitative methods. The experience of health, illness and medical intervention cannot always be counted and measured; researchers need to understand what they mean to individuals and groups. Knowledge gained from qualitative research methods can inform clinical practice, indicate how to support people living with chronic conditions and contribute to community education and awareness about people who are (for example) experiencing infertility or using assisted conception.

Each author drafted a section of the manuscript and the manuscript as a whole was reviewed and revised by all authors in consultation.

No external funding was either sought or obtained for this study.

The authors have no conflicts of interest to declare.

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Criteria for Good Qualitative Research: A Comprehensive Review

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

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

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

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Introduction

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

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

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

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

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

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

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

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

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

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

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

Qualitative Research: Interpretive Paradigms

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

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

Improving Quality: Strategies

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

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

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

Essential elements of a conceptual framework

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

How to Assess the Quality of the Research Findings?

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

Quality Checklists: Tools for Assessing the Quality

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

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

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

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

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

Conclusions, Future Directions, and Outlook

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

Prospects : A Road Ahead for Qualitative Research

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

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

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

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

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

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

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

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

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

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Chapter 11. Interviewing

Introduction.

Interviewing people is at the heart of qualitative research. It is not merely a way to collect data but an intrinsically rewarding activity—an interaction between two people that holds the potential for greater understanding and interpersonal development. Unlike many of our daily interactions with others that are fairly shallow and mundane, sitting down with a person for an hour or two and really listening to what they have to say is a profound and deep enterprise, one that can provide not only “data” for you, the interviewer, but also self-understanding and a feeling of being heard for the interviewee. I always approach interviewing with a deep appreciation for the opportunity it gives me to understand how other people experience the world. That said, there is not one kind of interview but many, and some of these are shallower than others. This chapter will provide you with an overview of interview techniques but with a special focus on the in-depth semistructured interview guide approach, which is the approach most widely used in social science research.

An interview can be variously defined as “a conversation with a purpose” ( Lune and Berg 2018 ) and an attempt to understand the world from the point of view of the person being interviewed: “to unfold the meaning of peoples’ experiences, to uncover their lived world prior to scientific explanations” ( Kvale 2007 ). It is a form of active listening in which the interviewer steers the conversation to subjects and topics of interest to their research but also manages to leave enough space for those interviewed to say surprising things. Achieving that balance is a tricky thing, which is why most practitioners believe interviewing is both an art and a science. In my experience as a teacher, there are some students who are “natural” interviewers (often they are introverts), but anyone can learn to conduct interviews, and everyone, even those of us who have been doing this for years, can improve their interviewing skills. This might be a good time to highlight the fact that the interview is a product between interviewer and interviewee and that this product is only as good as the rapport established between the two participants. Active listening is the key to establishing this necessary rapport.

Patton ( 2002 ) makes the argument that we use interviews because there are certain things that are not observable. In particular, “we cannot observe feelings, thoughts, and intentions. We cannot observe behaviors that took place at some previous point in time. We cannot observe situations that preclude the presence of an observer. We cannot observe how people have organized the world and the meanings they attach to what goes on in the world. We have to ask people questions about those things” ( 341 ).

Types of Interviews

There are several distinct types of interviews. Imagine a continuum (figure 11.1). On one side are unstructured conversations—the kind you have with your friends. No one is in control of those conversations, and what you talk about is often random—whatever pops into your head. There is no secret, underlying purpose to your talking—if anything, the purpose is to talk to and engage with each other, and the words you use and the things you talk about are a little beside the point. An unstructured interview is a little like this informal conversation, except that one of the parties to the conversation (you, the researcher) does have an underlying purpose, and that is to understand the other person. You are not friends speaking for no purpose, but it might feel just as unstructured to the “interviewee” in this scenario. That is one side of the continuum. On the other side are fully structured and standardized survey-type questions asked face-to-face. Here it is very clear who is asking the questions and who is answering them. This doesn’t feel like a conversation at all! A lot of people new to interviewing have this ( erroneously !) in mind when they think about interviews as data collection. Somewhere in the middle of these two extreme cases is the “ semistructured” interview , in which the researcher uses an “interview guide” to gently move the conversation to certain topics and issues. This is the primary form of interviewing for qualitative social scientists and will be what I refer to as interviewing for the rest of this chapter, unless otherwise specified.

Informal (unstructured conversations). This is the most “open-ended” approach to interviewing. It is particularly useful in conjunction with observational methods (see chapters 13 and 14). There are no predetermined questions. Each interview will be different. Imagine you are researching the Oregon Country Fair, an annual event in Veneta, Oregon, that includes live music, artisan craft booths, face painting, and a lot of people walking through forest paths. It’s unlikely that you will be able to get a person to sit down with you and talk intensely about a set of questions for an hour and a half. But you might be able to sidle up to several people and engage with them about their experiences at the fair. You might have a general interest in what attracts people to these events, so you could start a conversation by asking strangers why they are here or why they come back every year. That’s it. Then you have a conversation that may lead you anywhere. Maybe one person tells a long story about how their parents brought them here when they were a kid. A second person talks about how this is better than Burning Man. A third person shares their favorite traveling band. And yet another enthuses about the public library in the woods. During your conversations, you also talk about a lot of other things—the weather, the utilikilts for sale, the fact that a favorite food booth has disappeared. It’s all good. You may not be able to record these conversations. Instead, you might jot down notes on the spot and then, when you have the time, write down as much as you can remember about the conversations in long fieldnotes. Later, you will have to sit down with these fieldnotes and try to make sense of all the information (see chapters 18 and 19).

Interview guide ( semistructured interview ). This is the primary type employed by social science qualitative researchers. The researcher creates an “interview guide” in advance, which she uses in every interview. In theory, every person interviewed is asked the same questions. In practice, every person interviewed is asked mostly the same topics but not always the same questions, as the whole point of a “guide” is that it guides the direction of the conversation but does not command it. The guide is typically between five and ten questions or question areas, sometimes with suggested follow-ups or prompts . For example, one question might be “What was it like growing up in Eastern Oregon?” with prompts such as “Did you live in a rural area? What kind of high school did you attend?” to help the conversation develop. These interviews generally take place in a quiet place (not a busy walkway during a festival) and are recorded. The recordings are transcribed, and those transcriptions then become the “data” that is analyzed (see chapters 18 and 19). The conventional length of one of these types of interviews is between one hour and two hours, optimally ninety minutes. Less than one hour doesn’t allow for much development of questions and thoughts, and two hours (or more) is a lot of time to ask someone to sit still and answer questions. If you have a lot of ground to cover, and the person is willing, I highly recommend two separate interview sessions, with the second session being slightly shorter than the first (e.g., ninety minutes the first day, sixty minutes the second). There are lots of good reasons for this, but the most compelling one is that this allows you to listen to the first day’s recording and catch anything interesting you might have missed in the moment and so develop follow-up questions that can probe further. This also allows the person being interviewed to have some time to think about the issues raised in the interview and go a little deeper with their answers.

Standardized questionnaire with open responses ( structured interview ). This is the type of interview a lot of people have in mind when they hear “interview”: a researcher comes to your door with a clipboard and proceeds to ask you a series of questions. These questions are all the same whoever answers the door; they are “standardized.” Both the wording and the exact order are important, as people’s responses may vary depending on how and when a question is asked. These are qualitative only in that the questions allow for “open-ended responses”: people can say whatever they want rather than select from a predetermined menu of responses. For example, a survey I collaborated on included this open-ended response question: “How does class affect one’s career success in sociology?” Some of the answers were simply one word long (e.g., “debt”), and others were long statements with stories and personal anecdotes. It is possible to be surprised by the responses. Although it’s a stretch to call this kind of questioning a conversation, it does allow the person answering the question some degree of freedom in how they answer.

Survey questionnaire with closed responses (not an interview!). Standardized survey questions with specific answer options (e.g., closed responses) are not really interviews at all, and they do not generate qualitative data. For example, if we included five options for the question “How does class affect one’s career success in sociology?”—(1) debt, (2) social networks, (3) alienation, (4) family doesn’t understand, (5) type of grad program—we leave no room for surprises at all. Instead, we would most likely look at patterns around these responses, thinking quantitatively rather than qualitatively (e.g., using regression analysis techniques, we might find that working-class sociologists were twice as likely to bring up alienation). It can sometimes be confusing for new students because the very same survey can include both closed-ended and open-ended questions. The key is to think about how these will be analyzed and to what level surprises are possible. If your plan is to turn all responses into a number and make predictions about correlations and relationships, you are no longer conducting qualitative research. This is true even if you are conducting this survey face-to-face with a real live human. Closed-response questions are not conversations of any kind, purposeful or not.

In summary, the semistructured interview guide approach is the predominant form of interviewing for social science qualitative researchers because it allows a high degree of freedom of responses from those interviewed (thus allowing for novel discoveries) while still maintaining some connection to a research question area or topic of interest. The rest of the chapter assumes the employment of this form.

Creating an Interview Guide

Your interview guide is the instrument used to bridge your research question(s) and what the people you are interviewing want to tell you. Unlike a standardized questionnaire, the questions actually asked do not need to be exactly what you have written down in your guide. The guide is meant to create space for those you are interviewing to talk about the phenomenon of interest, but sometimes you are not even sure what that phenomenon is until you start asking questions. A priority in creating an interview guide is to ensure it offers space. One of the worst mistakes is to create questions that are so specific that the person answering them will not stray. Relatedly, questions that sound “academic” will shut down a lot of respondents. A good interview guide invites respondents to talk about what is important to them, not feel like they are performing or being evaluated by you.

Good interview questions should not sound like your “research question” at all. For example, let’s say your research question is “How do patriarchal assumptions influence men’s understanding of climate change and responses to climate change?” It would be worse than unhelpful to ask a respondent, “How do your assumptions about the role of men affect your understanding of climate change?” You need to unpack this into manageable nuggets that pull your respondent into the area of interest without leading him anywhere. You could start by asking him what he thinks about climate change in general. Or, even better, whether he has any concerns about heatwaves or increased tornadoes or polar icecaps melting. Once he starts talking about that, you can ask follow-up questions that bring in issues around gendered roles, perhaps asking if he is married (to a woman) and whether his wife shares his thoughts and, if not, how they negotiate that difference. The fact is, you won’t really know the right questions to ask until he starts talking.

There are several distinct types of questions that can be used in your interview guide, either as main questions or as follow-up probes. If you remember that the point is to leave space for the respondent, you will craft a much more effective interview guide! You will also want to think about the place of time in both the questions themselves (past, present, future orientations) and the sequencing of the questions.

Researcher Note

Suggestion : As you read the next three sections (types of questions, temporality, question sequence), have in mind a particular research question, and try to draft questions and sequence them in a way that opens space for a discussion that helps you answer your research question.

Type of Questions

Experience and behavior questions ask about what a respondent does regularly (their behavior) or has done (their experience). These are relatively easy questions for people to answer because they appear more “factual” and less subjective. This makes them good opening questions. For the study on climate change above, you might ask, “Have you ever experienced an unusual weather event? What happened?” Or “You said you work outside? What is a typical summer workday like for you? How do you protect yourself from the heat?”

Opinion and values questions , in contrast, ask questions that get inside the minds of those you are interviewing. “Do you think climate change is real? Who or what is responsible for it?” are two such questions. Note that you don’t have to literally ask, “What is your opinion of X?” but you can find a way to ask the specific question relevant to the conversation you are having. These questions are a bit trickier to ask because the answers you get may depend in part on how your respondent perceives you and whether they want to please you or not. We’ve talked a fair amount about being reflective. Here is another place where this comes into play. You need to be aware of the effect your presence might have on the answers you are receiving and adjust accordingly. If you are a woman who is perceived as liberal asking a man who identifies as conservative about climate change, there is a lot of subtext that can be going on in the interview. There is no one right way to resolve this, but you must at least be aware of it.

Feeling questions are questions that ask respondents to draw on their emotional responses. It’s pretty common for academic researchers to forget that we have bodies and emotions, but people’s understandings of the world often operate at this affective level, sometimes unconsciously or barely consciously. It is a good idea to include questions that leave space for respondents to remember, imagine, or relive emotional responses to particular phenomena. “What was it like when you heard your cousin’s house burned down in that wildfire?” doesn’t explicitly use any emotion words, but it allows your respondent to remember what was probably a pretty emotional day. And if they respond emotionally neutral, that is pretty interesting data too. Note that asking someone “How do you feel about X” is not always going to evoke an emotional response, as they might simply turn around and respond with “I think that…” It is better to craft a question that actually pushes the respondent into the affective category. This might be a specific follow-up to an experience and behavior question —for example, “You just told me about your daily routine during the summer heat. Do you worry it is going to get worse?” or “Have you ever been afraid it will be too hot to get your work accomplished?”

Knowledge questions ask respondents what they actually know about something factual. We have to be careful when we ask these types of questions so that respondents do not feel like we are evaluating them (which would shut them down), but, for example, it is helpful to know when you are having a conversation about climate change that your respondent does in fact know that unusual weather events have increased and that these have been attributed to climate change! Asking these questions can set the stage for deeper questions and can ensure that the conversation makes the same kind of sense to both participants. For example, a conversation about political polarization can be put back on track once you realize that the respondent doesn’t really have a clear understanding that there are two parties in the US. Instead of asking a series of questions about Republicans and Democrats, you might shift your questions to talk more generally about political disagreements (e.g., “people against abortion”). And sometimes what you do want to know is the level of knowledge about a particular program or event (e.g., “Are you aware you can discharge your student loans through the Public Service Loan Forgiveness program?”).

Sensory questions call on all senses of the respondent to capture deeper responses. These are particularly helpful in sparking memory. “Think back to your childhood in Eastern Oregon. Describe the smells, the sounds…” Or you could use these questions to help a person access the full experience of a setting they customarily inhabit: “When you walk through the doors to your office building, what do you see? Hear? Smell?” As with feeling questions , these questions often supplement experience and behavior questions . They are another way of allowing your respondent to report fully and deeply rather than remain on the surface.

Creative questions employ illustrative examples, suggested scenarios, or simulations to get respondents to think more deeply about an issue, topic, or experience. There are many options here. In The Trouble with Passion , Erin Cech ( 2021 ) provides a scenario in which “Joe” is trying to decide whether to stay at his decent but boring computer job or follow his passion by opening a restaurant. She asks respondents, “What should Joe do?” Their answers illuminate the attraction of “passion” in job selection. In my own work, I have used a news story about an upwardly mobile young man who no longer has time to see his mother and sisters to probe respondents’ feelings about the costs of social mobility. Jessi Streib and Betsy Leondar-Wright have used single-page cartoon “scenes” to elicit evaluations of potential racial discrimination, sexual harassment, and classism. Barbara Sutton ( 2010 ) has employed lists of words (“strong,” “mother,” “victim”) on notecards she fans out and asks her female respondents to select and discuss.

Background/Demographic Questions

You most definitely will want to know more about the person you are interviewing in terms of conventional demographic information, such as age, race, gender identity, occupation, and educational attainment. These are not questions that normally open up inquiry. [1] For this reason, my practice has been to include a separate “demographic questionnaire” sheet that I ask each respondent to fill out at the conclusion of the interview. Only include those aspects that are relevant to your study. For example, if you are not exploring religion or religious affiliation, do not include questions about a person’s religion on the demographic sheet. See the example provided at the end of this chapter.

Temporality

Any type of question can have a past, present, or future orientation. For example, if you are asking a behavior question about workplace routine, you might ask the respondent to talk about past work, present work, and ideal (future) work. Similarly, if you want to understand how people cope with natural disasters, you might ask your respondent how they felt then during the wildfire and now in retrospect and whether and to what extent they have concerns for future wildfire disasters. It’s a relatively simple suggestion—don’t forget to ask about past, present, and future—but it can have a big impact on the quality of the responses you receive.

Question Sequence

Having a list of good questions or good question areas is not enough to make a good interview guide. You will want to pay attention to the order in which you ask your questions. Even though any one respondent can derail this order (perhaps by jumping to answer a question you haven’t yet asked), a good advance plan is always helpful. When thinking about sequence, remember that your goal is to get your respondent to open up to you and to say things that might surprise you. To establish rapport, it is best to start with nonthreatening questions. Asking about the present is often the safest place to begin, followed by the past (they have to know you a little bit to get there), and lastly, the future (talking about hopes and fears requires the most rapport). To allow for surprises, it is best to move from very general questions to more particular questions only later in the interview. This ensures that respondents have the freedom to bring up the topics that are relevant to them rather than feel like they are constrained to answer you narrowly. For example, refrain from asking about particular emotions until these have come up previously—don’t lead with them. Often, your more particular questions will emerge only during the course of the interview, tailored to what is emerging in conversation.

Once you have a set of questions, read through them aloud and imagine you are being asked the same questions. Does the set of questions have a natural flow? Would you be willing to answer the very first question to a total stranger? Does your sequence establish facts and experiences before moving on to opinions and values? Did you include prefatory statements, where necessary; transitions; and other announcements? These can be as simple as “Hey, we talked a lot about your experiences as a barista while in college.… Now I am turning to something completely different: how you managed friendships in college.” That is an abrupt transition, but it has been softened by your acknowledgment of that.

Probes and Flexibility

Once you have the interview guide, you will also want to leave room for probes and follow-up questions. As in the sample probe included here, you can write out the obvious probes and follow-up questions in advance. You might not need them, as your respondent might anticipate them and include full responses to the original question. Or you might need to tailor them to how your respondent answered the question. Some common probes and follow-up questions include asking for more details (When did that happen? Who else was there?), asking for elaboration (Could you say more about that?), asking for clarification (Does that mean what I think it means or something else? I understand what you mean, but someone else reading the transcript might not), and asking for contrast or comparison (How did this experience compare with last year’s event?). “Probing is a skill that comes from knowing what to look for in the interview, listening carefully to what is being said and what is not said, and being sensitive to the feedback needs of the person being interviewed” ( Patton 2002:374 ). It takes work! And energy. I and many other interviewers I know report feeling emotionally and even physically drained after conducting an interview. You are tasked with active listening and rearranging your interview guide as needed on the fly. If you only ask the questions written down in your interview guide with no deviations, you are doing it wrong. [2]

The Final Question

Every interview guide should include a very open-ended final question that allows for the respondent to say whatever it is they have been dying to tell you but you’ve forgotten to ask. About half the time they are tired too and will tell you they have nothing else to say. But incredibly, some of the most honest and complete responses take place here, at the end of a long interview. You have to realize that the person being interviewed is often discovering things about themselves as they talk to you and that this process of discovery can lead to new insights for them. Making space at the end is therefore crucial. Be sure you convey that you actually do want them to tell you more, that the offer of “anything else?” is not read as an empty convention where the polite response is no. Here is where you can pull from that active listening and tailor the final question to the particular person. For example, “I’ve asked you a lot of questions about what it was like to live through that wildfire. I’m wondering if there is anything I’ve forgotten to ask, especially because I haven’t had that experience myself” is a much more inviting final question than “Great. Anything you want to add?” It’s also helpful to convey to the person that you have the time to listen to their full answer, even if the allotted time is at the end. After all, there are no more questions to ask, so the respondent knows exactly how much time is left. Do them the courtesy of listening to them!

Conducting the Interview

Once you have your interview guide, you are on your way to conducting your first interview. I always practice my interview guide with a friend or family member. I do this even when the questions don’t make perfect sense for them, as it still helps me realize which questions make no sense, are poorly worded (too academic), or don’t follow sequentially. I also practice the routine I will use for interviewing, which goes something like this:

• Introduce myself and reintroduce the study
• Provide consent form and ask them to sign and retain/return copy
• Ask if they have any questions about the study before we begin
• Ask if I can begin recording
• Ask questions (from interview guide)
• Turn off the recording device
• Ask if they are willing to fill out my demographic questionnaire
• Collect questionnaire and, without looking at the answers, place in same folder as signed consent form
• Thank them and depart

A note on remote interviewing: Interviews have traditionally been conducted face-to-face in a private or quiet public setting. You don’t want a lot of background noise, as this will make transcriptions difficult. During the recent global pandemic, many interviewers, myself included, learned the benefits of interviewing remotely. Although face-to-face is still preferable for many reasons, Zoom interviewing is not a bad alternative, and it does allow more interviews across great distances. Zoom also includes automatic transcription, which significantly cuts down on the time it normally takes to convert our conversations into “data” to be analyzed. These automatic transcriptions are not perfect, however, and you will still need to listen to the recording and clarify and clean up the transcription. Nor do automatic transcriptions include notations of body language or change of tone, which you may want to include. When interviewing remotely, you will want to collect the consent form before you meet: ask them to read, sign, and return it as an email attachment. I think it is better to ask for the demographic questionnaire after the interview, but because some respondents may never return it then, it is probably best to ask for this at the same time as the consent form, in advance of the interview.

What should you bring to the interview? I would recommend bringing two copies of the consent form (one for you and one for the respondent), a demographic questionnaire, a manila folder in which to place the signed consent form and filled-out demographic questionnaire, a printed copy of your interview guide (I print with three-inch right margins so I can jot down notes on the page next to relevant questions), a pen, a recording device, and water.

After the interview, you will want to secure the signed consent form in a locked filing cabinet (if in print) or a password-protected folder on your computer. Using Excel or a similar program that allows tables/spreadsheets, create an identifying number for your interview that links to the consent form without using the name of your respondent. For example, let’s say that I conduct interviews with US politicians, and the first person I meet with is George W. Bush. I will assign the transcription the number “INT#001” and add it to the signed consent form. [3] The signed consent form goes into a locked filing cabinet, and I never use the name “George W. Bush” again. I take the information from the demographic sheet, open my Excel spreadsheet, and add the relevant information in separate columns for the row INT#001: White, male, Republican. When I interview Bill Clinton as my second interview, I include a second row: INT#002: White, male, Democrat. And so on. The only link to the actual name of the respondent and this information is the fact that the consent form (unavailable to anyone but me) has stamped on it the interview number.

Many students get very nervous before their first interview. Actually, many of us are always nervous before the interview! But do not worry—this is normal, and it does pass. Chances are, you will be pleasantly surprised at how comfortable it begins to feel. These “purposeful conversations” are often a delight for both participants. This is not to say that sometimes things go wrong. I often have my students practice several “bad scenarios” (e.g., a respondent that you cannot get to open up; a respondent who is too talkative and dominates the conversation, steering it away from the topics you are interested in; emotions that completely take over; or shocking disclosures you are ill-prepared to handle), but most of the time, things go quite well. Be prepared for the unexpected, but know that the reason interviews are so popular as a technique of data collection is that they are usually richly rewarding for both participants.

One thing that I stress to my methods students and remind myself about is that interviews are still conversations between people. If there’s something you might feel uncomfortable asking someone about in a “normal” conversation, you will likely also feel a bit of discomfort asking it in an interview. Maybe more importantly, your respondent may feel uncomfortable. Social research—especially about inequality—can be uncomfortable. And it’s easy to slip into an abstract, intellectualized, or removed perspective as an interviewer. This is one reason trying out interview questions is important. Another is that sometimes the question sounds good in your head but doesn’t work as well out loud in practice. I learned this the hard way when a respondent asked me how I would answer the question I had just posed, and I realized that not only did I not really know how I would answer it, but I also wasn’t quite as sure I knew what I was asking as I had thought.

—Elizabeth M. Lee, Associate Professor of Sociology at Saint Joseph’s University, author of Class and Campus Life , and co-author of Geographies of Campus Inequality

How Many Interviews?

Your research design has included a targeted number of interviews and a recruitment plan (see chapter 5). Follow your plan, but remember that “ saturation ” is your goal. You interview as many people as you can until you reach a point at which you are no longer surprised by what they tell you. This means not that no one after your first twenty interviews will have surprising, interesting stories to tell you but rather that the picture you are forming about the phenomenon of interest to you from a research perspective has come into focus, and none of the interviews are substantially refocusing that picture. That is when you should stop collecting interviews. Note that to know when you have reached this, you will need to read your transcripts as you go. More about this in chapters 18 and 19.

Your Final Product: The Ideal Interview Transcript

A good interview transcript will demonstrate a subtly controlled conversation by the skillful interviewer. In general, you want to see replies that are about one paragraph long, not short sentences and not running on for several pages. Although it is sometimes necessary to follow respondents down tangents, it is also often necessary to pull them back to the questions that form the basis of your research study. This is not really a free conversation, although it may feel like that to the person you are interviewing.

Final Tips from an Interview Master

Annette Lareau is arguably one of the masters of the trade. In Listening to People , she provides several guidelines for good interviews and then offers a detailed example of an interview gone wrong and how it could be addressed (please see the “Further Readings” at the end of this chapter). Here is an abbreviated version of her set of guidelines: (1) interview respondents who are experts on the subjects of most interest to you (as a corollary, don’t ask people about things they don’t know); (2) listen carefully and talk as little as possible; (3) keep in mind what you want to know and why you want to know it; (4) be a proactive interviewer (subtly guide the conversation); (5) assure respondents that there aren’t any right or wrong answers; (6) use the respondent’s own words to probe further (this both allows you to accurately identify what you heard and pushes the respondent to explain further); (7) reuse effective probes (don’t reinvent the wheel as you go—if repeating the words back works, do it again and again); (8) focus on learning the subjective meanings that events or experiences have for a respondent; (9) don’t be afraid to ask a question that draws on your own knowledge (unlike trial lawyers who are trained never to ask a question for which they don’t already know the answer, sometimes it’s worth it to ask risky questions based on your hypotheses or just plain hunches); (10) keep thinking while you are listening (so difficult…and important); (11) return to a theme raised by a respondent if you want further information; (12) be mindful of power inequalities (and never ever coerce a respondent to continue the interview if they want out); (13) take control with overly talkative respondents; (14) expect overly succinct responses, and develop strategies for probing further; (15) balance digging deep and moving on; (16) develop a plan to deflect questions (e.g., let them know you are happy to answer any questions at the end of the interview, but you don’t want to take time away from them now); and at the end, (17) check to see whether you have asked all your questions. You don’t always have to ask everyone the same set of questions, but if there is a big area you have forgotten to cover, now is the time to recover ( Lareau 2021:93–103 ).

Sample: Demographic Questionnaire

ASA Taskforce on First-Generation and Working-Class Persons in Sociology – Class Effects on Career Success

Supplementary Demographic Questionnaire

Thank you for your participation in this interview project. We would like to collect a few pieces of key demographic information from you to supplement our analyses. Your answers to these questions will be kept confidential and stored by ID number. All of your responses here are entirely voluntary!

What best captures your race/ethnicity? (please check any/all that apply)

• White (Non Hispanic/Latina/o/x)
• Black or African American
• Hispanic, Latino/a/x of Spanish
• Asian or Asian American
• American Indian or Alaska Native
• Middle Eastern or North African
• Native Hawaiian or Pacific Islander
• Other : (Please write in: ________________)

What is your current position?

• Grad Student
• Full Professor

Please check any and all of the following that apply to you:

• I identify as a working-class academic
• I was the first in my family to graduate from college
• I grew up poor

What best reflects your gender?

• Transgender female/Transgender woman
• Transgender male/Transgender man
• Gender queer/ Gender nonconforming

Anything else you would like us to know about you?

Example: Interview Guide

In this example, follow-up prompts are italicized.  Note the sequence of questions.  That second question often elicits an entire life history , answering several later questions in advance.

Introduction Script/Question

Thank you for participating in our survey of ASA members who identify as first-generation or working-class.  As you may have heard, ASA has sponsored a taskforce on first-generation and working-class persons in sociology and we are interested in hearing from those who so identify.  Your participation in this interview will help advance our knowledge in this area.

• The first thing we would like to as you is why you have volunteered to be part of this study? What does it mean to you be first-gen or working class?  Why were you willing to be interviewed?
• How did you decide to become a sociologist?
• Can you tell me a little bit about where you grew up? ( prompts: what did your parent(s) do for a living?  What kind of high school did you attend?)
• Has this identity been salient to your experience? (how? How much?)
• How welcoming was your grad program? Your first academic employer?
• Why did you decide to pursue sociology at the graduate level?
• Did you experience culture shock in college? In graduate school?
• Has your FGWC status shaped how you’ve thought about where you went to school? debt? etc?
• Were you mentored? How did this work (not work)?  How might it?
• What did you consider when deciding where to go to grad school? Where to apply for your first position?
• What, to you, is a mark of career success? Have you achieved that success?  What has helped or hindered your pursuit of success?
• Do you think sociology, as a field, cares about prestige?
• Let’s talk a little bit about intersectionality. How does being first-gen/working class work alongside other identities that are important to you?
• What do your friends and family think about your career? Have you had any difficulty relating to family members or past friends since becoming highly educated?
• Do you have any debt from college/grad school? Are you concerned about this?  Could you explain more about how you paid for college/grad school?  (here, include assistance from family, fellowships, scholarships, etc.)
• (You’ve mentioned issues or obstacles you had because of your background.) What could have helped?  Or, who or what did? Can you think of fortuitous moments in your career?
• Do you have any regrets about the path you took?
• Is there anything else you would like to add? Anything that the Taskforce should take note of, that we did not ask you about here?

Further Readings

Britten, Nicky. 1995. “Qualitative Interviews in Medical Research.” BMJ: British Medical Journal 31(6999):251–253. A good basic overview of interviewing particularly useful for students of public health and medical research generally.

Corbin, Juliet, and Janice M. Morse. 2003. “The Unstructured Interactive Interview: Issues of Reciprocity and Risks When Dealing with Sensitive Topics.” Qualitative Inquiry 9(3):335–354. Weighs the potential benefits and harms of conducting interviews on topics that may cause emotional distress. Argues that the researcher’s skills and code of ethics should ensure that the interviewing process provides more of a benefit to both participant and researcher than a harm to the former.

Gerson, Kathleen, and Sarah Damaske. 2020. The Science and Art of Interviewing . New York: Oxford University Press. A useful guidebook/textbook for both undergraduates and graduate students, written by sociologists.

Kvale, Steiner. 2007. Doing Interviews . London: SAGE. An easy-to-follow guide to conducting and analyzing interviews by psychologists.

Lamont, Michèle, and Ann Swidler. 2014. “Methodological Pluralism and the Possibilities and Limits of Interviewing.” Qualitative Sociology 37(2):153–171. Written as a response to various debates surrounding the relative value of interview-based studies and ethnographic studies defending the particular strengths of interviewing. This is a must-read article for anyone seriously engaging in qualitative research!

Pugh, Allison J. 2013. “What Good Are Interviews for Thinking about Culture? Demystifying Interpretive Analysis.” American Journal of Cultural Sociology 1(1):42–68. Another defense of interviewing written against those who champion ethnographic methods as superior, particularly in the area of studying culture. A classic.

Rapley, Timothy John. 2001. “The ‘Artfulness’ of Open-Ended Interviewing: Some considerations in analyzing interviews.” Qualitative Research 1(3):303–323. Argues for the importance of “local context” of data production (the relationship built between interviewer and interviewee, for example) in properly analyzing interview data.

Weiss, Robert S. 1995. Learning from Strangers: The Art and Method of Qualitative Interview Studies . New York: Simon and Schuster. A classic and well-regarded textbook on interviewing. Because Weiss has extensive experience conducting surveys, he contrasts the qualitative interview with the survey questionnaire well; particularly useful for those trained in the latter.

• I say “normally” because how people understand their various identities can itself be an expansive topic of inquiry. Here, I am merely talking about collecting otherwise unexamined demographic data, similar to how we ask people to check boxes on surveys. ↵
• Again, this applies to “semistructured in-depth interviewing.” When conducting standardized questionnaires, you will want to ask each question exactly as written, without deviations! ↵
• I always include “INT” in the number because I sometimes have other kinds of data with their own numbering: FG#001 would mean the first focus group, for example. I also always include three-digit spaces, as this allows for up to 999 interviews (or, more realistically, allows for me to interview up to one hundred persons without having to reset my numbering system). ↵

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

A document listing key questions and question areas for use during an interview.  It is used most often for semi-structured interviews.  A good interview guide may have no more than ten primary questions for two hours of interviewing, but these ten questions will be supplemented by probes and relevant follow-ups throughout the interview.  Most IRBs require the inclusion of the interview guide in applications for review.  See also interview and  semi-structured interview .

A data-collection method that relies on casual, conversational, and informal interviewing.  Despite its apparent conversational nature, the researcher usually has a set of particular questions or question areas in mind but allows the interview to unfold spontaneously.  This is a common data-collection technique among ethnographers.  Compare to the semi-structured or in-depth interview .

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

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

Follow-up questions used in a semi-structured interview  to elicit further elaboration.  Suggested prompts can be included in the interview guide  to be used/deployed depending on how the initial question was answered or if the topic of the prompt does not emerge spontaneously.

A form of interview that follows a strict set of questions, asked in a particular order, for all interview subjects.  The questions are also the kind that elicits short answers, and the data is more “informative” than probing.  This is often used in mixed-methods studies, accompanying a survey instrument.  Because there is no room for nuance or the exploration of meaning in structured interviews, qualitative researchers tend to employ semi-structured interviews instead.  See also interview.

The point at which you can conclude data collection because every person you are interviewing, the interaction you are observing, or content you are analyzing merely confirms what you have already noted.  Achieving saturation is often used as the justification for the final sample size.

An interview variant in which a person’s life story is elicited in a narrative form.  Turning points and key themes are established by the researcher and used as data points for further analysis.

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

• Open access
• Published: 11 May 2024

Nurses’ and patients’ perceptions of physical health screening for patients with schizophrenia spectrum disorders: a qualitative study

• Långstedt Camilla 1 ,
• Bressington Daniel 2 , 3 &
• Välimäki Maritta 1 , 4  

BMC Nursing volume  23 , Article number:  321 ( 2024 ) Cite this article

Metrics details

Despite worldwide concern about the poor physical health of patients with schizophrenia spectrum disorders (SSD), physical health screening rates are low. This study reports nurses’ and patients’ experiences of physical health screening among people with SSD using the Finnish Health Improvement Profile (HIP-F) and their ideas for implementation improvements.

A qualitative exploratory study design with five group interviews with nurses ( n  = 15) and individual interviews with patients with SSD ( n  = 8) who had experience using the HIP-F in psychiatric outpatient clinics. Inductive content analysis was conducted.

Two main categories were identified. First, the characteristics of the HIP-F were divided into the subcategories of comprehensive nature, facilitating engagement, interpretation and rating of some items and duration of screening. Second, suggestions for the implementation of physical health screening consisted of two subcategories: improvements in screening and ideas for practice. Physical health screening was felt to increase the discussion and awareness of physical health and supported health promotion. The HIP-F was found to be a structured, comprehensive screening tool that included several items that were not otherwise assessed in clinical practice. The HIP-F was also considered to facilitate engagement by promoting collaboration in an interactive way. Despite this, most of the nurses found the HIP-F to be arduous and too time consuming, while patients found the HIP-F easy to use. Nurses found some items unclear and infeasible, while patients found all items feasible. Based on the nurses’ experiences, screening should be clear and easy to interpret, and condensation and revision of the HIP-F tool were suggested. The patients did not think that any improvements to the HIP-F were needed for implementation in clinical settings.

Conclusions

Patients with schizophrenia spectrum disorders are willing to participate in physical health screening. Physical health screening should be clear, easy to use and relatively quick. With this detailed knowledge of perceptions of screening, further research is needed to understand what factors affect the fidelity of implementing physical health screening in clinical mental health practice and to gain an overall understanding on how to improve such implementation.

Peer Review reports

The physical health state of people diagnosed with schizophrenia spectrum disorder (SSD) is a global problem [ 1 ]. Typically, poor physical health results from a range of issues, including the impact of psychiatric symptoms on health behavior, adverse effects of prescribed medication, difficulties observing physical health concerns, lifestyle, diagnostic overshadowing, and patient unwillingness to report health problems [ 2 , 3 ]. These factors may lead to obesity, metabolic syndrome, coronary vascular disease, diabetes, hypertension, or cancer [ 4 , 5 , 6 ]. High rates of infectious diseases such as hepatitis and HIV [ 7 ] and COVID-19 [ 8 ] have also been reported in patients with SSD. As an outcome of physical health issues, physical comorbidity is associated with psychiatric readmission [ 9 ] and high treatment costs. In Finland, the total healthcare costs caused by schizophrenia are approximately 700–900 million euros per year, mostly as a result of inpatient treatment costs [ 10 ]. Due to poor physical health, the life expectancy of persons with schizophrenia is approximately 20 years less than that of the general population [ 11 , 12 ]. Therefore, it is crucial that physical health screening is conducted regularly for patients with SSD. Improving regular screening helps to support earlier detection of risk factors that can, without detection and intervention, have deleterious effects on the physical health of patients with SSD [ 10 ].

Several international clinical guidelines have recommended how physical health screening for patients with SSD should be conducted [ 10 , 13 , 14 , 15 , 16 ]. According to guidelines persons with SSD who have been prescribed antipsychotic medication should have annual health checks focusing on full blood count, lipids, plasma glucose, prolactin, blood pressure, urea, electrolytes, liver function tests, weight, waist circumference measurement and electrocardiogram examination (ECG) [ 16 ]. Being aware of patients’ lifestyle habits, including smoking and use of other substances [ 10 , 13 , 15 ] is important for directing appropriate behavioral interventions to promote healthy lifestyles. In addition, a variety of screening instruments have been developed to assess physical health among people with SSD. Lamontagne-Godwin et al. [ 17 ] identified in their systematic review 44 intervention studies aiming to increase access to or uptake of physical health screening. Examples of monitoring tools in the included studies were Physical Health Check (PHC) [ 18 ]; physical health monitoring sheet [ 19 ]; systematic computerized cardiovascular health screening [ 20 ]; the Metabolic Syndrome Screening Tool (MSST) [ 21 ]; quality improvement (QI) [ 22 ] to increase rates of metabolic syndrome screening and the Health Improvement Profile (HIP), which is a comprehensive nurse-led profiling tool that assesses physical health risks, identifies unhealthy lifestyle behaviors, and provides associated recommended actions for health promotion [ 23 ]. Despite the abundance of available instruments, physical health screening is still poorly implemented in clinical mental health services [ 24 , 25 ].

To better understand this rationale for poor physical health screening, a quantitative study in Uganda [ 26 ] showed, that more than 75% of 28 nurses had a positive attitude towards metabolic screening and associated interventions. The same study reported that more than 50% of nurses were confident in providing physical activity and smoking cessation advice and nutritional counseling. However, 57% stated that their heavy workload prevented them from doing health screening. Voort et al. [ 27 ] reported in their qualitative study in Netherlands, that most nurses perceived physical health screening to be an important part of their professional role, but identified a discrepancy between their perceptions and actual clinical practice. Happell et al.’s qualitative study [ 28 ] reported in Australia that although nurses recognize their responsibility with respect to the physical health of patients with severe mental illness, they experienced factors such as staff shortages and lack of knowledge that prevented them from conducting screening properly. Further, Mwebe [ 29 ] reported in his UK study that nurses shared a clear commitment regarding their role in physical health screening in mental health care settings. Four themes emerged as follows: features of current practice and physical health monitoring; perceived barriers to physical health monitoring; education and training needs; and strategies to improve physical health monitoring. In the UK, Butler et al.’s qualitative study [ 30 ] revealed that patients varied in their awareness of the association between mental and physical health, but were engaged in physical health screening.

Moreover, Bressington et al. [ 31 ] revealed in their qualitative study, that nurses working in Hong Kong psychiatric care settings found the HIP (the Health Improvement Profile) to be comprehensive and perceived positive changes in their patients’ wellbeing, for example, by increasing motivation for patients to improve their health. HIP was developed to increase patient engagement in screening their physical health in collaboration with a nurse [ 32 ]. Earlier studies in the UK [ 33 ], Hong Kong [ 34 ], and Thailand [ 35 ] have reported patient acceptability and clinical utility of the HIP in identifying health risks where interventions are needed. These findings show that HIP may be feasible in engaging patients in discussions about physical health and in identifying areas of health risk [ 34 , 35 ]. Although Hardy et al. [ 33 ] found support for the usability of the HIP in clinical practice in a study in the UK, a subsequent RCT study conducted in the UK revealed that nurses found the use of the HIP unfeasible in a clinical setting due to its length [ 36 ]. In contrast, nurses in Hong Kong [ 31 ] found the HIP to be acceptable, feasible, and potentially useful in clinical practice. In Finland, our validation study of the Finnish Health Improvement Profile (HIP-F) supported this finding by detecting 399 areas of health and health behavior risk in a sample of 47 patients [ 37 ].

Previous international studies have only reported nurses’ and patients’ general attitudes toward health checks without detailed perceptions of the importance of comprehensively assessing different health parameters together with ideas for improvements. Implementation of physical health screening is influenced by services users’ perceptions and experiences. It is of paramount importance to involve potential users in the design and implementation of new procedures [ 38 ], and thus, when developing physical health screening for patients with SSD, the perceptions of both nurses and patients are vital [ 38 , 39 ]. Reconciling patients’ and nurses’ perceptions of physical health and its screening is an important step in promoting collaborative care and improving physical health screening rates [ 40 ]. Little detailed information is known about how nurses and patients perceive physical health screening; particularly, the assessment target areas and parameters, and how would nurses and patients improve screening so that it is more likely to regularly conducted in clinical practice. No previous studies have aimed to understand detailed perceptions and ideas for improvements of physical health screening by combining both nurses’ and patients’ perspectives using qualitative methods. The contrasting results regarding HIP instrument highlight that the acceptability and feasibility of HIP might be culturally and clinically context specific, and more research on patients’ and nurses’ perceptions of HIP in clinical practice is needed. To fulfill this knowledge gap, the current study sought to explore nurses’ and patients’ perceptions of physical health screening using the HIP-F profile as an example of physical health screening among patients with SSD in psychiatric settings in Finland and identify possible areas for improvement in the HIP-F tool and screening procedures.

The aim of this study was to explore (1) nurses’ and patients’ perceptions of physical health screening using the HIP-F profile as an example and (2) possible areas of improvement for implementation of physical health screening among patients with SSD in psychiatric settings in Finland. The information can be used to identify possible areas to be improved regarding implementation of systematic physical health screening activities as a part of treatment process among patients with SSD.

Study design

A qualitative exploratory study design, with focus group interviews for nurses and individual interviews for patients, was used to gain a better understanding of the real-life experiences of the study participants [ 41 , 42 ]. The qualitative exploratory design was appropriate for defining the terms of the research problem and to gain background information on a topic that little is known about [ 42 , 43 ]. For nurses, focus group interviews were used not only as a way of obtaining individual answers but also with the group interaction of participants to allow participants to explore and clarify individual and shared perspectives of specific phenomena in an open and flexible way [ 43 , 44 ]. For patients, individual interviews were chosen to receive deep insight into the respondent’s personal thoughts and feelings but also to ensure privacy, confidentiality, and a comfortable atmosphere, with concern for the vulnerability of patients with SSD [ 13 ] Moreover, individual interviews for patients were conducted to pursue personal disclosure and with consideration of the possible cognitive disabilities, such as attention and memory issues of patients with SSD [ 45 ]. Despite the potential for cognitive dysfunction, there is several benefits, such as receiving patients’ perspectives affecting engagement, involving consumers in developing interventions [ 46 ]. An exploratory approach was selected to obtain more detailed descriptions of the experiences of the participants. With this approach, we aimed to identify the phenomenon by using open-ended questions to allow nurses and patients to freely express their perceptions so that we could perform an inductive content analysis on the data without any theoretical framework or previously produced codes and categories [ 42 , 47 ].

We adhered to the consolidated criteria for reporting qualitative studies (COREQ) [ 48 ] when reporting the current study.

The study was conducted in five psychiatric outpatient clinics in Southern Finland. These clinics were selected because they offer a desirable representativeness of the study population, being part of the largest hospital area in Finland with a population of approximately 460,000 inhabitants [ 49 ]. The clinics provide mental health care for approximately 2,300 patients who have been diagnosed with a range of schizophrenia spectrum disorders (F20–29) [ 50 ]. The clinics provide both crisis and long-term mental health care and focuses on recovery and rehabilitation provided by multidisciplinary teams (psychiatrists, social workers, mental health nurses) as well as counseling and psychiatric examinations [ 51 ]. The patients’ frequency of attendance at the clinics depends on their individual treatment plan.

For nurses, a purposive sampling method was used to recruit enough participants and generate enough rich data to understand the studied phenomenon [ 52 ]. All 47 nurses who had previously been asked to use the HIP-F to assess the physical health of their patients, were invited to join the focus group interviews. These nurses had diverse backgrounds of various ages, education, and length of working experience and had the potential to provide relevant and diverse data pertinent to the research question [ 53 , 54 ]. The inclusion criteria for nurses were that they had professional education (registered nurse, mental health nurse), that they had permanent or long-term temporary employment and that they were currently working in mental health clinical practice as a patient’s primary nurse in coordinating and providing care. The exclusion criterion was being a nursing student. We aimed to sample a total of 5 focus groups, one from each study clinic, with 6–10 nurse participants in each focus group, which is close to an optimal size in focus groups to promote discussion. The sample size estimation was based on previous literature suggesting that at least four focus groups would be sufficient to identify new issues (code saturation), but more groups may be needed to completely understand these issues (meaning saturation)” [ 52 ].

For patients, a purposive sampling method was used to recruit eligible participants for the individual interviews. To be eligible to be invited to participate, the patients needed to have a diagnosis of a schizophrenia spectrum disorder, to have been treated as an outpatient in a clinic and to have been previously targeted for physical health screening with the HIP-F to elicit feedback on their experiences and perceptions [ 55 ]. We aimed to recruit 10 patients for the individual interviews since this number of interviews in qualitative content analysis was believed to allow us to reach a saturation of themes [ 56 ]. The inclusion criteria for patients were a minimum age of 18 years, being treated in outpatient clinics, having the ability to understand and speak Finnish, and a diagnosis of schizophrenia or another schizophrenia spectrum disorder F20-29 (ICD10) [ 50 ]. The exclusion criteria were having an acute psychosis or a very disturbed mental state, where participation would distress the patient or put nurses at risk.

Interview questions

Participants were asked to give their responses to open-ended questions, which focused on physical health screening with the HIP-F. The original HIP instrument, a physical health screening tool, was developed in the UK [ 32 ] and validated in Finland [ 37 ]. The HIP is a 27-item (28 for females) gender-specific profiling tool focusing on physical health and health behavior items (see Table  1 ). It enables nurses and patients to work together to assess physical health among patients with SSD. Health items (e.g., smoking status) are evaluated by categorizing them as green (e.g., nonsmoker) or red (e.g., passive smoker/smoker) depending on the result. If the health item is assessed as red, recommended actions (e.g., advice that all smoking is associated with health risks, refer to smoking cessation service) can be selected to produce a health care plan. The HIP is intended to be completed at least annually, which is the recommended frequency of screening for patients with SSD [ 12 , 50 ]. This assessment together with regular discussions with a nurse familiar with the patient might decrease barriers, for example, in talking about sensitive topics [ 17 ]. In this study, the perceptions of recommended actions have not been reported because we aimed to study only the nurses’ and patients’ experiences and perceptions of the screening procedure.

The interview questions were based on the process observation method used in a UK-based cluster-randomized controlled trial with HIP [ 36 ] and a qualitative descriptive HIP study in Hong Kong [ 31 ]. An overview of the open-ended questions is as follows:

How did you experience the physical health screening with the HIP-F?

What did you think about the physical health screening?

Which elements of assessing physical health with the HIP-F did you find most and least feasible?

How long did it take to complete the HIP-F?

What improvements could be made to physical health screening?

Recruitment

First, for potential nurse participants, one researcher (CL) provided information sessions about the study to each study clinic twice via Teams meetings. Information was given about the rights, voluntariness and confidentiality, and purpose of the study, as well as the process and the risks and benefits of participating. The main risk of participating would be the time spent participating in the research. The research would not produce immediate benefits for the nurse participants, but it would give an opportunity to influence the improvement of the usability of the HIP-F profile by giving feedback and suggestions for changes. Nurses were informed about what to expect from the focus group interviews to increase the likelihood of honesty. Participants also received written information by email before they gave their written informed consent. Nurses expressed verbally their possible desire to participate to the researcher during the information sessions and the researcher collected the consent form from the participating nurses from the study clinics at the agreed time. Of the 47 eligible nurses, 16 agreed to participate. However, one of the agreed nurses withdrew before the interview. The researcher regularly visited the study clinics (once a week), obtained informed consent from participants, and contacted the participating nurses to agree on dates for the focus groups.

Second, patients were recruited by nurses during their regular meetings in study clinics after they had been screened with the HIP-F. Nurses informed patients about the voluntariness and confidentiality as well as the purpose of the study, the process, and the risks and benefits of participating. There would be no direct benefit to the patients from participating, and no other disadvantages than the time spent on the interview. It was deemed unlikely that patient participants would experience any distress as a result of participating. Patients were given both oral and written information from nurses that participation or refusal to participate would affect their treatment in the clinic or their relationship with the clinical staff. Since cognitive problems may be associated with SSD [ 13 ], we aimed to ensure that each nurse would recruit familiar patients using an assessment of their cognitive ability and their capacity to give informed consent for participation [ 13 , 45 ]. Altogether, eight patients participated and gave their informed consent to a nurse who informed the researcher of the patient’s participation. The researcher contacted the patients to agree on dates for the individual interviews.

Data collection

Interviews were conducted using a semi-structured format to encourage participants to talk about issues that would answer the research question [ 57 , 58 ]. Before the interviews, participants gave their background information regarding gender and age. Nurses were also asked about their education and work experience in mental health care. The researcher guided the participants in the focus group interview and encouraged them to interact with each other [ 59 ]. The focus groups were preexisting work groups from clinics, and this facilitated open discussion and interaction with shared experiences in a comfortable and familiar setting [ 57 ].

All interviews were conducted between October and December 2022 by one female researcher (CL), a registered nurse (PhD student) with a long working experience with patients with SSD, who was working as a nurse manager in another unit. The researcher knew one nurse participant from an earlier HIP validation study. Participants knew that the research was a part of the researcher’s PhD study. Only the researcher and study participants were present during the interviews. Consent for recording was obtained from all participants. No pilot interviews were used. Altogether, four group interviews with nurses with two to six participants in each interview were conducted. One nurse was individually interviewed because the other consenting participant withdrew. Four of the nurses’ interviews occurred in clinic meeting rooms, and one was held via Microsoft Teams meeting. For the patients, eight individual interviews were conducted: seven by phone and one in Microsoft Teams meeting after the researcher called the patient with Microsoft Teams application. These approaches were chosen so that the subjects would experience as little harm as possible from participating in the study, for example an extra visit to the research outpatient clinic. When conducting the interviews, the current restrictions due to the COVID-19 pandemic also had to be taken into account. The duration of the interviews with nurses varied from 25 to 56 min, and the patients’ interviews lasted from 8 to 32 min. During the first two interviews, the researcher evaluated whether the questions were clear and relevant according to the information received. As no participant asked for clarification and the data were considered relevant, the questions were used in all interviews. No field notes were made during the focus group interviews and the patient interviews, but records were made about observations of nonverbal responses and reflections in the nurses’ interviews as soon as possible after each interview [ 60 ].

Data analysis

The data analysis was conducted concurrently with the interviews. The interviews, original transcriptions, and overall data analysis were in Finnish. An inductive content analysis method for audio-recorded interviews was chosen since there are no previous qualitative studies on the topic in Finland [ 61 ]. When conducting exploratory research in an area where little is known, content analysis might be suitable for the reporting of general issues in the data [ 62 ]. Furthermore, content analysis was well suited for analyzing our study topic, which is a sensitive, important, and multifaceted phenomenon of nursing [ 58 , 63 ]. Since we aimed to generate complementary perceptions and an enhanced understanding of the phenomenon, focus group and individual interview data were combined for analysis [ 64 ]. All interviews were transcribed in Word 2021 and analyzed using the five-step method by Graneheim and Lundman [ 65 ]. This approach enabled a systematic, reliable, and valid data analysis [ 58 ], which was led by research questions [ 66 ]. No software was used for coding in the analysis. First, all interviews were transcribed verbatim by one researcher (CL). Second, the researcher initially familiarized herself with the data through multiple careful readings of the transcripts to gain an understanding of the whole. Third, a sentence was selected as an analysis unit. Fourth, the text was distributed into meaning units, which were further condensed into sentences, and the condensed meaning units were abstracted and labeled with a code. Fifth, all 18 codes identified from the data were compared with each other for similarities and differences and sorted into six subcategories. The tentative categories were discussed between all authors and revised. A process of discussion and reflection resulted in an agreement on how to sort the codes.

Finally, the subcategories that were similar in terms of meaning and content were sorted into two main categories. Quotations from study participants were translated into English by one author (CL), checked by another bilingual researcher (MV) for equivalent meaning, and presented to illustrate the results (N as nurse, P as patient). From the first to the third nurses’ interview a total of 13 codes were added, and no further new codes were developed after the fourth interview. Based on code identification (88% of codes had been identified), code prevalence (90% of high-prevalence codes were identified) and codebook stability (94% of codebook changes were made), code saturation was reached after four interviews. Meaning saturation was reached at the last interview in which a new dimension of the code was identified. [52.] From patients’ interviews, code saturation was reached after the fourth individual interview and meaning saturation was achieved after the eighth interview as the repetition of content became obvious [ 52 , 67 ]. Examples of meaning units and codes are presented in Table  2 .

Demographic characteristics of study participants

A total of 15 nurses participated in the study (11 females and four males). The distribution of nurses was as follows: in the first interview there were three males and one female; in the second group there were two females; in group three there was one male and one female; the fourth interview contained one female and in the fifth interview there were six female nurses. The ages of the participants varied between 43 and 61 years, with a mean age of 49.47 years (SD 5.99). The majority were registered nurses. The length of their work experience in mental health nursing varied from one and a half years to 38 years, with a mean working experience of 21.73 years (SD 8.18). Among the patients, seven females and one male participated in the study. The ages of the participants varied between 21 and 65 years, with a mean age of 43.87 years (SD 17.27). The demographic characteristics of the study participants are presented in Table  3 .

Nurses’ and patients’ perceptions of physical health screening with the HIP-F and suggestions for improvement of screening in psychiatric settings

Both nurse and patient participants perceived physical health screening among patients with SSD to be important and the screening with HIP-F as an example screening tool to be comprehensive, but also highlighted some areas for improvement for conducting screening in psychiatric settings. Two main categories were identified from the analysis. First, the characteristics of the HIP-F were divided into subcategories: comprehensive nature , facilitating engagement , interpretation and rating of some items , and duration of screening . Second, suggestions for the implementation of physical health screening consisted of two subcategories: improvements in screening and ideas for practice . The summary of codes, subcategories and main categories is presented in Table  4 .

Characteristics of the HIP-F

Comprehensive nature.

The patients and nurses considered the HIP-F tool to be important, structured and able to comprehensively evaluate physical health. Patients found alcohol intake, activity and smoking status to be extremely important to assess among patients with SSD and expressed that it was the first time nurses had asked about several of the important items in HIP-F, including urine, caffeine intake and sexual satisfaction. Participants stated that the HIP-F includes several items, such as urine, caffeine intake, feet, and sexual satisfaction, which would not be assessed otherwise. Nurses expressed that in clinical practice a range of different nurses evaluate patients’ physical health parameters dependent on the clinical setting, however there is a current lack of appropriate structured, comprehensive screening tools. Based on the experiences of most nurses and all patient participants, all HIP-F items were considered feasible. Most of the nurses expressed that all items assessed with laboratory tests as well as body mass index (BMI), waist circumference, diet, activity, alcohol intake, teeth, smoking status, eyes, and caffeine intake were particularly feasible in physical health screening. However, despite the importance and feasibility, some HIP-F items were considered potentially challenging to talk about (e.g., sexual satisfaction) because of their sensitive nature.

The items are kind of structured here, because there is a lot, a lot of things we are asking, but they are being asked scattered in different situations, in different phases…yes, the comprehensiveness is good. (N5) Yes, there was the alcohol intake and smoking status and activity, they seemed essential. (P6) Yeah, well, it could be that for some people, the things related to their own sexual life are the same, which they don’t necessarily want to discuss. (P5) .

Facilitating engagement

All participants found the physical health screening with HIP-F to be an overall positive experience. Patients were fully aware of the significance of the relationship between physical health and mental health and were happy to have their physical health assessed. All study participants stated that physical health monitoring with the HIP-F on an annual basis is a relevant timespan for regular health checks. Based on the nurses’ and patients’ experiences, the participants felt that conducting the HIP-F together in an interactive way facilitates engagement with physical health screening and health promotion. The participants described this working model to be more desirable, making health checks easier and enabling patients to have feedback on their state of health immediately. Furthermore, nurses stressed the importance of engaging patients with SSD in their own care, something that is supported with HIP-F screening. The patients and most of the nurses expressed that the screening increased discussion in general, and discussion about physical health between nurses and patients in areas that would otherwise not be discussed. According to the study participants, screening improved information, raised some thoughts and increased awareness of physical health and health behavior in general and particularly about the items that affect patients with SSD. Nurses experienced that especially with patients with SSD it is more beneficial to conduct the screening together during a discussion because of patients’ potential cognitive challenges. The participants described that screening helped to identify physical health illnesses which helped them to start adequate treatment for the patient. Based on the participants’ experiences, screening might motivate patients to increase their activity, support physical health, and strengthen already healthy life behaviors.

Well, I wouldn’t mind if this assessment would be conducted once a year. (P5) Yes, it is very good, especially with our psychosis patients, that we are engaging them in treatment, especially in somatic health. (N5) Yes, it raised at least a little discussion about physical health. (P1) In fact, we caught quite a hypertension disease, so that was the end of it. (N2) .

Interpretation and rating of some items

Most of the nurse participants experienced HIP-F as arduous to conduct and challenging in screening, especially without routine. Nurses described the HIP-F to be too complicated and too precise and that some items were difficult to assess; for example, items pertaining to urine, fat intake (diet), five portions a day (diet), and activity were found to be difficult to assess. Nurses stated that the amount of urine passed is difficult to assess just by asking patients about it. Nurses also experienced that screening with HIP-F was too precise because nurses believed that their main work task is to evaluate mental health state, not physical health. Furthermore, some nurses were not familiar with the measurement units for some HIP-F items. However, patient participants expressed that HIP-F was easy to conduct. Moreover, nurses experienced that the HIP-F was ambiguous and partly difficult to interpret. Nurses described that some items, units of measure, and cutoff values were unclear; for example, the items for fluid, caffeine and alcohol intake, as well as the items concerning feet and urine, were overall experienced to be strange, and the significance of urine as an item remained unclear. Nurses stated that for some items, they could not find an adequate alternative to the cutoff values. This made most of the nurses consider the HIP-F to be ambiguous, which made conducting it frustrating. Some of the nurses experienced that the HIP-F also included items that were not feasible in physical health screening, such as safe sex, breast examination (men), body temperature, five portions a day (diet), caffeine intake, liver function, sexual satisfaction, BMI and feet check.

Some items felt weird, perhaps I didn’t quite understand why these were being asked so precisely in a mental health care context. (N10) I think one challenge was for example those…there are lipids or blood sugar, so, how was it, it’s quite a long time since you have done these…I had to check from the patient record how they are assessed in Finland, are they millimole or what, to find the congruent values and what are they then. (N1) The item alcohol intake is weird, there is no alternative to choose if you don’t use alcohol at all. (N9) It was a quite an easy questionnaire. Yes, it felt like that, and truly clear. (P6) .

Duration of screening

Nurses found the HIP-F too broad and time consuming to be used in clinical practice in a psychiatric setting and not feasible to be implemented in Finnish mental health services. Nurses described that although physical health screening among patients with SSD is crucial and the HIP-F includes important health items, it is too long to be used in clinical practice. Even those nurses who were first motivated to conduct screening, did not continue screening with several patients when they found out how long the screening took. Nurses reported the heavy workload of caring for many patients and their main tasks in the mental health treatment setting. Nurses experienced that the screening with HIP-F took all the time from the scheduled appointment and no time was left for discussion about the mental health of the patients, so they decided to choose to assess possible psychotic symptoms or patients’ functioning ability. Furthermore, nurses described that during screening, it was found that some health parameters, for example, annual laboratory tests, had not been conducted on patients, even if they should have been conducted according to the clinics’ regular procedures, and this challenged and delayed the screening. Nurses stated that conducting the HIP-F screening takes from 45 to 60 min, which they felt was too much for patient meetings, especially if patients only seldomly have appointments. Some nurses experienced the HIP-F to be easy to use but still too time consuming. Whereas, some of the patients had been prepared for a longer assessment and expressed that the HIP-F screening was suitable in length.

Well, I made one at the beginning, and when I noticed that it was arduous and how much time it takes, maybe that’s when the enthusiasm faded. (N9) I’m guessing 45–60 min, I haven’t recorded it, but usually we have 45-minute appointments and sometimes it takes slightly more, and it took me the whole time to do it. (N10) I was prepared for a longer questionnaire, but it wasn’t. (P5) .

Suggestions for the implementation of physical health screening

Improvements in screening.

Nurses suggested lightening and condensing the content of the HIP-F. They described that screening could be shorter and that some HIP-F items could be left out. For example, one nurse expressed that asking about temperature in physical health screening is pointless unless the patient has a cold. However, some of the nurses and all patients felt that no improvements were needed in screening for implementation. Some nurses suggested that the cutoff values could be removed, and the items could remain just as a checklist for discussion. However, other nurses thought that the cutoff values should be retained in screening and that there was nothing to develop or leave out. In addition, some nurses stated that items, such as blood pressure, could be assessed numerically but that there could be additional space for open narrative text. On the other hand, some nurse participants expressed that the assessment might be ineffective without cutoff values. Furthermore, participants expressed that some items could be assessed differently. Nurses suggested that, for example, instead of asking patients about their amount of urine output, patients could be asked about hematuria, and instead of asking about teeth checks, patients could be asked if they are brushing their teeth regularly. One patient suggested that instead of assessing activity levels, patients could be asked what kind of activity they prefer. Another patient suggested that sexual satisfaction could be assessed more broadly, taking sexual diversity into account. In addition, nurses suggested that the layout and order of the items could be different: the green and red areas could appear in green and red on the HIP-F form, and a yellow area could be added. This was considered to be more effective in demonstrating to patients their physical health state and highlighting possible areas which should be improved, rather than just discussing about the results of the HIP-F screening. Nurses stated, that adding yellow areas in HIP-F would show patients that although the result is still in a healthy area, if no improvements are made, subsequent physical health problems are likely.

I would remove temperature. It should be normal if you don’t have cold. (N12) I wouldn’t directly remove anything. (N5) Yes, I said that I could take all these cutoff values out of here and keep it just as a check list so these would be checked with a patient at least once a year. (N3) However, if there were no cutoff values for activity, sleep and smoking, then… I think these traffic light systems would be good if you could get it in color so that if it is shown to the patient who you now have this in red, that you should probably do something about it. (N1) Therefore, it could be three-part if there were the traffic light like you said just now, if it was the yellow light in between as well. (N4) .

Ideas for practice

Most of the nurses expressed that the HIP-F includes basic physical health items and that conducting health screening with the HIP-F in clinical practice does not require any additional training. However, one nurse expressed that education for talking about sensitive topics, such as safe sex and sexual satisfaction with patients, is needed. Some of the nurses suggested that the HIP-F could at least partly be completed beforehand by the patient before their clinic appointment so the screening would not take too much time from the appointment. One nurse suggested that this could happen by using an electronic version (i.e., a software application) instead of a paper questionnaire, especially for younger patients with technical skills. In addition, some of the nurses suggested a separate, longer appointment for patients in the clinics for physical health screening.

These are just basic things, there is no need for additional training. (N9) Yes, some could be doing it in advance, and some would be that who you would measure the blood pressure or something together…I think it would be reasonable, that it would already be…the patient would have already filled it in beforehand as best they could and perhaps thought about these things in peace at home, so that would speed it up in the appointment. (N10) .

As far we are aware, this study is the first study to explore perceptions among nurses and patients with SSD of physical health screening. We used the HIP-F profile as an example of a physical health screening tool. We aimed to identify possible areas for improvement in the tool and screening procedures. The study reveals several important aspects of how nurses and patients perceive physical health screening. At the same time, the HIP-F tool was also found to be arduous and time consuming, which led to recommendations on key improvements to the tool and physical health screening procedures.

Our study showed that nurses perceived physical health screening to be important [ 27 , 68 ] and that they appreciated the comprehensive physical health screening with HIP-F [ 28 , 31 ]. Nurses expressed that several HIP-F items were particularly feasible. Patients also found physical health screening beneficial in improving their awareness of physical health, which can potentially trigger health promotion conversations between nurses and patients [ 18 , 28 , 31 ]. Patients in our study were interested in and satisfied with having regular assessment of their health status [ 30 , 33 , 69 , 70 , 71 ]. Indeed, the theme ‘facilitating engagement’ was identified as a crucial factor for successful health screening in both nurses’ and patients’ data [ 26 , 27 , 30 ]. Our results are encouraging since previous studies have revealed that negative attitudes among nurses and a lack of support may restrict systematic health checks in mental health services [ 30 , 31 ]. In some countries, for example Turkey [ 72 ], nurses have stated that patients are not interested in participating in health checks. Positive perceptions among nurses towards any new intervention, including physical health screening, are important in facilitating the integration of new practices into patient care [ 73 , 74 ].

Some divergent perceptions were also found in nurses’ and patients’ perceptions in our study. Patients did not identify any infeasible or unclear items in their physical health assessment while nurses identified items regarding urine, caffeine intake, temperature, safe sex, or sexual satisfaction not meaningful or difficult to complete [ 37 ]. The finding regarding urine problems in patients with SSD is interesting as polydipsia may lead to water intoxication [ 75 ]. Patients with SSD are also 29 times more likely to get a urinary tract infection, which is a precipitating factor for acute psychosis [ 76 , 77 ]. Sometimes nurses perceive their subjective clinical view as more crucial in assessing patients’ health status than using the objective results of a standard screening tool [ 78 ]. In the future, the core reason for this discrepancy should be explored to fully understand nurses’ avoidant behavior in conducting systematic health screening with patients. This is important because our current results may be contradictory with the reality. For example, although health screening was seen as an important task in patient care, the nurses complained that using HIP-F took too much time, which made them avoid patient health screening. For example, in the current study out of 47 nurses who had been asked to conduct HIP-F screenings with their patients, only 16 were willing to use the HIP-F screening tool and monitor their patients’ physical health. This finding is interesting as it highlights the benefit of collaboration between nurses and patients when conducting screening together, as reported in previous studies [ 35 , 36 , 79 ]. At the same time, nurses expressed that the screening process was unclear and difficult to follow [ 17 , 29 , 80 ]. To adopt healthy lifestyles, e.g. physical activity and nutrition, nurses should integrate improvement initiatives for patient physical health into daily practice by making small changes [ 71 ]. In this study, however, nurses perceived assessment of patient physical health using HIP-F as a separate task, which caused double recording in patients’ health records. This finding concurs with earlier studies that health screening is poorly implemented into mental health practice [ 24 , 25 ].

In our study, nurses suggested condensation of the screening and revising the assessment with more culturally-understandable units of measurements. Item terminology should also be better suited into clinical practice [ 31 ]. To improve patients’ ability to understand the results of their health assessment, nurses suggested use of ‘a yellow traffic light’ as already used in the Chinese Health Improvement Profile (CHIP) [ 34 ]. Therefore, based on the data, some specific health components need a special effort, such as oral and general hygiene [ 72 ]. In addition, training in talking about such sensitive topics was suggested, such as topics around sexual health [ 81 , 82 ]. In addition, general training is needed to improve nurses’ understanding of the value of specific health screening items.

All these development ideas are feasible and realistic, but still leave us without a conclusion as to why these good ideas are not realized in daily practice. One reason for this may be nurses’ training needs [ 83 ]. For example, in our study, nurses had worked in mental health setting on average for over 20 years and still some health issues, e.g. adverse effects of medication, patients’ difficulties observing physical health concerns and lifestyle typical for patients with SSD, were unclear for nurses [ 2 , 3 ]. Furthermore, organizational culture can affect nurses’ self-confidence in conducting screenings [ 84 ] and our research results revealed that nurses have to prioritize the time used on an appointment between mental health and physical health assessment. Patients with SSD may not have the ability to fill the screening assessment by themself before the appointment [ 45 ] and may require the collaboration with a nurse. Moreover, possibilities of using digital technology [ 85 ] in physical health screening may be underrated.

Trustworthiness

We reflected on the trustworthiness of our study in terms of its credibility, dependability, conformability, and transferability [ 86 , 87 ] as follows. Credibility was confirmed by selecting the context and participants who had different experiences of the topic. By using focus groups and individual interviews in the data gathering, we gained knowledge of various experiences, which increased the possibility of shedding light on the research question from a variety of perspectives [ 40 ]. Credibility was further strengthened through presenting the coding process by illustrating how the meaning units from the interviews, extracted codes and categories were produced. The similarities and differences of the research findings are shown with representative quotations from the transcribed text. Dependability was improved through open dialogue among the authors and consistently during the data collection by asking all of the participants similar questions [ 63 ]. Conformability was achieved by reporting the research steps carefully. Transferability was increased by presenting a clear and distinct description of the context, recruitment and characteristics of the participants and of the data collection and data analysis.

Study strengths and limitations

The current study has some limitations that potentially impact the trustworthiness and transferability of the findings. Participants were recruited by a purposive sampling method, which likely caused bias by recruiting those more interested in discussing the topic [ 88 , 89 ]. Although nurses were trained to understand the meaning of specific inclusion and exclusion criteria for the patients, selection bias may still have occurred in the patient recruitment process and patient data may be biased toward those patients who are more motivated, capable and collaborative to join initiatives. All patient participants were diagnosed with a psychotic disorder (F20–29), but the sample size was relatively small and might limit the transferability of the findings to patients with SSD. Similarly, participants were recruited in one hospital only and due to their narrow ethnic background group, this may also may reduce the transferability of the findings outside Finland.

The qualitative study design itself might have imposed some limitations in several phases during the study. The researcher’s presence during the interviews may have affected the subjects’ responses, even if this is often unavoidable in qualitative research [ 88 , 90 ]. The researcher conducting the interviews had a deep understanding of the research topic based on her experience in working with persons with SSD. At the same time, having strong pre-assumptions may have caused bias due to a lack of openness to the topic, hence reducing the credibility. Furthermore, it is possible that the short duration of interviews limits the depth of understanding of the topic. Similarly, the small number of nurse participants in some of the focus groups is likely to have limited the potential for productive group discussion. Even though the interviews were conducted individually with patients, it is possible that the patients were hesitant to openly share their views to a person who represents a staff member. Moreover, the transcripts of the digitally recorded interviews were not returned to nurses or patient participants, so member checking of transcripts and categories was not carried out. Formal backtranslation was not conducted for the data, which might also decrease the credibility of the results. Regardless of these limitations, the study has some strengths and consists of rich and informative data regarding the perceptions of nurses and patients.

Our study results offer a novel diversity of perceptions from nurses and patients toward physical health screening in mental health settings. Patients with schizophrenia spectrum disorders are willing to participate in physical health screening. Although nurses found the HIP-F to be too long, they showed interest in assessing their patients’ physical health and suggested improvements to develop screening to improve its feasibility in clinical practice. Physical health screening should be clear, easy to use and relatively quick. Developing and improving health screening to better suit clinical practice, for example in their length, would further support professionals in conducting and encouraging patients to participate in physical health screening. With this detailed knowledge of perceptions of screening, further research is needed to understand what factors affect the implementation fidelity of physical health screening in clinical mental health practice and to gain an overall understanding on how to improve such implementation.

Implications

Several studies have emphasized the position of nurses in the assessment of physical health [ 28 , 68 , 73 ]. In order for patients to benefit from the results of physical health assessments in clinical practice, it is crucial that the treatment guidelines are followed, assessment results are available in patient record systems and actions are completed according to health promotion plans. Our findings can be used in supporting professionals to collaborate with patients to participate in physical health screening. Our results are also useful in planning curriculums in nursing education and clinical settings. Finally, our results should encourage nurses to implement regular physical health screenings for patients with SSD followed by appropriate effective health promotion interventions. For effective physical health screening and preventing physical comorbidity and premature deaths, the perceptions explored in our study can be taken into consideration by those who develop screening procedures and health screenings for clinical practice.

Data availability

Data generated during and/or analyzed during the study are not publicly available due to ethical restrictions and privacy.

Abbreviations

Body mass index

Chinese Health Improvement Profile

consolidated criteria for reporting qualitative studies

Coronavirus

electrocardiogram

Health improvement profile

Finnish health improvement profile

human immunodeficiency virus

Helsinki University Hospital

10th revision of the International Classification of Diseases and Related Health Problems

Metabolic Syndrome Screening Tool

metabolic syndrome

Nursing Research Center

The physical health check

Doctorate of Philosophy

quality improvement

randomized controlled trial

Standard deviation

schizophrenia spectrum disorder

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Acknowledgements

We would like to thank all patients and nurses for their indispensable assistance in conducting this research.

Helsinki University Hospitals (HUH) Nursing Research Center (NRC) and HUH Funding, Psychiatry supported this study by granting a paid research period for the first author (CL).

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CL designed the study, collected the data, contributed to data input, analyzed the data, and contributed to the writing of the manuscript and all tables. MV led the study design, data analysis, and writing of the manuscript. DB contributed to the study design, the data analysis, and writing of the final manuscript. All the authors have read and approved the final manuscript.

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Camilla, L., Daniel, B. & Maritta, V. Nurses’ and patients’ perceptions of physical health screening for patients with schizophrenia spectrum disorders: a qualitative study. BMC Nurs 23 , 321 (2024). https://doi.org/10.1186/s12912-024-01980-3

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Exploring factors affecting the unsafe behavior of health care workers’ in using respiratory masks during COVID-19 pandemic in Iran: a qualitative study

• Azadeh Tahernejad 1 ,
• Sanaz Sohrabizadeh   ORCID: orcid.org/0000-0002-9170-178X 1 &
• Somayeh Tahernejad 2  

BMC Health Services Research volume  24 , Article number:  608 ( 2024 ) Cite this article

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The use of respiratory masks has been one of the most important measures to prevent the spread of COVID-19 among health care workers during the COVID-19 pandemic. Therefore, correct and safe use of breathing masks is vital. The purpose of this study was to exploring factors affecting the unsafe behavior of health care workers’ in using respiratory masks during the COVID-19 pandemic in Iran.

This study was carried out using the conventional qualitative content analysis. Participants were the number of 26 health care workers selected by purposive sampling method. Data collection was conducted through in-depth semi-structured interviews. Data analysis was done using the content analysis approach of Graneheim and Lundman. This study aligns with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist and was conducted between December 2021 and April 2022.

The factors affecting the unsafe behavior of health care workers while using respiratory masks were divided into 3 main categories and 8 sub-categories. Categories included discomfort and pain (four sub-categories of headache and dizziness, skin discomfort, respiratory discomfort, feeling hot and thirsty), negative effect on performance (four sub-categories of effect on physical function, effect on cognitive function, system function vision, and hearing), and a negative effect on the mental state (two subcategories of anxiety and depression).

The findings can help identify and analyze possible scenarios to reduce unsafe behaviors at the time of using breathing masks. The necessary therapeutic and preventive interventions regarding the complications of using masks, as well as planning to train personnel for the correct use of masks with minimal health effects are suggested.

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The COVID-19 pandemic has brought unprecedented challenges to healthcare systems worldwide, requiring Health Care Workers (HCWs) to adopt strict infection control measures to protect themselves [ 1 ]. Among these measures, the proper use of respiratory masks plays a crucial role in preventing the transmission of the virus [ 2 ]. Iran was among the initial countries impacted by COVID-19. In Iran, as in many other countries, HCWs have been at the forefront of the battle against COVID-19, facing various challenges in utilizing respiratory masks effectively [ 3 ]. Over 7.6 million Iranians have been infected by the SARS-CoV-2 virus, with more than 146,480 reported deaths as of August 2023 [ 4 ]. Amid the COVID-19 pandemic, Iran’s healthcare system experienced significant impacts as well [ 5 ].

Despite the passage of several years since the onset of the COVID-19 pandemic, new variant of the virus continues to emerge worldwide. It is crucial to be prepared for future pandemics and similar biological disasters.

Due to the SARS-CoV-2 virus transmission via respiratory droplets, the use of masks and personal protective equipment is essential [ 6 ]. The World Health Organization recommended the use of medical masks, such as surgical masks, for HCWs during the COVID-19 pandemic [ 7 ]. These masks are designed to provide a barrier to respiratory droplets and help reduce the transmission of the virus [ 8 ].

Few studies have been devoted to negative aspects of using respiratory masks in human being. The physiological and adverse effects of using PPE have been investigated in a systematic review study [ 9 ]. In another review study, of skin problems related to the use of respiratory masks were studied [ 10 ]. Also, in some studies, a significant relationship has been found between the time of using masks and the severity of the adverse effects of using masks [ 11 ]. In all the above studies, questionnaires have been used to check the prevalence of these adverse effects among HCWs.

Incorrect use of masks is considered as the unsafe behaviors of HCWs. In some studies, unsafe behaviors are defined as disobeying an accepted safe method while working with the capability of causing an accident [ 12 ]. Since the reasons for unsafe behavior are complex and multifaceted, their prevention requires a clear understanding of important and influential factors. In various studies about the prevalence of unsafe behaviors in work environments, several factors such as individual characteristics, psychological aspects, safety conditions, perceived risk, and stress have been introduced as effective factors in demonstrating the unsafe behaviors [ 12 , 13 , 14 ]. However, the findings are still unable to provide a deep understanding of the underlying causes and motivations contributing to unsafe behaviors.

In the present study, unsafe behaviors while using respiratory masks is defined as the behaviors that are seen by some HCWs, which reduce the effectiveness of respiratory masks due to improper placement on the face or hand contact with the mask [ 15 ]. Some researchers in their studies indicated that other unknown factors are also effective in the unsafe behaviors [ 14 ]. However, the findings are still unable to provide a deep understanding of the underlying causes and motivations contributing to unsafe behaviors. Qualitative studies are needed to answer these questions and determine its causes. Hence, the present study is aimed to explore the factors affecting the unsafe behavior of HCWs while using respiratory masks during the COVID-19 pandemic through a qualitative study.

Study design

This study was carried out using conventional qualitative content analysis (item 9 in COREQ checklist). The interviews explored HCWs’ experiences regarding factors affecting the unsafe behavior in using respiratory masks during covid-19 pandemic in Iran. This research adheres to the guidelines outlined in the Consolidated Criteria for Reporting Qualitative Research (COREQ).

This study was conducted in government and non-government hospitals in Tehran, Mashhad and Rafsanjan that admitted patients with COVID-19 disease. The authors’ place of work and access to participants were important causes of choosing the settings. Moreover, these hospitals experienced a large amount of patients seeking healthcare during the Covid-19 pandemic. This study was performed between December 2021 and April 2022.

Participants

In this study, interviews were performed with healthcare workers (HCWs) including nurses, physicians and hospital workers who had direct contact with patients that used masks for more than 4 h in each work shift. Also, participants frequently utilized surgical masks. Among them, few employed filter masks or a combination of both types. The inclusion criteria were people with experience of using respiratory masks for more than one year and the ability to express their experiences and point of views. The sole exclusion criterion of the current study was a lack of interest in further participation. The participants were selected using purposive sampling method (item 10 in COREQ checklist) in which the researcher selected the most informed people who could explain their experiences regarding the research topic [ 16 ]. The number of participants was determined based on the data saturation principle in which no new concepts were obtained. Data saturation was achieved after 24 interviews, and to ensure saturation, two more interviews were also performed. Finally, the total number of participants was 26 people (items 12–13 in COREQ checklist).

Data gathering

Data collection was performed through in-depth face to face (item 11 in COREQ checklist) semi-structured interviews. The first author, who received training in qualitative research methods, conducted all the interviews (items 1–5 in COREQ checklist). The participants were presented with information about the research topic, objectives, and the researchers’ identities. The researcher thoroughly described the study procedure to those who consented to participate, and written informed consent was obtained from all participants (items 6–8 in COREQ checklist). The data was gathered in the workplace of the participants. Additionally, demographic data of the participants was documented (items 14–16 in COREQ checklist). At first, 5 unstructured interviews were done to extract the primary concept, and then, 21 semi-structured interviews were conducted using the interview guide. The interviews were done in a quiet and comfortable place. The interviews started with simple and general topics and were gradually directed to specific questions based on the answers. Some of the questions were: Based on your experience, what factors are effective in not using your mask safely?

New concepts were extracted from each interview, and this process continued until data saturation was reached. After obtaining permission from the participants to record the interviews, the implementation of the interviews was done immediately after the completion of each interview to increase the accuracy of the obtained data. The duration of the interviews was between 15 and 40 min (30 min on average). Field notes were made during or after the interview and transcripts were returned to participants for the comments and corrections (items 17–23 in COREQ checklist).

Data analysis

Data analysis was done using the five-step content analysis approach of Graneheim and Lundman [ 17 ]. Immediately after conducting each interview, the recorded file of the interview was transcribed in Word software. The interview text was read several times and based on the research question, all the content related to the participants’ experiences were extracted in the form of meaning units. In addition, notes were written in the margins of the text and then, the abstracted meaning units were designated as the code. Subsequently, the compiled codes were categorized into subcategories according to similarities. This process was repeated for all transcribed interviews until the main categories were established. The whole data analysis process was carried out by the researchers. Direct quotes from the interviews included in the results section to elucidate the codes, categories, and themes. (items 24–32 in COREQ checklist).

Trustworthiness

The strategies of transferability, dependability, credibility outlined by Lincoln and Guba were employed to achieve data trustworthiness [ 18 ]. Credibility and dependability were established through data triangulation approach, which involved interviews and field notes. Furthermore, peer check and member check were applied for ensuring credibility. To obtain member check, the transcribed interviews and codes were shared with some participants to receive their feedbacks. In the case of peer check, the research team and independent experts were verified the extracted codes and sub-categories. Data transferability and Confirmability were met through the detailed explanation of the research stages and process.

Women were 50% of all participants and the highest frequency of education was bachelor’s degree ( n  = 17). Furthermore, the highest amount of work experience was 22 years (Table  1 ).

In the present study, 689 initial codes were identified in the initial writing, and after removing duplicate codes and cleaning, the number of final codes included 132 codes. After reviewing and analyzing the data, the factors affecting the unsafe behavior of HCWs while using respiratory masks were divided into 3 main categories and 8 sub-categories (Table  2 ). Categories included discomfort and pain (four sub-categories of headache and dizziness, skin discomfort, respiratory discomfort, feeling hot and thirsty), negative effect on performance (four sub-categories of effect on physical function, effect on cognitive function, system function vision and hearing), and a negative effect on the mental state (two subcategories of anxiety and depression).

Pain and discomfort

Some of the participants reported that the reason for improper and unsafe use of the mask is feeling pain and discomfort, and the reasons include the four subcategories of headache and dizziness, skin discomfort, respiratory discomfort, discomfort caused by heat and thirst.

Skin disorders

The side effects of the mask on the skin are of the important factors in this category. Thus, some participants, due effects of the mask to their skin, limited the use of the mask or did not use it correctly. Among the skin problems experienced by the participants were acne and skin sensitivities, which in some cases required drug treatments. The subcategory of skin sensitivities such as itching and burning was mentioned by more than 70% of the samples as the most important cause of discomfort.

“…I can’t help touching my mask. After half an hour when I put on the new mask, my face, especially my nose, starts to itch badly and I often have to blow my nose from under the mask or over the mask with my fingers, palm or the back of my hand…” (P1)

Respiratory disorders

Most of the participants in the study noted to problems such as difficulty in breathing, heart palpitations, carbon dioxide and unpleasant smell inside the mask as the most important respiratory problems. Therefore, it can be one of the important reasons for removing the mask and unsafe behavior in using the mask.

“… at any opportunity, I remove my mask to take a breath…” (P15)

Feeling hot and thirsty

Temperature discomfort, especially in long-term use and when people had to use two masks, was mentioned as an annoying factor.

“… the heat inside the mask bothers me a lot, I sweat and the mask gets wet… no matter how much water I drink, I still feel thirsty…” (P6)

Unfitness of mask with the individual’s face

Another important point extracted from the interviews was the importance of when to use the mask. In this way, as the time of using the mask increased, the person’s feeling of discomfort due to the mismatch between the belt and the mask increased, because the feeling of pressure and pain on the nose, behind the ears, and the face usually occurs several hours after wearing the mask. Several participants reported experiencing discomfort and headaches after wearing the mask. Although These headaches were often short-term and didn’t have long-term complications according to the participants’ reports, they could affect the work performance of HCWs and their behavior in the correct use of respiratory masks.

“…. After a while, the mask puts pressure on my nose and parts of my head and face. Sometimes I touch and move it unintentionally…” (P3) “… if I don’t move the mask on my face, I get a headache because the mask strap puts pressure on my head and nose…” (P21)

Effects on performance

The participants reported that wearing a mask for a long time is one of their important problems in performing their duties, and one of the main categories extracted from this study is the effects on performance, which includes the physical, cognitive, vision and hearing performance.

Effects on physical performance

The effect on the physical performance of HCWs had less effect on their unsafe behavior in using masks than other cases. But when masks were used for a long time and people were more physically tired, sometimes people removed the mask to increase their ability to perform physical work.

“…when I wear a mask, it becomes difficult for me to walk and do physical work, as if I am short of breath…” (P17)

Effects on cognitive function

It was the most frequent subcategory. Because when people feel uncomfortable, their attention decreases and part of the working memory is involved in feeling uncomfortable. Of course, it should be noted that many of the participants in the present study reported the decrease in alertness to be an effective factor in reducing their cognitive performance.

“…When I take off the mask, I can focus better on my work. Especially when I wear it in longer times, I get tired. Many times, I move the mask to finish my job faster…” (P8)

Based on the participants’ point of views, data perception (understanding information through the visual and auditory systems) decreases while using the mask. However, the negative effect of mask on the visual performance affects the unsafe behavior of the HCWs in the incorrect use of the mask and moving it on the face more than other cases. Most of the people who used glasses reported the steam condensation under the glasses as an important cause of discomfort and interference of the mask with their work duties.

“…Using glasses with a mask is really annoying. I have eye pain and burning, and there is always a fog in front of my eyes…” (P2)

Effects on mental status

Among the other main categories extracted in this study is the effects on mental status, which includes the subcategories of depression and anxiety. The negative effect of the mask on the mental state unconsciously affects the person’s behavior in using the respiratory mask.

Some of the participants in this study reported feeling anxious while wearing the mask for various reasons. Therefore, they refuse to wear masks, although they have no justification for doing so. In many cases, the participants in this study expressed that during higher psychological stress, they suffer more from wearing masks and tend to wear them improperly.

“… Sometimes I distractedly take off my mask so that the other person hears my voice better. However, there are many patients, So I am afraid of getting infected. Sometimes I have to speak loudly and this makes me furious … I worry about making a mistake or misunderstanding the conversation, and …” (P4)

One of the most important factors mentioned as a cause of depression was harder communication with colleagues and patients while wearing a mask. This occurs by increasing the physical and mental workload and placing people in social isolation. In this situation, HCWs sometimes consciously take off their masks, so that they can communicate with each other more conveniently.

“…When I wear a mask, I get tired when talking to others. I prefer not to talk to my colleague. Sometimes I don’t pay attention, I take the mask down so they can understand me …” (P5)

To the best of our knowledge, this research is one of the first qualitative studies to extract the experiences of HCWs for explaining the factors affecting the unsafe behavior of HCWs in using respiratory masks during the COVID-19 pandemic in Iran. Although many reasons can cause the unsafe behavior of HCWs in the correct use of respiratory masks in the hospital, according to the present results, three main categories include discomfort and pain, effects on performance, effects on mental status. Skin and respiratory discomforts and the negative effect of the mask on cognitive functions are among the most important factors affecting the unsafe behavior of HCWs in the field of correct use of respiratory masks.

Based on the present study, the participants experienced discomfort and pain while using the mask, and this was one of the important factors of unsafe use of respiratory masks. Discomfort while wearing masks has been confirmed in several studies [ 19 ]. Additionally, in a similar study, researchers found that wearing face masks during the COVID-19 era heightens the discomfort experienced by HCWs [ 20 ]. Some studies have delved into these discomforts in greater detail. For example, the prevalence of skin disorders among HCWs using PPE during the COVID-19 pandemic was reported to be significant [ 21 ]. Some researchers also reported significant prevalence of respiratory disorders and headaches when using PPE [ 22 ]. The findings of a study suggested that a novel form of headache has emerged among HCWs when using a mask during the COVID-19 pandemic. Both exacerbation of existing headaches and the onset of new headaches have been observed to rise with mask usage, irrespective of the use duration [ 23 ]. In some studies, a significant percentage of people reported feeling thirsty and dehydrated after long-term use of respiratory masks [ 24 ]. Several studies reported disturbing rates of perspiration from prolonged use of respiratory masks [ 25 , 26 , 27 ]. A similar study reported that prolonged exposure to masks and protective gear, especially among HCWs, can lead to various issues such as acne, skin irritation, cognitive impairment, and headaches [ 28 ]. According to the results of the present study, discomfort often causes HCWs to move the mask and disturb the correct fitness of the mask on their face.

The results of the present study indicated that respiratory masks have the ability to hinder the work performance of their users. Various studies have confirmed the adverse effect of respiratory masks on HCWs performance. A similar research indicated that respiratory masks reduce physical performance [ 29 ]. Several studies have highlighted the issue of mask users’ ability to see and read being hindered by fogging of glasses [ 22 , 27 , 30 ]. The feel of weakness to perform cognitive tasks has also been reported in various studies [ 31 , 32 ]. An increase in physical fatigue has been mentioned in some studies as an adverse effect of respiratory masks [ 27 , 31 ]. A research showed the effect of respiratory mask on hearing and visual performance [ 33 ]. Another study reported that high-protection respiratory masks reduced physiological and psychological ability, especially if the workers perform physical work [ 34 ].

The third category is related to the negative impact on the psychological state of HCWs. Some studies noted the use of some PPE, including respiratory masks, as one of the possible reasons for the increase of mental health problems among HCWs [ 35 , 36 ]. Before the prevalence of the COVID-19 virus, the hypothesis of the negative effect of respiratory masks on the mental state of people was investigated and confirmed by some studies [ 37 ]. Furthermore, one study reported that wearing respiratory masks leads to an increase in anxiety [ 38 ].

The non-ergonomic nature of respiratory masks (the lack of suitability of masks for people for long-term use) can affect the effectiveness of respiratory masks by encouraging people to perform unsafe behaviors in using respiratory masks [ 39 ]. An important point was that the attitude and knowledge of health care works regarding the use of respiratory masks were not identified as the cause of unsafe behavior of HCWs. However, this factor has been reported in some previous studies as a reason for people not using PPE properly [ 40 ]. The COVID-19 pandemic situation and the extensive information collected about this pandemic may improve the level of awareness and the attitude of the HCWs.

The escalation in infection rates among HCWs, despite receiving training and utilizing personal protective equipment, served as a catalyst for this research endeavor. So far, there has been a deficiency in the context-specific research that could offer a more profound understanding of this issue. Therefore, the outcomes of this qualitative study may prove beneficial in enhancing the design and execution of respiratory protection programs for HCWs in infectious hospital departments or during similar pandemics.

Implications for nursing practice

It is expected that the findings of this study can provide a better understanding of the factors influencing the unsafe behavior of HCWs while using masks. Furthermore, it can be used as a preliminary study to evaluate the effectiveness of safety and infection control programs in hospitals in the COVID-19 pandemic and similar disasters in the future.

Discomfort and pain, effects on performance, and effects on mental status are important factors for unsafe behavior of HCWs’ in using respiratory masks. Our results could contribute to the identification and analysis of possible scenarios to reduce unsafe behaviors in the use of respiratory masks. Accordingly, it is recommended to provide the necessary therapeutic and preventive interventions regarding the complications of using masks. Planning to reduce the side effects of masks and training personnel on the correct use of masks with minimal health effects are recommended as well.

Limitations

The physical and cognitive workload of HCWs which increased during the COVID-19 pandemic [ 41 ], had possible impacts on the work ability of the staff [ 42 ]. Therefore, their explanation about the negative effects of wearing masks may be affected by their specific working conditions.

Data availability

The datasets used during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to appreciate all participants who accepted our invitations for interviews and shared their valuable experiences with us.

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Azadeh Tahernejad & Sanaz Sohrabizadeh

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All authors have read and approved the manuscript. AT, SS, ST are responsible for the overall conceptualization and oversight of the study, including study design, data interpretation, and manuscript write-up. AT is responsible for the first draft. All authors reviewed and provided feedback on the manuscript prior to submission.

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Tahernejad, A., Sohrabizadeh, S. & Tahernejad, S. Exploring factors affecting the unsafe behavior of health care workers’ in using respiratory masks during COVID-19 pandemic in Iran: a qualitative study. BMC Health Serv Res 24 , 608 (2024). https://doi.org/10.1186/s12913-024-11000-4

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General practitioners’ management of mastitis in breastfeeding women: a mixed method study in Australia

• Lisa H. Amir 1 , 2 ,
• Sharinne B. Crawford 1 , 3 ,
• Meabh Cullinane 1 , 4 &
• Luke E. Grzeskowiak 5 , 6  

BMC Primary Care volume  25 , Article number:  161 ( 2024 ) Cite this article

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Metrics details

Mastitis is a common reason new mothers visit their general practitioner (GP). In Australia, the Therapeutic Guidelines: Antibiotic provides practical advice to GPs managing a range of infections, including mastitis. It is not known if Australian GPs prescribe antibiotics and order investigations as recommended for the management of mastitis.

A convergent mixed methods design integrated quantitative analysis of a general practice dataset with analysis of interviews with GPs. Using the large-scale primary care dataset, MedicineInsight, (2021–2022), antibiotics prescribed and investigations ordered for mastitis encounters were extracted. Mastitis encounters were identified by searching ‘Encounter reason’, ‘Test reason’ and ‘Prescription reason’ free text field for the term ‘mastitis’; ‘granulomatous mastitis’ was excluded. Clinical encounters for mastitis occurring within 14 days of a previous mastitis encounter were defined as belonging to the same treatment episode. Semi-structured interviews were conducted with 14 Australian GPs using Zoom or telephone in 2021–2022, and analysed thematically. The Pillar Integration Process was used to develop a joint display table; qualitative codes and themes were matched with the quantitative items to illustrate similarities/contrasts in findings.

During an encounter for mastitis, 3122 (91.7%) women received a prescription for an oral antibiotic; most commonly di/flucloxacillin ([59.4%]) or cefalexin (937 [27.5%]). Investigations recorded ultrasound in 303 (8.9%), blood tests (full blood examination [FBE]: 170 [5.0%]; C-reactive protein [CRP]: 71 [2.1%]; erythrocyte sedimentation rate [ESR]: 34 [1.0%]) and breast milk or nipple swab cultures in approximately 1% of encounters. Analysis using pillar integration showed consistency between quantitative and qualitative data regarding mastitis management. The following themes were identified:

- GPs support continued breastfeeding.

- Antibiotics are central to GPs' management.

- Antibiotics are mostly prescribed according to Therapeutic Guidelines.

- Analgesia is a gap in the Therapeutic Guidelines.

- Low use of breast milk culture.

Conclusions

Prescribing antibiotics for mastitis remains central to Australian GPs’ management of mastitis. Interview data clarified that GPs were aware that antibiotics might not be needed in all cases of mastitis and that delayed prescribing was not uncommon. Overall, GPs followed principles of antibiotic stewardship, however there is a need to train GPs about when to consider ordering investigations.

Peer Review reports

Mastitis is a painful breast infection that is a common experience for new mothers [ 1 ]. Around one in five breastfeeding women experience at least one episode of mastitis. While mastitis can occur at any stage of lactation the highest incidence is in the first four weeks after birth [ 2 ]. Women experiencing mastitis in the first month after birth are more likely to stop breastfeeding abruptly and to have stopped breastfeeding by six months compared with women not reporting mastitis [ 3 ]. New mothers experiencing mastitis are recommended to consult their doctor [ 4 ], yet little is known about how mastitis is managed by general practitioners (GPs) in Australia. Internationally, there is a paucity of research on how medical practitioners support breastfeeding women [ 5 ].

Mastitis is understood to be an inflammatory condition occurring along a spectrum from mild inflammation to bacterial infection to abscess development [ 6 , 7 , 8 ]. Mastitis is often understood to be synonymous with breast infection in the medical literature (“an infectious condition of the breast” ([ 9 ] p. 293). Women presenting to medical professionals tend to be at the more severe end of the spectrum with fever and established breast inflammation.

In Australia, many GPs use the Therapeutic Guidelines: Antibiotic to guide their management of conditions such as mastitis. The Therapeutic Guidelines state that it is safe for women with mastitis to continue breastfeeding and lists appropriate antibiotics [ 10 ]. Since at least 1998, flucloxacillin has been recommended as first choice. However, evidence from the UK suggests that it is not uncommon for inappropriate antibiotics (i.e., ones that the causative bacterial agents are likely to be resistant to) such as amoxicillin, to be prescribed [ 11 , 12 ]. If women are prescribed the incorrect antibiotic they are likely to have a longer period of illness which may require admission to hospital, they may develop an abscess, or they may stop breastfeeding earlier than they planned [ 13 ].

While investigations are routine for many infections in general practice, for example, mid-stream urine testing for patients with suspected urinary tract infections, few investigations are conducted on the lactating breast. Mastitis is regarded as a “clinical diagnosis”, and milk culture is recommended only for patients with sepsis or who do not respond to first-line treatment [ 9 ]. Breast ultrasound is recommended when a fluctuant breast mass is present or if mastitis is not resolving and an abscess is suspected [ 9 , 14 ].

Given the lack of research into the management of mastitis within the Australian context, this study had two broad aims: (1) to describe how GPs around Australia treat mastitis with antibiotics to determine if they are following best practice guidelines, such as the Therapeutic Guidelines: Antibiotic [ 10 ], and (2) to understand how GPs make decisions about prescribing for breastfeeding women, and how they use guidelines. To address the first aim, we analysed GP prescribing patterns for women with mastitis using the MedicineInsight dataset of Australian general practice electronic records. The second aim was addressed by conducting interviews with GPs to explore their management of mastitis and use of the Therapeutic Guidelines. In this paper we integrate data from the GP consultation dataset and individual interviews.

Philosophical approach

The quantitative component of this study involved an analysis of Australian GP practice data (i.e., entries from medical records of GPs) in the MedicineInsight dataset. This component fits the positivist paradigm with a logical deductive approach. Although this reflects an empiricist epistemology, we recognise that there are multiple flaws in these assumptions (e.g., have GPs diagnosed mastitis correctly? Did patients purchase the antibiotics and take them?). In contrast, the qualitative component is based on a more interpretivist approach, involving in-depth interviews with GPs. We based the interview guide around the COM-B (‘capability, opportunity, motivation-behaviour’) system as a framework for understanding the barriers/enablers to GPs’ use of guidelines [ 15 ]. We used an inductive approach to coding and analysis of the interviews. We recognise that our attitudes influence the way we collect and analyse the data, and our prior knowledge of the topic, findings from the dataset study, and other factors were all be brought into our research conclusions. This component has a relativist ontology (meanings are constructed subjectively) and subjectivist epistemology (researchers are part of the investigation) [ 16 ]. In this paper, we bring the two components together with a pragmatic approach: there are multiple perspectives of reality or worldviews.

Study design

We used a convergent mixed methods design, where quantitative and qualitative data are collected and analysed separately over a similar period, and results are merged and compared [ 17 ]. In this study, quantitative analysis of a large dataset and qualitative data collection and analysis occurred over the same timeframe, with regular interaction between the researchers working on each component. The interview guide about GPs’ use of guidelines built on the preliminary findings from the dataset, and findings from both components were merged for analysis [ 17 ]. The findings are described in a weaving approach by presenting quantitative and qualitative findings topic by topic [ 17 ]. The data are brought together in a joint display [ 18 ], the Pillar Integration Process (described below) [ 19 ]. We followed the Good Reporting of A Mixed Methods Study (GRAMMS) framework for writing up the study [ 20 ].

Quantitative component

MedicineInsight is a large-scale primary care dataset of longitudinal de-identified electronic health records (EHRs) in Australia [ 21 ]. The MedicineInsight program collates routinely collected EHR data from clinical information systems from consenting general practices; currently over 500 practices with over 3,000 GPs involved. It includes information from 9% of all Australian GPs and 13% of all Australian patients who saw a GP at least once during the financial year (2018–2019) [ 22 ].

The independent MedicineInsight Data Governance Committee approved the quantitative component (protocol 2019–003) and the Human Research Ethics Committee of the University of Adelaide and La Trobe University exempted it from ethical review due to the use of non-identifiable data.

Using data from 2021–2022, we restricted our analysis to females of reproductive age (18–44 years inclusive) with one or more documented clinical encounters related to mastitis and documentation relating to a pregnancy within the previous 12-months of the encounter. Mastitis encounters were identified by searching the ‘Encounter reason’ free text field for the term ‘mastitis’. We also searched the ‘Test reason’ and ‘Prescription reason’ free text field for the term ‘mastitis’. We excluded the free text term ‘granulomatous mastitis’ as this was considered unlikely to be related to lactational mastitis. Clinical encounters for mastitis occurring within 14 days of a previous mastitis encounter were defined as belonging to the same treatment episode. Only the first episode per individual was included in the analysis. Documented pregnancies were identified using the separate ‘pregnancy’ dataset which included data on date of last menstrual period and estimated date of confinement. We also searched the ‘Encounter reason’ free text field using terms related to pregnancy (i.e., ‘Antenatal’, ‘Pregnancy’, ‘Hyperemesis gravidarum’, ‘Morning sickness’), postpartum (‘postnatal’, ‘postpartum’, ‘baby check’, ‘6 week check’), or breast feeding (i.e., ‘breast feeding’, ‘breastfeeding’, ‘lactation’) to identify women with a recent pregnancy. This was undertaken to increase the likelihood of the clinical encounter being related to lactational mastitis. Notably, the MedicineInsight program uses the terms sex and gender interchangeably and presents sex/gender information as a single binary variable (i.e., female/male). Pensioner concession status is an indication of low income and was extracted as yes/no.

We report the proportion of women prescribed oral antibiotics on the same date as a mastitis encounter. Prescribed antibiotics were identified from the corresponding ‘Prescriptions’ dataset. Secondary outcomes included the proportion of women ordered clinical investigations for mastitis including breast ultrasound, breast milk culture, nipple swab culture, blood test (i.e., C-reactive protein [CRP], Erythrocyte Sedimentation Rate [ESR], Full Blood Examination [FBE]), and breast aspirate. These were identified by searching the ‘Requested tests’ free text field for the previously listed terms. Additional secondary outcomes included the proportion of women prescribed other medications, including topical or intravenous antibiotics, antifungals, lactation suppressants (i.e., cabergoline, bromocriptine), or lactation stimulants (i.e., domperidone). We are assuming “ultrasound” applies to a diagnostic ultrasound, but may also refer to therapeutic ultrasound, therefore we recognise the estimate for ultrasound is a likely to be an overestimate of number of actual diagnostic ultrasounds ordered. The dataset only includes biochemistry pathology results, so we were unable to analyse bacteriology or radiology data. Stata MP 17 (Stata, College Station, Texas) was used for analysis of the MedicineInsight dataset.

Qualitative component

The qualitative component used semi-structured interviews to explore GPs’ perspectives of the issues they faced when managing mastitis, making decisions about prescribing medications, and how they used guidelines, such as the Therapeutic Guidelines . The qualitative component received approval from La Trobe University Human Research Ethics Committee (HREC Ethics Application Number: HEC21054). The study followed all relevant guidelines and regulations for conducting ethical research.

Recruitment and procedure

An invitation to participate in the study was posted on the Facebook group GPDU (GPs Down Under) with approval from the group administrator. The group has over 9,000 GP members from around Australia. The invitation briefly explained the purpose of the research and what participation involved, with a stock image (female doctor with a female patient) and a link to a short survey in REDCap [ 23 , 24 ]. Interested GPs provided basic information to assess their eligibility (i.e. had seen breastfeeding woman in previous year; location; gender; age) and their contact details. The invitation was posted on 17 May 2021 and 27 October 2021. We received between 5 and 10 expressions of interest after each post. Several GPs were recruited using snowballing from initial participants. Eligible participants were contacted via email and sent the Participant Information and Informed Consent Form and an interview was arranged at a convenient time. They were asked to return the signed Informed Consent Form (via post or electronically) prior to the interview.

Interviews were conducted by MC and SBC between June 2021 and March 2022. The interviews were conducted online, using the Zoom platform, or via telephone. Each interview lasted between 30 to 45 min. The interviews were audio recorded, with permission, and the audio-recording was transcribed verbatim by a professional transcribing service and anonymised before analysis. Transcripts of interviews were emailed to participants to allow for member checking and verification prior to analysis.

Directly after each interview, the researcher made field notes of general impressions and reflections from the interview. After each interview, participants were sent an AUD$100 gift voucher to acknowledge their time commitment.

Interview schedule

A semi-structured interview schedule was used to guide the interviews. We based the Interview schedule on the Capability, Opportunity, Motivation-Behaviour (COM-B) framework which is structured to understand clinicians’ behaviour and likely barriers to perform according to best practice [ 15 ]. The schedule covered the following topics: Capability includes knowledge about prescribing during lactation, Opportunity includes social norms about management of breastfeeding women, and Motivation includes reflective aspects (beliefs around use of guidelines) and automatic aspects (established habits in prescribing for women with mastitis). The COM-B theory/framework has been useful in exploring barriers and enablers of Australian GPs’ management of children’s check-ups [ 25 ]. Basic participant demographic data were also included in the interview schedule, to help describe the sample. For example, participant gender, location, years’ experience as a GP, where they conducted their GP training and the number of children they had, were collected at the beginning of the interview. The schedule was adapted in an iterative manner and the final version is provided as a supplementary document (Additional file 1. Interview guide).

Research team and reflexivity

LHA is an expert in mastitis and breastfeeding medicine research and led the study. LEG is an expert in pharmacoepidemiology in pregnancy and lactation and serves as an expert adviser to the Therapeutic Guidelines . He led the analysis of the MedicineInsight dataset for the quantitative study component. SBC has a background in health promotion and is an experienced mixed-methods public health researcher. She conducted interviews and led the analysis of the qualitative component of the study. MC has a background in microbiology and over ten years’ experience in breastfeeding/early parenting research. She arranged and conducted interviews. Prior to the interviews, SBC and MC conducted practice interviews with LHA who role-played different GPs to familiarise the interviewers with the topic, and allowed for minor changes to the interview schedule. Regular meetings helped to provide different perspectives on the findings during data collection and preliminary analysis phases, with LHA providing an insider view as a medical practitioner and the other team members reflecting on their experience as parents of young children, and experience from other research projects.

Data analysis

We tabulated the following:

Proportion of women presenting with mastitis who are prescribed antibiotics, and antibiotic class;

Investigations ordered during consultation: blood tests (FBE, CRE, ESR), ultrasound, breast milk and nipple swab culture.

SBC led analysis of the interviews, using a thematic analysis approach based on Green and colleagues’ four stage coding framework (data immersion, coding, creating categories, and identifying themes) to identify key themes and issues around GPs’ decision making around the management of mastitis in breastfeeding women and their use of guidelines for mastitis [ 26 , 27 ]. NVivo software was used to store and manage the data and support data analysis (QSR International). An iterative process to data analysis was used. Initially, SBC and LHA independently coded the first five interviews inductively, developed codes and compared coding. The codebook was then revised after discussion and consensus with team members. SBC coded the remaining interviews independently. LHA listened to recordings of all interviews while confirming written transcripts. Team members SBC, LHA and MC continued to meet to discuss the coding structure and reflect on the interviews, and the codebook continued to be refined until a consensus was reached. Data collection continued until a wide range of participants had been included and the team considered that no new codes were appearing (data saturation). Themes were generated based on the codebook, in collaboration with the team.

Integration

The research team met regularly to discuss the findings from both project components so the analysis benefitted from the knowledge acquired from both sources, and expertise from all members of the team.

We used the Pillar Integration Process (PIP) to develop a joint display table showing both quantitative and qualitative data [ 19 ]. The first step was to list the quantitative data on the outer left of the table, and summarise results as categories in the next column. Then, qualitative codes were placed in the outer right-hand column where they matched the quantitative items, with themes/categories in the next column. This process displays similarities or contrasts between the findings of the two components. Since our interviews covered a broader field than the quantitative data available in the GP dataset, we only used qualitative codes that relate to the management of mastitis (other qualitative data will be published separately). Where we had a qualitative theme that related to management of mastitis, but no relevant quantitative data were available in the dataset, we included the theme with an explanation, e.g., analgesia is important clinically. The team worked together to check the data were accurate and matching was complete and appropriate, and then patterns and insights were built in the Pillar column [ 19 ]. A separate paper will describe the barriers and enablers of GPs’ use of guidelines analysing the interview data using the COM-B framework. In addition, we prepared a report for the Therapeutic Guidelines Ltd and a poster depicting a GP consultation for a woman presenting with mastitis [ 28 ].

Quantitative data

Over 3,000 women with at least one episode of mastitis in 2021–2022 were identified in the dataset ( n  = 3046). Table 1 shows maternal age at encounter, concession card status, state or territory, and other characteristics of the sample. Most women were in their 30s, 13% had a Pensioner Concession Card, 69% lived in a major city and 2.5% were identified as Aboriginal and/or Torres Strait Islander. All states and territories were included, with 38% of the sample in NSW and 19% in Victoria. Figure  1 shows the geographical distribution of the sample as well as population in each State and Territory.

Distribution of participants in quantitative and qualitative components

Qualitative data

We recruited 14 GPs from a range of settings in Australia. Most States and the Australian Capital Territory were represented (see Fig.  1 ), with most participants residing in an Australian capital city ( n  = 9). Four GPs reported working in regional or remote locations. Participants were mostly female, but included four male GPs; practice locations were 9 urban, 3 regional, and 1 remote. One GP, who practiced in an Australian capital city, also spent one week each month practicing in an outer regional location (see Table  2 ). When quoting participants, we use a number to identify them (P01 to P14).

Joint display integrating quantitative and qualitative data

Using the pillar integration process described above, we developed a joint display table integrating analysis of quantitative and qualitative data (Additional file 2 ). Data extracted from MedicineInsight dataset are presented in left hand columns, sorted by medications, investigations, and advice. Data from coding the GP interviews were matched in right hand columns, and quotes selected to illustrate the relevant codes. Where the dataset provided no data (e.g., analgesia is usually not included in prescribing data), no data are shown in the left-hand column, and the reason explained. The quantitative and qualitative data were added in an iterative manner and compared to look for agreement or discordance, and areas of missing data. The team discussed the analyses from both data sources and developed a theme to integrate the findings in each row, shown in the central column – “pillar integration”. Footnotes to Additional file 2  summarise the recommendations in the Therapeutic Guidelines [ 10 ].

We found a high agreement between the quantitative and qualitative data. The findings are organised according to the five pillar themes: Antibiotics central to GPs’ management; Antibiotic selection mostly appropriate; Investigations uncommon; Support to continue breastfeeding; and Analgesia may be underutilised.

Antibiotics central to GPs’ management

Antibiotics were prescribed in over 90% of mastitis consultations: 3122 (91.7%) women received a prescription for an oral antibiotic (Additional file 2 ). In all GP interviews, the participants discussed their considerations for using antibiotics, when to start, which antibiotic to prescribe and issues involved in prescribing for breastfeeding women. Some participants described advising the patient to start the prescribed antibiotics if symptoms were not improving (“delayed prescribing”) [ 29 ]. However, from the quantitative data we are unable to measure the actual proportion of prescriptions dispensed by pharmacies or actually taken by patients.

I would more often than not provide a script for antibiotics. And you've got choices; you can either start straight away, or you can do delayed scripts. So, education that they can wait 24 hours and then if things haven't improved, to start the antibiotics. (P12)

Some participants mentioned the need to start antibiotics promptly. Here one participant describes possible consequences of not prescribing “early enough”:

If you don’t prescribe it early enough, well I guess my concern is that it will develop into a full-blown abscess, or develop sepsis for the mum, and I think that would be a horrible consequence. So, it’s always better to respond earlier, I think. (P04)

When asked about when antibiotics are needed, some participants explained that symptoms may have been present for over 24 h:

First of all, how is she presenting? Does she have systemic symptoms? How long has she had symptoms for? So, if – I guess, some women do come in two hours after they have a symptom, you know? And if she’s just got a symptom, there’s no systemic symptom, she’s completely well, I’m happy for her to continue doing the non-antibiotic measures, for up to two days. But I would give her the script then and there, so that if it’s either not settling at two days, or if it’s starting to get worse, I’d tell her to fill the script. But usually, it’s already been going on for two days by the time they come in. And usually, they – because I work in this well-educated area – usually they’ve done those basic measures for two days and it’s not getting better. (P10)

Antibiotic selection mostly appropriate

Prescribing data in the MedicineInsight dataset showed that dicloxacillin or flucloxacillin were prescribed in over half of mastitis consultations (59%) (Additional file 2 ). The next most common antibiotic prescribed was cefalexin (28%). The Therapeutic Guidelines recommend di/flucloxacillin as first line treatment for mastitis as these are narrow spectrum antibiotics appropriate for the most common bacterial pathogen, Staphylococcus aureus [ 10 ]. Cefalexin is recommended for people with a penicillin allergy, unless the allergy is severe, in which case clindamycin is recommended [ 10 ]. Most participants were familiar with the Therapeutic Guidelines recommendations, and some mentioned using the online guidelines provided by the Royal Women’s Hospital, Melbourne, which includes a table showing recommended antibiotic regimens and potential side-effects [ 30 ]. However, some participants preferred to commence with cefalexin as they felt it was more convenient (see quote by P11 in Additional file 2 ) or more appropriate for community infections:

Well look, I know that in terms of the advice is usually to do something like dicloxacillin or flucloxacillin for mastitis, I will always look at the severity first. At this very sort of early stage, very limited to a little area, then I will probably start more first line with Keflex [cefalexin], because I’m more comfortable with that in a community basis . (P04)

While prescribing cefalexin which is a broad spectrum antibiotic (i.e. active against Gram negative and Gram positive bacteria) for reasons such as “convenience” or “comfort” is not in line with Australian guidelines [ 10 ], it may be appropriate in cases where the cause of postpartum fever is unclear and differential diagnoses include endometritis [ 31 , 32 ].

Investigations uncommon

The most common investigation ordered for women with mastitis was a diagnostic breast ultrasound in 9% of encounters; other investigations recorded were FBE in 5%, CRP in 2%, and ESR in 1%, breast milk or nipple swab cultures in approximately 2% (Additional file 2 ). ESR and CRP are non-specific inflammatory markers; CRP may be used to decide on antibiotic use, e.g., for respiratory infections [ 33 ].

In our interviews with GPs, we asked whether they ordered investigations when seeing women with mastitis, such as breast milk culture or breast ultrasound. Five participants said they had never ordered a breast milk culture and several said they asked patients to return for review if not improving – examples of both can be seen in Additional file 2 .

It is concerning that a number of participants were unaware of the possibility of using a milk culture to confirm appropriate antibiotic selection: “ No, actually I haven’t done that before ” (P04).

Both our data sources indicated higher use of diagnostic ultrasound than microbiological testing; estimates from the dataset were 9% for ultrasound compared with about 2% for cultures. While one participant, P14, indicated frequent use (see quote in Additional file 2 ), most participants ordered a diagnostic ultrasound if breast lump persisted to rule out a breast abscess requiring drainage. Most participants were aware of the need for further evaluation if symptoms did not improve: “ If things don't improve, there's an abscess, then you go further, ultrasound .” (P12). Our participants focused on not missing a breast abscess and some participants mentioned referring to a hospital or specialist if complications occur:

. . . mastitis is this and if it’s not improving after treatment in 2-3 days get them back because it could be an abscess . . . If you don’t tell women about the red flags, they can end up with a breast abscess, they can become septic, women can die . (P01) Yeah, fairly comfortable in managing it [mastitis], starting antibiotics and monitoring them, and then obviously having a threshold to be like when it's gone out of my comfort zone and you need to go to hospital, or it's turned into a breast abscess. I've had to send a few patients for that, so watching out for those sort of conditions . (P06)

Support to continue breastfeeding

Women experiencing mastitis may consider stopping breastfeeding because they feel so unwell [ 1 ], however sudden cessation increases the risk of abscess formation and continued breastfeeding is recommended [ 7 ]. The MedicineInsight dataset indicated very low prescribing of lactation suppressant medication (~ 1%). The galactagogue, domperidone, used to increase milk supply, was also prescribed in about 1% of consultations. While infant feeding advice was not recorded in the dataset, most of our interviewees reported that they encouraged ongoing breastfeeding, “ Continuing to breastfeed that’s very important ” (P14), and no-one mentioned stopping breastfeeding.

Analgesia may be underutilised

In the row in the joint display table (Additional file 2 ) relating to analgesia, only qualitative data are shown because most analgesics used by women with mastitis are purchased over-the-counter and rarely prescribed and therefore not recorded in the GP dataset. Pain was commonly described as a presenting symptom of mastitis, but in response to our prompts about management of mastitis only five of our interviewees mentioned analgesia: “pain relief” (P01 and P09); “paracetamol” (P03); “for pain, ice packs, Panadol [paracetamol] and Nurofen [ibuprofen]” (P10); and “Nurofen [ibuprofen]” (P13). We coded these comments as “minimal use of analgesia” because most interviewed GPs did not mention any form or analgesia, and those who mentioned it did so briefly, almost dismissively.

We found consistency between the quantitative data in the MedicineInsight dataset and the qualitative interviews with GPs. Five themes were identified: Antibiotics central to GPs’ management; Antibiotic selection mostly appropriate; Investigations uncommon; Support to continue breastfeeding; and Analgesia may be underutilised.

The Therapeutic Guidelines promote the use of antibiotics and support delayed prescribing: “In patients with systemic symptoms, or symptoms or signs that have not resolved after 24 to 48 h of increased breastfeeding and expressing of milk, early antibiotic therapy is important to prevent abscess formation. Combine antibiotic therapy with increased breastfeeding and expressing of milk.” [ 10 ]. Advice to emergency physicians similarly urges “early antibiotic therapy... in all cases with symptoms greater than 24 h” ([ 9 ] p. 295]). In most situations, symptoms will be present for over 24 h by the time lactating women consult a GP, and therefore these recommendations are consistent with the high levels of antibiotic prescribing. However, the advice does recognise that not all cases of mastitis require antibiotics; general advice about relieving breast fullness, resting and applying cold may be all that is required [ 7 ].

A similarly high rate of antibiotic prescribing has been reported in a study of Croatian GPs: 93% reported prescribing an antibiotic [ 34 ]. A study from Taiwan investigating medical claims for postpartum mastitis in a national population-based database (2008–2017) identified that 79% of cases were prescribed antibiotics, mostly in the first month postpartum, as outpatients [ 35 ]. In the US, Foxman et al. reported 86% of women were prescribed antibiotics [ 36 ]. However, antibiotics are used to treat mastitis less frequently in Scandinavia, with only 15% of women receiving antibiotics in Kvist’s trial of acupuncture [ 37 ], 38% in Finland [ 38 ] and 37% in Norway [ 3 ].

Foxman’s US-based study of over 900 women found that the most commonly prescribed antibiotics for mastitis were cephalexin (46%), amoxicillin (7%), ampicillin (7%), and amoxicillin and clavulanic acid (7%) [ 36 ]. While over one third of participants in the Norwegian Mother-Baby cohort did not know the name of the antibiotic they had taken (36.5%); the most commonly reported antibiotic was a penicillin 53.4% with 9.7% reporting a macrolide and only 1.6% reporting a cephalosporin [ 3 ].

Our finding of low rates of investigations is consistent with other studies: no cultures were performed by clinicians in Foxman et al.’s US study [ 36 ].

The advice in the Therapeutic Guidelines is “If infection does not resolve with antibiotic therapy, evaluate the patient for an abscess and consider whether infection is caused by another pathogen” [ 10 ] . Scott suggests monitoring and further evaluation if symptoms do not improve to rule out resistant bacteria, abscess or malignancy [ 7 ].

Other guidelines are more specific about when and how to conduct milk culture:

A breastmilk culture is not necessary to guide antibiotic choice but may be useful in cases of treatment failure, antibiotic allergy, severe or frequent infections. If culture is needed, care should be taken to avoid skin contamination by first cleansing the nipple and areola with an alcohol swab and then expressing the milk into a sterile collection tube, such as those used for urine culture. [ 8 ] p. 526

While routine milk culture is not needed, it is valuable in locations with high levels of methicillin-resistant S. aureus (MRSA) [ 7 ]. A recent hospital-based study in Milan, Italy found that 45% of S. aureus isolates in cases of mastitis/abscess referred to a Breastfeeding Unit (2016–2018) were MRSA [ 39 ]. In a study of women admitted to a hospital in China with mastitis or breast abscess, 35% of S. aureus isolates were MRSA [ 40 ]. In Ukraine, 28% of S. aureus isolated was MRSA in mastitis (18427 breastfeeding women who gave birth in 11 regional hospitals of Ukraine in 2015–2017) [ 41 ]. While MRSA is less common in Australia, estimates are low in Victoria and Tasmania, but high in the Northern Territory [ 42 ], and needs to be considered if there is a poor response to standard antibiotics [ 30 ]. Unusual presentations, such as bilateral mastitis or a cellulitic appearance may be associated with streptococcal infections [ 43 ].

The safety of continuing to breastfeed during mastitis was strongly stated in the World Health Organization’s review of mastitis in 2000 [ 6 ], and reiterated in international guidelines since, including the Therapeutic Guidelines [ 7 , 9 , 10 , 44 ]. We are not aware of any guidelines that recommend lactation suppression during an episode of mastitis.

In contrast to our findings, several studies have reported that doctors inappropriately advised cessation of breastfeeding. In Scotland, one in ten women (6/57) were inappropriately advised to either stop breastfeeding from the affected breast or to discontinue breastfeeding altogether [ 12 ]. A recent interview study in Israel found that women described a low level of knowledge among physicians’ about treating breastfeeding problems and some women with mastitis were given incorrect advice to stop breastfeeding because of the need to take antibiotics [ 45 ]. The survey of Croatian GPs found that 11% (12/110) recommended infant formula during mastitis and 5% (7/155) prescribed a prolactin suppressant [ 34 ].

Analgesia was unable to be assessed using the MedicineInsight dataset, but was barely mentioned by our GP participants. Analgesia is also mentioned uncommonly in other studies of medical management: 35% in Croatia [ 34 ], 17% in the US [ 36 ].

In the section on management of mastitis in the Therapeutic Guidelines , analgesia is not mentioned [ 10 ]. Since analgesia is an important component of mastitis management, this is a gap in the Therapeutic Guidelines which needs to be addressed. This is a topic requiring research, as although non-steroidal anti-inflammatories are often recommended for mastitis (“NSAIDs also reduce mastitis-related inflammation and are compatible with breastfeeding” ([ 7 ] p. 74), efficacy trials comparing NSAIDS to paracetamol are lacking.

Strengths and limitations

Our research design involved collecting and analysing quantitative and qualitative data concurrently, enabling a more complete understanding of current management of mastitis by Australian general practitioners than would be possible with a single method study. Typically, mixed methods studies present quantitative and qualitative data separately, whereas we set out to show the rigour of our mixed method approach by integrating the findings in a joint display table [ 46 ]. Additional file 2  shows that clearly framing the management of mastitis around the Therapeutic Guidelines was useful in comparing findings from the quantitative and qualitative data, and highlights the similarity between the data sources, as well as the gap in management exposed (i.e., the potential underutilisation of analgesia).

The limitations of using electronic general practice records is that we cannot be certain that all women were being treated for lactational mastitis. We made the assumption that prescriptions or clinical investigations ordered on the same day as a clinical encounter for mastitis were related to that encounter reason. However, they may have been provided for alternative indications. As mentioned above, providing a prescription does not automatically mean that patients purchase (and take) the prescribed medication. Alternatively, some patients may have pressured the GP to prescribe an antibiotic in a situation where it may not be warranted.

Our interviews included GPs with a range of experience, some familiar with breastfeeding problems, and others less familiar. However, since we don’t have observations from actual GP consultations, we can only report what participants said they did in practice. Participants recruited from a Facebook group may not be representative of all GPs. Our findings might be different if we had been able to record consultations, for example perhaps more emphasis is given to analgesia than is evident from our interviews.

Our convergent mixed methods study of Australian GPs’ management of mastitis found congruency between the two data sources, a GP dataset and qualitative interviews. Prescribing antibiotics was central to GPs’ management in both the dataset analysis and interviews with GPs. Overall, GPs followed principles of antibiotic stewardship, however there is a need to inform GPs about when to consider ordering investigations as breast milk cultures may be underutilised. Australian GPs appear to provide support for continued breastfeeding during mastitis. GPs’ advice about analgesia for women with mastitis is unclear from this study, although they undoubtedly recognised that fever and pain are prominent symptoms. We recommend guidelines for clinicians strengthen their recommendations about the importance of analgesia for patients with inflammatory symptoms.

Availability of data and materials

Quantitative component : Data may be obtained from MedicineInsight and are not publicly available. Third parties may express an interest in the information collected through MedicineInsight. The provision of information in these instances undergoes a formal approval process and is guided by the MedicineInsight independent external Data Governance Committee. This Committee includes general practitioners, consumer advocates, privacy experts and researchers.

Qualitative component : The dataset used during the current study is not publicly available due to privacy conditions set by the University HREC but are available from the corresponding author on reasonable request.

Abbreviations

C-Reactive Protein

Erythrocyte Sedimentation Rate

Full Blood Examination

General practitioner

Methicillin-resistant S. aureus

Non-steroidal Anti-inflammatory Drugs

Staphylococcus aureus

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Ethical guidelines

The study followed all relevant guidelines and regulations for conducting ethical research.

This project was funded by a Therapeutic Guidelines Ltd (TGL) / RACGP Foundation Research Grant (TGL2020-02) awarded to LHA, LEG, SBC, and MC. LEG receives salary support from the Channel 7 Children’s Research Foundation (CRF-210323).

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Authors and affiliations.

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Victoria, Australia

Lisa H. Amir, Sharinne B. Crawford & Meabh Cullinane

Breastfeeding Service, Royal Women’s Hospital, Victoria, Australia

Lisa H. Amir

SPHERE Centre for Research Excellence, Department of General Practice, Monash University, Victoria, Australia

Sharinne B. Crawford

Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia

Meabh Cullinane

College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia

Luke E. Grzeskowiak

South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia

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Contributions

LHA conceived the project and led writing of the manuscript; SBC revised the interview topic guide, conducted interviews and led analysis of interview data; MC contributed to interview topic guide, conducted interviews, contributed to analysis of interview data; LEG analysed the MedicineInsight dataset. All authors contributed to Pillar Integration Process and writing the manuscript.

Corresponding author

Correspondence to Lisa H. Amir .

Ethics declarations

Ethics approval and consent to participate.

The qualitative component received approval from La Trobe University Human Research Ethics Committee (HREC Ethics Application Number: HEC21054). The independent MedicineInsight Data Governance Committee approved the quantitative component (protocol 2019–003) and the Human Research Ethics Committee of the University of Adelaide and La Trobe University exempted it from ethical review due to the use of non-identifiable data.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Supplementary Information

Additional file 1..

Interview guide.

Additional file 2.

Summary of joint display table.

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Amir, L.H., Crawford, S.B., Cullinane, M. et al. General practitioners’ management of mastitis in breastfeeding women: a mixed method study in Australia. BMC Prim. Care 25 , 161 (2024). https://doi.org/10.1186/s12875-024-02414-4

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Received : 23 October 2023

Accepted : 30 April 2024

Published : 10 May 2024

DOI : https://doi.org/10.1186/s12875-024-02414-4

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