qualitative research in visual analysis

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Using Visual Data in Qualitative Research

• Marcus Banks - University of Oxford, UK
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This book helps students and scholars get started on the exciting journey of using visual data in social research. It covers the many uses a researcher can make of images, from creating images as a part of the research process to collecting and analyzing images from diverse sources.  Exploring the opportunities and arming readers with tools to overcome some of the practical challenges, Using Visual Data in Qualitative Research is a perfect guide to uncovering new and unexpected dimensions of social life.

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Visual Data Analysis: New Interpretive Contexts for Qualitative Research?

By Ana Isabel Rodrigues – Beja Polytechnic Institute

The text that we present was constructed, essentially, with excerpts from the Editorial “Analysis of Visual Data: Challenges and Opportunities for Qualitative Research” (RODRIGUES, NERI DE SOUZA and COSTA, 2017), published in Revista de Pesquisa Qualitativa .

Aires (2015), referring to research contexts, says: “any scientific activity falls within a set of spatio-temporal and sociohistorical coordinates that condition and justify its methodological options” (p.4). Thus, a new context reveals itself to the researcher who, as we know, and especially in qualitative research, is much more sensitive to what surrounds them. A context is consubstantiated in an object of study characterized by emotions, feelings, perceptions, opinions, marked by the proliferation of technology, namely the internet.

It is in the face of new challenges to qualitative research that new opportunities emerge. “We can never forget that theories and methods have to do with the reality of the world,” says Minayo (2016, p. 31). And because the world has changed a lot in the last twenty years, qualitative research is going its own way and adapting itself to the “new” reality. An example of this is the emergence of Mixed Methods based on the premise that the combined use of quantitative and qualitative methods can provide a better understanding of the phenomenon under study than just one approach (BRYMAN, 2006; CRESWELL & PLANO CLARK, 2011; GREENE, 2008). This “new” understanding of the research process, considered as the “third methodological community” (TEDDLIE & TASHAKKORI, 2012) or the “interactive community” (NEWMAN & BENZ, 1998), is an expression that for “diverse and complex contexts we need more “complete” and / or combined methodologies” (NERI DE SOUZA & COSTA, p.1).

In the same line of thought, the use of the visual element in qualitative research materializes in the so-called “visual movement” (HEISLEY, 2001), with its application roots in the field of visual anthropology. Researchers today have at their disposal a set of data with visual support such as paintings, photographs, films, drawings, diagrams, among others, allowing the introduction of new interpretive elements that enrich the analysis and understanding of its object of study. Image informs, elucidates, documents, adds value and meaning to the phenomenon itself. Banks (2007) points out two main reasons for the adoption of visual data analysis in qualitative research:

• In contemporary society, images are omnipresent , and exactly from this premise, all visual representation must potentially be considered in all scientific studies of society. That is, image is everywhere and therefore cannot be “apart” from research projects that focus on the study and understanding of the world we live in.
• A study of images or a study using visual data may reveal new sociological perspectives that are not accessible through the use of other data.

However, according to Heisley (2001), and in response to his question “Why do researchers resist the adoption of the visual element?” , the following reasons are presented:

• In general, the visual element is still considered less “serious” by academia;
• Visual understanding is accessible to all, allowing those observing multiple interpretations. This loss of control can be uncomfortable and threatening to the researcher;
• Researchers are not yet familiar with the use of “video” as a data source;
• Researchers are still influenced and biased by the idea that words are more “intellectualized” than images;
• There seems to be no “peer review” yet to legitimize its adoption;
• It is very hard work and demanding.

In addition to the reasons mentioned above, we can add the fact that it was only in the last decades that technological tools have appeared that facilitate the technical treatment of visual data, such as image and video, in qualitative analysis in an integrated and flexible way. Many of these tools are still unknown to researchers. In general terms, it is possible to identify two main aspects in the adoption of visual elements in the social sciences (BANKS, 2007, p.67):

• The first refers to the creation of images (visual data) such as videos, photographs, drawings by the researcher him/herself to document or analyze aspects of social life and social interaction. The researcher makes his/her notes, records of what he/she observes and analyzes using visual elements.
• The second concerns the collection and study of images produced and / or “consumed / observed” by the research subjects. In this case, the research project is more “visual” and there is a greater social and personal connection of the subject being studied with these same images.

Banks (2007) proposes, in this book, some solutions to this problem in the field of research and visual methods. Despite the scientific value of the form of data recording as presented in point 1 above, it is still not accepted or simply known by the academic community that most software packages already incorporate features for description, interpretation and transcription of videos and images. For example, in Figure 1 we present a system of indexing, with descriptive or inferential texts, associated to the coding and analysis of an image through webQDA software (www.webqda.net).

Figure 1 – Example of analyzing an image in webQDA

In sum, as Banks (2007) points out, these two strands can be understood in a contrasting way. On the one hand, in the first case, the use of images for the study of society and, on the other, a study and more sociological approach to images. These two ways are neither mutually exclusive, nor are they exhaustive and exclusive to all visual research in the social sciences. We understand that qualitative research based on visual data, supported by specific technological tools, is still at an early stage, and we need to face many challenges and issues in order for this type of data to find its place of credibility in the academic community of Human and Social Sciences.

AIRES, L. Paradigma Qualitativo e Práticas de Investigação Educacional. Lisboa: Universidade Aberta. 2015. BANKS, M. Using Visual Data in Qualitative Research. Sage Publications, Thousand Oaks, CA. 2007. BRYMAN, A. Integrating Qualitative and Qualitative Research: How is it Done? Qualitative Research, v. 6, n. 1, p. 97-113. 2006. CRESWELL, J. W.; PLANO CLARK, V. L. Designing and Conducting Mixed Methods Research. 2ª Edição. USA: Sage. 2011. GREENE, J.C. Is Mixed Methods Social Inquiry a Distinctive Methodology? Journal of Mixed Methods Research, v. 2, n. 1, p. 7-22. 2008. HEISLEY, D. D. Visual Research: Current Bias and Future Direction. Advances in Consumer Research, v. 28, p. 45-47. 2001. MINAYO, M.C.S. Fundamentos, Percalços e Expansão das Abordagens Qualitativas. In: COSTA, A.P., NERI DE SOUZA, F. & NERI DE SOUZA, D. (Eds). Investigação Qualitativa: Inovação, Dilemas e Desafios, Vol.3, Oliveira de Azeméis: Ludomedia, p. 17-48. 2016. NERI DE SOUZA, F.; COSTA, A. P. Qual o Papel da Investigação Qualitativa no Contexto dos Métodos Mistos? In Investigação Qualitativa no Contexto dos Métodos Mistos. Revista Pesquisa Qualitativa, Editorial, v. 4, n. 5, iv-viii. 2016. NEWMAN, I.; BENZ, C. R. Qualitative-Quantitative Research Methodology: Exploring the Interactive Continuum. USA: Carbondale and Edwardsville, Southern Illinois University Press. 1998. RODRIGUES, A. I.; SOUZA, F. N. DE; COSTA, A. P. Análise de Dados Visuais: Desafios e Oportunidades à Investigação Qualitativa (Carta Editorial). Revista de Pesquisa de Qualitativa, p. no prelo, 2017. TEDDLIE, C.; TASHAKKORI, A. Common “Core” Characteristics of Mixed Methods Research: A Review of Critical Issues and Call for Grater Convergence. American Behavioral Scientist, v. 56, n. 6, p. 774-788, 2012.

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The visual vernacular: embracing photographs in research

• A Qualitative Space
• Open access
• Published: 02 June 2021
• Volume 10 , pages 230–237, ( 2021 )

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• Jennifer Cleland   ORCID: orcid.org/0000-0003-1433-9323 1 &
• Anna MacLeod   ORCID: orcid.org/0000-0002-0939-7767 2  

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The increasing use of digital images for communication and interaction in everyday life can give a new lease of life to photographs in research. In contexts where smartphones are ubiquitous and many people are “digital natives”, asking participants to share and engage with photographs aligns with their everyday activities and norms more than textual or analogue approaches to data collection. Thus, it is time to consider fully the opportunities afforded by digital images and photographs for research purposes. This paper joins a long-standing conversation in the social science literature to move beyond the “linguistic imperialism” of text and embrace visual methodologies. Our aim is to explain the photograph as qualitative data and introduce different ways of using still images/photographs for qualitative research purposes in health professions education (HPE) research: photo-documentation, photo-elicitation and photovoice, as well as use of existing images. We discuss the strengths of photographs in research, particularly in participatory research inquiry. We consider ethical and philosophical challenges associated with photography research, specifically issues of power, informed consent, confidentiality, dignity, ambiguity and censorship. We outline approaches to analysing photographs. We propose some applications and opportunities for photographs in HPE, before concluding that using photographs opens up new vistas of research possibilities.

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A Qualitative Space highlights research approaches that push readers and scholars deeper into qualitative methods and methodologies. Contributors to A Qualitative Space may: advance new ideas about qualitative methodologies, methods, and/or techniques; debate current and historical trends in qualitative research; craft and share nuanced reflections on how data collection methods should be revised or modified; reflect on the epistemological bases of qualitative research; or argue that some qualitative practices should end. Share your thoughts on Twitter using the hashtag: #aqualspace

Introduction

Smartphones, tablets, and other devices are increasingly embedded in everyday life, influencing how many people interact, think, behave and connect with other people [ 1 , 2 ]. Many people Whatsapp, tweet and text, and/or use Facebook, Instagram and Twitter for professional, social, educational and entertainment purposes. Images are increasingly accessed and used where words would have been used in the past. Indeed, more than 10 years ago, van Dijck [ 3 ] suggested that “digital cameras, camera phones, photoblogs and other multipurpose devices are used to promote the use of images as the preferred idiom of a new generation of users.”

The increasing use of digital images for communication and interaction in everyday life has given a new lease of life to a source of research data long embraced by sociology and anthropology [ 4 , 5 ]. In contexts where smartphones are ubiquitous and with groups of “digital natives” asking participants to share and engage with photographs, this aligns with their everyday activities and norms more than textual or analogue approaches to data collection. Thus, it is time to consider fully the opportunities afforded by digital images and photographs for research purposes [ 6 , 7 ].

This paper joins a long-standing conversation in the social science literature which advocates moving beyond the “linguistic imperialism” of text [ 8 ] to embrace visual methodologies. This conversation has relatively recently made its way into health professions education (HPE): for example, various authors have proposed video [ 9 ], video-reflexivity [ 10 ] and drawings [ 11 ] for research purposes. However, the use of still images or photographs in research remains niche to some areas of inquiry (e.g., exploring patient experiences, particularly mental health and experiences of serious illness (e.g., [ 12 , 13 , 14 ]) and some healthcare professions disciplines (e.g., nursing: [ 15 ])), and is an under-exploited approach in HPE research (see below for notable exceptions). Yet it is a method which offers many possibilities, particularly in respect to giving research participants more agency and power in the research process than is the case in traditional qualitative data collection approaches such as interviews.

In this paper, we discuss ways of using photographs in research, focusing on the use of photography within participatory research inquiry. We consider ethical and philosophical challenges associated with photography research, as well as its unique strengths. We outline some popular approaches to analysing photographic data. We finish with a brief consideration of how photographs could be used more in HPE research.

The photograph as data

Photography has been described as a silent voice, another language to communicate with and understand others, and a way of accessing complexities which may not be captured by text or oral language [ 16 ]. As instances of Latour’s “immutable, combinable mobiles” [ 17 ]—literally things which do not change but which carry action and meaning across time and place, as objects of memory and of relationship—photographs allow us to see what was “happening” at a particular point in time.

Photographs can be a source of data (photo-documentation and existing images) and a tool for eliciting data (photo-elicitation and photovoice). Each of these approaches are explained below.

Photo-documentation

Photo-documentation has been used in clinical medicine for nearly two centuries [ 18 ] Clinical photographs and images are vital for training purposes, to illustrate a clinical finding, steps in a process or procedure, or for comparative (“before” and “after”) purposes. They are an integral part of patient’s clinical notes in numerous specialties and are also used to offer the patient insight into realized or expected treatment results [ 19 ].

This way of using photographs—as objective records documenting an objective something—is quite different from how photographs are used in social science research. In fields such as sociology and social anthropology, photography has been used as a tool for the exploration of society [ 4 , 5 ]. Photographs help others understand how societies are culturally and socially constructed, to critically uncover the meaning people place on certain activities, places, things and rituals and to record and analyse important social events and problems. It is on this second use of photographs in research that we focus from this point onwards.

Existing images

A second way of using photographs in research is analysis of publicly available images: in other words, analysis of secondary (photographic) data. There are examples of this approach in medical education in relation to the messages given by images on public-facing documents and webpages, and how these might influence student choice of medical school [ 20 , 21 ]. Visual data is also used in research examining the relationships between architecture/space and learning [ 22 , 23 ]. Photographs can show us how people and things relate to each other. For example, what can we learn from a photo illustrating how staff are distributed around a coffee room, or around the table during a morbidity and mortality (M&M) meeting? Documenting the materials of a research space in a photograph serves as a mechanism for tracing the complexity of the field (see Fig.  1 and its accompanying explanation).

A photograph as an elicitation tool. Collected as part of a sociomaterial study to document the material complexity of simulation led by MacLeod. This photograph of a manikin in a typical simulation suite could serve as a useful elicitation tool in a study of simulation. Rather than asking research participants to use their memories to imagine a simulation suite, the photograph provides concrete detail, helping to reorient participants to the space. Rather than using a phrase like “simulation is complex”, the photograph serves as “evidence” of the complexity, documenting multiple non-human elements involved in a simulation at a particular time and place. This clarity can provide a jumping-off point for more detailed and specific conversations about the topic being studied

Photo-elicitation

In photo-elicitation (sometimes called photo production [ 24 ] or auto-photography), the specific area of focus is typically decided by the researcher. The photos are either taken by the researcher or participants.

In researcher-driven photo-elicitation the researcher decides on what people, objects, settings and/or scenes they find interesting or potentially important enough for a picture. These photographs are then used as prompts for discussion within an interview with the researcher. The photo(s) is a prompt to elicit data, akin to an open question in a semi-structured interview. Unlike interview or focus group questions however, participants not only respond to photographs with extended narratives but also supply interpretations of the images, drawing from and reflecting their experiences.

In participant-driven photo-elicitation, control of data collection is handed over to participants who have the freedom to pick and choose the representation(s) which is most salient to them in relation to the question under study. For example, to explore children’s experiences of hospital, Adams and colleagues [ 25 ] asked children to photograph architectural or design features that most interested them in a vast hospital atrium (the hospital’s primary non-medical space, full of shops, restaurants and so on). The children’s photographs were then used as the anchor to dialogue [ 26 ].

Participant-driven photo-elicitation empowers the participant to both choose the image and drive the dialogue about the image. Consider a picture of an alarm clock set to an early hour. This becomes meaningful only when the photographer explains that this image signifies their transition from student to first trained job. While the participant’s perspective on the transition to practice could potentially be accessed using traditional words-alone methodologies, photographs are different because they present what the participant felt was worthy to record, help capture the immediacy of the experience and stimulate memories and feelings. In other words, one of photo-elicitation’s strengths, and how it differs from interviews and focus groups, is its potential to collect data that not only taps into the perspective of the participant but does so at the time of the experience.

Images seem to prompt a different kind of reflection on lived experiences. Harper [ 26 ] suggests that images prompt emotions and thoughts in ways that narrative alone cannot. By seeing what they did, informants may help the researcher to better understand their behaviour. Moreover, by viewing and discussing photos together, the researcher and participant actively co-construct meaning. In this way photo-elicitation offers a way to potentially enrich and extend existing interview methodologies and give a combination of visual and verbal data for analysis purposes [ 27 ]. Furthermore, the act of interpreting an image creates a critically reflective space within the research process which is lacking in interview methods. Leibenberg suggests that “collectively then, images introduced into narrative research create important links that participants can use to more critically reflect on their lived experiences and to more accurately discuss and share these experiences with others” [ 28 , p. 4].

Arguably however, if the main source of data is not the photographs themselves but the transcripts from photo-elicited discussions, this may still privilege participants who are more skilled verbally—maintaining the “linguistic imperialism” of text, or, more accurately, of transcribed responses [ 8 ]. While this criticism cannot be wholly dismissed, the many empirical studies referred to in this paper suggest that photographs help make abstract ideas accessible and encourage reflection in groups which are less literate and who do not routinely engage in reflection. Moreover, there are approaches to data analysis which privilege the image, not the accompanying text (see below).

A specific research method within the bracket of photo-elicitation is photovoice. Developed by Wang and Buriss in 1997, photovoice involves asking community members to identify and represent their community through specific photographs and tell the stories of what these pictures mean, promoting critical dialogue and potentially catalysing social action and change [ 29 ]. Photovoice allows people to see the viewpoint of the people who live the lives, and as such is considered an example of participatory research [ 30 ]. For example, MacLeod et al. [ 31 ] asked adolescent youth to take photographs pertaining to the health of their community. The adolescents created a platform for discussion, and helped the researchers, who were medical students, learn about the community they were serving. Photovoice is often used to access and explore patient experiences, particularly mental health and experiences of serious and/or life-threatening illness [ 12 , 13 , 14 ].

The ease of taking photographs with a mobile phone has opened up new ways to utilise the photovoice methodology, particularly the method of “time-space diaries” [ 32 ] or digital journals. Participants record what is meaningful to them across time and activities, such as what and where they ate over a full day, or salient events in the first few weeks of medical school. Just like non-research social media activity, a series of images can provide insight into real, lived experiences and give participants a voice to reflect on their everyday lives on issues relevant to the research topic. Consider a resident taking pictures of things and people who were significant to their first experience of a full weekend shift. The nature of the images may change over time, reflecting exposure to different patients, working with different colleagues, task demands and fatigue.

In summary, the nature of photographs as data varies according to who produces them, whether they are independent of the research or created specifically for the research, how they are used in the research process and whether they are used in conjunction with narrative (verbal) data. These key decisions can be synthesised, according to Epstein et al. [ 33 ], into three basic questions:

Who is going to make or select the images to be used in the interviews?

What is the content of the images going to be?

Where are the images going to be used, and how?

How photographs and accompanying narratives can be analysed is discussed next.

Data analysis

There are two main ways of approaching photographic data analysis. The first, the dialogic approach, focuses on analysing the verbal or written reflection on the content of photographs and what they symbolise. This approach is fundamentally constructivist, “locating visual meaning as foundational in the social construction of reality” [ 34 , p. 492]. Traditional ways of analysing verbal/transcribed data such as thematic analysis [ 35 ], content analysis [ 36 ], grounded theory [ 37 ] and various forms of discourse analyses [ 38 ] are appropriate for analysis of photograph-prompted dialogue. In this approach, the photographs themselves are usually used merely for illustration purposes, if at all [ 38 ].

Alternatively, the data can be within the photograph itself, separate from its capacity to generate dialogue and independent of any explanation. Photographs can provide new ways of seeing the phenomena under study from their visual features. For example, in their analysis of existing images on medical school websites and prospectuses in 2019, MacArthur, Eaton and Marrick [ 21 ] recorded information including gender, ethnicity, assumed role and setting, of each person on each image. They found a predominance of hospital-themed images, compared to few community-themed images. They concluded that these images signalled to students a strong preference for hospital-based settings, despite a strong national drive to recruit more general practitioners.

This approach to analysis is referred to as “archaeological” because images inherently reflect the social norms of a point in time. Consider your graduating class photograph. Clothes and hairstyles which were chic at the time may look old-fashioned and incongruous when viewed many years later. In this way, photographs contain “sedimented social knowledge” [ 34 , p. 502], manifest through the photographer’s choices of scenes, subjects, styles, compositions and so on. An educational example of this is presented in Photograph S1, found in the Electronic Supplementary Material (ESM).

Grounded, visual pattern analysis (GVPA) combines both approaches [ 39 ]. Via a structured, multi-step process of analysis, GVPA investigates the meanings individual photographs have for their photographers and also attends to the broader field (sample) level meanings interpreted from analysis of collections of photographs. Paying attention to absence (what is not photographed) is also important [ 40 ]. The analysis process ends by building conceptual contributions rather than purely empirical ones from the photographic data (see Photograph S2 in ESM).

Whichever analysis approach is taken, as with any qualitative research, it is important to consider quality and rigour in respect to the credibility, dependability, confirmability and transferability of the data [ 41 ]. Providing details of the sampling strategy, the depth and volume of data, and the analytical steps taken helps ensure credibility and transferability. Photo-elicitation allows participants to work with and direct the researcher to generate data that is salient to them, thereby increasing the confirmability of research outcomes. Allowing participants to clarify what they meant to convey in their photographs is inherently a form of member checking. As for all research, ethical considerations should be considered and addressed, as well as a clear statement made on formal research ethics committee approval or waiver. Thought must be given to the power relationship between researcher and participants and how this might affect recruitment, the nature of the data and so on. Reflexivity, reflecting on the extent to which similarities or differences between researcher and researched may have influenced the process of research, is particularly critical in photo-elicitation studies [ 42 ]. Keeping written field and methodological notes as well as a reflexive diary is important for dependability and confirmability.

Finally, in terms of data presentation, in our discipline most journals have a limit on the number of tables, figures and/or images allowed per paper, and most do not publish colour photographs. This limits the visual data which can be presented in an article. However, journals also offer the option of supplementary e‑files. We suggest that one or two pictures in an article can support key evidential points, with additional data made available electronically.

Ethical considerations associated with photographs in research

As with any method, care must be taken to ensure the proper use of photographs for research purposes. Here we briefly consider the main ethical issues of power, informed consent, anonymity, dignity and image manipulation. We direct readers to Langmann and Pick [ 43 ] for more in-depth discussion.

In any researcher/participant situation, there is a power dynamic that privileges the “expert” researcher over the object of study, the participant. Certain ways of using photographs in research, specifically photo-elicitation, can change this dynamic and empower participants by giving them an active role in the research process, making them the experts, and allowing the researcher greater insight into participant perspectives [ 29 , 30 ]. Photo-elicitation also gives those who are not verbally fluent another way to express themselves effectively, avoids the use of survey questionnaires and other research instruments that might be culturally biased, and places participants as equals—able to reflect and decide how they want to represent themselves visually [ 43 ]. Photo-elicitation is thus firmly rooted in an approach to inquiry that draws on Paulo Freire’s (1970) critical pedagogy [ 44 ] and fits within the broader participatory action research method [ 29 , 30 , 37 , 38 , 39 , 40 , 45 ].

The use of mobile phones for data collection is considered a way of connecting younger groups with research [ 46 ], connecting with populations in more remote and rural communities across the globe [ 47 ] and with “difficult to reach” populations (e.g., [ 14 ]). However, it is important to again acknowledge the “digital divide” and the associated power differential: marginalised populations and certain societal groups may not have access to equipment to take and share photographs. Where this is the case, the researcher must consider whether to supply the necessary equipment or whether an alternative method of data collection is more feasible.

Informed consent

Informed consent is particularly challenging with photographs. It is difficult to ensure that every person in an image has given their consent to the photo being taken and used for research purposes. Where images are participant-generated, clear instructions about the purpose of the research and the photographs, and the processes of ethical consent, are essential [ 48 ].

Confidentiality

Confidentiality is an issue, particularly if a photograph includes a person’s face. Faces can be pixelated or blurred to protect participants’ identities, but these approaches may objectify the people in the photo and make the photographs less powerful [ 48 ].

Our third point relates to dignity. Langmann and Pick [ 43 ] suggest three ways of considering dignity in research photography: being sensitive to the social and cultural norms of the communities being researched, being aware that those who are the focus of the research will benefit by the presentation of an authentic view of the situation and considering the impression the photograph will give if and when it is published. In all cases, it is the researcher’s responsibility to exclude photographs which are not covered by ethical approvals, as well as any potentially harmful or compromising photographs.

Photographs can mean different things to different people [ 24 , 49 ] and meanings may change over time, depending on context and how they are associated in terms of text and other images (for example, one’s interpretation of a photograph taken as a teenager is likely to differ when viewing it as an adult). This ambiguity makes some researchers uncomfortable. However, if one takes a social constructivist stance, that we live in a multi-reality world, then this possibility of multiple meanings from a photograph adds to the data.

Conscious and unconscious “self-censorship”, including when, where or what to photograph, or editing a photo to convey an intended message, is inherent in photo-elicitation [ 45 ]. However, self-censorship is not an issue if one accepts that the purpose of photo-elicitation is to access the social reality of another individual.

Strengths of using photographs in research

Participation and co-construction.

As mentioned earlier, photo-elicitation and photovoice maximise opportunities for participant agency and engagement in the research process, allowing participants to work with and direct the researcher. Furthermore, in dialogic approaches, research involves a joint process of knowledge-production where narratives are co-constructed between participant and researcher through discussion. By using participant-driven photographs, the researcher gains an understanding of what the content of the photos means to the participants without imposing their own framework or perception of a topic on the process.

Participatory research requires trust, a safe space between participant and researcher, so people can express their thoughts and views. Wicks and Reason [ 50 ] suggest that establishing this safe space must be considered throughout the research process: empowering participants in the earlier stage of the research process can also build the connection and trust between researcher and participant—and reduce participant inhibition later on. This may be particularly useful where the topic is sensitive or taboo. For example, Meo [ 51 ] reported photo-elicitation was useful in tapping “class and gendered practices” (p. 152) in greater depth than with interviews alone.

Giving power to participants within the research process can be challenging for researchers. Adjusting to participants as co-researchers may be new and unfamiliar. Continuous flexibility and reflexivity on a personal (e.g., personal assumptions, values, experiences, etc. that shape the research) and epistemological (e.g., the limits of the research that are determined by the research question, methodology and method of analysis) considerations are critical [ 52 ].

Photographs provide structure to an interview, giving the researcher something to return to, to elicit more detailed discussions and/or trigger memories and reflection [ 53 ]. In addition, participants often give information about people or things outside of the photo (the invisible) as well as on who and what are visible [ 52 ]. Similarly, the researcher may be able to access parts of participants’ lives that would be difficult to see into otherwise. For example, Bourdieu argues that visual methods of research may be particularly helpful in investigating habitus, ways of being, acting and operating in the social environment that are “beyond the grasp of consciousness” [ 54 , 55 ].

Snapshots in time and of space

As mentioned earlier, photographs are inherently snapshots in time. They also provide snapshots of space, a means of examining the material assemblages of space, of how things are ordered and used [ 56 ]. For example, a photo of students in a learning space would illustrate who sits with whom, the spatial relationships between humans (e.g., student and student, students and teachers) and the non-human (e.g., bags, laptops, phones, snacks) (see Fig.  2 as an example).

An example of a photograph representing the assemblage of time and space: Students distributed in the space of a contemporary learning suite. Photograph from a publicly facing webpage on a medical school website. This photograph provides an example of how a photograph captures space and time. It provides a glimpse at a contemporary medical school. The photograph serves to document the complexity of modern medical schools, making clear the digitized learning environment. Such a photograph might evoke emotion and a sense of progress, in particular, when contrasted with more traditional images of students learning in a stadium-style lecture theatre

Applications and opportunities

Looking forward, we encourage researchers to consider the use of photographs as a source of data, as a way of accessing data that might otherwise have been obscured or overlooked if we had relied solely on language-based data. We encourage readers to consider what might be learned were we to augment current understanding by incorporating photographic data sources into healthcare professions research. In Table S1, found in ESM, we suggest some outstanding research questions and topics that could be explored. The list found there is by no means exhaustive. Rather it reflects our own interests and observations and should be regarded as a springboard to help readers consider diverse ways in which photographs may add richness in research endeavours.

There are many ways of conducting qualitative research in health professions education research (HPER). All have their affordances and limitations. In this article, we have offered a critical examination of how photographs can be used to generate rich and potentially different data to that generated through talk-only data collection. Using photographs in HPER research opens up new vistas of research possibilities, whether as a means of accessing snapshots of people and situations in time and space and/or as a means of engaging participants collaboratively, to explore taken-for-granted lived experiences which may not otherwise be accessible. This is a fertile area for future research and the empirical potential is vast, ranging from reflective practice to widening participation to questions which are as yet unknown.

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Acknowledgements

This paper was inspired by JC’s move to Singapore, a society which uses photographs rather than text in all spheres of life—as proof of payment or parcel delivery, to illustrate a point, to share information, to advertise an event, etc.

The authors neither sought nor received any funding for this project.

Author information

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Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore

Jennifer Cleland

Division of Medical Education, Dalhousie University, Halifax, NS, Canada

Anna MacLeod

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Contributions

JC suggested and coordinated this collaborative effort, initiated the writing outlines and drafts. AM helped create and revise outlines and drafts. Both authors contributed significantly to the intellectual contents, gave approval of the version to be published and agree to be accountable for the work.

Corresponding author

Correspondence to Jennifer Cleland .

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J. Cleland and A. MacLeod declarethat they have no competing interests.

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This is not applicable as no human or animal subjects were involved in the creation of this paper.

Supplementary Information

40037_2021_672_moesm1_esm.jpg.

Table S1 Potential applications and opportunities for using photographs in qualitative HPE research. This is arranged by area of Interest (e.g., simulation), potential research question, philosophical underpinnings, methodology, method and analysis for ease

40037_2021_672_MOESM2_ESM.jpg

An archeological example of the complexity of distributed medical education. Taken in the audio-visual control room of a video-conferenced medical education program (from MacLeod’s photograph research cannon)

40037_2021_672_MOESM3_ESM.docx

This example features a photograph from a publicly facing webpage on a medical school website. The combination of the photograph and its accompanying text would lend itself well to a Grounded Visual Pattern Analysis (GVPA)

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Cleland, J., MacLeod, A. The visual vernacular: embracing photographs in research. Perspect Med Educ 10 , 230–237 (2021). https://doi.org/10.1007/s40037-021-00672-x

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Visual Methods

How to Use Creative Data Visualization Techniques for Easy Comprehension of Qualitative Research

“A picture is worth a thousand words!”—an adage used so often stands true even whilst reporting your research data. Research studies with overwhelming data can perhaps be difficult to comprehend by some readers or can even be time-consuming. While presenting quantitative research data becomes easier with the help of graphs, pie charts, etc. researchers face an undeniable challenge whilst presenting qualitative research data. In this article, we will elaborate on effectively presenting qualitative research using data visualization techniques .

Table of Contents

What is Data Visualization?

Data visualization is the process of converting textual information into graphical and illustrative representations. It is imperative to think beyond numbers to get a holistic and comprehensive understanding of research data. Hence, this technique is adopted to help presenters communicate relevant research data in a way that’s easy for the viewer to interpret and draw conclusions.

What Is the Importance of Data Visualization in Qualitative Research?

According to the form in which the data is collected and expressed, it is broadly divided into qualitative data and quantitative data. Quantitative data expresses the size or quantity of data in a countable integer. Unlike quantitative data, qualitative data cannot be expressed in continuous integer values; it refers to data values ​​described in the non-numeric form related to subjects, places, things, events, activities, or concepts.

What Are the Advantages of Good Data Visualization Techniques?

Excellent data visualization techniques have several benefits:

• Human eyes are often drawn to patterns and colors. Moreover, in this age of Big Data , visualization can be considered an asset to quickly and easily comprehend large amounts of data generated in a research study.
• Enables viewers to recognize emerging trends and accelerate their response time on the basis of what is seen and assimilated.
• Illustrations make it easier to identify correlated parameters.
• Allows the presenter to narrate a story whilst helping the viewer understand the data and draw conclusions from it.
• As humans can process visual images better than texts, data visualization techniques enable viewers to remember them for a longer time.

Different Types of Data Visualization Techniques in Qualitative Research

Here are several data visualization techniques for presenting qualitative data for better comprehension of research data.

1. Word Clouds

• Word Clouds is a type of data visualization technique which helps in visualizing one-word descriptions.
• It is a single image composing multiple words associated with a particular text or subject.
• The size of each word indicates its importance or frequency in the data.
• Wordle and Tagxedo are two majorly used tools to create word clouds.

2. Graphic Timelines

• Graphic timelines are created to present regular text-based timelines with pictorial illustrations or diagrams, photos, and other images.
• It visually displays a series of events in chronological order on a timescale.
• Furthermore, showcasing timelines in a graphical manner makes it easier to understand critical milestones in a study.

3. Icons Beside Descriptions

• Rather than writing long descriptive paragraphs, including resembling icons beside brief and concise points enable quick and easy comprehension.

4. Heat Map

• Using a heat map as a data visualization technique better displays differences in data with color variations.
• The intensity and frequency of data is well addressed with the help of these color codes.
• However, a clear legend must be mentioned alongside the heat map to correctly interpret a heat map.
• Additionally, it also helps identify trends in data.

5. Mind Map

• A mind map helps explain concepts and ideas linked to a central idea.
• Allows visual structuring of ideas without overwhelming the viewer with large amounts of text.
• These can be used to present graphical abstracts

Do’s and Don’ts of Data Visualization Techniques

It perhaps is not easy to visualize qualitative data and make it recognizable and comprehensible to viewers at a glance. However, well-visualized qualitative data can be very useful in order to clearly convey the key points to readers and listeners in presentations.

Are you struggling with ways to display your qualitative data? Which data visualization techniques have you used before? Let us know about your experience in the comments section below!

nicely explained

None. And I want to use it from now.

Would it be ideal or suggested to use these techniques to display qualitative data in a thesis perhaps?

Using data visualization techniques in a qualitative research thesis can help convey your findings in a more engaging and comprehensible manner. Here’s a brief overview of how to incorporate data visualization in such a thesis:

Select Relevant Visualizations: Identify the types of data you have (e.g., textual, audio, visual) and the appropriate visualization techniques that can represent your qualitative data effectively. Common options include word clouds, charts, graphs, timelines, and thematic maps.

Data Preparation: Ensure your qualitative data is well-organized and coded appropriately. This might involve using qualitative analysis software like NVivo or Atlas.ti to tag and categorize data.

Create Visualizations: Generate visualizations that illustrate key themes, patterns, or trends within your qualitative data. For example: Word clouds can highlight frequently occurring terms or concepts. Bar charts or histograms can show the distribution of specific themes or categories. Timeline visualizations can help display chronological trends. Concept maps can illustrate the relationships between different concepts or ideas.

Integrate Visualizations into Your Thesis: Incorporate these visualizations within your thesis to complement your narrative. Place them strategically to support your arguments or findings. Include clear and concise captions and labels for each visualization, providing context and explaining their significance.

Interpretation: In the text of your thesis, interpret the visualizations. Explain what patterns or insights they reveal about your qualitative data. Offer meaningful insights and connections between the visuals and your research questions or hypotheses.

Maintain Consistency: Maintain a consistent style and formatting for your visualizations throughout the thesis. This ensures clarity and professionalism.

Ethical Considerations: If your qualitative research involves sensitive or personal data, consider ethical guidelines and privacy concerns when presenting visualizations. Anonymize or protect sensitive information as needed.

Review and Refinement: Before finalizing your thesis, review the visualizations for accuracy and clarity. Seek feedback from peers or advisors to ensure they effectively convey your qualitative findings.

Appendices: If you have a large number of visualizations or detailed data, consider placing some in appendices. This keeps the main body of your thesis uncluttered while providing interested readers with supplementary information.

Cite Sources: If you use specific software or tools to create your visualizations, acknowledge and cite them appropriately in your thesis.

Hope you find this helpful. Happy Learning!

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• Published: 22 March 2008

Methods of data collection in qualitative research: interviews and focus groups

• P. Gill 1 ,
• K. Stewart 2 ,
• E. Treasure 3 &
• B. Chadwick 4  

British Dental Journal volume  204 ,  pages 291–295 ( 2008 ) Cite this article

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Interviews and focus groups are the most common methods of data collection used in qualitative healthcare research

Interviews can be used to explore the views, experiences, beliefs and motivations of individual participants

Focus group use group dynamics to generate qualitative data

Qualitative research in dentistry

Conducting qualitative interviews with school children in dental research

Analysing and presenting qualitative data

This paper explores the most common methods of data collection used in qualitative research: interviews and focus groups. The paper examines each method in detail, focusing on how they work in practice, when their use is appropriate and what they can offer dentistry. Examples of empirical studies that have used interviews or focus groups are also provided.

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Introduction

Having explored the nature and purpose of qualitative research in the previous paper, this paper explores methods of data collection used in qualitative research. There are a variety of methods of data collection in qualitative research, including observations, textual or visual analysis (eg from books or videos) and interviews (individual or group). 1 However, the most common methods used, particularly in healthcare research, are interviews and focus groups. 2 , 3

The purpose of this paper is to explore these two methods in more detail, in particular how they work in practice, the purpose of each, when their use is appropriate and what they can offer dental research.

Qualitative research interviews

There are three fundamental types of research interviews: structured, semi-structured and unstructured. Structured interviews are, essentially, verbally administered questionnaires, in which a list of predetermined questions are asked, with little or no variation and with no scope for follow-up questions to responses that warrant further elaboration. Consequently, they are relatively quick and easy to administer and may be of particular use if clarification of certain questions are required or if there are likely to be literacy or numeracy problems with the respondents. However, by their very nature, they only allow for limited participant responses and are, therefore, of little use if 'depth' is required.

Conversely, unstructured interviews do not reflect any preconceived theories or ideas and are performed with little or no organisation. 4 Such an interview may simply start with an opening question such as 'Can you tell me about your experience of visiting the dentist?' and will then progress based, primarily, upon the initial response. Unstructured interviews are usually very time-consuming (often lasting several hours) and can be difficult to manage, and to participate in, as the lack of predetermined interview questions provides little guidance on what to talk about (which many participants find confusing and unhelpful). Their use is, therefore, generally only considered where significant 'depth' is required, or where virtually nothing is known about the subject area (or a different perspective of a known subject area is required).

Semi-structured interviews consist of several key questions that help to define the areas to be explored, but also allows the interviewer or interviewee to diverge in order to pursue an idea or response in more detail. 2 This interview format is used most frequently in healthcare, as it provides participants with some guidance on what to talk about, which many find helpful. The flexibility of this approach, particularly compared to structured interviews, also allows for the discovery or elaboration of information that is important to participants but may not have previously been thought of as pertinent by the research team.

For example, in a recent dental public heath study, 5 school children in Cardiff, UK were interviewed about their food choices and preferences. A key finding that emerged from semi-structured interviews, which was not previously thought to be as highly influential as the data subsequently confirmed, was the significance of peer-pressure in influencing children's food choices and preferences. This finding was also established primarily through follow-up questioning (eg probing interesting responses with follow-up questions, such as 'Can you tell me a bit more about that?') and, therefore, may not have emerged in the same way, if at all, if asked as a predetermined question.

The purpose of research interviews

The purpose of the research interview is to explore the views, experiences, beliefs and/or motivations of individuals on specific matters (eg factors that influence their attendance at the dentist). Qualitative methods, such as interviews, are believed to provide a 'deeper' understanding of social phenomena than would be obtained from purely quantitative methods, such as questionnaires. 1 Interviews are, therefore, most appropriate where little is already known about the study phenomenon or where detailed insights are required from individual participants. They are also particularly appropriate for exploring sensitive topics, where participants may not want to talk about such issues in a group environment.

Examples of dental studies that have collected data using interviews are 'Examining the psychosocial process involved in regular dental attendance' 6 and 'Exploring factors governing dentists' treatment philosophies'. 7 Gibson et al . 6 provided an improved understanding of factors that influenced people's regular attendance with their dentist. The study by Kay and Blinkhorn 7 provided a detailed insight into factors that influenced GDPs' decision making in relation to treatment choices. The study found that dentists' clinical decisions about treatments were not necessarily related to pathology or treatment options, as was perhaps initially thought, but also involved discussions with patients, patients' values and dentists' feelings of self esteem and conscience.

There are many similarities between clinical encounters and research interviews, in that both employ similar interpersonal skills, such as questioning, conversing and listening. However, there are also some fundamental differences between the two, such as the purpose of the encounter, reasons for participating, roles of the people involved and how the interview is conducted and recorded. 8

The primary purpose of clinical encounters is for the dentist to ask the patient questions in order to acquire sufficient information to inform decision making and treatment options. However, the constraints of most consultations are such that any open-ended questioning needs to be brought to a conclusion within a fairly short time. 2 In contrast, the fundamental purpose of the research interview is to listen attentively to what respondents have to say, in order to acquire more knowledge about the study topic. 9 Unlike the clinical encounter, it is not to intentionally offer any form of help or advice, which many researchers have neither the training nor the time for. Research interviewing therefore requires a different approach and a different range of skills.

The interview

When designing an interview schedule it is imperative to ask questions that are likely to yield as much information about the study phenomenon as possible and also be able to address the aims and objectives of the research. In a qualitative interview, good questions should be open-ended (ie, require more than a yes/no answer), neutral, sensitive and understandable. 2 It is usually best to start with questions that participants can answer easily and then proceed to more difficult or sensitive topics. 2 This can help put respondents at ease, build up confidence and rapport and often generates rich data that subsequently develops the interview further.

As in any research, it is often wise to first pilot the interview schedule on several respondents prior to data collection proper. 8 This allows the research team to establish if the schedule is clear, understandable and capable of answering the research questions, and if, therefore, any changes to the interview schedule are required.

The length of interviews varies depending on the topic, researcher and participant. However, on average, healthcare interviews last 20-60 minutes. Interviews can be performed on a one-off or, if change over time is of interest, repeated basis, 4 for example exploring the psychosocial impact of oral trauma on participants and their subsequent experiences of cosmetic dental surgery.

Developing the interview

Before an interview takes place, respondents should be informed about the study details and given assurance about ethical principles, such as anonymity and confidentiality. 2 This gives respondents some idea of what to expect from the interview, increases the likelihood of honesty and is also a fundamental aspect of the informed consent process.

Wherever possible, interviews should be conducted in areas free from distractions and at times and locations that are most suitable for participants. For many this may be at their own home in the evenings. Whilst researchers may have less control over the home environment, familiarity may help the respondent to relax and result in a more productive interview. 9 Establishing rapport with participants prior to the interview is also important as this can also have a positive effect on the subsequent development of the interview.

When conducting the actual interview it is prudent for the interviewer to familiarise themselves with the interview schedule, so that the process appears more natural and less rehearsed. However, to ensure that the interview is as productive as possible, researchers must possess a repertoire of skills and techniques to ensure that comprehensive and representative data are collected during the interview. 10 One of the most important skills is the ability to listen attentively to what is being said, so that participants are able to recount their experiences as fully as possible, without unnecessary interruptions.

Other important skills include adopting open and emotionally neutral body language, nodding, smiling, looking interested and making encouraging noises (eg, 'Mmmm') during the interview. 2 The strategic use of silence, if used appropriately, can also be highly effective at getting respondents to contemplate their responses, talk more, elaborate or clarify particular issues. Other techniques that can be used to develop the interview further include reflecting on remarks made by participants (eg, 'Pain?') and probing remarks ('When you said you were afraid of going to the dentist what did you mean?'). 9 Where appropriate, it is also wise to seek clarification from respondents if it is unclear what they mean. The use of 'leading' or 'loaded' questions that may unduly influence responses should always be avoided (eg, 'So you think dental surgery waiting rooms are frightening?' rather than 'How do you find the waiting room at the dentists?').

At the end of the interview it is important to thank participants for their time and ask them if there is anything they would like to add. This gives respondents an opportunity to deal with issues that they have thought about, or think are important but have not been dealt with by the interviewer. 9 This can often lead to the discovery of new, unanticipated information. Respondents should also be debriefed about the study after the interview has finished.

All interviews should be tape recorded and transcribed verbatim afterwards, as this protects against bias and provides a permanent record of what was and was not said. 8 It is often also helpful to make 'field notes' during and immediately after each interview about observations, thoughts and ideas about the interview, as this can help in data analysis process. 4 , 8

Focus groups

Focus groups share many common features with less structured interviews, but there is more to them than merely collecting similar data from many participants at once. A focus group is a group discussion on a particular topic organised for research purposes. This discussion is guided, monitored and recorded by a researcher (sometimes called a moderator or facilitator). 11 , 12

Focus groups were first used as a research method in market research, originating in the 1940s in the work of the Bureau of Applied Social Research at Columbia University. Eventually the success of focus groups as a marketing tool in the private sector resulted in its use in public sector marketing, such as the assessment of the impact of health education campaigns. 13 However, focus group techniques, as used in public and private sectors, have diverged over time. Therefore, in this paper, we seek to describe focus groups as they are used in academic research.

When focus groups are used

Focus groups are used for generating information on collective views, and the meanings that lie behind those views. They are also useful in generating a rich understanding of participants' experiences and beliefs. 12 Suggested criteria for using focus groups include: 13

As a standalone method, for research relating to group norms, meanings and processes

In a multi-method design, to explore a topic or collect group language or narratives to be used in later stages

To clarify, extend, qualify or challenge data collected through other methods

To feedback results to research participants.

Morgan 12 suggests that focus groups should be avoided according to the following criteria:

If listening to participants' views generates expectations for the outcome of the research that can not be fulfilled

If participants are uneasy with each other, and will therefore not discuss their feelings and opinions openly

If the topic of interest to the researcher is not a topic the participants can or wish to discuss

If statistical data is required. Focus groups give depth and insight, but cannot produce useful numerical results.

Conducting focus groups: group composition and size

The composition of a focus group needs great care to get the best quality of discussion. There is no 'best' solution to group composition, and group mix will always impact on the data, according to things such as the mix of ages, sexes and social professional statuses of the participants. What is important is that the researcher gives due consideration to the impact of group mix (eg, how the group may interact with each other) before the focus group proceeds. 14

Interaction is key to a successful focus group. Sometimes this means a pre-existing group interacts best for research purposes, and sometimes stranger groups. Pre-existing groups may be easier to recruit, have shared experiences and enjoy a comfort and familiarity which facilitates discussion or the ability to challenge each other comfortably. In health settings, pre-existing groups can overcome issues relating to disclosure of potentially stigmatising status which people may find uncomfortable in stranger groups (conversely there may be situations where disclosure is more comfortable in stranger groups). In other research projects it may be decided that stranger groups will be able to speak more freely without fear of repercussion, and challenges to other participants may be more challenging and probing, leading to richer data. 13

Group size is an important consideration in focus group research. Stewart and Shamdasani 14 suggest that it is better to slightly over-recruit for a focus group and potentially manage a slightly larger group, than under-recruit and risk having to cancel the session or having an unsatisfactory discussion. They advise that each group will probably have two non-attenders. The optimum size for a focus group is six to eight participants (excluding researchers), but focus groups can work successfully with as few as three and as many as 14 participants. Small groups risk limited discussion occurring, while large groups can be chaotic, hard to manage for the moderator and frustrating for participants who feel they get insufficient opportunities to speak. 13

Preparing an interview schedule

Like research interviews, the interview schedule for focus groups is often no more structured than a loose schedule of topics to be discussed. However, in preparing an interview schedule for focus groups, Stewart and Shamdasani 14 suggest two general principles:

Questions should move from general to more specific questions

Question order should be relative to importance of issues in the research agenda.

There can, however, be some conflict between these two principles, and trade offs are often needed, although often discussions will take on a life of their own, which will influence or determine the order in which issues are covered. Usually, less than a dozen predetermined questions are needed and, as with research interviews, the researcher will also probe and expand on issues according to the discussion.

Moderating a focus group looks easy when done well, but requires a complex set of skills, which are related to the following principles: 15

Participants have valuable views and the ability to respond actively, positively and respectfully. Such an approach is not simply a courtesy, but will encourage fruitful discussions

Moderating without participating: a moderator must guide a discussion rather than join in with it. Expressing one's own views tends to give participants cues as to what to say (introducing bias), rather than the confidence to be open and honest about their own views

Be prepared for views that may be unpalatably critical of a topic which may be important to you

It is important to recognise that researchers' individual characteristics mean that no one person will always be suitable to moderate any kind of group. Sometimes the characteristics that suit a moderator for one group will inhibit discussion in another

Be yourself. If the moderator is comfortable and natural, participants will feel relaxed.

The moderator should facilitate group discussion, keeping it focussed without leading it. They should also be able to prevent the discussion being dominated by one member (for example, by emphasising at the outset the importance of hearing a range of views), ensure that all participants have ample opportunity to contribute, allow differences of opinions to be discussed fairly and, if required, encourage reticent participants. 13

Other relevant factors

The venue for a focus group is important and should, ideally, be accessible, comfortable, private, quiet and free from distractions. 13 However, while a central location, such as the participants' workplace or school, may encourage attendance, the venue may affect participants' behaviour. For example, in a school setting, pupils may behave like pupils, and in clinical settings, participants may be affected by any anxieties that affect them when they attend in a patient role.

Focus groups are usually recorded, often observed (by a researcher other than the moderator, whose role is to observe the interaction of the group to enhance analysis) and sometimes videotaped. At the start of a focus group, a moderator should acknowledge the presence of the audio recording equipment, assure participants of confidentiality and give people the opportunity to withdraw if they are uncomfortable with being taped. 14

A good quality multi-directional external microphone is recommended for the recording of focus groups, as internal microphones are rarely good enough to cope with the variation in volume of different speakers. 13 If observers are present, they should be introduced to participants as someone who is just there to observe, and sit away from the discussion. 14 Videotaping will require more than one camera to capture the whole group, as well as additional operational personnel in the room. This is, therefore, very obtrusive, which can affect the spontaneity of the group and in a focus group does not usually yield enough additional information that could not be captured by an observer to make videotaping worthwhile. 15

The systematic analysis of focus group transcripts is crucial. However, the transcription of focus groups is more complex and time consuming than in one-to-one interviews, and each hour of audio can take up to eight hours to transcribe and generate approximately 100 pages of text. Recordings should be transcribed verbatim and also speakers should be identified in a way that makes it possible to follow the contributions of each individual. Sometimes observational notes also need to be described in the transcripts in order for them to make sense.

The analysis of qualitative data is explored in the final paper of this series. However, it is important to note that the analysis of focus group data is different from other qualitative data because of their interactive nature, and this needs to be taken into consideration during analysis. The importance of the context of other speakers is essential to the understanding of individual contributions. 13 For example, in a group situation, participants will often challenge each other and justify their remarks because of the group setting, in a way that perhaps they would not in a one-to-one interview. The analysis of focus group data must therefore take account of the group dynamics that have generated remarks.

Focus groups in dental research

Focus groups are used increasingly in dental research, on a diverse range of topics, 16 illuminating a number of areas relating to patients, dental services and the dental profession. Addressing a special needs population difficult to access and sample through quantitative measures, Robinson et al . 17 used focus groups to investigate the oral health-related attitudes of drug users, exploring the priorities, understandings and barriers to care they encounter. Newton et al . 18 used focus groups to explore barriers to services among minority ethnic groups, highlighting for the first time differences between minority ethnic groups. Demonstrating the use of the method with professional groups as subjects in dental research, Gussy et al . 19 explored the barriers to and possible strategies for developing a shared approach in prevention of caries among pre-schoolers. This mixed method study was very important as the qualitative element was able to explain why the clinical trial failed, and this understanding may help researchers improve on the quantitative aspect of future studies, as well as making a valuable academic contribution in its own right.

Interviews and focus groups remain the most common methods of data collection in qualitative research, and are now being used with increasing frequency in dental research, particularly to access areas not amendable to quantitative methods and/or where depth, insight and understanding of particular phenomena are required. The examples of dental studies that have employed these methods also help to demonstrate the range of research contexts to which interview and focus group research can make a useful contribution. The continued employment of these methods can further strengthen many areas of dentally related work.

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Gill, P., Stewart, K., Treasure, E. et al. Methods of data collection in qualitative research: interviews and focus groups. Br Dent J 204 , 291–295 (2008). https://doi.org/10.1038/bdj.2008.192

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The Ultimate Guide to Qualitative Research - Part 2: Handling Qualitative Data

• Handling qualitative data
• Transcripts
• Field notes
• Survey data and responses
• Introduction

Non-textual data in qualitative research

Images as qualitative data, audio data in qualitative research.

• Data organization
• Data coding
• Coding frame
• Auto and smart coding
• Organizing codes
• Qualitative data analysis
• Content analysis
• Thematic analysis
• Thematic analysis vs. content analysis
• Narrative research
• Phenomenological research
• Discourse analysis
• Grounded theory
• Deductive reasoning
• Inductive reasoning
• Inductive vs. deductive reasoning
• Qualitative data interpretation
• Qualitative analysis software

Images, audio, and video in qualitative research

If you think about qualitative and social science research, you probably have text data in mind. As research projects have evolved, however, researchers have found a need to conduct analysis on video data, audio files, images, and so much more.

Let's look at how video, images, and audio are used in qualitative data analysis in this section.

In the realm of qualitative data analysis , there has traditionally been a strong focus on text such as interviews , focus groups, documents, and diaries. However, the role of non-textual data - specifically images, audio, and video - is increasingly being recognized for its ability to offer rich, complex, and nuanced insights that complement and extend our understanding derived from textual data. Non-textual data provide a unique vantage point from which researchers can delve deeper into participants' lived experiences, cultural practices, social interactions, and personal narratives.

Understanding lived experiences

One of the key strengths of non-textual data is the capacity to capture the richness and complexity of lived experiences. Videos can record participant actions and interactions in their natural settings, providing an unfiltered lens into their world. Images, whether photographs or drawings, can encapsulate emotions, cultural nuances, and personal meanings that may be difficult to articulate in words. Audio recordings, with their attention to voice inflections, pauses, and tonality, can reveal underlying feelings or attitudes that textual data might miss. These forms of data capture the world as directly experienced by the participants, providing the researcher with a more comprehensive understanding of their perspectives.

Non-verbal and contextual data

Non-textual data can also capture non-verbal and contextual information. For instance, video data can record body language, facial expressions, gestures, and spatial arrangements, offering additional layers of meaning. Image data can represent complex ideas, connections, or feelings in a condensed and immediate way that text cannot always achieve. Audio data can reveal elements such as tone, pitch, volume, rhythm, or silences, adding depth to our understanding of verbal communication. This non-verbal and contextual information often provides crucial insights into social dynamics, power relations, cultural practices, or personal experiences.

Participatory research

Non-textual data also open up new possibilities for participatory research. Participants can be involved in creating videos, images, or audio recordings, giving them greater control over what and how their experiences are represented. Techniques such as photovoice, video diaries, or audio elicitation engage participants creatively, potentially empowering them and facilitating deeper self-reflection. These methods can generate data that are personally meaningful to the participants and offer unique insights into their lived realities.

Reporting research findings

Lastly, non-textual data can enhance the communication of research findings. Videos, images, and audio clips can be incorporated into presentations, reports, or publications, making the findings more accessible, engaging, and impactful. They can help to "show" rather than "tell", allowing audiences to see, hear, and feel the research context and participants' experiences. This can be particularly effective in conveying complex or emotive issues, fostering empathy, and facilitating dialogue.

With all of this in mind, let's look at the various forms of non-textual data that a qualitative researcher will likely encounter.

Gestures, body language, and facial expressions are important components of analysis of social interaction. Observing everyday movements in public places requires an understanding of spatial relations between objects and people. Joint social action in cultural rituals like religious ceremonies and ballet performances have considerations of temporality as interactants move in tandem with each other. These examples and more illustrate the collection and presentation of video data in research.

How are videos used in qualitative research?

If you are using videos in a research project gathering data from interviews or focus groups , you may be recording these interactions to get perspectives from your research participants. In most cases, simply transcribing the utterances in videos into text form is sufficient for data analysis .

However, you may also be interested in recording how people interact with each other. Their gestures, facial expressions, body posture, proximity to others, and a whole host of other factors can be visually analyzed through video analysis.

An example of this kind of research involving the study of video data includes the analysis of user-generated content on platforms like YouTube and Vimeo to understand how creators try to get their message across to their audience. Analysis of online video recordings can contrast with the analysis of television programs to provide a sense of how the development of presentation practices has evolved from medium to medium.

In other contexts, video content analysis in health care situations can look at not only the messages that doctors convey to patients and colleagues but also how they stand and act in relation to those around them. Perhaps they adopt a caring touch, which might be represented by standing in closer proximity to patients who require emotional support. In contrast, they might be more standoffish with nurses and other doctors by standing far apart or standing while others are sitting in meetings or casual conversations.

These sorts of examples highlight the limitations of a purely text-based approach to qualitative data analysis. As such, analyzing video and presenting the right video segment when sharing novel theory can be important skills in social science research.

What is video data analysis?

Researchers engage in the systematic examination and interpretation of video recordings to generate insights and understand phenomena under investigation. Video data analysis is a valuable method for capturing and analyzing rich, complex data that goes beyond what can be obtained through exclusively text-based research methods.

Video data is typically transcribed into text format to facilitate analysis. However, transcripts do not merely record the words uttered between speakers in a video. Transcription also involves creating a written record of the non-verbal aspects of the video, including gestures, facial expressions, and environmental cues. This more inclusive approach to transcription allows for easier coding and analysis of the data. On the other hand, qualitative data analysis software such as ATLAS.ti also makes it convenient to code video data directly, permitting a more nuanced examination of your data.

Researchers then organize the video or text data into manageable units such as video segments, episodes, or events. These units are often defined based on the research questions, objectives, or relevant themes emerging from the data. For example, suppose the research project deals with identifying the basic facial expressions in a given situation. In that case, the unit of analysis may be reduced to mere moments in interaction represented by segments of video data. On the other hand, if a researcher is looking at how people's facial expressions change over time, the video data analysis may look at larger episodes of interaction (e.g., a single interview or an entire classroom observation).

The researcher then tags or labels segments of the video or text data with descriptive or interpretive labels called codes . Researchers identify patterns, themes, or categories in the data and assign appropriate codes to capture the meaning or significance of those segments. Using qualitative data analysis software, coding can be done manually or, in the case of ATLAS.ti, with the use of automated tools to identify useful segments of text data.

Once the data is sufficiently coded, researchers analyze the coded data to identify relationships, patterns, and themes within the video recordings. They explore the data to gain a deeper understanding of the research question or objective and draw meaningful conclusions. This analysis often involves iterative processes of comparing, contrasting, and refining codes and themes.

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In qualitative research , images can serve as a potent tool for understanding human experiences, behaviors, social dynamics, and cultural phenomena. They provide an alternative lens through which to view the world, offering a rich, nuanced perspective that textual data may sometimes fail to capture. The use of images in research can include photographs, drawings, diagrams, maps, or any other visual materials that can help researchers gain insight into their subject of interest.

Collecting images

Collecting image data involves either creating images as part of the research process or using pre-existing images. In the former approach, researchers or participants may take photographs, make drawings, or generate other visual materials during the study. This method can offer a particularly rich source of data because the act of creating an image can bring forth subconscious thoughts, emotions, and perspectives.

Pre-existing images, on the other hand, can include anything from historical photographs to social media images, advertisements, and artworks. The key here is to ensure that these images are relevant to the research question and can contribute meaningful insights.

While collecting image data, it's critical to maintain an ethical stance. If you're taking photographs or using others' images, consider privacy issues , obtain necessary permissions, and maintain the anonymity of individuals if required.

Image analysis

Analyzing images in qualitative research involves the careful examination and interpretation of visual data to discern patterns, themes, and meanings. Researchers generally employ a two-step process: description and interpretation .

In the description phase, researchers meticulously document the physical details of the image, such as its color, size, form, and the subjects or objects it contains. This stage is purely observational, with researchers providing a factual account of what is present in the image. These descriptive details can be jotted down in memos , and qualitative data analysis software such as ATLAS.ti makes it even easier to analyze images as the images can be viewed and any segment of the image can be selected and coded.

During the interpretation phase, researchers delve deeper, attempting to understand the meaning behind the visual elements in the image. They may analyze the relationship between different parts of the image, consider the use of symbols, study the context in which the image was created or is viewed, and reflect on their own responses to the image. Here, researchers often draw on existing theories or frameworks to guide their interpretation, which can be developed through memo-writing and coding .

Two common analytical frameworks used for images include semiotics, which looks at the signs and symbols within the image, and discourse analysis , which examines the image in the context of social and cultural narratives.

Considerations for image analysis

Incorporating images into qualitative research can have numerous benefits. They can provide a wealth of detail and convey aspects of reality that are difficult to capture in words alone, including emotions, moods, atmospheres, and tacit knowledge. Images can facilitate participants' expression and engagement, particularly when dealing with sensitive topics, complex concepts, or with populations who might struggle with verbal communication.

However, the use of images also presents several challenges. Analysis can be time-consuming and requires a certain level of expertise in visual literacy. The interpretation of images is inherently subjective, and images can sometimes be ambiguous or open to multiple interpretations. Moreover, cultural differences can impact how images are perceived and interpreted, which researchers must carefully consider in multicultural studies.

How do varieties of a language sound different from each other? Do passengers on a train or an airplane respond differently when the announcement is spoken by a man or a woman? At what decibel level does random noise become a problem and disrupt people's work or conversations? To answer these questions, audio data offer a unique and valuable source of information. Audio recordings provide access to elements such as tone, pace, volume, and pauses, which may be lost in written transcriptions . Audio data can come from interviews , focus groups , and naturalistic recordings. You can also take audio data from non-traditional data sources like voice notes, podcasts, music, and more. Let's delve into the collection , analysis , and interpretation of audio data in qualitative research .

Audio data collection

Audio data are typically collected through recording devices or applications. Often, researchers record in-person or remote interviews and focus groups. However, audio data can also be collected by recording naturalistic settings, such as meetings, public spaces, or events, to understand social dynamics, communication patterns, or ambient soundscape. In certain research projects, participants may be invited to contribute audio diaries or voice notes, offering personal narratives and reflections in their own time and space.

Consideration of ethics and consent is pivotal in audio data collection. Participants must be fully informed about the recording process, how the data will be used, stored, and who will have access to it. In naturalistic recordings, additional consent may be required from all individuals present or the custodian of the space, depending on the context and local regulations.

Approaches to audio analysis

Unlike images or text, audio data are time-based and sequential, which poses unique challenges and opportunities for analysis. Researchers can choose between verbatim transcription, where the audio is converted into text for analysis, or direct analysis of the audio data, where the focus is more on the sonic and aural aspects.

In transcriptions , the audio data are transformed into text, which can then be coded and analyzed using traditional qualitative analysis methods. The transcription should be as detailed as possible, capturing not only what is said but also how it is said, including nuances such as hesitations, laughs, emphasis, or overlaps in conversation. However, transcription inevitably loses certain elements of the original audio, such as tone, accent, or background noises.

Direct analysis of audio data focuses on the auditory experience. Researchers listen for patterns in sounds, silences, tones, accents, pace, or rhythm. This type of analysis can be especially valuable in sociolinguistic studies, conversation analysis , or research focusing on soundscapes or musical elements. Listening and re-listening to the audio are crucial steps in this process.

Use of software tools

Various software tools can assist in the organization, transcription, and analysis of audio data. Transcription software, such as Express Scribe or Trint, can facilitate the conversion of speech into text. Qualitative data analysis software programs like ATLAS.ti can import and analyze audio files directly, allowing researchers to code and annotate within the audio file, thus preserving the sonic richness of the data.

Moreover, audio editing software, such as Audacity or Adobe Audition, can be useful for manipulating audio data, isolating specific sound elements, or analyzing sound waves. Sonographic representation can offer a visual dimension to the audio data, aiding in pattern recognition or comparative analysis.

Triangulation and validation

Just as with other types of data, triangulation can be employed to cross-check findings from audio data. For example, the results from audio analysis could be compared with text, visual, or observational data. It can also involve using different theoretical frameworks to interpret the data or having multiple researchers independently analyze the data.

Validation in audio analysis can be quite challenging due to the subjective nature of interpreting sounds and spoken language. Member checking or respondent validation, where the researcher's interpretation is verified with the participants, and peer debriefing can help to enhance the trustworthiness and credibility of the findings.

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• Knowledge Base

Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

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

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

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

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

Table of contents

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

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

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

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

There are five common approaches to qualitative research :

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

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

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

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

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

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How to Use Intersectional Analysis in Qualitative Research

• By: Safaa Charafi Edited by: Anna CohenMiller
• Product: Sage Research Methods: Diversifying and Decolonizing Research
• Publisher: SAGE Publications Ltd
• Publication year: 2024
• Online pub date: March 21, 2024
• Discipline: Sociology , Education , Psychology , Health , Anthropology , Social Policy and Public Policy , Social Work , Political Science and International Relations , Geography , Criminology and Criminal Justice , Nursing , Business and Management , Communication and Media Studies , Counseling and Psychotherapy , History , Economics , Marketing , Science , Technology , Engineering , Mathematics , Computer Science , Medicine
• Methods: Sensitive topics , Qualitative data analysis , Intersectionality
• DOI: https:// doi. org/10.4135/9781529689327
• Keywords: ethical considerations , identity , intersectionality , multiple identities , privilege , social identity , social inequality , social justice , social power Show all Show less
• Academic Level: Advanced Undergraduate Online ISBN: 9781529689327 More information Less information

This how-to guide explores the application of intersectional analysis in qualitative research, addressing the methodologic and practical challenges involved. Intersectionality, a framework examining social identities’ interconnectedness, has garnered attention in social sciences research. However, effectively incorporating it into qualitative research is complex. This guide provides researchers with a comprehensive understanding of intersectionality and offers insights on how to employ intersectional analysis in their research, focusing on a broader perspective beyond conventional data analysis. First, it introduces the concept and its relevance in diverse research settings. It emphasizes the need to consider intersecting social identities and their impact on individuals’ experiences. Real-world examples are used to illustrate the significance of intersectional analysis in uncovering power dynamics and exploring complex social phenomena. Intersectional analysis is not solely about data analysis but also serves as a broader research lens or framework. To clarify this distinction, this guide provides contextual information to differentiate intersectional analysis from conventional data-analysis methods. Then a step-by-step approach is outlined, covering important considerations in research design, including research questions, sampling strategies, and data-collection methods. This guide also explores data-analysis techniques, highlighting the importance of identifying intersecting identities within the data and analyzing their interplay. Other considerations are addressed, including reflexivity, confidentiality, and participant empowerment. Researchers are encouraged to engage in critical self-reflection to navigate their own positionality and biases. This how-to guide empowers them to effectively incorporate intersectional analysis into their research, which enhances the depth and richness of research findings and promotes more nuanced understandings of society.

Learning Outcomes

By the end of this guide, readers should be able to

• understand the concept of intersectionality and its relevance in diverse, intersectional, and decolonial research settings.
• apply intersectional analysis as a methodologic approach in qualitative research to explore the interconnectedness of social identities and power dynamics.
• implement a step-by-step approach to incorporating intersectional analysis in research design, including formulating research questions, selecting appropriate sampling strategies, and employing effective data-collection methods.
• analyze qualitative data through an intersectional lens, identifying intersecting social identities and examining their interplay within the data.
• navigate practical and ethical considerations when conducting intersectional analysis, including reflexivity, confidentiality, and participant empowerment.

Introduction

Qualitative research plays a foundational role in understanding complex social phenomena and exploring individuals’ lived experiences. However, traditional qualitative methodologies often overlook the intricate interplay of intersecting social identities and power dynamics that shape these experiences. To address this limitation, intersectional analysis has emerged as a crucial framework that acknowledges and examines the interconnections among social identities and systems of power. This guide aims to provide students with a comprehensive understanding of effectively incorporating intersectional analysis into qualitative research.

The primary objective is to explore the methodologic and practical challenges associated with integrating intersectional analysis into research and equip students with the necessary knowledge and skills to apply it in their own work. To ensure the relevance and applicability of intersectional analysis across diverse fields, including sociology, real-life examples will be used to exemplify its use and shed light on critical societal aspects within real-world contexts.

The following sections delve into the key concepts and steps used for an intersectional analysis within qualitative research. This guide explores the significance of intersectionality within diverse, intersectional, and decolonial research settings and provides practical guidance on research design, data collection, data analysis, and ethical considerations related to the application of intersectional analysis.

By equipping students with the necessary tools and knowledge, this guide aims to empower them to conduct research that is more inclusive, nuanced, and attuned to the intricate complexities of intersecting social identities and power dynamics. Ultimately, students will be able to effectively integrate intersectional analysis into their research, enabling a more comprehensive and nuanced understanding of social phenomena.

What Is Intersectionality in the First Place?

Defining intersectionality.

To begin, it is essential to understand the concept of intersectionality and its relevance to qualitative research. The notion of intersectionality has a dual nature, originating from its political origins deeply rooted in the history of Black feminism and its subsequent academic conceptualization by Crenshaw ( 1989 ), which prompted a significant scholarly discourse. It emphasizes the interrelatedness of social identities and acknowledges that individuals simultaneously embody multiple interconnected categories, including race, gender, sexuality, class, ethnicity, ability, and age ( Crenshaw, 1991 ; Hankivsky, 2014 ). The term was coined to address the limitations of understanding discrimination solely through a single-axis framework. Crenshaw highlighted that the experiences of individuals facing intersecting oppressions, such as race and gender, cannot be fully grasped by analyzing each factor independently. Instead of considering these categories as discrete and mutually exclusive, intersectionality recognizes their overlapping and mutually constitutive nature, revealing how they intersect and interact to shape individuals’ experiences and perpetuate social inequalities ( Collins, 2015 ).

By examining the interplay of multiple social categories, intersectionality provides a more comprehensive understanding of the complexities of individuals’ lives and the systems of power that influence them ( Rice, Harrison, & Friedman, 2019 ). It moves beyond simplistic analyses that isolate single dimensions of identity, enabling a more nuanced examination of how social hierarchies and forms of discrimination intersect and compound each other. Far from being just an exercise in semantics—despite taking the experiences of historically oppressed or marginalized communities as its vantage point—it calls for the need to consider various dimensions of privilege and disadvantage that intersect within individuals’ lives, recognizing that privilege and oppression operate simultaneously. In other words, individuals can experience both privilege and marginalization based on different social categories ( Shields, 2008 ). For example, a White woman may experience gender-based discrimination but also benefit from racial privilege compared with women of color. A poor lesbian Black woman will be discriminated against due to her sexual orientation, social class, and race—making her experience different from that of a rich Black woman or man.

As such, Crenshaw’s foundational work emphasized the experiences of Black women within legal frameworks and highlighted how their intersectional identities rendered them invisible within dominant narratives of discrimination ( Crenshaw, 1989 ). Shortly after, by emphasizing the interconnectedness of systems of power and the importance of centering marginalized voices, scholars such as Patricia Hill Collins, with her “Matrix of Domination,” expanded the concept and led to its development ( Collins, 1998 , p. 543). Her contribution extends the foundational concept by revealing the complex web of privilege and oppression individuals navigate across various facets of their identities. Collins’ framework offers a nuanced perspective, going beyond singular dimensions of discrimination to reveal the intricate and dynamic nature of power structures and providing a comprehensive lens to analyze the multidimensional manifestations of privilege and oppression within society.

Since then, the concept has evolved, with scholars applying it to various contexts to uncover the complex ways in which multiple systems of oppression intersect. It has been employed to examine issues related to race, gender, sexuality, disability, and class, revealing the intertwined nature of these systems ( Hancock, 2016 ). Its interdisciplinary nature also encouraged dialogue across academic disciplines and shaped social justice movements, contributing to a broader understanding of social inequalities.

Yet, while this concept has been a valuable analytical tool, it is not exempt from criticism. Some scholars argue that the concept risks essentializing identities, reducing individuals to fixed categories and undermining their agency ( Collins, 2015 ), others contend that it has been coopted and depoliticized, losing sight of its radical roots and becoming a diluted concept ( Buchanan & Wiklund, 2021 ; Dhamoon, 2011 ), whereas others argue that operationalizing it in practice presents challenges, hindering its potential to create meaningful change in society ( Banks, 2018 ).

Despite its limitations, the concept played a significant role in advancing social justice agendas. By highlighting the interconnectedness of systems of oppression, it contributed to more inclusive approaches in policymaking, activism, and social research. Ultimately, it calls for a comprehensive understanding of the complex dynamics of power and privilege, urging scholars and practitioners to consider the intersections of social identities in their analyses and interventions.

Relevance of Intersectionality in Research

The relevance of intersectionality in research is significant because it provides a framework for understanding and analyzing the complex and intersecting factors that contribute to social inequalities and oppression ( Grzanka et al., 2020 ). One of intersectionality’s greatest strengths is its emphasis on centering marginalized individuals’ voices, particularly those who are often overlooked or historically oppressed within existing research frameworks ( Watson-Singleton, Lewis, & Dworkin, 2023 a).

The category of oppression encompasses the integration of inequality, power, and social justice, thereby encompassing the examination of power dynamics and social inequalities. In research, the exploration of complexity and context is achieved through comparative analysis and the identification of the inherent instability of categories, or the process of deconstruction ( Misra, Curington, & Green, 2021 ). As Mary Romero ( 2023 ) posits, “the category ‘relational’ goes beyond recognizing social identities to acknowledge that one’s subordination is related to another’s privilege” (p. 3). Intersectionality’s core focus is historically oppressed or marginalized identities, yet, despite this, it does not presume that all interlocking identities are equally disadvantaged. By incorporating intersectionality into qualitative research, researchers can uncover the nuances and complexities of individuals’ lived experiences and the social structures that contribute to their marginalization or privilege ( Harris, 2016 ). This approach allows for a more nuanced and comprehensive understanding of social phenomena and can contribute to the development of more inclusive and equitable research practices ( Love, Booysen, & Essed, 2018 ).

However, it is important to note that incorporating intersectionality into qualitative research is not without challenges. Researchers must navigate the complexities of multiple intersecting identities and power dynamics, ensuring that their research is sensitive to the experiences and perspectives of marginalized individuals ( Logie et al., 2022 ). They also must critically reflect on their own positionality and biases, recognizing the potential for their own identities and social locations to influence the research process ( Maxwell et al., 2016 ). Additionally, researchers must consider ethical considerations and the potential for harm when exploring sensitive topics related to intersectionality, as I will dive into later.

Section Summary

• Intersectionality is a theoretical framework that recognizes the interconnectedness of social identities.
• It was introduced by Kimberlé Crenshaw in 1989 to address the limitations of single-axis approaches to social justice.
• It allows researchers to understand how different social identities intersect and shape individuals’ experiences and social structures.
• It challenges essentialist and simplified understandings of identity and power.

Intersectional Analysis in Qualitative Research

Intersectionality recognizes that individuals are characterized by multiple social categories that are interconnected and intertwined and that these categories are embedded with dimensions of inequality or power ( Else-Quest & Hyde, 2016 ). It also acknowledges that these categories are fluid and dynamic and that they are both properties of the individual and characteristics of the social context ( Davis, 2008 a).

Selecting Research Questions

Crafting intersectional research questions necessitates a critical and contextually sensitive approach informed by theoretical frameworks. Researchers should explicitly consider multiple dimensions of identity and power: this means going beyond studying isolated single social categories and instead examining how these categories intersect and interact with each other to shape individuals’ experiences of privilege and oppression. For example, instead of asking how gender or race alone influences participants’ experiences, researchers should aim to uncover how the intersection of the two, along with other relevant social categories, shapes participants’ experiences ( Atewologun, Sealy, & Vinnicombe, 2016 ; Banks, 2018 ). To do so effectively, researchers should apply an intersectionality framework at each stage of the research ( Grabe, 2020 ). This includes generating hypotheses, sampling, operationalization, analysis, and interpretation of findings. Moreover, engaging in a reflexive and iterative process of dialogue with diverse stakeholders, including individuals with lived experiences, can further enhance the development of research questions that are sensitive, responsive, and socially relevant.

However, it is important to note that this exercise can be challenging. Available methodologic tools and traditional research designs may impede a comprehensive understanding of intersectionality and hinder its meaningful incorporation ( Shields, 2008 ). For example, quantitative methods often focus on additive processes and independent factors, which may not fully capture the interdependent nature of intersecting social categories ( McCormick-Huhn et al., 2019 ). As a result, intersectional approaches have been used predominantly in qualitative research, whereas quantitative research often uses components of the approach without explicitly framing them as intersectional ( Else-Quest & Hyde, 2016 ).

Sampling Strategies

When conducting intersectional research analysis, there are various sampling strategies to include diverse perspectives and experiences. One approach is purposeful sampling , also known as selective or criterion sampling , where participants are intentionally selected based on specific characteristics or experiences related to intersecting identities ( Jackson, Mohr, & Kindahl, 2021 ; Robinson, 2014 ). This method can be used to intentionally select participants who represent different intersections of social identities relevant to the research topic. For example, if the research focuses on the experiences of women of color in leadership positions, the sampling strategy should aim to include participants who identify as women, belong to racial or ethnic minority groups, and hold leadership positions.

Another similar approach is stratified purposeful sampling , which involves the selection of participants from diverse social strata based on intersecting identities crucial to the research inquiry. This approach aims to critically capture a spectrum of individuals representing various dimensions of privilege and oppression, such as race, gender, class, and other pertinent categories. By intentionally curating a sample that reflects these intersecting identities, the method enables a more nuanced exploration of how power dynamics operate at the crossroads of multiple social identities, fostering a critical understanding of the complexities shaping individuals’ experiences within the research framework ( Bauer et al., 2021 ). In essence, purposeful sampling concentrates on selecting participants based on their relevance to the research, whereas stratified purposeful sampling specifically targets diverse categories or strata, particularly in studies emphasizing intersectional analysis. While intersectional approaches traditionally have been associated with qualitative methods, quantitative researchers can incorporate an intersectional approach by understanding key features that define quantitative intersectionality analyses and improving reporting practices ( Else-Quest & Hyde, 2016 ).

Researchers have proposed various methodologic approaches and frameworks for conducting intersectional research, including the use of stratification and latent class analysis to derive classes of intersectional social status. Other approaches include using regression with interactions, multilevel analysis, and decision trees to examine the interaction among social positions and their effects on health outcomes ( Hancock, 2007 ; Zhang, Chang, & Du, 2021 a). These approaches go beyond considering single indicators and help capture the complex ways in which intersecting identities influence health outcomes. Ideally, researchers should approach the design of intersectional quantitative research by treating complex differences and inequalities between groups as assumptions or hypotheses. This ensures that the research design accounts for the multifaceted nature of social inequality and captures the nuances of intersecting identities. Despite this, there are certain limitations associated with using multiplicative approaches in intersectional research. One major limitation pertains to the interpretation of variable interactions alongside main effects within regression models. To prevent statistical misspecification, it is necessary to include the variables separately and jointly as an interaction term, as emphasized in studies conducted by Bailey et al. ( 2019 ) and Bowleg ( 2012 ).

Moreover, maintaining a diverse and representative sample is crucial ( Bauer et al., 2021 ), yet researchers must be mindful of avoiding tokenism or reductionism while achieving such a sample. By employing latent variable and clustering methods, they can further engage with intersectionality by providing definitions and citing foundational sources ( Bauer et al., 2021 ). In this way, they enhance the analysis of intersectional dynamics and provide a deeper understanding of the complex relationships between intersecting identities.

Data-Collection Methods

Qualitative methods such as in-depth interviews, focus groups, participant observation, ethnography, photo voice, and participatory action research provide rich data on intersectional dynamics:

• The use of in-depth interviews as a prevalent method for gathering intersectional data involves conducting individualized sessions where participants share detailed narratives about their experiences. These interviews, characterized by open-ended conversations, allow researchers to delve into the intricate navigation and negotiation of intersecting identities by individuals, unveiling the challenges they encounter within systems of oppression ( Robinson, 2014 ). Further academic exploration could encompass specific interview techniques, such as empathetic interviewing or employing various question types such as role playing and grand or mini tours, which could encourage and elicit intersectional dynamics during the interview process. These methodologies have shown promise in facilitating a more profound exploration of the multifaceted dimensions of participants’ experiences within the intersectional framework.
• Focus groups are another method for collecting intersectional data. They involve bringing together a group of individuals with similar intersecting identities to discuss their experiences and perspectives. Focus groups provide a space for participants to share their stories, engage in dialogue, and explore commonalities and differences in their experiences, which allow them to capture the collective experiences of a group and identify shared themes and patterns.
• Participant observation involves researchers immersing themselves in the natural settings of participants to observe and document their behaviors, interactions, and experiences. This method allows researchers to gain a deep understanding of the social context in which individuals with intersecting identities navigate their lives. By actively participating in the lives of participants, researchers can gain insights into the daily challenges, interactions, and dynamics that shape their experiences ( Bonu, 2022 ).
• Ethnography involves the systematic study of a particular culture or social group ( Small, 2009 ). It allows researchers to immerse themselves in the community or group being studied, gaining an in-depth understanding of their experiences, practices, and beliefs. Ethnographic research is particularly useful for exploring the intersectional experiences of marginalized communities and understanding how intersecting identities shape their lives ( Collins, 2023 ).
• Art-based methods offer a diverse range of approaches within participatory research, facilitating creative expression and narrative sharing among participants. One specific technique within this spectrum is participatory photography, often referred to as PhotoVoice , which amalgamates photography and storytelling to empower individuals to convey their experiences and viewpoints ( Miller & Kurth, 2022 ). Participants are given cameras and are encouraged to use them to document visual representations of their daily experiences. They then hold group conversations about the images and the stories behind them. This technique provides participants with a one-of-a-kind platform to graphically express their intersecting identities and experiences, providing for a compelling and distinct capture of their narratives.
• Participatory action research (PAR) is an approach that emphasizes collaboration between researchers and the participants being studied. When used in intersectional research, researchers actively involve participants from marginalized communities in the process, ensuring that their voices and perspectives are central to the study ( Pittaway, Bartolomei, & Hugman, 2010 ). It challenges traditional power dynamics by involving participants as co-researchers and agents of change ( Fine & Torre, 2019 ) and as such uses methods such as community-based participatory research, narrative inquiry, mapping, and PhotoVoice ( Moffitt, Juang, & Syed, 2020 ). One of its benefits is to generate more relevant, meaningful, and applicable knowledge. By involving participants in the research process, PAR ensures that the research questions, methods, and outcomes are aligned with their needs and priorities ( Bennett, 2020 ). It also promotes community capacity building and empowerment because it enables them to develop research skills, critical-thinking abilities, and a sense of ownership over the research process ( Rogers & Kelly, 2011 ). However, it also has limitations. These include the time and resources required to establish and maintain collaborative partnerships with communities, potential power imbalances and conflicts, and the need to navigate ethical considerations and ensure the protection of participants’ rights and well-being ( Brabeck et al., 2015 ). As Fine et al. ( 2021 ) noted, the tenet of “no research on us without us” is valid yet raises some questions: “Who holds the vision? With whom and for whom is the project designed? . . . Coresearchers: Who constitutes the research team? . . . Recruiting an inclusive sample: Who is being interviewed, surveyed, engaged in the inquiry? . . . Speaking to/with varied audiences” (p. 348). Additionally, its participatory nature may limit the generalizability of findings because the focus is often on specific contexts and communities ( Bailey et al., 2019 ).

To illustrate the application of intersectional analysis in qualitative research, consider a study on the experiences of Muslim women with disabilities in accessing healthcare services. The research design may involve conducting semistructured interviews with Muslim women who identify as having disabilities. The interviews would explore the intersections of their religious identity, gender, and disability and how these intersections shape their experiences with healthcare. The data analysis would involve identifying themes related to the barriers and facilitators these women encounter in accessing healthcare services, considering the intersections of their social identities. The findings could contribute to a better understanding of the unique challenges faced by Muslim women with disabilities and inform the development of more inclusive and culturally sensitive healthcare practices.

In the realm of education, intersectional analysis has been instrumental in examining how the intersectionality of social identities such as race, class, and gender influences educational opportunities and outcomes within specific educational institutions or communities. Similarly, in the context of health, intersectional analysis has provided valuable insights into how intersecting social identities contribute to disparities in health outcomes, access to healthcare services, and experiences of healthcare discrimination among marginalized populations ( Bowleg, 2012 ; Rogers & Kelly, 2011 ).

• 1. Intersectional analysis in qualitative research acknowledges the complex interplay of multiple dimensions of identity and power, going beyond studying single social categories in isolation.
• 2. Incorporating intersectionality in research design involves selecting an appropriate theoretical lens and methodologic framework, considering the timing and approach to incorporating intersectionality.
• 3. Sampling strategies should ensure the inclusion of diverse perspectives and experiences, using techniques such as purposive sampling or incorporating intersectionality into quantitative research.
• 4. Data-collection methods such as in-depth interviews, focus groups, participant observation, ethnography, PhotoVoice, and PAR are valuable for capturing the complex experiences of individuals with intersecting identities.

Ethical Considerations

Reflexivity.

Reflexivity in intersectional research significantly extends beyond ethical considerations not only because it crucially demands that researchers critically reflect on their positionality and biases but also because it fosters relational accountability and bolsters the trustworthiness of the collected data ( Adams, 2021 ; Palaganas et al., 2017 ). Guillemin and Gillam’s ( 2004 ) exploration distinguishes between procedural ethics and “ethics in practice” within qualitative research, shedding light on the impact of reflexivity on research conduct. This self-reflective approach aids in navigating potential power imbalances inherent in studying intersecting identities and marginalized communities.

To adopt reflexive practices in research, researchers could consider implementing strategies such as regular journaling or maintaining reflective logs to document their evolving thoughts, personal biases, and the influence of their social location on the research process. Additionally, peer debriefing or forming reflexive research groups offers a platform for researchers to discuss their reflections and receive constructive feedback, further enhancing the depth and accuracy of the research outcomes ( Rodriguez & Ridgway, 2023 ). Engaging in such reflexive strategies not only encourages a more transparent and accountable research practice but also nurtures a deeper comprehension of the intricate dynamics present within intersectional studies.

Confidentiality

Confidentiality is a vital ethical consideration when conducting intersectional research, particularly when working with sensitive data. Researchers must prioritize participant confidentiality and ensure that information shared by participants remains secure and anonymous ( Brabeck et al., 2015 ). This is especially critical when studying individuals who belong to multiple marginalized groups because they may face heightened risks of discrimination and harm if their identities are revealed (e.g., Muslim LGBTQI+ asylum seekers can be at risk if outed to their Muslim communities). Consent processes should address the potential risks associated with intersecting identities, clearly outlining measures taken to protect participant confidentiality. Researchers should be transparent about data storage, protection, and any limitations to confidentiality that may exist while also respecting participants’ right to privacy and anonymity. Upholding confidentiality not only safeguards participants but also promotes trust, enhancing the validity and integrity of the research.

Participant Empowerment

Researchers should strive to involve participants as active contributors to the research process and as agents of change and ensure that they are not “used” in the research ( Collins, 2015 ). This can be achieved through feedback sessions, collaborative analysis, and coauthorship opportunities, when possible. Engaging participants in these ways acknowledges their agency, promotes ownership over the research, and ensures that their voices are central to the interpretation and dissemination of findings ( Grbich, 2013 ). As such, researchers can challenge traditional power dynamics inherent in research relationships and work toward a more equitable and inclusive research practice. Furthermore, participant empowerment can lead to research outcomes that are more meaningful and applicable to the communities being studied, fostering social change and promoting the well-being of marginalized groups ( Naples, 2013 ; Rice, Harrison, & Friedman, 2019 ).

Avoiding Homogenization and Essentialization

One of the critical considerations in intersectional research is the avoidance of homogenization and essentialization of identities. Homogenization occurs when researchers overlook the diverse experiences and perspectives within a particular social category, treating individuals as a monolithic group ( Hancock, 2016 ). Essentialization, in contrast, means reducing complex and multifaceted identities to simplified stereotypes or fixed characteristics ( McCall, 2005 ). Both homogenization and essentialization can perpetuate stereotypes and reinforce oppressive systems.

To avoid homogenization, researchers must recognize and acknowledge the diversity within each social category they study. Intersectionality highlights the intersecting and unique experiences of individuals with multiple marginalized identities, emphasizing the need to explore the nuances and variations within these groups ( Collins, 2015 ). Researchers also should be mindful of the intersectional complexity of individuals’ lives, accounting for how multiple identities interact and shape their experiences. People’s identities are not monolithic. Essentialization can be avoided by recognizing the fluidity and complexity of social identities. Researchers should be cautious not to reduce individuals to a single dimension of their identity because this overlooks how various social categories intersect and influence their lived experiences ( McCall, 2005 ).

The principle of do no harm is a central ethical consideration in intersectional research. Researchers have a responsibility to minimize any potential harm that may arise from their research process and outcomes, particularly when studying individuals with intersecting marginalized identities. This principle necessitates careful attention to the potential risks and vulnerabilities faced by participants and the broader communities they represent ( Rice, Harrison, & Friedman, 2019 ). For example, Corbin and Morse ( 2003 ) discuss the ethical considerations in unstructured interactive interviews, highlighting the need for researchers to possess interviewing skills and adhere to a rigid code of ethics; they acknowledge that qualitative interviews may cause emotional distress but suggest that this distress is not necessarily greater than what individuals experience in everyday life.

To uphold this principle, researchers should conduct a thorough risk assessment before initiating their research, which involves identifying potential physical, psychological, and social risks participants may encounter because of their involvement in the research ( Grbich, 2013 ). For instance, discussing sensitive topics related to intersecting identities (e.g., migration status, drug use, family trauma, health issues, and abuse) may evoke emotional distress or trigger trauma responses in participants. Researchers should proactively address these risks through informed consent, providing participants with detailed information about the nature of the study, potential risks, and available support resources. Ideally, researchers should create a safe and respectful research environment by asking for informed consent, maintaining open lines of communication with participants, actively listening to their concerns, and providing opportunities for them to withdraw their participation without consequences ( Mackenzie, McDowell, & Pittaway, 2007 ). Researchers also should establish clear boundaries and ethical guidelines for data collection, storage, and dissemination to protect participants’ confidentiality and privacy as well as ensure their well-being and autonomy.

Additionally, researchers should be mindful of potential power imbalances and the potential for the research process to reproduce or exacerbate existing inequalities. Engaging in reflexive practices, as discussed earlier, enables them to critically examine their own positions of power and privilege and take proactive measures to mitigate any negative impacts ( Logie et al., 2022 ). As a matter of fact, they should aim to actively challenge oppressive systems and practices by centering the voices and perspectives of marginalized individuals and communities throughout the research process.

• Researchers must navigate the complexities of multiple intersecting identities, avoiding essentialization and homogenization.
• Researchers should prioritize ethical principles, including informed consent, participant confidentiality, and privacy and upholding the do-no-harm principle.
• Reciprocity and long-term engagement with participants ensure that research outcomes contribute to meaningful change and empowerment.
• Reflexivity and contextual sensitivity are essential for respecting individual agency and diversity.

This comprehensive how-to guide addresses the methodologic and practical challenges associated with using intersectional analysis in qualitative research. By engaging with it, readers gain valuable insights and practical guidance to enhance their research in terms of inclusivity, rigor, and social relevance.

Intersectional analysis is a critical framework for understanding social phenomena because traditional qualitative methodologies often overlook interconnected social identities and power dynamics, limiting the depth of analysis. Intersectional analysis enables researchers to go beyond single-axis approaches and examine the complex interplay of intersecting social identities such as race, gender, class, sexuality, and disability and how they shape individuals’ experiences.

This guide provides guidance on research design, sampling strategies, and data-collection methods to ensure the inclusion of diverse perspectives and the exploration of intersectional experiences. It also highlights the ethical considerations researchers should uphold while conducting intersectional research, including obtaining informed consent, safeguarding participant confidentiality, and protecting privacy. Moving beyond transactional relationships, researchers are encouraged to foster reciprocity, long-term engagement, collaboration, and active involvement of participants and make sure to engage in reflexivity and contextual sensitivity to respect individual agency and acknowledge the diversity within intersecting identities. Researchers also must critically reflect on their biases, assumptions, and positionality throughout the research process.

In conclusion, embracing an intersectional perspective allows researchers to capture the multidimensionality and contextual nature of individuals’ identities, enabling a more nuanced analysis. By doing so, they can better capture the multidimensionality and contextual nature of individuals’ identities, moving beyond simplistic categorizations and allowing for a more nuanced analysis.

Multiple-Choice Quiz Questions

1. Intersectionality acknowledges that identities and social categories are

Incorrect Answer

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Correct Answer

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2. Qualitative research is primarily focused on

3. Which of the following is an example of an intersectional approach in qualitative research?

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4. When conducting intersectional research, it is important to consider

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5. What is the main goal of intersectionality in qualitative research?

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Causality-Based Visual Analysis of Questionnaire Responses

• Renzhong Li ,
• Weiwei Cui ,
• Tianqi Song ,
• Haidong Zhang ,
• Hong Zhou ,

| October 2023

Author's Version | DOI

As the final stage of questionnaire analysis, causal reasoning is the key to turning responses into valuable insights and actionable items for decision-makers. During the questionnaire analysis, classical statistical methods (e.g., Differences-in-Differences) have been widely exploited to evaluate causality between questions. However, due to the huge search space and complex causal structure in data, causal reasoning is still extremely challenging and time-consuming, and often conducted in a trial-and-error manner. On the other hand, existing visual methods of causal reasoning face the challenge of bringing scalability and expert knowledge together and can hardly be used in the questionnaire scenario. In this work, we present a systematic solution to help analysts effectively and efficiently explore questionnaire data and derive causality. Based on the association mining algorithm, we dig question combinations with potential inner causality and help analysts interactively explore the causal sub-graph of each question combination. Furthermore, leveraging the requirements collected from the experts, we built a visualization tool and conducted a comparative study with the state-of-the-art system to show the usability and efficiency of our system.

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• Volume 41, Issue 4
• Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study
• Article Text
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• http://orcid.org/0000-0003-3067-9416 Jo Daniels 1 , 2 ,
• http://orcid.org/0000-0002-8013-3297 Emilia Robinson 1 ,
• http://orcid.org/0000-0001-5686-5132 Elizabeth Jenkinson 3 ,
• http://orcid.org/0000-0002-2064-4618 Edward Carlton 4 , 5
• 1 Department of Psychology , University of Bath , Bath , UK
• 2 Psychology , North Bristol NHS Trust , Westbury on Trym , Bristol , UK
• 3 Department of Health and Social Sciences , University of the West of England , Bristol , UK
• 4 Emergency Department, Southmead Hospital , North Bristol NHS Trust , Westbury on Trym , UK
• 5 Bristol Medical School , University of Bristol , Bristol , UK
• Correspondence to Dr Jo Daniels, Department of Psychology, University of Bath, Bath, UK; j.daniels{at}bath.ac.uk

Background Staff retention in Emergency Medicine (EM) is at crisis level and could be attributed in some part to adverse working conditions. This study aimed to better understand current concerns relating to working conditions and working practices in Emergency Departments (EDs).

Methods A qualitative approach was taken, using focus groups with ED staff (doctors, nurses, advanced care practitioners) of all grades, seniority and professional backgrounds from across the UK. Snowball recruitment was undertaken using social media and Royal College of Emergency Medicine communication channels. Focus group interviews were conducted online and organised by profession. A semi-structured topic guide was used to explore difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Data were analysed using a directive content analysis to identify common themes.

Results Of the 116 clinical staff who completed the eligibility and consent forms, 46 met criteria and consented, of those, 33 participants took part. Participants were predominantly white British (85%), females (73%) and doctors (61%). Four key themes were generated: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data pertaining to barriers and opportunities for change were identified as sub-themes. In particular, strong leadership emerged as a key driver of change across all aspects of working practices.

Conclusion This study identified four key themes related to workplace concerns and their associated barriers and opportunities for change. Culture, working environment and need for support echoed current narratives across healthcare settings. Leadership emerged more prominently than in prior studies as both a barrier and opportunity for well-being and retention in the EM workplace. Further work is needed to develop leadership skills early on in clinical training, ensure protected time to deliver the role, ongoing opportunities to refine leadership skills and a clear pathway to address higher levels of management.

• qualitative research
• staff support

Data availability statement

Data are available upon reasonable request. Requests go to the corresponding author - Jo Daniels ([email protected], University of Bath, UK). De-identified participant data can be made available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/emermed-2023-213189

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Retention of staff in emergency medicine is at crisis level and has been a high priority area for over a decade.

Multiple guidelines have been published to outline improvements that need to be made to retain staff; however, little improvement has been seen on the ground in EDs.

Key factors such as staff burnout and poor working conditions are known to influence intention to leave; however, it is unclear why change has not taken place despite knowledge of these problems and existing guidelines seeking to address these issues.

WHAT THIS STUDY ADDS

This qualitative study assessed perceived barriers that may be inhibiting the implementation to working conditions and working practices in EDs.

Leadership is identified as an important driver of change in working practices and can play an important role in workplace well-being and retention.

Key recommendations for avenues of improvement are made, identifying key actions at government, professional, organisational and personal level.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

This study identifies leadership as a key opportunity for change and as a result makes specific recommendations for policy and practice regarding leadership in emergency medicine.

Introduction

Emergency Medicine (EM) is facing a global staffing crisis. 1 Record numbers of staff continue to leave the UK NHS with EM the most affected specialty. 2 EM reports the highest work intensity of all medical specialties, 3 with ‘intensity’ recognised as one of the leading factors in job dissatisfaction, attrition and career burnout. 3–5 These factors are amplified in an already stretched workforce. 2 Psychological well-being of the EM workforce is compromised, with working conditions recognised as playing a key role. 6 7 Staff attrition has a systemic impact: lower staff ratios lead to higher workloads, reduced quality of care, 8 higher levels of medical errors 9 and poorer staff well-being, 10 all factors associated with staff absence and intention to leave. 11 The landscape of EM has also changed; increased prevalence of high patient acuity, multimorbidity and an ageing population all bear considerable impact.

Key sector stakeholder initiatives and policy recommendations relating to retention and well-being 12–14 are largely generic and forfeit relevance to the specialty due to the lack of specificity to the clinical context within which these guidelines need to be implemented. Retention improvement programmes suggest approaches should be tailored per organisation, 12 however, this assumes that the challenges faced by staff across specialities and disciplines are homogeneous. In a specialty which reports the highest pressured environment, highest attrition and rates of burnout, 15 considerations of workplace context and specificity of policy recommendations are likely to be crucial. Interventions or initiatives must take account of the unique demands of the EM working environment, and how feasible it is to implement recommendations.

The James Lind Alliance (JLA) priority setting partnership in EM 16 identified initiatives to improve staff retention as research priorities in 2017 and again in the 2022 JLA refresh, 17 signalling the need for further research in this area due to a deepening workforce crisis. Current guidelines and initiatives target working conditions which are known to be associated with retention; however, these initiatives have been poorly implemented or enforced, with few formal evaluations of such interventions. 5 Moreover, current research is limited to the perspectives of specific professional groups and most are survey-based studies. 18

In order to better address current working conditions, with a view to improving retention, this research was aimed at determining practical barriers and opportunities for change in the ED working environment as perceived by professional staff working in this environment. This will tooffer insight into the shared experiences, constraints and priorities of those working within the ED.

Enhanced understanding of these issues can provide a firm basis from which to shape, inform and underpin future policies and workplace initiatives, ensuring that practical barriers and opportunities for change are embedded in a way that optimises relevance and feasibility of implementation in the ED working environment.

Study aims and objectives

This study sought to engage three core professional groups (doctors, nurses, advanced care practitioners; ACPs) who work within an EM context to better understand (a) primary concerns relating to working conditions; (b) perceived barriers to implementing change and (c) perceived opportunities and targets for change. Findings will be used to underpin key recommendations that are tailored to the needs of an over-burdened and under-resourced ED.

This qualitative study forms part of a larger collaborative project between the University of Bath and the Royal College of Emergency Medicine (RCEM), funded by a UKRI Policy Fund. The full recommendations relating to the four core themes are available on the RCEM website (Psychologically Informed Practice and Policy (PIPP) | RCEM).

Methodology

This study uses a qualitative approach involving online focus groups in order to gain a rich and detailed understanding of participant perspectives and views, unrestricted by closed question responses. Focus groups offer the opportunity to gain an understanding of shared experiences and narratives, using a dynamic approach to the subject matter, allowing further probing for clarification and participant interaction for deeper insights. The COVID Clinicians Cohort (CoCCo) study 19 was used to organise data into key categories; this model mirrors Maslow’s Hierarchy of Needs 20 from a workplace perspective.

Participants

To be eligible for participation, ED staff must have been currently employed in a UK NHS ED as either a doctor, nurse or ACP.

ACPs are a recently developed workforce of accredited clinicians who have received advanced training to expand the scope of their usual role (eg, paramedic, nurse), permitting them to take on additional clinical responsibility in the ED.

These three groups are core affiliates of the RCEM and represent the majority of the workforce in the ED. The ED setting was used as the focus (rather than all acute care settings) as this represents the core and central setting for EM.

Recruitment and procedure

Online adverts and qualtrics survey links were distributed through social media (ie, Twitter) and RCEM communication channels using snowball recruitment methods. Profession-specific focus group interviews were conducted online using MS teams by two study researchers (JD, ER) using a semi-structured topic guide (see online supplemental materials ). The guide was shaped by the scope of study aims and the current evidence base and explored difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Focus groups were 60–90 min in duration and were recorded using encrypted audio recorders, transcribed and stored securely. Participants were given debrief information sheets following the focus group. Transcripts were not returned to participants and no repeat focus groups were carried out.

Supplemental material

Directive content analysis was applied to the data. 21 This analysis strategy was used to identify common themes from participant responses, using deductive codes by identifying key concepts from existing theory 19 and prior research. Two researchers (ER, JD) read through each transcript, highlighting passages that could be categorised in the pre-determined codes. Any passages that could not be categorised within the initial coding theme were given new codes. Further coding was then conducted and this iteration was reviewed and updated. After coding was completed, initial notes from the focus groups were revisited to ensure all reflective notes were incorporated where relevant. Final themes were refined through an iterative process between JD, ER and EJ (qualitative analysis expert), with all stages of analysis reaching consensus agreement with regard to the content and labelling of codes and themes.

Patient and public involvement

As this study focused on staff experiences in an EM workplace, a Clinical Advisory Group (CAG) was used in place of patient or public involvement. The CAG comprised of five clinicians working in the ED who advised on the scope and priorities of the study. This included two medical consultants, one charge nurse, one trainee and one specialty grade doctor. Of those, three were males and two were females. All CAG members were offered renumeration for their time.

Of the 117 total responses to the study advert, 16 respondents were eligible but not available to attend focus groups and 55 either did not consent or were not eligible based on their role and/or department. From the remaining 46 respondents, 13 of these could not attend or cancelled, leaving a final sample of N=33 (28% of total responses). Due to higher response rates from doctors, these focus groups were further grouped by grade; nurses and ACPs were grouped by profession only and were organised base on availability. There were 11 groups in total (see table 1 ). Participants were mostly female, and from a white British background. Ages were spread fairly evenly across the categories, except ages 35–44 which included substantially fewer participants.

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Participant and focus group characteristics

Following analysis of the qualitative data, four key themes were generated. These were termed: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data within these themes that were identified as ‘barriers’ or ‘opportunities’ for change were extracted ( table 2 ). Illustrative participant quotes are identified by researcher codes, which reflect the profession and a recoded group number, to preserve anonymity.

Primary concerns, barriers and opportunities for change

Culture of blame and negativity

When asked about the most difficult aspects of their working conditions, participants commonly reported a culture of blame and negativity in the ED. The work culture not only felt unsupportive and ‘toxic’ but had a marked effect on well-being. Participants described a culture which was quick to blame rather than support:

You worry about making a mistake, and if you did make a mistake who would have your back. (ACP, G7) You very rarely get anyone saying that was a good job. (SAS doctor, G8)

This was particularly felt top-down, where those in management position were perceived to take an unsympathetic view of extended waiting times and unmet targets, despite the tangible constraints of operating at overcapacity and ‘exit block’, problems that participants perceived to be out of their control. Participants in all groups indicated that the negative culture instils anxiety over how they might be perceived by peers, but particularly by senior colleagues:

That’s a classic example… she’s a senior member of the team, really knows her job…. She was quite critical really, in a very negative way about how you managed that patient. (Nurse, G11)

Some participants reported senior colleagues having unrealistic expectations of the more junior staff, with little consideration of the increased pressures that have arisen in recent years:

It’s ridiculous to compare the needs, even for our senior colleagues who were registrars five years ago, the reality of running the department overnight is not the same as it was then. (SAS doctor, G1)

Existing structures and working practices of the NHS were described as ‘archaic’ and ‘old fashioned’, leading staff to feel blamed if they could not cope with the pressures and disempowered to seek support due to the expectation that they should be ‘unbreakable’ (Trainee, G9). Participants also voiced that they were unclear on lines of accountability, who to approach for what problem. This barrier to escalating their concerns was further compounded by the belief that both clinical leadership and higher management were generally overburdened and unreceptive to discussions on workplace concerns.

Increasing pressure and longer waiting times were described as driving antisocial behaviour from patients, exposing staff to risks to physical and psychological well-being:

So the long wait causes verbal or physical violence and aggression, which has a massive impact on staff well-being. (Nurse, G11)

Participants highlighted the desire to be supported to learn from difficult experiences and develop in light of them, suggesting that a simple checking in on how individual staff members are progressing would be well received and beneficial to well-being:

We have intermittent debriefs… but it’s not every time. It doesn’t necessarily need to be every time, but it’s not as frequent as it should be. Even if it is just ask are you okay? (Trainee, G5)

Interprofessional respect and development of a more empathic culture of shared responsibility were flagged as key opportunities for change that would support better team cohesion:

We need to change how we speak and respect each group, and we need to try and understand each other’s point of view, and if we could get better ways of working, but just talking to each other about what are my problems, what are your problems, why is this stressing you, what’s stressing us, how can we work together to do that. (ACP, G2)

Findings suggest that EM professionals are confronted with outdated perceptions of clinical demand from within teams and systems, with unrealistic expectations which compound a blame and shame culture when expectations are not met. Operating within this chronically under-resourced system was framed as compromising workforce well-being and risking burnout, yet participants indicated that simple interventions such as check-ins, clearer lines of accountability and a more civil and respectful culture would offer key opportunities for growth and sustainability even in the face of a staffing crisis.

Untenable work environments

The complex work environment within the ED was described as being of significant concern, compromising care and leaving staff feeling undervalued due to basic needs being unmet. Participants frequently reported poor quality or inadequate facilities, such as provision of toilets, lockers and changing rooms, hot food only available within limited hours, poorly functioning IT systems and rest spaces being in a different building.

So you’re just basically sharing (toilets) with the patients. In the urgent care centre there’s two toilets for the whole of the department in there, often one of those is broken…and not enough lockers for every member of staff. (ACP, G2) Stuff like working computers, a consistently working POD system… those little things I think make a bigger impact on your life than how many people come in through the front door. (Trainee, G5)

A lack of physical space for administrative tasks was highlighted by many clinical staff, being described as ‘woefully inadequate’ (ACP, G2). Wards were described as ‘unfit for purpose ’ (Nurse, G11), which was attributed, in part, to higher management lacking understanding of the needs and practices of the ED. One example highlighted the long-term impact of ED workspace changes that were not fit for purpose:

…it was clear that no clinical staff had been involved. Doors were in the wrong space, no sinks in the right place, not enough storage, poor flow, poor layout (ACP, G2)

Existing rest spaces or staff rooms were reported to be taken over to provide more clinical room, limiting the space for staff to change, rest and decompress.

The nurses were getting changed in a corridor, now they seem to have a cubicle they can get changed in. But the facilities for the same trust are really very different. (Nurse, G10)

This was perceived to be particularly important due to working in the high-pressure environments of a crowded ED, where staff voiced concerns regarding the sustainability of working with a high workload safely without private spaces.

EDs were perceived to be more busy, for reasons associated with shifts in societal expectations and perceptions of the scope and role of ED:

Go back ten years ago in the emergency department and people would try their best at home, would take painkillers, will see how it goes, not wanting to trouble A&E, but seems like now it seems like A&E is the open door for everybody just to come in with everything. (ACP, G7)

Participants used emotionally laden language when describing the intensity of the workload itself, with parallels drawn between being at war and working on the NHS frontline, where staff worked under similar levels of intensity but longer term and without rest.

…when people are deployed (in the forces) they are deployed for 6 months…because that 6 months is intense, it’s intense on your body, it’s intense on your mind, it’s intense on your family, it’s intense on everything about you, and that’s while you were deployed for 6 months, and then there’s some recovery time coming back. (Consultant, G4)

Comparisons were also made to the sinking of ‘the Titanic’:

There is the jollying everybody along, being the redcoat on the shift, cheering everybody up, saying everything is going to be okay, but feeling like you’re just rearranging the deckchairs on the Titanic (Nurse, G10)

The impact of a consistently high workload was described as being compacted by a lack of agency and autonomy over working patterns, which was perceived to be related to non-clinical staff making decisions about shifts without understanding the inherent pressures:

The people who control our rotas are… her job is a rota co-ordinator, she works in an office, she is administrative, and the person who signs that off is the manager for the department, again non-clinical, and getting leave is a nightmare, it’s awful. (Trainee doctor, G5)

Consultants identified that there were limited options to reduce workload when approaching retirement, and they did not necessarily feel well-equipped to continue operating under high pressure and for long hours. Those in training posts reported insufficient time to meet requirements or study due to workload, influencing both career progression and confidence in the role.

You are getting no progression because you’re not getting your training, and I know that personally in the last year I made my decision that I will not continue to work clinically, I will step back in the next few years because there’s… why would I stay doing something that there’s no reward for? (Nurse, G11)

Participants agreed that there was both a need and an opportunity for the ED to be a ‘nicer place to work’ (ACP, G2). Specific suggestions included a full staffing quota, ensuring staff are adequately rested to return to work and the opportunity for peer support:

My top three things would be coming on with a full staffing quote so you know there’s no gaps in the rota, so you’re all there. Everyone is well rested and ready for the shift, just being able to talk to each other on the shop floor and being quite open with each other on how everyone is feeling. (ACP, G7)

Many of the suggested changes directed at making working conditions in the ED more sustainable related to basic needs such as being able to take breaks, access healthy food and functioning IT when needed:

…having those opportunities to go off and have a five minutes when you need to, to be able to continue your shift. (ACP, G7) It would be really nice to be able to have some healthy nice food in the department. (Nurse, G11) As more and more of our job goes electronic, electronic notes, electronic prescribing, actually having IT systems that are fit for purpose, everyone has access to (Trainee doctor, G9)

Self-rostering was frequently mentioned as a positive experience for participants and a useful avenue to help participants to deliver better care and improve well-being:

One day off between a set of shifts is not enough to decompress and be re-energised to start back on your next set of shifts. So I think the rota, we have moved to a more self-rostering method now, and I think that’s helping with staff well-being, especially in our team. (A7)

Overall, working in existing ED environments was described as ‘untenable’ and ‘unsustainable’ in terms of both the working environment and the lack of agency and autonomy over high-intensity workloads. Many of the problems and solutions relate to provision of resources to meet basic needs, many of which are subject to professional and NHS regulations; however, due to pressures this is not being implemented.

Compromised leadership

Clinical leads in the ED were perceived to hold responsibility for setting the tone for culture and behaviour in the ED, leading by example:

And you lead by example as well, so if your consultant in charge is not taking a break you feel like you can’t ask to take a break. It’s the same with the nurses, if the nurse in charge is not taking a break then a lot of the junior nurses won’t come and ask for a break because again you’re guided by the leadership aren’t you? (A7)

The clinical lead in the ED is a key conduit for change, from a cultural and environmental perspective especially. However, participants expressed frustration about feeling that their voices were not heard or valued outside of the department, in part due to clinical leads being reluctant to escalate their concerns due to the discrepancies between clinical priorities within the ED and the priorities expressed by trust level executive management:

You’ve got the clinical side, and we are to one degree or another worried about the patients, and then you have got the management side and they are worried about figures, times or money, and those two things don’t really mesh together (ACP, G2)

Yet, within the EDs, leadership was described as being poorly supported in terms of protected time to train and deliver the role fully. Consultants voiced reluctance to take on a leadership role due to lack of ‘visible leaders’ to provide inspiration or exemplar: ‘There is no one for us to look up to, to lead us’ (Consultant, G4), ‘We need compassionate leadership’ (SAS doctor, G1).

A lack of definition or clear understanding of what the clinical role entailed was reported to make it difficult for clinical leads to be effective in their role:

People tell you that you’re there to lead, and you’re like I know but what does that mean? And then you don’t know if you’ve got to go to all these meetings, which ones you really need to go to, which ones can I not go to, also for me I do the job on my own. (Clinical lead, G6)

Participants emphasised they need a ‘clear definition of what the college would see the role to be, and how much time they would expect it to take of your job ’ (Clinical lead, G6). Any possibility for growth was hampered by a lack of training or support from colleagues to help with even the practicalities of the role (such as recruitment and personnel management):

I have literally started last week on a leadership course that’s been for other clinical leads in the organisation. But I feel a bit could have done with this maybe earlier. But that’s more about your leadership qualities and conflict resolution, it’s all that side of it as opposed to the actual practicalities of the job. (Clinical Lead, G6)

When considering possible solutions to these difficulties, participants suggested that an accessible time to do the job and an online repository may offer an opportunity to share resources, learn from one another and foster development:

I think sharing all the stuff we shared on the WhatsApp, trying to share stuff, so how to write a business case, what you need to do. (Clinical lead, G6) I should be doing work at a time I am getting paid, so you need to give me that time. (Trainee doctor, G9)

Mentorship was also deemed to be important for successful delivery of the role:

I think personally as leads and stuff we should all have some kind of mentoring type…Supervision, that’s the thing, we don’t get any. (Nurses, G10)

Participants described having difficulties feeding into emerging issues to address unmet need, blocked from communication with leaders by ‘layers of bureaucratic sediment’. This was compounded by the career trajectory of NHS management, where often those in post would swiftly move on for promotion.

Overall, clinical leadership within the ED was described as compromised, unsupported and, ultimately, a key barrier or missed opportunity for change in culture and working practices in the ED. However, there were clear indications of opportunities for growth and change, including a need for compassionate leadership, shared resources, time to do the job and mentorship.

Striving for support

This final theme encompasses the concerns raised by participants regarding well-being and staff support, specifically the barriers to accessing well-being support and their preferences in relation to what changes are likely to improve their well-being. Common barriers included having to attend support or well-being services during time off, with the scheduling of support geared to a ‘nine to five’ non-clinical workforce (ACP, G2). Mental health stigma in the ED was also cited as a key barrier.

I think for me it still feels like a bit of a stigma about saying I am struggling what should I do next. (Nurses, G11) There’s nowhere that I can express how I am feeling or even understand how I am feeling. (Consultant, G4)

This was reinforced by well-being not being viewed as a priority, with team check-ins or formal appraisals described as having ‘nothing in there about wellbeing’ (Clinical lead, G6), despite suggestions that simple well-being check-ins would suffice.

Participants suggested that support should not be purely accessed after the fact but something that should be prioritised and routinely available to staff to safeguard mental health:

… psychological support…it shouldn’t be something that we access when there is a problem, it should be something where we go well every month on a Friday at this time I go and talk to someone about what I have seen. (Trainee, G9)

Participants’ lack of understanding about which services were being offered was raised by many, with participants often able to list services available, or where the staff support centre was based, but not how or when one might access them. This offers a key opportunity for collaboration between staff support services and the ED to develop clearer pathways or a clear role for a departmental well-being lead.

Peer support was consistently highlighted as a highly valued resource that should be considered part of supportive culture ‘gives you somebody else to share the load with, and not be that single voice’ (Trainee doctor, G9). However, limited physical space and time to engage in peer activities were cited as barriers:

Well yeah it would be lovely to sit down and chat with my peers, apart from the fact that 1) we’re constantly busy, 2) we don’t have anywhere where we can sit and have a confidential gas. (SAS doctor, G8)

Overall, accounts suggested that existing support was largely unfit for purpose, and where it was easy to access (such as peer support) and available, it was often incompatible with ED working practices and within a culture where seeking support was often stigmatised.

Some participants expressed that having a psychologist embedded within the department was highly valued as a resource, particularly the different levels of support dependent on need:

…(during the pandemic) we setup weekly drop-in sessions with the psychologist… and it was really great for a lot of people to be able to drop-in, and then that led on to having one to one for people who felt they needed that, and also within ED we had a psychologist come round to our supervision when we needed them. (ACP, G7)

Participants reflected that psychological input introduced in response to the impact of the COVID-19 pandemic was highly valued. While many were open to discussion about their mental health and well-being, for many, stigma still permeates the ED culture and is further compounded by poor understanding and communication of available resources. Appointment of well-being leads, more value placed on well-being (including informal peer support) and routine access to psychology are suggested as opportunities to make strides towards improved well-being.

This study identified four key themes describing the difficulties in the ED work place. Working culture, physical working environment, pathways to care and leadership represent the core workplace concerns within our sample. These issues were perceived to play an instrumental role in their ability to sustain good working practices, well-being and, importantly, their intention to leave. Participants identified key barriers and opportunities within their work contexts which resonate with existing research and policy and can be used to shape the future policy and research development. 22 , 2 5 These findings act as a basis for the development of specialty-specific targets for change that are aligned with the views and voices of those working in this working environment and also take account the barriers and opportunities faced in the fast-paced unique environment of the ED. For a full set of EM-specific recommendations to underpin change across all of these four areas, see the Psychologically Informed Practice and Policy (PIPP) recommendations ( https://rcem.ac.uk/workforce/psychologically-informed-practice-and-policy-pipp/ )

Several of our findings have been noted in previous studies, particularly the role of culture, environment and access to support. 22 Most of the research examining factors associated with working conditions and retention in EM are profession specific 3 6 18 19 and are not readily generalisable to other professional groups in the ED. However, our study included doctors, nurses and ACPs from which emerged common cross-cutting themes affecting all of these professions working in the ED, themes which are consistent with the broader literature 9 10 but specific to the EM working environment.

As reflected in the work by Darbyshire et al , 5 the nature of the problems described were systemic; the workplace challenges were interrelated and appeared reciprocal in influence, arguably maintaining one another. The cyclical nature itself proves a key barrier to change, which raises the question: which is the primary target to effect most change? Leadership has a pivotal influence across these themes and is unequivocally vital to workforce transformation; however, this is an area that has been largely neglected in EM, with very little research seeking to develop or evaluate leadership interventions in this environment. Indeed, there is an assumption that leadership naturally develops over time and is fully formed on appointment to the role. 23 However, leadership within the ED is particularly complex and demanding due to the range of competencies required (clinical, managerial and administrative) 23 and the high-pressured environment within which this role needs to be delivered. This warrants tailored training and support to fully succeed. In settings where the nature of the work is unpredictable and at times clinically critical, leadership is pivotal to patient outcomes and team functioning, 23 24 which are particularly crucial in the ED setting. Leadership has the potential to be a powerful driver in workforce transformation, cultural change 25 and team functioning within these highly skilled, professionally interdependent teams. 26 To fully harness the capacity of leaders as agents of change, those in leadership positions must be sufficiently skilled, 27 feel supported to act on important issues 27 and have time to do the job. Yet, participants in this study reported poor role definition, lack of training and absence of protected time to deliver the role. This was compounded by blurred lines of accountability that led to impotence to effect change.

Implications

The development of leadership in EM should now be a primary focus. There are clear steps that can be taken to begin to mobilise and maximise the pivotal influence of leadership in effecting change, across government, professional, organisational and individual levels.

On a public policy level, there has been a rapid growth of government level publications and resources to recognise the role of leadership as a conduit to better patient and team health. 28 However, recommended leadership training is often generic and never mandated. This is surprising given the clear links with patient safety and team functioning. 23 24 Leadership training in healthcare should be mandated by government bodies, not least due to links with patient safety. 29

Significant work has been undertaken by RCEM to integrate and embed mandatory leadership training into the training curriculum for EM trainees, without which they cannot progress. While this demonstrates forward thinking and some future-proofing for the medical profession, it cannot cease at this point, it must be supported with continuing professional development post-training. The relevant professional bodies provide access to good quality leadership training such as the RCEM EM Leaders Programme and the RCN Leadership Programme, however, this is largely online without protected time to access or support development. More work is needed to ensure leadership training is visible, supported as part of a workplan, and a priority area championed by all relevant professional bodies.

Further work is needed to ensure that leadership competencies are introduced at an early stage of training 23 so the necessary skills are embedded and cultivated on the pathway towards and within leadership roles, rather than ad hoc when necessity dictates. This falls to both training and professional bodies to work together to ensure that theory-driven leadership is a core part of the teaching curriculum, with mentorship and practical resources (such as role definition, a personal development plan, human resource support) to complement and facilitate the necessary continuing professional development throughout a clinical career. Responsibility then moves to the employing local NHS trusts to support the development of those individuals within leadership positions. It is at this level that ED clinical leads and their teams can harness their influence; local NHS trust policies are driven by guidance from government and professional bodies, however, they have the power to shape local policy and mandate change in view of the needs of a service. We summarise key recommendations to underpin change at a local NHS level in Box 1 .

Key leadership recommendations for local NHS trust level commissioning

Those in leadership positions should be supported to attend leadership training as part of their workplan, within their workplace hours. This would include top-up training and training assignments.

Support to engage with a leadership mentorship or coaching programme as part of their workplan, with a view to continuing professional leadership development and creating safe spaces to problem-solve, reflect and seek support.

Access to the consultation service within the local NHS staff support services.

Appointment of a designated ‘Wellbeing Lead’ with protected time and support to deliver the role.

Clear description of roles and responsibilities, to include protected time dedicated to undertaking additional responsibilities associated with a leadership role and a professional development plan that is reviewed annually.

Support to engage with the EM clinical lead network in order to access resources to support the delivery of the role and access peer support when necessary.

Clear lines of accountability at an NHS organisational level with identified pathways to escalate concerns.

EM, emergency medicine.

Appointment of well-being leads within the ED, as outlined in the RCEM PIPP recommendations 30 and other key documents, 22 is also a key step towards workplace transformation through leadership; however, it is imperative this role is also supported with protected time and development. A well-being lead with a clearly defined remit and role would play a pivotal gatekeeper role in encouraging attitudes towards well-being in the ED by delivering ‘warm handovers’ and well-being initiatives, such as informal check-ins, staff team activities (ie, safety huddles), and well-being surveys.

On an individual level, those in leadership positions are more likely to succeed by harnessing the influence and opportunity that accompanies the role, identifying and taking inventory of challenges and barriers, clarifying lines of accountability to drive forward change and advocating for the needs of their team. Two mechanisms by which leadership bears the greatest influence include leading and prioritising a continuous cycle of quality improvement (eg, autonomy over work patterns, access to rest spaces, patient flow, taking steps to address the diversity gap) and role modelling of positive professional behaviours. 26 The latter includes compassionate and inclusive attributes but also speaks to the necessity to meet basic needs: taking breaks, adhering to annual leave, destigmatising views on mental health and openness to learning and change. Those in leadership roles should be encouraged to engage with the leadership networks, broadened to encompass a platform or virtual environment (ie, repository) to share and access resources and be granted access to leadership consultation with the well-being team as and when necessary. Those in leadership positions should also be provided with clear referral processes and internal professional standards to help address any incivility, including bullying, harassment and issues of inclusion. This would help promote a culture of care and interprofessional valuing and respect, improving team cohesion.

Finally, it is imperative that lines of accountability are clear for those in a leadership position. While many NHS trusts differ in their management structures, each trust will have communication pathways to divisional and executive management leadership teams. In order to drive the full potential of leaders to action change through these mechanisms, it is fundamental that pathways from ‘shop floor’ to the chief executive are clear and opinions and concerns of ED leadership are welcomed.

Flow through the ED, staff ratios, pay and pension structures are of course prime targets for change and where the current high-profile focus lies. However, leadership is a key conduit to change and those with mandatory powers must now move to recognise this in order to unlock the full potential of this role.

Limitations and future directions

There are inherent limitations in the small size of some of the participant groups, and as such the views and opinions expressed cannot be considered transferable across their respective professions. While many prospective participants did not proceed to focus group meetings due to last minute requests to cover shifts, the participant pool was comfortably within the bounds of what is acceptable for a qualitative study.

Findings should be interpreted in light of the sample consisting mainly of white women, therefore the views of males and minority groups may not be fully represented. Doctors made up a higher proportion of the final sample; this may be a consequence of using RCEM communication channels as a primary recruitment method, which has more members registered as doctors than nurses. As not all professions working in ED were included (eg, physiotherapy, psychology) it is possible that additional themes or differences might have been missed.

The geographical spread reflects a broad reach; however, there was a preponderance towards the South West, where the research was conducted. While none of the interviewees were known to the research team, those in the South West may have been more exposed to recruitment drives through mutual connections.

The development and testing of leadership training and packages should be a priority for professional bodies and at organisational level. This should take account of the overlapping and competing competencies required of ED leadership, including managerial, administrative and clinical components and the high-pressured context within which these skills are required.

This study identified key themes in understanding workplace concerns in the ED, and their associated barriers and opportunities for change. Leadership in EM should now be a primary focus, with further investment and support to target the development of leadership skills early on in training and provide protected time to refine these leadership skills and qualities across the working lifetime. This will serve to harness the pivotal influence of leadership in EM, which, if properly supported, holds the potential to act as a conduit for change across all areas of focus.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by University of Bath Psychology Research Ethics Committee (22-039). The Health Research Authority toolkit confirmed further approval was not required. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The study authors would like to extend thanks to all who contributed to this project including participants and the clinical advisory group. The authors would also like to acknowledge and thank RCEM President (AB) and policy advisor (SMcI) who advised on the policy priorities of RCEM and wellbeing clinical leads (Dr Jo Poitier, Consultant Clinical Psychologist at Alder Hey Children's NHS Foundation Trust; Dr Olivia Donnelly, Consultant Clinical Psychologist at North Bristol NHS Trust) who were consulted on their respective areas of expertise. They also thank Rita De Nicola for help in preparing the manuscript.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3

Handling editor Caroline Leech

Twitter @drjodaniels

Contributors The original concept for the paper was developed by JD and shaped in consultation with EC and the RCEM President AB. JD was the primary contributor, guarantor and lead for the content and refinement of the paper. EJ gave expert methodological advice and contributed to the reporting and refinement of results. ER and JD performed the analysis, both contributing to the reporting of the results. ER prepared the manuscript for publication. EC gave expert advice on all aspects of the study from an Emergency Medicine standpoint and also contributed to the write-up of the paper. All authors contributed to the final version of the paper and approved for publication.

Funding This research has been carried out through funding from the UK Research and Innovation Policy (UKRI) Support Fund. The funder did not provide a grant number for this project, it is part of block 'UKRI Policy Support' funding from UKRI directly to Universities who distribute within their institutions. The funders had no role in considering the study design or in the collection, analysis or interpretation of data; the writing of the report or the decision to submit the article for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Open access
• Published: 26 March 2024

A qualitative evaluation of stakeholder perspectives on sustainable financing strategies for ‘priority’ adolescent sexual and reproductive health interventions in Ghana

• Evans Otieku   ORCID: orcid.org/0000-0002-6809-5160 1 , 2 ,
• Ama P. Fenny   ORCID: orcid.org/0000-0001-9367-1265 2 , 3 ,
• Daniel M. Achala 3 &
• John E. Ataguba   ORCID: orcid.org/0000-0002-7746-3826 3 , 4 , 5 , 6  

BMC Health Services Research volume  24 , Article number:  373 ( 2024 ) Cite this article

Metrics details

Adolescent sexual and reproductive health (ASRH) interventions are underfunded in Ghana. We explored stakeholder perspectives on innovative and sustainable financing strategies for priority ASRH interventions in Ghana.

Using qualitative design, we interviewed 36 key informants to evaluate sustainable financing sources for ASRH interventions in Ghana. Thematic content analysis of primary data was performed. Study reporting followed the consolidated criteria for reporting qualitative research.

Proposed conventional financing strategies included tax-based, need-based, policy-based, and implementation-based approaches. Unconventional financing strategies recommended involved getting religious groups to support ASRH interventions as done to mobilize resources for the Ghana COVID-19 Trust Fund during the global pandemic. Other recommendations included leveraging existing opportunities like fundraising through annual adolescent and youth sporting activities to support ASRH interventions. Nonetheless, some participants believed financial, material, and non-material resources must complement each other to sustain funding for priority ASRH interventions.

There are various sustainable financing strategies to close the funding gap for ASRH interventions in Ghana, but judicious management of financial, material, and non-material resources is needed to sustain priority ASRH interventions in Ghana.

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Introduction

Adolescents, a critical mass of the world’s population, have, in the last 29 years since the launch of the International Conference on Population and Development (ICPD), undergone significant demographic, health, and socioeconomic transitions. In 2019, the world had an estimated 1.3 billion adolescents aged 10–19 years, representing a 14.8% increase since 1994, and up to 30% if the age bracket is extended to < 24 years [ 1 ]. Compared to other regions, the population of adolescents in sub-Saharan Africa (SSA) has more than doubled over the last three decades and may triple by 2050 [ 1 , 2 ].

As the population of adolescents increases with growing economies, so are the challenges peculiar to adolescents [ 3 , 4 ]. Compared to a global average of 5%, approximately 12% of adolescent girls in SSA are forced into early marriages before their fifteenth birthday [ 5 ]. Between 1994 and 2017, the prevalence of sexually transmitted infections (STIs), including HIV, gonorrhea, trichomoniasis, and genital herpes among adolescents, increased by 30.3%, equivalent to over 5 million new STIs [ 6 ]. Increased adverse events accompanying adolescent sexual and reproductive health (ASRH) like early pregnancy and childbirth are well documented [ 6 , 7 ]. For example, a multi-country study by the World Health Organization (WHO) shows that about 20% of maternal-related deaths in SSA occur among adolescents [ 7 ]. Likewise, in some African countries, more than 40% of adolescents have experienced various forms of intimate partner violence [ 1 ]. We argue that the problems adolescents go through are more than we have projected and there are notable disparities across regions and countries in the world.

As of 2021, Ghana had an estimated close to 10 million adolescents aged 10 to 24 years, representing about a 25% increase from 2010 [ 8 ]. A joint study by the Ghana Health Service (GHS) and the United Nations Children Fund (UNICEF) indicates that 36% of adolescents in Ghana were sexually active, of which 50% and 13% were either forced or physically coerced, respectively [ 9 ]. At the same time, another study shows that unsafe abortion remains the leading cause of maternal deaths for adolescent girls less than 19 years old [ 10 ]. In general, published evidence indicates that adolescents are being caught up in essential health service delivery gaps in low-and-middle-income countries (LMIC) as ASRH challenges are overlooked and less prioritized [ 11 , 12 ]. By WHO estimation, countries in LMIC need approximately US$9.00 per capita to implement one priority ASRH preventive intervention such as contraception, counselling, fertility care, pregnancy-related care, capacity building to prevent intimate partner violence, and unsafe abortion [ 13 ]. Deductively, Ghana may require not less than US$10 million for each adolescent to benefit from one priority ASRH preventive intervention annually. The question is how sustainable Ghana can raise such money to continuously provide priority ASRH intervention for the growing adolescent population. Elsewhere, we have addressed the question regarding the funding gap for ASRH interventions [ 14 , 15 ]. Therefore, this present study by the African Health Economics and Policy Association (AfHEA) is part of an ongoing project on the Economics of Adolescent Sexual and Reproductive Health (EcASaRH) interventions. The aim is to answer the question of how to sustain strategic funding for priority ASRH interventions by drawing on the suggestions and experiences of stakeholder institutions in Ghana. Using the definition by Salam et al. [ 16 ], this study defines priority ASRH interventions as effective interventions related to improving ASRH outcomes such as prevention of unintended pregnancies, unsafe abortions, micronutrient supplementation and nutrition for pregnant adolescents. Others may include strategies to prevent substance abuse, early marriages, STIs, and access to needed essential health services, more generally.

Materials and methods

This study used a sequential qualitative design [ 17 , 18 ] involving cross-sectional data collected from key informants to perform thematic content analysis. The design was sequential because we collected data in two phases where Phase 1 data informed how and what data to collect in Phase 2. The study received ethics approval from the Ghana Health Service Ethics Review Committee with reference number GHS-ERC:004/10/2019. Reporting quality and transparency were checked using the consolidated criteria for reporting qualitative research (COREQ) [ 19 ].

The setting is Ghana, one of two countries in sub-Saharan Africa where the EcASaRH project is being implemented. At the time of this study, the government of Ghana had no specific budget earmarked for implementing priority ASRH interventions. Rather, a composite fiscal allocation is made available to address all health-related problems through the Ministry of Health, the Ghana Health Service, and the National Health Insurance Authority, supported by health aid from bilateral and multilateral development partners. It is public knowledge that fiscal austerity and competing demand for scarce resources, typical in most LMIC settings, mean that priority ASRH interventions are given less attention regardless of the persistent adolescent health problems accompanying the increasing adolescent population.

Participant and sampling

Participants were purposively invited key informants drawn from multiple institutions in public and private sectors as well as academia/research, civil society organizations, non-governmental organizations, and multi-national development partner institutions. We contacted participants through emails and placed follow-up mobile phone calls on those who did not respond to their emails after 72 h. We obtained their contact information from a list compiled during participant registration to attend an ASRH stakeholder conference organized by the AfHEA in the previous year as part of EcASaRH project activities. In total, 11 participants from 15 invited institutions participated in Phase 1 data collection between December 2022 and January 2023, while additional 25 key informants, making 36 participants in total, partook in Phase 2 data collection on July 4, 2023. Because this study is a qualitative study, the sample size was purposively determined as representative of ARSH stakeholder institutions in Ghana. The invited institutional participation rate was 73% in Phase 1 (11/15) and 100% (19/19) in Phase 2). The 27% non-participation rate in Phase 1 was because four invited participants were unavailable for the interview but participated in Phase 2.

Over 70% of participants served in management capacities as programme managers, monitoring and evaluation officers, budget officers, research fellows, principal nursing officers, operation managers and grant managers. The remaining 30% were in senior management positions as director, founding officer, chief executive, lawmaker/parliamentarian. Additionally, 20 invited adolescents joined the workshop as observers to listen and learn from the expert discussions during the Phase 2 data collection. Table  1 gives an overview of the distribution of invited participants and their institutional affiliations. Regarding gender, Phase 1 had 54.5% (6/11) women participation and Phase 2 had 58.3% (21/36) women participation.

Data curation and processing

We collected data from key informants through in-person interviews and group discussions. An interview guide developed by the AfHEA in consultation with one senior academic staff of the University of Ghana (see supplementary material) was used to elicit data. Using 10% of the targeted sample, we scheduled four interviews to pilot the instrument for two days to identify potential data incoherence and difficulties in administering the instrument before Phase 1 data collection began. The piloting informed the restructuring of the sub-questions and how to moderate the interview to keep to time, as most participant interviews in Phase 1 took place during working hours. Phase 1 data collection took place face-to-face on an agreed date, time, and location, mainly at participant offices, while four interviews were held using zoom communication service technology. Except for 2 participants who shared office space with other staff, requiring that the interview be held in the presence of their colleague and at their convenience, we held the remaining interviews in Phase 1 privately. The Phase 1 data collection gathered data on funding gaps for ASRH interventions in Ghana. Participants were also asked to suggest ways to address the funding gap. However, not enough data points were generated from Phase 1 on ways to address the funding gaps. Consequently, AfHEA invited all key informants from ASRH stakeholder institutions to an organized information workshop at the University of Ghana Medical Centre on July 4, 2023, to share knowledge and discuss sustainable ways to finance priority ASRH interventions in Ghana, which form Phase 2 of the data collection. For each participant interviewed, we determined data saturation if responses to specific questions were reoccurring, and we were convinced that we had obtained enough data points to justify our study conclusion. As participants were adults, educated and employed in various senior management positions at their designated institutions, we did not collect further background data on these variables, except noting their gender for equal representation.

We sought permission from participants to collect data using digital audio recording devices (smart mobile phone recorders for Phase 1 and laptop computer for Phase 2) supplemented by interviewer notes on relevant points. Phase 1 interviews lasted 20 min on average, while Phase 2 lasted about 2 h as each group participant was allowed to speak followed by additional 10-minute coffee break after every hour group discussion. Phase 1 data collection was collected by an independent Ghanaian consultant, while in Phase 2, a trained staff of the AfHEA assisted the consultant, given that we grouped the workshop participants into two for the discussion and data collection. Both data collectors had training and experience managing other funded qualitative data collection in Ghana and other African countries. The consultant managed data coding alone and stored the audio recording for further reference.

We established data reliability in two ways. First, at the end of each session of the interview in Phase 1, we made sure participants validated what data we collected by providing a verbal summary of the notes and major points taken. Second, all Phase 1 participants attended the workshop in Phase 2, and we briefed them on the results of Phase 1 through an information session that allowed feedback and validation. Again, at the end of the workshop, we assembled all participants in one conference room and summarized the main points taken from the breakout group discussion.

Data analysis

Thematic content analysis of primary data was performed. Data points were assigned unique color codes and reclassified into 4 major and 2 minor themes using the number of participants as a weight to determine the order of significance of each theme as embedded in grounded theory of qualitative science [ 18 ]. Two of the investigators established the qualitative themes from the audio-recorded interview and field notes taken. The process involved listening to each recorded audio file twice to extract the themes in participant responses to each question and grouping similar themes from different participants. We transcribed the audio file using Microsoft Word and tabulated the themes in Microsoft Excel. Having ensured participants validated the data for reliability, we subject the transcript and result to internal quality control checks through double peer review of the themes and quotations extracted from the audio file to buttress each point in the result. Final draft manuscript was reviewed and approved by all the investigators. As the interviews and discussions with study participants during data collection were performed in English Language, no technical language interpretation of data was required before the analysis.

We asked participants to recommend and give reasons for at least one strategy they believed could help the government to sustainably finance ASRH interventions in Ghana. Overall, participant responses to the question were grouped into four major themes in descending order of significance using the number of observations as measured weight (Table  2 ).

Tax-based strategies

Taxed-based strategies emerged the most dominant theme for sustainable financing of priority ASRH interventions in Ghana. Twelve participants shared this view and suggested ways the government could mobilize sustainable domestic revenue for ASRH interventions. One of the 12 participants mentioned that removing taxes on sanitary pads alone could keep approximately 3.8 million adolescent girls in school annually and avert tendencies where needy young girls do not go to school because they cannot afford sanitary wares during their menstrual cycle. She added that:

Tax-based strategies for sustainable financing of priority ASRH interventions may involve widening the tax net for more revenue, recalibrating existing taxes, or removing some retrogressive taxes. In Ghana, nine out of ten adolescent girls regularly stay out of school between 2 and 5 days every month because they cannot afford sanitary pads during their menstrual cycle. Simply removing taxes on sanitary pads will make them affordable, keep our daughters in school, and reduce the likelihood of them engaging in risky sexual behaviours because they are home. Though such a strategy will marginally reduce tax revenue, the macroeconomic benefit will be enormous as the demand and supply-side effects will be positive for producers and consumers, including adolescent girls (Key informant, NGO, July 4, 2023).

Two other participants recommended government recalibrate some taxes to provide sustainable funding for priority ASRH interventions. They agreed that government could mobilize significant sustainable domestic revenue for the Ghana Health Service to implement priority ASRH interventions by allocating 1% out of the 5% taxes on Minerals and Mining Operations in Ghana. One participant reiterated that:

Natural mineral resources are blessings from God and are meant for all to benefit, including generations unborn. As adolescents constitute approximately a third of the country’s population and the future of the country, it will be right that a percentage of revenue from mineral royalties go to fund adolescent health interventions to avert unintended consequences associated with ASRH (Key informant, Development Partner, July 4, 2023).

Another tax-based strategy mentioned was for the government to redirect the 1% COVID-19 levy on imported goods and services to finance ASRH interventions. This financing strategy, according to participants, was against the backdrop that the World Health Organization no longer consider COVID-19 a global/public health threat, which renders the COVID-19 Health Recovery Levy, 2021 (Act 1068) unconstitutional for raising revenue to support COVID-19-related expenditures. Most participants agreed with this strategy. A key informant had this to say:

It will not be out of place to redirect the COVID-19 levy on imported goods and services to address the health needs of adolescents. As a country, we should evaluate our priorities and consider health financing, such as those for ASRH, an economic investment to drive macroeconomic prosperity for Ghana in the long term. (Key informant, NGO, July 4, 2023).

Four key informants agreed to a proposition that if the government had challenges with limited domestic revenue for financing priority ASRH service, it could adapt appropriate technology to broaden the tax net to collect more taxes from the overwhelming informal economy where people make profits and incomes without paying taxes to the government. Excerpts from two participants are presented below.

Indeed, the government lack strategy and commitment to mobilize tax revenue from the informal sector. If the government had mobilized tax revenue from the informal sector, we may not be here deliberating on ways to address funding gaps for priority ASRH interventions. One difference between Ghana and advanced countries that are meeting the health needs of adolescents is that health interventions by the state are funded from tax revenue collected from both formal and informal sectors (Key informant, Ministry of Education, January 5, 2023).

In some parts of the world, tax revenue is a sustainable source of domestic revenue to finance public health interventions like ASRH. In Ghana, it appears the government uses more than 60% of tax revenue to pay salaries and allowances of public sector workers. Meanwhile, our needs as a country outweigh the revenue we mobilize domestically. Therefore, drawing in taxes from the informal sector may be one solution to raise domestic revenue for ASRH interventions without always relying on health aid and grants from our development partners (Key informant, Academia/Research, July 4, 2023).

Policy-based strategies

Participants recommended three policy-based financing strategies for ASRH interventions. First, one participant said having a long-term national policy and legal framework that entrenches sustainable fiscal allocation to finance specific ASRH intervention programmes is a prerequisite. The participant reiterated that:

There is a need for policymakers to have legal provisions and policies that stipulate strategic funding sources and consistent annual allocations for the Ghana Health Service and other service providers to implement ASRH interventions. Civil society organizations representing the interest of adolescents in Ghana could spearhead advocacy or national debate for this effort to allow parliament to make a law to that effect (Key informant, Development Partner, July 4, 2023).

Second, another participant added that because female adolescents are more vulnerable, policies that promote gender-sensitive fiscal allocation for ASRH interventions could be one solution if Ghana has limited resources. The participant said that:

It will be good that government prioritize policy-based interventions that insulate vulnerable adolescent groups when allocating scarce resources for ASRH interventions. Such policy considerations may include a national establishment of community gender-based clubs and rehabilitation centers where girls could meet professional peer counsellors to engage in informal conversations regarding ASRH. This intervention could be a modest cost-saving way of insulating young girls from stigma, suicidal thoughts and averting many other problems adolescents encounter (Key informant, Public Sector, January 11, 2023).

Third, a different participant proposed a deliberate involvement of the private sector to support government efforts in financing ASRH interventions. Five participants agreed that the government cannot fund every intervention. Therefore, policies promoting public-private partnerships for ASRH may be a suitable alternative to sustain funding for priority ASRH interventions. The participant said that:

Some medium and large-scale enterprises may be willing to support ASRH interventions through corporate social responsibility because adolescents are their target market. However, the government must identify such organizations and enter into a long-term agreement to support adolescents with critical health needs. Often this support may not be financial but adequate supplies such as sanitary pads and nutrition supplements to mitigate adolescent health challenges (Key informant, Private Sector, Ghana, July 4, 2023).

Need-based strategies

Need-based strategies for sustainable financing of ASRH interventions were the third dominant theme recommended by stakeholders. Six participants agreed that adolescents have several needs to improve their health and well-being, but some may be to avert adverse outcomes and requires national attention. The following were some suggestions by two participants to improve funding of priority ASRH interventions in Ghana.

Need-based strategies have proven to be a reliable strategy in resource-constraint settings. For instance, the government must financially equip ASRH service providers to provide targeted need-based services for adolescents who cannot afford life-saving health services when needed. It is one plausible way to cut costs by focusing interventions on adolescents who cannot afford essential services (Key informant, Public Sector, July 4, 2023). There is so much wastage and corruption in public sector financing. Sustained reliable financing of ASRH interventions is possible if the government can reduce wastage by cutting down unnecessary spending and corruption in the public sector (Key informant, NGO, July 4, 2023).

Implementation-based strategies

Five participants suggested implementation-based strategies to improve sustainable financing for priority ASRH interventions. The strategies included budget and expenditure tracking of funded ASRH interventions through effective monitoring and evaluation. Others were public and private partnerships, using appropriate technology to deliver preventive intervention at reduced cost and building a culture of credibility and transparency when implementing ASRH interventions to attract financial support from development partners. For example, one participant representing a development partner institution shared the following:

Countries worldwide are developing budget, expenditure and programme tracking systems to reduce duplication and save limited funds for cost-effective interventions. For example, United Nation Agencies have systems to track resource use and programme implementations to reduce costs. The government of Ghana can do the same through the Ministry of Monitoring and Evaluation if they have not started already (Key informant, Development Partner, July 4, 2023).

Reiterating a similar point, a second participant from a non-governmental organization said:

Building a culture of credibility and transparency can attract sustainable funding for ASRH interventions. For us in the NGO sector, that has been a crucial factor in attracting competitive grants and health aid from Foundations and multinational financial institutions. State-implementing institutions and service providers can do the same for ASRH (Key informant, NGO, July 4, 2023).

A third participant suggested the need for government and ASRH service providers to generate reliable data through actuarial studies that quantify the potential cost-benefit of ASRH interventions. The participant believed lobbying politicians and policymakers for funding requires accurate data. Three other participants who shared the same view said:

Implementation science data can help reduce ASRH-associated costs by discontinuing interventions that are not cost-effective and prioritizing those that are cost-effective (Key informant, Development Partner, July 4, 2023). Interventions like those to prevent unsafe abortions and forced adolescent early marriages should be co-created with communities to encourage continued communal support/ownership at relatively reduced costs during and beyond the intervention lifecycle (Key informant, NGO, January 11, 2023).

Cutting costs is another way to sustain funding for ASRH interventions. Appropriate digital technologies could be a cheaper alternative to delivering preventive ASRH services. However, the appropriateness of such technologies should be piloted locally before a national rollout. Telecommunication companies can facilitate this process as part of corporate social responsibility to reduce the financial burden from the state (Key informant, Public Sector, January 2, 2023).

Support of religious groups

Besides the strategies mentioned above, two other participants said Ghana was underestimating the potential support of religious groups in terms of their ability to offer counselling and material support for ASRH interventions. One of the participants shared the following:

Issues of child marriages, risky sexual behaviours among adolescents, unintended pregnancy and unsafe abortions are issues of morality that religious groups could help resolve through adolescent counselling sessions, biblical teachings, and material support like donation of sanitary wares adolescents in remote villages. It will be less costly if the government appeal to the Christian Council of Ghana to discuss ways in which, for example, churches could contribute to reducing adverse outcomes associated with ASRH at relatively little or no cost to the government (Key informant, Private Sector, January 11, 2023).

Another participant gave an example of the generous contributions of religious groups during COVID-19. She said:

Government and institutional stakeholders should appeal to religious groups to offer support like they did to support the national COVID-19 Trust Fund. One thing is that some ASRH interventions may require material and non-material resources that religious groups can support by appealing to their congregants working in industries and other businesses (Key informant, NGO, July 4, 2023).

Funding through adolescent sporting activities

One participant suggested adolescents themselves can facilitate fundraising efforts through annual sporting activities coordinated by the Ministry of Youth and Sports.

Organized adolescent sporting activities can generate revenue annually to support ASRH interventions for vulnerable adolescents. The Ministry of Youth and Sports can coordinate this effort to support priority ASRH interventions. Alternatively, a percentage of every income from general sporting activities could be dedicated to financing priority ASRH interventions as adolescents dominate the sporting sector (Key informant, Policy Think Tank, July 4, 2023).

Summary of findings

Table  3 presents a snapshot of the major findings/themes from the study. It indicates that both financial and material resources are needed to complement each order to close the funding gap for priority ASRH interventions in Ghana.

As countries in sub-Saharan Africa face an imminent escalation of the adolescent population amidst scarcity of resources to address the funding gap for ASRH interventions due to donor fatigue [ 20 , 21 , 22 ], this qualitative study explored feasible resource mobilization strategies to sustain funding for priority ASRH interventions. Several financing strategies were recommended by key informants purposively selected due to their role in offering direct and indirect ASRH services in Ghana. In reverse order of significance, dominant financing strategies included tax-based, policy-based, need-based, and implementation-based approaches. Others were state mobilization of support from religious groups and revenue from mainstream adolescent sporting activities.

The suggestion by participants that tax-based financing approaches could be a feasible option for financing ASRH interventions in Ghana was congruent with a study by the World Health Organization [ 13 ]. In the WHO study, tax-based financing was mentioned as the most reliable domestic resource mobilization strategy compared to need-based approaches because it involves relatively less administrative cost and is easy to mobilize. State revenue collection institutions can mobilize, allocate and account for tax revenue given to ASRH service providers and at the same time benefits can reach every target group. For example, approximately 6% of the estimated US$190.27 million worth of royalty from crude oil in Ghana for 2023 [ 23 ] could fund one priority ASRH intervention programme each year, as indicated by WHO [ 13 ].

As one participant pointed out, a lack of strategy and commitment by government to mobilize tax revenue from informal sector contributes to the lack of funding for priority interventions like those for ASRH. We argue from societal perspective that a major reason this challenge persist is the over politicization of taxation and the persistent need to please citizens for fear of government losing political power to opposition political party if they commit to implementing such taxes. Unlike the formal sector, there is limited data on the informal economy for tax purposes compounded by irregular earnings in the informal sector and the fear that disclosing income to tax authorities will affect their economic fortunes. Nevertheless, the digitalization policy of government and the introduction of 1% digital tax on financial transaction is one way government can mobilize tax revenue from the informal sector. Perhaps, it is a question of whether government can properly identify how much of the digital taxes come from the informal economy or informal sector employees. Moreover, the decision by the government to waive taxes on locally produced sanitary wares and import duties on raw materials for the same as reported in the 2024 Budget Statement and Economic Policy by the Ministry of Finance is commendable [ 24 ]. The tax waiver means less production costs and millions of adolescent girls can afford sanitary wares during their monthly cycle.

We argue that when taxpayers are overburdened with taxes and resisting paying more for priority interventions, need-based financing may be an alternative strategy to reduce costs through exemption policies [ 25 , 26 ]. Thus, most adolescents who can afford essential ASRH services should pay to sustain free provision for those who cannot afford them. Regardless of the strength associated with need-based financing, its application could be cumbersome due to bias in allocation criteria [ 27 ].

Some of the proposed implementation-based financing strategies in this present study build on the principal-agent theory of performance-based financing, where scarce resource allocations favor cost-effective intervention programmes [ 28 ]. Investors, development partners, and policymakers acting as principal financiers may be willing to provide financial support for priority ASRH service providers (agents) if they have reasons to believe there will be prudent use for their investments. Irrespective of how simple this financing strategy may seem, there could be setbacks in implementing new interventions that are yet to generate data to show evidence of effectiveness, requiring that other sustainable financing strategies should run parallel to performance-based financing [ 29 ]. Therefore, implementation-based financing strategies may not be the most suitable when implementing new priority ASRH interventions [ 30 , 31 ].

Besides the recommended conventional sources of sustainable financing for priority ASRH interventions, participants believed unconventional sources like support from religious groups could complement existing financing sources. The belief was that religious groups made generous cash and kind donations to support the national COVID-19 Trust Fund during the global pandemic. Therefore, governments and other stakeholder institutions could solicit similar support to fund ASRH interventions. Whether this financing source is feasible may depend on factors like accountability, which became a topical public discussion because of the lack of transparency regarding COVID-19 expenditures in Ghana and elsewhere [ 32 , 33 , 34 ].

As another participant indicated, the government can generate revenue through adolescent sporting activities like annual fun games, in which tickets sold can generate revenue for ASRH intervention. If well-coordinated by the Ministry of Youth and Sports, such initiatives may attract sponsorship from corporate Ghana to support the most vulnerable adolescents. In summary, sustainable resource mobilization for priority ASRH interventions may come in several forms, but prudent management of such resources is crucial to achieving the intended purpose.

The strength of this study hinges on the quality and reliable data triangulated from a cross-section of participants with working knowledge and experience regarding funding for adolescent sexual and reproductive health interventions. To the best of our knowledge, the study contributes to the literature by identifying, evaluating, and documenting scientific evidence on ways to sustain funding for ASRH services to improve the well-being of vulnerable adolescents in an LMIC setting. Regarding limitations, this study adopts a qualitative design using a limited sample of participants, which limits the generalizability of the findings.

Data availability

Data used for this research are available upon request to the corresponding author.

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Acknowledgements

We thank all invited key informants who honoured our invitation to participate in this study. We also thank colleague faculty at the University of Ghana Medical Centre who made it possible for AfHEA to organize a knowledge dissemination workshop to further collect data for this study.

Funding support for this work was provided by the International Development Research Centre (IDRC) as part of EcASaRH project in Ghana and Senegal. Besides providing access to funding, IDRC did not influence any aspect of this work.

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EO: Conception, data acquisition, methodology, analysis and writing the original draft. APF: Project administration, methodology, review, and editing. DMA: Project administration, data acquisition, review, and editing. JEA: Project administration, funding acquisition, review, and editing.

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Reflexivity statement.

This study was conducted by four investigators comprising three males and one female with institutional affiliations in Ghana, Kenya, South Africa, Denmark and Canada. APF and JEA holds PhD in Health Economics and occupy senior academic positions, EO is an early career researcher and holds PhD in Health Economics, and DMA is an administrative staff of the AfHEA. EO conducted the interviews with the support of DMA. Before the data collection, we informed participants about the team of investigators and the study objective, and knew the mandate of participant institutions as ASRH stakeholders.

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This study received ethics approval from the Ghana Health Service Ethics Review Committee with reference number GHS-ERC:004/10/2019. Study participants gave written informed consent to participate in the study in accordance with ethical guidelines. This study did not involve human experiment or use of human tissue samples. Processing of data obtained from participants were in accordance with ethics review guidelines.

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Otieku, E., Fenny, A.P., Achala, D.M. et al. A qualitative evaluation of stakeholder perspectives on sustainable financing strategies for ‘priority’ adolescent sexual and reproductive health interventions in Ghana. BMC Health Serv Res 24 , 373 (2024). https://doi.org/10.1186/s12913-024-10743-4

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Received : 01 November 2023

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DOI : https://doi.org/10.1186/s12913-024-10743-4

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