research background of the study sample

• Privacy Policy

Buy Me a Coffee

Home » Background of The Study – Examples and Writing Guide

Background of The Study – Examples and Writing Guide

Table of Contents

Background of The Study

Definition:

Background of the study refers to the context, circumstances, and history that led to the research problem or topic being studied. It provides the reader with a comprehensive understanding of the subject matter and the significance of the study.

The background of the study usually includes a discussion of the relevant literature, the gap in knowledge or understanding, and the research questions or hypotheses to be addressed. It also highlights the importance of the research topic and its potential contributions to the field. A well-written background of the study sets the stage for the research and helps the reader to appreciate the need for the study and its potential significance.

How to Write Background of The Study

Here are some steps to help you write the background of the study:

Identify the Research Problem

Start by identifying the research problem you are trying to address. This problem should be significant and relevant to your field of study.

Provide Context

Once you have identified the research problem, provide some context. This could include the historical, social, or political context of the problem.

Review Literature

Conduct a thorough review of the existing literature on the topic. This will help you understand what has been studied and what gaps exist in the current research.

Identify Research Gap

Based on your literature review, identify the gap in knowledge or understanding that your research aims to address. This gap will be the focus of your research question or hypothesis.

State Objectives

Clearly state the objectives of your research . These should be specific, measurable, achievable, relevant, and time-bound (SMART).

Discuss Significance

Explain the significance of your research. This could include its potential impact on theory , practice, policy, or society.

Finally, summarize the key points of the background of the study. This will help the reader understand the research problem, its context, and its significance.

How to Write Background of The Study in Proposal

The background of the study is an essential part of any proposal as it sets the stage for the research project and provides the context and justification for why the research is needed. Here are the steps to write a compelling background of the study in your proposal:

• Identify the problem: Clearly state the research problem or gap in the current knowledge that you intend to address through your research.
• Provide context: Provide a brief overview of the research area and highlight its significance in the field.
• Review literature: Summarize the relevant literature related to the research problem and provide a critical evaluation of the current state of knowledge.
• Identify gaps : Identify the gaps or limitations in the existing literature and explain how your research will contribute to filling these gaps.
• Justify the study : Explain why your research is important and what practical or theoretical contributions it can make to the field.
• Highlight objectives: Clearly state the objectives of the study and how they relate to the research problem.
• Discuss methodology: Provide an overview of the methodology you will use to collect and analyze data, and explain why it is appropriate for the research problem.
• Conclude : Summarize the key points of the background of the study and explain how they support your research proposal.

How to Write Background of The Study In Thesis

The background of the study is a critical component of a thesis as it provides context for the research problem, rationale for conducting the study, and the significance of the research. Here are some steps to help you write a strong background of the study:

• Identify the research problem : Start by identifying the research problem that your thesis is addressing. What is the issue that you are trying to solve or explore? Be specific and concise in your problem statement.
• Review the literature: Conduct a thorough review of the relevant literature on the topic. This should include scholarly articles, books, and other sources that are directly related to your research question.
• I dentify gaps in the literature: After reviewing the literature, identify any gaps in the existing research. What questions remain unanswered? What areas have not been explored? This will help you to establish the need for your research.
• Establish the significance of the research: Clearly state the significance of your research. Why is it important to address this research problem? What are the potential implications of your research? How will it contribute to the field?
• Provide an overview of the research design: Provide an overview of the research design and methodology that you will be using in your study. This should include a brief explanation of the research approach, data collection methods, and data analysis techniques.
• State the research objectives and research questions: Clearly state the research objectives and research questions that your study aims to answer. These should be specific, measurable, achievable, relevant, and time-bound.
• Summarize the chapter: Summarize the chapter by highlighting the key points and linking them back to the research problem, significance of the study, and research questions.

How to Write Background of The Study in Research Paper

Here are the steps to write the background of the study in a research paper:

• Identify the research problem: Start by identifying the research problem that your study aims to address. This can be a particular issue, a gap in the literature, or a need for further investigation.
• Conduct a literature review: Conduct a thorough literature review to gather information on the topic, identify existing studies, and understand the current state of research. This will help you identify the gap in the literature that your study aims to fill.
• Explain the significance of the study: Explain why your study is important and why it is necessary. This can include the potential impact on the field, the importance to society, or the need to address a particular issue.
• Provide context: Provide context for the research problem by discussing the broader social, economic, or political context that the study is situated in. This can help the reader understand the relevance of the study and its potential implications.
• State the research questions and objectives: State the research questions and objectives that your study aims to address. This will help the reader understand the scope of the study and its purpose.
• Summarize the methodology : Briefly summarize the methodology you used to conduct the study, including the data collection and analysis methods. This can help the reader understand how the study was conducted and its reliability.

Examples of Background of The Study

Here are some examples of the background of the study:

Problem : The prevalence of obesity among children in the United States has reached alarming levels, with nearly one in five children classified as obese.

Significance : Obesity in childhood is associated with numerous negative health outcomes, including increased risk of type 2 diabetes, cardiovascular disease, and certain cancers.

Gap in knowledge : Despite efforts to address the obesity epidemic, rates continue to rise. There is a need for effective interventions that target the unique needs of children and their families.

Problem : The use of antibiotics in agriculture has contributed to the development of antibiotic-resistant bacteria, which poses a significant threat to human health.

Significance : Antibiotic-resistant infections are responsible for thousands of deaths each year and are a major public health concern.

Gap in knowledge: While there is a growing body of research on the use of antibiotics in agriculture, there is still much to be learned about the mechanisms of resistance and the most effective strategies for reducing antibiotic use.

Edxample 3:

Problem : Many low-income communities lack access to healthy food options, leading to high rates of food insecurity and diet-related diseases.

Significance : Poor nutrition is a major contributor to chronic diseases such as obesity, type 2 diabetes, and cardiovascular disease.

Gap in knowledge : While there have been efforts to address food insecurity, there is a need for more research on the barriers to accessing healthy food in low-income communities and effective strategies for increasing access.

Examples of Background of The Study In Research

Here are some real-life examples of how the background of the study can be written in different fields of study:

Example 1 : “There has been a significant increase in the incidence of diabetes in recent years. This has led to an increased demand for effective diabetes management strategies. The purpose of this study is to evaluate the effectiveness of a new diabetes management program in improving patient outcomes.”

Example 2 : “The use of social media has become increasingly prevalent in modern society. Despite its popularity, little is known about the effects of social media use on mental health. This study aims to investigate the relationship between social media use and mental health in young adults.”

Example 3: “Despite significant advancements in cancer treatment, the survival rate for patients with pancreatic cancer remains low. The purpose of this study is to identify potential biomarkers that can be used to improve early detection and treatment of pancreatic cancer.”

Examples of Background of The Study in Proposal

Here are some real-time examples of the background of the study in a proposal:

Example 1 : The prevalence of mental health issues among university students has been increasing over the past decade. This study aims to investigate the causes and impacts of mental health issues on academic performance and wellbeing.

Example 2 : Climate change is a global issue that has significant implications for agriculture in developing countries. This study aims to examine the adaptive capacity of smallholder farmers to climate change and identify effective strategies to enhance their resilience.

Example 3 : The use of social media in political campaigns has become increasingly common in recent years. This study aims to analyze the effectiveness of social media campaigns in mobilizing young voters and influencing their voting behavior.

Example 4 : Employee turnover is a major challenge for organizations, especially in the service sector. This study aims to identify the key factors that influence employee turnover in the hospitality industry and explore effective strategies for reducing turnover rates.

Examples of Background of The Study in Thesis

Here are some real-time examples of the background of the study in the thesis:

Example 1 : “Women’s participation in the workforce has increased significantly over the past few decades. However, women continue to be underrepresented in leadership positions, particularly in male-dominated industries such as technology. This study aims to examine the factors that contribute to the underrepresentation of women in leadership roles in the technology industry, with a focus on organizational culture and gender bias.”

Example 2 : “Mental health is a critical component of overall health and well-being. Despite increased awareness of the importance of mental health, there are still significant gaps in access to mental health services, particularly in low-income and rural communities. This study aims to evaluate the effectiveness of a community-based mental health intervention in improving mental health outcomes in underserved populations.”

Example 3: “The use of technology in education has become increasingly widespread, with many schools adopting online learning platforms and digital resources. However, there is limited research on the impact of technology on student learning outcomes and engagement. This study aims to explore the relationship between technology use and academic achievement among middle school students, as well as the factors that mediate this relationship.”

Examples of Background of The Study in Research Paper

Here are some examples of how the background of the study can be written in various fields:

Example 1: The prevalence of obesity has been on the rise globally, with the World Health Organization reporting that approximately 650 million adults were obese in 2016. Obesity is a major risk factor for several chronic diseases such as diabetes, cardiovascular diseases, and cancer. In recent years, several interventions have been proposed to address this issue, including lifestyle changes, pharmacotherapy, and bariatric surgery. However, there is a lack of consensus on the most effective intervention for obesity management. This study aims to investigate the efficacy of different interventions for obesity management and identify the most effective one.

Example 2: Antibiotic resistance has become a major public health threat worldwide. Infections caused by antibiotic-resistant bacteria are associated with longer hospital stays, higher healthcare costs, and increased mortality. The inappropriate use of antibiotics is one of the main factors contributing to the development of antibiotic resistance. Despite numerous efforts to promote the rational use of antibiotics, studies have shown that many healthcare providers continue to prescribe antibiotics inappropriately. This study aims to explore the factors influencing healthcare providers’ prescribing behavior and identify strategies to improve antibiotic prescribing practices.

Example 3: Social media has become an integral part of modern communication, with millions of people worldwide using platforms such as Facebook, Twitter, and Instagram. Social media has several advantages, including facilitating communication, connecting people, and disseminating information. However, social media use has also been associated with several negative outcomes, including cyberbullying, addiction, and mental health problems. This study aims to investigate the impact of social media use on mental health and identify the factors that mediate this relationship.

Purpose of Background of The Study

The primary purpose of the background of the study is to help the reader understand the rationale for the research by presenting the historical, theoretical, and empirical background of the problem.

More specifically, the background of the study aims to:

• Provide a clear understanding of the research problem and its context.
• Identify the gap in knowledge that the study intends to fill.
• Establish the significance of the research problem and its potential contribution to the field.
• Highlight the key concepts, theories, and research findings related to the problem.
• Provide a rationale for the research questions or hypotheses and the research design.
• Identify the limitations and scope of the study.

When to Write Background of The Study

The background of the study should be written early on in the research process, ideally before the research design is finalized and data collection begins. This allows the researcher to clearly articulate the rationale for the study and establish a strong foundation for the research.

The background of the study typically comes after the introduction but before the literature review section. It should provide an overview of the research problem and its context, and also introduce the key concepts, theories, and research findings related to the problem.

Writing the background of the study early on in the research process also helps to identify potential gaps in knowledge and areas for further investigation, which can guide the development of the research questions or hypotheses and the research design. By establishing the significance of the research problem and its potential contribution to the field, the background of the study can also help to justify the research and secure funding or support from stakeholders.

Advantage of Background of The Study

The background of the study has several advantages, including:

• Provides context: The background of the study provides context for the research problem by highlighting the historical, theoretical, and empirical background of the problem. This allows the reader to understand the research problem in its broader context and appreciate its significance.
• Identifies gaps in knowledge: By reviewing the existing literature related to the research problem, the background of the study can identify gaps in knowledge that the study intends to fill. This helps to establish the novelty and originality of the research and its potential contribution to the field.
• Justifies the research : The background of the study helps to justify the research by demonstrating its significance and potential impact. This can be useful in securing funding or support for the research.
• Guides the research design: The background of the study can guide the development of the research questions or hypotheses and the research design by identifying key concepts, theories, and research findings related to the problem. This ensures that the research is grounded in existing knowledge and is designed to address the research problem effectively.
• Establishes credibility: By demonstrating the researcher’s knowledge of the field and the research problem, the background of the study can establish the researcher’s credibility and expertise, which can enhance the trustworthiness and validity of the research.

Disadvantages of Background of The Study

Some Disadvantages of Background of The Study are as follows:

• Time-consuming : Writing a comprehensive background of the study can be time-consuming, especially if the research problem is complex and multifaceted. This can delay the research process and impact the timeline for completing the study.
• Repetitive: The background of the study can sometimes be repetitive, as it often involves summarizing existing research and theories related to the research problem. This can be tedious for the reader and may make the section less engaging.
• Limitations of existing research: The background of the study can reveal the limitations of existing research related to the problem. This can create challenges for the researcher in developing research questions or hypotheses that address the gaps in knowledge identified in the background of the study.
• Bias : The researcher’s biases and perspectives can influence the content and tone of the background of the study. This can impact the reader’s perception of the research problem and may influence the validity of the research.
• Accessibility: Accessing and reviewing the literature related to the research problem can be challenging, especially if the researcher does not have access to a comprehensive database or if the literature is not available in the researcher’s language. This can limit the depth and scope of the background of the study.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Data Collection – Methods Types and Examples

Delimitations in Research – Types, Examples and...

Research Process – Steps, Examples and Tips

Research Design – Types, Methods and Examples

Institutional Review Board – Application Sample...

Evaluating Research – Process, Examples and...

• Resources Home 🏠
• Try SciSpace Copilot
• Search research papers
• Add Copilot Extension
• Try AI Detector
• Try Paraphraser
• Try Citation Generator
• April Papers
• June Papers
• July Papers

How to Write an Effective Background of the Study: A Comprehensive Guide

Table of Contents

The background of the study in a research paper offers a clear context, highlighting why the research is essential and the problem it aims to address.

As a researcher, this foundational section is essential for you to chart the course of your study, Moreover, it allows readers to understand the importance and path of your research.

Whether in academic communities or to the general public, a well-articulated background aids in communicating the essence of the research effectively.

While it may seem straightforward, crafting an effective background requires a blend of clarity, precision, and relevance. Therefore, this article aims to be your guide, offering insights into:

• Understanding the concept of the background of the study.
• Learning how to craft a compelling background effectively.
• Identifying and sidestepping common pitfalls in writing the background.
• Exploring practical examples that bring the theory to life.
• Enhancing both your writing and reading of academic papers.

Keeping these compelling insights in mind, let's delve deeper into the details of the empirical background of the study, exploring its definition, distinctions, and the art of writing it effectively.

What is the background of the study?

The background of the study is placed at the beginning of a research paper. It provides the context, circumstances, and history that led to the research problem or topic being explored.

It offers readers a snapshot of the existing knowledge on the topic and the reasons that spurred your current research.

When crafting the background of your study, consider the following questions.

• What's the context of your research?
• Which previous research will you refer to?
• Are there any knowledge gaps in the existing relevant literature?
• How will you justify the need for your current research?
• Have you concisely presented the research question or problem?

In a typical research paper structure, after presenting the background, the introduction section follows. The introduction delves deeper into the specific objectives of the research and often outlines the structure or main points that the paper will cover.

Together, they create a cohesive starting point, ensuring readers are well-equipped to understand the subsequent sections of the research paper.

While the background of the study and the introduction section of the research manuscript may seem similar and sometimes even overlap, each serves a unique purpose in the research narrative.

Difference between background and introduction

A well-written background of the study and introduction are preliminary sections of a research paper and serve distinct purposes.

Here’s a detailed tabular comparison between the two of them.

What is the relevance of the background of the study?

It is necessary for you to provide your readers with the background of your research. Without this, readers may grapple with questions such as: Why was this specific research topic chosen? What led to this decision? Why is this study relevant? Is it worth their time?

Such uncertainties can deter them from fully engaging with your study, leading to the rejection of your research paper. Additionally, this can diminish its impact in the academic community, and reduce its potential for real-world application or policy influence .

To address these concerns and offer clarity, the background section plays a pivotal role in research papers.

The background of the study in research is important as it:

• Provides context: It offers readers a clear picture of the existing knowledge, helping them understand where the current research fits in.
• Highlights relevance: By detailing the reasons for the research, it underscores the study's significance and its potential impact.
• Guides the narrative: The background shapes the narrative flow of the paper, ensuring a logical progression from what's known to what the research aims to uncover.
• Enhances engagement: A well-crafted background piques the reader's interest, encouraging them to delve deeper into the research paper.
• Aids in comprehension: By setting the scenario, it aids readers in better grasping the research objectives, methodologies, and findings.

How to write the background of the study in a research paper?

The journey of presenting a compelling argument begins with the background study. This section holds the power to either captivate or lose the reader's interest.

An effectively written background not only provides context but also sets the tone for the entire research paper. It's the bridge that connects a broad topic to a specific research question, guiding readers through the logic behind the study.

But how does one craft a background of the study that resonates, informs, and engages?

Here, we’ll discuss how to write an impactful background study, ensuring your research stands out and captures the attention it deserves.

Identify the research problem

The first step is to start pinpointing the specific issue or gap you're addressing. This should be a significant and relevant problem in your field.

A well-defined problem is specific, relevant, and significant to your field. It should resonate with both experts and readers.

Here’s more on how to write an effective research problem .

Provide context

Here, you need to provide a broader perspective, illustrating how your research aligns with or contributes to the overarching context or the wider field of study. A comprehensive context is grounded in facts, offers multiple perspectives, and is relatable.

In addition to stating facts, you should weave a story that connects key concepts from the past, present, and potential future research. For instance, consider the following approach.

• Offer a brief history of the topic, highlighting major milestones or turning points that have shaped the current landscape.
• Discuss contemporary developments or current trends that provide relevant information to your research problem. This could include technological advancements, policy changes, or shifts in societal attitudes.
• Highlight the views of different stakeholders. For a topic like sustainable agriculture, this could mean discussing the perspectives of farmers, environmentalists, policymakers, and consumers.
• If relevant, compare and contrast global trends with local conditions and circumstances. This can offer readers a more holistic understanding of the topic.

Literature review

For this step, you’ll deep dive into the existing literature on the same topic. It's where you explore what scholars, researchers, and experts have already discovered or discussed about your topic.

Conducting a thorough literature review isn't just a recap of past works. To elevate its efficacy, it's essential to analyze the methods, outcomes, and intricacies of prior research work, demonstrating a thorough engagement with the existing body of knowledge.

• Instead of merely listing past research study, delve into their methodologies, findings, and limitations. Highlight groundbreaking studies and those that had contrasting results.
• Try to identify patterns. Look for recurring themes or trends in the literature. Are there common conclusions or contentious points?
• The next step would be to connect the dots. Show how different pieces of research relate to each other. This can help in understanding the evolution of thought on the topic.

By showcasing what's already known, you can better highlight the background of the study in research.

Highlight the research gap

This step involves identifying the unexplored areas or unanswered questions in the existing literature. Your research seeks to address these gaps, providing new insights or answers.

A clear research gap shows you've thoroughly engaged with existing literature and found an area that needs further exploration.

How can you efficiently highlight the research gap?

• Find the overlooked areas. Point out topics or angles that haven't been adequately addressed.
• Highlight questions that have emerged due to recent developments or changing circumstances.
• Identify areas where insights from other fields might be beneficial but haven't been explored yet.

State your objectives

Here, it’s all about laying out your game plan — What do you hope to achieve with your research? You need to mention a clear objective that’s specific, actionable, and directly tied to the research gap.

How to state your objectives?

• List the primary questions guiding your research.
• If applicable, state any hypotheses or predictions you aim to test.
• Specify what you hope to achieve, whether it's new insights, solutions, or methodologies.

Discuss the significance

This step describes your 'why'. Why is your research important? What broader implications does it have?

The significance of “why” should be both theoretical (adding to the existing literature) and practical (having real-world implications).

How do we effectively discuss the significance?

• Discuss how your research adds to the existing body of knowledge.
• Highlight how your findings could be applied in real-world scenarios, from policy changes to on-ground practices.
• Point out how your research could pave the way for further studies or open up new areas of exploration.

Summarize your points

A concise summary acts as a bridge, smoothly transitioning readers from the background to the main body of the paper. This step is a brief recap, ensuring that readers have grasped the foundational concepts.

How to summarize your study?

• Revisit the key points discussed, from the research problem to its significance.
• Prepare the reader for the subsequent sections, ensuring they understand the research's direction.

Include examples for better understanding

Research and come up with real-world or hypothetical examples to clarify complex concepts or to illustrate the practical applications of your research. Relevant examples make abstract ideas tangible, aiding comprehension.

How to include an effective example of the background of the study?

• Use past events or scenarios to explain concepts.
• Craft potential scenarios to demonstrate the implications of your findings.
• Use comparisons to simplify complex ideas, making them more relatable.

Crafting a compelling background of the study in research is about striking the right balance between providing essential context, showcasing your comprehensive understanding of the existing literature, and highlighting the unique value of your research .

While writing the background of the study, keep your readers at the forefront of your mind. Every piece of information, every example, and every objective should be geared toward helping them understand and appreciate your research.

How to avoid mistakes in the background of the study in research?

To write a well-crafted background of the study, you should be aware of the following potential research pitfalls .

• Stay away from ambiguity. Always assume that your reader might not be familiar with intricate details about your topic.
• Avoid discussing unrelated themes. Stick to what's directly relevant to your research problem.
• Ensure your background is well-organized. Information should flow logically, making it easy for readers to follow.
• While it's vital to provide context, avoid overwhelming the reader with excessive details that might not be directly relevant to your research problem.
• Ensure you've covered the most significant and relevant studies i` n your field. Overlooking key pieces of literature can make your background seem incomplete.
• Aim for a balanced presentation of facts, and avoid showing overt bias or presenting only one side of an argument.
• While academic paper often involves specialized terms, ensure they're adequately explained or use simpler alternatives when possible.
• Every claim or piece of information taken from existing literature should be appropriately cited. Failing to do so can lead to issues of plagiarism.
• Avoid making the background too lengthy. While thoroughness is appreciated, it should not come at the expense of losing the reader's interest. Maybe prefer to keep it to one-two paragraphs long.
• Especially in rapidly evolving fields, it's crucial to ensure that your literature review section is up-to-date and includes the latest research.

Example of an effective background of the study

Let's consider a topic: "The Impact of Online Learning on Student Performance." The ideal background of the study section for this topic would be as follows.

In the last decade, the rise of the internet has revolutionized many sectors, including education. Online learning platforms, once a supplementary educational tool, have now become a primary mode of instruction for many institutions worldwide. With the recent global events, such as the COVID-19 pandemic, there has been a rapid shift from traditional classroom learning to online modes, making it imperative to understand its effects on student performance.

Previous studies have explored various facets of online learning, from its accessibility to its flexibility. However, there is a growing need to assess its direct impact on student outcomes. While some educators advocate for its benefits, citing the convenience and vast resources available, others express concerns about potential drawbacks, such as reduced student engagement and the challenges of self-discipline.

This research aims to delve deeper into this debate, evaluating the true impact of online learning on student performance.

Why is this example considered as an effective background section of a research paper?

This background section example effectively sets the context by highlighting the rise of online learning and its increased relevance due to recent global events. It references prior research on the topic, indicating a foundation built on existing knowledge.

By presenting both the potential advantages and concerns of online learning, it establishes a balanced view, leading to the clear purpose of the study: to evaluate the true impact of online learning on student performance.

As we've explored, writing an effective background of the study in research requires clarity, precision, and a keen understanding of both the broader landscape and the specific details of your topic.

From identifying the research problem, providing context, reviewing existing literature to highlighting research gaps and stating objectives, each step is pivotal in shaping the narrative of your research. And while there are best practices to follow, it's equally crucial to be aware of the pitfalls to avoid.

Remember, writing or refining the background of your study is essential to engage your readers, familiarize them with the research context, and set the ground for the insights your research project will unveil.

Drawing from all the important details, insights and guidance shared, you're now in a strong position to craft a background of the study that not only informs but also engages and resonates with your readers.

Now that you've a clear understanding of what the background of the study aims to achieve, the natural progression is to delve into the next crucial component — write an effective introduction section of a research paper. Read here .

Frequently Asked Questions

The background of the study should include a clear context for the research, references to relevant previous studies, identification of knowledge gaps, justification for the current research, a concise overview of the research problem or question, and an indication of the study's significance or potential impact.

The background of the study is written to provide readers with a clear understanding of the context, significance, and rationale behind the research. It offers a snapshot of existing knowledge on the topic, highlights the relevance of the study, and sets the stage for the research questions and objectives. It ensures that readers can grasp the importance of the research and its place within the broader field of study.

The background of the study is a section in a research paper that provides context, circumstances, and history leading to the research problem or topic being explored. It presents existing knowledge on the topic and outlines the reasons that spurred the current research, helping readers understand the research's foundation and its significance in the broader academic landscape.

The number of paragraphs in the background of the study can vary based on the complexity of the topic and the depth of the context required. Typically, it might range from 3 to 5 paragraphs, but in more detailed or complex research papers, it could be longer. The key is to ensure that all relevant information is presented clearly and concisely, without unnecessary repetition.

You might also like

AI for Meta Analysis — A Comprehensive Guide

Cybersecurity in Higher Education: Safeguarding Students and Faculty Data

How To Write An Argumentative Essay

• Manuscript Preparation

What is the Background of a Study and How Should it be Written?

• 3 minute read
• 849.1K views

Table of Contents

The background of a study is one of the most important components of a research paper. The quality of the background determines whether the reader will be interested in the rest of the study. Thus, to ensure that the audience is invested in reading the entire research paper, it is important to write an appealing and effective background. So, what constitutes the background of a study, and how must it be written?

What is the background of a study?

The background of a study is the first section of the paper and establishes the context underlying the research. It contains the rationale, the key problem statement, and a brief overview of research questions that are addressed in the rest of the paper. The background forms the crux of the study because it introduces an unaware audience to the research and its importance in a clear and logical manner. At times, the background may even explore whether the study builds on or refutes findings from previous studies. Any relevant information that the readers need to know before delving into the paper should be made available to them in the background.

How is a background different from the introduction?

The introduction of your research paper is presented before the background. Let’s find out what factors differentiate the background from the introduction.

• The introduction only contains preliminary data about the research topic and does not state the purpose of the study. On the contrary, the background clarifies the importance of the study in detail.
• The introduction provides an overview of the research topic from a broader perspective, while the background provides a detailed understanding of the topic.
• The introduction should end with the mention of the research questions, aims, and objectives of the study. In contrast, the background follows no such format and only provides essential context to the study.

How should one write the background of a research paper?

The length and detail presented in the background varies for different research papers, depending on the complexity and novelty of the research topic. At times, a simple background suffices, even if the study is complex. Before writing and adding details in the background, take a note of these additional points:

• Start with a strong beginning: Begin the background by defining the research topic and then identify the target audience.
• Cover key components: Explain all theories, concepts, terms, and ideas that may feel unfamiliar to the target audience thoroughly.
• Take note of important prerequisites: Go through the relevant literature in detail. Take notes while reading and cite the sources.
• Maintain a balance: Make sure that the background is focused on important details, but also appeals to a broader audience.
• Include historical data: Current issues largely originate from historical events or findings. If the research borrows information from a historical context, add relevant data in the background.
• Explain novelty: If the research study or methodology is unique or novel, provide an explanation that helps to understand the research better.
• Increase engagement: To make the background engaging, build a story around the central theme of the research

Avoid these mistakes while writing the background:

• Ambiguity: Don’t be ambiguous. While writing, assume that the reader does not understand any intricate detail about your research.
• Unrelated themes: Steer clear from topics that are not related to the key aspects of your research topic.
• Poor organization: Do not place information without a structure. Make sure that the background reads in a chronological manner and organize the sub-sections so that it flows well.

Writing the background for a research paper should not be a daunting task. But directions to go about it can always help. At Elsevier Author Services we provide essential insights on how to write a high quality, appealing, and logically structured paper for publication, beginning with a robust background. For further queries, contact our experts now!

How to Use Tables and Figures effectively in Research Papers

• Research Process

The Top 5 Qualities of Every Good Researcher

You may also like.

Make Hook, Line, and Sinker: The Art of Crafting Engaging Introductions

Can Describing Study Limitations Improve the Quality of Your Paper?

A Guide to Crafting Shorter, Impactful Sentences in Academic Writing

6 Steps to Write an Excellent Discussion in Your Manuscript

How to Write Clear and Crisp Civil Engineering Papers? Here are 5 Key Tips to Consider

The Clear Path to An Impactful Paper: ②

The Essentials of Writing to Communicate Research in Medicine

Changing Lines: Sentence Patterns in Academic Writing

Input your search keywords and press Enter.

What Is Background in a Research Paper?

So you have carefully written your research paper  and probably ran it through your colleagues ten to fifteen times. While there are many elements to a good research article, one of the most important elements for your readers is the background of your study.

What is Background of the Study in Research

The background of your study will provide context to the information discussed throughout the research paper . Background information may include both important and relevant studies. This is particularly important if a study either supports or refutes your thesis.

Why is Background of the Study Necessary in Research?

The background of the study discusses your problem statement, rationale, and research questions. It links  introduction to your research topic  and ensures a logical flow of ideas.  Thus, it helps readers understand your reasons for conducting the study.

Providing Background Information

The reader should be able to understand your topic and its importance. The length and detail of your background also depend on the degree to which you need to demonstrate your understanding of the topic. Paying close attention to the following questions will help you in writing background information:

• Are there any theories, concepts, terms, and ideas that may be unfamiliar to the target audience and will require you to provide any additional explanation?
• Any historical data that need to be shared in order to provide context on why the current issue emerged?
• Are there any concepts that may have been borrowed from other disciplines that may be unfamiliar to the reader and need an explanation?

Related: Ready with the background and searching for more information on journal ranking? Check this infographic on the SCImago Journal Rank today!

Is the research study unique for which additional explanation is needed? For instance, you may have used a completely new method

How to Write a Background of the Study

The structure of a background study in a research paper generally follows a logical sequence to provide context, justification, and an understanding of the research problem. It includes an introduction, general background, literature review , rationale , objectives, scope and limitations , significance of the study and the research hypothesis . Following the structure can provide a comprehensive and well-organized background for your research.

Here are the steps to effectively write a background of the study.

1. Identify Your Audience:

Determine the level of expertise of your target audience. Tailor the depth and complexity of your background information accordingly.

2. Understand the Research Problem:

Define the research problem or question your study aims to address. Identify the significance of the problem within the broader context of the field.

3. Review Existing Literature:

Conduct a thorough literature review to understand what is already known in the area. Summarize key findings, theories, and concepts relevant to your research.

4. Include Historical Data:

Integrate historical data if relevant to the research, as current issues often trace back to historical events.

5. Identify Controversies and Gaps:

Note any controversies or debates within the existing literature. Identify gaps , limitations, or unanswered questions that your research can address.

6. Select Key Components:

Choose the most critical elements to include in the background based on their relevance to your research problem. Prioritize information that helps build a strong foundation for your study.

7. Craft a Logical Flow:

Organize the background information in a logical sequence. Start with general context, move to specific theories and concepts, and then focus on the specific problem.

8. Highlight the Novelty of Your Research:

Clearly explain the unique aspects or contributions of your study. Emphasize why your research is different from or builds upon existing work.

Here are some extra tips to increase the quality of your research background:

Example of a Research Background

Here is an example of a research background to help you understand better.

The above hypothetical example provides a research background, addresses the gap and highlights the potential outcome of the study; thereby aiding a better understanding of the proposed research.

What Makes the Introduction Different from the Background?

Your introduction is different from your background in a number of ways.

• The introduction contains preliminary data about your topic that  the reader will most likely read , whereas the background clarifies the importance of the paper.
• The background of your study discusses in depth about the topic, whereas the introduction only gives an overview.
• The introduction should end with your research questions, aims, and objectives, whereas your background should not (except in some cases where your background is integrated into your introduction). For instance, the C.A.R.S. ( Creating a Research Space ) model, created by John Swales is based on his analysis of journal articles. This model attempts to explain and describe the organizational pattern of writing the introduction in social sciences.

Points to Note

Your background should begin with defining a topic and audience. It is important that you identify which topic you need to review and what your audience already knows about the topic. You should proceed by searching and researching the relevant literature. In this case, it is advisable to keep track of the search terms you used and the articles that you downloaded. It is helpful to use one of the research paper management systems such as Papers, Mendeley, Evernote, or Sente. Next, it is helpful to take notes while reading. Be careful when copying quotes verbatim and make sure to put them in quotation marks and cite the sources. In addition, you should keep your background focused but balanced enough so that it is relevant to a broader audience. Aside from these, your background should be critical, consistent, and logically structured.

Writing the background of your study should not be an overly daunting task. Many guides that can help you organize your thoughts as you write the background. The background of the study is the key to introduce your audience to your research topic and should be done with strong knowledge and thoughtful writing.

The background of a research paper typically ranges from one to two paragraphs, summarizing the relevant literature and context of the study. It should be concise, providing enough information to contextualize the research problem and justify the need for the study. Journal instructions about any word count limits should be kept in mind while deciding on the length of the final content.

The background of a research paper provides the context and relevant literature to understand the research problem, while the introduction also introduces the specific research topic, states the research objectives, and outlines the scope of the study. The background focuses on the broader context, whereas the introduction focuses on the specific research project and its objectives.

When writing the background for a study, start by providing a brief overview of the research topic and its significance in the field. Then, highlight the gaps in existing knowledge or unresolved issues that the study aims to address. Finally, summarize the key findings from relevant literature to establish the context and rationale for conducting the research, emphasizing the need and importance of the study within the broader academic landscape.

The background in a research paper is crucial as it sets the stage for the study by providing essential context and rationale. It helps readers understand the significance of the research problem and its relevance in the broader field. By presenting relevant literature and highlighting gaps, the background justifies the need for the study, building a strong foundation for the research and enhancing its credibility.

The presentation very informative

It is really educative. I love the workshop. It really motivated me into writing my first paper for publication.

an interesting clue here, thanks.

thanks for the answers.

Good and interesting explanation. Thanks

Thank you for good presentation.

Hi Adam, we are glad to know that you found our article beneficial

The background of the study is the key to introduce your audience to YOUR research topic.

Awesome. Exactly what i was looking forwards to 😉

Hi Maryam, we are glad to know that you found our resource useful.

my understanding of ‘Background of study’ has been elevated.

Hi Peter, we are glad to know that our article has helped you get a better understanding of the background in a research paper.

thanks to give advanced information

Hi Shimelis, we are glad to know that you found the information in our article beneficial.

When i was studying it is very much hard for me to conduct a research study and know the background because my teacher in practical research is having a research so i make it now so that i will done my research

Very informative……….Thank you.

The confusion i had before, regarding an introduction and background to a research work is now a thing of the past. Thank you so much.

Thanks for your help…

Thanks for your kind information about the background of a research paper.

Thanks for the answer

Very informative. I liked even more when the difference between background and introduction was given. I am looking forward to learning more from this site. I am in Botswana

Hello, I am Benoît from Central African Republic. Right now I am writing down my research paper in order to get my master degree in British Literature. Thank you very much for posting all this information about the background of the study. I really appreciate. Thanks!

The write up is quite good, detailed and informative. Thanks a lot. The article has certainly enhanced my understanding of the topic.

Rate this article Cancel Reply

Your email address will not be published.

Enago Academy's Most Popular Articles

• AI in Academia
• Infographic
• Manuscripts & Grants
• Reporting Research
• Trending Now

Can AI Tools Prepare a Research Manuscript From Scratch? — A comprehensive guide

As technology continues to advance, the question of whether artificial intelligence (AI) tools can prepare…

Abstract Vs. Introduction — Do you know the difference?

Ross wants to publish his research. Feeling positive about his research outcomes, he begins to…

• Old Webinars
• Webinar Mobile App

Demystifying Research Methodology With Field Experts

Choosing research methodology Research design and methodology Evidence-based research approach How RAxter can assist researchers

• Manuscript Preparation
• Publishing Research

How to Choose Best Research Methodology for Your Study

Successful research conduction requires proper planning and execution. While there are multiple reasons and aspects…

Top 5 Key Differences Between Methods and Methodology

While burning the midnight oil during literature review, most researchers do not realize that the…

How to Draft the Acknowledgment Section of a Manuscript

Discussion Vs. Conclusion: Know the Difference Before Drafting Manuscripts

Sign-up to read more

Subscribe for free to get unrestricted access to all our resources on research writing and academic publishing including:

• 2000+ blog articles
• 50+ Webinars
• 10+ Expert podcasts
• 50+ Infographics
• 10+ Checklists
• Research Guides

We hate spam too. We promise to protect your privacy and never spam you.

I am looking for Editing/ Proofreading services for my manuscript Tentative date of next journal submission:

What should universities' stance be on AI tools in research and academic writing?

How to Write the Background of a Study

• Research Process

The background to a study sets the scene . It lays out the “state of the art”. It tells your reader about other research done on the topic in question, via useful review papers and other summaries of the literature.

Updated on May 5, 2023

The background to your study, sometimes called the ‘state of the art’ (especially in grant writing), sets the scene for a paper. This section shows readers why your research is important, relevant, and why they should continue reading. You must hook them in with a great background to your study, which is part of the overall introduction to your research paper.

In higher impact articles, such as those published in Nature or Science (which is what we are all aiming for, after all …), the study background is t he middle section of an essentially three-part introduction . This section is framed by a presentation of ‘the question’ (first part of the introduction) and a quick explanation of ‘what this paper will do’ (the third part of the introduction).

The introduction of a research paper should be “shaped” like an upside down triangle: 

Start broad. Set the scene with a large-scale general research area [e.g., why doing a PhD erases your writing skills (ha ha) or mental health in teenagers and why this is such a widespread global issue] and then focus down to the question your research addresses (e.g., how can writing skills be improved in PhD students, or brain scans and how these can be used in treatment).

Read on to learn more about framing your next research paper with a well-written and researched background section.

What is the background of a study?

The background to a study sets the scene . It lays out the “state of the art”. It tells your reader about other research done on the topic in question, via useful review papers and other summaries of the literature. 

A background is not a literature review: No one wants to read endless citations back-to-back in this section. You don’t need to list all the papers you’ve read, or all the work done in the past on this topic. 

Set the scene and frame your question in the context of the literature. Seek out review articles in particular. The aim of this section is to build on what has come before so your reader will be armed with all the information they need to understand the remainder of your article, and why - in context - the aims of your study are important.

How to write the background to your research paper

Cater to your audience.

It’s important to frame your background to the right audience.

The background of your study needs to be pitched differently depending on your target journal. A more subject-area specific journal (e.g. Journal of Brain Studies ) will be read by specialists in your field. Generally, less information to set up the paper in a wider context and less background information will be required. Your readers are already experts on the topic in question .

However, if you are aiming your paper at a more general audience (a journal like Nature or Science , for example) then you're going to need to explain more in your background. A reader of a specialized journal will know about the neocortex within the brain and where this is located, but a general reader will need you to set things up more.

Readers are always the most important people in research publishing, after all: If you want your work to be read, used, and cited (and therefore drive up your H-index as well as your institution’s ranking) you’ll need a well-pitched background of your study.

What is included in the background of a study?

Remember this section sits in the middle of the introduction. Here’s a handy template for what to include:

• Existing research on the area of study (not everything, but a broad overview. Aim to cite review papers if you can). Start this section with preliminary data and then build it out;
• Mention any controversies around your topic (either that you’ve identified, or that have been picked up by earlier work. Check the discussion sections of recent articles for pointers here);
• Any gaps in existing research?, and;
• How will your study fill these gaps? State your research methodologies. Any further research that needs to be done?

Aim for one paragraph , or a series of short paragraphs within one section. The last two of the topics outlined above can be short, just one or two sentences. These are there to hook the reader in and to frame your background so that the text leads into the final section of the introduction where you explain ‘What your paper is going to do’.

Simple really.

And finally…some thoughts

I used to get really bogged down with article writing, especially the shape of the introduction.

Here’s a trick to keep in mind: Remember that the average length of an academic research paper published in a peer reviewed journal is around 4,000 - 5,000 words - not too long. 

This means that you're likely going to be aiming for an article of about this length the next time you sit down to write: Not too many words for an effective and well-structured introduction. You’ve got about 1,500 - 2,000 words maximum. And aim to keep it short (this will be enforced by word count limits, especially in higher impact journals like Nature and Science ). Editors at these journals are trained to cut down your writing to make sure your research fits in.

Less is more, in other words.

Keeping tight word count limits in mind means you can’t write an expansive, flowing background to your study that goes off in all directions and covers a huge amount of ground. Keep an eye on our tips for what to include, cite review papers, and keep your readers interested in the question your paper seeks to address.

A well written background to your study will ensure your paper gets read all the way through to the end. Can’t ask for more than that!

The AJE Team

See our "Privacy Policy"

Writing Research Background

Research background is a brief outline of the most important studies that have been conducted so far presented in a chronological order. Research background part in introduction chapter can be also headed ‘Background of the Study.” Research background should also include a brief discussion of major theories and models related to the research problem.

Specifically, when writing research background you can discuss major theories and models related to your research problem in a chronological order to outline historical developments in the research area.  When writing research background, you also need to demonstrate how your research relates to what has been done so far in the research area.

Research background is written after the literature review. Therefore, literature review has to be the first and the longest stage in the research process, even before the formulation of research aims and objectives, right after the selection of the research area. Once the research area is selected, the literature review is commenced in order to identify gaps in the research area.

Research aims and objectives need to be closely associated with the elimination of this gap in the literature. The main difference between background of the study and literature review is that the former only provides general information about what has been done so far in the research area, whereas the latter elaborates and critically reviews previous works.

John Dudovskiy

• USC Libraries
• Research Guides

Organizing Your Social Sciences Research Paper

• Background Information
• Purpose of Guide
• Design Flaws to Avoid
• Independent and Dependent Variables
• Glossary of Research Terms
• Reading Research Effectively
• Narrowing a Topic Idea
• Broadening a Topic Idea
• Extending the Timeliness of a Topic Idea
• Academic Writing Style
• Choosing a Title
• Making an Outline
• Paragraph Development
• Research Process Video Series
• Executive Summary
• The C.A.R.S. Model
• The Research Problem/Question
• Theoretical Framework
• Citation Tracking
• Content Alert Services
• Evaluating Sources
• Primary Sources
• Secondary Sources
• Tiertiary Sources
• Scholarly vs. Popular Publications
• Qualitative Methods
• Quantitative Methods
• Insiderness
• Using Non-Textual Elements
• Limitations of the Study
• Common Grammar Mistakes
• Writing Concisely
• Avoiding Plagiarism
• Footnotes or Endnotes?
• Further Readings
• Generative AI and Writing
• USC Libraries Tutorials and Other Guides
• Bibliography

Background information identifies and describes the history and nature of a well-defined research problem with reference to contextualizing existing literature. The background information should indicate the root of the problem being studied, appropriate context of the problem in relation to theory, research, and/or practice , its scope, and the extent to which previous studies have successfully investigated the problem, noting, in particular, where gaps exist that your study attempts to address. Background information does not replace the literature review section of a research paper; it is intended to place the research problem within a specific context and an established plan for its solution.

Fitterling, Lori. Researching and Writing an Effective Background Section of a Research Paper. Kansas City University of Medicine & Biosciences; Creating a Research Paper: How to Write the Background to a Study. DurousseauElectricalInstitute.com; Background Information: Definition of Background Information. Literary Devices Definition and Examples of Literary Terms.

Importance of Having Enough Background Information

Background information expands upon the key points stated in the beginning of your introduction but is not intended to be the main focus of the paper. It generally supports the question, what is the most important information the reader needs to understand before continuing to read the paper? Sufficient background information helps the reader determine if you have a basic understanding of the research problem being investigated and promotes confidence in the overall quality of your analysis and findings. This information provides the reader with the essential context needed to conceptualize the research problem and its significance before moving on to a more thorough analysis of prior research.

Forms of contextualization included in background information can include describing one or more of the following:

• Cultural -- placed within the learned behavior of a specific group or groups of people.
• Economic -- of or relating to systems of production and management of material wealth and/or business activities.
• Gender -- located within the behavioral, cultural, or psychological traits typically associated with being self-identified as male, female, or other form of  gender expression.
• Historical -- the time in which something takes place or was created and how the condition of time influences how you interpret it.
• Interdisciplinary -- explanation of theories, concepts, ideas, or methodologies borrowed from other disciplines applied to the research problem rooted in a discipline other than the discipline where your paper resides.
• Philosophical -- clarification of the essential nature of being or of phenomena as it relates to the research problem.
• Physical/Spatial -- reflects the meaning of space around something and how that influences how it is understood.
• Political -- concerns the environment in which something is produced indicating it's public purpose or agenda.
• Social -- the environment of people that surrounds something's creation or intended audience, reflecting how the people associated with something use and interpret it.
• Temporal -- reflects issues or events of, relating to, or limited by time. Concerns past, present, or future contextualization and not just a historical past.

Background information can also include summaries of important research studies . This can be a particularly important element of providing background information if an innovative or groundbreaking study about the research problem laid a foundation for further research or there was a key study that is essential to understanding your arguments. The priority is to summarize for the reader what is known about the research problem before you conduct the analysis of prior research. This is accomplished with a general summary of the foundational research literature [with citations] that document findings that inform your study's overall aims and objectives.

NOTE : Research studies cited as part of the background information of your introduction should not include very specific, lengthy explanations. This should be discussed in greater detail in your literature review section. If you find a study requiring lengthy explanation, consider moving it to the literature review section.

ANOTHER NOTE : In some cases, your paper's introduction only needs to introduce the research problem, explain its significance, and then describe a road map for how you are going to address the problem; the background information basically forms the introduction part of your literature review. That said, while providing background information is not required, including it in the introduction is a way to highlight important contextual information that could otherwise be hidden or overlooked by the reader if placed in the literature review section.

Background of the Problem Section: What do you Need to Consider? Anonymous. Harvard University; Hopkins, Will G. How to Write a Research Paper. SPORTSCIENCE, Perspectives/Research Resources. Department of Physiology and School of Physical Education, University of Otago, 1999; Green, L. H. How to Write the Background/Introduction Section. Physics 499 Powerpoint slides. University of Illinois; Pyrczak, Fred. Writing Empirical Research Reports: A Basic Guide for Students of the Social and Behavioral Sciences . 8th edition. Glendale, CA: Pyrczak Publishing, 2014; Stevens, Kathleen C. “Can We Improve Reading by Teaching Background Information?.” Journal of Reading 25 (January 1982): 326-329; Woodall, W. Gill. Writing the Background and Significance Section. Senior Research Scientist and Professor of Communication. Center on Alcoholism, Substance Abuse, and Addictions. University of New Mexico.

Structure and Writing Style

Providing background information in the introduction of a research paper serves as a bridge that links the reader to the research problem . Precisely how long and in-depth this bridge should be is largely dependent upon how much information you think the reader will need to know in order to fully understand the problem being discussed and to appreciate why the issues you are investigating are important.

From another perspective, the length and detail of background information also depends on the degree to which you need to demonstrate to your professor how much you understand the research problem. Keep this in mind because providing pertinent background information can be an effective way to demonstrate that you have a clear grasp of key issues, debates, and concepts related to your overall study.

The structure and writing style of your background information can vary depending upon the complexity of your research and/or the nature of the assignment. However, in most cases it should be limited to only one to two paragraphs in your introduction.

Given this, here are some questions to consider while writing this part of your introduction :

• Are there concepts, terms, theories, or ideas that may be unfamiliar to the reader and, thus, require additional explanation?
• Are there historical elements that need to be explored in order to provide needed context, to highlight specific people, issues, or events, or to lay a foundation for understanding the emergence of a current issue or event?
• Are there theories, concepts, or ideas borrowed from other disciplines or academic traditions that may be unfamiliar to the reader and therefore require further explanation?
• Is there a key study or small set of studies that set the stage for understanding the topic and frames why it is important to conduct further research on the topic?
• Y our study uses a method of analysis never applied before;
• Your study investigates a very esoteric or complex research problem;
• Your study introduces new or unique variables that need to be taken into account ; or,
• Your study relies upon analyzing unique texts or documents, such as, archival materials or primary documents like diaries or personal letters that do not represent the established body of source literature on the topic?

Almost all introductions to a research problem require some contextualizing, but the scope and breadth of background information varies depending on your assumption about the reader's level of prior knowledge . However, despite this assessment, background information should be brief and succinct and sets the stage for the elaboration of critical points or in-depth discussion of key issues in the literature review section of your paper.

Writing Tip

Background Information vs. the Literature Review

Incorporating background information into the introduction is intended to provide the reader with critical information about the topic being studied, such as, highlighting and expanding upon foundational studies conducted in the past, describing important historical events that inform why and in what ways the research problem exists, defining key components of your study [concepts, people, places, phenomena] and/or placing the research problem within a particular context. Although introductory background information can often blend into the literature review portion of the paper, essential background information should not be considered a substitute for a comprehensive review and synthesis of relevant research literature.

Hart, Cris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage, 1998; Pyrczak, Fred. Writing Empirical Research Reports: A Basic Guide for Students of the Social and Behavioral Sciences . 8th edition. Glendale, CA: Pyrczak Publishing, 2014.

• << Previous: The C.A.R.S. Model
• Next: The Research Problem/Question >>
• Last Updated: Apr 5, 2024 1:38 PM
• URL: https://libguides.usc.edu/writingguide

PHILO-notes

Free Online Learning Materials

How to Write the Background of the Study in Research (Part 1)

Background of the Study in Research: Definition and the Core Elements it Contains

Before we embark on a detailed discussion on how to write the background of the study of your proposed research or thesis, it is important to first discuss its meaning and the core elements that it should contain. This is obviously because understanding the nature of the background of the study in research and knowing exactly what to include in it allow us to have both greater control and clear direction of the writing process.

So, what really is the background of the study and what are the core elements that it should contain?

The background of the study, which usually forms the first section of the introduction to a research paper or thesis, provides the overview of the study. In other words, it is that section of the research paper or thesis that establishes the context of the study. Its main function is to explain why the proposed research is important and essential to understanding the main aspects of the study.

The background of the study, therefore, is the section of the research paper or thesis that identifies the problem or gap of the study that needs to addressed and justifies the need for conducting the study. It also articulates the main goal of the study and the thesis statement, that is, the main claim or argument of the paper.

Given this brief understanding of the background of the study, we can anticipate what readers or thesis committee members expect from it. As we can see, the background of the study should contain the following major points:

1) brief discussion on what is known about the topic under investigation; 2) An articulation of the research gap or problem that needs to be addressed; 3) What the researcher would like to do or aim to achieve in the study ( research goal); 4) The thesis statement, that is, the main argument or contention of the paper (which also serves as the reason why the researcher would want to pursue the study); 5) The major significance or contribution of the study to a particular discipline; and 6) Depending on the nature of the study, an articulation of the hypothesis of the study.

Thus, when writing the background of the study, you should plan and structure it based on the major points just mentioned. With this, you will have a clear picture of the flow of the tasks that need to be completed in writing this section of your research or thesis proposal.

Now, how do you go about writing the background of the study in your proposed research or thesis?

The next lessons will address this question.

How to Write the Opening Paragraphs of the Background of the Study?

To begin with, let us assume that you already have conducted a preliminary research on your chosen topic, that is, you already have read a lot of literature and gathered relevant information for writing the background of your study. Let us also assume that you already have identified the gap of your proposed research and have already developed the research questions and thesis statement. If you have not yet identified the gap in your proposed research, you might as well go back to our lesson on how to identify a research gap.

So, we will just put together everything that you have researched into a background of the study (assuming, again, that you already have the necessary information). But in this lesson, let’s just focus on writing the opening paragraphs.

It is important to note at this point that there are different styles of writing the background of the study. Hence, what I will be sharing with you here is not just “the” only way of writing the background of the study. As a matter of fact, there is no “one-size-fits-all” style of writing this part of the research or thesis. At the end of the day, you are free to develop your own. However, whatever style it would be, it always starts with a plan which structures the writing process into stages or steps. The steps that I will share with below are just some of the most effective ways of writing the background of the study in research.

So, let’s begin.

It is always a good idea to begin the background of your study by giving an overview of your research topic. This may include providing a definition of the key concepts of your research or highlighting the main developments of the research topic.

Let us suppose that the topic of your study is the “lived experiences of students with mathematical anxiety”.

Here, you may start the background of your study with a discussion on the meaning, nature, and dynamics of the term “mathematical anxiety”. The reason for this is too obvious: “mathematical anxiety” is a highly technical term that is specific to mathematics. Hence, this term is not readily understandable to non-specialists in this field.

So, you may write the opening paragraph of your background of the study with this:

“Mathematical anxiety refers to the individual’s unpleasant emotional mood responses when confronted with a mathematical situation.”

Since you do not invent the definition of the term “mathematical anxiety”, then you need to provide a citation to the source of the material from which you are quoting. For example, you may now say:

“Mathematical anxiety refers to the individual’s unpleasant emotional mood responses when confronted with a mathematical situation (Eliot, 2020).”

And then you may proceed with the discussion on the nature and dynamics of the term “mathematical anxiety”. You may say:

“Lou (2019) specifically identifies some of the manifestations of this type of anxiety, which include, but not limited to, depression, helplessness, nervousness and fearfulness in doing mathematical and numerical tasks.”

After explaining to your readers the meaning, nature, and dynamics (as well as some historical development if you wish to) of the term “mathematical anxiety”, you may now proceed to showing the problem or gap of the study. As you may already know, the research gap is the problem that needs to be addressed in the study. This is important because no research activity is possible without the research gap.

Let us suppose that your research problem or gap is: “Mathematical anxiety can negatively affect not just the academic achievement of the students but also their future career plans and total well-being. Also, there are no known studies that deal with the mathematical anxiety of junior high school students in New Zealand.” With this, you may say:

“If left unchecked, as Shapiro (2019) claims, this problem will expand and create a total avoidance pattern on the part of the students, which can be expressed most visibly in the form of cutting classes and habitual absenteeism. As we can see, this will negatively affect the performance of students in mathematics. In fact, the study conducted by Luttenberger and Wimmer (2018) revealed that the outcomes of mathematical anxiety do not only negatively affect the students’ performance in math-related situations but also their future career as professionals. Without a doubt, therefore, mathematical anxiety is a recurring problem for many individuals which will negatively affect the academic success and future career of the student.”

Now that you already have both explained the meaning, nature, and dynamics of the term “mathematical anxiety” and articulated the gap of your proposed research, you may now state the main goal of your study. You may say:

“Hence, it is precisely in this context that the researcher aims to determine the lived experiences of those students with mathematical anxiety. In particular, this proposed thesis aims to determine the lived experiences of the junior high school students in New Zealand and identify the factors that caused them to become disinterested in mathematics.”

Please note that you should not end the first paragraph of your background of the study with the articulation of the research goal. You also need to articulate the “thesis statement”, which usually comes after the research goal. As is well known, the thesis statement is the statement of your argument or contention in the study. It is more of a personal argument or claim of the researcher, which specifically highlights the possible contribution of the study. For example, you may say:

“The researcher argues that there is a need to determine the lived experiences of these students with mathematical anxiety because knowing and understanding the difficulties and challenges that they have encountered will put the researcher in the best position to offer some alternatives to the problem. Indeed, it is only when we have performed some kind of a ‘diagnosis’ that we can offer practicable solutions to the problem. And in the case of the junior high school students in New Zealand who are having mathematical anxiety, determining their lived experiences as well as identifying the factors that caused them to become disinterested in mathematics are the very first steps in addressing the problem.”

If we combine the bits and pieces that we have written above, we can now come up with the opening paragraphs of your background of the study, which reads:

As we can see, we can find in the first paragraph 5 essential elements that must be articulated in the background of the study, namely:

1) A brief discussion on what is known about the topic under investigation; 2) An articulation of the research gap or problem that needs to be addressed; 3) What the researcher would like to do or aim to achieve in the study (research goal); 4) The thesis statement , that is, the main argument or claim of the paper; and 5) The major significance or contribution of the study to a particular discipline. So, that’s how you write the opening paragraphs of your background of the study. The next lesson will talk about writing the body of the background of the study.

How to Write the Body of the Background of the Study?

If we liken the background of the study to a sitting cat, then the opening paragraphs that we have completed in the previous lesson would just represent the head of the cat.

This means we still have to write the body (body of the cat) and the conclusion (tail). But how do we write the body of the background of the study? What should be its content?

Truly, this is one of the most difficult challenges that fledgling scholars faced. Because they are inexperienced researchers and didn’t know what to do next, they just wrote whatever they wished to write. Fortunately, this is relatively easy if they know the technique.

One of the best ways to write the body of the background of the study is to attack it from the vantage point of the research gap. If you recall, when we articulated the research gap in the opening paragraphs, we made a bold claim there, that is, there are junior high school students in New Zealand who are experiencing mathematical anxiety. Now, you have to remember that a “statement” remains an assumption until you can provide concrete proofs to it. This is what we call the “epistemological” aspect of research. As we may already know, epistemology is a specific branch of philosophy that deals with the validity of knowledge. And to validate knowledge is to provide concrete proofs to our statements. Hence, the reason why we need to provide proofs to our claim that there are indeed junior high school students in New Zealand who are experiencing mathematical anxiety is the obvious fact that if there are none, then we cannot proceed with our study. We have no one to interview with in the first. In short, we don’t have respondents.

The body of the background of the study, therefore, should be a presentation and articulation of the proofs to our claim that indeed there are junior high school students in New Zealand who are experiencing mathematical anxiety. Please note, however, that this idea is true only if you follow the style of writing the background of the study that I introduced in this course.

So, how do we do this?

One of the best ways to do this is to look for literature on mathematical anxiety among junior high school students in New Zealand and cite them here. However, if there are not enough literature on this topic in New Zealand, then we need to conduct initial interviews with these students or make actual classroom observations and record instances of mathematical anxiety among these students. But it is always a good idea if we combine literature review with interviews and actual observations.

Assuming you already have the data, then you may now proceed with the writing of the body of your background of the study. For example, you may say:

“According to records and based on the researcher’s firsthand experience with students in some junior high schools in New Zealand, indeed, there are students who lost interest in mathematics. For one, while checking the daily attendance and monitoring of the students, it was observed that some of them are not always attending classes in mathematics but are regularly attending the rest of the required subjects.”

After this sentence, you may insert some literature that will support this position. For example, you may say:

“As a matter of fact, this phenomenon is also observed in the work of Estonanto. In his study titled ‘Impact of Math Anxiety on Academic Performance in Pre-Calculus of Senior High School’, Estonanto (2019) found out that, inter alia, students with mathematical anxiety have the tendency to intentionally prioritize other subjects and commit habitual tardiness and absences.”

Then you may proceed saying:

“With this initial knowledge in mind, the researcher conducted initial interviews with some of these students. The researcher learned that one student did not regularly attend his math subject because he believed that he is not good in math and no matter how he listens to the topic he will not learn.”

Then you may say:

“Another student also mentioned that she was influenced by her friends’ perception that mathematics is hard; hence, she avoids the subject. Indeed, these are concrete proofs that there are some junior high school students in New Zealand who have mathematical anxiety. As already hinted, “disinterest” or the loss of interest in mathematics is one of the manifestations of a mathematical anxiety.”

If we combine what we have just written above, then we can have the first two paragraphs of the body of our background of the study. It reads:

“According to records and based on the researcher’s firsthand experience with students in some junior high schools in New Zealand, indeed there are students who lost interest in mathematics. For one, while checking the daily attendance and monitoring of the students, it was observed that some of them are not always attending classes in mathematics but are regularly attending the rest of the required subjects. As a matter of fact, this phenomenon is also observed in the work of Estonanto. In his study titled ‘Impact of Math Anxiety on Academic Performance in Pre-Calculus of Senior High School’, Estonanto (2019) found out that, inter alia, students with mathematical anxiety have the tendency to intentionally prioritize other subjects and commit habitual tardiness and absences.

With this initial knowledge in mind, the researcher conducted initial interviews with some of these students. The researcher learned that one student did not regularly attend his math subject because he believed that he is not good in math and no matter how he listens to the topic he will not learn. Another student also mentioned that she was influenced by her friends’ perception that mathematics is hard; hence, she avoids the subject. Indeed, these are concrete proofs that there are some junior high school students in New Zealand who have mathematical anxiety. As already hinted, “disinterest” or the loss of interest in mathematics is one of the manifestations of a mathematical anxiety.”

And then you need validate this observation by conducting another round of interview and observation in other schools. So, you may continue writing the body of the background of the study with this:

“To validate the information gathered from the initial interviews and observations, the researcher conducted another round of interview and observation with other junior high school students in New Zealand.”

“On the one hand, the researcher found out that during mathematics time some students felt uneasy; in fact, they showed a feeling of being tensed or anxious while working with numbers and mathematical problems. Some were even afraid to seat in front, while some students at the back were secretly playing with their mobile phones. These students also show remarkable apprehension during board works like trembling hands, nervous laughter, and the like.”

Then provide some literature that will support your position. You may say:

“As Finlayson (2017) corroborates, emotional symptoms of mathematical anxiety involve feeling of helplessness, lack of confidence, and being nervous for being put on the spot. It must be noted that these occasionally extreme emotional reactions are not triggered by provocative procedures. As a matter of fact, there are no personally sensitive questions or intentional manipulations of stress. The teacher simply asked a very simple question, like identifying the parts of a circle. Certainly, this observation also conforms with the study of Ashcraft (2016) when he mentions that students with mathematical anxiety show a negative attitude towards math and hold self-perceptions about their mathematical abilities.”

And then you proceed:

“On the other hand, when the class had their other subjects, the students show a feeling of excitement. They even hurried to seat in front and attentively participating in the class discussion without hesitation and without the feeling of being tensed or anxious. For sure, this is another concrete proof that there are junior high school students in New Zealand who have mathematical anxiety.”

To further prove the point that there indeed junior high school students in New Zealand who have mathematical anxiety, you may solicit observations from other math teachers. For instance, you may say:

“The researcher further verified if the problem is also happening in other sections and whether other mathematics teachers experienced the same observation that the researcher had. This validation or verification is important in establishing credibility of the claim (Buchbinder, 2016) and ensuring reliability and validity of the assertion (Morse et al., 2002). In this regard, the researcher attempted to open up the issue of math anxiety during the Departmentalized Learning Action Cell (LAC), a group discussion of educators per quarter, with the objective of ‘Teaching Strategies to Develop Critical Thinking of the Students’. During the session, one teacher corroborates the researcher’s observation that there are indeed junior high school students in New Zealand who have mathematical anxiety. The teacher pointed out that truly there were students who showed no extra effort in mathematics class in addition to the fact that some students really avoided the subject. In addition, another math teacher expressed her frustrations about these students who have mathematical anxiety. She quipped: “How can a teacher develop the critical thinking skills or ability of the students if in the first place these students show avoidance and disinterest in the subject?’.”

Again, if we combine what we have just written above, then we can now have the remaining parts of the body of the background of the study. It reads:

So, that’s how we write the body of the background of the study in research . Of course, you may add any relevant points which you think might amplify your content. What is important at this point is that you now have a clear idea of how to write the body of the background of the study.

How to Write the Concluding Part of the Background of the Study?

Since we have already completed the body of our background of the study in the previous lesson, we may now write the concluding paragraph (the tail of the cat). This is important because one of the rules of thumb in writing is that we always put a close to what we have started.

It is important to note that the conclusion of the background of the study is just a rehashing of the research gap and main goal of the study stated in the introductory paragraph, but framed differently. The purpose of this is just to emphasize, after presenting the justifications, what the study aims to attain and why it wants to do it. The conclusion, therefore, will look just like this:

“Given the above discussion, it is evident that there are indeed junior high school students in New Zealand who are experiencing mathematical anxiety. And as we can see, mathematical anxiety can negatively affect not just the academic achievement of the students but also their future career plans and total well-being. Again, it is for this reason that the researcher attempts to determine the lived experiences of those junior high school students in New Zealand who are experiencing a mathematical anxiety.”

If we combine all that we have written from the very beginning, the entire background of the study would now read:

If we analyze the background of the study that we have just completed, we can observe that in addition to the important elements that it should contain, it has also addressed other important elements that readers or thesis committee members expect from it.

On the one hand, it provides the researcher with a clear direction in the conduct of the study. As we can see, the background of the study that we have just completed enables us to move in the right direction with a strong focus as it has set clear goals and the reasons why we want to do it. Indeed, we now exactly know what to do next and how to write the rest of the research paper or thesis.

On the other hand, most researchers start their research with scattered ideas and usually get stuck with how to proceed further. But with a well-written background of the study, just as the one above, we have decluttered and organized our thoughts. We have also become aware of what have and have not been done in our area of study, as well as what we can significantly contribute in the already existing body of knowledge in this area of study.

Please note, however, as I already mentioned previously, that the model that I have just presented is only one of the many models available in textbooks and other sources. You are, of course, free to choose your own style of writing the background of the study. You may also consult your thesis supervisor for some guidance on how to attack the writing of your background of the study.

Lastly, and as you may already know, universities around the world have their own thesis formats. Hence, you should follow your university’s rules on the format and style in writing your research or thesis. What is important is that with the lessons that you learned in this course, you can now easily write the introductory part of your thesis, such as the background of the study.

Global site navigation

• Celebrities
• Celebrity biographies
• Messages - Wishes - Quotes
• TV-shows and movies
• Fashion and style
• Capital Market
• Family and Relationships

Local editions

• Legit Nigeria News
• Legit Hausa News
• Legit Spanish News
• Legit French News

Background of the study in research: guide on how to write one

The background of the study is one of the key aspects you need to get right when you are writing a research paper. It is the key to introducing your readers to the topic of your research, and it is different from the lead part. Here is how to write the background of the study in research studies.

Here is all you need to know about the study's science background and how to write one.

What is the background of the study?

Background of the study meaning: The background of the study is a part of the research provided in the introduction section of the paper. It is a compilation of adequate information that is based on the analysis of the problem or proposed argument, the steps and methods needed to arrive at the design, the implementation of the results achieved, and feasible solutions.

It is different from the introduction. The introduction only contains preliminary information about your research question or thesis topic. It is simply an overview of the research question or thesis topic. But the background of your study is more in-depth - it explains why your research topic or thesis is worth your readers' time.

Exclusive: Former presidential aide reveals why PDP will dislodge APC, win presidential election in 2023

The background of the study will provide your readers with context to the information discussed throughout your research paper. It can include both relevant and essential studies.

The background of the study is used to prove that a thesis question is relevant and also to develop the thesis. In summary, a good background of the study is the work done to determine that your research question or thesis topic is a problem and that the method used is the one required to solve the issue or answer the question.

What is the importance of the background of the study?

The background of the study helps your reader determine if you have a basic understanding of the research problem being investigated and promotes confidence in the overall quality of your analysis and findings.

How to write the background of the study in a research paper

• Stage 1. At the beginning stages of formulating your thesis, many of the issues are still very unclear, and you need to solidify your thoughts, so you should conduct preliminary research. This will help you put forward a research question or thesis statement that will lead to more relevant and specific research. You can visit a library, check the internet and other electronic databases to find preliminary sources such as scholarly journals and books about your background of the study.
• Stage 2. Read and gather the info you need to develop - a thesis statement or research question that will guide your thesis. You should take notes and keep an accurate track of the sources of information you have used up to this point. Many people use note cards, but it’s easier and better to use electronic note-taking programs in this electronic age. Just make sure to use a form that is comfortable and easier for you. Also, make sure you cite the source of every piece of information you are using on each note so that you won’t forget where you got the information from, just in case you want to use it in your thesis.
• Stage 3. Develop and pen down the research question or thesis statement. Think about the things you’ve read and searched and the issues or solutions that have been found by other people, and then formulate your stance or opinion on the issue. Write out your position or opinion as an authoritative statement. You may conduct more detailed research at this point and look for more sources that are more relevant to your research question or thesis.
• Stage 4. Complete your research using the thesis statement as your guide. Find sources that are relevant to your specific thesis and provide more insight into your research question using these sources. Your sources should provide information on your thesis's history and past research.
• Stage 5. As you create your background study, create relevant sections. When you start writing, create five sections with the key issues, major findings, and controversies surrounding your thesis, and a section that provides evaluation and a conclusion.
• Stage 6. Identify the further studies that need to be done in the conclusion section. Also, mention possible solutions to the issues that have not been considered in the past.
• Stage 7. Revise and edit your background of the study carefully. You can write out several drafts of your work, revising, editing, and adding more information before coming up with the final one. Make sure each draft is better than the previous one. You can also ask someone else to help you go through it.

Call of the void: why do we feel the urge to jump off high places?

The writing format

You can follow this format when writing your background of the study:

• Start by giving a general overview of your thesis topic and introduce the key ideas you will use throughout your thesis.
• Then, give precise information about all the methodologies used in the research. This can take up to several paragraphs depending on the individual and research question or thesis topic.
• Cite your sources where necessary to avoid plagiarism.
• Then you can briefly introduce the experiment by describing your choice of methodology, why you have decided to use this methodology instead of others, and the objective of the methodology.

What does a good background of the study example contain?

A good example of the background of the study is one that:

• Contains reviews of the area being researched
• Has currently available information about the problem of the study
• Captures the previous studies on the issue
• Indicates the history of the issue of the study from previous research done on the subject

Amazing 5 Forbes Tips for Investors, Entrepreneurs on Building Business, Brand and Ideas in Nigeria

A good background of the study sample has all these qualities.

How is the background of the study different from the literature review?

The section of literature review follows the background of the study section. It is the second section of your thesis. The literature review supports the study section's background by providing evidence for the proposed hypothesis.

Hopefully, this information on the background of the study has been helpful to you. Read other useful posts on our website to improve your writing skills.

READ ALSO: Can you start a sentence with but: A grammatical explanation

Legit.ng reported that one of the most deeply ingrained grammar rules involves the usage of the word 'but'. For a long time, teachers have told their students that they cannot use conjunctions at the beginning of sentences. If you asked your English teacher, "Can you start a sentence with but?" you would be met with a resounding 'No!'

Tianjin Binhai: Photos and video show Chinese big library with 1.2 million books and tall shelves

But where did this 'rule' even come from? And does it hold water? Find out by reading Legit.ng's take on the usage of 'but' at the beginning of a sentence.

Source: Legit.ng

• Affiliate Program

• UNITED STATES
• 台灣 (TAIWAN)
• TÜRKIYE (TURKEY)
• Academic Editing Services
• - Research Paper
• - Journal Manuscript
• - Dissertation
• - College & University Assignments
• Admissions Editing Services
• - Application Essay
• - Personal Statement
• - Recommendation Letter
• - Cover Letter
• - CV/Resume
• Business Editing Services
• - Business Documents
• - Report & Brochure
• - Website & Blog
• Writer Editing Services
• - Script & Screenplay
• Our Editors
• Client Reviews
• Editing & Proofreading Prices
• Wordvice Points
• Partner Discount
• Plagiarism Checker
• APA Citation Generator
• MLA Citation Generator
• Chicago Citation Generator
• Vancouver Citation Generator
• - APA Style
• - MLA Style
• - Chicago Style
• - Vancouver Style
• Writing & Editing Guide
• Academic Resources
• Admissions Resources

How to Write the Rationale of the Study in Research (Examples)

What is the Rationale of the Study?

The rationale of the study is the justification for taking on a given study. It explains the reason the study was conducted or should be conducted. This means the study rationale should explain to the reader or examiner why the study is/was necessary. It is also sometimes called the “purpose” or “justification” of a study. While this is not difficult to grasp in itself, you might wonder how the rationale of the study is different from your research question or from the statement of the problem of your study, and how it fits into the rest of your thesis or research paper. 

The rationale of the study links the background of the study to your specific research question and justifies the need for the latter on the basis of the former. In brief, you first provide and discuss existing data on the topic, and then you tell the reader, based on the background evidence you just presented, where you identified gaps or issues and why you think it is important to address those. The problem statement, lastly, is the formulation of the specific research question you choose to investigate, following logically from your rationale, and the approach you are planning to use to do that.

Table of Contents:

How to write a rationale for a research paper , how do you justify the need for a research study.

• Study Rationale Example: Where Does It Go In Your Paper?

The basis for writing a research rationale is preliminary data or a clear description of an observation. If you are doing basic/theoretical research, then a literature review will help you identify gaps in current knowledge. In applied/practical research, you base your rationale on an existing issue with a certain process (e.g., vaccine proof registration) or practice (e.g., patient treatment) that is well documented and needs to be addressed. By presenting the reader with earlier evidence or observations, you can (and have to) convince them that you are not just repeating what other people have already done or said and that your ideas are not coming out of thin air. 

Once you have explained where you are coming from, you should justify the need for doing additional research–this is essentially the rationale of your study. Finally, when you have convinced the reader of the purpose of your work, you can end your introduction section with the statement of the problem of your research that contains clear aims and objectives and also briefly describes (and justifies) your methodological approach. 

When is the Rationale for Research Written?

The author can present the study rationale both before and after the research is conducted. 

• Before conducting research : The study rationale is a central component of the research proposal . It represents the plan of your work, constructed before the study is actually executed.
• Once research has been conducted : After the study is completed, the rationale is presented in a research article or  PhD dissertation  to explain why you focused on this specific research question. When writing the study rationale for this purpose, the author should link the rationale of the research to the aims and outcomes of the study.

What to Include in the Study Rationale

Although every study rationale is different and discusses different specific elements of a study’s method or approach, there are some elements that should be included to write a good rationale. Make sure to touch on the following:

• A summary of conclusions from your review of the relevant literature
• What is currently unknown (gaps in knowledge)
• Inconclusive or contested results  from previous studies on the same or similar topic
• The necessity to improve or build on previous research, such as to improve methodology or utilize newer techniques and/or technologies

There are different types of limitations that you can use to justify the need for your study. In applied/practical research, the justification for investigating something is always that an existing process/practice has a problem or is not satisfactory. Let’s say, for example, that people in a certain country/city/community commonly complain about hospital care on weekends (not enough staff, not enough attention, no decisions being made), but you looked into it and realized that nobody ever investigated whether these perceived problems are actually based on objective shortages/non-availabilities of care or whether the lower numbers of patients who are treated during weekends are commensurate with the provided services.

In this case, “lack of data” is your justification for digging deeper into the problem. Or, if it is obvious that there is a shortage of staff and provided services on weekends, you could decide to investigate which of the usual procedures are skipped during weekends as a result and what the negative consequences are. 

In basic/theoretical research, lack of knowledge is of course a common and accepted justification for additional research—but make sure that it is not your only motivation. “Nobody has ever done this” is only a convincing reason for a study if you explain to the reader why you think we should know more about this specific phenomenon. If there is earlier research but you think it has limitations, then those can usually be classified into “methodological”, “contextual”, and “conceptual” limitations. To identify such limitations, you can ask specific questions and let those questions guide you when you explain to the reader why your study was necessary:

Methodological limitations

• Did earlier studies try but failed to measure/identify a specific phenomenon?
• Was earlier research based on incorrect conceptualizations of variables?
• Were earlier studies based on questionable operationalizations of key concepts?
• Did earlier studies use questionable or inappropriate research designs?

Contextual limitations

• Have recent changes in the studied problem made previous studies irrelevant?
• Are you studying a new/particular context that previous findings do not apply to?

Conceptual limitations

• Do previous findings only make sense within a specific framework or ideology?

Study Rationale Examples

Let’s look at an example from one of our earlier articles on the statement of the problem to clarify how your rationale fits into your introduction section. This is a very short introduction for a practical research study on the challenges of online learning. Your introduction might be much longer (especially the context/background section), and this example does not contain any sources (which you will have to provide for all claims you make and all earlier studies you cite)—but please pay attention to how the background presentation , rationale, and problem statement blend into each other in a logical way so that the reader can follow and has no reason to question your motivation or the foundation of your research.

Background presentation

Since the beginning of the Covid pandemic, most educational institutions around the world have transitioned to a fully online study model, at least during peak times of infections and social distancing measures. This transition has not been easy and even two years into the pandemic, problems with online teaching and studying persist (reference needed) . 

While the increasing gap between those with access to technology and equipment and those without access has been determined to be one of the main challenges (reference needed) , others claim that online learning offers more opportunities for many students by breaking down barriers of location and distance (reference needed) .  

Rationale of the study

Since teachers and students cannot wait for circumstances to go back to normal, the measures that schools and universities have implemented during the last two years, their advantages and disadvantages, and the impact of those measures on students’ progress, satisfaction, and well-being need to be understood so that improvements can be made and demographics that have been left behind can receive the support they need as soon as possible.

Statement of the problem

To identify what changes in the learning environment were considered the most challenging and how those changes relate to a variety of student outcome measures, we conducted surveys and interviews among teachers and students at ten institutions of higher education in four different major cities, two in the US (New York and Chicago), one in South Korea (Seoul), and one in the UK (London). Responses were analyzed with a focus on different student demographics and how they might have been affected differently by the current situation.

How long is a study rationale?

In a research article bound for journal publication, your rationale should not be longer than a few sentences (no longer than one brief paragraph). A  dissertation or thesis  usually allows for a longer description; depending on the length and nature of your document, this could be up to a couple of paragraphs in length. A completely novel or unconventional approach might warrant a longer and more detailed justification than an approach that slightly deviates from well-established methods and approaches.

Consider Using Professional Academic Editing Services

Now that you know how to write the rationale of the study for a research proposal or paper, you should make use of our free AI grammar checker , Wordvice AI, or receive professional academic proofreading services from Wordvice, including research paper editing services and manuscript editing services to polish your submitted research documents.

You can also find many more articles, for example on writing the other parts of your research paper , on choosing a title , or on making sure you understand and adhere to the author instructions before you submit to a journal, on the Wordvice academic resources pages.

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• Topic Collection
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 7, Issue 3
• Attributes, skills and actions of clinical leadership in nursing as reported by hospital nurses: a cross-sectional study
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0001-8401-4976 Majd T Mrayyan 1 ,
• http://orcid.org/0000-0002-6393-3022 Abdullah Algunmeeyn 2 ,
• http://orcid.org/0000-0002-2639-9991 Hamzeh Y Abunab 3 ,
• Ola A Kutah 2 ,
• Imad Alfayoumi 3 ,
• Abdallah Abu Khait 1
• 1 Department of Community and Mental Health Nursing, Faculty of Nursing , The Hashemite University , Zarqa , Jordan
• 2 Advanced Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• 3 Basic Nursing Department, Faculty of Nursing , Isra University , Amman , Jordan
• Correspondence to Dr Majd T Mrayyan, Department of Community and Mental Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa 13133, Jordan; mmrayyan{at}hu.edu.jo

Background Research shows a significant growth in clinical leadership from a nursing perspective; however, clinical leadership is still misunderstood in all clinical environments. Until now, clinical leaders were rarely seen in hospitals’ top management and leadership roles.

Purpose This study surveyed the attributes and skills of clinical nursing leadership and the actions that effective clinical nursing leaders can do.

Methods In 2020, a cross-sectional design was used in the current study using an online survey, with a non-random purposive sample of 296 registered nurses from teaching, public and private hospitals and areas of work in Jordan, yielding a 66% response rate. Data were analysed using descriptive analysis of frequency and central tendency measures, and comparisons were performed using independent t-tests.

Results The sample consists mostly of junior nurses. The ‘most common’ attributes associated with clinical nursing leadership were effective communication, clinical competence, approachability, role model and support. The ‘least common’ attribute associated with clinical nursing leadership was ‘controlling’. The top-rated skills of clinical leaders were having a strong moral character, knowing right and wrong and acting appropriately. Leading change and service improvement were clinical leaders’ top-rated actions. An independent t-test on key variables revealed substantial differences between male and female nurses regarding the actions and skills of effective clinical nursing leadership.

Conclusions The current study looked at clinical leadership in Jordan’s healthcare system, focusing on the role of gender in clinical nursing leadership. The findings advocate for clinical leadership by nurses as an essential element of value-based practice, and they influence innovation and change. As clinical leaders in various hospitals and healthcare settings, more empirical work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership of nursing leaders and nurses.

• clinical leadership
• health system
• leadership assessment

Data availability statement

Data are available on request due to privacy/ethical restrictions. https://authorservices.taylorandfrancis.com/data-sharing/share-your-data/data-availability-statements/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/leader-2022-000672

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

WHAT IS ALREADY KNOWN ON THIS TOPIC

Clinical leadership was limited to service managers; however, currently, all clinicians are invited to participate in leadership practices. Clinical leaders are needed in various healthcare settings to produce positive outcomes.

WHAT THIS STUDY ADDS

This study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership better. The current study highlighted the role of gender in clinical nursing leadership, and it asserts that effective clinical nursing leadership is warranted to improve the efficiency and effectiveness of care. The results call for nurses’ clinical leadership as essential in today’s turbulent work environment.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Nurses and clinical leaders need additional attributes, skills and actions. Clinical nursing leaders should use innovative interventions and have skills or actions to manage current work environments. Further work is needed to build on clinical nursing in general and the attributes, skills and actions of clinical nursing leadership. Clinical leadership programmes must be integrated into the nursing curricula.

Introduction

Clinical leadership is a matter of global importance. Currently, all clinicians are invited to participate in leadership practices. 1 This invitation is based on the fact that people deliver healthcare within complex systems. Effective clinicians must understand systems of care to function effectively. 1 2 Engaging in clinical leadership is an obligation, not a choice, for all clinicians at all levels. This obligation is more critical in nursing with many e merging global health issues , 2 such as the COVID-19 pandemic.

The systematic literature review of Cummings et al 3 shows the differences in leadership literature. In early 2000, clinical leadership emerged in scientific literature. 4 It is about having the knowledge, skills and competencies needed to effectively balance the needs of patients and team members within resource constraints. 4 Clinical leadership is vital in nursing as nurses face complex challenges in clinical settings, especially in acute care settings. 4 Although developed from the management domain, leadership and management are two concepts used interchangeably, 5–9 leading to further misunderstanding of the relationship between clinical leadership and management. While different types of leadership have been evident in nursing and health industry literature, clinical leadership is still misunderstood in clinical environments. 8 Clinical leadership is not fully understood among health professionals trained to care for patients, as clinical leadership is a management concept, leaving the concept open to different interpretations. 10 For example, Gauld 10 reported that clinical leaders might be professionals (such as doctors and nurses) who are no longer clinically active, mandating that clinical leaders should also be involved in delivering care. 10

There is no clear definition of ‘clinical leadership’. However, effective clinical leadership involves individuals with the appropriate clinical leadership skills and attributes at different levels of an organisation, focusing on multidisciplinary and interdisciplinary work. 10 The main skills associated with clinical leadership were having values and beliefs consistent with their actions and interventions, being supportive of colleagues, communicating effectively, serving as a role model and engaging in reflective practice. 4–9 The main attributes associated with clinical leadership were using effective communication, clinical competence, being a role model, supportive and approachability. 4–9 Stanley and colleagues reported that clinical leaders are found across health organisations and are presented in all clinical environments. Clinical leaders are often found at the highest level for clinical interaction but not commonly found at the highest management level in wards or units. 4–9

With the increasing urgency to improve the efficiency and effectiveness of care, effective nursing leadership is warranted. 4 11–17 Clinical leaders can be found in various healthcare settings, 4 most often at the highest clinical level, but they are uncommon at the top executive level. 6–9 18–24 In the UK, the National Health Service (NHS) 25 empowers clinicians and front-line staff to build their decision-making capabilities, which is required for clinical leadership. This empowerment encourages a broader practice of clinical leadership without being limited to top executives alone. 25 26

Purpose and significance

This study assesses clinical nursing leadership in Jordan. More specifically, it answers the following research questions: (1) What attributes are associated with clinical nursing leadership in Jordanian hospitals? (2) What skills are important for effective clinical nursing leadership? (3) What actions are important for effective clinical nursing leadership? (4) What are the differences in skills critical to effective clinical nursing leadership based on the sample’s characteristics? (5) What are the differences in effective clinical nursing leaders’ actions based on the sample’s characteristics?

Nursing leadership studies are abundant; however, clinical leadership research is not well established. 8 27 Until fairly recently, clinical leadership in nursing has tended to focus on nursing leaders in senior leadership positions, ignoring nurse managers in clinical positions. 8 There has been significant growth in research exploring clinical leadership from a nursing perspective. 4 8 9 14–17 24 26–32 A new leadership theory, ‘congruent leadership’, has emerged, claiming that clinical leaders acted on their values and beliefs about care and thus were followed. 6–9 20 This study is the first in Jordan’s nursing and health-related research about clinical leadership. Clarifying this concept from nurses’ perspectives will support greater healthcare delivery efficiencies.

Search methods

The initial search was done using ‘clinical nursing leadership’ at the Clarivate database and Google Scholar database from 2017 to 2021, yielded 35 studies, of which, after abstracting, 14 studies were selected. However, Stanley’s work (12 studies), including those before 2017, was included because we followed the researcher’s passion and methodology of studying clinical leadership; also, some classical models of clinical leadership because they were essential for the conceptualisation of the study as well as the discussion, such as the NHS Leadership Academy (three studies; ref 25 33 34 ).

Another search was run using the words ‘attributes’, ‘skills’ or ‘actions’ using the same time frame; most of the yielded studies were not relevant, this search year was expanded to 2013–2021 because the years 2013–2015 were the glorious time of studying these concepts. Using ‘clinical leadership’ rather than ‘leadership studies’, 15 studies were yielded; however, Stanley’s above work was excluded to avoid repetition, resulting in using three studies (ref 29 30 35 ). A relevant reference of 2022 similar to our study (ref 36 ) was added at the stages of revisions. The remaining 16 of 49 references were related to the methodology and explanation of some results, such as those related to gender differences in leadership. The following limits were set: the language was English; and the year of publication was basically the last 5 years to ensure that the search was current.

Clinical leadership

Clinical leadership ensures quality patient care by providing safe and efficient care and creating a healthy clinical work environment. 4 10–17 27 31 32 It also decreases the high costs of clinical litigation settlements and improves the safety of service delivery to consumers. 4 11–17 32 For these reasons, healthcare organisations should initiate interventions to develop clinical leadership among front-line clinicians, including nurses. 8 9

Literature was scarce on clinical leadership in nursing. 4 8–10 14–17 27 28 31 Stanley and Stanley 8 defined clinical leadership as developing a culture and leading a set of tasks to improve the quality and safety of service delivery to consumers.

Clinical leadership is about focusing on direct patient care, delivering high-quality direct patient care, motivating members of the team to provide effective, safe and satisfying care, promoting staff retention, providing organisational support and improving patient outcomes. 31 Clinical leadership roles include providing the vision, setting the direction, promoting professionalism, teamwork, interprofessional collaborations, good practice and continued medical education, contributing to patient care and performing tasks effectively. 31 Moreover, the researchers added that clinical leadership is having the approachability and the ability to communicate effectively, the ability to gain support and influence others, role modelling, visibility and availability to support, the ability to promote change, advise and guide. 31 Clinical leadership competencies include demonstrating clinical expertise, remaining clinically focused and engaged and comprehending clinical leadership roles and decision-making. In addition, clinical leadership was not associated with a position within the management and organisational structure, unlike health service management. 31 33

Clinical leadership is hindered by many barriers that include the lack of time and the high clinical/client demand on their time. 8 9 Clinical leadership is limited because of the deficit in intrapersonal and interpersonal capabilities among team members and interdisciplinary and organisational factors, such as a lack of influence in interdisciplinary care planning and policy. 37 Other barriers include limited organisational leadership opportunities, the perceived need for leadership development before serving in leadership roles and a lack of funding for advancement. 38

This paper aligns with the theory of congruent leadership proposed by Stanley. 19 This theory is best suited for understanding clinical leadership because it defines leadership as a congruence between the activities and actions of the leader and the leader’s values, beliefs and principles, and those of the organisation and team.

Attributes of clinical leadership

The clinical leadership attributes needed for nurses 8 28 to perform their roles effectively are: (1) personal attributes: nurses are confident in their abilities to provide best practice, communicate effectively and have emotional intelligence; (2) team attributes: encouraging trust and commitment to others, team focus and valuing others’ skills and expertise; and (3) capabilities: encouraging contribution from others, building and maintaining relationships, creating clear direction and being a role model. 8 28 Clinical leadership attributes are linked to communicating effectively, role modelling, promoting change, providing advice and guidance, gaining support and influencing others. 28–30 Other attributes to include are clinical leaders’ engagement in reflective practice, 29 provision of the vision; setting direction, having the resources to perform tasks effectively and promoting professionalism, teamwork, interprofessional collaborations, effective practice and continued education. 27 28 31

Skills of clinical leadership

Clinical leadership skills include (1) a ‘clinical focus’: being expert knowledge, providing evidence-based rationale and systematic thinking, understanding clinical leadership, understanding clinical decision-making, being clinically focused, remaining clinically engaged and demonstrating clinical expertise; (2) a ‘follower/team focus’: being supportive of colleagues, effectively communicating communication skills, serving as a role model and empowering the team; and (3) a ‘personal qualities focus’: engaging in reflective practice, initiating change and challenging the status quo. 17 30 32 Clinical leaders have advocacy skills, facilitate and maintain healthier workplaces by driving changes in cultural issues among all health professionals. 17 29 Moreover, the overlap between the attributes and skills of clinical leaders includes being credible to colleagues because of clinical competence and the skills and capacity to support multidisciplinary teams effectively. 17 29 32

Actions of clinical leadership

A clinical leader is anyone in a clinical position exercising leadership. 26 The clinical leader’s role is to continuously instil in clinicians the capability to improve healthcare on small and large scales. 26 Furthermore, Stanley et al 9 demonstrated that clinical leaders are not always managers or higher-ups in organisations. Clinical leaders act following their values and beliefs, are approachable and provide superior service to their clients. 9 Clinical leaders define and delegate safety and quality responsibilities and roles. 14 32 39 They also ensure safety and quality of care, manage the operation of the clinical governance system, implement strategic plans and implement the organisation’s safety culture. 14 32 39 The Australian Commission on Safety and Quality in Health Care 39 also reported that clinical leaders might support other clinicians by reviewing safety and quality performance data, supervising the clinical workforce, conducting performance appraisals and ensuring that the team understands the clinical governance system.

In summary, clinical leadership attributes, skills and actions were outlined to understand clinical nursing leadership. The literature shows limited nursing research on clinical leadership, calling for clinical leadership that paves the road for nurses in the current turbulent work environment.

Study design

A descriptive quantitative analysis was developed to collect data about the attributes and skills of clinical nursing leadership and the actions that effective nursing clinical leaders can take. A cross-sectional design was employed to measure clinical leadership using an online survey in 2020. This design was appropriate for such a study as it allows the researchers to measure the outcome and the exposures of the study participants at the same time. 40

Sample and settings

The general population was registered nurses in medical centres in Jordan. The target population was registered nurses in teaching, public and private hospitals. Most nurses in Jordan are females working at different shifts on a full-time basis in different types of healthcare services. The baccalaureate degree is the minimum entry into the clinical practice of registered nurses. As previous nurses, we would like to attest that nurses in Jordanian hospitals commonly use team nursing care delivery models with different decision-making styles. The size of the sample was calculated by using Thorndike’s rule as follows: N≥10(k)+50 (where N was the sample size, k is the number of independent variables) (attributes, skills, actions), the minimum sample size should be 80 participants. 40 From experience, the researcher considers the sample’s demographics and subscales as independent variables (k=17); the overall sample should not be less than 220.

Research participants were recruited through a ‘direct recruitment strategy’ from the hospitals where the nursing students were trained. A survey was used to collect data using non-random purposive sampling; of possible 450 Jordanian nurses, 296 were recruited from different types of hospitals: teaching (51 of possible 120 nurses), public (180 of possible 210 nurses) and private (65 of possible 120 nurses), with a response rate of 66%, which is adequate for an online survey. The inclusion criteria were that nurses should work in hospital settings, and any nurses who work in non-hospital settings were excluded. No incentives were applied.

Using a direct measurement method, Stanley’s Clinical Leadership Scale ( online supplemental file 1 ) was used to collect the data using the English version of the scale because English is the official education language of nursing in Jordan. 8 9 The original questionnaire consists of 24 questions: 12 quantitative and qualitative questions relevant to clinical leadership, and 12 related to the sample’s demographics. Several studies about clinical leadership among nurses and paramedics in the UK and Australia used modified versions of a survey tool 5 8 9 18–24 ; construct validity was ensured using exploratory factor analysis or triangulation of validation. Cronbach’s alpha measures the homogeneity in the survey, and it was reported to be 0.87 8 9 and 0.88 in the current study.

Supplemental material

Several questions were measured on a 5-point Likert scale in the original scale, and others were qualitative. The survey for the current study consists of 12 quantitative and qualitative questions related to clinical leadership and 14 questions related to the sample’s demographics. However, the qualitative data obtained were scattered and incomplete; thus, only the quantitative questions were analysed and reported, and another qualitative study about clinical leadership was planned. For the current study, three quantitative questions only focused on clinical leadership, leadership skills and the actions of clinical leaders, and 14 questions focused on the sample’s characteristics relevant to the Jordanian healthcare system developed by the first author. The sample characteristics were gender, marital status, shift worked, time commitment, level of education, age, years of experience in nursing, years of experience in leadership and the number of employees directly supervised. Other characteristics include the type of unit/ward, model of nursing care, ward/unit’s decision-making style, formal leadership-related education (yes/no) and formal management-related education (yes/no). Before data collection, permission to use the tool was granted.

Ethical considerations

Nurses were invited to answer the survey while assuring the voluntary nature of their participation. The participants were told that their participation in the survey was their consent form. Participants’ anonymity and confidentiality of information were assured; all questionnaires were numerically coded, and the overall results were shared with nursing and hospital administrators. 40

Patient and public involvement

There was no patient or public involvement in this research’s design, conduct, reporting or dissemination.

Data collection procedures

After a pilot study on 12 December 2020, which checked for the suitability of the questionnaire for the Jordanian healthcare settings, data were collected over a month on 23 December 2020. Data were collected through Google Forms; the survey was posted on various WhatsApp groups and Facebook pages. Using purposive snowball sampling, nurses were asked to invite their contacts and to submit the survey once. To assure one submission, the Google Forms was designed to allow for one submission only.

No problem was encountered during data collection. The two attrition prevention techniques used were effective communication and asserting to the participants that the study was relevant to them.

The researchers controlled for all possible extraneous and confounding variables by including them in the study. A possible non-accounted extraneous variable is the organisational structure; a centralised organisational structure may hinder the use of clinical nursing leadership.

Data analyses

After data cleaning and checking wild codes and outliers, all coded variables were entered into the Statistical Package for Social Sciences (SPSS) (V.25), 35 which was used to generate statistics according to the level of measurement. A descriptive analysis focused on frequency and central tendency measures. 40 Part 1 of the scale comprises 54 qualities or characteristics to answer the first research question. Responses related to skills were measured on a 1–5 Likert scale; thus, means and SDs were reported to answer the second research question. Eight actions were rated on a 1–5 Likert scale; thus, means and SDs were reported to answer the third research question. Independent t-tests using all sample characteristics were performed to answer the fourth and fifth research questions.

The preanalysis phase of data analysis was performed; data were eligible and complete as few missing data were found; thus, they were left without intervention. The assumption of normality was met; both samples are approximately normally distributed, and there were no extreme differences in the sample’s SDs.

Characteristics of the sample

There were 296 nurses in the current study from different types of hospitals: teaching (51 nurses), public (180 nurses) and private (65 nurses), with a response rate of 66%. Most nurses were females (209, 70.6%), single (87, 29.4%), working a day shift (143, 48.3%) or rotating shifts (92, 31.1%), on a full-time basis (218, 73.6%), with a baccalaureate degree (236, 79.7%), aged less than 25 years (229, 77.4%) and 25–34 years (45, 15.2%), respectively. Also, 65.1% (166) of nurses reported having less than 1 year of experience in nursing; thus, they have few nurses under them to supervise (145, 49% supervise one to two nurses), and 23.3% (69) of nurses reported having 1–9 years of experience in leadership. Nurses reported that their unit or ward has a primary (81, 27.4%) or team nursing care delivery model (162, 54.7%), with a mixed (94, 31.8%) or participatory decision-making style (113, 38.2%), and had formal leadership-related education (191, 64.5%), and had no formal management-related education (210, 70.9%) ( table 1 ).

• View inline

Sample’s characteristics (N=296*)

Attributes of clinical nursing leadership

Nurses were asked to think about the attributes and features of clinical leadership. Based on Stanley’s Clinical Leadership Scale, 8 9 nurses were given a list of 54 qualities and characteristics and asked to select the most strongly associated with clinical leadership, followed by those least strongly associated with clinical leadership. Table 2 shows the respondents’ ‘top ten’ selected qualities in ranked order.

'Most’ and ‘Least’ important attributes associated with clinical nursing leadership (N=296)

Skills of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the skills of effective clinical leaders from ‘not relevant’ or ‘not important’ to 5=‘very relevant’ or ‘very important’. The top skills were having a strong moral character, knowing right and wrong and acting appropriately which received a high rating, with a mean of 4.17 out of 5 (0.92). Being in a management position to be effective was ranked as the least skill of an effective leader, with a mean value of 3.78 out of 5 (1.00). As indicated by respondents, other skills of effective clinical leaders are shown in table 3 .

Skills of effective clinical nursing leaders (N=296)

Actions of effective clinical nursing leaders

On a Likert scale of 1–5, respondents were asked to rank the actions of effective clinical leaders. Leading change and service management achieved a high rating of 4.07 out of 5 points (0.90). Influencing organisational policy was rated last, with a mean score of 3.95 out of 5 (1.01), which may reflect the very junior nature of the majority of the sample. As described by respondents, some of the other actions of effective leaders are shown in table 4 .

Actions effective clinical nursing leaders can do (N=296)

Significant differences in skills of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fourth research question. Gender was the only characteristic variable that differentiated clinical leadership skills. An independent t-test demonstrates that males and females have distinct perspectives on 3 out of 10 items measuring clinical leadership skills. Female participants outperform male participants in terms of ‘working within the team (p value=0.021)’, ‘being visible in the clinical environment (p value=0.004)’ and ‘recognizing optimal performance and expressing appreciation promptly (p value=0.042) ( table 5 )’.

Significant differences in skills and actions of effective clinical nursing leaders based on gender (n=296)

Significant differences in actions of effective clinical nursing leaders based on gender

Independent t-tests using all sample’s characteristics were performed to answer the fifth research question. Gender was the only characteristic variable that differentiated clinical leadership actions, and it was discovered that five of the eight propositions varied in their actions: the way clinical care is administered (p=0.010); participating in staff development education (p=0.006); providing valuable staff support (p=0.033); leading change and service improvement (p=0.014); and encouraging and leading service management (p=0.019). The independent t-test results revealed that female participants scored higher in those acts, corresponding to effective leaders’ competencies. The mean values of participants’ responses to the actions of effective clinical leaders are shown in table 5 .

The characteristics of the current sample are similar to those of the structure of the task force in Jordan. The remaining question is how men in Jordan be supported in nursing to develop clinical leadership skills on par with females. Al-Motlaq et al 41 proposed using a part-time nurses policy to address nurses’ gender imbalances. Although this is necessary for both genders, we propose to develop a clinical leadership training package to promote working male nurses’ clinical leadership. In Jordan, we apply the modern trend of using leadership in nursing rather than management. About 65% of the nurses reported having formal leadership-related education, while around 71% reported no formal management-related education.

The findings clearly showed what nurses seek in a clinical leader. They appear to refer to a good communicator who values relationships and encouragement, is flexible, approachable and compassionate, can set goals and plans, resource allocation, is clinically competent and visible and has integrity. They necessitate clinical nursing leaders who can be role models for others in practice and deal with change. They should be supportive decision-makers, mentors and motivators. They should be emphatic; otherwise, they should not be in a position of control. These findings align with other research on clinical leadership. 7–9 21 Clinical leaders should be visible and participate in team activities. They should be highly skilled clinicians who instil trust and set an example, and their values should guide them in providing excellent patient care. 8 9

Participants chose other terms or functions associated with leadership roles less frequently or perceived as unrelated to clinical leadership functions. Management, creativity and vision were among the terms and functions mentioned. The absence of the word ‘visionary’ from the list of the most important characteristics suggests that traditional leadership theories, as transformational leadership and situational leadership, do not provide a solid foundation for understanding clinical leadership approaches in the clinical setting. This result can also be influenced by the junior level of the majority of the sample.

Skills of clinical nursing leadership

Numerous studies have documented the characteristics and skills of clinical leaders. 27 29 31 Clinical leaders’ skills include advocacy, facilitation and healthier workplaces. 27 29 31 Our participants were rated as having high morals (similar to other studies) 27 29 31 and worked within teams. 29 In turn, they were flexible and expressed appreciation promptly. 7–9 21 They were clinically competent; thus, they improvised and responded to various situations with appropriate skills and interventions. They recognised optimal performance, initiated interventions, led actions and procedures and had the skills and resources necessary to perform their tasks.

The lowest mean was ‘ being in a management position to be effective ’. This lowest meaning ‘ somehow ’ makes sense; all nurses can be effective leaders rather than managers, assuming effective clinical leadership roles without having management positions. 28 42

Actions of clinical nursing leadership

Influential nursing leaders are clinically competent and can initiate interventions and lead actions; these skills translate to actions. Clinical leaders are qualified to lead and manage the service improvement change (similar to Major). 42 This role will not suddenly happen; it requires clinical nursing leaders who encourage and participate in staff development education (consistent with Major). 42 This is an essential milestone and an example of providing valuable staff support. As these were the lowest reported actions, clinical nursing leaders should initiate and lead improvement initiatives in their clinical settings, 42 resulting in service improvement. They also have to influence evidence-based policies to improve work–life integration 43 and enhance patients, nurses and organisational outcomes. These outcomes include quality of care, nurses’ empowerment, job satisfaction, quality of life and work engagement. 4 11–17 32

Female nurses had more clinical leadership skills. Because the findings of this study have never been reported in the previous clinical leadership research literature, they are considered novel. This finding indicates that one possible explanation is that the overwhelming majority of respondents were females, with the proportion of females in favour (70.6%) exceeding that of males (29.4%). Furthermore, the current findings could be explained because the study was conducted in Jordan, a traditionally female-dominated gender nursing career.

This study discovered that there are gender differences in the characteristics of nurses and their clinical leadership skills, with female clinical nursing leaders scoring higher on the t-test than male clinical nursing leaders in the following areas: this is contrary to Masanotti et al , 43 who reported that male nurses have a greater sense of coherence and, in turn, more teamwork than female nurses, who commonly have job dissatisfaction and less teamwork. These could apply to female clinical nursing leaders. These female nurses had more ‘visibility in the clinical environment’, as expected in female-dominated gender nursing careers. As they were commonly dissatisfied as nurses, 43 clinical nursing leaders would be competent in caring for their nurses’ psychological status. These leaders know that even ‘thank you’ is the simplest way to show appreciation and recognition; however, this should be given promptly.

In Arab and developing countries, the perception that females have more skills with effective clinical leadership characteristics than males is consistent with Alghamdi et al 44 and Yaseen. 45 They found that females outperform males on leadership scales, which may also apply to clinical leadership. This study shows consistency between female and male clinical nursing leaders’ general perceptions of clinical leadership skills in female-dominated gender nursing careers but not in male-dominated, gender-segregated countries, including Jordan.

Female nurses had more clinical leadership actions, which differed in five out of eight actions. Female clinical nursing leaders were better at impacting clinical care delivery, participating in staff development education, providing valuable staff support, leading change and improving service.

It is aware that the nursing profession has a difficult context in some Arab and developing countries. For example, a study conducted in Saudi Arabia could explain the current findings that male nurses face various challenges, including a lack of respect and discrimination, resulting in fewer opportunities for professional growth and development. 46 The researchers reported that female clinical nursing leaders are preferred over male nurses because nursing is a nurturing and caring profession; it has been dubbed a ‘female profession’. 46 Additionally, this study corroborates a study that found many males avoid the nursing profession entirely due to its negative connotations 47 ; the profession is geared towards females. These and other stereotypes have influenced male nurses to pursue masculine nursing roles.

The study’s findings are unique because they have never been published in the previous clinical leadership research literature. However, these results can be explained indirectly based on non-clinical leadership literature. Consistent with Khammar et al , 48 as it is a female-dominated profession, it is apparent that female clinical nursing leaders are better at delivering clinical care. This result could also be related to female clinical nursing leaders having a better attitude towards clinical conditions and managing different conditions. 48 Female clinical nursing leaders, in turn, are better at influencing patient care and improving patient safety 36 and overall care and services. This improvement will not happen suddenly; it should be accompanied by paying more attention to providing continuous support, especially during induced change.

The current study reported that female clinical nursing leaders supported staff development and education because it is a female-oriented sample. Yet, Khammar et al 48 reported that men had more opportunities to educate themselves in nursing; this is true in a male-dominated country like Jordan. They also noted that males could communicate better during nursing duties. Regardless of gender, all of us should pay attention to our staff’s working environment and related issues, including promoting open communication, providing support, encouraging continuing education, managing change and improving the overall outcomes.

Limitations

Even though the study’s findings are intriguing, further investigation is needed to comprehend them. Because of the cross-sectional design used in the current study, we cannot establish causality. For this reason, the results should be interpreted with caution. Also, the purposive sample limits the generalisability; thus, this research should be carried out again with a broader selection of nursing candidates and clinical settings. Moreover, the sample consists mostly of nurses with minimal experience compared with nurses in other international countries such as Canada, the UK and the USA. 5 The current study also included nurses in their 40s and above, with male nurses less represented, and this causes misunderstanding of the true clinical leadership in nursing.

Implications

For practice, our sample consists of nurses with minimal experience compared with nurses in other developed counties. Our sample reported ‘influencing organizational policy’ as the last clinical leadership skill, which reflects the very junior nature of the sample. Unlike our study, in their systematic review, Guibert-Lacasa and Vázquez-Calatayud 36 reported that the profiles of the care clinical nurses’ experience usually varied, ranging from recent graduates to senior nurses. If our nurses were more experienced, it might lead to different results. More nurses’ clinical experience would increase nurses’ abilities at the bedside, especially in areas related to reasoning and problem solving. 36 More experienced nurses tend to work collaboratively within the team with greater competency and autonomy. 36 More experienced nurses would provide high-quality care, 36 resulting in patient satisfaction. To generate positive outcomes of clinical nursing leadership, such early-career nurses should be qualified. Guibert-Lacasa and Vázquez-Calatayud 36 suggested using the nursing clinical leadership programme based on the American Organization for Nursing Leadership 34 competency model, pending the presence of organisational support for such an initiative. 36

‘Most’ important clinical nursing leadership attributes should be promoted at all organisational and clinical levels. Clinical nursing leadership’s ‘least’ important attributes should be defeated to achieve better outcomes. Clinical nursing leaders should use innovative interventions and have skills or actions conducive to a healthy work environment. These interventions include being approachable to enable their staff to cope with change, 28 using open and consistent communication, 28–30 being visible and consistently available as role models and mentors and taking risks. 28 Hospital administrators must help their clinical leaders, including nursing leaders, to effectively use their authority, responsibility and accountability; clinical leadership is not only about complying with the job description. A good intervention to start with to promote the culture of clinical leadership is setting an award for the ‘ideal nursing leaders’. This award will bring innovative attributes, skills and actions.

Moreover, as they are in the front line of communication, nurses and clinical nursing leaders should be involved in policy-related matters and committees. 49 An interventional programme that gives nurses more autonomy in making decisions is warranted. In turn, various patient, nurse and organisational outcomes will be improved. 13–17 32

The study’s findings revealed statistically significant differences in the skills and actions of effective clinical leaders, with female nurses scoring higher in many skills and actions. Hence, healthcare organisations must re-evaluate current leadership and staff development policies and prioritise professional development for nurses while also introducing new modes of evaluation and assessment that are explicitly geared at improving clinical leadership among nurses, particularly males.

For education, this study outlined clinical leadership attributes, skills and actions to understand clinical nursing leadership in Jordan better. Nevertheless, nurses and clinical leaders need additional attributes, skills and actions. Consequently, undergraduate nursing students might benefit from clinical leadership programmes integrated into the academic curriculum to teach them the fundamentals of clinical leadership. A master’s degree programme in ‘Clinical Nursing Leadership’ would prepare nurses for this pioneering role and today and tomorrow’s clinical nursing leaders. However, all nurses are clinical leaders regardless of their degrees and experience. Conducting presentations, convening meetings, overseeing organisational transformation and settling disagreements are common ways to hone these abilities.

For research purposes, it is worth exploring the concept of clinical leadership from a practice nurse’s perspective to provide insight into practice nurses’ feelings and perceptions. Thus, a longitudinal quantitative design or a phenomenological qualitative design might be adopted to assess the subjective experience of the nurses involved. It is better in future research to focus on both young and veteran clinical leaders; some of our nurses were aged 45 years and above, and those nurses may not be clinically focused.

Summary and conclusion

The current study put clinical leadership into the context of the healthcare system in Jordan. This study highlighted the role of gender in clinical nursing leadership. Nurses’ clinical leadership is a milestone for influencing innovation and change. The current study identified the ‘most’ and ‘least’ important attributes, skills and actions associated with clinical leadership. However, the male and female nurses found substantial differences in effective clinical nursing leadership skills and actions. This study is unique; little is known about the collective concepts of attributes, skills and actions necessary for clinical nursing leadership.

Nurses need leadership attributes, skills and actions to influence policy development and change in their work environments. Leadership attributes can help develop programmes that give nurses more autonomy in making decisions. As a result, nurses will be more active as clinical leaders.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by The Hashemite University, Jordan (IRB number: 1/1/2020/2021) on 18 October 2020. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The researchers thank the subjects who participated in the study, and Mrs Othman and Mr Sayaheen who collected the data.

• Folaron I ,
• Colburn JA , et al
• Edmonson C ,
• McCarthy C ,
• Trent-Adams S , et al
• Cummings GG ,
• Tate K , et al
• Connolly M ,
• Stanley D ,
• Blanchard D ,
• Hohol A , et al
• Cao T , et al
• Cordeiro R ,
• Rengel-Diaz C ,
• Duignan M ,
• Drennan J ,
• McCarthy VJC
• Tao Z , et al
• Cuthbertson J ,
• Metcalfe H , et al
• Latimer K ,
• NHS Leadership Academy
• Loewenthal L , et al
• Claus S , et al
• Jackson D ,
• Mannix J , et al
• Siegel EO ,
• American Organization for Nursing Leadership
• Guibert-Lacasa C ,
• Vázquez-Calatayud M
• McNamara MS ,
• Casey M , et al
• Peltzer JN ,
• Shen Q , et al
• Australian Commission on Safety and Quality in Health Care
• Al-Motlaq M ,
• Masanotti GM ,
• Paolucci S ,
• Abbafati E , et al
• Alghamdi MG ,
• Abdelkader MA ,
• Abdelrahman S
• Abushaikha L ,
• Mahadeen A ,
• AbdelKader R , et al
• Khammar A ,
• Poursadeghiyan M ,
• Marioryad H , et al
• Kitson AL ,
• Gifford W , et al

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

Contributors MTM developed the study conception, abstract, introduction, literature review and methods; collected the data and wrote the first draft of this research paper and the final proofreading. HAN analysed the data and wrote the results. AA wrote the discussion and updated the literature review. OK wrote the limitations, implications, and summary and conclusion. IAF and AAK did the critical revisions and the final proofreading. All authors contributed to the current work.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

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.

Read the full text or download the PDF:

• Search Menu
• Advance articles
• Editor's Choice
• Focus Issue Archive
• Open Access Articles
• Author Guidelines
• Submission Site
• Open Access
• Call for Papers
• About Journal of the American Medical Informatics Association
• About the American Medical Informatics Association
• Journals Career Network
• Editorial Board
• Advertising and Corporate Services
• Self-Archiving Policy
• Dispatch Dates
• For Reviewers
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Background and significance, acknowledgments, author contributions, supplementary material, conflict of interest, data availability.

• < Previous

A national survey of digital health company experiences with electronic health record application programming interfaces

• Article contents
• Figures & tables
• Supplementary Data

Wesley Barker, Natalya Maisel, Catherine E Strawley, Grace K Israelit, Julia Adler-Milstein, Benjamin Rosner, A national survey of digital health company experiences with electronic health record application programming interfaces, Journal of the American Medical Informatics Association , Volume 31, Issue 4, April 2024, Pages 866–874, https://doi.org/10.1093/jamia/ocae006

• Permissions Icon Permissions

This study sought to capture current digital health company experiences integrating with electronic health records (EHRs), given new federally regulated standards-based application programming interface (API) policies.

We developed and fielded a survey among companies that develop solutions enabling human interaction with an EHR API. The survey was developed by the University of California San Francisco in collaboration with the Office of the National Coordinator for Health Information Technology, the California Health Care Foundation, and ScaleHealth. The instrument contained questions pertaining to experiences with API integrations, barriers faced during API integrations, and API-relevant policy efforts.

About 73% of companies reported current or previous use of a standards-based EHR API in production. About 57% of respondents indicated using both standards-based and proprietary APIs to integrate with an EHR, and 24% worked about equally with both APIs. Most companies reported use of the Fast Healthcare Interoperability Resources standard. Companies reported that standards-based APIs required on average less burden than proprietary APIs to establish and maintain. However, companies face barriers to adopting standards-based APIs, including high fees, lack of realistic clinical testing data, and lack of data elements of interest or value.

The industry is moving toward the use of standardized APIs to streamline data exchange, with a majority of digital health companies using standards-based APIs to integrate with EHRs. However, barriers persist.

A large portion of digital health companies use standards-based APIs to interoperate with EHRs. Continuing to improve the resources for digital health companies to find, test, connect, and use these APIs “without special effort” will be crucial to ensure future technology robustness and durability.

Over the past decade, and increasingly over the past few years, electronic health record (EHR) developers have implemented application programming interfaces (APIs) in response to the need to open their systems to third-party applications. In particular, as called for in the 2014 JASON report, A Robust Health Data Infrastructure , and Office of the National Coordinator for Health IT (ONC)-funded work led by Substitutable Medical Apps & Reusable Technology (SMART) and the Argonaut Project, standards-based APIs were essential to allow scalable integrations. 1–3 Standards-based APIs harmonize connections across different EHRs and facilitate third-party software integration, thereby improving interoperability by enabling streamlined and secure data exchange. 4 The progress of these efforts and maturity of APIs set the stage for federal regulations, implementing provisions of the 21st Century Cures Act, that made standards-based APIs the default method for third-party applications to access and exchange patient electronic health information from EHRs certified to the criteria and standards adopted by the US Department of Health and Human Services (HHS). 5 In particular, these regulations, finalized in 2020, adopted the Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) data exchange standard to enable third-party app developers to connect to certified EHRs. 6 Certified health IT developers were required to implement these APIs by 2022.

While the intent of these efforts—to improve interoperability—is clear, to what extent and for what use cases these standards-based APIs succeed in doing so is less clear. Historically, a 2016 survey of digital health companies found that a substantial number had attempted integrations with EHRs but encountered barriers, including a lack of developer support from EHR vendors, overall difficulty partnering with EHRs, and high associated costs. 7 A follow-up survey in 2018 found progress in companies’ abilities to integrate with EHRs through APIs, though challenges still remained. 8 Other studies have examined the availability of certain technologies integrated with EHRs (ie, capturing what was successfully integrated) and the overall robustness and durability of individual EHR company’s resources for third-party developers. 4 , 9 However, both prior digital health company surveys took place before the 2022 implementation deadline and included responses from less than 100 companies that had ever integrated their technology with an EHR. We therefore undertook an updated survey of these companies to capture the early impact of these regulations. We specifically sought to assess 3 dimensions. First, it is important to evaluate the use of standards-based versus proprietary EHR APIs to get a snapshot of national progress toward streamlined health data exchange between EHRs and third-party applications. Second, understanding company experiences integrating with specific EHR vendors (eg, Epic, Cerner) as well as the total number of vendors provides insight into the extent of interoperability of digital health company products. Third, it is critical to understand enablers of and barriers to EHR integration to inform ongoing policy and industry efforts to advance APIs and EHR integration.

This study sought to capture current digital health company experiences integrating with EHRs, now that new federally regulated standards-based API policies are in place and being implemented by EHR vendors. The survey covered company experience with EHR API integration, barriers to EHR integrations, and API policy and advancement efforts to ensure a robust perspective from digital health companies who are the primary consumers of these EHR APIs. These perspectives directly inform both policymakers and industry stakeholders on how to deliver next-generation technology solutions to health care providers and consumers. In particular, results will serve to guide the Department of Health and Human Services (HHS) on where ongoing policymaking may be needed to fulfill the intent of the 21st Century Cures Act. Results will also serve to guide EHR vendors and third-party software companies on the prevalence of ecosystem pain points that could lend themselves to private-sector solutions.

Sample data sources

A list of digital health companies to survey was compiled from a variety of data sources. The majority of companies ( n  = 605) came from a data scraping methodology developed by Barker & Johnson, which pulled company data from public app galleries for EHR-integrated solutions available from 1uphealth, Allscripts, athenahealth, CMS Bluebutton, CARIN Alliance, Cerner Corporation, eMDs, Epic Systems Corporation, Greenway, NextGen, and SMART. 9 Scraped data included the company name, the number of app galleries in which a company was found; the number of unique apps, names of apps, and functional app categories associated with a company; the targeted users of the company’s technology, and the company’s webpage. Since this method only identified companies that had been successful in integrating at least 1 app with an EHR or EHR-associated platform, we sought to capture a broader set of companies that may have attempted EHR integrations but have not been successful. We supplemented the preliminary list by pulling companies from: (1) a 2020 CB Insights Report titled “The digital health startups transforming the future of healthcare,” ( n  = 20), 10 (2) an analysis of relied upon software reported through the ONC Health IT Certification Program ( n  = 9), and (3) members of a national expert advisory board convened to support this project ( n  = 110) (see Table S1 for the list of members).

Inclusion criteria

Once we developed the list of companies across these 4 sources, we sought to limit it to those that develop solutions that enable human interaction with an API, such as provider-facing apps that access clinical data, either alone or in combination with non-clinical data, as well as patient-facing apps that access clinical or non-clinical data. These criteria exclude companies that solely make solutions that do not enable human interaction with an API, such as external databases or networks that connect to EHRs, apps that enable integration between 2 EHR systems, and provider-facing apps that do not access clinical data—given that these use cases are not the focus of federal regulations and face a different set of challenges. We also sought to exclude companies that make solutions that do not connect to an EHR (primarily those sourced from the CB Insights Report), as well as EHR vendors themselves.

To apply our inclusion criteria, we leveraged the app categories from the data scraping methodology. Companies and apps that were categorized as “clinical use” or “patient care” were included, while companies and apps that were categorized as “administrative” only were excluded. Companies and apps that were categorized as “patient engagement” were manually reviewed to determine inclusion. Manual review primarily involved accessing the app developer’s website or reviewing marketing materials obtained from the online marketplace or gallery to learn more about the app and its intended use. If it was determined that an app’s patient engagement function allowed access to patient records and clinical data, the company was included. For the remaining companies—those that did not have information on their app category, either because they had missing data or were not sourced using the scraping methodology—we first relied on data from the Apple and Google app stores to identify the app’s category. Among apps that could be found in the Apple or Google app stores, those categorized as “medical” were included in our sample, while those categorized as “health and fitness” were excluded. Apps that could not be found in the Apple or Google app stores were manually reviewed by evaluating the marketing materials on the app developer’s website to determine if they met inclusion criteria. This resulted in a final sampling frame of 704 companies.

Survey development

To capture the current state of progress and challenges that digital health companies face when integrating tools with EHRs, we developed and fielded a survey. The survey instrument was developed by the University of California San Francisco (UCSF) in collaboration with ONC, the California Health Care Foundation, and ScaleHealth (a healthcare solutions marketplace). It was refined based on feedback from the expert advisory board. The survey had 3 sections: (1) Experiences with API integrations, (2) barriers faced during API integrations, and (3) API-relevant policy efforts. The survey was pilot tested with 5 companies and then refined based on feedback. The final instrument can be found in the Supplementary Material .

Survey administration

Contact information for a target respondent at each company was sourced by ScaleHealth. The survey was distributed via the survey software Qualtrics and was fielded from June to November 2022.

To maximize the response rate, we employed a variety of outreach strategies. These included individual emails not only from UCSF but also from ScaleHealth, our expert advisors, and together. Health to target companies with whom they had existing relationships. We also posted the survey link and information to a variety of message boards, online forums, and listservs (which resulted in capturing 9 additional companies not in our original sampling frame that met inclusion criteria), increasing our total sample to 713. These boards, forums, and listservs included Health Tech Nerds, the American Medical Association Innovation Network, HIMSS Accelerate, ScaleHealth email listservs, the Society of Physician Entrepreneurs LinkedIn group, and the CARIN Alliance email listserv. Lastly, we printed business cards with a QR code link to the survey and distributed them to companies at the 2022 HLTH Conference. We followed-up with non-respondents up to 15 times over the course of survey administration. Incentives to participate in the survey included listing participating companies on public and peer-reviewed reports, providing a copy of the reports to respondents, and inviting respondents to a special session hosted by ONC during which the results and insights from the findings will be shared.

We conducted a set of descriptive analyses based on survey responses. First, we assessed the organizational demographics of the sample, including company relationship with protected heath information (eg, healthcare provider or other covered entity), primary application domain(s), and 2 proxies for size/maturity: company development stage and number of full time equivalent (FTE) staff working on products that integrate with commercial EHRs.

Our first set of analyses sought to capture use of standards-based versus proprietary APIs. We used survey questions that captured company status of integrations with EHRs via proprietary APIs, standards-based APIs, and third-party integration service (eg, Redox). For each integration type, companies were given the following response options: “Yes, in production (currently or previously),” “Yes, in process but not in production,” “Yes, but stopped (incomplete),” or “No.”

We then measured the relationship between the use of standards-based and proprietary APIs by calculating the percent of companies that use 1 type only (standards-based or proprietary), both types, and neither type. We also examined the relative use of proprietary and standards-based EHR APIs for companies that reported using both types by measuring the percent of respondents that reported using each API predominantly, mostly, or equally. Finally, within each of the groups, we calculated the percent of companies that reported using FHIR at all and the percent that used FHIR “extensively” to assess differences between companies’ use of FHIR in their apps across types of EHR API integrations. As FHIR represents the leading industry data standard for RESTful API-based data exchange, it is important to measure how companies’ adoption and use of the standard associates with the types of APIs they used to integrate with EHRs.

Our second set of analyses focused on experiences integrating with specific EHR vendors (eg, Epic, Cerner) as well as the total number of vendors. Through these analyses, we sought to assess the share of companies that integrate with specific EHRs and how adoption of standards-based APIs varies across companies that integrate with 1 or more EHR vendors. Specifically, we calculated the percent of companies that had a successful integration or 1 underway with an EHR. We then stratified the use of FHIR by the number of vendors with which a company integrated (1 vendor, 2-3 vendors, 4+ vendors) and calculated the percent of companies that reported using FHIR at all and the percent that reported using FHIR “extensively” to assess whether companies integrating with more than 1 EHR had higher rates of FHIR use. The core impetus for standardizing API-based exchange is to facilitate app and software integrations across multiple EHRs. We evaluated FHIR use this way because it is important to understand whether FHIR adoption by companies in their products correlates with the number of EHRs with which they integrate.

Our third set of analyses focused on enablers and barriers. First, we calculated the percent of companies that endorsed different dimensions of APIs as “moderately critical” or “critical to a great extent” to the company’s ability to work successfully with EHR APIs. These listed dimensions on the survey included: technical performance, breadth of data elements, and cost. We then calculated the top 10 most prevalent barriers reported by companies as “substantial” barriers to integration from a closed list of 20 barriers. We also compared the effort to establish and maintain proprietary and standards-based APIs to show how reported barriers may differently impact companies’ abilities to establish versus maintain EHR integrations. Finally, we examined open-ended responses to the questions of (1) high-priority clinical data types for future federally regulated availability and (2) future directions for policy efforts in promoting or enforcing access to data. We performed a text analysis of the free-text responses and report the 5 most common responses (grouped by key terms and themes) for each of the questions.

Sample sizes for each measure varied based on item non-response and skip logic (eg, if a company had no API-based EHR integrations, the survey programming logic had them skip many questions on the survey). Missing data were excluded from reported percentages. We conducted a non-response bias analysis to compare company characteristics between respondents and non-respondents. We did not do non-response weighting for reported statistics.

Of the 713 digital health companies on our final list, 125 companies completed the survey and 16 were considered sufficient partial completers (defined as completing through the questions on effort/resources to establish and maintain integrations with EHR vendors), for a response rate of 20%. A summary of respondent characteristics is included in Table 1 .

Characteristics of digital health company survey respondents.

Groups are not mutually exclusive.

Denominator differs due to survey question skip logic. Characteristic was collected only from respondents who reported an “in production” or “in process” integration with a commercial EHR.

Use of standards-based and proprietary APIs

Respondents reported using standards-based APIs to integrate their technologies with EHRs at high levels. Overall, 73% of companies reported current or previous use of a standards-based API in production, and another 13% reported having a standards-based API integration in process ( Figure 1 ). The second most frequently reported method for integration with EHRs was proprietary APIs, which 68% of companies reported as having currently or previously in production. About 30% of respondents indicated currently using or having previously used a third-party integration service in production. It was more common for companies to integrate their solutions using the EHR APIs directly than using a third-party integrator.

Digital health company status of integrations with EHRs. N = 141.

A majority of respondents (57%) indicated using both standards-based and proprietary APIs to integrate with an EHR ( Figure 2 ). Overall, 85% of companies reported supporting the FHIR standard as part of their application, with 61% using the standard extensively. Reported use of the FHIR standard was much higher among companies that used a standards-based EHR API (either alone or alongside a proprietary EHR API) compared to those that did not. 82% of companies using standards-based EHR APIs only and 79% of companies using standards-based EHR APIs alongside proprietary APIs reported use of FHIR in their products, with 89% and 75% of those companies using FHIR, respectively, reporting extensive use of the standard. Conversely, fewer companies that did not use standards-based EHR APIs used the FHIR standard. About 67% of companies only using proprietary APIs to integrate with an EHR and 52% of companies using neither API type, reported use of FHIR, with 50% of those companies using FHIR reporting extensive use of the standard.

Digital health company use of APIs and the FHIR standard. N = 141.

We found that 24% of companies worked about equally with both standards-based and proprietary APIs and 44% mostly or predominantly used standards-based APIs ( Figure 3 ).

The extent to which digital health companies report currently working with proprietary versus standards-based EHR APIs. N = 141.

EHR vendors

Companies reported successful integrations most frequently with market leading EHRs, including Epic (64%), athenahealth (37%), and Cerner (36%). An additional 18% (Epic), 13% (athenahealth), and 24% (Cerner) of companies reported that API-based integration efforts were underway ( Figure 4 ).

Status of integrations using varying EHR APIs. N = 141.

About 92% of companies had integrations underway with at least 1 EHR and 78% had integrations underway with 2 or more EHRs. Those companies that worked with more than 1 EHR vendor more frequently reported extensive use of the FHIR standard ( Figure 5 ). Specifically, among companies that worked with more than 1 EHR vendor, 73% reported extensive use of FHIR, compared to 27% of companies working with just 1 EHR vendor. About 47% of companies with integrations with just 1 EHR vendor reported using FHIR in a limited way, and 27% reported no use of the FHIR standard. The percent of companies that reported no use of the FHIR standard was just 9% for companies with integrations with 2-3 EHR vendors and 5% for companies with integrations with 4 or more vendors.

Digital health company respondent use of the FHIR standard, stratified by the number of EHR vendors with which their apps are integrated. N = 141.

Enablers and barriers

Several dimensions were identified by most respondents as critical for a company’s ability to work successfully with APIs ( Table 2 ). Technical performance (61%), breadth of data elements (60%), cost (56%), and quality documentation (51%) were reported most frequently as dimensions that were critical “to a great extent” for successful work with APIs, followed by EHR vendor support (50%), and effort to implement (45%).

Percent of digital health company respondents that indicated dimensions were “moderately critical” and “critical to a great extent” for a company’s ability to work successfully with EHR APIs ( N  = 141).

About 28% of companies rated standards-based APIs as very good based on the critical dimensions for a company to be able to work successfully with an API; this was a larger percent than proprietary APIs (25%), but a lesser percent compared to API-based third-party integration (40%).

Barriers pose challenges to digital health company use of EHR APIs. Among companies that reported using APIs, 47% reported high fees associated with accessing an EHR API as a substantial barrier ( Figure 6 ). The next most common challenges included a lack of realistic clinical testing data (41%), access to data elements of interest or value through APIs (40%), availability of standards-based APIs from the EHR vendor (38%), and standardized data elements (35%).

Top 10 “substantial” barriers to integrate with EHRs via APIs. N = 141.

Efforts to establish and maintain proprietary and standards-based APIs differed substantially. Companies reported that standards-based APIs required on average less burden than proprietary APIs to establish and maintain, with 52% and 21% of companies reporting that substantial effort is required for establishment and maintenance of proprietary APIs, and just 40% and 13% reporting substantial effort required for the establishment and maintenance of standards-based APIs.

Digital health company respondents provided open-ended responses regarding high-priority clinical data types for future federally regulated availability via EHR APIs, as well as future opportunities for policy efforts to promote or enforce access to data. This is summarized in Table 3 .

Five most requested improvements to high-priority clinical data types and future policy opportunities ( N  = 141).

In brief, respondents indicated interest in federally regulated availability (through EHR APIs) of social determinants of health (SDoH) and demographic data, genomic testing results, prescription and administered medications lists, clinical notes, and claims data. In addition to expanded data element availability, companies frequently highlighted the need for cost controls on EHR integration, as well as enforcement and incentivization of EHR vendor adherence to API standards.

Non-response bias analysis

Given the survey’s relatively low response rate (20%), we assessed non-response bias and found a few statistically significant differences between respondents and non-respondents. However, the observed, small-magnitude differences are unlikely to bias the representativeness of our results (Appendix SA2).

This study sought to capture current digital health company experiences integrating with EHRs, now that new federally regulated standards-based API policies are in place and being implemented by EHR vendors. Our analysis focused on 3 domains: the use of standards-based and proprietary EHR APIs, integrations across EHR vendors, and enablers and barriers to integrate with EHR APIs. Our results reveal that the majority of respondents use standards-based APIs to integrate with EHRs and support use of the HL7 FHIR standard in their products, likely facilitating their use of standards-based APIs. Although nearly the same number of companies reported use of proprietary EHR APIs, more companies reported predominantly or mostly using standards-based versus proprietary APIs, signaling that both API types were needed to successfully integrate, but that standards-based APIs were more integral. Taken together, this suggests that the field is making important progress in moving toward use of APIs that streamline data exchange through a common language but that a notable portion of digital health companies rely to some extent on non-standards-based APIs.

Substantial barriers such as high fees, lack of realistic clinical testing data, and lack of data elements of interest or value, indicate that progress has not been without associated friction. This is further supported by the significant difference we found in companies’ reported efforts to establish and maintain EHR API integrations—where efforts to establish were more than twice as burdensome. Companies’ recommendations for improving upon the current state of integration included that federal policy should promote more access through cost controls, testing and validation, and an expanded set of data elements available through APIs, which directly address these barriers. Further private sector support and federal policy are needed to ensure APIs are available to reduce barriers to entry and nurture competition “without special effort.”

In particular, results signal an opportunity for industry and ONC to consider and gain input on other high value use cases not currently adopted in the United States Core Data for Interoperability standard and standards-based APIs. Government and industry efforts, through pilots, standards accelerators, and standards development work groups, can help further standardize the data elements that can be accessed using standards-based APIs. 11 ONC also accepts and uses public feedback and complaints on real-world certified health IT use and barriers through the ONC Health IT Feedback portal to inform agency actions. 12

Reported barriers related to the uneven availability of APIs and access across different EHRs could lead more digital health companies to focus their integration efforts and customer recruitment across a subset of EHR vendors who provide more robust developer support and a wider availability of data elements beyond just the floor set by federal requirements. The percent of companies, however, that integrate with each EHR vendor align with the EHR market share we calculated across office-based sites and acute care hospitals derived from recent public data sources. 13 , 14 Even though the EHR marketplace skews toward a few predominant market leaders, it is important to ensure the market remains competitive and the burgeoning app ecosystem is built across all technologies (not just a few leaders). High rates of FHIR use among respondents, especially among companies working with multiple EHR vendors, suggest that FHIR-based APIs are successful in supporting apps developed with the intention to scale across multiple EHRs.

Limitations

The sample and respondents may not comprise a representative sample of digital health companies or all companies that are actively integrating and using EHR APIs. Nonetheless, our methodology to base our sample primarily on a list of companies pulled from public app galleries maintained by EHR vendors and other organizations and evolve and modify that list based on technical expert input resulted in a comprehensive list that, to our knowledge, exists nowhere else. We found through our market research no other representative list or sampling frame for this study, so novel methods and expert insights were needed to derive a sample of companies knowledgeable and experienced to answer the survey’s technical questions.

Our study was also limited to primarily commercial users of EHR APIs and did not include perspectives from clinicians, academic medical center researchers, and other EHR data users, who have research and business cases to use the APIs to connect and integrate their technologies and applications to the EHR. Their perspectives are no less important but were determined as out of scope for this study.

This study used a novel survey and sampling methodology to derive a robust sample of digital health companies to glean novel, national insights into companies’ experiences using EHR APIs and how the industry and federal policy can continue to shape the healthcare technology ecosystem. We found that a high proportion of digital health companies use standards-based APIs to interoperate with EHRs and support standards as part of their product base. The results show that an iterative and inclusive approach that incorporates industry feedback (not just EHRs, but the digital health and app developer community, too) can help push the technical and functional properties of standards-based APIs forward and in step with developer needs. Continuing to improve the resources for digital health companies to find, test, connect, and use these APIs “without special effort” will be crucial to ensure the technology is robust and durable into the future.

We would like to acknowledge Robert Plush, Scale Health; Hong Truong, formerly California Health Care Foundation; Christian Johnson, PhD, formerly Office of the National Coordinator for Health IT; and Vaishali Patel, PhD, Office of the National Coordinator for Health IT for their work informing the survey instrument, sampling frame, and fielding of the final survey.

W.B. contributed to the conception and design of the manuscript; data acquisition, analysis, and interpretation of the data; and drafted and critically revised the manuscript. N.M. contributed to the design, data acquisition, analysis, and interpretation of the data and drafted and critically revised the manuscript. C.S. contributed to the analysis and interpretation of the data and drafted and critically revised the manuscript. G.I. contributed to the design, data acquisition, and analysis of the data and drafted and critically revised the manuscript. J.A.M. contributed to the conception and design of the manuscript; data acquisition and interpretation of the data; and critically revised the manuscript. B.R. contributed to the conception and design of the manuscript; interpretation of the data; and critically revised the manuscript. All authors provided final approval of the final manuscript and agree to be accountable for all aspects of the work.

Supplementary material is available at Journal of the American Medical Informatics Association online.

This study was funded by the California Health Care Foundation (CHCF) (grant number G-31685). CHCF was involved in developing the survey instrument and recruiting respondents. CHCF had no role in the collection, analysis, and interpretation of the data, or in preparation of the manuscript.

The authors have no conflicts of interest.

The data underlying this article, even deidentified data, cannot be shared publicly with outside groups to preserve the privacy of individual survey responses. We are able to share aggregated results upon request.

The MITRE Corporation . A robust health data infrastructure. AHRQ Publication No. 14-0041-EF; April 2014 . Accessed May 24, 2023. https://www.healthit.gov/sites/default/files/ptp13-700hhs_white.pdf

Office of the National Coordinator for Health IT . Final report: Assessing the SHARP experience; July 2014 . Accessed May 24, 2023. https://www.healthit.gov/sites/default/files/sharp_final_report.pdf

HL7 International . Argonaut project. Accessed May 24, 2023 . https://confluence.hl7.org/display/AP/Argonaut+Project+Home

Office of the National Coordinator for Health IT . Accelerating application programing interfaces for scientific discovery: app developer and data integrator perspectives; March 2022 . Accessed May 24, 2023. https://www.healthit.gov/sites/default/files/page/2022-06/App-Developer-and-Integrator-Perspectives.pdf

Anthony E. The cures act final rule: interoperability-focused policies that empower patients and support providers; March 9, 2020 . Accessed June 22, 2023. https://www.healthit.gov/buzz-blog/21st-century-cures-act/the-cures-final-rule

Office of the National Coordinator for Health IT . 21st Century Cures Act: interoperability, information blocking, and the ONC health IT certification program. 85 FR 25642. Accessed May 24, 2023 . https://www.federalregister.gov/documents/2020/05/01/2020-07419/21st-century-curesact-interoperability-information-blocking-and-the-onc-health-it-certification

California HealthCare Foundation . Health 2.0 EMR API report; September 19, 2016 . Accessed May 24, 2023. https://www.slideshare.net/health2dev/health-20-emr-api-report

California HealthCare Foundation . Health 2.0 EMR API report 2018; November 28, 2018. Accessed May 24, 2023. https://www.slideshare.net/health2dev/helath-20-emr-api-report-2018

Barker W , Johnson C. The ecosystem of apps and software integrated with certified health information technology . J Am Med Inform Assoc . 2021 ; 28 ( 11 ): 2379 - 2384 .

Google Scholar

CB Insights . Digital health 150 of 2020: the digital health startups transforming the future of healthcare; August 13, 2020 . Accessed: June 22, 2023. https://www.cbinsights.com/research/digital-health-startups-redefining-healthcare-2020/

Office of the National Coordinator for Health IT . Interoperability standards advisory: United States core data for interoperability. Accessed May 24, 2023 . https://www.healthit.gov/isa/united-states-core-data-interoperability-uscdi

Office of the National Coordinator for Health IT . Health IT feedback and inquiry portal. Accessed December 12, 2023. https://inquiry.healthit.gov/support/plugins/servlet/desk/portal/2

National Center for Health Statistics (NCHS) . 2021 National Electronic Health Record Survey (NEHRS). Accessed May 24, 2023 . https://www.cdc.gov/nchs/nehrs/about.htm

American Hospital Association (AHA) . 2022 information technology supplement. Accessed May 24, 2023 . https://www.ahadata.com/aha-healthcare-it-database

Supplementary data

Email alerts, citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1527-974X
• Copyright © 2024 American Medical Informatics Association
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Open access
• Published: 02 April 2022

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

• Nicholas C. Coombs 1 ,
• Duncan G. Campbell 2 &
• James Caringi 1  

BMC Health Services Research volume  22 , Article number:  438 ( 2022 ) Cite this article

22k Accesses

19 Citations

10 Altmetric

Metrics details

Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Peer Review reports

Unequal access to healthcare services is an important element of health disparities in the United States [ 1 ], and there remains much about access that is not fully understood. The lack of understanding is attributable, in part, to the lack of uniformity in how access is defined and evaluated, and the extent to which access is often oversimplified in research [ 2 ]. Subsequently, attempts to address population-level barriers to healthcare access are insufficient, and access remains an unresolved, complex health challenge [ 3 , 4 , 5 ]. This paper presents a study that aims to explore some of the less well studied barriers to healthcare access, particularly those that influence healthcare acceptability and appropriateness.

In truth, healthcare access entails a complicated calculus that combines characteristics of individuals, their households, and their social and physical environments with characteristics of healthcare delivery systems, organizations, and healthcare providers. For one to fully ‘access’ healthcare, they must have the means to identify their healthcare needs and have available to them care providers and the facilities where they work. Further, patients must then reach, obtain, and use the healthcare services in order to have their healthcare needs fulfilled. Levesque and colleagues critically examined access conceptualizations in 2013 and synthesized all ways in which access to healthcare was previously characterized; Levesque et al. proposed five dimensions of access: approachability, acceptability, availability, affordability and appropriateness [ 2 ]. These refer to the ability to perceive, seek, reach, pay for, and engage in services, respectively.

According to Levesque et al.’s framework, the five dimensions combine to facilitate access to care or serve as barriers. Approachability indicates that people facing health needs understand that healthcare services exist and might be helpful. Acceptability represents whether patients see healthcare services as consistent or inconsistent with their own social and cultural values and worldviews. Availability indicates that healthcare services are reached both physically and in a timely manner. Affordability simplifies one’s capacity to pay for healthcare services without compromising basic necessities, and finally, appropriateness represents the fit between healthcare services and a patient’s specific healthcare needs [ 2 ]. This study focused on the acceptability and appropriateness dimensions of access.

Before the novel coronavirus (SARS-CoV-2; COVID-19) pandemic, approximately 13.3% of adults in the US did not have a usual source of healthcare [ 6 ]. Millions more did not utilize services regularly, and close to two-thirds reported that they would be debilitated by an unexpected medical bill [ 7 , 8 , 9 ]. Findings like these emphasized a fragility in the financial security of the American population [ 10 ]. These concerns were exacerbated by the pandemic when a sudden surge in unemployment increased un- and under-insurance rates [ 11 ]. Indeed, employer-sponsored insurance covers close to half of Americans’ total cost of illness [ 12 ]. Unemployment linked to COVID-19 cut off the lone outlet to healthcare access for many. Health-related financial concerns expanded beyond individuals, as healthcare organizations were unequipped to manage a simultaneous increase in demand for specialized healthcare services and a steep drop off for routine revenue-generating healthcare services [ 13 ]. These consequences of the COVID-19 pandemic all put additional, unexpected pressure on an already fragmented US healthcare system.

Other structural barriers to healthcare access exist in relation to the rural–urban divide. Less than 10% of US healthcare resources are located in rural areas where approximately 20% of the American population resides [ 14 ]. In a country with substantially fewer providers per capita compared to many other developed countries, persons in rural areas experience uniquely pressing healthcare provider shortages [ 15 , 16 ]. Rural inhabitants also tend to have lower household income, higher rates of un- or under-insurance, and more difficulty with travel to healthcare clinics than urban dwellers [ 17 ]. Subsequently, persons in rural communities use healthcare services at lower rates, and potentially preventable hospitalizations are more prevalent [ 18 ]. This disparity often leads rural residents to use services primarily for more urgent needs and less so for routine care [ 19 , 20 , 21 ].

The differences in how rural and urban healthcare systems function warranted a federal initiative to focus exclusively on rural health priorities and serve as counterpart to Healthy People objectives [ 22 ]. The rural determinants of health, a more specific expression of general social determinants, add issues of geography and topography to the well-documented social, economic and political factors that influence all Americans’ access to healthcare [ 23 ]. As a result, access is consistently regarded as a top priority in rural areas, and many research efforts have explored the intersection between access and rurality, namely within its less understood dimensions (acceptability and appropriateness) [ 22 ].

Acceptability-related barriers to care

Acceptability represents the dimension of healthcare access that affects a patient’s ability to seek healthcare, particularly linked to one’s professional values, norms and culture [ 2 ]. Access to health information is an influential factor for acceptable healthcare and is essential to promote and maintain a healthy population [ 24 ]. According to the Centers for Disease Control and Prevention, health literacy or a high ‘health IQ’ is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others, which impacts healthcare use and system navigation [ 25 ]. The literature indicates that lower levels of health literacy contribute to health disparities among rural populations [ 26 , 27 , 28 ]. Evidence points to a need for effective health communication between healthcare organizations and patients to improve health literacy [ 24 ]. However, little research has been done in this area, particularly as it relates to technologically-based interventions to disseminate health information [ 29 ].

Stigma, an undesirable position of perceived diminished status in an individual’s social position, is another challenge that influences healthcare acceptability [ 30 ]. Those who may experience stigma fear negative social consequences in relation to care seeking. They are more likely to delay seeking care, especially among ethnic minority populations [ 31 , 32 ]. Social media presents opportunities for the dissemination of misleading medical information; this runs further risk for stigma [ 33 ]. Stigma is difficult to undo, but research has shown that developing a positive relationship with a healthcare provider or organization can work to reduce stigma among patients, thus promoting healthcare acceptability [ 34 ].

A provider’s attempts to engage patients and empower them to be active decision-makers regarding their treatment has also been shown to improve healthcare acceptability. One study found that patients with heart disease who completed a daily diary of weight and self-assessment of symptoms, per correspondence with their provider, had better care outcomes than those who did not [ 35 ]. Engaging with household family members and involved community healers also mitigates barriers to care, emphasizing the importance of a team-based approach that extends beyond those who typically provide healthcare services [ 36 , 37 ]. One study, for instance, explored how individuals closest to a pregnant woman affect the woman’s decision to seek maternity care; partners, female relatives, and community health-workers were among the most influential in promoting negative views, all of which reduced a woman’s likelihood to access care [ 38 ].

Appropriateness-related barriers to care

Appropriateness marks the dimension of healthcare access that affects a patient’s ability to engage, and according to Levesque et al., is of relevance once all other dimensions (the ability to perceive, seek, reach and pay for) are achieved [ 2 ]. The ability to engage in healthcare is influenced by a patient’s level of empowerment, adherence to information, and support received by their healthcare provider. Thus, barriers to healthcare access that relate to appropriateness are often those that indicate a breakdown in communication between a patient with their healthcare provider. Such breakdown can involve a patient experiencing miscommunication, confrontation, and/or a discrepancy between their provider’s goals and their own goals for healthcare. Appropriateness represents a dimension of healthcare access that is widely acknowledged as an area in need of improvement, which indicates a need to rethink how healthcare providers and organizations can adapt to serve the healthcare needs of their communities [ 39 ]. This is especially true for rural, ethnic minority populations, which disproportionately experience an abundance of other barriers to healthcare access. Culturally appropriate care is especially important for members of minority populations [ 40 , 41 , 42 ]. Ultimately, patients value a patient-provider relationship characterized by a welcoming, non-judgmental atmosphere [ 43 , 44 ]. In rural settings especially, level of trust and familiarity are common factors that affect service utilization [ 45 ]. Evidence suggests that kind treatment by a healthcare provider who promotes patient-centered care can have a greater overall effect on a patient’s experience than a provider’s degree of medical knowledge or use of modern equipment [ 46 ]. Of course, investing the time needed to nurture close and caring interpersonal connections is particularly difficult in under-resourced, time-pressured rural health systems [ 47 , 48 ].

The most effective way to evaluate access to healthcare largely depends on which dimensions are explored. For instance, a population-based survey can be used to measure the barrier of healthcare affordability. Survey questions can inquire directly about health insurance coverage, care-related financial burden, concern about healthcare costs, and the feared financial impacts of illness and/or disability. Many national organizations have employed such surveys to measure affordability-related barriers to healthcare. For example, a question may ask explicitly about financial concerns: ‘If you get sick or have an accident, how worried are you that you will not be able to pay your medical bills?’ [ 49 ]. Approachability and availability dimensions of access are also studied using quantitative analysis of survey questions, such as ‘Is there a place that you usually go to when you are sick or need advice about your health?’ or ‘Have you ever delayed getting medical care because you couldn’t get through on the telephone?’ In contrast, the remaining two dimensions–acceptability and appropriateness–require a qualitative approach, as the social and cultural factors that determine a patient’s likelihood of accepting aspects of the services that are to be received (acceptability) and the fit between those services and the patient’s specific healthcare needs (appropriateness) can be more abstract [ 50 , 51 ]. In social science, qualitative methods are appropriate to generate knowledge of what social events mean to individuals and how those individuals interact within them; these methods allow for an exploration of depth rather than breadth [ 52 , 53 ]. Qualitative methods, therefore, are appropriate tools for understanding the depth of healthcare providers’ experiences in the inherently social context of seeking and engaging in healthcare.

In sum, acceptability- and appropriateness-related barriers to healthcare access are multi-layered, complex and abundant. Ensuring access becomes even more challenging if structural barriers to access are factored in. In this study, we aimed to explore barriers to healthcare access among persons in Montana, a historically underserved, under-resourced, rural region of the US. Montana is the fourth largest and third least densely populated state in the country; more than 80% of Montana counties are classified as non-core (the lowest level of urban/rural classification), and over 90% are designated as health professional shortage areas [ 54 , 55 ]. Qualitative methods supported our inquiry to explore barriers to healthcare access related to acceptability and appropriateness.

Participants

Qualitative methods were utilized for this interpretive, exploratory study because knowledge regarding barriers to healthcare access within Montana’s rural health systems is limited. We chose Montana healthcare providers, rather than patients, as the population of interest so we may explore barriers to healthcare access from the perspective of those who serve many persons in rural settings. Inclusion criteria required study participants to provide direct healthcare to patients at least one-half of their time. We defined ‘provider’ as a healthcare organization employee with clinical decision-making power and the qualifications to develop or revise patients’ treatment plans. In an attempt to capture a group of providers with diverse experience, we included providers across several types and specialties. These included advanced practice registered nurses (APRNs), physicians (MDs and DOs), and physician assistants (PAs) who worked in critical care medicine, emergency medicine, family medicine, hospital medicine, internal medicine, pain medicine, palliative medicine, pediatrics, psychiatry, and urgent care medicine. We also included licensed clinical social workers (LCSWs) and clinical psychologists who specialize in behavioral healthcare provision.

Recruitment and Data Collection

We recruited participants via email using a snowball sampling approach [ 56 ]. We opted for this approach because of its effectiveness in time-pressured contexts, such as the COVID-19 pandemic, which has made healthcare provider populations hard to reach [ 57 ]. Considering additional constraints with the pandemic and the rural nature of Montana, interviews were administered virtually via Zoom video or telephone conferencing with Zoom’s audio recording function enabled. All interviews were conducted by the first author between January and September 2021. The average length of interviews was 50 min, ranging from 35 to 70 min. There were occasional challenges experienced during interviews (poor cell phone reception from participants, dropped calls), in which case the interviewer remained on the line until adequate communication was resumed. All interviews were included for analysis and transcribed verbatim into NVivo Version 12 software. All qualitative data were saved and stored on a password-protected University of Montana server. Hard-copy field notes were securely stored in a locked office on the university’s main campus.

Data analysis included a deductive followed by an inductive approach. This dual analysis adheres to Levesque’s framework for qualitative methods, which is discussed in the Definition of Analytic Domains sub-section below. Original synthesis of the literature informed the development of our initial deductive codebook. The deductive approach was derived from a theory-driven hypothesis, which consisted of synthesizing previous research findings regarding acceptability- and appropriateness-related barriers to care. Although the locations, patient populations and specific type of healthcare services varied by study in the existing literature, several recurring barriers to healthcare access were identified. We then operationalized three analytic domains based on these findings: cultural considerations, patient-provider communication, and provider-provider communication. These domains were chosen for two reasons: 1) the terms ‘culture’ and ‘communication’ were the most frequently documented characteristics across the studies examined, and 2) they each align closely with the acceptability and appropriateness dimensions of access to healthcare, respectively. In addition, ‘culture’ is included in the definition of acceptability and ‘communication’ is a quintessential aspect of appropriateness. These domains guided the deductive portion of our analysis, which facilitated the development of an interview guide used for this study.

Interviews were semi-structured to allow broad interpretations from participants and expand the open-ended characterization of study findings. Data were analyzed through a flexible coding approach proposed by Deterding and Waters [ 58 ]. Qualitative content analysis was used, a method particularly beneficial for analyzing large amounts of qualitative data collected through interviews that offers possibility of quantifying categories to identify emerging themes [ 52 , 59 ]. After fifty percent of data were analyzed, we used an inductive approach as a formative check and repeated until data saturation, or the point at which no new information was gathered in interviews [ 60 ]. At each point of inductive analysis, interview questions were added, removed, or revised in consideration of findings gathered [ 61 ]. The Standards for Reporting Qualitative Research (SRQR) was used for reporting all qualitative data for this study [ 62 ]. The first and third authors served as primary and secondary analysts of the qualitative data and collaborated to triangulate these findings. An audit approach was employed, which consisted of coding completed by the first author and then reviewed by the third author. After analyses were complete, member checks ensured credibility and trustworthiness of findings [ 63 ]. Member checks consisted of contacting each study participant to explain the study’s findings; one-third of participants responded and confirmed all findings. All study procedures were reviewed and approved by the Human Subjects Committee of the authors’ institution’s Institutional Review Board.

Definitions of Analytic Domains

Cultural considerations.

Western health systems often fail to consider aspects of patients’ cultural perspectives and histories. This can manifest in the form of a providers’ lack of cultural humility. Cultural humility is a process of preventing imposition of one’s worldview and cultural beliefs on others and recognizing that everyone’s conception of the world is valid. Humility cultivates sensitive approaches in treating patients [ 64 ]. A lack of cultural humility impedes the delivery of acceptable and appropriate healthcare [ 65 ], which can involve low empathy or respect for patients, or dismissal of culture and traditions as superstitions that interfere with standard treatments [ 66 , 67 ]. Ensuring cultural humility among all healthcare employees is a step toward optimal healthcare delivery. Cultural humility is often accomplished through training that can be tailored to particular cultural- or gender-specific populations [ 68 , 69 ]. Since cultural identities and humility have been marked as factors that can heavily influence patients’ access to care, cultural considerations composed our first analytic domain. To assess this domain, we asked participants how they address the unique needs of their patients, how they react when they observe a cultural behavior or attitude from a patient that may not directly align with their treatment plan, and if they have received any multicultural training or training on cultural considerations in their current role.

Patient-provider communication

Other barriers to healthcare access can be linked to ineffective patient-provider communication. Patients who do not feel involved in healthcare decisions are less likely to adhere to treatment recommendations [ 70 ]. Patients who experience communication difficulties with providers may feel coerced, which generates disempowerment and leads patients to employ more covert ways of engagement [ 71 , 72 ]. Language barriers can further compromise communication and hinder outcomes or patient progress [ 73 , 74 ]. Any miscommunication between a patient and provider can affect one’s access to healthcare, namely affecting appropriateness-related barriers. For these reasons, patient-provider communication composed our second analytic domain. We asked participants to highlight the challenges they experience when communicating with their patients, how those complications are addressed, and how communication strategies inform confidentiality in their practice. Confidentiality is a core ethical principle in healthcare, especially in rural areas that have smaller, interconnected patient populations [ 75 ].

Provider-Provider Communication

A patient’s journey through the healthcare system necessitates sufficient correspondence between patients, primary, and secondary providers after discharge and care encounters [ 76 ]. Inter-provider and patient-provider communication are areas of healthcare that are acknowledged to have some gaps. Inconsistent mechanisms for follow up communication with patients in primary care have been documented and emphasized as a concern among those with chronic illness who require close monitoring [ 68 , 77 ]. Similar inconsistencies exist between providers, which can lead to unclear care goals, extended hospital stays, and increased medical costs [ 78 ]. For these reasons, provider-provider communication composed our third analytic domain. We asked participants to describe the approaches they take to streamline communication after a patient’s hospital visit, the methods they use to ensure collaborative communication between primary or secondary providers, and where communication challenges exist.

Healthcare provider characteristics

Our sample included 12 providers: four in family medicine (1 MD, 1 DO, 1 PA & 1 APRN), three in pediatrics (2 MD with specialty in hospital medicine & 1 DO), three in palliative medicine (2 MDs & 1 APRN with specialty in wound care), one in critical care medicine (DO with specialty in pediatric pulmonology) and one in behavioral health (1 LCSW with specialty in trauma). Our participants averaged 9 years (range 2–15) as a healthcare provider; most reported more than 5 years in their current professional role. The diversity of participants extended to their patient populations as well, with each participant reporting a unique distribution of age, race and level of medical complexity among their patients. Most participants reported that a portion of their patients travel up to five hours, sometimes across county- or state-lines, to receive care.

Theme 1: A friction exists between aspects of patients’ rural identities and healthcare systems

Our participants comprised a collection of medical professions and reported variability among health-related reasons their patients seek care. However, most participants acknowledged similar characteristics that influence their patients’ challenges to healthcare access. These identified factors formed categories from which the first theme emerged. There exists a great deal of ‘rugged individualism’ among Montanans, which reflects a self-sufficient and self-reliant way of life. Stoicism marked a primary factor to characterize this quality. One participant explained:

True Montanans are difficult to treat medically because they tend to be a tough group. They don’t see doctors. They don’t want to go, and they don’t want to be sick. That’s an aspect of Montana that makes health culture a little bit difficult.

Another participant echoed this finding by stating:

The backwoods Montana range guy who has an identity of being strong and independent probably doesn’t seek out a lot of medical care or take a lot of medications. Their sense of vitality, independence and identity really come from being able to take care and rely on themselves. When that is threatened, that’s going to create a unique experience of illness.

Similar responses were shared by all twelve participants; stoicism seemed to be heavily embedded in many patient populations in Montana and serves as a key determinant of healthcare acceptability. There are additional factors, however, that may interact with stoicism but are multiply determined. Stigma is an example of this, presented in this context as one’s concern about judgement by the healthcare system. Respondents were openly critical of this perception of the healthcare system as it was widely discussed in interviews. One participant stated:

There is a real perception of a punitive nature in the medical community, particularly if I observe a health issue other than the primary reason for one’s hospital visit, whether that may be predicated on medical neglect, delay of care, or something that may warrant a report to social services. For many of the patients and families I see, it’s not a positive experience and one that is sometimes an uphill barrier that I work hard to circumnavigate.

Analysis of these factors suggest that low use of healthcare services may link to several characteristics, including access problems. Separately, a patient’s perceived stigma from healthcare providers may also impact a patient’s willingness to receive services. One participant put it best by stating

Sometimes, families assume that I didn’t want to see them because they will come in for follow up to meet with me but end up meeting with another provider, which is frustrating because I want to maintain patients on my panel but available time and resource occasionally limits me from doing so. It could be really hard adapting to those needs on the fly, but it’s an honest miss.

When a patient arrives for a healthcare visit and experiences this frustration, it may elicit a patient’s perceptions of neglect or disorganization. This ‘honest miss’ may, in turn, exacerbate other acceptable-related barriers to care.

Theme 2: Facilitating access to healthcare requires application of and respect for cultural differences

The biomedical model is the standard of care utilized in Western medicine [ 79 , 80 ]. However, the US comprises people with diverse social and cultural identities that may not directly align with Western conceptions of health and wellness. Approximately 11.5% of the Montana population falls within an ethnic minority group. 6.4% are of American Indian or Alaska Native origin, 0.5% are of Black or African American origin, 0.8% are of Asian origin and 3.8% are of multiple or other origins. [ 81 ]. Cultural insensitivity is acknowledged in health services research as an active deterrent for appropriate healthcare delivery [ 65 ]. Participants for this study were asked how they react when a patient brings up a cultural attitude or behavior that may impact the proposed treatment plan. Eight participants noted a necessity for humility when this occurs. One participant conceptualized this by stating:

When this happens, I learn about individuals and a way of life that is different to the way I grew up. There is a lot of beauty and health in a non-patriarchal, non-dominating, non-sexist framework, and when we can engage in such, it is really expansive for my own learning process.

The participants who expressed humility emphasized that it is best to work in tandem with their patient, congruently. Especially for those with contrasting worldviews, a provider and a patient working as a team poses an opportunity to develop trust. Without it, a patient can easily fall out of the system, further hindering their ability to access healthcare services in the future. One participant stated:

The approach that ends up being successful for a lot of patients is when we understand their modalities, and they have a sense we understand those things. We have to show understanding and they have to trust. From there, we can make recommendations to help get them there, not decisions for them to obey, rather views based on our experiences and understanding of medicine.

Curiosity was another reaction noted by a handful of participants. One participant said:

I believe patients and their caregivers can be engaged and loving in different ways that don’t always follow the prescribed approach in the ways I’ve been trained, but that doesn’t necessarily mean that they are detrimental. I love what I do, and I love learning new things or new approaches, but I also love being surprised. My style of medicine is not to predict peoples’ lives, rather to empower and support what makes life meaningful for them.

Participants mentioned several other characteristics that they use in practice to prevent cultural insensitivity and support a collaborative approach to healthcare. Table 1 lists these facilitating characteristics and quotes to explain the substance of their benefit.

Consensus among participants indicated that the use of these protective factors to promote cultural sensitivity and apply them in practice is not standardized. When asked, all but two participants said they had not received any culturally-based training since beginning their practice. Instead, they referred to developing skills through “on the job training” or “off the cuff learning.” The general way of medicine, one participant remarked, was to “throw you to the fire.” This suggested that use of standardized cultural humility training modules for healthcare providers was not common practice. Many attributed this to time constraints.

Individual efforts to gain culturally appropriate skills or enhance cultural humility were mentioned, however. For example, three participants reported that they attended medical conferences to discuss cultural challenges within medicine, one participant sought out cultural education within their organization, and another was invited by Native American community members to engage in traditional peace ceremonies. Participants described these additional efforts as uncommon and outside the parameters of a provider’s job responsibilities, as they require time commitments without compensation.

Additionally, eight participants said they share their personal contact information with patients so they may call them directly for medical needs. The conditions and frequency with which this is done was variable and more common among providers in specialized areas of medicine or those who described having a manageable patient panel. All who reported that they shared their personal contact information described it as an aspect of rural health service delivery that is atypical in other, non-rural healthcare systems.

Theme 3: Communication between healthcare providers is systematically fragmented

Healthcare is complex and multi-disciplinary, and patients’ treatment is rarely overseen by a single provider [ 82 ]. The array of provider types and specialties is vast, as is the range of responsibilities ascribed to providers. Thus, open communication among providers both within and between healthcare systems is vital for the success of collaborative healthcare [ 83 ]. Without effective communication achieved between healthcare providers, the appropriate delivery of healthcare services may be become compromised. Our participants noted that they face multiple challenges that complicate communication with other providers. Miscommunication between departments, often implicating the Emergency Department (ED), was a recurring point noted among participants. One participant who is a primary care physician said:

If one of my patients goes to the ER, I don’t always get the notes. They’re supposed to send them to the patient’s primary care doc. The same thing happens with general admissions, but again, I often find out from somebody else that my patient was admitted to the hospital.

This failure to communicate can negatively impact the patient, particularly if time sensitivity or medical complexity is essential to treatment. A patient’s primary care physician is the most accurate source of their medical history; without an effective way to obtain and synthesize a patient’s health information, there may be increased risk of medical error. One participant in a specialty field stated:

One of the biggest barriers I see is obtaining a concise description of a patient’s history and needs. You can imagine if you’re a mom and you’ve got a complicated kid. You head to the ER. The ER doc looks at you with really wide eyes, not knowing how to get information about your child that’s really important.

This concern was highlighted with a specific example from a different participant:

I have been unable to troubleshoot instances when I send people to the ER with a pretty clear indication for admission, and then they’re sent home. For instance, I had an older fellow with pretty severe chronic kidney disease. He presented to another practitioner in my office with shortness of breath and swelling and appeared to have newly onset decompensated heart failure. When I figured this out, I sent him to the ER, called and gave my report. The patient later came back for follow up to find out not only that they had not been admitted but they lost no weight with outpatient dialysis . I feel like a real opportunity was missed to try to optimize the care of the patient simply because there was poor communication between myself and the ER. This poor guy… He ended up going to the ER four times before he got admitted for COVID-19.

In some cases, communication breakdown was reported as the sole cause of a poor outcome. When communication is effective, each essential member of the healthcare team is engaged and collaborating with the same information. Some participants called this process ‘rounds’ when a regularly scheduled meeting is staged between a group of providers to ensure access to accurate patient information. Accurate communication may also help build trust and improve a patient’s experience. In contrast, ineffective communication can result in poor clarity regarding providers’ responsibilities or lost information. Appropriate delivery of healthcare considers the fit between providers and a patient’s specific healthcare needs; the factors noted here suggest that provider-provider miscommunication can adversely affect this dimension of healthcare access.

Another important mechanism of communication is the sharing of electronic medical records (EMRs), a process that continues to shift with technological advances. Innovation is still recent enough, however, for several of our study participants to be able to recall a time when paper charts were standard. Widespread adoption and embrace of the improvements inherent in electronic medical records expanded in the late 2000’s [ 84 ]. EMRs vastly improved the ability to retain, organize, safeguard, and transfer health information. Every participant highlighted EMRs at one point or another and often did so with an underlying sense of anger or frustration. Systematic issues and problems with EMRs were discussed. One participant provided historical context to such records:

Years back, the government aimed to buy an electronic medical record system, whichever was the best, and a number of companies created their own. Each were a reasonable system, so they all got their checks and now we have four completely separate operating systems that do not talk to each other. The idea was to make a router or some type of relay that can share information back and forth. There was no money in that though, so of course, no one did anything about it. Depending on what hospital, clinic or agency you work for, you will most likely work within one of these systems. It was a great idea; it just didn’t get finished.

Seven participants confirmed these points and their impacts on making coordination more difficult, relying on outdated communication strategies more often than not. Many noted this even occurs between facilities within the same city and in separate small metropolitan areas across the state. One participant said:

If my hospital decides to contract with one EMR and the hospital across town contracts with another, correspondence between these hospitals goes back to traditional faxing. As a provider, you’re just taking a ‘fingered crossed’ approach hoping that the fax worked, is picked up, was put in the appropriate inbox and was actually looked at. Information acquisition and making sure it’s timely are unforeseen between EMRs.

Participants reported an “astronomic” number of daily faxes and telephone calls to complete the communication EMRs were initially designed to handle. These challenges are even more burdensome if a patient moves from out of town or out of state; obtaining their medical records was repeatedly referred to as a “chore” so onerous that it often remains undone. Another recurring concern brought up by participants regarded accuracy within EMRs to lend a false sense of security. They are not frequently updated, not designed to be family-centered and not set up to do anything automatically. One participant highlighted these limitations by stating:

I was very proud of a change I made in our EMR system [EPIC], even though it was one I never should have had to make. I was getting very upset because I would find out from my nursing assistant who read the obituary that one of my patients had died. There was a real problem with the way the EMR was notifying PCP’s, so I got an EPIC-level automated notification built into our EMR so that any time a patient died, their status would be changed to deceased and a notification would be sent to their PCP. It’s just really awful to find out a week later that your patient died, especially when you know these people and their families really well. It’s not good care to have blind follow up.

Whether it be a physical or electronic miscommunication between healthcare providers, the appropriate delivery of healthcare can be called to question

Theme 4: Time and resource constraints disproportionately harm rural health systems

Several measures of system capacity suggest the healthcare system in the US is under-resourced. There are fewer physicians and hospital beds per capita compared to most comparable countries, and the growth of healthcare provider populations has stagnated over time [ 15 ]. Rural areas, in particular, are subject to resource limitations [ 16 ]. All participants discussed provider shortages in detail. They described how shortages impact time allocation in their day-to-day operations. Tasks like patient intakes, critical assessments, and recovering information from EMRs take time, of which most participants claimed to not have enough of. There was also a consensus in having inadequate time to spend on medically complex cases. Time pressures were reported to subsequently influence quality of care. One participant stated:

With the constant pace of medicine, time is not on your side. A provider cannot always participate in an enriching dialogue with their patients, so rather than listen and learn, we are often coerced into the mindset of ‘getting through’ this patient so we can move on. This echoes for patient education during discharge, making the whole process more arduous than it otherwise could be if time and resources were not as sparse.

Depending on provider type, specialty, and the size of patient panels, four participants said they have the luxury of extending patient visits to 40 + minutes. Any flexibility with patient visits was regarded as just that: a luxury. Very few providers described the ability to coordinate their schedules as such. This led some study participants to limit the number of patients they serve. One participant said:

We simply don’t have enough clinicians, which is a shame because these people are really skilled, exceptional, brilliant providers but are performing way below their capacity. Because of this, I have a smaller case load so I can engage in a level of care that I feel is in the best interest of my patients. Everything is a tradeoff. Time has to be sacrificed at one point or another. This compromise sets our system up to do ‘ok’ work, not great work.

Of course, managing an overly large number of patients with high complexity is challenging. Especially while enduring the burden of a persisting global pandemic, participants reflected that the general outlook of administering healthcare in the US is to “do more with less.” This often forces providers to delegate responsibilities, which participants noted has potential downsides. One participant described how delegating patient care can cause problems.

Very often will a patient schedule a follow up that needs to happen within a certain time frame, but I am unable to see them myself. So, they are then placed with one of my mid-level providers. However, if additional health issues are introduced, which often happens, there is a high-risk of bounce-back or need to return once again to the hospital. It’s an inefficient vetting process that falls to people who may not have specific training in the labs and imaging that are often included in follow up visits. Unfortunately, it’s a forlorn hope to have a primary care physician be able to attend all levels of a patient’s care.

Several participants described how time constraints stretch all healthcare staff thin and complicate patient care. This was particularly important among participants who reported having a patient panel exceeding 1000. There were some participants, however, who praised the relationships they have with their nurse practitioners and physician’s assistants and mark transparency as the most effective way to coordinate care. Collectively, these clinical relationships were built over long standing periods of time, a disadvantage to providers at the start of their medical career. All but one participant with over a decade of clinical experience mentioned the usefulness of these relationships. The factors discussed in Theme 4 are directly linked to the Availability dimension of access to healthcare. A patient’s ability to reach care is subject to the capacity of their healthcare provider(s). Additionally, further analysis suggests these factors also link to the Appropriateness dimension because the quality of patient-provider relationships may be negatively impacted if a provider’s time is compromised.

Theme 5: Profits are prioritized over addressing barriers to healthcare access in the US.

The US healthcare system functions partially for-profit in the public and private sectors. The federal government provides funding for national programs such as Medicare, but a majority of Americans access healthcare through private employer plans [ 85 ]. As a result, uninsurance rates influence healthcare access. Though the rate of the uninsured has dropped over the last decade through expansion of the Affordable Care Act, it remains above 8 percent [ 86 ]. Historically, there has been ethical criticism in the literature of a for-profit system as it is said to exacerbate healthcare disparities and constitute unfair competition against nonprofit institutions. Specifically, the US healthcare system treats healthcare as a commodity instead of a right, enables organizational controls that adversely affect patient-provider relationships, undermines medical education, and constitutes a medical-industrial complex that threatens influence on healthcare-related public policy [ 87 ]. Though unprompted by the interviewer, participants raised many of these concerns. One participant shared their views on how priorities stand in their practice:

A lot of the higher-ups in the healthcare system where I work see each patient visit as a number. It’s not that they don’t have the capacity to think beyond that, but that’s what their role is, making sure we’re profitable. That’s part of why our healthcare system in the US is as broken as it is. It’s accentuated focus on financially and capitalistically driven factors versus understanding all these other barriers to care.

Eight participants echoed a similar concept, that addressing barriers to healthcare access in their organizations is largely complicated because so much attention is directed on matters that have nothing to do with patients. A few other participants supported this by alluding to a “cherry-picking” process by which those at the top of the hierarchy devote their attention to the easiest tasks. One participant shared an experience where contrasting work demands between administrators and front-line clinical providers produces adverse effects:

We had a new administrator in our hospital. I had been really frustrated with the lack of cultural awareness and curiosity from our other leaders in the past, so I offered to meet and take them on a tour of the reservation. This was meant to introduce them to kids, families and Tribal leaders who live in the area and their interface with healthcare. They declined, which I thought was disappointing and eye-opening.

Analysis of these factors suggest that those who work directly with patients understand patient needs better than those who serve in management roles. This same participant went on to suggest an ulterior motive for a push towards telemedicine, as administrators primarily highlight the benefit of billing for virtual visits instead of the nature of the visits themselves.

This study explored barriers and facilitators to healthcare access from the perspective of rural healthcare providers in Montana. Our qualitative analysis uncovered five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. Themes 2 and 3 were directly supported by earlier qualitative studies that applied Levesque’s framework, specifically regarding healthcare providers’ poor interpersonal quality and lack of collaboration with other providers that are suspected to result from a lack of provider training [ 67 , 70 ]. This ties back to the importance of cultural humility, which many previous culture-based trainings have referred to as cultural competence. Cultural competence is achieved through a plethora of trainings designed to expose providers to different cultures’ beliefs and values but induces risk of stereotyping and stigmatizing a patient’s views. Therefore, cultural humility is the preferred idea, by which providers reflect and gain open-ended appreciation for a patient’s culture [ 88 ].

Implications for Practice

Perhaps the most substantial takeaway is how embedded rugged individualism is within rural patient populations and how difficult that makes the delivery of care in rural health systems. We heard from participants that stoicism and perceptions of stigma within the system contribute to this, but other resulting factors may be influential at the provider- and organizational-levels. Stoicism and perceived stigma both appear to arise, in part, from an understandable knowledge gap regarding the care system. For instance, healthcare providers understand the relations between primary and secondary care, but many patients may perceive both concepts as elements of a single healthcare system [ 89 ]. Any issue experienced by a patient when tasked to see both a primary and secondary provider may result in a patient becoming confused [ 90 ]. This may also overlap with our third theme, as a disjointed means of communication between healthcare providers can exacerbate patients’ negative experiences. One consideration to improve this is to incorporate telehealth programs into an existing referral framework to reduce unnecessary interfacility transfers; telehealth programs have proven effective in rural and remote settings [ 91 ].

In fact, telehealth has been rolled out in a variety of virtual platforms throughout its evolution, its innovation matched with continued technological advancement. Simply put, telehealth allows health service delivery from a distance; it allows knowledge and practice of clinical care to be in a different space than a patient. Because of this, a primary benefit of telehealth is its impact on improving patient-centered outcomes among those living in rural areas. For instance, text messaging technology improves early infant diagnosis, adherence to recommended diagnostic testing, and participant engagement in lifestyle change interventions [ 92 , 93 , 94 ]. More sophisticated interventions have found their way into smartphone-based technology, some of which are accessible even without an internet connection [ 95 , 96 ]. Internet accessibility is important because a number of study participants noted internet connectivity as a barrier for patients who live in low resource communities. Videoconferencing is another function of telehealth that has delivered a variety of health services, including those which are mental health-specific [ 97 ], and mobile health clinics have been used in rural, hard-to-reach settings to show the delivery of quality healthcare is both feasible and acceptable [ 98 , 99 , 100 ]. While telehealth has potential to reduce a number of healthcare access barriers, it may not always address the most pressing healthcare needs [ 101 ]. However, telehealth does serve as a viable, cost-effective alternative for rural populations with limited physical access to specialized services [ 102 ]. With time and resource limitations acknowledged as a key theme in our study, an emphasis on expanding telehealth services is encouraged as it will likely have significant involvement on advancing healthcare in the future, especially as the COVID-19 pandemic persists [ 103 ].

Implications for Policy

One could argue that most of the areas of fragmentation in the US healthcare system can be linked to the very philosophy on which it is based: an emphasis on profits as highest priority. Americans are, therefore, forced to navigate a health service system that does not work solely in their best interests. It is not surprising to observe lower rates of healthcare usage in rural areas, which may be a result from rural persons’ negative views of the US healthcare system or a perception that the system does not exist to support wellness. These perceptions may interact with ‘rugged individualism’ to squelch rural residents’ engagement in healthcare. Many of the providers we interviewed for this study appeared to understand this and strived to improve their patients’ experiences and outcomes. Though these efforts are admirable, they may not characterize all providers who serve in rural areas of the US. From a policy standpoint, it is important to recognize these expansive efforts from providers. If incentives were offered to encourage maximum efforts be made, it may lessen burden due to physician burnout and fatigue. Of course, there is no easy fix to the persisting limit of time and resources for providers, problems that require workforce expansion. Ultimately, though, the current structure of the US healthcare system is failing rural America and doing little to help the practice of rural healthcare providers.

Implications for Future Research

It is important for future health systems research efforts to consider issues that arise from both individual- and system-level access barriers and where the two intersect. Oftentimes, challenges that appear linked to a patient or provider may actually stem from an overarching system failure. If failures are critically and properly addressed, we may refine our understanding of what we can do in our professional spaces to improve care as practitioners, workforce developers, researchers and advocates. This qualitative study was exploratory in nature. It represents a step forward in knowledge generation regarding challenges in access to healthcare for rural Americans. Although mental health did not come up by design in this study, future efforts exploring barriers to healthcare access in rural systems should focus on access to mental healthcare. In many rural areas, Montana included, rates of suicide, substance use and other mental health disorders are highly prevalent. These characteristics should be part of the overall discussion of access to healthcare in rural areas. Optimally, barriers to healthcare access should continue to be explored through qualitative and mixed study designs to honor its multi-dimensional stature.

Strengths and Limitations

It is important to note first that this study interviewed healthcare providers instead of patients, which served as both a strength and limitation. Healthcare providers were able to draw on numerous patient-provider experiences, enabling an account of the aggregate which would have been impossible for a patient population. However, accounts of healthcare providers’ perceptions of barriers to healthcare access for their patients may differ from patients’ specific views. Future research should examine acceptability- and appropriateness-related barriers to healthcare access in patient populations. Second, study participants were recruited through convenience sampling methods, so results may be biased towards healthcare providers who are more invested in addressing barriers to healthcare access. Particularly, the providers interviewed for this study represented a subset who go beyond expectations of their job descriptions by engaging with their communities and spending additional uncompensated time with their patients. It is likely that a provider who exhibits these behavioral traits is more likely to participate in research aimed at addressing barriers to healthcare access. Third, the inability to conduct face-to-face interviews for our qualitative study may have posed an additional limitation. It is possible, for example, that in-person interviews might have resulted in increased rapport with study participants. Notwithstanding this possibility, the remote interview format was necessary to accommodate health risks to the ongoing COVID-19 pandemic. Ultimately, given our qualitative approach, results from our study cannot be generalizable to all rural providers’ views or other rural health systems. In addition, no causality can be inferred regarding the influence of aspects of rurality on access. The purpose of this exploratory qualitative study was to probe research questions for future efforts. We also acknowledge the authors’ roles in the research, also known as reflexivity. The first author was the only author who administered interviews and had no prior relationships with all but one study participant. Assumptions and pre-dispositions to interview content by the first author were regularly addressed throughout data analysis to maintain study integrity. This was achieved by conducting analysis by unique interview question, rather than by unique participant, and recoding the numerical order of participants for each question. Our commitment to rigorous qualitative methods was a strength for the study for multiple reasons. Conducting member checks with participants ensured trustworthiness of findings. Continuing data collection to data saturation ensured dependability of findings, which was achieved after 10 interviews and confirmed after 2 additional interviews. We further recognize the heterogeneity in our sample of participants, which helped generate variability in responses. To remain consistent with appropriate means of presenting results in qualitative research however, we shared minimal demographic information about our study participants to ensure confidentiality.

The divide between urban and rural health stretches beyond a disproportionate allocation of resources. Rural health systems serve a more complicated and hard-to-reach patient population. They lack sufficient numbers of providers to meet population health needs. These disparities impact collaboration between patients and providers as well as the delivery of acceptable and appropriate healthcare. The marker of rurality complicates the already cumbersome challenge of administering acceptable and appropriate healthcare and impediments stemming from rurality require continued monitoring to improve patient experiences and outcomes. Our qualitative study explored rural healthcare providers’ views on some of the social, cultural, and programmatic factors that influence access to healthcare among their patient populations. We identified five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. This study provides implications that may shift the landscape of a healthcare provider’s approach to delivering healthcare. Further exploration is required to understand the effects these characteristics have on measurable patient-centered outcomes in rural areas.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to individual privacy could be compromised but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate.

All study procedures and methods were carried out in accordance with relevant guidelines and regulations from the World Medical Association Declaration of Helsinki. Ethics approval was given by exempt review from the Institutional Review Board (IRB) at the University of Montana (IRB Protocol No.: 186–20). Participants received oral and written information about the study prior to interview, which allowed them to provide informed consent for the interviews to be recorded and used for qualitative research purposes. No ethical concerns were experienced in this study pertaining to human subjects.

Consent for publication.

The participants consented to the publication of de-identified material from the interviews.

Riley WJ. Health Disparities: Gaps in Access, Quality and Affordability of Medical Care. Trans Am Clin Climatol Assoc. 2012;123:167–74.

PubMed   PubMed Central   Google Scholar  

Levesque J, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. https://doi.org/10.1186/1475-9276-12-18 .

Article   PubMed   PubMed Central   Google Scholar  

Serban N. A Multidimensional Framework for Measuring Access. In: Serban N. Healthcare System Access: Measurement, Inference, and Intervention. New Jersey: John Wiley & Sons; 2019. p. 13–59.

Google Scholar  

Roncarolo F, Boivin A, Denis JL, et al. What do we know about the needs and challenges of health systems? A scoping review of the international literature. BMC Health Serv Res. 2017;17:636. https://doi.org/10.1186/s12913-017-2585-5 .

Cabrera-Barona P, Blaschke T. Kienberger S. Explaining Accessibility and Satisfaction Related to Healthcare: A Mixed-Methods Approach. Soc Indic Res. 2017;133,719–739. https://doi.org/10.1007/s11205-016-1371-9 .

Coombs NC, Meriwether WE, Caringi J, Newcomer SR. Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study. SSM Popul Health. 2021;15:100847. https://doi.org/10.1016/j.ssmph.2021.100847 .

Farietta TP, Lu B, Tumin R. Ohio’s Medicaid Expansion and Unmet Health Needs Among Low-Income Women of Reproductive Age. Matern Child Health. 2018;22(12):1771–9. https://doi.org/10.1007/s10995-018-2575-1 .

Article   Google Scholar  

Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance. JAMA Intern Med. 2016;1;176(10):1501–1509. https://doi.org/10.1001/jamainternmed.2016.4419 .

National Alliance on Mental Illness: The Doctor is Out. Continuing Disparities in Access to Mental and Physical Health Care. 2017. https://www.nami.org/Support-Education/Publications-Reports/Public-Policy-Reports/The-Doctor-is-Out . Accessed 29 Aug 2021.

Pollitz K, Lopes L, Kearney A, Rae M, Cox C, Fehr F, Rousseau D, Kaiser Family Foundation. US Statistics on Surprise Medical Billing. JAMA. 2020;323(6):498. https://doi.org/10.1001/jama.2020.0065 .

Kahraman C, Orobello C, Cirella GT. hanging Dynamics with COVID-19: Future Outlook. In: XX Cirella GT, editor. Human Settlements: Urbanization, Smart Sector Development, and Future Outlook. Singapore: Springer; 2022. p. 235–52.

Book   Google Scholar  

Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19 — Implications for the Health Care System. N Engl J Med. 2020;383(15):1483–8. https://doi.org/10.1056/NEJMsb2021088 .

Article   CAS   PubMed   Google Scholar  

Defêche J, Azarzar S, Mesdagh A, Dellot P, Tytgat A, Bureau F, Gillet L, Belhadj Y, Bontems S, Hayette M-P, Schils R, Rahmouni S, Ernst M, Moutschen M, Darcis G. In-Depth Longitudinal Comparison of Clinical Specimens to Detect SARS-CoV-2. Pathogens. 2021;10(11):1362. https://doi.org/10.3390/pathogens10111362 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Rosenblatt RA, Hart LG. Physicians and rural America. West J Med. 2000;173(5):348–51. https://doi.org/10.1136/ewjm.173.5.348 .

Kaiser Family Foundation Analysis of OECD Data. 2020. https://www.healthsystemtracker.org/chart-collection/u-s-health-care-resources-compare-countries/#item-physicians-density-per-1000-population-2000-2018 . Accessed 31 Oct 2021.

Government Accounting Office. Physician Workforce: Locations and Types of Graduate Training Were Largely Unchanged, and Federal Efforts May Not Be Sufficient to Meet Needs. 2017. https://www.gao.gov/assets/gao-17-411.pdf . Accessed 31 Oct 2021.

The Kaiser Family Foundation: The Uninsured in Rural America. 2003. https://www.kff.org/wp-content/uploads/2013/01/the-uninsured-in-rural-america-update-pdf.pdf . Accessed 15 Sept 2021.

Wright B, Potter AJ, Trivedi AN, Mueller KJ. The Relationship Between Rural Health Clinic Use and Potentially Preventable Hospitalizations and Emergency Department Visits Among Medicare Beneficiaries. J Rural Health. 2018;34(4):423–30. https://doi.org/10.1111/jrh.12253 .

Article   PubMed   Google Scholar  

Weichelt B, Bendixsen C, Patrick T. A Model for Assessing Necessary Conditions for Rural Health Care’s Mobile Health Readiness: Qualitative Assessment of Clinician-Perceived Barriers. JMIR Mhealth Uhealth. 2019;7(11): e11915. https://doi.org/10.2196/11915 .

Mangundu M, Roets L, Janse van Rensberg E. Accessibility of healthcare in rural Zimbabwe: The perspective of nurses and healthcare users. Afr J Prim Health Care Fam Med. 2020;12(1):e1-e7. https://doi.org/10.4102/phcfm.v12i1.2245 .

Rahayu YYS, Araki T, Rosleine D. Factors affecting the use of herbal medicines in the universal health coverage system in Indonesia. J Ethnopharmacol. 2020;260: 112974. https://doi.org/10.1016/j.jep.2020.112974 .

Bolin JN, Bellamy GR, Ferdinand AO, et al. Rural Healthy People 2020: New Decade, Same Challenges. Journal of Rural Health. 2015;31(3):326–33.

Reid S. The rural determinants of health: using critical realism as a theoretical framework. Rural Remote Health. 2019;19(3):5184. https://doi.org/10.22605/RRH5184 .

Wynia MK, Osborn CY. Health literacy and communication quality in health care organizations. J Health Commun. 2010;15 Suppl 2(Suppl 2):102–115. https://doi.org/10.1080/10810730.2010.499981 .

Centers for Disease Control and Prevention. What is Health Literacy? 2022. https://www.cdc.gov/healthliteracy/learn/index.html . Accessed 25 Feb 2022.

Davis TC, Arnold CL, Rademaker A, et al. Differences in barriers to mammography between rural and urban women. J Womens Health (Larchmt). 2012;21(7):748–55. https://doi.org/10.1089/jwh.2011.3397 .

Halverson J, Martinez-Donate A, Trentham-Dietz A, et al. Health literacy and urbanicity among cancer patients. J Rural Health. 2013;29(4):392–402. https://doi.org/10.1111/jrh.12018 .

Zahnd WE, Scaife SL, Francis ML. Health literacy skills in rural and urban populations. Am J Health Behav. 2009;33(5):550–7. https://doi.org/10.5993/ajhb.33.5.8 .

Dogba MJ, Dossa AR, Breton E, Gandonou-Migan R. Using information and communication technologies to involve patients and the public in health education in rural and remote areas: a scoping review. BMC Health Serv Res. 2019;19(1):128. https://doi.org/10.1186/s12913-019-3906-7 .

Committee on the Science of Changing Behavioral Health Social Norms, Board on Behavioral, Cognitive, and Sensory Sciences, Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine. In: Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington: National Academics Press; 2016. p. 33–52.

Wu Y, Zhou H, Wang Q, Cao M, Medina A, Rozelle S. Use of maternal health services among women in the ethnic rural areas of western China. BMC Health Serv Res. 2019;19(1):179. https://doi.org/10.1186/s12913-019-3996-2 .

Meyer E, Hennink M, Rochat R, et al. Working Towards Safe Motherhood: Delays and Barriers to Prenatal Care for Women in Rural and Peri-Urban Areas of Georgia. Matern Child Health J. 2016;20(7):1358–65. https://doi.org/10.1007/s10995-016-1997-x .

Heinrich S. Medical science faces the post-truth era: a plea for the grassroot values of science. Curr Opin Anaesthesiol. 2020;33(2):198–202. https://doi.org/10.1097/ACO.0000000000000833 .

Esquivel MM, Chen JC, Woo RK, et al. Why do patients receive care from a short-term medical mission? Survey study from rural Guatemala. J Surg Res. 2017;215:160–6. https://doi.org/10.1016/j.jss.2017.03.056 .

Park LG, Dracup K, Whooley MA, et al. Symptom Diary Use and Improved Survival for Patients With Heart Failure [published correction appears in Circ Heart Fail. 2017 Dec;10(12):]. Circ Heart Fail. 2017;10(11):e003874. https://doi.org/10.1161/CIRCHEARTFAILURE.117.003874 .

Taleb F, Perkins J, Ali NA, et al. Transforming maternal and newborn health social norms and practices to increase utilization of health services in rural Bangladesh: a qualitative review. BMC Pregnancy Childbirth. 2015;15:75. https://doi.org/10.1186/s12884-015-0501-8 .

Billah SM, Hoque DE, Rahman M, et al. Feasibility of engaging “Village Doctors” in the Community-based Integrated Management of Childhood Illness (C-IMCI): experience from rural Bangladesh. J Glob Health. 2018;8(2): 020413. https://doi.org/10.7189/jogh.08.020413 .

Kaiser JL, Fong RM, Hamer DH, et al. How a woman’s interpersonal relationships can delay care-seeking and access during the maternity period in rural Zambia: An intersection of the Social Ecological Model with the Three Delays Framework. Soc Sci Med. 2019;220:312–21. https://doi.org/10.1016/j.socscimed.2018.11.011 .

Rao KD, Sheffel A. Quality of clinical care and bypassing of primary health centers in India. Soc Sci Med. 2018;207:80–8. https://doi.org/10.1016/j.socscimed.2018.04.040 .

Lee YT, Lee YH, Kaplan WA. Is Taiwan’s National Health Insurance a perfect system? Problems related to health care utilization of the aboriginal population in rural townships. Int J Health Plann Manage. 2019;34(1):e6–10. https://doi.org/10.1002/hpm.2653 .

Lyford M, Haigh MM, Baxi S, Cheetham S, Shahid S, Thompson SC. An Exploration of Underrepresentation of Aboriginal Cancer Patients Attending a Regional Radiotherapy Service in Western Australia. Int J Environ Res Public Health. 2018;15(2):337. https://doi.org/10.3390/ijerph15020337 .

Article   PubMed Central   Google Scholar  

Rohr JM, Spears KL, Geske J, Khandalavala B, Lacey MJ. Utilization of Health Care Resources by the Amish of a Rural County in Nebraska. J Community Health. 2019;44(6):1090–7. https://doi.org/10.1007/s10900-019-00696-9 .

Johnston K, Harvey C, Matich P, et al. Increasing access to sexual health care for rural and regional young people: Similarities and differences in the views of young people and service providers. Aust J Rural Health. 2015;23(5):257–64. https://doi.org/10.1111/ajr.12186 .

Legido-Quigley H, Naheed A, de Silva HA, et al. Patients’ experiences on accessing health care services for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: A qualitative study. PLoS ONE. 2019;14(1): e0211100. https://doi.org/10.1371/journal.pone.0211100 .

Shaw B, Amouzou A, Miller NP, Bryce J, Surkan PJ. A qualitative exploration of care-seeking pathways for sick children in the rural Oromia region of Ethiopia. BMC Health Serv Res. 2017;17(1):184. https://doi.org/10.1186/s12913-017-2123-5 .

Larson E, Vail D, Mbaruku GM, Kimweri A, Freedman LP, Kruk ME. Moving Toward Patient-Centered Care in Africa: A Discrete Choice Experiment of Preferences for Delivery Care among 3,003 Tanzanian Women. PLoS ONE. 2015;10(8): e0135621. https://doi.org/10.1371/journal.pone.0135621 .

Spleen AM, Lengerich EJ, Camacho FT, Vanderpool RC. Health care avoidance among rural populations: results from a nationally representative survey. J Rural Health. 2014;30(1):79–88. https://doi.org/10.1111/jrh.12032 .

Weisgrau S. Issues in rural health: access, hospitals, and reform. Health Care Financ Rev. 1995;17(1):1–14.

CAS   PubMed   PubMed Central   Google Scholar  

National Center for Health Statistics. 2018. https://www.cdc.gov/nchs/surveys.htm . Accessed 29 Aug 2021.

Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17(1):88. https://doi.org/10.1186/s12913-017-2031-8 .

Dyer TA, Owens J, Robinson PG. The acceptability of healthcare: from satisfaction to trust. Community Dent Health. 2016;33(4):242–51. https://doi.org/10.1922/CDH_3902Dyer10 .

Padgett DK. Qualitative and Mixed Methods in Public Health. Thousand Oaks, California: SAGE Publications Inc.; 2012.

Tolley EE, Ulin PR, Mack N, Robinson ET, Succop SM. Qualitative Methods in Public Health: A Field Guide for Applied Research. 2nd ed. San Francisco, California: John Wiley & Sons, Inc.; 2016.

Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties. In: National Center for Health Statistics: Vital Health Statistics. 2014. https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf . Accessed 31 Oct 2021.

Health Resources & Services Administration. Health Professional Shortage Area Find. 2021. https://data.hrsa.gov/tools/shortage-area/hpsa-find . Accessed 31 Oct 2021.

Shaghaghi A, Bhopal RS, Sheikh A. Approaches to Recruiting “Hard-To-Reach” Populations into Re-search: A Review of the Literature. Health Promot Perspect. 2011;1(2):86–94. https://doi.org/10.5681/hpp.2011.009 .

Sadler GR, Lee HC, Lim RS, Fullerton J. Recruitment of hard-to-reach population subgroups via adaptations of the snowball sampling strategy. Nurs Health Sci. 2010;12(3):369–74. https://doi.org/10.1111/j.1442-2018.2010.00541.x .

Deterding NM, Waters MC. Flexible Coding of In-depth Interviews: A Twenty-first-century Approach. Sociological Methods & Research. 2021;50(2):708–39. https://doi.org/10.1177/0049124118799377 .

Schreier M, Stamann C, Janssen M, Dahl T, Whittal A. Qualitative Content Analysis: Conceptualizations and Challenges in Research Practice-Introduction to the FQS Special Issue" Qualitative Content Analysis I". InForum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2019;20:26 DEU.

Guest G, Namey E, Chen M. A simple method to assess and report thematic saturation in qualitative research. PLoS ONE. 2020;15(5): e0232076. https://doi.org/10.1371/journal.pone.0232076 .

Mayring P. Qualitative Content Analysis. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research. 2000;1(2). https://doi.org/10.17169/fqs-1.2.1089 .

O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic Medicine, Vol. 89, No. 9 / Sept 2014. https://doi.org/10.1097/ACM.0000000000000388 .

Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014;41(5):545–7. https://doi.org/10.1188/14.ONF.545-547 .

Miller S. Cultural humility is the first step to becoming global care providers. J Obstet Gynecol Neonatal Nurs. 2009;38(1):92–3. https://doi.org/10.1111/j.1552-6909.2008.00311.x .

Prasad SJ, Nair P, Gadhvi K, Barai I, Danish HS, Philip AB. Cultural humility: treating the patient, not the illness. Med Educ Online. 2016;21:30908. https://doi.org/10.3402/meo.v21.30908 .

George MS, Davey R, Mohanty I, Upton P. “Everything is provided free, but they are still hesitant to access healthcare services”: why does the indigenous community in Attapadi, Kerala continue to experience poor access to healthcare? Int J Equity Health. 2020;19(1):105. https://doi.org/10.1186/s12939-020-01216-1 .

Romanelli M, Hudson KD. Individual and systemic barriers to health care: Perspectives of lesbian, gay, bisexual, and transgender adults. Am J Orthopsychiatry. 2017;87(6):714–28. https://doi.org/10.1037/ort0000306 .

Bailie J, Schierhout G, Laycock A, et al. Determinants of access to chronic illness care: a mixed-methods evaluation of a national multifaceted chronic disease package for Indigenous Australians. BMJ Open. 2015;5(11): e008103. https://doi.org/10.1136/bmjopen-2015-008103 .

Reeve C, Humphreys J, Wakerman J, Carter M, Carroll V, Reeve D. Strengthening primary health care: achieving health gains in a remote region of Australia. Med J Aust. 2015;202(9):483–7. https://doi.org/10.5694/mja14.00894 .

Swan LET, Auerbach SL, Ely GE, Agbemenu K, Mencia J, Araf NR. Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse. Int J Environ Res Public Health. 2020;17(4):1198. https://doi.org/10.3390/ijerph17041198 .

Kabia E, Mbau R, Oyando R, et al. “We are called the et cetera”: experiences of the poor with health financing reforms that target them in Kenya. Int J Equity Health. 2019;18(1):98. https://doi.org/10.1186/s12939-019-1006-2 .

Ho JW, Kuluski K, Im J. “It’s a fight to get anything you need” - Accessing care in the community from the perspectives of people with multimorbidity. Health Expect. 2017;20(6):1311–9. https://doi.org/10.1111/hex.12571 .

Latif A, Mandane B, Ali A, Ghumra S, Gulzar N. A Qualitative Exploration to Understand Access to Pharmacy Medication Reviews: Views from Marginalized Patient Groups. Pharmacy (Basel). 2020;8(2):73. https://doi.org/10.3390/pharmacy8020073 .

Tschirhart N, Diaz E, Ottersen T. Accessing public healthcare in Oslo, Norway: the experiences of Thai immigrant masseuses. BMC Health Serv Res. 2019;19(1):722. https://doi.org/10.1186/s12913-019-4560-9 .

Ireland S, Belton S, Doran F. “I didn’t feel judged”: exploring women’s access to telemedicine abortion in rural Australia. J Prim Health Care. 2020;12(1):49–56. https://doi.org/10.1071/HC19050 .

Stokes T, Tumilty E, Latu ATF, et al. Improving access to health care for people with severe chronic obstructive pulmonary disease (COPD) in Southern New Zealand: qualitative study of the views of health professional stakeholders and patients. BMJ Open. 2019;9(11): e033524. https://doi.org/10.1136/bmjopen-2019-033524 .

Jafar TH, Ramakrishnan C, John O, et al. Access to CKD Care in Rural Communities of India: a qualitative study exploring the barriers and potential facilitators. BMC Nephrol. 2020;21(1):26. https://doi.org/10.1186/s12882-020-1702-6 .

Doetsch J, Pilot E, Santana P, Krafft T. Potential barriers in healthcare access of the elderly population influenced by the economic crisis and the troika agreement: a qualitative case study in Lisbon, Portugal. Int J Equity Health. 2017;16(1):184. https://doi.org/10.1186/s12939-017-0679-7 .

Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196(4286):129–36. https://doi.org/10.1126/science.847460 .

Risberg G, Hamberg K, Johansson E.E. Gender perspective in medicine: a vital part of medical scientific rationality. A useful model for comprehending structures and hierarchies within medical science. BMC Med. 2006;4(1):1.

Montana Census & Economic Information Center. 2021. https://ceic.mt.gov/ . Accessed 18 Sept 2021.

Smith M, Saunders R, Stuckhardt L, McGinnis JM, Committee on the Learning Health Care System in America, Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington: National Academies Press; 2013.

O’Daniel M, Rosenstein AH, Professional Communication and Team Collaboration. In: Hughes RG, editor. Chapter 33: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality: Rockville; 2008.

Evans RS. Electronic Health Records: Then, Now, and in the Future. Yearb Med Inform. 2016;Suppl 1(Suppl 1):S48-S61. https://doi.org/10.15265/IYS-2016-s006 .

Tikkanen R, Osborn R, Mossialos E, Djordjevic A, Wharton GA. International Health Care System Profiles: United States. The Commonwealth Fund. 2020. https://www.commonwealthfund.org/international-health-policy-center/countries/united-states . Accessed 19 Sept 2021.

Berchick ER, Barnett JC, Upton RD. Health Insurance Coverage in the United States. Washington: United States Census Bureau; 2018.

Brock DW, Buchanan A. Ethical Issues in For-Profit Health Care. In: Gray BH, editor. For-Profit Enterprise in Health Care. Washington: National Academics Press; 1986.

Lekas HM, Pahl K, Fuller Lewis C. Rethinking Cultural Competence: Shifting to Cultural Humility. Health Serv Insights. 2020;13:1178632920970580. https://doi.org/10.1177/1178632920970580 .

Beaulieu MD. Primary and secondary care: Breaking down barriers for our patients with chronic diseases. Can Fam Physician. 2013;59(2):221.

Crafford L, Jenkins LS. Why seek a second consultation at an emergency centre? A qualitative study. Afr J Prim Health Care Fam Med. 2017;9(1):e1–8. https://doi.org/10.4102/phcfm.v9i1.1397 .

Sorensen MJ, von Recklinghausen FM, Fulton G, et al. Secondary overtriage: The burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg. 2013;148:763–8.

Sutcliffe CG, Thuma PE, van Dijk JH, et al. Use of mobile phones and text messaging to decrease the turnaround time for early infant HIV diagnosis and notification in rural Zambia: an observational study. BMC Pediatr. 2017;17(1):66. https://doi.org/10.1186/s12887-017-0822-z .

Baldwin LM, Morrison C, Griffin J, et al. Bidirectional Text Messaging to Improve Adherence to Recommended Lipid Testing. J Am Board Fam Med. 2017;30(5):608–14. https://doi.org/10.3122/jabfm.2017.05.170088 .

Albright K, Krantz MJ, Backlund Jarquín P, DeAlleaume L, Coronel-Mockler S, Estacio RO. Health Promotion Text Messaging Preferences and Acceptability Among the Medically Underserved. Health Promot Pract. 2015;16(4):523–32. https://doi.org/10.1177/1524839914566850 .

Cramer ME, Mollard EK, Ford AL, Kupzyk KA, Wilson FA. The feasibility and promise of mobile technology with community health worker reinforcement to reduce rural preterm birth. Public Health Nurs. 2018;35(6):508–16. https://doi.org/10.1111/phn.12543 .

Gbadamosi SO, Eze C, Olawepo JO, et al. A Patient-Held Smartcard With a Unique Identifier and an mHealth Platform to Improve the Availability of Prenatal Test Results in Rural Nigeria: Demonstration Study. J Med Internet Res. 2018;20(1): e18. https://doi.org/10.2196/jmir.8716 .

Trondsen MV, Tjora A, Broom A, Scambler G. The symbolic affordances of a video-mediated gaze in emergency psychiatry. Soc Sci Med. 2018;197:87–94. https://doi.org/10.1016/j.socscimed.2017.11.056 .

Schwitters A, Lederer P, Zilversmit L, et al. Barriers to health care in rural Mozambique: a rapid ethnographic assessment of planned mobile health clinics for ART. Glob Health Sci Pract. 2015;3(1):109–16. https://doi.org/10.9745/GHSP-D-14-00145 .

Kojima N, Krupp K, Ravi K, et al. Implementing and sustaining a mobile medical clinic for prenatal care and sexually transmitted infection prevention in rural Mysore, India. BMC Infect Dis. 2017;17(1):189. https://doi.org/10.1186/s12879-017-2282-3 .

Gorman SE, Martinez JM, Olson J. An assessment of HIV treatment outcomes among utilizers of semi-mobile clinics in rural Kenya. AIDS Care. 2015;27(5):665–8. https://doi.org/10.1080/09540121.2014.986053 .

Lee S, Black D, Held ML. Factors Associated with Telehealth Service Utilization among Rural Populations. J Health Care Poor Underserved. 2019;30(4):1259–72. https://doi.org/10.1353/hpu.2019.0104 .

Agha Z, Schapira RM, Maker AH. Cost effectiveness of telemedicine for the delivery of outpatient pulmonary care to a rural population. Telemed J E Health. 2002;8(3):281–91. https://doi.org/10.1089/15305620260353171 .

Doraiswamy S, Abraham A, Mamtani R, Cheema S. Use of Telehealth During the COVID-19 Pandemic: Scoping Review. J Med Internet Res. 2020;22(12): e24087. https://doi.org/10.2196/24087 .

Download references

Acknowledgements

This research was supported by the Center for Biomedical Research Excellence award (P20GM130418) from the National Institute of General Medical Sciences of the National Institute of Health. The first author was also supported by the University of Montana Burnham Population Health Fellowship. We would like to thank Dr. Christopher Dietrich, Dr. Jennifer Robohm and Dr. Eric Arzubi for their contributions on determining inclusion criteria for the healthcare provider population used for this study.

 This research did not receive any specific grant from funding agencies in the public, commercial, and not-for-profit sectors. 

Author information

Authors and affiliations.

School of Public & Community Health Sciences, University of Montana, 32 Campus Dr, Missoula, MT, 59812, USA

Nicholas C. Coombs & James Caringi

Department of Psychology, University of Montana, 32 Campus Dr, Missoula, MT, 59812, USA

Duncan G. Campbell

You can also search for this author in PubMed   Google Scholar

Contributions

The authors confirm contribution to the paper as follows: study conception and design: NC and JC; data collection: NC; analysis and interpretation of results: NC and JC; draft manuscript preparation: NC, DC and JC; and manuscript editing: NC, DC and JC. All authors reviewed the results and approved the final version of the manuscript.

Corresponding author

Correspondence to Nicholas C. Coombs .

Ethics declarations

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher's note.

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

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Coombs, N.C., Campbell, D.G. & Caringi, J. A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res 22 , 438 (2022). https://doi.org/10.1186/s12913-022-07829-2

Download citation

Received : 11 January 2022

Accepted : 21 March 2022

Published : 02 April 2022

DOI : https://doi.org/10.1186/s12913-022-07829-2

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

• Access to healthcare
• Rural health
• Qualitative methods

BMC Health Services Research

ISSN: 1472-6963

• General enquiries: [email protected]

Divergent views on drivers of early phase clinical trial participation among ethnically diverse potential trial participants in the United Kingdom: A Mixed Methods Study

• Find this author on Google Scholar
• Find this author on PubMed
• Search for this author on this site
• For correspondence: [email protected]
• Info/History
• Preview PDF

Background: Novel therapeutics should always be tested in a sample representative of the population in need of treatment. Initial efforts of drug development take place in early phase trials (phase-I and -II), setting the direction for late-stage studies (phase-III and -IV). However, study samples in early phase trials typically fail to recruit Black, Asian and minority ethnic groups, which might produce results which don't generalise to a broader population in later trials, and ultimately, clinical practice. Focusing on early phase clinical trials the present study (1) explored the barriers and incentives that determine participation of ethnic minorities in clinical research, and (2) proposes strategies that mitigate such barriers. Methods: A systematic literature review explored barriers affecting participation rates from individuals from diverse ethnic backgrounds. An exploratory phase involved two online surveys (researchers and general population) and focus groups (general population) analysed using thematic analysis. Results: The systematic review found little published evidence, with most studies undertaken in the USA and focused on specific clinical areas. The exploratory phase showed a discordance between researchers' and general public's perspectives on both drivers and barriers to early phase trial participation. Discussion: These findings were synthesised into a Clinical Trials Participatory Framework, which contextualises reasons for reduced trial participation, while providing mechanisms/strategies to increase uptake among minority ethnic participants. This may guide researchers when implementing strategies to aid under-representation in their samples. Further research should evaluate the framework by actively implementing, testing, and iterating upon the strategies.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study did not receive any funding

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

North Star Review Board, nonprofit IRB. Determined to not require ethical review, likely would have been exempt if under jurisdiction of the Common Rule

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

All data produced in the present work are contained in the manuscript

View the discussion thread.

Thank you for your interest in spreading the word about medRxiv.

NOTE: Your email address is requested solely to identify you as the sender of this article.

Citation Manager Formats

• EndNote (tagged)
• EndNote 8 (xml)
• RefWorks Tagged
• Ref Manager
• Tweet Widget
• Facebook Like
• Google Plus One
• Addiction Medicine (316)
• Allergy and Immunology (618)
• Anesthesia (159)
• Cardiovascular Medicine (2277)
• Dentistry and Oral Medicine (279)
• Dermatology (201)
• Emergency Medicine (370)
• Endocrinology (including Diabetes Mellitus and Metabolic Disease) (798)
• Epidemiology (11579)
• Forensic Medicine (10)
• Gastroenterology (678)
• Genetic and Genomic Medicine (3580)
• Geriatric Medicine (336)
• Health Economics (617)
• Health Informatics (2305)
• Health Policy (913)
• Health Systems and Quality Improvement (864)
• Hematology (335)
• HIV/AIDS (752)
• Infectious Diseases (except HIV/AIDS) (13154)
• Intensive Care and Critical Care Medicine (757)
• Medical Education (359)
• Medical Ethics (100)
• Nephrology (389)
• Neurology (3351)
• Nursing (191)
• Nutrition (507)
• Obstetrics and Gynecology (651)
• Occupational and Environmental Health (646)
• Oncology (1758)
• Ophthalmology (524)
• Orthopedics (209)
• Otolaryngology (284)
• Pain Medicine (223)
• Palliative Medicine (66)
• Pathology (438)
• Pediatrics (1004)
• Pharmacology and Therapeutics (422)
• Primary Care Research (406)
• Psychiatry and Clinical Psychology (3062)
• Public and Global Health (5992)
• Radiology and Imaging (1222)
• Rehabilitation Medicine and Physical Therapy (714)
• Respiratory Medicine (811)
• Rheumatology (367)
• Sexual and Reproductive Health (353)
• Sports Medicine (316)
• Surgery (386)
• Toxicology (50)
• Transplantation (170)
• Urology (142)