journal of pakistan medical research

This website uses cookies to ensure you get the best experience. Learn more about DOAJ’s privacy policy.

Hide this message

You are using an outdated browser. Please upgrade your browser to improve your experience and security.

The Directory of Open Access Journals

Quick search, pakistan journal of medical research.

0030-9842 (Print)

• ISSN Portal

Publishing with this journal

There are no publication fees ( article processing charges or APCs ) to publish with this journal.

Look up the journal's:

• Aims & scope
• Instructions for authors
• Editorial Board
• Double anonymous peer review

→ This journal checks for plagiarism .

Expect on average 20 weeks from submission to publication.

Best practice

This journal began publishing in open access in 2010 . What does DOAJ define as Open Accesss?

This journal uses a CC BY-NC license.

Attribution Non-Commercial

→ Look up their open access statement and their license terms .

The author retains unrestricted copyrights and publishing rights.

→ Learn more about their copyright policy .

Journal metadata

Publisher Health Research Institute (HRI), National Institute of Health (NIH) , Pakistan Manuscripts accepted in English

LCC subjects Look up the Library of Congress Classification Outline Medicine Keywords public health medicine research promotion infectious diseases non-communicable diseases mental health

WeChat QR code

Pakistan Journal of Medical Sciences

Subject Area and Category

• Medicine (miscellaneous)

Professional Medical Publications

Publication type

1681715X, 1682024X

Information

How to publish in this journal

[email protected]

The set of journals have been ranked according to their SJR and divided into four equal groups, four quartiles. Q1 (green) comprises the quarter of the journals with the highest values, Q2 (yellow) the second highest values, Q3 (orange) the third highest values and Q4 (red) the lowest values.

The SJR is a size-independent prestige indicator that ranks journals by their 'average prestige per article'. It is based on the idea that 'all citations are not created equal'. SJR is a measure of scientific influence of journals that accounts for both the number of citations received by a journal and the importance or prestige of the journals where such citations come from It measures the scientific influence of the average article in a journal, it expresses how central to the global scientific discussion an average article of the journal is.

Evolution of the number of published documents. All types of documents are considered, including citable and non citable documents.

This indicator counts the number of citations received by documents from a journal and divides them by the total number of documents published in that journal. The chart shows the evolution of the average number of times documents published in a journal in the past two, three and four years have been cited in the current year. The two years line is equivalent to journal impact factor ™ (Thomson Reuters) metric.

Evolution of the total number of citations and journal's self-citations received by a journal's published documents during the three previous years. Journal Self-citation is defined as the number of citation from a journal citing article to articles published by the same journal.

Evolution of the number of total citation per document and external citation per document (i.e. journal self-citations removed) received by a journal's published documents during the three previous years. External citations are calculated by subtracting the number of self-citations from the total number of citations received by the journal’s documents.

International Collaboration accounts for the articles that have been produced by researchers from several countries. The chart shows the ratio of a journal's documents signed by researchers from more than one country; that is including more than one country address.

Not every article in a journal is considered primary research and therefore "citable", this chart shows the ratio of a journal's articles including substantial research (research articles, conference papers and reviews) in three year windows vs. those documents other than research articles, reviews and conference papers.

Ratio of a journal's items, grouped in three years windows, that have been cited at least once vs. those not cited during the following year.

Evolution of the percentage of female authors.

Evolution of the number of documents cited by public policy documents according to Overton database.

Evoution of the number of documents related to Sustainable Development Goals defined by United Nations. Available from 2018 onwards.

Leave a comment

Name * Required

Email (will not be published) * Required

* Required Cancel

The users of Scimago Journal & Country Rank have the possibility to dialogue through comments linked to a specific journal. The purpose is to have a forum in which general doubts about the processes of publication in the journal, experiences and other issues derived from the publication of papers are resolved. For topics on particular articles, maintain the dialogue through the usual channels with your editor.

Follow us on @ScimagoJR Scimago Lab , Copyright 2007-2024. Data Source: Scopus®

Cookie settings

Cookie Policy

Legal Notice

Privacy Policy

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Research design and statistical methods in Pakistan Journal of Medical Sciences (PJMS)

Affiliations.

• 1 Dr. Sohail Akhtar, PhD (UK), Department of Statistics, University of Malakand, Lower Dir, KPK, Pakistan.
• 2 Syed Wadood Ali Shah (PhD Candidate), Department of Pharmacy, University of Malakand, Lower Dir, KPK, Pakistan.
• 3 M. Rafiq (M.Phil), Department of Statistics, University of Malakand, Lower Dir, KPK, Pakistan.
• 4 Ajmal Khan, Department of Zoology, University of Malakand, Lower Dir, KPK, Pakistan.
• PMID: 27022365
• PMCID: PMC4795858
• DOI: 10.12669/pjms.321.9033

Objective: This article compares the study design and statistical methods used in 2005, 2010 and 2015 of Pakistan Journal of Medical Sciences (PJMS).

Methods: Only original articles of PJMS were considered for the analysis. The articles were carefully reviewed for statistical methods and designs, and then recorded accordingly. The frequency of each statistical method and research design was estimated and compared with previous years.

Results: A total of 429 articles were evaluated (n=74 in 2005, n=179 in 2010, n=176 in 2015) in which 171 (40%) were cross-sectional and 116 (27%) were prospective study designs. A verity of statistical methods were found in the analysis. The most frequent methods include: descriptive statistics (n=315, 73.4%), chi-square/Fisher's exact tests (n=205, 47.8%) and student t-test (n=186, 43.4%). There was a significant increase in the use of statistical methods over time period: t-test, chi-square/Fisher's exact test, logistic regression, epidemiological statistics, and non-parametric tests.

Conclusion: This study shows that a diverse variety of statistical methods have been used in the research articles of PJMS and frequency improved from 2005 to 2015. However, descriptive statistics was the most frequent method of statistical analysis in the published articles while cross-sectional study design was common study design.

Keywords: Bibliometric analysis; Biostatistics; Statistical analysis; Statistical methods; Study design.

PubMed Disclaimer

Similar articles

• Pakistan Journal of Medical Sciences: A bibliometric assessment 2001-2010. Baladi ZH, Umedani LV. Baladi ZH, et al. Pak J Med Sci. 2017 May-Jun;33(3):714-719. doi: 10.12669/pjms.333.13258. Pak J Med Sci. 2017. PMID: 28811801 Free PMC article.
• Descriptive and inferential statistical methods used in burns research. Al-Benna S, Al-Ajam Y, Way B, Steinstraesser L. Al-Benna S, et al. Burns. 2010 May;36(3):343-6. doi: 10.1016/j.burns.2009.04.030. Epub 2009 Jun 21. Burns. 2010. PMID: 19541424
• Comparison of statistical methods, type of articles and study design used in selected Pakistani medical journals in 1998 and 2007. Rao MH, Khan N. Rao MH, et al. J Pak Med Assoc. 2010 Sep;60(9):745-50. J Pak Med Assoc. 2010. PMID: 21381583
• Review of the Statistical Methods Used in Original Articles Published in Iranian Journal of Public Health from 2015-2019: A Review Article. Bahariniya S, Madadizadeh F. Bahariniya S, et al. Iran J Public Health. 2021 Aug;50(8):1577-1585. doi: 10.18502/ijph.v50i8.6803. Iran J Public Health. 2021. PMID: 34917528 Free PMC article. Review.
• A 5-year review of statistical methods presented in The Journal of Foot & Ankle Surgery. Meyr AJ. Meyr AJ. J Foot Ankle Surg. 2010 Sep-Oct;49(5):471-4. doi: 10.1053/j.jfas.2010.05.005. J Foot Ankle Surg. 2010. PMID: 20619692 Review.
• Current Practices in Data Analysis Procedures in Psychology: What Has Changed? Blanca MJ, Alarcón R, Bono R. Blanca MJ, et al. Front Psychol. 2018 Dec 13;9:2558. doi: 10.3389/fpsyg.2018.02558. eCollection 2018. Front Psychol. 2018. PMID: 30618979 Free PMC article.
• Knowledge of Postgraduate Medical Trainees Regarding Epidemiology. Shafi S, Faisal T, Naseem S, Javed S, Ghazanfar H. Shafi S, et al. Cureus. 2018 Feb 8;10(2):e2171. doi: 10.7759/cureus.2171. Cureus. 2018. PMID: 29657905 Free PMC article.
• Research Designs and Statistical Methods Trends in the Annals of Rehabilitation Medicine. Kim J, Yoon S, Kang JJ, Han K, Kim JM, Kim SK. Kim J, et al. Ann Rehabil Med. 2017 Jun;41(3):475-482. doi: 10.5535/arm.2017.41.3.475. Epub 2017 Jun 29. Ann Rehabil Med. 2017. PMID: 28758086 Free PMC article.
• Cadarso-Suárez C, González-Manteiga W. Statistics in Biomedical Research. Arbor Ciencia Pensamientoy Cultura. 2007;725:353–361. doi:10.3989/arbor.2007.i725.108.
• Armitage P, Berry G, Matthews JNS. Statistical methods in medical research. Edition 4th. John Wiley & Sons; 2008.
• Forthofer RN, Lee ES, Hernandez M. Biostatistics: A Guide to Design, Analysis and Discovery. 2 edition. Academic Press; 2006.
• Emerson JD, Colditz GA. Use of statistical analysis in the New England Journal of Medicine. N Engl J Med. 1983;309:709–713. doi:10.1056/NEJM198309223091206. - PubMed
• Schwart SJ, Sturr M, Golberg G. Statistical methods in rehabilitation literature: a survey of recent publications. Arch Phys Med Rehabil. 1996;77:497–500. doi:10.1016/S0003-9993(96)90040-4. - PubMed

LinkOut - more resources

Full text sources.

• Europe PubMed Central
• PubMed Central
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

ISSN: 0030-9842

Make a Submission

How-to-submit.

How to Submit an Article PDF Guide | Video Guide

hec-recognition

Pakistan Journal of Medical Research (PJMR) is an official journal of Health Research Institute (HRI), National Institute of Health (NIH), Islamabad, and is recognized as Standard Medical Journal by Higher Education Commission (HEC).  On Higher Education Commission Journal Recognition System (HJRS) for accreditation of research Journals, PJMR is placed in the “Y”  category. Moreover, PJMR is now on  Open Journal System (OJS) , authors can have free access for articles submission. For further details please visit HEC JRS .

past-issues

Past issues, information.

• For Readers
• For Authors
• For Librarians

Pakistan Journal of Medical Research is the official journal published by the Health Research Institute (HRI), National Institute of Health (NIH), Islamabad, Government of Pakistan.

Pakistan Journal of Medical & Health Sciences

About the journal.

PJMHS is a Peer-reviewd , open Access Monthly  Journal            

ISSN (Online): 2957-899X |  ISSN (Print): 1996-7195 

The Pakistan Journal of Medical & Health Sciences (PJMHS) is a monthly journal that publishes scholarly material (original paper, reviews, case reports, short communication, letter to editors, and editorial) based on the author's opinion and does not reflect official policy. All rights reserved. Reproduction or transmission without permission is strictly prohibited.

All material submitted for publication should be sent exclusively to the Pakistan Journal of Medical & Health Sciences. Work that has already been reported in a published paper or is described in a paper sent or accepted elsewhere for publication should not be submitted. However, a complete report is following publication of the preliminary report, usually in the form of an abstract, or a paper that has been presented at a scientific meeting. If not published in full in a proceedings or similar publication, may be submitted. Press reports of meetings will not be considered as breach of this rule, but such reports should not be amplified by additional data or copies of tables and illustrations. In case of doubt, a copy of the published material should be included with a manuscript to help the editors decide how to deal with the matter.

Pakistan Journal of Medical & Health Sciences is published monthly from Basement Barkat Center, Royal Park, Lahore Pakistan

Current Issue

Workplace Violence: Consequences and Solutions in Healthcare Institutions

Review articles, urinary tract infection among infants and school aged children: a review, determine the prevalence and factors contributing to increase the caesarean section rate amongst post-partum women at lyari town karachi, pakistan, cytological and histological correlation of medullary carcinoma of thyroid based on bethesda system for reporting thyroid cytology: a single center experience, the prevalence, rainbow of histological features and initial clinical presentation of post-transplant iga nephropathy, make a submission, index and registered with, indexed and registered.

Information

• For Readers
• For Authors
• For Librarians

                                      Pakistan Journal of Medical & Health Sciences (PJMHS)

                            Published by: Pakistan Journal of Medical & Health Sciences (PJMHS)

                                         ISSN (Online): 2957-899X |  ISSN (Print): 1996-7195 

INSTRUCTIONS TO AUTHORS

Ensure that you have the following supporting documents prepared before you attempt to submit the manuscript.

Obligatory Document 1: Cover Letter

A cover letter is an obligatory supporting document for all types of manuscripts except letter to the editor, without which the OJS will not upload and accept the manuscript.

A cover letter should be kept succinct and include the following information. (Maximum 200 to 250 words)

• Title of the manuscript.
• What is already known on the subject?
• What will the results of your study add?
• How will your results help in clinical practice and or further Research?
• An explanation of any issues (if any) relating to JPMA policies.

Acceptable formats for cover letter include: jpg, jpeg, gif, png, doc, docx or pdf.

Download the cover letter template here.

Obligatory Document 2: Ethical Approval of Research

Ethical approval of research in the form of letters from the ethical review committee (ERC), ethical review board (ERB), institutional review board (IRB), or any other relevant form of ethical approval is mandatory for all manuscripts submitted to JPMA. The only exceptions to this rule include letters to the editor based on some new information, narrative reviews, and special communications in the form of a review. Reporting a case report or case series in retrospect does not require an IRB certificate but a letter of approval from the head of the department on the institute’s letterhead is required. Ensure that you have read our editorial policy on ethical approval here .

• IRB number.
• Date when IRB approval was given.
• Permission of time period during which the research can be conducted.
• Signature of chairperson of the IRB/ERB with additional designation of chairperson if any. Stamp of the IRB of the institute should be present.
• Letter should be on the letter head of the IRB of the institute.

Download the Ethical Approval letter template here.

For letters, review articles etc, upload an MS Word document stating the reason for exception to the rule. Note that this method of bypassing the system would not be accepted in cases where ethical approval is mandatory. The manuscript will be reviewed by the technical team and will be returned to the authors.

Acceptable formats for ethical approval of research include: jpg, jpeg, gif, png, doc, docx or pdf.

Obligatory Document 3: Submission Form

Download the submission statement form from here .

This form can be typed on and saved before taking a print-out. It is preferable to fill out the form in type. Alternatively, the form may be printed and handwritten. The form has to be signed by ALL authors. Electronic signatures are not acceptable. After printing and signing the form (by hand), it can be scanned and uploaded to the OJS.

Ensure that the form has been filled correctly and completely. Incomplete forms will result in return of the manuscript and will cause delays in processing.

Ensure that you have the following information in hand while filling out the form:

• Details of the contributions made by each author
• List of disclaimers if required
• List of possible conflict of interests for disclosure
• List of possible sources of funding for disclosure
• Details regarding all authors including:
• Full names of all authors
• Email addresses of all authors
• Phone numbers of all authors
• Full current affiliation of all authors
• Year of study if any of the authors are undergraduate students
• Highest degree if the authors are not undergraduate students

Note that the order of the authors will not be changed at any stage. You can read the full details regarding our policy regarding authorship here .

All authors must read the copyright statement and the undertaking detailed on the form before signing it. JPMA assumes that all authors comply with the editorial policy on receipt of the signed submission form.

Obligatory Document 4: Withdrawal From

Download the Withdrawal form from here .

Systematic Review and Meta-Analysis:

Prospective protocol registration with an international database is desirable. Please provide the registration number if the protocol of Systematic Review was prospectively registered with PROSPERO or any other international database.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees:

CPSP List of Pakistani-Approved Journals

Note: This article is not valid now. CPSP has changed its criteria vide Ref # CPSP/Sec/2022/250 Dated 2nd June 2022. Read at this link .

College of Physicians and Surgeons Pakistan (CPSP) Publishes its list of approved Journals (Ref# CPSP/Sec/2022/227 Dated: 21st / May /2022).

“This is for the information of all residents of Fellowship and Membership Programs of the College of Physicians and Surgeons Pakistan, who have opted to write an article(s) for the award of CPSP qualification as a prerequisite for appearing in the examination, they can do so by submitting evidence of publication/acceptance for publication in any journals listed in Index Medicus of National Library of Medicine or following journals “

Link of Notice: https://www.cpsp.edu.pk/files/news_notifications/cpsp-sec-2022-227.pdf

Our Social Media Profiles

Related posts, important points you should know about covid-19 vaccines.

A few days ago (March 29, 2021, to April 13, 2021) an online Certification Course in “Development and Rollout of Covid-19 Vaccines” was arranged by…

Pakistan Medical Commission to start Biometric Verifications of all the doctors

CIP PRP June / July 2021 Induction Lists

Important: If you are using mobile, you should view the table in Landscape mode. We missed the ‘first merit list’ because of some technical issues.

Applications through proper channel

Question Almost every government job announcement notice specifies that employees of the government should apply through the proper channel / No Objection Certificate (NOC). Details…

Pakistan Journal of Public Health

Current Issue

• Table of Contents

Letter to the Editor

Short communication, nutritional status of women, adolescent girls and young children in khyber pakhtunkhwa, pakistan, current topics, improving maternal nutrition through food security in pakistan, original articles, maternal malnutrition and its associated adverse pregnancy outcomes and childbirth in dadu district, sindh, pakistan, effects of oral iron supplements in pregnancy with ida in association with oxidative stress, assessment of nutritional status using composite index of anthropometric failure among children aged < 5 years and its correlates, status of vitamin d levels in reproductive age women of quetta, pakistan, factors associated with malnutrition among pregnant women and lactating mothers in ajk, pakistan, the influence of postpartum stay on maternal nutrition, relationships, and the overall experience of childbirth in rawalpindi, pakistan, review articles, a systematic review of multiple micronutrient supplementation trials concerning maternal health, promoting breastfeeding and complementary feeding practices for optimal maternal and child nutrition, make a submission.

P-ISSN: 2225-0891 E-ISSN: 2226-7018

Vol. 14, No. Special.NI, 2024

 Published Quarterly

Accreditation & Indexation

• Recognized by Higher Education Comission (HEC), Pakistan On HEC Journal Recognition System (HJRS) for accreditation of research Journals, PJPH is placed in the “Y”  category. HJRS | HEC
• Indexed at WHO | Index Medicus for the Eastern Mediterranean Region
• Google Scholar

ReviewerCredits

Pakistan Journal of Public Health is the official journal published by the Health Services Academy, Government of Pakistan.

Pakistan Biomedical Journal

• Go To Journal

welcome to green forest

Save the world.

By Planting Tree Tomorrow!

About the Journal

Title of Journal: Pakistan Biomedical Journal (ISSN Online: 2709-2798, Print: 2709-278X)

Frequency: Monthly

Affiliated with: Lahore Medical Research Center

      www.lmrc.com.pk

     746-A, Kashmir Block, Allama Iqbal Town, Lahore, Pakistan

Published By: CrossLinks International Publishers (CLIP), Lahore, Pakistan

      www.clip.com.pk

      590-Karim Block, Allama Iqbal Town, Lahore, Pakistan

Pakistan BioMedical Journal (PBMJ) is an Official Journal of "Lahore Medical Research Center LLP" (LMRC) and is being funded and supported by Lahore Medical Research Center LLP (LMRC).

• Research papers
• Short communications
• Review or mini-reviews
• Commentaries
• Perspectives, opinion
• Meta-analysis
• Case reports
• Case studies
• Case-control studies

Popular News

We are pleased to inform that our Journal has been approved and accredited by Higher Education Commission of Pakistan (HEC) in "Y" Category for the year 2021-22

29th Nov 2021

Review Articles

Systmetic reviews, original articles, commenteries, case series.

Get in Touch

Professionally mesh enterprise wide imperatives without world class paradigms.Dynamically deliver ubiquitous leadership awesome skills.

Pakistan Journal of Medical Sciences

Announcements, important announcement for authors.

Current Issue

Pak J Med Sci Vol.40, No.9 2024

Original Articles

Systematic review, brief communication, case reports.

PAKISTAN JOURNAL OF MEDICAL SCIENCES is a peer reviewed journal. It is published monthly. It has controlled circulation. We accept original research, review articles, guest editorials, case reports, short communications, drug trials and letters.

All articles published in Pak J Med Sci under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Journal Citation Report 2022 (Copyright © 2023 Clarivate™ )  Journal Impact Factor: 1.2    (Five years IF: 1.893)   Quartile Ranking Q2, h-Index: 48, Journal Cite Score: 4.1 (Scopus)

PJMS at Tehqeeqat 

Recognized by Higher Education Commission, Government of Pakistan.

Indexed & abstracted in Science Citation Index Expanded (SCIE) by Clarivate™ (formerly Thomson Reuters/ISI) USA, Web of Science, Embase/Excerpta Medica Netherlands, WHO IMEMR Current Contents, Index Copernicus Poland, SCOPUS, INIS Database, CAB Abstract and Global Health UK, Pakistan Science Abstract, Registered with International Serials Data System of France, approved by the PM&DC and covered by Pakmedinet, Open-J gate India, doaj and emrmedex.com Iran

Pak J Med Sci at PubMed Central

• For Readers
• For Authors
• For Librarians

Pakistan Journal of Medical Sciences is published by

• Open access
• Published: 23 September 2024

Un/met: a mixed-methods study on primary healthcare needs of the poorest population in Khyber Pakhtunkhwa province, Pakistan

• Maira Shaukat 1 ,
• Alina Imping 2 ,
• Lisa Rogge 2 ,
• Fatima Khalid 3 ,
• Safat Ullah 4 ,
• Fayaz Ahmad 3 ,
• Zeeshan Kibria 4 ,
• Andreas Landmann 2 ,
• Zohaib Khan 4 &
• Manuela De Allegri 1  

International Journal for Equity in Health volume  23 , Article number:  190 ( 2024 ) Cite this article

70 Accesses

Metrics details

Access of all people to the healthcare they need, without financial hardship is the goal of Universal Health Coverage (UHC). As UHC initiatives expand, assessing the needs of vulnerable populations can reveal gaps in the system which may be covered by relevant policies. In this study we (i) identify the met and unmet primary healthcare needs of the poorest population of Khyber Pakhtunkhwa province (KP), Pakistan, and (ii) explore why the gaps exist.

We used Leveque’s Framework of Patient-centred Access to Healthcare to examine unmet primary healthcare (PHC) needs and their underlying causes for the poorest population in four districts of Khyber Pakhtunkhwa province, Pakistan. Using a triangulation mixed methods design, we analysed data from a quantitative household survey of744 households, 17 focus group discussions with household members and, 11 interviews with healthcare providers.

Our results show that indicate that despite service utilization, PHC needs were not met, primarily due to prohibitively high costs at each stage of access. Furthermore, gaps in outreach and information (approachability), and varying availability of medicines and diagnostics at facilities (appropriateness) the supply side as well as difficulties in navigating the system (inability to perceive) and adhering to prescriptions (inability to engage) on the demand side, also led to unmet PHC needs. Going beyond utilization, our findings highlight that engagement with care is an important determinant of met needs for vulnerable populations.

Social health protection policies can contribute to advancing UHC for primary care. However, in our setting, enhancing communication and outreach, addressing gender and age disparities, and improving quality of care and health infrastructure are necessary to fully meet the needs of the poorest populations.

• The primary health needs of the poorest population of Khyber Pakhtunkhwa remain largely unmet or are met with difficulties, across the care-seeking pathway.

• Major contributors to unmet primary healthcare needs in the study area are: low outreach, crowded facilities and, varying availability of medicines and diagnostics at facilities on the supply side, and difficulties in navigating care and inability to afford prescribed care on the demand side.

• Social Health Protection is a crucial tool for advancing Universal Health Coverage and improving primary healthcare, however these needs cannot be met without quality service provision and outreach from facilities.

• Levesque’s framework of access to care (2013) can be effectively employed to identify broad-based unmet needs and assess gaps in primary healthcare systems.

Poverty increases health vulnerability two-fold: on one hand, poorest population segments have worse health outcomes and greater need; on the other, they are more likely to face access barriers [ 1 ]. As countries across the world strive to achieve the goal of Universal Health Coverage (UHC) is defined as access of all people to the healthcare they need, without incurring financial hardship [ 2 ]. Based on sustainable development goal 3.8 [ 3 ] countries across the world are striving to achieve UHC. Identifying unmet health needs of the poorest is key to ensure equitable inclusion of this vulnerable group in UHC initiatives.

Social health protection (SHP) programs are implemented as to facilitate UHC through financial risk protection [ 4 , 5 , 6 , 7 ]. In South Asia, countries have adopted SHP policies, with a common starting point often being secondary and tertiary (inpatient) care coverage [ 7 , 8 ]. As full effects of these programs are calibrated, extending them to include primary care could offer higher financial protection as evidence shows that outpatient care constitutes the largest portion of healthcare expenditures in this region [ 9 , 10 ]. The importance of primary healthcare (PHC) systems to deliver basic healthcare for all was highlighted in the Alma Ata declaration in 1978, and described as socially acceptable, universally approachable, and scientifically sound care [ 11 ]. Since then, progress towards strengthening PHC systems has been slow [ 12 ]. In the recent years, including in the wake of the COVID-19 pandemic, the unexploited potential of PHC systems to meet the needs of vulnerable populations has come to the forefront again offering opportunities for primary care programs to prioritize it [ 13 ]. Identifying the needs of vulnerable groups, can support in designing equitable PHC initiatives, and understanding the nature of unmet needs can elaborate necessary mechanisms to achieve this.

Unmet needs in primary care have been examined frequently in higher-income settings [ 14 , 15 , 16 , 17 , 18 ] but evidence from low-and-middle income countries (LMICs) remains sparse; most published peer-reviewed literature is relatively recent [ 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. Specifically examining PHC needs, one study from Kenya identifies moderate unmet PHC needs with women, the elderly, and less wealthy groups more likely to forgo care [ 23 ]. A study from India elicited high unmet needs for non-communicable disease (NCD) diagnosis [ 26 ], and recommended qualitative approaches in future studies to understand appropriateness of care in relation to unmet needs [ 26 ]. Evidence from Pakistan describing PHC unmet needs is also sparse. One study highlighted gender related difference in access to PHC in Balochistan province [ 27 ]. A systematic review on women’s PHC access barriers, identified cultural and health service related barriers [ 28 ]. While supply and demand side factors are mentioned in these studies, the link between them resulting in unmet needs has not been established. The influence of poverty is also not the focus of these studies.

In this study we (i) identify the met and unmet PHC need of the poorest population of Khyber Pakhtunkhwa (KP) province, Pakistan, and (ii) explore why the gaps exist. Through this, we offer recommendations for UHC policymakers to design equitable PHC initiatives. The context in KP of an emerging SHP system partially covering secondary and tertiary services, but not PHC, is furthermore representative for the challenges many LMICs face currently [ 9 ]. Given that it has a weak, but existent PHC system – a well-known phenomenon around the world [ 29 ] - KP can offer insights for other similar settings. We applied a mixed-methods approach [ 30 ], with demand and supply side data to provide perspectives of and on the end-users of the healthcare system, respectively, to consider primary care health needs, and their complexity using Levesque’s Framework of Access to Patient Centred Health care [ 31 ].

Study setting

Pakistan has made significant progress towards UHC in the past decade [ 32 ] although indications of unmet needs have been made by previous studies [ 33 ]. The public health infrastructure consists of three tiers of facilities offering highly subsidized rates at the point of care [ 34 ]. A largely unregulated private sector thrives due to low capacities of public facilities [ 34 ]. Average out of pocket expenditures were 53.2% in 2019-20 [ 35 ]. An Essential Package of Health Services was presented in 2021 as high priority and high cost-effectiveness interventions to be covered under UHC programs [ 36 ].

A donor supported SHP program was launched in 2015 in KP followed by other regions of Pakistan [ 37 ]. Offering financial coverage for inpatient procedures, these programs started with covering the poorest income quintile of the population [ 37 ]. The government of KP, wants to extend its SHP program coverage to include outpatient department (OPD) services for the poorest population, with a PHC strengthening focus. The scheme – called Social Health Protection Initiative phase-II (SHPI-II) – is planned for a 2024 pilot, and is supported with financial contributions from the German government.

We conducted this study as part of the INSPIRE Pakistan research consortium [ 38 ] to support the implementers in the process of developing and implementing the SHPI-II. We therefore collected data in four districts of KP, where SHPI-II will be launched (Fig. 1 ). These districts are diverse in terms of geography and health infrastructure, helping us profile a variety of experiences within the poorest population of KP. The target population of our study were the potential beneficiaries of the SHPI-II program, who have been set to be the poorest (21%) households in the four districts. Eligibility information on these households was drawn from the Proxy Means Test scores lists prepared for the Benazir Income Support Programme (BISP) [ 39 ] in 2010, which were considered to be used for the SHPI-II program at the time of the study. Being asset-based the BISP scores are a more accurate measure of socio-economic deprivation than income level, useful for identifying the most vulnerable population.

Map of Khyber Pakhtunkhwa province with location of selected districts

Conceptual framework

Unmet needs.

Unmet needs are sociomedical : they present both at the social level as well as in the state of an individual’s physical health [ 40 ]. They are described as, ‘the differences, if any, between those services judged necessary to deal appropriately with defined health problems and those services actually being received’ [ 40 ]. The spectrum of needs, thus, is influenced by factors of and beyond medical care. Recent scholarship considers subjective approaches (described by individuals themselves) to understanding unmet needs superior as they can draw on perceived needs that were not brought to care or ‘forgone’ [ 14 , 41 , 42 ]. This also acknowledges ‘people-centeredness’, which has consistently been encouraged in PHC systems [ 29 , 43 ]. People-centredness can guide research and practice communities towards creating structures and processes which are based on peoples’ needs, angled towards fulfilling them [ 29 , 43 ]. We therefore centered our study on subjective unmet needs in line with our objectives.

Levesque’s framework of access to care

We conceptualized needs as antecedent to access using Levesque’s framework of patient-centred access to care [ 31 ] (Fig. 2 ). The framework presents access to healthcare on a pathway; to move from one stage to another, the ability of an individual and the capacity of the system must align, categorizing clearly where the met and unmet needs can lie.

Levesque et al.’s framework of access to care (Levesque et al. 2013) [ 31 ]

We used this framework as it conceptualizes health needs on a continuum over the course of care-seeking, compared to other frameworks of access [ 44 ], which refer to needs at a fixed moment during care seeking. Secondly, the role of the supply and demand side in meeting needs is crucial to this framework, and our research.

Not all stages of the framework were empirically examinable in the quantitative model as comprehensively as we conceptualized them. We operationalized two main concepts in the following ways: utilization was defined as care seeking at a public or private health facility; forgone care was any time a person considered seeking care but did not go to a formal facility. We categorized health facilities as higher level including secondary and tertiary care, and primary care facilities.

It is important to acknowledge that in our setting people may seek primary care at ‘outpatient departments’ (OPD) located at different levels, as well as in the private sector. Basic healthcare in Pakistan is not always accessed at the primary level, and people may directly approach higher levels [ 45 , 46 ]. We hence referred to primary care as OPD care during data collection to align our language with the emic understanding of our respondents.

Study design

We chose a mixed-methods approach to strengthen the validity and decrease the limitations of inherent in each method [ 47 ]: qualitative data provide in-depth explanatory and exploratory insights into the framework dimensions, while quantitative data offer an overall picture of met and unmet needs. We collected data for the two components separately and interpreted results jointly, i.e., methodological triangulation [ 48 ].

Data Collection

We conducted two focus group discussions (FGD) each, with male and female respondents in all four districts, using a purposive sampling strategy and sought saturation within and across districts -one additional FGD was conducted with men in Chitral, for a total of 17 FGDs. All FGDs included 5–8 participants, representing a potential beneficiary household, preferably aged over 35 years to report for the entire household. We used an FGD guide (see Additional File 1) based on the framework. We conducted in-depth interviews (IDI) with one physician each at a public primary, public higher level, and private facility, in all districts. After refusal from one public higher-level facility, we completed 11 in-depth interviews. We interviewed physicians among healthcare providers owing to their higher access to information about administration and regulations. A semi-structured interview guide based on the framework was used (see Additional File 1).

We drew respondents for the quantitative survey via random sampling from the list of potential beneficiaries in all four districts restricting to accessible union councils (UC) considering safety, weather, and distance to a potentially covered health facility. Among these, the sample was randomly drawn in three stages: four UCs per district, up to four villages per UC, then households within these villages (see Additional File 2).

We interviewed one main respondent per household in an in-person interview (January-March 2022), who answered questions for him/herself and their household members. In addition, we collected detailed information on the health needs of children via a follow-up phone survey (May 2022), for which we reached almost 90% of respondents from the in-person interviews. The final sample comprised 744 households with a total of 4,017 family members Footnote 1 . The survey (see Additional file 4) was administered via a tablet-based questionnaire.

Data were collected between December 2021, and May 2022. All tools were translated into Urdu and Pashto and piloted before formal data collection. Data were collected by trained graduate and undergraduate level research assistants, well-versed in local languages and dialects. We obtained written consent of all participants, for qualitative data also to record audio until verbatim transcription. There was no overlap between the qualitative and quantitative samples, not to exhaust the respondents.

Data Analysis

Transcripts of FGD’s and IDI’s were translated into English. Three researchers (MS, FK, and SU) systematically coded them in Nvivo 13 using a deductive codebook, reflecting the Levesque’s framework, with a few codes added inductively. We conducted an interrater reliability exercise on three test transcripts until high agreement was reached. We concentrated all information from the codes into Microsoft Excel and after three stages of concentrating data, presented the main findings, with examples and descriptions under each of the 10 dimensions of the framework.

The main measure of primary care need in the quantitative survey was self-reported health care utilization. We recorded the number of OPD visits and neglected OPD visits within a one-month recall period differentiated by facility types (higher/lower level, public/private) and reasons for seeking care for each core family member. We separately recorded pharmacy visits and asked for other health problems where seeking care was not considered. For survey time reasons, we only recorded out-of-pocket expenditures for the most recent OPD case per person, which we consider to be representative of all health needs of the respective person.

Survey data were analysed descriptively along the framework dimensions to describe the process of care step-by-step. In the first dimension, we added a logit regression, in which we used need for care as an outcome and age, gender, health status, district, distance to next health facility and a wealth index as explanatory factors. We chose the respective factors based on common factors to explain health need from the literature and analytical hints derived from the qualitative analysis. All reported figures accounted for sampling weights to factor differing sampling probabilities of target households across districts, UCs and villages. We conducted all quantitative analyses in Stata 16. For estimation of the logit regression we used the logit-command and clustered standard errors at the household level. For other descriptive analyses, we derived frequencies and estimated weighted means, for which we reported point estimates and 95% confidence intervals where appropriate.

After initial analysis, qualitative and quantitative findings were integrated using a narrative weaving approach [ 49 ].

A total of 129 people participated in focus group discussions of whom 67 were male and 62 were female. Eleven healthcare practitioners participated, two of whom were female. Age data for practitioners was not collected due its irrelevance with the study objectives. In the household survey 744 households were represented with an average of 4.05 adult members and 1.62 under 15. The average monthly out-of-pocket health expenditures were PKR 38,106. The characteristics of respondents of both study components are shown in Tables 1 and 2 .

Utilized and forgone OPD care

From the household survey, we saw the following patterns: The majority of families (82.38%) and 41.28% of individuals reported at least one OPD care visit within the past month. On average, we recorded 0.85 OPD visits per person per month to formal care facilities. Almost half of the families (48.22%) reported at least one case where they considered seeking OPD care but did not go within the past month. On the individual level, this corresponded to 15.45% of the 4,017 family members or a per-person average of 0.37 forgone OPD visits within the past month.

Survey data revealed that the majority of OPD visits (58%) were due to acute illnesses. However, substantial preventive visits (12%) and a few accidents or injuries (5%) were also reported. Only a small fraction of respondents reported pregnancy or childbirth related OPD visits (2%) (Fig. 3 ). Private primary-level facilities were most frequented (45%), followed by public higher-level facilities (22%) (Fig. 4 ).

Reasons for seeking OPD care. Bars represent the weighted percentage of persons who reported the respective reason for seeking OPD care among those with at least one OPD visit within the past month

Monthly OPD utilization rate by facility type. Bars represent the average monthly OPD utilization rate (weighted mean) by facility type based on all core family members

Participants in the qualitative component mentioned that some health needs were neglected while for others care was simply sought later i.e., delayed care seeking:

‘We tolerate pain and resist our medical condition until we can , but if condition gets worst then we have to take loans and pay for our treatment. For relieving pain , we take painkillers.’ (Female, Chitral).

Self-care during this period did or did not not alleviate the need, and physicians attributed delayed care-seeking to their poorest patients especially, which sometimes resulted in complications for example, for pregnant women.

Understanding unmet needs

Perception of needs and desire for care.

At the first stage, health needs require perception, followed by decisions for pursuing care which are based on knowledge of healthcare and desire for care, respectively.

FGD respondents had a basic awareness of health conditions, diagnostics, and medication i.e. they could name but not explain the underlying mechanisms and connections between them. Common information sources were word-of-mouth, and previous experiences. The practitioners interviewed described that while their patients from low economic segments displayed a good vocabulary regarding diseases and healthcare, they did not have accurate knowledge about the extent of their illness and the need for immediate care; poorer patients visited with exacerbated symptoms, compared with others. The physicians however also acknowledged that the information and outreach functions of public facilities were not being exploited well e.g., one interviewee remarked that facility waiting rooms could use multimedia to deliver messages about care and prevention, but this was not being practised.

‘One more thing that is even more important is that we should have health educators , female and male in every waiting area. They would guide people about the disease and tell them how to manage and what changes to bring in their lifestyle for the management of the disease.’ (Physician, Public secondary facility, Kohat).

Respondents explained that they took rest at the first recognition of illness, tried home remedies such as drinking tea, and if symptoms subsided, no formal care was sought. In our household survey, we asked for health events where seeking formal care was not considered: around 19.5% of family members reported such a health need, which they managed through self-medication including purchasing medicine without a prescription, home remedies, spiritual healing, and prayer, or doing nothing. Alternative care was reported by FGD respondents and in survey data but availing it was not a substitute for, but in addition to biomedical care, and predominantly for chronic conditions.

FGD respondents remarked that lack of accurate information negatively affected their ability to navigate the health system. To reach the first point of care, the choice of provider was made by the patient and their family, as referrals are not required; leading to patients being turned over from facility to facility. Decisions about where to seek care were based on previous experiences, the reputation of the physician, and recommendations from friends or family.

‘ [My daughter] sometimes went to one doctor and sometimes to another. Some doctors said that she had pain in the intestine , some doctors said there is swelling in her uterus… After that some doctors said she had only 3 days left to live. Different doctors have different comments.’ (Female, Mardan).

The desire for seeking facility-based care was also affected by trust in the system as a whole, although in the quantitative survey, trust in physicians was reported to be high (see Additional File 3, Table 1). There was an understanding among the FGD respondents that the health system favoured the rich and the well-connected, and that poor people could not expect any support. People mentioned feeling coerced to use low quality health services compared to others.

‘ In public hospitals they have such big egos that they won’t even look at a poor patient. That’s why I don’t go to the hospital. ’ (Female, Kohat).

When explaining reported outpatient need in the quantitative survey data in a multivariable regression we saw that (see Additional File 3, Table 2): households having more older or female members, characteristics that are expected to be associated with higher health need, had significantly higher odds of reporting a need (age: OR 2.83 95% CI 1.95–4.09, female gender: OR 1.316 95% CI 1.0-1.66). On the other hand, higher wealth was also associated with higher odds of reporting a need (OR 1.36 95% CI 1.18–1.157), which is in line with the hypothesis that the poor might exhibit a lower desire to seek care.

Healthcare seeking

After the desire for seeking care is established, the Leveseque’s Framework of access to care considers social, cultural, and individual factors which may influence access.

Examining utilization by gender, the quantitative data showed similar levels of healthcare utilization for female (44%) and male family member (40%) and the same applied to foregone care (males 15%, females 17%) (Fig. 5 ). Discussing barriers to care seeking, female FGD respondents mentioned that transport was more expensive for them, as they preferred not to use public transport. The quantitative survey data confirmed that on average, transportation costs for women are higher, yet not statistically significantly different from those of men (see Additional File 3, Table 3). In addition, there were difficulties in leaving household chores and children behind, even though support was available from neighbours or relatives, and they mentioned lack of autonomy to reach all aspects of healthcare independently such as buying medication, or visiting facility without male family members.

Utilized and forgone care by age and gender. Bars represent the average monthly OPD utilization rate based on all core family members by gender (upper left panel) and age groups (upper right panel) and average monthly foregone OPD visits based on all core family members by gender (lower left panel) and age groups (lower right panel); with 95% confidence interval around weighted mean

‘If a male [relative] is not with us then we have to ask some other person or request them to please bring medicines for us.’ (Female, Kohat).

Men reported delaying or forgoing care due to the opportunity costs of skipping work, as a significant portion of the respondents was employed in the informal sector.

In survey data on health decision-making, while 71% male adult family members reported to be decision-makers, only 40% of females did (see Additional File 3, Table 4). FGD respondents explained that health decision-making was actually a collective process within families, but the final decision lay mostly with the older male household head.

The position of an individual in the family also determined if care would be received; respondents mentioned doing everything in their capacity to ensure care of children and the elderly, even if it cost more. For example, the elderly had higher transport expenditures on average (PKR 309 vs. PKR183) (see Additional File 3, Table 5). Women reported forgoing care to save resources for their children. We did not see large differences in utilization across age groups in survey data, but children (up to 15 years) and older people (above 50 years) reported to use and to forego OPD care more (Fig. 5 ).

In terms of supply side consideration of social and individual factors, physicians mentioned that many primary care facilities did not have female health service providers, particularly laboratory technicians, however, male staff was not observed as prohibitive for women to seek care, except for gynaecological issues. While gender segregation norms were said to be respected, some facilities did not have enough resources to ensure this.

‘If a female requires a detailed examination , I shall take her to LHV’s [Lady Health Visitor] room rather than do the inspection here… but there are occasions when I am obliged to use another bed since the female bed is filled.’ (Public primary facility, Chitral).

No special age-related services were mentioned.

Healthcare reaching

Physical access to care is multifaceted and an important stage in the care seeking pathway to examine systemic gaps.

Our household survey measured the distance of the household to any type of health facility, in minutes (by usual mode of transport). It revealed that the study population had physical access in terms of distance as self-reported travel time to reach care was less than one hour, and substantially lower for primary facilities for most respondents (Fig. 6 ). However, people associated public facilities, particularly higher-level facilities, with long queues, extensive waiting, and some people recalled missing the consultation due to overcrowding. Waiting times hindered particularly those with informal jobs, from visiting a facility. Specialist OPD care and diagnostics were only available in public facilities on certain days of the week, coercing people to choose private care for urgent treatment or for seeking care in the evening hours. People recounted travelling frequently to the provincial capital and other cities to get appropriate care or diagnostics, and chronically ill respondents had higher costs of transport (see Additional File 3, Table 6). Acknowledging this, physicians shared that the patients begin to queue before the opening hours even started yet owing to high patient load in combination with time spent on administrative tasks, there was nothing they could do to improve the situation. Emergency services were available round the clock in higher level facilities, but primary level facilities only operated during the day.

Self-reported travel time to reach nearest facility. Bars represent the average self-reported travel times (weighted mean) to the nearest health facility respondents reported in minutes by facility types for district Chitral (right panel) and the other districts (left panel)

In Chitral, FDG respondents and physicians alike remarked on the remoteness of the area making care seeking highly subject to the weather and road conditions.

‘ Right now , there is no snow in winters but otherwise all the roads get blocked. ’ (Public secondary facility, Chitral).

Quantitative data on utilization by level revealed that in the previous month, people visited private primary care facilities most often (45%), followed by public higher-level facilities (22%), public primary (11%) and lastly, private higher-level facilities (7%) (Fig. 4 ). FGD respondents explained preferring public facilities as they were the cheapest overall, including specialized care and subsidized diagnostics, yet, private primary care facilities were most frequented due to their proximity, and familiarity with the provider. Respondents acknowledged that private primary facilities may be run by unqualified practitioners i.e. ‘village doctors’. In one FGD respondents proposed the idea of decentralized public primary facilities to save costs of travelling, Interviewed physicians acknowledged the variable availability of services in public primary facilities.

Another aspect of managing care access in our setting were community members who provided substantial support by offering or, arranging for transport, and accompanying the patient to the facility.

‘Our community’s tradition dictates that in an emergency , everyone with a car will assist in transporting the patient. And the volunteers are so numerous that if the patient is unable to pay , they will spend from their own pockets.’ (Male, Kohat).

As patient attendants community and family members supported patient needs and, in some cases, even made the follow-up facility visits. Many respondents mentioned using social connections to skip queues and get medicines from limited stocks, and preferred to visit facilities where they knew someone.

Healthcare utilization

Costs of seeking care are the fundamental concern of SHP policies, and the Levesque’s framework of access to care not only considers direct, but also indirect costs of seeking care.

We assessed the costs of care for illness episodes across the entire care-seeking pathway, instead of only at the point of utilization (Fig. 7 ). The average expenditure for an OPD care visit was 1,954 PKR (9.9 EUR, January 2021) across all reported visits, around 5% of average monthly household expenditures, but with a lot of variation across facilities and visits. While visits to primary facilities were more frequent, they were on average less costly than secondary facilities. Exceptionally high expenditures were concentrated in private secondary facilities. Medication expenditures took the highest share among expenditures, followed by diagnosis and treatment, and by transport expenditures. Expenditures were paid out-of-pocket and financed by loans from family or friends and savings. A non-negligible share of our sample also reported to increase the number of jobs or working hours, asked for donations from family, friends, or neighbours, or even reduced consumption to finance the health expenditures. Poor people donated and fundraised for their community members when needed and participants mentioned taking medicines on credit from medical stores. People also mentioned requesting their physician to prescribe less medication to save their costs.

Cost of care by level and component. Bars represent the reported average out-of-pocket expenditures (weighted mean) for the most recent OPD visit of those who reported at least one OPD visit within the past month by facility types in PKR. Different shades of grey indicate the average expenditure composition

FGD participants mentioned indirect expenditures like accommodation costs if the facility was out of town, food during waiting hours, and informal payments to get medicines from limited stocks, earlier appointments, and quicker diagnostic results.

‘They are good to those who pay them some money. Their tests take no time , also in OPD , their turn comes first.’ (Male, Kohat).

Supply-side interviews mentioned physicians deliberately writing shorter prescriptions if they observed that the patient was poor. All interviewed physicians recognized the hardships of the poorest patients in meeting health needs; public facilities reported that they exempted a small number of patients each day, one used donation to buy medicines for the poor, and a private facility physician said that they set up free medical camps sporadically.

Healthcare consequences

In the last stage of a care seeking, we consider experiences of care seeking including perceived technical quality and interpersonal interactions.

In public facilities, FGD respondents reported substandard technical quality: medicines were almost never available, and people were asked to bring their own equipment such as thermometers and bandages. Physicians, mentioned that some public primary health centers in KP may not even have the most basic equipment like blood pressure monitors and glucometers. In Chitral, none of the public facilities had a Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) machine. Physicians at public facilities mentioned requesting relevant authorities to improve the situation, but the bureaucratic processes took long.

‘In my opinion we cannot give 100% services to people. I can say about 50/50 as our hospital is not fully equipped. Our human resource has always been less. We have a deficiency of doctors , staff nurses. Lab is also overburdened. Workload is high in our hospital.’ (Public secondary facility, Mardan).

Respondents from private facilities on the other hand, mentioned better laboratories, diagnostics, and pharmacies but with large variations and people reported to visiting laboratories in the market for specialized tests. FGD respondents also experienced slow diagnoses and having to travel to other cities to receive care and diagnostic tests.

Physicians across all facility types were rated well, and people saw them as helpful and knowledgeable, yet private sector physicians were reported to give more attention, time, and be friendlier. Other facility staff such as nurses and receptionists received predominantly negative impressions and were accused of mistreating people based on their socio-economic status.

People’s inability to adhere to the care regimen prescribed to them emerged as a strong theme in the FGD’s: medication was not or only partially purchased, referrals and follow-up instructions were not always followed, at perceived recovery treatment could be given up immediately, and a special diet suited to health conditions could not be arranged, due to lack of finances.

‘The main reason why we do not have any left money for medicines is because we pay some for ultrasound , some in consultation fees , and some in lab tests. Since we do not have money , we come back home and keep the OPD slip on one side; we are helpless we do not have any other option. ’ (Female, Malakand).

Physicians also reported non-adherence to care among the poorest patients. Very few, however, mentioned measures taken to counter non-adherence mostly in the form of prescribing fewer medications when requested.

As efforts emerge to strengthen PHC systems across the world, complementary knowledge of the health needs of vulnerable populations is crucial to design people-centred initiatives. We offer insights from the poorest population segment in the KP province, Pakistan to add to this body of knowledge. Our results show that poor people’s basic health needs remained unmet, and in cases where they may be considered met, people incurred significant financial and systemic barriers. Gaps in approachability (providing adequate information about navigating the health system), and availability and accommodation (availability of necessary drugs and equipment) made the supply side unable to fully meet the health needs of the poor. On the other hand, people found it difficult to travel to the care that they would prefer (ability to reach) and adhere to prescriptions (ability to engage) leading to unmet needs. We found that out-of-pocket expenditures were a major deterring factor, as expected and shown in other settings [ 17 , 23 ], yet they were not the only determinant of unmet need. Problematizing simplistic conceptualizations of health needs, we argue that unmet needs are multifaceted; they can exist despite utilization of care. We observed a negative perception of the health system among the poorest population in KP. Previous studies focusing on public trust in health systems have shown that vulnerable populations such as minority races, physically disabled persons, and refugees have lower trust in the public health system, and recommend explicit focus on integration [ 50 , 51 , 52 ]. Leveraging trust through policies to strengthen PHC systems could be an opportunity that serves the long-term goals of greater healthcare utilization, trust in public systems, and broader social solidarity [ 53 , 54 ]. Better staff training [ 55 ] and allocating resources for outreach and communication programs could improve the impression of health facilities among the poorest population, invite people to visit facilities for their health needs without delays, and support them in navigating the health system. Complementary programs in the local contexts should be integrated with UHC policies to this end, such as the Primary Care Management Committees in KP, which engage local representation in healthcare decision-making [ 56 ].

At the level of seeking healthcare, we observed the intersectional role of poverty with age and gender in determining unmet needs. The differences in underlying factors of unmet need among men and women, reinforce the importance of reflecting on disparate gender effects when studying unmet needs among vulnerable groups. Our findings are consistent with a study conducted by Panezai et al.. in a rural Balochistan, Pakistan, where utilized and forgone BHU care was similar for both sexes, yet factors influencing utilization were different [ 27 ]. Other studies on unmet need across various settings also confirm that men and women’s unmet needs are due to different underlying causes [ 17 , 57 ] therefore it is important to explore, beyond numbers, how access can be improved. Calls to explore the effect of gender in UHC policies have been raised [ 58 ], which can be extended to PHC systems as well: while conceptually PHC systems aim to be accessible to all, a gender-blind approach can exacerbate the differences among men and women’s ability to seek and reach the healthcare they need. Considerations of protecting the health of middle-aged people in SHP programs can be done through lowering opportunity costs by offering compensation for daily wages during healthcare facility visits. This is important as middle-aged people are typically seen as independent and empowered enough to meet their needs which was not the case among our respondents.

More broadly, our results have policy implications in that they highlight that SHP is an important tool for advancing UHC for improving PHC but is incomplete without investments made to the overall health system including towards quality and service delivery improvement at public facilities. Moreover, health needs are not limited to the health sector alone and require action from the entire society and the role of multiple administrative sectors. Engaging with different sectors inside and outside of the health system as evident from our results, must go hand in hand with financial protection offered by SHP programs, to improve PHC access for the poor.

Reflecting on the use of Levesque’s framework of access to care, we observed that the stage-by-stage care seeking pathway, while conceptually sound for the purpose of this study, does not reflect the reality for our respondents. As people were unable to complete their care, they found themselves sent back to previous stages a few times, until they were able to meet their needs. Another shortcoming of the framework we observed was the unified idea of a ‘health system’, interacting with the population. In reality, KP’s health system is a combination of providers, some able to meet their needs better than others.

Methodological considerations

The study has potential limitations. Our quantitative results are an upper bound for monthly health care utilization because we expect some recall bias, i.e., over-reporting due to recall of OPD visits that lie outside the relevant month. It is important to note that we could distinguish between initial and follow-up visits within the same illness episode and to several facility types thus we counted them as separate visits. Moreover, self-assessment of health needs can only capture the perceived needs i.e., health needs not recognized by respondents, could not possibly become a part of our data. Second, while we took utmost care to draw a representative sample from within the selected study districts, remoteness and safety concerns led us to avoid certain neighbourhoods. Thirdly, facility experience could not be captured in our survey as it was conducted at the household level as opposed to a facility exit interview, which would be more suitable to shed light on quality of care experienced. We also acknowledge a power gap between the poorest population and our data collection team, which may have influenced responses despite efforts made to build rapport. To offset these limitations, we reinstate the strengths of our study in its mixed methods design eliciting broad patterns, as well as deeper reflections from our respondents. We tried to ensure cultural sensitivity by working with local researchers to guide us and collecting data in local languages. We conducted regular debriefings between field researchers and the rest of the team allowing for emergent considerations in the research design. Using unmet needs across an access pathway to elicit gaps in the health system offered us a very broad yet patient centred lens to judge the system and make recommendations. Future research analysing objective assessments such as facility surveys would complement this study to establish the capacity of the system to meet health needs.

Conclusions

The poorest population in KP province, Pakistan reported unmet PHC needs. The needs that were met came with considerable barriers, including but not limited to the affordability of care. Our findings highlight the essential role that awareness plays in the health seeking process, suggesting the need to invest in facility outreach and information programs to ensure that people feel welcome to access care and can be supported to navigate the health system. Having recognised that limited resource provision at facilities contributes to people’s unmet needs, we further recommend that investments are made to improve health facility infrastructure and provision of essential products and services proximate to those with higher needs, to improve overall service quality.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author, M.S., only in anonymized form, and upon reasonable request.

We follow the program’s definition of core family members that are covered under one beneficiary card: main insurance cardholder (household head), spouse and unmarried children who live in the same household.

Abbreviations

Benazir Income Support Programme

Focus Group Discussion

In-depth Interview

Khyber Pakhtunkhwa

Low-and-Middle Income Countries

Primary Healthcare

Social Health Protection

II-Social Health Protection Initiative phase-II

Union Council

Universal Health Coverage

Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Hafizur Rahman M. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008;1136(1):161–71.

Article   PubMed   Google Scholar  

World Health Organization. Tracking universal health coverage: 2017 global monitoring report: executive summary. Geneva: World Health Organization; 2017.

The United Nations. The UN Sustainable Development Goals. United Nations no date. Available from: https://sdgs.un.org/goals .

Ifeagwu SC, Yang JC, Parkes-Ratanshi R, Brayne C. Health financing for universal health coverage in Sub-saharan Africa: a systematic review. Glob Health Res Policy. 2021;6(1):1–9.

Article   Google Scholar  

Bayarsaikhan D, Kwon S, Chimeddagva D. Social health insurance development in Mongolia: opportunities and challenges in moving towards Universal Health Coverage. Int Social Secur Rev. 2015;68(4):93–113.

Cotlear D, Nagpal S, Smith O, Tandon A, Cortez R. Going universal: how 24 developing countries are implementing universal health coverage from the bottom up. Washington, D.C.: World Bank; 2015.

van Weel C, Kassai R, Qidwai W, Kumar R, Bala K, Gupta PP, et al. Primary healthcare policy implementation in South Asia. BMJ Global Health. 2016;1(2):e000057.

Article   PubMed   PubMed Central   Google Scholar  

Yates R, Hamer J, van der Mark N, Nganizi S. Accelerating progress towards universal health coverage in South Asia in the era of COVID-19: how universal primary care can tackle the inseparable agendas of universal health coverage and health security. Kathmandu: United Nations Children’s Fund; 2021. Sept 2021.

Van Weel C, Kidd MR. Why strengthening primary health care is essential to achieving universal health coverage. CMAJ. 2018;190(15):E463-6.

Selvaraj S, Farooqui HH, Karan A. Quantifying the financial burden of households’ out-of-pocket payments on medicines in India: a repeated cross-sectional analysis of National Sample Survey data. BMJ open. 2018;8(5):1994–2014.

World Health Organization. Declaration of alma-ata. World Health Organization. Alma-Ata: Regional Office for Europe; 1978.

Rasanathan K, Evans TG. Primary health care, the declaration of Astana and COVID-19. Bull World Health Organ. 2020;98(11):801.

Mhazo AT, Maponga CC. Retracing loss of momentum for primary health care: can renewed political interest in the context of COVID-19 be a turning point? BMJ Global Health. 2023;8(7):e012668.

Allin S, Masseria C. Unmet need as an indicator of health care access. Eurohealth. 2009;15(3):7–9.

Google Scholar  

Cunningham A, Mautner D, Ku B, Scott K, LaNoue M. Frequent emergency department visitors are frequent primary care visitors and report unmet primary care needs. J Eval Clin Pract. 2017;23(3):567–73.

García-Gómez P, Hernández-Quevedo C, Jiménez-Rubio D, Oliva-Moreno J. Inequity in long-term care use and unmet need: two sides of the same coin. J Health Econ. 2015;39:147–58.

Pappa E, Kontodimopoulos N, Papadopoulos A, Tountas Y, Niakas D. Investigating unmet health needs in primary health care services in a representative sample of the Greek population. Int J Environ Res Public Health. 2013;10(5):2017–27.

Schokkaert E, Steel J, Van de Voorde C. Out-of-pocket payments and subjective unmet need of healthcare. Appl Health Econ Health Policy. 2017;15(5):545–55.

Kefale B, Adane B, Damtie Y, Arefaynie M, Yalew M, Andargie A, et al. Unmet need for family planning among reproductive-age women living with HIV in Ethiopia: a systematic review and meta-analysis. PLoS ONE. 2021;16(8):e0255566.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Njagi P, Arsenijevic J, Groot W. Cost–related unmet need for healthcare services in Kenya. BMC Health Serv Res. 2020;20(1):1–12.

Obagha CE, Danladi B, Kamateeka M, Chori BS, Ogbonnaya U, Maduka D, et al. Unmet needs of hypertension care in Nigeria: results of the community action against non-communicable diseases (COMAAND) project preintervention survey. Blood Press Monit. 2021;27(1):27–32.

Okunola TO, Ijaduola KT, Adejuyigbe EA. Unmet need for contraception among HIV-positive women in Ile-Ife, Nigeria. Trop Doct. 2019;49(1):26–31.

Otieno PO, Kiroro F, Runyenje C, Kamau P. Unmet need for primary healthcare and associated individual and household-level factors in Kenya: results from a national survey. BMJ open. 2021;11(5):e041032.

Vongmongkol V, Viriyathorn S, Wanwong Y, Wangbanjongkun W, Tangcharoensathien V. Annual prevalence of unmet healthcare need in Thailand: evidence from national household surveys between 2011 and 2019. Int J Equity Health. 2021;20(1):1–10.

Yadav K, Agarwal M, Shukla M, Singh JV, Singh VK. Unmet need for family planning services among young married women (15–24 years) living in urban slums of India. BMC Womens Health. 2020;20(1):1–17.

Ranjan A, Thiagarajan S, Garg S. Measurement of unmet healthcare needs to assess progress on universal health coverage-exploring a novel approach based on household surveys. BMC Health Serv Res. 2023;23(1):525.

Panezai S, Ahmad MM, Saqib SE. Factors affecting access to primary health care services in Pakistan: a gender-based analysis. Dev Pract. 2017;27(6):813–27.

Jafree SR, Barlow J. Systematic review and narrative synthesis of the key barriers and facilitators to the delivery and uptake of primary healthcare services to women in Pakistan. BMJ open. 2023;13(10):e076883.

Hanson K, Brikci N, Erlangga D, Alebachew A, De Allegri M, Balabanova D, et al. The lancet global health commission on financing primary health care: putting people at the centre. Lancet Global Health. 2022;10(5):e715-772.

Article   PubMed   CAS   Google Scholar  

Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Sage; 2017.

Levesque J-F, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12(1):1–9.

Hasan SS, Mustafa ZU, Kow CS, Merchant HA. Sehat Sahulat Program: a leap into the universal health coverage in Pakistan. Int J Environ Res Public Health. 2022;19(12):6998.

Khalid F, Brunal M, Sattar A, Laokri S, Jowett M, Raza W, et al. Assessing the Efficiency of Sub-National Units in Making Progress Towards Universal Health Coverage: Evidence from Pakistan, Health Systems & Reform, 2009. https://doi.org/101080/232886042019.1617026 .

Asian Development Bank. Khyber Pakhtunkhwa Health Sector Review: Hospital Care. Manila: Asian Development and the Pakistan Bureau of Statistics; 2019. http://dx.doi.org/10.22617/TCS190481-2 .

Pakistan Bureau of Statistics. National Health Accounts-Pakistan 2019-20. Islamabad: Asian Development and the Pakistan Bureau of Statistics; 2022. https://www.pbs.gov.pk/sites/default/files/national_accounts/national_health_accounts/NHA-Pakistan_2019-20.pdf .

Alwan A, Siddiqi S, Safi M, Zaidi R, Khalid M, Baltussen R, et al. Addressing the UHC challenge using the Disease Control priorities 3 approach: lessons learned and an overview of the Pakistan experience. Int J Health Policy Manage. 2023;12(Special):8003.

Farooq M, Arshad MI, Usman M. Towards universal health coverage in Pakistan: challenges ahead. Lancet Reg Health-Southeast Asia. 2022;100003.

INSPIRE Pakistan. Informing the social health protection initiative through rigorous evidence. 2024.

Farooq S. Effectiveness of cash transfer programmes for household welfare in Pakistan: the case of the Benazir Income Support Programme. Pakistan Dev Rev. 2014;53(2):145–74.

Carr W, Wolfe S. Unmet needs as sociomedical indicators. In: Elinson J, Siegmann A editors. Socio-medical health indicators. New York: Routledge; 2019. pp. 33–46.

Allin S, Grignon M, Le Grand J. Subjective unmet need and utilization of health care services in Canada: what are the equity implications? Soc Sci Med. 2010;70(3):465–72.

Fiorillo D. Reasons for unmet needs for health care: the role of social capital and social support in some western EU countries. Int J Health Econ Manage. 2020;20(1):79–98.

Sheikh K, Ranson MK, Gilson L. Explorations on people centredness in health systems. Health Policy Plann. 2014;29(Suppl 2):ii1.

Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974;9(3):208.

PubMed   PubMed Central   CAS   Google Scholar  

Siddiqi S, Kielmann A, Khan M, Ali N, Ghaffar A, Sheikh U, et al. The effectiveness of patient referral in Pakistan. Health Policy Plann. 2001;16(2):193–8.

Article   CAS   Google Scholar  

Akram W, Hussain M, Sana A, Sultan M, Abbas S. Role of referral system in provision of health service to the patients: a prospective study in South Punjab, Pakistan. Med Discoveries. 2023;2(1):1008.

Greene JC, Caracelli VJ, Graham WF. Toward a conceptual framework for mixed-method evaluation designs. Educ Eval Policy Anal. 1989;11(3):255–74.

Flick U, Garms-Homolová V, Herrmann WJ, Kuck J, Röhnsch G. I can’t prescribe something just because someone asks for It… using mixed methods in the Framework of Triangulation. J Mixed Methods Res. 2012;6(2):97–110.

Fetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs—principles and practices. Health Serv Res. 2013;48(6pt2):2134–56.

Schwei RJ, Kadunc K, Nguyen AL, Jacobs EA. Impact of sociodemographic factors and previous interactions with the health care system on institutional trust in three racial/ethnic groups. Patient Educ Couns. 2014;96(3):333–8.

Webb Hooper M, Mitchell C, Marshall VJ, Cheatham C, Austin K, Sanders K, et al. Understanding multilevel factors related to urban community trust in healthcare and research. Int J Environ Res Public Health. 2019;16(18):3280.

Haj-Younes J, Abildsnes E, Kumar B, Diaz E. The road to equitable healthcare: a conceptual model developed from a qualitative study of Syrian refugees in Norway. Soc Sci Med. 2022;292:114540.

Gilson L. Trust and the development of health care as a social institution. Soc Sci Med. 2003;56(7):1453–68.

Wesson DE, Lucey CR, Cooper LA. Building trust in health systems to eliminate health disparities. JAMA. 2019;322(2):111–2.

Gilson L. Trust in health care: theoretical perspectives and research needs. J Health Organ Manag. 2006;20(5):359–75.

The khyber pakhtunkhwa healthcare facilities management, ACT. 2022., (2022).

Baroudi M, Nkulu Kalengayi F, Goicolea I, Jonzon R, San Sebastian M, Hurtig A-K. Access of migrant youths in Sweden to sexual and reproductive healthcare: a cross-sectional survey. Int J Health Policy Manag. 2022;11(3):287.

Witter S, Govender V, Ravindran TKS, Yates R. Minding the gaps: health financing, universal health coverage and gender. Health Policy Plan. 2017;32(suppl5):v4-12.

Download references

Acknowledgements

We acknowledge the support of Asad Ullah, Henrik Berberich, Hessam Ul Haq, Ikram Khan, Mariyam Rahim, Rida Zarkaish, Sarah Syring, Sikandar Sultan, Teresa Leikard, Urooj Aftab, and Valery Ridde for this study. We are also grateful to the Social Health Protection Initiative, KP, and the KP Health Department for their cooperation.

Open Access funding enabled and organized by Projekt DEAL. We gratefully acknowledge financial support as part of a scientific collaboration with the KfW Development Bank (“Scientific implementation research on outpatient-department (OPD) services in the social health protection initiative, Khyber Pakhtunkhwa (KP) province and the Gilgit Baltistan (GB) area”).

Author information

Authors and affiliations.

Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany

Maira Shaukat & Manuela De Allegri

Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany

Alina Imping, Lisa Rogge & Andreas Landmann

Institute of Public Health & Social Sciences, Khyber Medical University, Peshawar, Pakistan

Fatima Khalid & Fayaz Ahmad

Office of Research, Innovation, and Commercialization (ORIC), Khyber Medical University, Peshawar, Pakistan

Safat Ullah, Zeeshan Kibria & Zohaib Khan

You can also search for this author in PubMed   Google Scholar

Contributions

M.D.A, A.L. and Z.Kh. conceptualized the overall study goals while M.D.A., M.S., L.R. and A.I. conceptualized the flow of the mixed methods paper. M.S. drafted the manuscript supported by contributions from L.R., A.I. and M.D.A.. M.S., F.K., F.A. and S.U. collected and analysed qualitative data guided by M.D.A.. L.R., A.I., and Z.Ki. supervised the collection of quantitative data, and analysed it, guided by A.L.. Z.Kh. supervised the data integration for mixed methods analysis. All co-authors reviewed and commented on the final draft. Reflexivity statement. Five of the ten authors are from and based in Khyber Pakhtunkhwa province Pakistan. The rest are based in Germany; four come from high-income European countries while one is from Pakistan. All except two authors have previously conducted research in Pakistan. None come from the poorest socio-economic quintile as described for our research participants. All have prior experience, to differential degrees, in research on Universal Health Coverage and Leaving No One Behind/Pro-Poor Policies.

Corresponding author

Correspondence to Maira Shaukat .

Ethics declarations

Competing interests.

We gratefully acknowledge financial support as part of a scientific collaboration with the KfW Development Bank (“Scientific implementation research on outpatient-department (OPD) services in the social health protection initiative, Khyber Pakhtunkhwa (KP) province and the Gilgit Baltistan (GB) area”). Any opinions, findings, conclusions, or recommendations expressed in this material are those of the authors(s) and do not necessarily reflect the views of the funder.

This research was disseminated to the policy designers of Social Health Protection Program for outpatient care in KP in June 2022. None of the authors have any direct stakes in the program.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1., additional file 2., additional file 3., additional file 4., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Shaukat, M., Imping, A., Rogge, L. et al. Un/met: a mixed-methods study on primary healthcare needs of the poorest population in Khyber Pakhtunkhwa province, Pakistan. Int J Equity Health 23 , 190 (2024). https://doi.org/10.1186/s12939-024-02274-5

Download citation

Received : 17 January 2024

Accepted : 13 September 2024

Published : 23 September 2024

DOI : https://doi.org/10.1186/s12939-024-02274-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Universal health coverage
• Universal health insurance
• Primary health care
• Access to primary care
• Health equity
• Needs assessment pakistan

International Journal for Equity in Health

ISSN: 1475-9276

• General enquiries: [email protected]

ARTIFICIAL INTELLIGENCE AND MENTAL HEALTH SERVICES

• Pakistan Postgraduate Medical Journal
• This person is not on ResearchGate, or hasn't claimed this research yet.

• Forman Christian College

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations

• Akkapon Wongkoblap

• BMC MED INFORM DECIS

• Cherise Chin Fatt

• Philip J Harrison

• Evid Base Ment Health
• Joseph Geraci
• Pamela Wilansky

• Molly Vierhile

• Mandar Deshpande
• Vignesh Rao
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

Journal Notes: Avoiding the Pitfalls of Qualitative Research – A Conversation with JGME Associate Editor Rachel Gottlieb-Smith, MD

What is qualitative research, and what do the editors at The Journal of Graduate Medical Education ( JGME ) wish authors knew about it? In its August issue, JGME published the second editorial in a two-part series entitled, “ Common Pitfalls to Avoid in Qualitative Submissions to JGME .” While the first editorial presents advice for each section of a qualitative research article, from introduction to conclusion, the second attempts to help authors steer clear of some common traps when conducting this type of work.

Qualitative research can be an excellent way to explore some of the phenomena that many in the graduate medical education (GME) community seek to better understand, such as how professional identity, resilience, and learning relationships are experienced. While quantitative research relies on the kind of measurable numerical data that most associate with traditional research, qualitative methods use descriptive data, often obtained through interviews or discussion groups, to gain deeper insights into participants’ experiences and perceptions.

JGME Associate Editor Rachel Gottlieb-Smith, MD co-authored both editorials with Deputy Editor Lalena M. Yarris, MD, Associate Editor Dorene Balmer, PhD, and Editor-in-Chief Gail Sullivan, MD. As a child neurologist, Dr. Gottlieb-Smith is well-versed in quantitative research and data, but her interests as an educator led her to questions around career choice, exploring how medical students progress through their education, and why some choose the field of neurology. To understand more fully how and why that career choice happens, she employed qualitative methods to learn more from students’ own experiences and perspectives.

Dr. Gottlieb-Smith learned about the unique challenges of qualitative research through her own experience and through good mentorship, particularly working with Dr. Balmer. “As I was starting, I didn’t have a great understanding of how to approach the project,” she recalls. “[Dr. Balmer] helped me see that I needed to have a strong conceptual framework to guide the study. I needed to know how I was contributing to conversations that were already happening, what theories I could apply, and how those theories could structure my thought process and interview guides.”

She notes that researchers are often unaware of how many paradigms and worldviews there are in approaching this kind of work. “I grew up and trained in a very positivist mentality, where there is one reality and one truth. But qualitative research often uses a constructivist paradigm, where individuals and communities can co-construct meaning and their own understanding of reality,” she recounts. “So asking myself which paradigm I was sitting in helped me to ask better research questions.”

Because qualitative research often lives in this constructivist worldview, there are some who believe that it’s not possible to assess rigor and quality. After all, if you are co-constructing reality, could you just be making things up? On the contrary, the editors at JGME want to dispel that notion. As Dr. Gottlieb-Smith argues, “There are ways of doing quality control. It is important to carefully explain the process of how you obtained and analyzed the data. You can keep detailed notes on the data collection and analysis, called an audit trail. Member checking, going back to participants to confirm the study accurately reflects their opinions, is another example. We need to stay true to what the participants are telling us about their experiences, and we need quality control there to prove it.”

Many of the pitfalls in this work stem from not properly describing the framework or paradigm used and not aligning that framework with the study’s methods. “If you’re using a constructivist paradigm, then you don’t want to set yourself up with a question that is answered with a yes or no,” she explains. “Also, there are some terms that get used often in qualitative research that sound jargony, and some authors might include them believing they will help the paper get published. ‘Grounded theory’ is an example. There are different types of grounded theory, and it’s not always clear that the authors chose methods that align with their theory. So, it’s important that the authors all understand what those terms mean so they can accurately describe them in the work.”

The editors at JGME find great value in qualitative research when it’s done well. Their hope is that authors considering a qualitative study will take advantage of these editorials, as well as other articles on this topic, to help set themselves up for success. To learn even more, check out the articles on qualitative research on the Resources for Authors page and let us know at [email protected] what you think.

Journal Notes blogger Kevin Gladish is a staff editor for the  Journal of Graduate Medical Education . He’s been at the ACGME since 2016, and is also a performer, writer, and storyteller.  

Popular Topics