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  • v.5(4); September 2014-November 2014

Qualitative research method-interviewing and observation

Shazia jamshed.

Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia

Buckley and Chiang define research methodology as “a strategy or architectural design by which the researcher maps out an approach to problem-finding or problem-solving.”[ 1 ] According to Crotty, research methodology is a comprehensive strategy ‘that silhouettes our choice and use of specific methods relating them to the anticipated outcomes,[ 2 ] but the choice of research methodology is based upon the type and features of the research problem.[ 3 ] According to Johnson et al . mixed method research is “a class of research where the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, theories and or language into a single study.[ 4 ] In order to have diverse opinions and views, qualitative findings need to be supplemented with quantitative results.[ 5 ] Therefore, these research methodologies are considered to be complementary to each other rather than incompatible to each other.[ 6 ]

Qualitative research methodology is considered to be suitable when the researcher or the investigator either investigates new field of study or intends to ascertain and theorize prominent issues.[ 6 , 7 ] There are many qualitative methods which are developed to have an in depth and extensive understanding of the issues by means of their textual interpretation and the most common types are interviewing and observation.[ 7 ]

Interviewing

This is the most common format of data collection in qualitative research. According to Oakley, qualitative interview is a type of framework in which the practices and standards be not only recorded, but also achieved, challenged and as well as reinforced.[ 8 ] As no research interview lacks structure[ 9 ] most of the qualitative research interviews are either semi-structured, lightly structured or in-depth.[ 9 ] Unstructured interviews are generally suggested in conducting long-term field work and allow respondents to let them express in their own ways and pace, with minimal hold on respondents’ responses.[ 10 ]

Pioneers of ethnography developed the use of unstructured interviews with local key informants that is., by collecting the data through observation and record field notes as well as to involve themselves with study participants. To be precise, unstructured interview resembles a conversation more than an interview and is always thought to be a “controlled conversation,” which is skewed towards the interests of the interviewer.[ 11 ] Non-directive interviews, form of unstructured interviews are aimed to gather in-depth information and usually do not have pre-planned set of questions.[ 11 ] Another type of the unstructured interview is the focused interview in which the interviewer is well aware of the respondent and in times of deviating away from the main issue the interviewer generally refocuses the respondent towards key subject.[ 11 ] Another type of the unstructured interview is an informal, conversational interview, based on unplanned set of questions that are generated instantaneously during the interview.[ 11 ]

In contrast, semi-structured interviews are those in-depth interviews where the respondents have to answer preset open-ended questions and thus are widely employed by different healthcare professionals in their research. Semi-structured, in-depth interviews are utilized extensively as interviewing format possibly with an individual or sometimes even with a group.[ 6 ] These types of interviews are conducted once only, with an individual or with a group and generally cover the duration of 30 min to more than an hour.[ 12 ] Semi-structured interviews are based on semi-structured interview guide, which is a schematic presentation of questions or topics and need to be explored by the interviewer.[ 12 ] To achieve optimum use of interview time, interview guides serve the useful purpose of exploring many respondents more systematically and comprehensively as well as to keep the interview focused on the desired line of action.[ 12 ] The questions in the interview guide comprise of the core question and many associated questions related to the central question, which in turn, improve further through pilot testing of the interview guide.[ 7 ] In order to have the interview data captured more effectively, recording of the interviews is considered an appropriate choice but sometimes a matter of controversy among the researcher and the respondent. Hand written notes during the interview are relatively unreliable, and the researcher might miss some key points. The recording of the interview makes it easier for the researcher to focus on the interview content and the verbal prompts and thus enables the transcriptionist to generate “verbatim transcript” of the interview.

Similarly, in focus groups, invited groups of people are interviewed in a discussion setting in the presence of the session moderator and generally these discussions last for 90 min.[ 7 ] Like every research technique having its own merits and demerits, group discussions have some intrinsic worth of expressing the opinions openly by the participants. On the contrary in these types of discussion settings, limited issues can be focused, and this may lead to the generation of fewer initiatives and suggestions about research topic.

Observation

Observation is a type of qualitative research method which not only included participant's observation, but also covered ethnography and research work in the field. In the observational research design, multiple study sites are involved. Observational data can be integrated as auxiliary or confirmatory research.[ 11 ]

Research can be visualized and perceived as painstaking methodical efforts to examine, investigate as well as restructure the realities, theories and applications. Research methods reflect the approach to tackling the research problem. Depending upon the need, research method could be either an amalgam of both qualitative and quantitative or qualitative or quantitative independently. By adopting qualitative methodology, a prospective researcher is going to fine-tune the pre-conceived notions as well as extrapolate the thought process, analyzing and estimating the issues from an in-depth perspective. This could be carried out by one-to-one interviews or as issue-directed discussions. Observational methods are, sometimes, supplemental means for corroborating research findings.

  • Harvard Library
  • Research Guides
  • Faculty of Arts & Sciences Libraries

Library Support for Qualitative Research

  • Interview Research
  • Resources for Methodology
  • Remote Research & Virtual Fieldwork

Resources for Research Interviewing

Nih-funded qualitative research.

  • Oral History
  • Data Management & Repositories
  • Campus Access

Types of Interviews

  • Engaging Participants

Interview Questions

  • Conducting Interviews
  • Transcription
  • Coding and Analysis
  • Managing & Finding Interview Data
  • UX & Market Research Interviews

Textbooks, Guidebooks, and Handbooks  

  • The Ethnographic Interview by James P. Spradley  “Spradley wrote this book for the professional and student who have never done ethnographic fieldwork (p. 231) and for the professional ethnographer who is interested in adapting the author’s procedures (p. iv). Part 1 outlines in 3 chapters Spradley’s version of ethnographic research, and it provides the background for Part 2 which consists of 12 guided steps (chapters) ranging from locating and interviewing an informant to writing an ethnography. Most of the examples come from the author’s own fieldwork among U.S. subcultures . . . Steps 6 and 8 explain lucidly how to construct a domain and a taxonomic analysis” (excerpted from book review by James D. Sexton, 1980).  
  • Fundamentals of Qualitative Research by Johnny Saldana (Series edited by Patricia Leavy)  Provides a soup-to-nuts overview of the qualitative data collection process, including interviewing, participant observation, and other methods.  
  • InterViews by Steinar Kvale  Interviewing is an essential tool in qualitative research and this introduction to interviewing outlines both the theoretical underpinnings and the practical aspects of the process. After examining the role of the interview in the research process, Steinar Kvale considers some of the key philosophical issues relating to interviewing: the interview as conversation, hermeneutics, phenomenology, concerns about ethics as well as validity, and postmodernism. Having established this framework, the author then analyzes the seven stages of the interview process - from designing a study to writing it up.  
  • Practical Evaluation by Michael Quinn Patton  Surveys different interviewing strategies, from, a) informal/conversational, to b) interview guide approach, to c) standardized and open-ended, to d) closed/quantitative. Also discusses strategies for wording questions that are open-ended, clear, sensitive, and neutral, while supporting the speaker. Provides suggestions for probing and maintaining control of the interview process, as well as suggestions for recording and transcription.  
  • The SAGE Handbook of Interview Research by Amir B. Marvasti (Editor); James A. Holstein (Editor); Jaber F. Gubrium (Editor); Karyn D. McKinney (Editor)  The new edition of this landmark volume emphasizes the dynamic, interactional, and reflexive dimensions of the research interview. Contributors highlight the myriad dimensions of complexity that are emerging as researchers increasingly frame the interview as a communicative opportunity as much as a data-gathering format. The book begins with the history and conceptual transformations of the interview, which is followed by chapters that discuss the main components of interview practice. Taken together, the contributions to The SAGE Handbook of Interview Research: The Complexity of the Craft encourage readers simultaneously to learn the frameworks and technologies of interviewing and to reflect on the epistemological foundations of the interview craft.  
  • The SAGE Handbook of Online Research Methods by Nigel G. Fielding, Raymond M. Lee and Grant Blank (Editors) Bringing together the leading names in both qualitative and quantitative online research, this new edition is organised into nine sections: 1. Online Research Methods 2. Designing Online Research 3. Online Data Capture and Data Collection 4. The Online Survey 5. Digital Quantitative Analysis 6. Digital Text Analysis 7. Virtual Ethnography 8. Online Secondary Analysis: Resources and Methods 9. The Future of Online Social Research

ONLINE RESOURCES, COMMUNITIES, AND DATABASES  

  • Interviews as a Method for Qualitative Research (video) This short video summarizes why interviews can serve as useful data in qualitative research.  
  • Companion website to Bloomberg and Volpe's  Completing Your Qualitative Dissertation: A Road Map from Beginning to End,  4th ed Provides helpful templates and appendices featured in the book, as well as links to other useful dissertation resources.
  • International Congress of Qualitative Inquiry Annual conference hosted by the International Center for Qualitative Inquiry at the University of Illinois at Urbana-Champaign, which aims to facilitate the development of qualitative research methods across a wide variety of academic disciplines, among other initiatives.  
  • METHODSPACE ​​​​​​​​An online home of the research methods community, where practicing researchers share how to make research easier.  
  • SAGE researchmethods ​​​​​​​Researchers can explore methods concepts to help them design research projects, understand particular methods or identify a new method, conduct their research, and write up their findings. A "methods map" facilitates finding content on methods.

The decision to conduct interviews, and the type of interviewing to use, should flow from, or align with, the methodological paradigm chosen for your study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

Structured:

  • Structured Interview. Entry in The SAGE Encyclopedia of Social Science Research Methodsby Floyd J. Fowler Jr., Editors: Michael S. Lewis-Beck; Alan E. Bryman; Tim Futing Liao (Editor)  A concise article noting standards, procedures, and recommendations for developing and testing structured interviews. For an example of structured interview questions, you may view the Current Population Survey, May 2008: Public Participation in the Arts Supplement (ICPSR 29641), Apr 15, 2011 at https://doi.org/10.3886/ICPSR29641.v1 (To see the survey questions, preview the user guide, which can be found under the "Data and Documentation" tab. Then, look for page 177 (attachment 8).

Semi-Structured:

  • Semi-Structured Interview. Entry in The SAGE Encyclopedia of Qualitative Research Methodsby Lioness Ayres; Editor: Lisa M. Given  The semi-structured interview is a qualitative data collection strategy in which the researcher asks informants a series of predetermined but open-ended questions. The researcher has more control over the topics of the interview than in unstructured interviews, but in contrast to structured interviews or questionnaires that use closed questions, there is no fixed range of responses to each question.

Unstructured:

  • Unstructured Interview. Entry in The SAGE Encyclopedia of Qualitative Research Methodsby Michael W. Firmin; Editor: Lisa M. Given  Unstructured interviews in qualitative research involve asking relatively open-ended questions of research participants in order to discover their percepts on the topic of interest. Interviews, in general, are a foundational means of collecting data when using qualitative research methods. They are designed to draw from the interviewee constructs embedded in his or her thinking and rationale for decision making. The researcher uses an inductive method in data gathering, regardless of whether the interview method is open, structured, or semi-structured. That is, the researcher does not wish to superimpose his or her own viewpoints onto the person being interviewed. Rather, inductively, the researcher wishes to understand the participant's perceptions, helping him or her to articulate percepts such that they will be understood clearly by the journal reader.

Genres and Uses

Focus groups:.

  • "Focus Groups." Annual Review of Sociology 22 (1996): 129-1524.by David L. Morgan  Discusses the use of focus groups and group interviews as methods for gathering qualitative data used by sociologists and other academic and applied researchers. Focus groups are recommended for giving voice to marginalized groups and revealing the group effect on opinion formation.  
  • Qualitative Research Methods: A Data Collector's Field Guide (See Module 4: "Focus Groups")by Mack, N., et al.  This field guide is based on an approach to doing team-based, collaborative qualitative research that has repeatedly proven successful in research projects sponsored by Family Health International (FHI) throughout the developing world. With its straightforward delivery of information on the main qualitative methods being used in public health research today, the guide speaks to the need for simple yet effective instruction on how to do systematic and ethically sound qualitative research. The aim of the guide is thus practical. In bypassing extensive discussion on the theoretical underpinnings of qualitative research, it distinguishes itself as a how-to guide to be used in the field.

In-Depth (typically One-on-One):

  • A Practical Introduction to in-Depth Interviewingby Alan Morris  Are you new to qualitative research or a bit rusty and in need of some inspiration? Are you doing a research project involving in-depth interviews? Are you nervous about carrying out your interviews? This book will help you complete your qualitative research project by providing a nuts and bolts introduction to interviewing. With coverage of ethics, preparation strategies and advice for handling the unexpected in the field, this handy guide will help you get to grips with the basics of interviewing before embarking on your research. While recognising that your research question and the context of your research will drive your approach to interviewing, this book provides practical advice often skipped in traditional methods textbooks.  
  • Qualitative Research Methods: A Data Collector's Field Guide (See Module 3: "In-Depth Interviews")by Mack, N., et al.  This field guide is based on an approach to doing team-based, collaborative qualitative research that has repeatedly proven successful in research projects sponsored by Family Health International (FHI) throughout the developing world. With its straightforward delivery of information on the main qualitative methods being used in public health research today, the guide speaks to the need for simple yet effective instruction on how to do systematic and ethically sound qualitative research. The aim of the guide is thus practical. In bypassing extensive discussion on the theoretical underpinnings of qualitative research, it distinguishes itself as a how-to guide to be used in the field.

Folklore Research and Oral Histories:

In addition to the following resource, see the  Oral History   page of this guide for helpful resources on Oral History interviewing.

American Folklife Center at the Library of Congress. Folklife and Fieldwork: A Layman’s Introduction to Field Techniques Interviews gathered for purposes of folklore research are similar to standard social science interviews in some ways, but also have a good deal in common with oral history approaches to interviewing. The focus in a folklore research interview is on documenting and trying to understand the interviewee's way of life relative to a culture or subculture you are studying. This guide includes helpful advice and tips for conducting fieldwork in folklore, such as tips for planning, conducting, recording, and archiving interviews.

An interdisciplinary scientific program within the Institute for Quantitative Social Science which encourages and facilitates research and instruction in the theory and practice of survey research. The primary mission of PSR is to provide survey research resources to enhance the quality of teaching and research at Harvard.

  • Internet, Phone, Mail, and Mixed-Mode Surveysby Don A. Dillman; Jolene D. Smyth; Leah Melani Christian  The classic survey design reference, updated for the digital age. The new edition is thoroughly updated and revised, and covers all aspects of survey research. It features expanded coverage of mobile phones, tablets, and the use of do-it-yourself surveys, and Dillman's unique Tailored Design Method is also thoroughly explained. This new edition is complemented by copious examples within the text and accompanying website. It includes: Strategies and tactics for determining the needs of a given survey, how to design it, and how to effectively administer it. How and when to use mail, telephone, and Internet surveys to maximum advantage. Proven techniques to increase response rates. Guidance on how to obtain high-quality feedback from mail, electronic, and other self-administered surveys. Direction on how to construct effective questionnaires, including considerations of layout. The effects of sponsorship on the response rates of surveys. Use of capabilities provided by newly mass-used media: interactivity, presentation of aural and visual stimuli. The Fourth Edition reintroduces the telephone--including coordinating land and mobile.

User Experience (UX) and Marketing:

  • See the  "UX & Market Research Interviews"  tab on this guide, above. May include  Focus Groups,  above.

Screening for Research Site Selection:

  • Research interviews are used not only to furnish research data for theoretical analysis in the social sciences, but also to plan other kinds of studies. For example, interviews may allow researchers to screen appropriate research sites to conduct empirical studies (such as randomized controlled trials) in a variety of fields, from medicine to law. In contrast to interviews conducted in the course of social research, such interviews do not typically serve as the data for final analysis and publication.

ENGAGING PARTICIPANTS

Research ethics  .

  • Human Subjects (IRB) The Committee on the Use of Human Subjects (CUHS) serves as the Institutional Review Board for the University area which includes the Cambridge and Allston campuses at Harvard. Find your IRB  contact person , or learn about  required ethics training.  You may also find the  IRB Lifecycle Guide  helpful. This is the preferred IRB portal for Harvard graduate students and other researchers. IRB forms can be downloaded via the  ESTR Library  (click on the "Templates and Forms" tab, then navigate to pages 2 and 3 to find the documents labelled with “HUA” for the Harvard University Area IRB. Nota bene: You may use these forms only if you submit your study to the Harvard University IRB). The IRB office can be reached through email at [email protected] or by telephone at (617) 496-2847.  
  • Undergraduate Research Training Program (URTP) Portal The URTP at Harvard University is a comprehensive platform to create better prepared undergraduate researchers. The URTP is comprised of research ethics training sessions, a student-focused curriculum, and an online decision form that will assist students in determining whether their project requires IRB review. Students should examine the  URTP's guide for student researchers: Introduction to Human Subjects Research Protection.  
  • Ethics reports From the Association of Internet Researchers (AoIR)  
  • Respect, Beneficence, and Justice: QDR General Guidance for Human Participants If you are hoping to share your qualitative interview data in a repository after it has been collected, you will need to plan accordingly via informed consent, careful de-identification procedures, and data access controls. Consider  consulting with the Qualitative Research Support Group at Harvard Library  and consulting with  Harvard's Dataverse contacts  to help you think through all of the contingencies and processes.  
  • "Conducting a Qualitative Child Interview: Methodological Considerations." Journal of Advanced Nursing 42/5 (2003): 434-441 by Kortesluoma, R., et al.  The purpose of this article is to illustrate the theoretical premises of child interviewing, as well as to describe some practical methodological solutions used during interviews. Factors that influence data gathered from children and strategies for taking these factors into consideration during the interview are also described.  
  • "Crossing Cultural Barriers in Research Interviewing." Qualitative Social Work 63/3 (2007): 353-372 by Sands, R., et al.  This article critically examines a qualitative research interview in which cultural barriers between a white non-Muslim female interviewer and an African American Muslim interviewee, both from the USA, became evident and were overcome within the same interview.  
  • Decolonizing Methodologies: Research and Indigenous Peoples by Linda Tuhiwai Smith  This essential volume explores intersections of imperialism and research - specifically, the ways in which imperialism is embedded in disciplines of knowledge and tradition as 'regimes of truth.' Concepts such as 'discovery' and 'claiming' are discussed and an argument presented that the decolonization of research methods will help to reclaim control over indigenous ways of knowing and being. The text includes case-studies and examples, and sections on new indigenous literature and the role of research in indigenous struggles for social justice.  

This resource, sponsored by University of Oregon Libraries, exemplifies the use of interviewing methodologies in research that foregrounds traditional knowledge. The methodology page summarizes the approach.

  • Ethics: The Need to Tread Carefully. Chapter in A Practical Introduction to in-Depth Interviewing by Alan Morris  Pay special attention to the sections in chapter 2 on "How to prevent and respond to ethical issues arising in the course of the interview," "Ethics in the writing up of your interviews," and "The Ethics of Care."  
  • Handbook on Ethical Issues in Anthropology by Joan Cassell (Editor); Sue-Ellen Jacobs (Editor)  This publication of the American Anthropological Association presents and discusses issues and sources on ethics in anthropology, as well as realistic case studies of ethical dilemmas. It is meant to help social science faculty introduce discussions of ethics in their courses. Some of the topics are relevant to interviews, or at least to studies of which interviews are a part. See chapters 3 and 4 for cases, with solutions and commentary, respectively.  
  • Research Ethics from the Chanie Wenjack School for Indigenous Studies, Trent University  (Open Access) An overview of Indigenous research ethics and protocols from the across the globe.  
  • Resources for Equity in Research Consult these resources for guidance on creating and incorporating equitable materials into public health research studies that entail community engagement.

The SAGE Handbook of Qualitative Research Ethics by Ron Iphofen (Editor); Martin Tolich (Editor)  This handbook is a much-needed and in-depth review of the distinctive set of ethical considerations which accompanies qualitative research. This is particularly crucial given the emergent, dynamic and interactional nature of most qualitative research, which too often allows little time for reflection on the important ethical responsibilities and obligations. Contributions from leading international researchers have been carefully organized into six key thematic sections: Part One: Thick Descriptions Of Qualitative Research Ethics; Part Two: Qualitative Research Ethics By Technique; Part Three: Ethics As Politics; Part Four: Qualitative Research Ethics With Vulnerable Groups; Part Five: Relational Research Ethics; Part Six: Researching Digitally. This Handbook is a one-stop resource on qualitative research ethics across the social sciences that draws on the lessons learned and the successful methods for surmounting problems - the tried and true, and the new.

RESEARCH COMPLIANCE AND PRIVACY LAWS

Research Compliance Program for FAS/SEAS at Harvard : The Faculty of Arts and Sciences (FAS), including the School of Engineering and Applied Sciences (SEAS), and the Office of the Vice Provost for Research (OVPR) have established a shared Research Compliance Program (RCP). An area of common concern for interview studies is international projects and collaboration . RCP is a resource to provide guidance on which international activities may be impacted by US sanctions on countries, individuals, or entities and whether licenses or other disclosure are required to ship or otherwise share items, technology, or data with foreign collaborators.

  • Harvard Global Support Services (GSS) is for students, faculty, staff, and researchers who are studying, researching, or working abroad. Their services span safety and security, health, culture, outbound immigration, employment, financial and legal matters, and research center operations. These include travel briefings and registration, emergency response, guidance on international projects, and managing in-country operations.

Generative AI: Harvard-affiliated researchers should not enter data classified as confidential ( Level 2 and above ), including non-public research data, into publicly-available generative AI tools, in accordance with the University’s Information Security Policy. Information shared with generative AI tools using default settings is not private and could expose proprietary or sensitive information to unauthorized parties.

Privacy Laws: Be mindful of any potential privacy laws that may apply wherever you conduct your interviews. The General Data Protection Regulation is a high-profile example (see below):

  • General Data Protection Regulation (GDPR) This Regulation lays down rules relating to the protection of natural persons with regard to the processing of personal data and rules relating to the free movement of personal data. It protects fundamental rights and freedoms of natural persons and in particular their right to the protection of personal data. The free movement of personal data within the Union shall be neither restricted nor prohibited for reasons connected with the protection of natural persons with regard to the processing of personal data. For a nice summary of what the GDPR requires, check out the GDPR "crash course" here .

SEEKING CONSENT  

If you would like to see examples of consent forms, ask your local IRB, or take a look at these resources:

  • Model consent forms for oral history, suggested by the Centre for Oral History and Digital Storytelling at Concordia University  
  • For NIH-funded research, see this  resource for developing informed consent language in research studies where data and/or biospecimens will be stored and shared for future use.

POPULATION SAMPLING

If you wish to assemble resources to aid in sampling, such as the USPS Delivery Sequence File, telephone books, or directories of organizations and listservs, please contact our  data librarian  or write to  [email protected] .

  • Research Randomizer   A free web-based service that permits instant random sampling and random assignment. It also contains an interactive tutorial perfect for students taking courses in research methods.  
  • Practical Tools for Designing and Weighting Survey Samples by Richard Valliant; Jill A. Dever; Frauke Kreuter  Survey sampling is fundamentally an applied field. The goal in this book is to put an array of tools at the fingertips of practitioners by explaining approaches long used by survey statisticians, illustrating how existing software can be used to solve survey problems, and developing some specialized software where needed. This book serves at least three audiences: (1) Students seeking a more in-depth understanding of applied sampling either through a second semester-long course or by way of a supplementary reference; (2) Survey statisticians searching for practical guidance on how to apply concepts learned in theoretical or applied sampling courses; and (3) Social scientists and other survey practitioners who desire insight into the statistical thinking and steps taken to design, select, and weight random survey samples. Several survey data sets are used to illustrate how to design samples, to make estimates from complex surveys for use in optimizing the sample allocation, and to calculate weights. Realistic survey projects are used to demonstrate the challenges and provide a context for the solutions. The book covers several topics that either are not included or are dealt with in a limited way in other texts. These areas include: sample size computations for multistage designs; power calculations related to surveys; mathematical programming for sample allocation in a multi-criteria optimization setting; nuts and bolts of area probability sampling; multiphase designs; quality control of survey operations; and statistical software for survey sampling and estimation. An associated R package, PracTools, contains a number of specialized functions for sample size and other calculations. The data sets used in the book are also available in PracTools, so that the reader may replicate the examples or perform further analyses.  
  • Sampling: Design and Analysis by Sharon L. Lohr  Provides a modern introduction to the field of sampling. With a multitude of applications from a variety of disciplines, the book concentrates on the statistical aspects of taking and analyzing a sample. Overall, the book gives guidance on how to tell when a sample is valid or not, and how to design and analyze many different forms of sample surveys.  
  • Sampling Techniques by William G. Cochran  Clearly demonstrates a wide range of sampling methods now in use by governments, in business, market and operations research, social science, medicine, public health, agriculture, and accounting. Gives proofs of all the theoretical results used in modern sampling practice. New topics in this edition include the approximate methods developed for the problem of attaching standard errors or confidence limits to nonlinear estimates made from the results of surveys with complex plans.  
  • "Understanding the Process of Qualitative Data Collection" in Chapter 13 (pp. 103–1162) of 30 Essential Skills for the Qualitative Researcher by John W. Creswell  Provides practical "how-to" information for beginning researchers in the social, behavioral, and health sciences with many applied examples from research design, qualitative inquiry, and mixed methods.The skills presented in this book are crucial for a new qualitative researcher starting a qualitative project.  
  • Survey Methodology by Robert M. Groves; Floyd J. Fowler; Mick P. Couper; James M. Lepkowski; Eleanor Singer; Roger Tourangeau; Floyd J. Fowler  coverage includes sampling frame evaluation, sample design, development of questionnaires, evaluation of questions, alternative modes of data collection, interviewing, nonresponse, post-collection processing of survey data, and practices for maintaining scientific integrity.

The way a qualitative researcher constructs and approaches interview questions should flow from, or align with, the methodological paradigm chosen for the study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

Constructing Your Questions

Helpful texts:.

  • "Developing Questions" in Chapter 4 (pp. 98–108) of Becoming Qualitative Researchers by Corrine Glesne  Ideal for introducing the novice researcher to the theory and practice of qualitative research, this text opens students to the diverse possibilities within this inquiry approach, while helping them understand how to design and implement specific research methods.  
  • "Learning to Interview in the Social Sciences" Qualitative Inquiry, 9(4) 2003, 643–668 by Roulston, K., deMarrais, K., & Lewis, J. B. See especially the section on "Phrasing and Negotiating Questions" on pages 653-655 and common problems with framing questions noted on pages 659 - 660.  
  • Qualitative Research Interviewing: Biographic Narrative and Semi-Structured Methods (See sections on “Lightly and Heavily Structured Depth Interviewing: Theory-Questions and Interviewer-Questions” and “Preparing for any Interviewing Sequence") by Tom Wengraf  Unique in its conceptual coherence and the level of practical detail, this book provides a comprehensive resource for those concerned with the practice of semi-structured interviewing, the most commonly used interview approach in social research, and in particular for in-depth, biographic narrative interviewing. It covers the full range of practices from the identification of topics through to strategies for writing up research findings in diverse ways.  
  • "Scripting a Qualitative Purpose Statement and Research Questions" in Chapter 12 (pp. 93–102) of 30 Essential Skills for the Qualitative Researcher by John W. Creswell  Provides practical "how-to" information for beginning researchers in the social, behavioral, and health sciences with many applied examples from research design, qualitative inquiry, and mixed methods.The skills presented in this book are crucial for a new qualitative researcher starting a qualitative project.  
  • Some Strategies for Developing Interview Guides for Qualitative Interviews by Sociology Department, Harvard University Includes general advice for conducting qualitative interviews, pros and cons of recording and transcription, guidelines for success, and tips for developing and phrasing effective interview questions.  
  • Tip Sheet on Question Wording by Harvard University Program on Survey Research

Let Theory Guide You:

The quality of your questions depends on how you situate them within a wider body of knowledge. Consider the following advice:

A good literature review has many obvious virtues. It enables the investigator to define problems and assess data. It provides the concepts on which percepts depend. But the literature review has a special importance for the qualitative researcher. This consists of its ability to sharpen his or her capacity for surprise (Lazarsfeld, 1972b). The investigator who is well versed in the literature now has a set of expectations the data can defy. Counterexpectational data are conspicuous, readable, and highly provocative data. They signal the existence of unfulfilled theoretical assumptions, and these are, as Kuhn (1962) has noted, the very origins of intellectual innovation. A thorough review of the literature is, to this extent, a way to manufacture distance. It is a way to let the data of one's research project take issue with the theory of one's field.

McCracken, G. (1988), The Long Interview, Sage: Newbury Park, CA, p. 31

When drafting your interview questions, remember that everything follows from your central research question. Also, on the way to writing your "operationalized" interview questions, it's  helpful to draft broader, intermediate questions, couched in theory. Nota bene:  While it is important to know the literature well before conducting your interview(s), be careful not to present yourself to your research participant(s) as "the expert," which would be presumptuous and could be intimidating. Rather, the purpose of your knowledge is to make you a better, keener listener.

If you'd like to supplement what you learned about relevant theories through your coursework and literature review, try these sources:

  • Annual Reviews   Review articles sum up the latest research in many fields, including social sciences, biomedicine, life sciences, and physical sciences. These are timely collections of critical reviews written by leading scientists.  
  • HOLLIS - search for resources on theories in your field   Modify this example search by entering the name of your field in place of "your discipline," then hit search.  
  • Oxford Bibliographies   Written and reviewed by academic experts, every article in this database is an authoritative guide to the current scholarship in a variety of fields, containing original commentary and annotations.  
  • ProQuest Dissertations & Theses (PQDT)   Indexes dissertations and masters' theses from most North American graduate schools as well as some European universities. Provides full text for most indexed dissertations from 1990-present.  
  • Very Short Introductions   Launched by Oxford University Press in 1995, Very Short Introductions offer concise introductions to a diverse range of subjects from Climate to Consciousness, Game Theory to Ancient Warfare, Privacy to Islamic History, Economics to Literary Theory.

CONDUCTING INTERVIEWS

Equipment and software:  .

  • Lamont Library  loans microphones and podcast starter kits, which will allow you to capture audio (and you may record with software, such as Garage Band). 
  • Cabot Library  loans digital recording devices, as well as USB microphones.

If you prefer to use your own device, you may purchase a small handheld audio recorder, or use your cell phone.

  • Audio Capture Basics (PDF)  - Helpful instructions, courtesy of the Lamont Library Multimedia Lab.
  • Getting Started with Podcasting/Audio:  Guidelines from Harvard Library's Virtual Media Lab for preparing your interviewee for a web-based recording (e.g., podcast, interview)
  • ​ Camtasia Screen Recorder and Video Editor
  • Zoom: Video Conferencing, Web Conferencing
  • Visit the Multimedia Production Resources guide! Consult it to find and learn how to use audiovisual production tools, including: cameras, microphones, studio spaces, and other equipment at Cabot Science Library and Lamont Library.
  • Try the virtual office hours offered by the Lamont Multimedia Lab!

TIPS FOR CONDUCTING INTERVIEWS

Quick handout:  .

  • Research Interviewing Tips (Courtesy of Dr. Suzanne Spreadbury)

Remote Interviews:  

  • For Online or Distant Interviews, See "Remote Research & Virtual Fieldwork" on this guide .  
  • Deborah Lupton's Bibliography: Doing Fieldwork in a Pandemic

Seeking Consent:

Books and articles:  .

  • "App-Based Textual Interviews: Interacting With Younger Generations in a Digitalized Social Reallity."International Journal of Social Research Methodology (12 June 2022). Discusses the use of texting platforms as a means to reach young people. Recommends useful question formulations for this medium.  
  • "Learning to Interview in the Social Sciences." Qualitative Inquiry, 9(4) 2003, 643–668 by Roulston, K., deMarrais, K., & Lewis, J. B. See especially the section on "Phrasing and Negotiating Questions" on pages 653-655 and common problems with framing questions noted on pages 659-660.  
  • "Slowing Down and Digging Deep: Teaching Students to Examine Interview Interaction in Depth." LEARNing Landscapes, Spring 2021 14(1) 153-169 by Herron, Brigette A. and Kathryn Roulston. Suggests analysis of videorecorded interviews as a precursor to formulating one's own questions. Includes helpful types of probes.  
  • Using Interviews in a Research Project by Nigel Joseph Mathers; Nicholas J Fox; Amanda Hunn; Trent Focus Group.  A work pack to guide researchers in developing interviews in the healthcare field. Describes interview structures, compares face-to-face and telephone interviews. Outlines the ways in which different types of interview data can be analysed.  
  • “Working through Challenges in Doing Interview Research.” International Journal of Qualitative Methods, (December 2011), 348–66 by Roulston, Kathryn.  The article explores (1) how problematic interactions identified in the analysis of focus group data can lead to modifications in research design, (2) an approach to dealing with reported data in representations of findings, and (3) how data analysis can inform question formulation in successive rounds of data generation. Findings from these types of examinations of interview data generation and analysis are valuable for informing both interview practice as well as research design.

Videos:  

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The way a qualitative researcher transcribes interviews should flow from, or align with, the methodological paradigm chosen for the study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

TRANSCRIPTION

Before embarking on a transcription project, it's worthwhile to invest in the time and effort necessary to capture good audio, which will make the transcription process much easier. If you haven't already done so, check out the  audio capture guidelines from Harvard Library's Virtual Media Lab , or  contact a media staff member  for customized recommendations. First and foremost, be mindful of common pitfalls by watching this short video that identifies  the most common errors to avoid!

SOFTWARE:  

  • Otter  provides a new way to capture, store, search and share voice conversations, lectures, presentations, meetings, and interviews. The startup is based in Silicon Valley with a team of experienced Ph.Ds and engineers from Google, Facebook, Yahoo and Nuance (à la Dragon). Free accounts available. This is the software that  Zoom  uses to generate automated transcripts, so if you have access to a Zoom subscription, you have access to Otter transcriptions with it (applicable in several  languages ). As with any automated approach, be prepared to correct any errors after the fact, by hand.  
  • Panopto  is available to Harvard affiliates and generates  ASR (automated speech recognition) captions . You may upload compatible audio files into it. As with any automatically generated transcription, you will need to make manual revisions. ASR captioning is available in several  languages .  
  • GoTranscript  provides cost-effective human-generated transcriptions.  
  • pyTranscriber  is an app for generating automatic transcription and/or subtitles for audio and video files. It uses the Google Cloud Speech-to-Text service, has a friendly graphical user interface, and is purported to work nicely with Chinese.   
  • REV.Com  allows you to record and transcribe any calls on the iPhone, both outgoing and incoming. It may be useful for recording phone interviews. Rev lets you choose whether you want an AI- or human-generated transcription, with a fast turnaround.  
  • Scribie Audio/Video Transcription  provides automated or manual transcriptions for a small fee. As with any transcription service, some revisions will be necessary after the fact, particularly for its automated transcripts.  
  • Sonix  automatically transcribes, translates, and helps to organize audio and video files in over 40 languages. It's fast and affordable, with good accuracy. The free trial includes 30 minutes of free transcription.  
  • TranscriptionWing  uses a human touch process to clean up machine-generated transcripts so that the content will far more accurately reflect your audio recording. 

EQUIPMENT:  

  • Transcription pedals  are in circulation and available to borrow from the Circulation desk at Lamont, or use at Lamont Library's Media Lab on level B. For hand-transcribing your interviews, they work in conjunction with software such as  Express Scribe , which is loaded on Media Lab computers, or you may download for free on your own machine (Mac or PC versions; scroll down the downloads page for the latter). The pedals are plug-and-play USB, allow a wide range of playback speeds, and have 3 programmable buttons, which are typically set to rewind/play/fast-forward. Instructions are included in the bag that covers installation and set-up of the software, and basic use of the pedals.

NEED HELP?  

  • Try the virtual office hours offered by the Lamont Multimedia Lab!    
  • If you're creating podcasts, login to  Canvas  and check out the  Podcasting/Audio guide . 

Helpful Texts:  

  • "Transcription as a Crucial Step of Data Analysis" in Chapter 5 of The SAGE Handbook of Qualitative Data Analysisby Uwe Flick (Editor)  Covers basic terminology for transcription, shares caveats for transcribers, and identifies components of vocal behavior. Provides notation systems for transcription, suggestions for transcribing turn-taking, and discusses new technologies and perspectives. Includes a bibliography for further reading.  
  • "Transcribing the Oral Interview: Part Art, Part Science " on p. 10 of the Centre for Community Knowledge (CCK) newsletter: TIMESTAMPby Mishika Chauhan and Saransh Srivastav

QUALITATIVE DATA ANALYSIS

Software  .

  • Free download available for Harvard Faculty of Arts and Sciences (FAS) affiliates
  • Desktop access at Lamont Library Media Lab, 3rd floor
  • Desktop access at Harvard Kennedy School Library (with HKS ID)
  • Remote desktop access for Harvard affiliates from  IQSS Computer Labs . Email them at  [email protected] and ask for a new lab account and remote desktop access to NVivo.
  • Virtual Desktop Infrastructure (VDI) access available to Harvard T.H. Chan School of Public Health affiliates

CODING AND THEMEING YOUR DATA

Data analysis methods should flow from, or align with, the methodological paradigm chosen for your study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these). Some established methods include Content Analysis, Critical Analysis, Discourse Analysis, Gestalt Analysis, Grounded Theory Analysis, Interpretive Analysis, Narrative Analysis, Normative Analysis, Phenomenological Analysis, Rhetorical Analysis, and Semiotic Analysis, among others. The following resources should help you navigate your methodological options and put into practice methods for coding, themeing, interpreting, and presenting your data.

  • Users can browse content by topic, discipline, or format type (reference works, book chapters, definitions, etc.). SRM offers several research tools as well: a methods map, user-created reading lists, a project planner, and advice on choosing statistical tests.  
  • Abductive Coding: Theory Building and Qualitative (Re)Analysis by Vila-Henninger, et al.  The authors recommend an abductive approach to guide qualitative researchers who are oriented towards theory-building. They outline a set of tactics for abductive analysis, including the generation of an abductive codebook, abductive data reduction through code equations, and in-depth abductive qualitative analysis.  
  • Analyzing and Interpreting Qualitative Research: After the Interview by Charles F. Vanover, Paul A. Mihas, and Johnny Saldana (Editors)   Providing insight into the wide range of approaches available to the qualitative researcher and covering all steps in the research process, the authors utilize a consistent chapter structure that provides novice and seasoned researchers with pragmatic, "how-to" strategies. Each chapter author introduces the method, uses one of their own research projects as a case study of the method described, shows how the specific analytic method can be used in other types of studies, and concludes with three questions/activities to prompt class discussion or personal study.   
  • "Analyzing Qualitative Data." Theory Into Practice 39, no. 3 (2000): 146-54 by Margaret D. LeCompte   This article walks readers though rules for unbiased data analysis and provides guidance for getting organized, finding items, creating stable sets of items, creating patterns, assembling structures, and conducting data validity checks.  
  • "Coding is Not a Dirty Word" in Chapter 1 (pp. 1–30) of Enhancing Qualitative and Mixed Methods Research with Technology by Shalin Hai-Jew (Editor)   Current discourses in qualitative research, especially those situated in postmodernism, represent coding and the technology that assists with coding as reductive, lacking complexity, and detached from theory. In this chapter, the author presents a counter-narrative to this dominant discourse in qualitative research. The author argues that coding is not necessarily devoid of theory, nor does the use of software for data management and analysis automatically render scholarship theoretically lightweight or barren. A lack of deep analytical insight is a consequence not of software but of epistemology. Using examples informed by interpretive and critical approaches, the author demonstrates how NVivo can provide an effective tool for data management and analysis. The author also highlights ideas for critical and deconstructive approaches in qualitative inquiry while using NVivo. By troubling the positivist discourse of coding, the author seeks to create dialogic spaces that integrate theory with technology-driven data management and analysis, while maintaining the depth and rigor of qualitative research.   
  • The Coding Manual for Qualitative Researchers by Johnny Saldana   An in-depth guide to the multiple approaches available for coding qualitative data. Clear, practical and authoritative, the book profiles 32 coding methods that can be applied to a range of research genres from grounded theory to phenomenology to narrative inquiry. For each approach, Saldaña discusses the methods, origins, a description of the method, practical applications, and a clearly illustrated example with analytic follow-up. Essential reading across the social sciences.  
  • Flexible Coding of In-depth Interviews: A Twenty-first-century Approach by Nicole M. Deterding and Mary C. Waters The authors suggest steps in data organization and analysis to better utilize qualitative data analysis technologies and support rigorous, transparent, and flexible analysis of in-depth interview data.  
  • From the Editors: What Grounded Theory is Not by Roy Suddaby Walks readers through common misconceptions that hinder grounded theory studies, reinforcing the two key concepts of the grounded theory approach: (1) constant comparison of data gathered throughout the data collection process and (2) the determination of which kinds of data to sample in succession based on emergent themes (i.e., "theoretical sampling").  
  • “Good enough” methods for life-story analysis, by Wendy Luttrell. In Quinn N. (Ed.), Finding culture in talk (pp. 243–268). Demonstrates for researchers of culture and consciousness who use narrative how to concretely document reflexive processes in terms of where, how and why particular decisions are made at particular stages of the research process.   
  • Presentation slides on coding and themeing your data, derived from Saldana, Spradley, and LeCompte Click to request access.  
  • Qualitative Data Analysis by Matthew B. Miles; A. Michael Huberman   A practical sourcebook for researchers who make use of qualitative data, presenting the current state of the craft in the design, testing, and use of qualitative analysis methods. Strong emphasis is placed on data displays matrices and networks that go beyond ordinary narrative text. Each method of data display and analysis is described and illustrated.  
  • "A Survey of Qualitative Data Analytic Methods" in Chapter 4 (pp. 89–138) of Fundamentals of Qualitative Research by Johnny Saldana   Provides an in-depth introduction to coding as a heuristic, particularly focusing on process coding, in vivo coding, descriptive coding, values coding, dramaturgical coding, and versus coding. Includes advice on writing analytic memos, developing categories, and themeing data.   
  • "Thematic Networks: An Analytic Tool for Qualitative Research." Qualitative Research : QR, 1(3), 385–405 by Jennifer Attride-Stirling Details a technique for conducting thematic analysis of qualitative material, presenting a step-by-step guide of the analytic process, with the aid of an empirical example. The analytic method presented employs established, well-known techniques; the article proposes that thematic analyses can be usefully aided by and presented as thematic networks.  
  • Using Thematic Analysis in Psychology by Virginia Braun and Victoria Clark Walks readers through the process of reflexive thematic analysis, step by step. The method may be adapted in fields outside of psychology as relevant. Pair this with One Size Fits All? What Counts as Quality Practice in Reflexive Thematic Analysis? by Virginia Braun and Victoria Clark

TESTING OR GENERATING THEORIES

The quality of your data analysis depends on how you situate what you learn within a wider body of knowledge. Consider the following advice:

Once you have coalesced around a theory, realize that a theory should  reveal  rather than  color  your discoveries. Allow your data to guide you to what's most suitable. Grounded theory  researchers may develop their own theory where current theories fail to provide insight.  This guide on Theoretical Models  from Alfaisal University Library provides a helpful overview on using theory.

MANAGING & FINDING INTERVIEW DATA

Managing your elicited interview data, help with securing, storing, and sharing data:  .

  • Research Data Management @ Harvard A reference guide with information and resources to help you manage your research data. See also: Harvard Research Data Security Policy , on the Harvard University Research Data Management website.  
  • Data Security Levels at Harvard - Research Data Examples This resource provided by Harvard Data Security helps you determine what level of access is appropriate for your data. Determine whether it should be made available for public use, limited to the Harvard community, or be protected as either "confidential and sensitive," "high risk," or "extremely sensitive." See also:  Harvard Data Classification Table  
  • Harvard's Best Practices for Protecting Privacy and  Harvard Information Security Collaboration Tools Matrix Follow the nuts-and-bolts advice for privacy best practices at Harvard. The latter resource reveals the level of security that can be relied upon for a large number of technological tools and platforms used at Harvard to conduct business, such as email, Slack, Accellion Kiteworks, OneDrive/SharePoint, etc.  
  • Generative AI Harvard-affiliated researchers should not enter data classified as confidential ( Level 2 and above ), including non-public research data, into publicly-available generative AI tools, in accordance with the University’s Information Security Policy. Information shared with generative AI tools using default settings is not private and could expose proprietary or sensitive information to unauthorized parties.  
  • Harvard Information Security Quick Reference Guide Storage guidelines, based on the data's security classification level (according to its IRB classification) is displayed on page 2, under "handling."  
  • Email Encryption Harvard Microsoft 365 users can now send encrypted messages and files directly from the Outlook web or desktop apps. Encrypting an email adds an extra layer of security to the message and its attachments (up to 150MB), and means only the intended recipient (and their inbox delegates with full access) can view it. Message encryption in Outlook is approved for sending high risk ( level 4 ) data and below.  
  • Data Management For Researchers: Organize, Maintain and Share Your Data for Research Success by Kristin Briney. A comprehensive guide for scientific researchers providing everything they need to know about data management and how to organize, document, use and reuse their data.  
  • Open Science Framework (OSF) An open-source project management tool that makes it easy to collaborate within and beyond Harvard throughout a project's lifecycle. With OSF you can manage, store, and share documents, datasets, and other information with your research team. You can also publish your work to share it with a wider audience.  
  • QDS Qualitative Data Sharing Toolkit Provides tools and resources to help researchers share qualitative research data while protecting privacy and confidentiality. It offers guidance on preparing data for sharing through de-identification and access control.   
  • Repositories for Qualitative Data If you have cleared this intention with your IRB, secured consent from participants, and properly de-identified your data, consider sharing your interviews in one of the data repositories included in the link above. Depending on the nature of your research and the level of risk it may present to participants, sharing your interview data may not be appropriate. If there is any chance that sharing such data will be desirable, you will be much better off if you build this expectation into your plans from the beginning.  
  • Guide for Sharing Qualitative Data at ICPSR The Inter-university Consortium for Political and Social Research (ICPSR) has created this resource for investigators planning to share qualitative data at ICPSR. This guide provides an overview of elements and considerations for archiving qualitative data, identifies steps for investigators to follow during the research life cycle to ensure that others can share and reuse qualitative data, and provides information about exemplars of qualitative data  
  • Research Compliance Program for FAS/SEAS at Harvard The Faculty of Arts and Sciences (FAS), including the School of Engineering and Applied Sciences (SEAS), and the Office of the Vice Provost for Research (OVPR) have established a shared Research Compliance Program (RCP). An area of common concern for interview studies is international projects and collaboration . RCP is a resource to provide guidance on which international activities may be impacted by US sanctions on countries, individuals, or entities and whether licenses or other disclosure are required to ship or otherwise share items, technology, or data with foreign collaborators.

Finding Extant Interview Data

Finding journalistic interviews:  .

  • Academic Search Premier This all-purpose database is great for finding articles from magazines and newspapers. In the Advanced Search, it allows you to specify "Document Type":  Interview.  
  • Guide to Newspapers and Newspaper Indexes Use this guide created to Harvard Librarians to identify newspapers collections you'd like to search. To locate interviews, try adding the term  "interview"  to your search, or explore a database's search interface for options to  limit your search to interviews.  Nexis Uni  and  Factiva  are the two main databases for current news.   
  • Listen Notes Search for podcast episodes at this podcast aggregator, and look for podcasts that include interviews. Make sure to vet the podcaster for accuracy and quality! (Listen Notes does not do much vetting.)  
  • NPR  and  ProPublica  are two sites that offer high-quality long-form reporting, including journalistic interviews, for free.

Finding Oral History and Social Research Interviews:  

  • To find oral histories, see the Oral History   page of this guide for helpful resources on Oral History interviewing.  
  • Repositories for Qualitative Data It has not been a customary practice among qualitative researchers in the social sciences to share raw interview data, but some have made this data available in repositories, such as the ones listed on the page linked above. You may find published data from structured interview surveys (e.g., questionnaire-based computer-assisted telephone interview data), as well as some semi-structured and unstructured interviews.  
  • If you are merely interested in studies interpreting data collected using interviews, rather than finding raw interview data, try databases like  PsycInfo ,  Sociological Abstracts , or  Anthropology Plus , among others. 

Finding Interviews in Archival Collections at Harvard Library:

In addition to the databases and search strategies mentioned under the  "Finding Oral History and Social Research Interviews" category above,  you may search for interviews and oral histories (whether in textual or audiovisual formats) held in archival collections at Harvard Library.

  • HOLLIS searches all documented collections at Harvard, whereas HOLLIS for Archival Discovery searches only those with finding aids. Although HOLLIS for Archival Discovery covers less material, you may find it easier to parse your search results, especially when you wish to view results at the item level (within collections). Try these approaches:

Search in  HOLLIS :  

  • To retrieve items available online, do an Advanced Search for  interview* OR "oral histor*" (in Subject), with Resource Type "Archives/Manuscripts," then refine your search by selecting "Online" under "Show Only" on the right of your initial result list.  Revise the search above by adding your topic in the Keywords or Subject field (for example:  African Americans ) and resubmitting the search.  
  •  To enlarge your results set, you may also leave out the "Online" refinement; if you'd like to limit your search to a specific repository, try the technique of searching for  Code: Library + Collection on the "Advanced Search" page .   

Search in  HOLLIS for Archival Discovery :  

  • To retrieve items available online, search for   interview* OR "oral histor*" limited to digital materials . Revise the search above by adding your topic (for example:  artist* ) in the second search box (if you don't see the box, click +).  
  • To preview results by collection, search for  interview* OR "oral histor*" limited to collections . Revise the search above by adding your topic (for example:  artist* ) in the second search box (if you don't see the box, click +). Although this method does not allow you to isolate digitized content, you may find the refinement options on the right side of the screen (refine by repository, subject or names) helpful.  Once your select a given collection, you may search within it  (e.g., for your topic or the term interview).

UX & MARKET RESEARCH INTERVIEWS

Ux at harvard library  .

  • User Experience and Market Research interviews can inform the design of tangible products and services through responsive, outcome-driven insights. The  User Research Center  at Harvard Library specializes in this kind of user-centered design, digital accessibility, and testing. They also offer guidance and  resources  to members of the Harvard Community who are interested in learning more about UX methods. Contact [email protected] or consult the URC website for more information.

Websites  

  • User Interviews: The Beginner’s Guide (Chris Mears)  
  • Interviewing Users (Jakob Nielsen)

Books  

  • Interviewing Users: How to Uncover Compelling Insights by Steve Portigal; Grant McCracken (Foreword by)  Interviewing is a foundational user research tool that people assume they already possess. Everyone can ask questions, right? Unfortunately, that's not the case. Interviewing Users provides invaluable interviewing techniques and tools that enable you to conduct informative interviews with anyone. You'll move from simply gathering data to uncovering powerful insights about people.  
  • Rapid Contextual Design by Jessamyn Wendell; Karen Holtzblatt; Shelley Wood  This handbook introduces Rapid CD, a fast-paced, adaptive form of Contextual Design. Rapid CD is a hands-on guide for anyone who needs practical guidance on how to use the Contextual Design process and adapt it to tactical projects with tight timelines and resources. Rapid Contextual Design provides detailed suggestions on structuring the project and customer interviews, conducting interviews, and running interpretation sessions. The handbook walks you step-by-step through organizing the data so you can see your key issues, along with visioning new solutions, storyboarding to work out the details, and paper prototype interviewing to iterate the design all with as little as a two-person team with only a few weeks to spare *Includes real project examples with actual customer data that illustrate how a CD project actually works.

Videos  

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Instructional Presentations on Interview Skills  

  • Interview/Oral History Research for RSRA 298B: Master's Thesis Reading and Research (Spring 2023) Slideshow covers: Why Interviews?, Getting Context, Engaging Participants, Conducting the Interview, The Interview Guide, Note Taking, Transcription, File management, and Data Analysis.  
  • Interview Skills From an online class on February 13, 2023:  Get set up for interview research. You will leave prepared to choose among the three types of interviewing methods, equipped to develop an interview schedule, aware of data management options and their ethical implications, and knowledgeable of technologies you can use to record and transcribe your interviews. This workshop complements Intro to NVivo, a qualitative data analysis tool useful for coding interview data.

NIH Data Management & Sharing Policy (DMSP) This policy, effective January 25, 2023, applies to all research, funded or conducted in whole or in part by NIH, that results in the generation of  scientific data , including NIH-funded qualitative research. Click here to see some examples of how the DMSP policy has been applied in qualitative research studies featured in the 2021 Qualitative Data Management Plan (DMP) Competition . As a resource for the community, NIH has developed a resource for developing informed consent language in research studies where data and/or biospecimens will be stored and shared for future use. It is important to note that the DMS Policy does NOT require that informed consent obtained from research participants must allow for broad sharing and the future use of data (either with or without identifiable private information). See the FAQ for more information.

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Except where otherwise noted, this work is subject to a Creative Commons Attribution 4.0 International License , which allows anyone to share and adapt our material as long as proper attribution is given. For details and exceptions, see the Harvard Library Copyright Policy ©2021 Presidents and Fellows of Harvard College.

  • Open access
  • Published: 27 May 2020

How to use and assess qualitative research methods

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

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

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

figure 1

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

figure 2

Possible combination of data collection methods

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

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

Data analysis

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

figure 3

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

figure 4

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

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Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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

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qualitative research interview study

Qualitative study design: Interviews

  • Qualitative study design
  • Phenomenology
  • Grounded theory
  • Ethnography
  • Narrative inquiry
  • Action research
  • Case Studies
  • Field research
  • Focus groups
  • Observation
  • Surveys & questionnaires
  • Study Designs Home

Interviews are intended to find out the experiences, understandings, opinions, or motivations of participants. The relationship between the interviewer and interviewee is crucial to the success of the research interview; the interviewer builds an environment of trust with the interviewee/s, guiding the interviewee/s through a set of topics or questions to be discussed in depth.

Interviews are the most commonly used qualitative data gathering technique and are used with grounded theory, focus groups, and case studies.

  • Interviews are purposive conversations between the researcher and the interviewee, either alone or as part of a group
  • Interviews can be face to face, via telecommunications (Skype, Facetime, or phone), or via email (internet or email interview)
  • The length of an interview varies. They may be anywhere from thirty minutes to several hours in length, depending on your research approach
  • Structured interviews use a set list of questions which need to be asked in order, increasing the reliability and credibility of the data but decreasing responsiveness to interviewee/s. Structured interviews are like a verbal survey
  • Unstructured interviews are where the interviewer has a set list of topics to address but no predetermined questions. This increases the flexibility of the interview but decreases the reliability of the data. Unstructured interviews may be used in long-term field observation research
  • Semi-structured interviews are the middle ground. Semi-structured interviews require the interviewer to have a list of questions and topics pre-prepared, which can be asked in different ways with different interviewee/s. Semi-structured interviews increase the flexibility and the responsiveness of the interview while keeping the interview on track, increasing the reliability and credibility of the data. Semi-structured interviews are one of the most common interview techniques.
  • Flexible – probing questions can be asked, and the order of questions changed, depending on the participant and how structured or unstructured the interview is
  • Quick way to collect data
  • Familiarity – most interviewees are familiar with the concept of an interview and are comfortable with this research approach

Limitations

  • Not all participants are equally articulate or perceptive
  • Questions must be worded carefully to reduce response bias
  • Transcription of interviews can be time and labour intensive

Example questions

  • What are the experiences of midwives in providing care to high-risk mothers, where there is a history of drug or alcohol use?

Example studies

Sandelin, A., Kalman, S., Gustafsson, B. (2019). Prerequisites for safe intraoperative nursing care and teamwork – operating theatre nurses’ perspectives: a qualitative interview study, Journal of Clinical Nursing, 28, 2635-2643. Doi: 10.1111/jocn.14850  

Babbie, E. (2008). The basics of social research (4th ed). Belmont: Thomson Wadsworth

Creswell, J.W. & Creswell, J.D. (2018). Research design: Qualitative, quantitative and mixed methods approaches (5th ed). Thousand Oaks: SAGE

Jamshed, S. (2014). Qualitative research method-interviewing and observation. Journal of basic and clinical pharmacy, 5(4), 87-88. doi:10.4103/0976-0105.141942

Lindlof, T. & Taylor, B. (2002). Qualitative communication research methods (2nd ed). Thousand Oaks: SAGE .

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  • What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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qualitative research interview study

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

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

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

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

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

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

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

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

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

  • Flexibility

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

  • Natural settings

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

  • Meaningful insights

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

  • Generation of new ideas

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

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

  • Unreliability

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

  • Subjectivity

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

  • Limited generalizability

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

  • Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Qualitative Research 101: Interviewing

5 Common Mistakes To Avoid When Undertaking Interviews

By: David Phair (PhD) and Kerryn Warren (PhD) | March 2022

Undertaking interviews is potentially the most important step in the qualitative research process. If you don’t collect useful, useable data in your interviews, you’ll struggle through the rest of your dissertation or thesis.  Having helped numerous students with their research over the years, we’ve noticed some common interviewing mistakes that first-time researchers make. In this post, we’ll discuss five costly interview-related mistakes and outline useful strategies to avoid making these.

Overview: 5 Interviewing Mistakes

  • Not having a clear interview strategy /plan
  • Not having good interview techniques /skills
  • Not securing a suitable location and equipment
  • Not having a basic risk management plan
  • Not keeping your “ golden thread ” front of mind

1. Not having a clear interview strategy

The first common mistake that we’ll look at is that of starting the interviewing process without having first come up with a clear interview strategy or plan of action. While it’s natural to be keen to get started engaging with your interviewees, a lack of planning can result in a mess of data and inconsistency between interviews.

There are several design choices to decide on and plan for before you start interviewing anyone. Some of the most important questions you need to ask yourself before conducting interviews include:

  • What are the guiding research aims and research questions of my study?
  • Will I use a structured, semi-structured or unstructured interview approach?
  • How will I record the interviews (audio or video)?
  • Who will be interviewed and by whom ?
  • What ethics and data law considerations do I need to adhere to?
  • How will I analyze my data? 

Let’s take a quick look at some of these.

The core objective of the interviewing process is to generate useful data that will help you address your overall research aims. Therefore, your interviews need to be conducted in a way that directly links to your research aims, objectives and research questions (i.e. your “golden thread”). This means that you need to carefully consider the questions you’ll ask to ensure that they align with and feed into your golden thread. If any question doesn’t align with this, you may want to consider scrapping it.

Another important design choice is whether you’ll use an unstructured, semi-structured or structured interview approach . For semi-structured interviews, you will have a list of questions that you plan to ask and these questions will be open-ended in nature. You’ll also allow the discussion to digress from the core question set if something interesting comes up. This means that the type of information generated might differ a fair amount between interviews.

Contrasted to this, a structured approach to interviews is more rigid, where a specific set of closed questions is developed and asked for each interviewee in exactly the same order. Closed questions have a limited set of answers, that are often single-word answers. Therefore, you need to think about what you’re trying to achieve with your research project (i.e. your research aims) and decided on which approach would be best suited in your case.

It is also important to plan ahead with regards to who will be interviewed and how. You need to think about how you will approach the possible interviewees to get their cooperation, who will conduct the interviews, when to conduct the interviews and how to record the interviews. For each of these decisions, it’s also essential to make sure that all ethical considerations and data protection laws are taken into account.

Finally, you should think through how you plan to analyze the data (i.e., your qualitative analysis method) generated by the interviews. Different types of analysis rely on different types of data, so you need to ensure you’re asking the right types of questions and correctly guiding your respondents.

Simply put, you need to have a plan of action regarding the specifics of your interview approach before you start collecting data. If not, you’ll end up drifting in your approach from interview to interview, which will result in inconsistent, unusable data.

Your interview questions need to directly  link to your research aims, objectives and  research questions - your "golden thread”.

2. Not having good interview technique

While you’re generally not expected to become you to be an expert interviewer for a dissertation or thesis, it is important to practice good interview technique and develop basic interviewing skills .

Let’s go through some basics that will help the process along.

Firstly, before the interview , make sure you know your interview questions well and have a clear idea of what you want from the interview. Naturally, the specificity of your questions will depend on whether you’re taking a structured, semi-structured or unstructured approach, but you still need a consistent starting point . Ideally, you should develop an interview guide beforehand (more on this later) that details your core question and links these to the research aims, objectives and research questions.

Before you undertake any interviews, it’s a good idea to do a few mock interviews with friends or family members. This will help you get comfortable with the interviewer role, prepare for potentially unexpected answers and give you a good idea of how long the interview will take to conduct. In the interviewing process, you’re likely to encounter two kinds of challenging interviewees ; the two-word respondent and the respondent who meanders and babbles. Therefore, you should prepare yourself for both and come up with a plan to respond to each in a way that will allow the interview to continue productively.

To begin the formal interview , provide the person you are interviewing with an overview of your research. This will help to calm their nerves (and yours) and contextualize the interaction. Ultimately, you want the interviewee to feel comfortable and be willing to be open and honest with you, so it’s useful to start in a more casual, relaxed fashion and allow them to ask any questions they may have. From there, you can ease them into the rest of the questions.

As the interview progresses , avoid asking leading questions (i.e., questions that assume something about the interviewee or their response). Make sure that you speak clearly and slowly , using plain language and being ready to paraphrase questions if the person you are interviewing misunderstands. Be particularly careful with interviewing English second language speakers to ensure that you’re both on the same page.

Engage with the interviewee by listening to them carefully and acknowledging that you are listening to them by smiling or nodding. Show them that you’re interested in what they’re saying and thank them for their openness as appropriate. This will also encourage your interviewee to respond openly.

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3. Not securing a suitable location and quality equipment

Where you conduct your interviews and the equipment you use to record them both play an important role in how the process unfolds. Therefore, you need to think carefully about each of these variables before you start interviewing.

Poor location: A bad location can result in the quality of your interviews being compromised, interrupted, or cancelled. If you are conducting physical interviews, you’ll need a location that is quiet, safe, and welcoming . It’s very important that your location of choice is not prone to interruptions (the workplace office is generally problematic, for example) and has suitable facilities (such as water, a bathroom, and snacks).

If you are conducting online interviews , you need to consider a few other factors. Importantly, you need to make sure that both you and your respondent have access to a good, stable internet connection and electricity. Always check before the time that both of you know how to use the relevant software and it’s accessible (sometimes meeting platforms are blocked by workplace policies or firewalls). It’s also good to have alternatives in place (such as WhatsApp, Zoom, or Teams) to cater for these types of issues.

Poor equipment: Using poor-quality recording equipment or using equipment incorrectly means that you will have trouble transcribing, coding, and analyzing your interviews. This can be a major issue , as some of your interview data may go completely to waste if not recorded well. So, make sure that you use good-quality recording equipment and that you know how to use it correctly.

To avoid issues, you should always conduct test recordings before every interview to ensure that you can use the relevant equipment properly. It’s also a good idea to spot check each recording afterwards, just to make sure it was recorded as planned. If your equipment uses batteries, be sure to always carry a spare set.

Where you conduct your interviews and the equipment you use to record them play an important role in how the process unfolds.

4. Not having a basic risk management plan

Many possible issues can arise during the interview process. Not planning for these issues can mean that you are left with compromised data that might not be useful to you. Therefore, it’s important to map out some sort of risk management plan ahead of time, considering the potential risks, how you’ll minimize their probability and how you’ll manage them if they materialize.

Common potential issues related to the actual interview include cancellations (people pulling out), delays (such as getting stuck in traffic), language and accent differences (especially in the case of poor internet connections), issues with internet connections and power supply. Other issues can also occur in the interview itself. For example, the interviewee could drift off-topic, or you might encounter an interviewee who does not say much at all.

You can prepare for these potential issues by considering possible worst-case scenarios and preparing a response for each scenario. For instance, it is important to plan a backup date just in case your interviewee cannot make it to the first meeting you scheduled with them. It’s also a good idea to factor in a 30-minute gap between your interviews for the instances where someone might be late, or an interview runs overtime for other reasons. Make sure that you also plan backup questions that could be used to bring a respondent back on topic if they start rambling, or questions to encourage those who are saying too little.

In general, it’s best practice to plan to conduct more interviews than you think you need (this is called oversampling ). Doing so will allow you some room for error if there are interviews that don’t go as planned, or if some interviewees withdraw. If you need 10 interviews, it is a good idea to plan for 15. Likely, a few will cancel , delay, or not produce useful data.

You should consider all the potential risks, how you’ll reduce their probability and how you'll respond if they do indeed materialize.

5. Not keeping your golden thread front of mind

We touched on this a little earlier, but it is a key point that should be central to your entire research process. You don’t want to end up with pages and pages of data after conducting your interviews and realize that it is not useful to your research aims . Your research aims, objectives and research questions – i.e., your golden thread – should influence every design decision and should guide the interview process at all times. 

A useful way to avoid this mistake is by developing an interview guide before you begin interviewing your respondents. An interview guide is a document that contains all of your questions with notes on how each of the interview questions is linked to the research question(s) of your study. You can also include your research aims and objectives here for a more comprehensive linkage. 

You can easily create an interview guide by drawing up a table with one column containing your core interview questions . Then add another column with your research questions , another with expectations that you may have in light of the relevant literature and another with backup or follow-up questions . As mentioned, you can also bring in your research aims and objectives to help you connect them all together. If you’d like, you can download a copy of our free interview guide here .

Recap: Qualitative Interview Mistakes

In this post, we’ve discussed 5 common costly mistakes that are easy to make in the process of planning and conducting qualitative interviews.

To recap, these include:

If you have any questions about these interviewing mistakes, drop a comment below. Alternatively, if you’re interested in getting 1-on-1 help with your thesis or dissertation , check out our dissertation coaching service or book a free initial consultation with one of our friendly Grad Coaches.

qualitative research interview study

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  • Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

  • P. Gill 1 &
  • J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

You have full access to this article via your institution.

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Introduction

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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Issue Date : 12 October 2018

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Interviews in Qualitative Research

Interviews in Qualitative Research

  • Nigel King - University of Huddersfield, UK
  • Christine Horrocks - Manchester Metropolitan University, UK
  • Joanna Brooks - University of Manchester
  • Description

This dynamic user-focused book will help you to get the data you want from your interviews. It provides practical guidance regarding technique, gives top-tips from real world case studies and shares achievable checklists and interview plans.

Whether you are doing interviews in your own research or just using other researchers’ data, this book will tell you everything you need to know about designing, planning, conducting and analyzing quality interviews. It explains how to:

-          Construct ethical research designs

-          Record and manage your data

-          Transcribe your notes

-          Analyse your findings

-          Disseminate your conclusions

Written using clear, jargon-free terminology and with coverage of practical, theoretical and philosophical issues all grounded in examples from real interviews, this is the ideal guide for new and experienced researchers alike.

Nigel King  is Professor of Applied Psychology at the University of Huddersfield.

Christine Horrocks  is Professor of Applied Social Psychology and Head of the Department of Psychology at Manchester Metropolitan University. 

Joanna Brooks  is Lecturer in the Manchester Centre for Health Psychology at the University of Manchester. 

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

SAGE 2455 Teller Road Thousand Oaks, CA 91320 www.sagepub.com

As a researcher and educator I find this book to be an invaluable resource, a detailed yet accessible guide for all those engaged in qualitative research . 

Interviews in Qualitative Research (Second Edition)  should be your first line of defense as you voyage through the minefield of using the method of interviewing. As a supervisor and qualitative researcher, this is a must-have, accessible read to support researchers at any stage. A helping, comforting hand to hold for qualitative researchers!

This is an impressive and comprehensive exploration of the use of interviews in qualitative research  –  theoretically rich, practically sensible, robust in application and academically relevant. It is essential reading for researchers at all levels of their research journey – an excellent resource and contribution to the literature.

Interviews in Qualitative Research is a must read for ambitious students and developing researchers. The authors holistically detail the interview method whilst remaining clear, concise and coherent. I am confident this book will help produce high quality qualitative research!

A comprehensive and accessible introduction to qualitative interviews. It is particularly strong on the practical aspects of designing and conducting interview-based studies using a wide range of settings, methods and approaches. It will become a trusted companion to many an undergraduate or postgraduate student, especially those who value an applied perspective. The new edition therefore deserves to defend its place on many a qualitative methods reading list – including my own.

This is an accessible and authoritative text that provides a detailed outline of the interview process from start to finish [...] The book usefully adopts an applied perspective and draws on ‘real world’ case studies to exemplify the possibilities and challenges that might arise throughout the interview process. It provides much practical guidance about how interviews might be planned, conducted and analysed – with boxes, tables and figures proving a particularly useful feature

This is a very good resource for students and teaching

This is a very good reference in qualitative research. The chapters are nicely laid and it is very easy to follow both from students and teachers' perspectives. I will highly recommend this book for students, teachers and researchers.

A useful book on using qualitative interviews in research for my students who spend this year undertaking a research project.

this books outlines the benefits of conducting interviews within the area of field data. The suggestion allow students to identify areas that they are interested in and also highlights potential pitfalls that they may encounter on the way to completing a dissertation.

Preview this book

For instructors, select a purchasing option, related products.

A Practical Introduction to In-depth Interviewing

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qualitative research interview study

  • Health and social care
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Interview study: qualitative studies

How to use interviews to evaluate your digital health product.

This page is part of a collection of guidance on evaluating digital health products .

Interviews with users of a digital health product can be carried out to understand their views and experiences.

What to use it for

Use an interview study when:

  • you want a more in-depth understanding of users’ thoughts and experiences of your product
  • you’re developing your product, to work out how to make it better (formative or iterative evaluation)
  • you have open-ended questions about your product

Benefits include:

  • provide in-depth insight into experiences
  • can be carried out with low numbers of participants

Drawbacks include:

  • can be time-consuming to carry out
  • require participants to give some of their time
  • can describe the range of user views, but not how common each view is

How to carry out an interview study

You can use interviews to collect quantitative or qualitative data or both.

Semi-structured interviews are a common approach for collecting qualitative data. These involve open-ended discussion with the participant, guided by a pre-existing plan. Write a discussion guide with a few important questions in advance and use this to guide your conversation. The guide may evolve for later interviews based on responses in earlier interviews.

Interviews can vary in length depending on the context, 20 minutes to an hour is common. Make sure the participant does not feel time-pressured or distracted. You should try to establish a rapport with them.

Sometimes participants are given a task to do before the interview, such as using the product. You may need fewer participants for an interview study than for a quantitative study. One approach is to keep recruiting participants until you are not getting any new insights from extra interviews (saturation of answers).

You should record the interview, using one or more of these methods:

  • audio recordings
  • video recordings
  • notes taken by the evaluator or an assistant

Taking notes is a useful back-up if the recording fails, but note-taking should not get in the way of establishing a rapport with the interviewee.

Transcribe the recordings after the interviews and try to review the transcripts soon after each interview. You may want to share transcripts with participants, allowing them to add to their comments.

Interviews can be carried out in person, by telephone or video conference. They can be carried out via text communication, such as email, but you may get less rich answers.

Interviews are usually analysed using thematic analysis or other qualitative data analysis methods.

Example: physical activity apps for cancer survivors

Roberts and others (2019), Breast, Prostate, and Colorectal Cancer Survivors’ Experiences of Using Publicly Available Physical Activity Mobile Apps: Qualitative Study

The team wanted to evaluate 4 existing apps for the promotion of physical activity to see whether they would work well for cancer survivors.

They chose an interview study because the work was at an early stage of development. They were working out what sort of app or features would work for this patient group.

Recruitment was done through the support of community-based cancer support groups, Facebook cancer support groups and charities. Participants were offered a £10 voucher for their time and to cover any costs of downloading the apps.

Participants had to meet these criteria:

  • at least 18 years old
  • diagnosed with breast, prostate or colorectal cancer
  • has finished primary curative treatment (surgery, radiotherapy and chemotherapy)
  • has not been advised by a clinician not to exercise
  • owns a smartphone

Ethical approval for this study was granted by a university research ethics committee.

Short telephone interviews were carried out to confirm participants’ eligibility and to get some background details. Each participant was then randomly assigned 2 of the 4 apps and instructed to use them for a week each consecutively. Afterwards, they were interviewed over the telephone using a discussion guide.

Forty participants were recruited, but 8 dropped out, so 32 completed the study.

The interviews were recorded and transcribed. They were analysed using thematic analysis . This found many factors that affected the participants’ engagement with physical activity apps and how relevant the apps were perceived as being to cancer survivors. Views of different behaviour change techniques used by the apps – for example, prompts, goal setting, incentives – varied a lot.

More information and resources

Braun and Clarke (2006), Using thematic analysis in psychology . This paper outlines how to do thematic analysis.

O’Brien and others (2014), Standard for reporting qualitative research . This paper describes the main elements of a qualitative study.

Qualitative Interview Design: A Practical Guide for Novice Investigators

Examples of interview studies in digital health

Gowin and others (2015), Health and Fitness App Use in College Students: A Qualitative Study . This study interviewed participants about a range of different apps.

Thies and others (2017), Lack of Adoption of a Mobile App to Support Patient Self-Management of Diabetes and Hypertension in a Federally Qualified Health Center: Interview Analysis of Staff and Patients in a Failed Randomized Trial . Researchers tried to carry out a randomised controlled trial but had to abandon this because of low numbers using and engaging with the app. Instead, they interviewed patients and staff about their experience of the app and how it was introduced to patients to understand what had happened.

Crane and others (2017), Factors Influencing Usability of a Smartphone App to Reduce Excessive Alcohol Consumption: Think Aloud and Interview Studies . Researchers conducted 2 sorts of interview studies about an app to reduce alcohol consumption. The first was a ‘think aloud’ study, the second was an interview after users had been given the app to use for 2 weeks.

Langius-Eklöf and others (2017), Adherence to Report and Patient Perception of an Interactive App for Managing Symptoms During Radiotherapy for Prostate Cancer: Descriptive Study of Logged and Interview Data .

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  • Open access
  • Published: 15 February 2024

Transcultural nursing: a qualitative analysis of nursing students’ experiences in a multicultural context in North-Eastern Namibia

  • Vistolina Nuuyoma   ORCID: orcid.org/0000-0002-5744-1355 1 ,
  • Sitembile Muvumwaeni 1 &
  • Leonard Chihururu 1  

BMC Nursing volume  23 , Article number:  123 ( 2024 ) Cite this article

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Metrics details

Culture is a fundamental concept in healthcare settings due to the reason that care provided to patients is holistic and encompasses their perspectives on health, which are greatly influenced by the patients’ cultures. To prepare culturally competent nursing graduates, it is important to understand the experiences of students on transcultural nursing during clinical practice. However, there are limited studies that have explored experiences of students on transcultural nursing, specifically those located in multicultural societies. In addition, studies focus on experiences of international students who visit with student - exchange programme. Nevertheless, their experiences of transcultural nursing may differ since they are not residents and have limited exposure to transcultural nursing, and therefore cannot be generalized to undergraduate resident students. This study aimed to explore and describe transcultural nursing experiences of nursing students during clinical practice at an intermediate hospital in north-eastern Namibia.

Descriptive and explorative qualitative designs were used, data were collected via individual interviews from 16 final year nursing students, who were sampled using maximum variation purposive and snowballing sampling. During data collection, an interview guide was used together with audiotape and field notes. Data analysis followed Tesch’s eight steps in qualitative coding process. Trustworthiness was ensured using four principles of Lincoln and Guba, Moreover, ethical clearance and permission were granted by research ethics committees from two institutions.

Four main themes emerged as findings of the study are: nursing students’ exposure to different cultural practices and beliefs; personal feelings experienced by nursing students during transcultural nursing; challenges experienced by students during transcultural nursing; and nursing students coping mechanisms.

Conclusions

Nursing students had mixed experiences on transcultural nursing which touch on aspects such as exposure to cultural aspects, personal feelings, challenges, and coping mechanisms. These findings are useful in helping nurse educators, clinical mentors, students, and future researchers to understand experiences of students on transcultural nursing. Consequently, assist in enriching transcultural nursing issues in curricula and for adequate preparation of graduates to become culturally competent when providing nursing care.

Peer Review reports

Introduction

Culture refers to dynamic system that creates, and is created by people, places, and practices [ 1 ]. It consists of sets of values and beliefs, or a cluster of learned behaviors that are shared with others in a particular society therefore, giving people a sense of belongingness and identity [ 2 ]. Culture is a fundamental concept in healthcare settings due to the reason that care provided to patients is holistic and encompasses their perspectives on health, which are greatly influenced by the patients’ cultures [ 3 ]. The P- Model designed by Causadias [ 1 ] to define culture consists of four concepts, which are people, places, practices, and power. People in culture refers to population dynamics, social relations, and culture in groups. Places indicate institutional influences, ecological dynamics, and culture in contexts. Practices pertain to community engagement, participatory dynamics, and culture in action. While power refers to forcing others into compliance, controlling access to space, and behaving as desired. Most definitions of culture found in literature pointed out on values and norms shared among members of a social group as part of culture and that they create expectations for certain behaviors [ 4 ]. Organizations such as health care facilities are generally classified as multi-cultural entities due to various professional and specialized teams that operate within them, therefore, creating subcultures within them. A subculture is typically comprised of people who have a distinct identity and yet are related to a larger cultural group. Individuals in subcultures share same ethnic origin and physical characteristics with the larger cultural group however, they conform to norms, values and practices affiliated to their occupational and societal groups [ 3 ].

Due to globalization of healthcare, nurses and midwives throughout the world are increasingly expected to come into contact with patients, families and colleagues from diverse cultures and backgrounds [ 5 ], consequently, providing transcultural nursing. The concept transcultural nursing was coined by Madeline Leininger in the 1950s, hence the development of Theory of Transcultural Nursing. The theory emphasized that patient care and communication exhibited by nurses should actively incorporates the patient’s background, values and beliefs into every step of the nursing process [ 6 ]. It also involves associating differences and similarities between cultures and relates them to caring values and life practices in order to envisage individual’s care needs and promote culturally congruent care. It focuses on the universality of human caring and analysis of diversity as well as dynamics of world in relation to human beliefs, behaviors and their caring values [ 7 ]. Leininger appealed for nurses to develop knowledge on and to possess ability for provision of culturally competent care [ 8 ]. Although the ultimate aim of nursing should be to provide a caring service that respects people’s cultural values and lifestyles, it is also influenced by nurses’ own values, beliefs and customs since they have own cultures that are different from patients [ 9 ]. Therefore, the nurse’s self-awareness can be the starting point to understand the patient’s culturally and master the skill of providing culturally competent care.

Through clinical nursing practice, nursing students become part of the healthcare and therefore expected to be culturally competent when providing transcultural nursing care. According to Çingöl et al., [ 10 ], receiving culturally appropriate healthcare service is a human right, and every individual has the right to receive nursing care in accordance with their culture. It is therefore expected that health professions education prepares well equipped graduates who adopt a neutral and positive approach to provide quality care tailored to cultural contexts of different people.

A review by Qui and Jiang [ 11 ] revealed that nursing students benefits from transcultural nursing by learning global nursing knowledge and experience cross-cultural interpersonal relationships. The same review also revealed that nursing students are prone to psychological problems and have encountered language problems during transcultural nursing. Other challenges of provision of transcultural care experienced by nursing students are intrapersonal struggle, cultural conflicts, varied expressions of discomforts such as pain and suffering, as well as personal and organizational constraints [ 12 ]. In a study by Okeya [ 13 ], findings revealed that nursing students lacked confidence, sufficient knowledge and experiences required to provide quality care for ethnic minority patients who are from diverse cultures.

Namibia is a multicultural society with 13 ethnic groups that practice diverse cultures. Of the 13 groups, there is a Kavango ethnic group which predominantly occupies Kavango east and west regions, which is further divided into five sub-ethnic groups namely: Mbukushu, Sambyu, Rukwangali, Mbunza and Gciriku. Rundu town in Kavango east region has recently become an ethnically diverse town with its population having increased drastically. Due to this population increase and migration of people from diverse ethnic groups in Namibia and other countries, the health care facilities have become multicultural settings and have incorporated transcultural nursing in provision of healthcare services. The observation at an intermediate hospital in Rundu is that there are language barriers between nurses and patients due to multiculturalism and lack of common language spoken by all residents.

Many nursing schools include intercultural nursing courses in their curricula and also providing short training for nurses to be culturally sensitive, capable of providing culturally adequate care, and who have improved empathy skills [ 10 ]. Course objectives incorporated in curriculum to prepare students for transcultural nursing are cultural awareness, cultural knowledge, cultural skills and cultural encounters [ 7 ]. These objectives are derived from components proposed by Campinha-Bacote Model to be included in the curriculum in order to develop culturally sensitive graduates [ 14 ]. In Namibia, nursing curricula incorporate transcultural nursing aspects in courses like nursing ethics and professional practice, general nursing science, foundations of sociology and community health nursing science. While Prosen [ 7 ] suggested learning and teaching activities such as clinical practice, cultural immersion experience, reflective writing and mentoring to be included in curriculum to promote cultural encounters, which is one of the vital aspects in transcultural nursing. It is however a concern that most courses in Namibia merely touch on the importance of recognizing and understanding diverse cultures without experiential learning outcomes related to cultural encounters. Moreover, it is not known how undergraduate nursing students in north-eastern Namibia experience transcultural nursing during clinical practice. There seems to be limited studies that have explored experiences of students on transcultural nursing, specifically those located in multicultural societies. The only study conducted in Namibia on experiences of transcultural nursing focuses on international nursing students who visit through the student - exchange programme [ 15 ]. Their experiences may differ due to the reason that they are not residents and have limited exposures to clinical practice, and therefore cannot be generalized to undergraduate nursing students who are residence of the country.

Aim of the study

The aim of this study was to explore and describe transcultural nursing experiences of nursing students during clinical practice in a multicultural context in north-eastern Namibia.

Study design

This study followed a qualitative descriptive– explorative approach as its research design. This design was chosen to allow nursing students to share their experiences of transcultural nursing and how these experiences impact on their clinical practice at an intermediate hospital in a multicultural context. This design follows the assumptions of a social constructivist philosophical research paradigm. Moreover, the Consolidated Criteria for Reporting Qualitative Research (COREQ) was followed as a reporting guideline [ 16 ].

Study setting

This study was conducted at an intermediate hospital, a 530-bed capacity health care facility situated in Rundu town, Kavango east region, Namibia. The hospital is 716 km from Windhoek, which is a capital city of Namibia. The facility serves as a referral point for five district hospitals located in three regions in eastern Namibia. It includes departments such as outpatient and casualty; high care and isolation care ward; surgical ward; medical wards separated for females and males; maternity and neonatal care ward; paediatric ward; tuberculosis ward; operating theatre and medical sterilizing unit. To emphasize experiential learning, which is part of constructivism educational philosophy as followed by many nursing schools [ 17 ], nursing students are placed for clinical practice at those departments, for a duration of two– one month, depending on the academic calendar.

Kavango east region border with Angola, separated mostly by Kavango river, while on the northeast, there is Caprivi strip, which share border with Botswana, Zambia and Zimbabwe. Patients and clients who get health care services from an intermediate hospital where students are placed for clinical practice are from various cultures in Namibia and neighboring countries such as Botswana, Angola, Zambia, and Zimbabwe since the hospital is located at the border town, which is a transit point for many non-Namibians. Kavango east region also receives other African and international visitors due to tourist attractions such as river, game parks, museums, unique vegetations and cultures. In addition, people who originates from China, India and Pakistan become inhabitants of Kavango east region, mainly for business and trading purposes. Nursing students are placed to be part of the team rendering care to these patients and clients.

Conversely, most nursing schools in Namibia demonstrates intercultural relations through catering for students from different cultural backgrounds as well as international students. This has led to the nursing school at a public university being multicultural accommodating students from the Namibian tribes of Okavango, Caprivi, Owambo, Ovahimba, Ovaherero, Nama and Damara, tribes originate from countries like Zimbabwe, Zambia, and Angola.

Study population and sample

The target population was final year nursing students in the Bachelor of Nursing Science (clinical) honours programme at the public university campus located in Kavango east region, Namibia. The final year nursing group of 2020 academic year had a population of 70 registered students at the time the study was conducted. The group was targeted because of its cultural diversity as evidenced by students from Namibian cultures such as Owambo, Rukwangali, Nyemba, Subiya, Gciriku and Nama as well as Shona from Zimbabwe.

Researchers used maximum variations purposive sampling technique to select participants of the study [ 18 ]. Maximum variation sampling involves purposefully selecting persons with variation on dimensions of interest. This was considered to allow for rich and diverse data needed to understand experiences of transcultural nursing at the intermediate hospital. Therefore, ensuring participants from diverse cultural backgrounds are represented in the sample. As advised by Polit and Beck [ 18 ], the researcher also use snowballing to ask early participants for referrals to students who are from unique and minority cultures in order to obtain different perspectives of transcultural experiences. In addition, other variations considered were sex and age groups as they are one of the factors determining cultural practices, beliefs, values, and norms [ 3 ].

The sample, as determined by data saturation consisted of 16 study participants. Of all participants approached to participate in the study, no one opted out or dropped out of the study. Researchers applied the following criteria in the sampling process:

Participants had to be available and agreed to participate in the study by signing informed consent form.

Nursing students from diverse cultural backgrounds.

To select participants, the second author approached final year students face to face during clinical practice and also by instant messages sent to their cohort-based WhatsApp group. On both approaches used to recruit participants, researchers explained the purpose and objectives of the study followed by signing written informed consents. To avoid conflicting with clinical practice schedules, students were given rights to choose date, time, and venue for face-to-face data collection. Options were also given for telephonic interviews as data were collected during the time Namibia recorded her first two COVID-19 positive cases in 2020.

Data collection procedures

Data were collected in April to June 2020 through semi-structed individual interviews. A semi-structed interview guide was used to guide the data collection process. The interview guide was developed by the first and second authors, specifically for this study and is attached to this manuscript as supplementary file 1 . Participants were asked to tell interviewers about their experiences of transcultural nursing during clinical practice, followed by prompts to understand their positive and negative experiences and how these impact on their experiences of clinical practice. The interview guide was piloted with two participants prior to the main data collection process. This assisted researchers on probing when responses were insufficient and not clear in order to seek for more clarity. Piloting was necessary to ensure high research quality when a depth of understanding is sought [ 19 ]. Participants who participated in pretesting the interview guide were not part of the main study, data obtained from the two interviews were analysed and form part of the main study.

The main interviews were conducted by the first and second authors, each with one participant at a time. No other people were present in the interview venue or listening to the conversations during telephonic interviews. Participants interviewed telephonically were phoned at a time agreed with them to minimize distractions and increase privacy [ 20 ]. All were conducted in English, and were audio recorded. In addition, field notes were made during and after the interviews to note body languages, non-verbal communication, researchers’ reflection and bracketing of own experiences. The duration of the interviews was determined by participants’ responses, lasted 38–55 min. Each interview was concluded when no new information emerged, and the interviewer included all prompts in the interview guide. All audio recording from the interviews were transcribed verbatim and were returned to participants for member checking before data analysis commenced.

Data analysis

The second author transcribed the audio-taped interviews which were done verbatim. Tesch [ 21 ] eight steps in the coding process of qualitative data analysis guided the process which was manually done by the two authors. In step one, the second author read through all transcriptions carefully to understand the content, this was followed by step two, which involved writing down underlying meanings on the page margins. In step three, meanings on margins were given topic names and similar topics were clustered together into columns. This was followed by step four, writing down codes, then arranging them into categories. In step five, the author gave descriptive words to the topics and assembled all similar data materials that belong to each category together. In step six, names of topic were transformed into themes and sub-themes were made. In addition, field notes were read together with transcribed data. In step seven, themes and sub-themes were further refined, these represent preliminary findings of the study. In step eight, the first author repeated the same process of coding, then the two authors came together to agree on final themes. During data analysis, authors designed a coding tree for understanding and presentation of themes and how sub-themes emerged as well as codes that formed them. The third author validated the findings. Member checking was done by taking back transcriptions and themes to study participants, while audit inquiry was done as discussed in data quality criteria section of this article.

Ethical considerations

The Declaration of Helsinki’s ethical principles for medical research involving human subjects were used as ethical guidance for this study [ 22 ]. In addition, participants gave their informed consent through signing a form preceding their participation in the study. As advised by Polit and Beck [ 18 ], participants were told that there would be no coercion if they wanted to opt out of the study, and that participation was voluntary. Participants could opt out of the study at any point and did not have to answer any questions they were not comfortable with. Inclusion criteria were met to ensure fairness. Numbers were allocated to participants instead of using their names, and no names were used in research findings, this ensured anonymity. Confidentiality was ensured by storing audio recordings on password-protected devices and only the researchers had access to them. Moreover, no other people listen to interview conversations during data collection [ 18 ]. The study was granted ethical clearance and permission by the departmental research ethics committee in the public university (ref 13/2019). In addition, ethical clearance was granted by the research unit in the Ministry of Health and Social Services (letter dated 06 January 2020).

Ten female and six male nursing students participated, their age ranging from 22 to 31 years. Nyemba, Rukwangali and Aawambo cultural groups had three participants each, Subiya and Shona had two participants each, Gciriku, Mbukushu and Nama cultural groups had one participant each. Of the 16 participants, 14 were Namibian, while two were international students. Three participants were having prior nursing experience with a certificate in Nursing and midwifery, while thirteen participants were generic students, only with secondary education qualification. This difference is expected, in the study setting, the Bachelor of Nursing Science (clinical) honours programme admits a very limited number of candidates who apply through mature entry and recognition of prior learning. Four main themes and 12 subthemes emerged that reflected the experiences of nursing students on transcultural nursing during clinical practice and are presented in Table  1 .

Theme 1: nursing students’ exposure of different cultural practices and beliefs through transcultural nursing

This theme describes the participants’ experiences of their exposure to cultural practices and beliefs of different clients and patients while they are in clinical settings. This includes communication practices, role of gender and age in caring for a sick person, and Western and traditional health systems’ practices and believes related to health care.

Communication practices during transcultural nursing

Participants indicated that in some cultures, the elders are the ones who greet young ones first while in other cultures the young ones greet the elders first, in both situations, it serves as a sign of respect. As far as greeting practices are concerned, in some cultures, hand shaking is preferred, while in some cultures, people prefer hugging each other, hand clapping and distance greeting. This implies that there are differences in greeting practices across different cultures. Moreover, nursing students also observed that some of their clients and patients prefer greeting in their own languages. This was mentioned by participants;

I noticed some elderly patients gets annoyed when I greet them, then I realise ooh, I should wait for them to greet me (laughing). It’s like they expected me to come stand in front of them, they greet, then I greet back. (Participant 6)
There are so many differences especially manner of greeting, in my culture, wait for an elder to greet me, now here it’s like I am expected to greet first. (Participant 14)

Participants revealed that at times, they are not sure as to whether keep eye contact with the patients/clients or not as it is perceived differently in different cultures depending on values and beliefs. This is because in some cultures, eye contact is emphasized, while it may be perceived as a sign of disrespect in some. This was mentioned;

……. consulting an old patient and you are starring at her like straight into her eyes was like……. (shaking hands and smiling). You know in some cultures eye contact is a taboo, they might think you are disrespectful. (Participant 1)
In my culture, young people are prohibited from direct eye to eye contact with older people. Here at the hospital, one day an elderly man told me that I am not honest and I was probably under the influence of some drugs, just because I couldn’t keep eye contact, but you know its not allowed in my culture. (Participant 16)

Role of gender and age in caring for a sick person experienced during transcultural nursing

Participants indicated that most patients are not comfortable to be examined by young nursing students, especially when it comes to examining private parts like genitals. Seeing nakedness of an elder person was associated with lack of respect in some cultures, while it is accepted in some cultures. This caused confusion as first year students are expected to perform basic nursing procedures, which include full wash of patients and providing a bed pan and urinals to patients not immobile patients. Moreover, participants have experienced that in some cultures, the young person is perceived as a novice and lack experience in whatever task they have to perform therefore, patients prefer to be cared for by mature nurses. Participants have experienced that some patients do not agree to be examined by nurses of the opposite sex, irrespective to whether the nurse is a student or a qualified cadre. The following was said by participants:

‘…….but the old “tates” are always refusing to be injected by young female student nurses, but people from my culture were not a problem at all (seemingly worried). (Participant 10)
I remember in the last clinical rotation I was allocated in female ward, there was a woman who was bedridden but always refuse to be assisted by male nurses whenever she wants to change her clothes, dressing her wounds or bath. (Participant 12)
Eeeh one time when I was allocated in female ward, I was delegated to examine a certain patient who was almost 60 years old. The patient was a female so I had to examine the private parts because she was complaining of itching and she was saying she feels like she has developed some rash so the senior nurse ordered me to check the rashes. So, the patient refused because she felt like I am disrespecting her since um very young, I cannot just look or check her private parts just like that so yaa that’s the other challenge. And then another one,……. (long silent), that one was a male who refused to be examined by a female student nurse and that male was, he was young he was in his 20s so he refused to be examined by a female student nurse, yaa so that is something that I experienced. (Participant 6)

Healthcare practices and beliefs related to western and traditional care systems

Participants revealed that there are different traditional herbs used by pregnant women and females in general for various reason. For example, pregnant women in some cultures take traditional herbs to speed up the labour process before coming to the hospital and some take herbs as they believe they minimizes labour pains. In some cultures, females also engage in vaginal packing whereby they put traditional herbs in the vagina to tighten it. Traditional herbs are also used in some cultures as means of family planning. The following was said by participants:

I saw one pregnant women who arrive in labour room with an underwear full of greenish stuff, I enquired during admission and she told me her grandmother inserted them to like make the process quicker and also with just a little pain, I was like how……… and then……. She didn’t want to discuss further. (Participant 10)
One day I was working in family planning room whereby we asked all the females to show their pads in order to confirm whether they are on their periods those who want to start family planning whereby I came across with a lot of clients who did vaginal packing so you tell the patient like can I see your pad so you see the blood at least which is a sign of menstruation and the person will tell you ‘no I have a tampon’ so you ask the patient may you please remove the tampon for me at least to see the blood before you give the injection just to make sure the person is on her periods. Then the person will start telling you the truth that no there in a tampon I did put in herbs in my vagina and she will continue telling you that we do it traditionally to tighten the vagina traditionally so which is a new thing to me (participant 4).

Use of traditional medicines was also discussed by nursing students as part of the experiences of transcultural nursing during clinical practice. Some patients use traditional medicines to supplement treatment they get from the hospital, some prefer to take traditional medicines instead of Westen medicines prescribed by medical doctors at health care facilities. There is a believe that traditional medicines are more effective for chronic illnesses such as epilepsy and some mental disorders.

People like to use roots of trees, crushed leaves, dry herbs and dry animal skin as medicine to cure chronic illnesses, like that disease which make people to fall, and specific mental issues. They believe medicines from the hospital are slow acting and cause a lot of side effects. (Participant 8)

Other practices are that some family members or even other patients prefer coming to different wards and pray for their relatives who are be admitted. Participants have observed while in clinical practice that some family members perform rituals on the patient’s bedside. This can be done to cure an illness or to prevent illness from spreading further. The following was said by participants:

………. during visiting time, family member or even patients from other wards may come and pray for the patients which is also happening in my place of origin.
One day I was allocated in paediatric ward, I noticed an elderly woman who can there with a small calabash with some powder, she started applying on the baby’s abdomen, the baby who was a patient. Ooh, I asked her what she was doing, she responded that it was their cultural rituals I must not interfere at all. I went back to the nurses’ post and didn’t tell anyone as I was afraid of the women, she looked like a “Sangoma” (looking warried) (Participant 5) .

Theme 2: personal feelings experienced by nursing students during transcultural nursing

Participants explained that as they were caring for patients from diverse cultures, they experienced different feelings that resulted from exposure to patients and clients’ different culture than oneself. Some experienced positive feelings while others experienced negative feelings.

Positive feelings during transcultural nursing

Some of the participants experienced positive feelings as they care for patients from diverse cultural backgrounds. These include feeling of confident, competent, proud, respected, and comfortable. This could be because, for some students it is first time coming closer to a person from a specific culture, therefore it arouses different feelings. Participants experienced feeling of being appreciated and accepted by the patients from different cultures, whom they rendered care to. Participants also felt welcomed especially by elderly patients who would show interest in talking to them. Some of the positive feelings experienced by participants are described below:

It makes me feel more welcomed in Kavango region because when it comes to old people I mean old patients they show interest in us that we came to Kavango to help them so which is really nice. (Participant 3)
………. it makes you to be confident like you will be confident of meeting capable of you speaking with people from different background and you will be competent to react with them because of how you are used to working with different people that are coming from different cultural backgrounds. (Participant 8)

Negative feelings during transcultural nursing

Participants experienced negative feelings as they cared for patients from different cultures. These include feeling unwanted especially by young female patients who claimed that students from other regions were taking their education and their jobs. Other negative feelings include nervousness, rejected, annoyed, sad, stressed, belittled, uncomfortable, incompetent, misunderstood, not trusted, and insulted. The following was mentioned during the interviews:

……. at some point it made me feel belittled. It made me feel like maybe I am not competent enough or what. Even though I knew in my heart that I am competent since I can do this and that, I mean all procedures required at my level, I am able to do them (smiling). But because the patients were not comfortable with me treating them or with me eeh attending to them, it made me uncomfortable (participant 1).
Sometimes I feel nervous because you will always be too careful of whatever you are doing, you don’t know what’s right and wrong about their cultures, so you work with worries. (Participant 4)

Theme 3: challenges experienced by nursing students during transcultural nursing

Participants discussed challenges they face in caring for patients from different cultures whole in clinical practice. Some of these challenges interfere with learning processes in clinical settings, some served as lesson for future practices. Challenges revealed by students were related to language barriers, cultural practices, values, norms, and cultural expectations.

Language barriers during transcultural nursing

Language barrier was mentioned as a very big challenge to most participants because patients from different cultures speak their languages and therefore not able to communicate to nursing students from other cultural groups. This hinders nursing students from providing proper nursing care due to the reasons that they are not able to comprehend patients ’complains, progress and other subjective data required for health intervention. It was also revealed that nursing students came across patients who do not speak English, which they mostly use as an alternative language when dealing with a client or patient who speak different vernacular language. The feedback on services provided by nursing students was also described to be compromised due to language barrier. The following was described by the participants:

The most difficult experience is language barrier. And because of language barrier most of the time I don’t know whether the service I am rendering is satisfactory. Sometimes it’s just difficult to talk to the patients, let’s talk about the primary health care clinics, when taking history and screening this someone and this someone is telling me about their complains, most of the time I don’t know whether um understanding these complains correctly. (Participant 3)
The worse part is that, I cannot get feedback on the service I provide to the clients because it’s not possible to speak to them. They cannot speak English and I cannot speak their languages and they cannot speak my language. (Participant 5)

Lack of awareness on cultural practices, values and norms

Lack of awareness on cultural practices, values and norms was experienced as one of the barriers during transcultural nursing in clinical practice. For example, in some cultures, a patient is expected to clean his or her mouth with hot water before talking to anyone in the morning. Also, the openness about illness, personal belongings to keep on bedsides, ambulation of a sick person and mealtimes were challenges to nursing students because patients prefer different practices other than what is suggested by hospital routines. This was mentioned:

In some cultures, they prefer a family member to do first baby bath and take care of the baby on the first day as this has serious consequences on the baby’s life if it’s done by a stranger. I was not aware (shaking hands). (Participant 16)
I once nursed a client who was refusing to remove her traditional necklace, its like she totally refused because according to her culture, it was so important for her to wear it at all times. But I didn’t know because in my culture we do not wear such items, I was just telling her to remove because it’s a policy when going for surgery. (Participant 9)

Cultural-related expectation of patients and resistance to health care interventions

Participants indicated that patients from different cultures had different expectations towards their health as well as towards the care givers. For example, patients and clients expected nurses to be fluent in all languages spoken in the geographical region where they work. Some patients also expect to be admitted only a few days and go home to be taken care by relatives, while others expect to be admitted for long.

One day I was told by a patient, how come you can’t speak Rukwangali when you are working in Kavango region. What kind of nurse are you? I was like no I am from another regions. (Participant 3)
A 36 years old woman discharged from maternity ward stayed for extra day because she thought it was too early to go home. Apparently in her culture, the man should not see her too soon after deliver, so she wanted to stay a bit longer. (Participant 14)

Participant identified patients and clients’ resistance to health care interventions as part of their experience on transcultural nursing. For example, patients from some cultures have tendency to refuse medication, major operation, and some invasive procedures such as colonoscopy and haemorrhoidectomy and genital examination, regardless of explanation given. While for some, they accept interventions as long as proper explanation is given to them. This was mentioned during interviews:

We used to have problems when it comes to giving medications to patients. They used to spit it out or to refuse just to refuse that I don’t want to take the medication. I can relate this to cultures because it was more common in some cultural groups. (Participant 2)

Theme 4: nursing students’ coping mechanisms during transcultural nursing

Participants described that as they are faced with different challenges in caring for patients from diverse cultural backgrounds, they had different ways which helped them to cope during transcultural nursing. Coping mechanisms of nursing students during transcultural nursing involve being culturally competent, getting support from peers, and use patients’ Charters of Rights as a guiding document.

Being culturally competent

Participants explained that learning different languages and a few cultural practises, norms and values related to health was very important as it facilitate communication and awareness of cultures, which may result in improved nurse-patient relation. It helped them to know patient’s beliefs and how they perceive things in order to understand different human behaviours associated with cultures. The following was described by some of the participants:

………….to learn languages of different people from different cultural background and you will tend to learn some of their traditional things like what they value and what is considered a taboo. (Participant 3)

Participants further indicated that they learn to be careful about what to say in front of patients and avoiding sensitive questions as well as being accommodative. Moreover, accepting cultural differences about health care and daily living was also mentioned as a coping mechanism during cultural nursing. Participants mention this:

……. working with people from different cultures really has taught me to look at things differently not only in the way you consider them to be but in the you take things and see them in other perspectives things that you consider wrong maybe considered right or good in the other tribe or so. (participant 16)
…….also try to understand a patient better by understanding their background and where they come from. (Participant 14)

Peers support during transcultural nursing

Participants revealed that providing care to patients from different cultures was made easy by support of peers. For example, by teaching each other different languages, teaching each other about different cultural practices, use other students as interpreters when a nursing student and patient speak different languages, in case a patient is not comfortable to be examined by students from opposite sex, the student of same sex would take over the task.

In my clinical allocation group, I can say we are all from different cultural group, what we do we teach other basic terminologies during tea and lunch break. Yaa, I remember other day we discussed myths and taboos, cultural rituals and many others happening in Kavango region. (Participant 3)
I really help my male colleagues a lot, like with full wash of female bedridden elderly patients who refused to be seen there. (Participant 12)

Role of patients’ charters of rights during transcultural nursing

Respect and dignity of patients was viewed as important aspects in the coping mechanisms during transcultural nursing. Participants expressed that allowing patients choices and autonomy in decision related to their health was one of the mechanisms utilized in transcultural nursing as well as adhering to privacy and confidentiality of patients, both in patients and outpatients. Allowing patients to be an active participant in promoting their own health, curative activities, prevention of further injuries or diseases and rehabilitation while admitted was one the aspects nursing students said to have experience during transcultural nursing. The following was explained by participants:

When the patient says we don’t do this and that, just talk to them softly by explaining benefits so you obtain informed consent. (Participant 10)
We need to work together, the nurse and the patient must work together with the same goal helping the patient. Ask them to do something for themselves like exercising, going to other therapies other than just taking medicines. (Participant 1)

In this study, students’ experiences on transcultural nursing during clinical practice were explored and described. It was evident that students’ experiences of transcultural nursing during clinical practice leads them to be exposed to different cultural practices and beliefs. Nursing students experienced personal feelings, challenges and have developed some coping mechanisms during transcultural nursing.

Due to patients and clients from diverse cultural groups nursing students coming in contact through clinical practice, participants in this study revealed that they are exposed to different cultural practices and beliefs. This may be seen as an advantage to nurses providing transcultural nursing because according to Paric et al., [ 23 ], being exposed to diversity is crucial to developing cultural competence. The findings on exposure to different cultures were also reported by Halabi and de Beer [ 24 ] who documented that students deal with patients from different cultures during their clinical training.

The use of traditional herbal medicine is common practice among urban and rural context in African continent. As far as traditional health practices are concerned, there are some childhood illnesses that are considered as not for Western healthcare services offered in hospitals, therefore requiring traditional and spiritual interventions [ 25 ]. This is similar in a current study where participants revealed that through transcultural nursing, they have seen patients using traditional medicines and perform rituals that are believed to be solutions to health issues they are experiencing or may be used to supplement medicines given at the hospital. Moreover, other traditional herbal medicines and cultural practices experienced by nursing students through transcultural nursing relates to care of pregnant women, post-partum period and care of the newborns. These findings were not surprising as multiple studies over the last decade reveal that pregnant women may take a variety of herbal medicines in forms of herbal extracts, crude herbal preparations, medicinal products of herbal origin, and dietary supplements consisting of proprietary blends of herbal medicines, minerals, and vitamins [ 26 ].

Another experience of students on transcultural nursing revealed in this study is the role of gender and age in caring for a sick person. In general, gender socialization and gender stereotypes may have influence on health-related behavior [ 27 ]. Asuquo and Akpan– Idiok [ 28 ] documented that caregiving is a primary role of female family members, which is designated by ideologies and is endorsed by cultures. In most situations, care is provided by adult female members, who are perceived as mature members of the family. This ideology could be causing patients to refuse care from young nursing students as they perceive them to be immature and inexperienced to care for a sick person, specifically if student and patient are of opposite sex. Similar findings were reported by Lilja and Tornerhjelm [ 29 ] who reported that due cultural beliefs, female participants were not allowed to bath a male patient. The student ends up making an alternative for another colleague to provide needed care. Although young adults aged 18 to 39 years reported to experience less physical strain and burden during care as compared to middle and older adults [ 30 ], the current study revealed that patients do not prefer to be cared for by young adults due to their cultural beliefs. Experience of different communication practices related to culture revealed in the current study was not surprising. Shirazi et al., [ 31 ] reported various interpersonal interaction across cultures, like lack of greeting, lack of eye contact, lack of physical touch and physical movement.

The personal experiences of nursing students during transcultural nursing include both positive and negative feelings. Positive feelings include confident, competent, proud, respected, welcomed, comfortable, appreciated and accepted by the patients from different cultures, whom they rendered care to. Similar findings were reported by Adamson [ 5 ] who documented feeling of encouragement, happy, wonderful, competent, appreciated and sense of belonging in students when nursing patients from other cultures. Notable was the negative feeling experienced by nursing students displayed through feeling unwanted especially by young female patients who claimed that students from other regions were taking their education and their jobs, nervousness, rejected, annoyed, sad, stressed, belittled, uncomfortable, incompetent, misunderstood, not trusted and insulted. These findings may be indicative of anxiety and fear due to the possibility of making mistakes and not correctly interpreting feelings, thoughts and wishes of the patients who are from different cultures [ 32 ].

It was evident in this study that students experienced some challenges during transcultural nursing. These challenges were language barriers, lack of awareness on cultural practices, values, and norms, as well as cultural expectations of patients and resistance to health care interventions. The language barrier experienced by students did not come as a surprise since Namibia is a multicultural society with more than 20 languages spoken by indigenous people. In addition, there are a lot of tourist attractions and business activities in town where study was conducted, this brings in people from other countries, who also receive healthcare services at the facilities where students do clinical practice. Previous research on experiences of newly qualified registered nurses and midwives in a rural health district in Namibia revealed cultural shock, language barriers and labelled as outsiders [ 33 ]. Therefore, this indicates diverse cultural groups pose challenges not only to nursing students but also to qualified nurses. Disrupted communication due to students and patients speaking different languages was also previously reported [ 29 ]. Although not revealed in the current study, language barriers lead to problems such as misinterpretations of information during counseling and health education sessions, delayed treatment, and medication errors [ 34 ].

According to Nur’ainun and Novieastari [ 35 ], the diverse places of origin of students do not hinder them in applying proper transcultural nursing. However, in the current study, the findings revealed that being from a diverse culture and place of origin was a challenge to provide care due to lack of awareness on cultural practices, norms, values, and beliefs. Similarly, Lilja and Tornerhjelm [ 29 ] also documented limited levels of knowledge of the different cultures in nursing students. These were major hindrances for nursing students providing care to diverse patients due to the reason that culture determines health care practices, beliefs and conceptions of health and illness. Cultural beliefs, norms, practices, and beliefs also determine the expectations of patients when they come to seek health care and therefore, determine their acceptability of health care interventions.

Individuals overcome stressful and uncomfortable situations by applying appropriate coping strategies. In transcultural nursing, nurses emphasize the importance of diverse language skills in order to be linguistically capable of understanding patients’ health issues and also to communicate with colleagues [ 34 ]. Although not revealed from the current findings, Larsen et al., [ 34 ] encouraged nurses to be prepared in the globalized health care system through nursing education. This is to adequately prepare nurse graduates to cope during transcultural nursing. Also, findings of the current study showed that nursing students cope by being culturally competent. They do it by being aware of their own culture, being aware there are different cultures in the context where they do clinical practice, improve their knowledge on different cultures, being sensitive to other cultures and have encounters with individuals from different cultures. The more nurses experience provision of care to patients from different cultures, the more they become culturally competent [ 36 ]. Peer support was also mentioned as a coping mechanism in the current study. This is because nursing students from schools located in multicultural societies tend to have more diverse students, like the case in the context of this study. This is an advantage since students may help each other with language translation, interpretations, and teaching on cultural practices. These help other students to understand patients’ needs and in return help to be culturally competent.

It was identified in the current study that Patients Charter of Rights has role to play in the coping mechanisms for nursing students during transcultural nursing. As an independent republic, Namibia has a documented patient charter policy which explains core values of the Ministry of Health and Social Services. It also consists of principles guiding public health and social care services, expectations for clients from health care providers and responsibilities of clients visiting health care facilities [ 37 ]. Therefore, to cope during transcultural nursing, students use the charter document to ensure the care provided does not violate basic human rights and is according to the guiding principles, which are applicable to all patients irrespective of their cultures.

The findings of the current study have significance in the local, national, and international contexts. For local and national context, Namibia is a multicultural society with 13 ethnic groups, which practice diverse cultures. In addition, due to migration, business activities and tourism, health care facilities have become multicultural entities. Thus, findings may assist training institutions to understand students’ experiences and help nursing students to cope during transcultural nursing since they are exposed to patients from diverse cultures. At international contexts, findings add to the body of knowledge on experiences of students during transcultural nursing, this may be helpful in enriching transcultural nursing courses in the curricula to help students while in clinical practice.

Strengths and limitations of the study

The strength of the study lies in the fact that participants are from diverse cultural groups, which also include international students. Due to COVID-19 pandemic, this study utilized both telephonic and face to face interviews during data collection. Telephonic interviews were limited in observing facial expressions and other nonverbal communication cues that may display emotions such as fear, anger, sad and anxiety in participants and thus, limited researchers from identifying participants who might need emotional support, so this was considered as a study limitation.

Recommendations

Recommendations are made for nurse education, clinical practice, and future research. For nursing education, students should be encouraged to write reflective essays on their exposure of transcultural nursing at the end of clinical practice rotation as this may help improve their future practice. Another recommendation for nursing education is that nursing schools located in multicultural societies should revise students’ selection criteria to ensure proportional representation of ethnic groups as well as international applicants. For clinical practice, the researchers recommended clinical supervisors to incorporate transcultural nursing issues into their routine meetings in the units as well as during students’ feedback time. Additionally, its recommended for future researchers to explore experiences of patients on care provided by nurses from diverse cultural backgrounds as well as experiences of qualified nurses on transcultural nursing to provide broader understanding on the topic.

Due to globalization of healthcare, nurses and midwives throughout the world are increasingly expected to have encounters with patients, families and colleagues from diverse cultures and backgrounds, consequently, providing transcultural nursing. Through clinical nursing education practice, students become part of the healthcare and thus exposed to transcultural nursing. It was identified that students are exposed to different cultural practices and beliefs during transcultural nursing and also experience positive and negative personal feelings. They also experience some challenges related to language barriers, lack of awareness on cultural practices, norms, values and beliefs, cultural expectations of patients and resistance to health care interventions. As a result, students developed mechanisms to help them cope during transcultural nursing. These findings confirm the need to strengthen nursing education, clinical practice, and future research on transcultural nursing. The study has practical implications for nurses in clinical settings as it may provide baseline information to help students in becoming competent in providing transcultural nursing care. For nursing educators and professors, they may include students’ coping mechanisms during transcultural nursing in formal curriculum, and extra-curricular activities. Future researchers may consider quantitative assessment of nursing students’ cultural competence while in clinical practice.

Data availability

The data analysed during the study will be made available by the corresponding author upon reasonable request.

Abbreviations

Corona virus disease 2019

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SM: Conceptualisation; methodology; data collection and analysis; project administration; resources; writing and editing. VN: Conceptualisation; methodology; data analysis; validation; project administration; resources; supervision; validation; writing and editing. LC: conceptualization; data analysis; validation; resources; writing review and editing. All authors reviewed the manuscript.

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Nuuyoma, V., Muvumwaeni, S. & Chihururu, L. Transcultural nursing: a qualitative analysis of nursing students’ experiences in a multicultural context in North-Eastern Namibia. BMC Nurs 23 , 123 (2024). https://doi.org/10.1186/s12912-024-01773-8

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Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi

  • Thulani Maphosa   ORCID: orcid.org/0000-0001-5164-8913 1 ,
  • Lise Denoeud-Ndam 2 ,
  • Lester Kapanda 1 ,
  • Sarah Khatib 3 ,
  • Lloyd Chilikutali 1 ,
  • Eddington Matiya 1 ,
  • Boswell Munthali 1 ,
  • Rosalia Dambe 1 ,
  • Brown Chiwandira 4 ,
  • Bilaal Wilson 4 ,
  • Rose Nyirenda 4 ,
  • Laywell Nyirenda 1 ,
  • Bongani Chikwapulo 5 ,
  • Owen Madeira Musopole 5 ,
  • Appolinaire Tiam 6 &
  • Leila Katirayi 6  

BMC Health Services Research volume  24 , Article number:  244 ( 2024 ) Cite this article

Metrics details

Despite tremendous progress in antiretroviral therapy (ART) and access to ART, many patients have advanced human immunodeficiency virus (HIV) disease (AHD). Patients on AHD, whether initiating ART or providing care after disengagement, have an increased risk of morbidity and mortality. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) launched an enhanced care package using a hub-and-spoke model to optimize AHD care in Malawi. This model improves supply availability and appropriate linkage to care. We utilized a hub-and-spoke model to share health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support.

This qualitative study assessed the facility-level experiences of healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through an intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility nurse to identify those most involved in supporting patients with AHD. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants’ responses.

While HCWs and LCs stated that most medications are often available at both hub and spoke sites, they reported that there are sometimes limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both the hub and spoke levels. HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing a linkage of care to facilities, specifically improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services.

Conclusions

These findings highlight the importance of offering comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and provided services through a hub-and-spoke model, improved supply availability, and strengthened linkage to care. Additionally, addressing the recommendations of service providers and patients is essential to improve the health and survival of patients with AHD.

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Malawi has one of the highest HIV prevalence rates in the world, with an HIV prevalence of 8.9% among adults aged 15–49 years, corresponding to approximately 946,000 adults living with HIV, according to MPHIA 2020–2021 [ 1 ]. HIV and AIDS remain the most common causes of death in Malawi, with an estimated 13,000 deaths from AIDS in 2021 [ 1 , 2 ]. Despite tremendous progress in improving antiretroviral therapy (ART) access through testing and treatment strategies in Malawi, a significant proportion of patients have advanced HIV disease (AHD), which has remained constant in recent years despite ongoing improvements in access to antiretroviral therapy (ART) [ 3 ]. AHD is defined by the World Health Organization (WHO) as a CD4 cell count < 200 cells/mm3 and/or stage III or IV disease in children older than 5 years and adults [ 4 ].

In Malawi, 28% of patients present with AHD at the time of the initial HIV diagnosis. Additionally, an increasing number of patients receive care at an advanced stage of HIV, following disengagement from treatment [ 5 ]. In Malawi, 22% of patients returned to AHD care. Patients with AHD are at a higher risk of death even after starting/restarting treatment, with the risk increasing with decreasing CD4 cell counts, especially with a CD4 cell count of less than 100 cells/mm 3 [ 6 ]. The leading causes of mortality among adults with AHD include tuberculosis (TB), severe bacterial infections, cryptococcal meningitis (CM), toxoplasmosis, and Pneumocystis jirovecii pneumonia (PCP) [ 7 , 8 , 9 ].

The WHO has developed guidelines for managing AHD to reduce morbidity and mortality in patients with AHD. This package of interventions includes rapid ART initiation, enhanced screening and treatment, and/or prophylaxis for major opportunistic infections such as TB and CM and strengthened adherence support, including tailored counseling to ensure optimal adherence to the AHD care package [ 4 ].

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) supported an AHD intervention model to optimize the services offered to patients with AHD in Malawi. The integrated AHD package is built on WHO guidelines and includes enhanced decentralization of care through a hub-and-spoke model to bring AHD care geographically closer to patients. An enhanced package of AHD interventions was implemented, including decentralized CD4 tests, TB-lipoarabinomannan antigen assay (LAM), and initiation of prophylaxis, including TB preventive therapy (TPT) and cotrimoxazole prophylaxis (CPT) [ 4 ]. The facilities adopted a model for improvement used in quality improvement approaches to respond to system issues that fall within their control. A prioritization matrix was used, which focused on addressing problems that required fewer resources, less time to respond, and a higher impact on AHD care. Locally formulated solutions complemented the system improvements made at the national level. The team met weekly to review their response plans, termed the Plan Do Study Act (PDSA), to address weak client flow, stock management inefficiencies, and human-related bottlenecks. Quality improvement (QI) teams have innovated around AHD care bottlenecks to drive the uptake of newly introduced treatment regimens for opportunistic infections and strengthen their pharmacovigilance.

A hub-and-spoke model was used to deliver appropriate healthcare services to the peripheral sites. A hub site was defined as a health facility with comprehensive packages of AHD care that managed patients requiring hospitalization. Spoke sites offer outpatient and routine care to stable AHD patients, and refer critically ill patients to nearby hubs. This hub-and-spoke model was implemented to create linkages between referral networks and provide strengthened community-based care to reduce the risk of loss to follow-up. As part of the evaluation, the project conducted a qualitative assessment to examine the views of healthcare service providers on AHD care. This study focused on the population of healthcare providers, but it is important to note that as part of this qualitative evaluation, we also conducted in-depth interviews (IDIs) with HIV-positive men and women aged 18 years or older who received AHD services for at least two months in the same facilities. The results from these patients were shared in another study.

This study assessed providers’ experiences of implementing an enhanced package of AHD care through the hub-and-spoke model, aiming to contribute to a more comprehensive understanding of the challenges in delivering optimal care to AHD patients. Based on their suggestions, we identified ways to strengthen service delivery for patients with AHD.

Study design

This qualitative study used in-depth interviews (IDIs) with healthcare workers (HCWs) and lay cadres (LCs) to explore facility-level experiences in providing an enhanced package of AHD services.

Site selection

Four sites were purposively selected from the intervention sites, including two hubs and two spokes. Hub sites are larger sites that supports smaller ‘spoke’ sites by providing supplies, technical support and accepting patients with more complicated health problems. Spoke sites provide services at the community level, and offer basic care. These sites are located in the Dedza and Ntcheu districts in the Central Region. Mchinji and Ntcheu District Hospitals are public hub sites dedicated to providing comprehensive secondary-level care under the MoH while Sister Theresa Hospital is a private hub site in the Ntcheu district that operates under the Christian Health Association of Malawi (CHAM). Of spoke the sites, Mtemdere Health Center is a private health facility in Dedza under CHAM, which delivers primary care within a rural setting while, Lizulu Health Center is also a is a public health facility in Ntcheu under MoH in an urban setting.

The selection was based on the area with the highest patient volume. The sites were selected to have equal numbers of rural and urban locations.

Study population

The study population included those involved in delivering HIV care at four selected sites, including HCWs and LCs. Eligible HCWs were involved in HIV care at the intervention sites, including laboratory staff, ART nurses, and clinically trained staff including clinical officers (COs), medical assistants (MA), and medical doctors (MDs) who consented to participate. HCWs in training were excluded from the study.

Due to the shortage of clinically trained medical professionals in Africa, ‘lay cadres,’ those not clinically trained, often provide critical support, including counseling, follow-up, tracking, etc. to health care patients [ 10 ]. Lay workers involved in the screening and follow-up of PLHIV were eligible for LCs. This group included expert clients (ECs), Health Surveillance Assistants (HSAs), HIV Diagnostic Assistants (HDAs), ART clerks, adherence support officers (ASO), and hospital attendants. ECs that were not involved in the screening and follow-up of patients were excluded.

Participant recruitment

Convenience sampling was used to recruit participants. To recruit HCWs, research assistants (RAs) spoke with the health facility nurse to identify eligible participants who provided AHD services to patients and were present on days when data collection occurred at the facility. There was more emphasis on recruiting ECs because they are generally more involved in the counseling and follow-up of patients at their homes. In the selected health facilities, all HCWs and LCs that met the inclusion criteria were included in the study.

Data collection

The RAs were previously experienced in collecting data and participated in 40-hour data collection training to familiarize themselves with the study protocol, data collection tools, human subjects, and the standard operating procedures (SOPs) of the study. The training involved role-playing and examinations to ensure that the RAs fully grasped the materials.

The data were collected between December 2021 and February 2022. Written informed consent was obtained from all study participants prior to data collection. All the data were collected from a health facility.

The IDIs were conducted with study participants using semi-structured IDI guides (Supplementary File 1 , Supplementary File 2 , Supplementary File 3 ). The guides included topics such as knowledge required for the diagnosis and treatment of patients with AHD, perceptions of one’s own self-efficacy in diagnosing and treating patients presenting with AHD, experiences providing AHD services, and how the enhanced AHD program affected job satisfaction (Supplementary File 1 , Supplementary File 2 , Supplementary File 3 ). IDIs were led by RAs who were hired and trained by the EGPAF. The RAs used semi-structured interview guides and probes to obtain in-depth responses during the interview process. All IDIs were audio-recorded and completed in English or Chichewa depending on the participant’s preference. The Interviews lasted–50–90 min. The recorded IDIs were translated from Chichewa into English as appropriate. IDIs were transcribed by RAs soon after data collection to minimize recall errors. The interview transcripts also documented descriptions of the participants’ nonverbal responses, referred to as ‘field notes. The participants’ demographic data were also collected.

Thirty-two IDIs were conducted, including 16 for HCWs and 16 for LCs. Previous literature determined that saturation was reached in 12 interviews [ 11 ].

The data were analyzed using a thematic analysis. A short-answer analysis was conducted, which consisted of two research assistants manually compiling all the responses per question from the interview transcripts. The collected responses were then analyzed for overarching themes derived from the data, and the findings were summarized using text-based summaries and data display tables. In the data display tables, data were separated by study population and study site type (hub vs. spoke), and compared for similarities and differences. Textual data were carefully analyzed to identify recurrent patterns and themes. Text excerpts representing identified themes were included.

The mean ages of HCWs and LCs were higher at spoke facilities at 37 years of age than at hub facilities at 35 years of age. There were three clinicians, one registered nurse, two laboratory technicians, and one nurse midwife from the hub site. From spoke sites, there were three clinicians, four nurse midwife technicians, one adherence and support officer (ASO), and one hospital attendant. Notably, more female HCWs and LCs were present at spokes than at hubs. Hub facilities also had more HCWs and LCs working for more than ten years in their positions, with 20% working for more than ten years at hubs, compared to 13% working for more than ten years at spokes (Table  1 ).

The results were organized into four themes: perceived benefits of improved AHD packages of services, positive changes reported with the new AHD program, challenges in providing AHD services to patients and solutions, and HCWs and LC recommendations.

Perceived benefits of new AHD care package according to healthcare workers and lay cadres

The participants highlighted that introducing quality improvement (QI) sessions under AHD care added value to their work, because they could discuss patient welfare and make appropriate decisions. They felt that QI brought additional value to their services and facilities because they could see their work’s direct impact on improving patient care in real time. HCWs at spoke sites said that they felt better equipped to handle AHD patients and provide better services by identifying gaps and conditions they may have previously missed (Table  2 ). They felt that this resulted in the AHD program helping with timely treatment initiation (Table  2 ).

HCWs and LCs in both hubs and spokes reported that improvements in patient care through AHD-related services resulted in increased job satisfaction. HCWs described feeling empowered because they saw progress in their patients’ health, fewer deaths and better health outcomes (Table  2 ). Overall, they feel motivated and have a strong desire to stay focused on the client’s welfare, and see that everyone receives proper support (Table  2 ).

HCWs and LCs also described feeling more empowered and equipped to provide AHD care for their patients. LCs reported that they were now able to provide more support to defaulters as opposed to just giving patients their medications and sending them home (Table  2 ).

At both spokes and hubs, the HCWs expressed that they could directly observe the impact of their work on improving patient care. HCWs at spoke sites said that they feel better equipped to handle AHD patients and provide better services by identifying gaps and conditions they may have previously missed (Table  2 ).

Positive changes from the AHD program

HCWs and LCs across hub and spoke sites discussed enhanced AHD services and how they strengthened their ability to treat patients. Most HCWs said that they are now more capable and confident of screening for opportunistic infections among patients with AHD. Many said they had testing and treatment available at their facilities. Because of the improved AHD services available owing to the program, HCWs mentioned that they engaged with patients more and could provide tailored care depending on their needs (Table  3 ).

Furthermore, HCWs and LCs have also reported an increased ability to identify patients with AHD due to training. They specifically mentioned that they could better identify patients who required special care and were better equipped to follow-up with them (Table  3 ).

HCWs noted increased mentoring and support in providing AHD services. HCWs expressed that they were satisfied with the mentoring necessary to provide care to patients with AHD. They also explained that they could seek guidance and support when they experienced difficulties in providing care to patients with AHD (Table  3 ).

Service providers need help in providing AHD services.

Half of the healthcare workers felt that AHD training required improvement. The main concerns were the short duration of training, insufficient information provided during training, and challenges with frequent staff turnover requiring the training of new staff. HCWs at spoke sites said that training sessions needed to be longer. HCWs at spoke sites also complained that additional training was required because of heavy staff turnover. LCs from both hubs and spokes reported that they found it challenging to learn secondhand skills from others who had been trained and were now training them. LCs at hub sites further explained that the training they received from their peers needed to be improved and that they needed more information (Table  4 ).

While HCWs and LCs in both hubs and spokes described medications as almost always available to patients, many HCWs and LCs expressed concern about their facilities’ lack of available supplies. They noted the need for more sample collection kits for CD4 tests and cartridges for the TB LAM tests. HCWs and LCs at both hub and spoke sites described inadequacies in the equipment and machines used to run tests, including point-of-care (PoC) machines, CD4 counters, and chemical analyzers. Both site levels also reported that only a few staff members knew how to use the machines. Some HCWs and LCs at spoke sites reported staff shortages when collecting samples for PoC machines. HCWs and LCs at hub sites noted that the additional machines lacking in the facilities were chest X-ray machines, abdominal ultrasound scanners, and GeneXpert machines. HCWs stated that when spoke sites ran out of supply, they requested kits from the hub sites. Therefore, hub sites were overwhelmed by receiving requests from the two spoke sites (Table  4 ).

HCWs from hubs said that the referral system to transfer AHD patients was going well because they had ambulances that could transport the patients, whereas most HCWs from spoke sites noted that they faced issues with transportation transfers. One of the main challenges reported by HCWs at spoke sites is that the ambulance system must be fixed to transport AHD patients to hubs. They said that ambulances were not always available, or sometimes did not have a petrol. This would leave patients to find their mode of transportation, which could be challenging and unsustainable owing to financial challenges. HCWs at both hubs and spokes said that they faced issues and difficulties with the vehicle when referring to patients with AHD. HCWs at spoke sites reported problems with referral documentation for patients arriving at the facility, including the need for proper health passports, written treatment history information, and referral letters. Many HCWs at spoke sites explained that the biggest challenge in transferring patients is their reluctance to transfer care, because they prefer to go to the same facility with which they are familiar and comfortable (Table  4 ).

HCWs at hubs have noted that delays in receiving laboratory results create challenges in diagnosing patients with TB. In addition, hub site HCWs reported that spoke sites must correctly fill out the information for the samples. HCWs at hubs and spokes said that the space to enter the text in the register was too small, and they found it challenging to fill it out. Furthermore, transportation for home visits was noted as a challenge for providing AHD services. HCWs noted that adding clients who were not from Malawi to the register and following up with them was difficult. HCWs at spokes reported challenges dealing with patients who were in denial of their diagnosis and unprepared to begin treatment (Table  4 ).

HCWs at hubs and spokes reported that new AHD training and service provision increased their workload. The increased workload is attributed to more rigor in assisting patients adequately without missing any conditions, which are considered additional tasks. They noted that completing the new protocol and the AHD register was time consuming. However, they remain motivated and know that they provide improved patient care and services. (Table  4 ).

HCW and LC requests & recommendations

HCWs reported that a constant availability of supplies and equipment is needed to improve their ability to provide care for patients with AHD. They requested that equipment, including CD4 count machines, X-ray machines, viral load machines, and FBC machines be made available. They highlighted the need for an adequate supply of CD4 cartridges and sample collectors for serum Cr-Ag and urine LF-LAM testing. HCWs also noted that healthcare worker capacity must be increased to provide better AHD care, including hiring additional staff members such as lab technicians and clinicians. HCWs recommended establishing meetings with HCWs from hub and spoke sites to discuss gaps in AHD treatment guidelines (Table  5 ).

HCWs at both hub and spoke sites emphasized the need for additional training on many topics. Hub sites reported that spoke sites required more training on labeling samples because they arrived incorrectly labeled, causing challenges in determining which tests to conduct at the hub sites. This prevented them from running the tests because they were unaware of the reasons for testing. HCWs said that they needed training in CM, including questions regarding drug preparation, administration, and different treatment plans for CM. Furthermore, training was requested on new topics including viral load interpretation and liver function tests. HCWs also requested training on best practices to keep records organized in the registry (Table  5 ).

HCWs emphasized the need for additional training on counseling skills to help them better advise patients and strengthen patient adherence to care. This would also help them address the challenges faced by the defaulters. Finally, the HCWs stated that they wanted refresher training to keep their knowledge updated and for continuous mentorship and supervision (Table  5 ).

HCWs noted that additional support was needed to strengthen adherence through community-based support/home visits. LCs from both hubs and spokes mentioned the need for more help in home visits, including other allowances, to increase the frequency of visits. They also wanted food parcels to provide clients with when they visit their homes. They described difficulties during the rainy season and requested raincoats and transportation support for home visits (Table  5 ).

Implementation of real-time mitigation efforts

This study was conducted as operations research to identify the challenges of the enhanced AHD program and implement solutions to the identified problems in real time. The solutions were implemented after data collection; therefore, interview data were unaffected. It is essential to acknowledge the steps that are required to address these challenges.

To address the inadequacies in training, facility orientations are now jointly provided by deployed AHD clinicians and trained facility Ministry of Health staff. Regarding the increased workload resulting from the enhanced package of services, facilities have used data review meetings at the ward level to motivate a team with progress made in patients’ health. Concerns about increased workload dissipating over time. Finally, regarding the request for increased mentorship and supervision, the QI team successfully lobbied for the retention of specific leaders of the AHD program in the wards and facilities until the upcoming team was sufficiently acquainted with the processes and delivery of the AHD services.

HCWs and LCs have described solutions they have implemented to help address the gaps in delivering AHD care to patients. HCWs at both hubs and spokes reached out to head staff members or district health officers when they were low in supply and equipment. Regarding staff shortages, HCWs at hub sites said that they had learned the tasks of other positions to provide support when needed. HCWs also provided additional counseling to patients who were not ready to start treatment. For patients who lived far away, HCWs said that they would occasionally send medications to other community members. Lastly, HCWs at spokes reported using WhatsApp to send test results and avoid further delays and noted that bike and scratch cards helped them reach patients needing AHD care. If a patient was too ill, LCs reported that they could counsel a guardian or wait until the patient was sufficiently stable to counsel. For patients who moved out of Malawi, LCs at spokes attempted to contact them through relatives in the village; if unsuccessful, they were documented in the register that the patient had left.

Our study confirms the successful implementation and acceptance of an enhanced WHO-recommended package for Advanced HIV Disease (AHD) care echoes and consolidates the existing body of literature. Numerous studies support our findings. Frank et al. [ 12 ] and Gupta et al. [ 13 ] echoed similar success stories in different regions, highlighting the consistent feasibility and acceptability of enhanced care packages in diverse healthcare settings. Additionally, studies conducted by Thurman et al. [ 14 ] and Musengimana et al. [ 15 ] not only reiterated the feasibility but also emphasized the significant impact of these packages in improving patient outcomes, reinforcing the importance of their implementation in combating the AIDS epidemic.

HCWs highlighted the crucial challenges inherent in the patient referral system, emphasizing the paramount need for comprehensive paperwork and documentation to ensure a seamless connection of care between central hubs and peripheral facilities. This finding echoes the findings of various studies that underscore the pivotal role of well-functioning referral systems in initiating care and mitigating patient disengagement. For example, research conducted in Tanzania not only emphasized the significance of providing referral forms but also demonstrated how these forms facilitated swift patient entry into healthcare facilities or directed them to appropriate clinics, significantly streamlining the care continuum [ 16 ]. Similarly, investigations in Mozambique corroborated these findings by stressing the indispensable nature of referral slips, showcasing their efficacy in expediting treatment at health facilities and ensuring the unbroken continuity of care [ 17 ]. Furthermore, the challenges posed by transportation issues within the patient referral system have been reiterated in the literature, emphasizing the critical role of proximity and access to transportation in optimizing the linkage of care [ 18 ]. Studies have consistently highlighted that accessibility and availability of transportation resources significantly impact the efficiency of care linkages, thereby emphasizing the necessity for viable transport options to ensure timely and continuous healthcare access for patients within these referral systems [ 19 ].

HCWs underscored critical concerns regarding the scarcity of supplies and equipment within healthcare facilities, highlighting the shortage of test kits as a significant impediment to the delivery of adequate care. Insufficient supply, notably in point-of-care (POC) CD4 testing, creates substantial challenges and frustration for HCWs involved in providing care for Advanced HIV Disease (AHD). Disturbances in equipment and shortages significantly contribute to diagnostic hurdles and delayed test results. When spoke sites exhaust their supplies and rely on central hub sites, they strain the latter’s resources, causing disruptions in service provision and amplifying the burden on these hubs [ 18 ]. Effective stock management has emerged as a critical determinant in addressing these issues, with research demonstrating that well-organized inventory control significantly mitigates delays in turnaround times and ensures the availability of essential supplies for uninterrupted care delivery. Additionally, studies have emphasized the importance of innovative stock management strategies, such as predictive modeling and real-time inventory tracking, in averting supply shortages and streamlining the distribution of resources across healthcare facilities, thereby enhancing the overall efficiency of care provision [ 20 ].

Addressing these inadequacies requires a strategic approach, including targeted training for HCWs that leverages pre- and post-test evaluations to identify and address skill gaps, consequently enhancing diagnostic and management proficiency. Research corroborates the significance of such targeted training programs, showing their effectiveness in improving HCWs’ skills and knowledge, thereby optimizing patient care outcomes [ 21 ]. Specifically, in the context of point-of-care (POC) testing, various studies have emphasized the criticality of comprehensive training modules that emphasize quality assurance, standardized documentation practices, proficiency testing, and thorough verification of new kit lots [ 22 ]. Structured training programs to boost HCWs’ confidence and competence in POC testing will ultimately ensure the accuracy and reliability of test results. Furthermore, innovative communication methods play a pivotal role in mitigating challenges associated with delays in test results and patient tracing. Studies have shown that employing instant messaging platforms such as WhatsApp or utilizing text messaging and telephone consultations facilitates prompt communication, aiding result dissemination and patient follow-up [ 23 ]. These findings underscore the efficacy of leveraging technology-enabled communication tools to streamline healthcare processes and improve patient engagement, ultimately contributing to more efficient and effective healthcare delivery.

Furthermore, HCWs emphasized the crucial necessity for home visit support, particularly for critically ill patients, citing challenges such as geographical distance, challenging terrain, and adverse weather conditions that significantly hinder timely and high-quality home visits. These obstacles have been consistently highlighted across various studies, highlighting the universal challenges faced by HCWs in reaching and providing care to patients residing in remote or geographically inaccessible areas. For instance, research conducted in diverse settings has reiterated the impact of geographical barriers, emphasizing the difficulties faced by HCWs in delivering timely and consistent home-based care to patients in remote or rural regions [ 24 , 25 , 26 ]. Moreover, adverse weather conditions exacerbate these challenges, disrupt healthcare access, and necessitate implementation of tailored strategies. Studies exploring healthcare delivery during extreme weather events or in geographically challenging areas have proposed innovative solutions, such as the utilization of specialized transport systems, community health worker networks, and telemedicine initiatives to ensure uninterrupted care delivery, especially during inclement weather or in geographically isolated regions [ 27 , 28 ]. These findings underscore the need for adaptable and context-specific strategies to address geographical and weather-related challenges and to ensure continuous and high-quality care provision for the most vulnerable patient populations.

Strengths and limitations

The main strength of this study lies in its use of a qualitative approach, which helped obtain a rich, complete, and in-depth exploration of the issues surrounding the feasibility and acceptability of an enhanced package of AHD care from diverse groups of service providers. The limitations include the subjective nature of the interviewees’ responses and the risk of social desirability to please the research team. Conducting interviews in the location of employment may have also contributed to social bias. In addition, the data were collected from only four sites, and HCWs and LCs at other sites may have faced different challenges. The study did not interview any former HCWs who may have left their positions; this group may have shared a different perspective.

In conclusion, our study underscores the feasibility and acceptance of enhanced AHD care while pinpointing critical issues within patient referral systems, supply shortages, POC testing challenges, and the need for improved home visit support. Addressing these challenges requires a multifaceted approach, including streamlined referral systems, effective stock management, comprehensive HCW training, and innovative patient contact methods, to ensure sustained and optimal care delivery, particularly for vulnerable individuals. These findings suggest the importance of addressing weaknesses in the delivery of services within the hub-and-spoke model to comprehensively tackle facility-level challenges and ensure that they do not impede the services provided to patients with AHD. Adequately addressing the weaknesses in delivering services within the hub-and-spoke model, improving supply availability, and appropriate linkage to care is necessary to implement enhanced AHD care successfully.

Data availability

Data are available upon reasonable request to the corresponding author.

Abbreviations

advanced HIV disease

antiretroviral treatment

Adherence Support Officers

clinical officer

Elizabeth Glaser Pediatric AIDS Foundation

expert client

health care worker

HIV diagnostic assistant

Health Surveillance Assistant

in-depth interview

institutional review board

lay counselor

Medical Assistant

medical doctor

research assistant

tuberculosis

World Health Organization

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Acknowledgements

The authors thank the study participants and the research assistants who collected the data. We would also like to thank EGPAF and the Ministry of Health through the Department of HIV and AIDS for operational guidance on the scope and content of the project to strengthen HIV care and treatment service delivery for people with advanced HIV disease (AHD) and for the review of this manuscript. This study was supported by the Bill and Melinda Gates Foundation [INV-004547]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the author’s Accepted Manuscript version, which might arise from this submission.

Bill Melinda Gates Foundation ( BMGF): Responsible for funding and supporting EGPAF activities by the BMGF-EGPAF cooperative agreement/ investment number ID: INV-004547 scope of responsibilities; providing high-level oversight and strategic direction for the project to strengthen HIV care and treatment service delivery for people living with AHD by the Country Work Plan. The discussions, implementation framework, and conclusions in this study are those of the authors and do not necessarily represent the views of funding agencies.

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T Maphosa, L Katirayi, A Tiam, and L Denoeud-Ndam, R Nyirenda, B Wilson, B Chiwandira O Musapole, L Nyirenda, B Chikwapulo, E Matiya, R Dambe and L Kapanda designed the study. T Maphosa, L Chilukutali, B Munthali, and R Dambe oversaw data collection in the field. L Katirayi, S Khatib, and analyzed the data. T Maphosa, L Katirayi, and S Khatib drafted the manuscript. All authors were involved in reading and approving the final manuscript.

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Maphosa, T., Denoeud-Ndam, L., Kapanda, L. et al. Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi. BMC Health Serv Res 24 , 244 (2024). https://doi.org/10.1186/s12913-024-10700-1

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Background and objective

The needs and characteristics of veterans with post-traumatic stress disorder (PTSD) create significant challenges in family life, particularly for spouses. Identifying the nature of these challenges from the perspective of spouses leads to a more comprehensive and profound understanding of their existing problems and can be used for targeted interventions. Therefore, this research was conducted to explore the challenges of living with veterans suffering from PTSD from the perspective of their spouses.

This qualitative study used conventional content analysis to explore Challenges of spouses of veterans with post-traumatic stress disorder. Fifteen spouses of veterans with PTSD from the Veterans Affairs Center in Iran between June 2022 and January 2023, were purposively selected to participate in the study. Semi-structured in-depth interviews were conducted to collect data. The interviews were audio-recorded and transcribed verbatim. The data were analyzed using the method proposed by Graneheim and Lundman content analysis method with the support of MAXQDA 2020 software.

The mean age of the participants was 56.74 ± 6.43 years. Through data analysis, seven main categories and sixteen subcategories were identified. These categories included burnout (sleep disturbances, feelings of exhaustion), apathy towards self-care and caring for the veteran (neglecting self-care, lack of interest in continuing care), depression (feelings of hopelessness and being at the end of the line, decreased self-confidence ( Crushed and ignored (being mistreated, having multiple roles), relationship disturbances (Dissatisfaction with marital relationship,isolation and limited social interactions, disconnection from God), financial burden (heavy costs of care, lack of insurance support), and declining social status (negative attitude of the society, suffering from discrimination and inequality).

The consequences of PTSD-related injuries in veterans directly and indirectly affect the overall living conditions of their spouses. These spouses experience emotional detachment and constant rejection, leading to a decrease in their resilience against existing stressors and exposing them to disruptive and challenging issues in individual, family, and social dimensions of life that affect their physical and mental well-being. Therefore, these spouses require empowerment and access to social support in dimensions of educational, caregiving, therapeutic, and supportive. It is recommended that health policymakers pay special attention to designing up-to-date interventions to enhance the health of these spouses in physical, mental, spiritual, and social dimensions.

Peer Review reports

Introduction

Post-traumatic stress disorder (PTSD) is the occurrence of specific symptoms after experiencing or witnessing one or more very severe or unfortunate stressful events with the possibility of real death or the threat of death and severe injury [ 1 ]. It is a chronic mental disorder that may cause a person to feel fear, disorder or panic after seeing or experiencing a traumatic event [ 2 , 3 ]. According to the DSM-5, people may encounter such stressful events in one of the following ways: experiencing the event directly, witnessing the event for others, learning that an unfortunate event has happened to a loved one or close friend. War, physical attack, terrorist attacks, and natural disasters are all examples of traumatic events [ 2 ]. four specific symptoms of this disorder are: intrusions, avoidance, negative alterations in mood and cognition, and alterations in arousal or reactivity. These symptoms must persist for more than 1 month and cause functional impairment to be diagnosed with PTSD [ 2 , 3 ]. PTSD is the most common mental disorder among veterans returning from war [ 4 ]. This disorder occurs mainly in the first two years after experiencing trauma [ 5 ] in 9–25% of war casualties [ 6 ], and its prevalence in Vietnamese soldiers is 30%, in women [ 7 ] and men who served in Iraq [ 8 ], 14%, and the prevalence of this disorder has been reported as 14.9% in the Iranian military personnel [ 9 ]. According to available medical records, more than 80% of Iranian veterans have been diagnosed with PTSD [ 10 ].The most mental problems are reported among people who were often present on the front lines of war [ 11 ].

According to conducted studies, this disorder can have unpredictable, destructive, and irreparable consequences and outcomes for veterans, their family members, and the community [ 12 , 13 ]. These, in turn, result in significant indirect costs in terms of physical, mental, and social damages for both veterans and their family members, especially their spouses [ 14 , 15 ]. The spouses of these veteran’s act as like a refuge against these issues and are actually a way for the family to connect with the society [ 16 , 17 ].

Evidence shows that PTSD veterans often have problems such as anger, aggression and lack of intimacy between spouses. Lifelong contact with these veterans, having the roles of caregiver, wife, mother at the same time attending to the needs of children, taking care of other family members, being in charge of all the duties and responsibilities of life alone, they face problems in their daily life that lead to these people not having a normal routine in life like other members of the society. As a result, these individuals, unlike other members of the society, do not have a typical routine in their lives [ 18 , 19 , 20 ]. In fact, these spouses have a unique position because, despite having conditions similar to other individuals in society, they are particularly involved in dealing with the consequences of physical and mental disabilities endured by the veteran. This, in turn, threatens the well-being of these spouses and results in a decrease in their quality of life [ 19 , 21 ]. The results of a study conducted by Ghahramani et al. in Iran in 2022 revealed that spouses of veterans experience a low quality of life, particularly in terms of their mental well-being compared to other dimensions. Thus, it is crucial to pay attention to the families of veterans, especially their spouses [ 22 ]. Similarly, the findings of a study by Mousavi and colleagues in 2021 in Iran indicate that spouses of veterans with psychiatric disorders and PTSD obtained significantly lower scores on various subscales of the quality of life [ 19 , 23 , 24 ]. Moreover, a study by Allen et al. in Croatia in 2018 demonstrated the detrimental impact of chronic PTSD in veterans on the physical and mental health, social relationships, and overall quality of life of their spouses [ 25 ].

The spouses of veterans with PTSD, as indirect victims of war and the closest individuals to these patients, play a vital and key role in the lives of these veterans [ 26 ]. They face numerous unavoidable challenges in their social, professional, and family lives, and neglecting these challenges and problems can have detrimental effects on their well-being and functioning [ 18 ].

One of the important factors that play a role in the interactions of family members is family dynamics. Family dynamics are defined as unique methods used by each family member to interact within the family [ 27 ].

This theory holds that family interactions are interconnected like the links of a chain, it is not possible for one family member to experience difficulties without affecting other family members [ 28 ]. Furthermore, the family is the primary source of emotional support during psychological and social pressures. When this source encounters problems, each family member becomes exposed to considerable psychological and social pressures. Therefore, these pressures can have a negative impact on the function of family members and cause a crisis in the family [ 29 ].

Since the mental effects caused by war are chronic and progressive and continuously affect the quality of life of the affected person, family members, especially their spouses who try to support the veteran [ 30 , 31 ].

Previous research indicates that the challenges faced by spouses of veterans with PTSD have not been directly studied as a distinct topic until now. Considering that these spouses are among the most influential individuals in promoting the health and improving the quality of life of family members, and considering that most studies conducted in Iran have primarily focused on veterans and fewer studies have specifically targeted the spouses who are often the forgotten victims of war, it is essential to address their specific challenges [ 32 , 33 ]. Wives are an integral part of veterans’ lives, unfortunately, as a result of living with the injured person for a long time, signs and symptoms of post-traumatic stress disorder are observed in them [ 34 ]. Also, considering the cultural and religious differences of the Iranian society, especially in this group of people, and the existence of a gap between theoretical and practical knowledge among the life experiences of the veterans’ caregivers, these experiences can be obtained with the help of a qualitative study [ 35 ]. This study was conducted to answer the question, “What are the challenges of living with a veteran diagnosed with PTSD and what effect does it have on their personal, family and social life? " In other words, the research team intended to elucidate the challenges faced by spouses of veterans with PTSD in order to design targeted interventions to improve their mental well-being. Therefore, it is necessary to deeply explore these challenges through a qualitative study. Qualitative research data are of a subjective nature, derived from the perceptions and beliefs of the study participants. As a result, these studies provide a valuable approach to describe lived experiences and contribute to understanding human experiences [ 36 , 37 ]. By explaining the challenges faced by the wives of PTSD veterans, a more comprehensive view and knowledge can be obtained on the problems of this group of women, who have received less attention, also the identification of these challenges can be the basis for further studies for effective planning to improve the performance of these women, because these women are close The most important people are considered to be veterans, and by improving the performance of these women. Regarding the above mentioned issues, we designed this qualitative study with the aim of exploring the challenges of living with a veteran diagnosed with PTSD from the perspective of their spouses.

Materials and methods

Type of study.

A qualitative study with a conventional content analysis approach was conducted from June 2022 to January 2023. In this method, information is directly obtained from the participants without preconceived ideas, imposed opinions, or predetermined theoretical perspectives. The knowledge generated through this approach is based on the perspectives of the participants and obtained from the data derived from the interview transcripts [ 38 ].

Participants and research setting

The research population consisted of the spouses of veterans with PTSD. The inclusion criteria for participants in this study were women whose spouses were veterans diagnosed with PTSD by a psychiatrist, who were in a current marital relationship at the time of the study, were able to communicate in Persian, had no hearing problems, and had at least basic literacy skills in reading and writing. The exclusion criteria were severe mental disorders and receiving psychiatric treatments, an obvious physical disorder that leads to the creation of limitations and challenges in the individual, so that due to this disorder, the veteran does not have the necessary ability to seek care, for example, paralysis., and withdrawal from the study at any time of the study. In this study, 15 spouses of veterans who spoke Farsi were selected. The research was conducted at the Veterans Affairs Center in Iran. This center serves as the main source of information and services for veterans returning from war in Saveh County. Due to easy access to the research population and the participants being covered by this center, it was selected as the research setting.

The process of selecting the participants was such that the researcher was present at the Department of Veterans and after obtaining permission from the head of the center to study the files of the veterans, she first identified the veterans suffering from post-traumatic stress disorder and then made a phone call to their spouses, and receiving information from them, if they met the entry criteria and were willing to participate in the study, while explaining the objectives of the research, he invited them to an interview to get their experiences. The average duration of each interview ranged from 30 to 45 min Three interviewees were re-interviewed.

Data collection method

In order to collect the data, semi-structured, in-depth, face-to-face interviews were conducted in a quiet room without any environmental distractions at the Veterans Affairs Center. The interviews commenced with open-ended questions and were purposefully guided to explore the challenges of living with a veteran diagnosed with PTSD. The interview method was flexible, allowing the researcher to gather more detailed information compared to other methods. The interviews were conducted based on an interview guide developed by the research team, which included questions such as: “please describe your experiences of living with your veteran’s husband” and “please explain your difficulties and challenges in your life” and “How has your husband’s condition affected your family life? ”and “How has living with this person affected you socially?” Probing questions were also used during the interviews to ensure the researcher’s understanding of the participants’ statements, encourage further elaboration, and explore emerging topics. Unlike the main study questions, probing questions were not predetermined [ 39 ]. Probing questions were asked for further clarification (e.g. “What do you mean?”, “Will you elaborate further?”). Silent probes allowed participants to reflect on descriptions Towards the end of each interview, participants were invited to share any additional thoughts, and the possibility of future interviews with them was discussed. All the interviews were conducted in Persian by the first author, a doctoral student trained in healthcare qualitative research. Data collection and analysis were simultaneous and during this process the topic guide was modified to explore emerging areas of interest. The participants were also asked for their permission to be contacted if the researcher had any further questions. Data collection continued until data saturation was reached, meaning that in the last two interviews, participants reiterated ideas similar to the information obtained from previous interviews, and no new concepts or categories emerged. Data saturation occurs when no new information can be extracted from the data, and the categories have reached their maximum possible development [ 40 ]. The participants’ interviews were recorded using an audio recording device with their full awareness and consent. Subsequently, the participants’ conversations were transcribed verbatim as soon as possible after each interview.

Data analysis

The data were analyzed using the conventional content analysis approach. Content analysis is a qualitative data analysis method used to categorize sentences. It is a research method to describe the content derived from communication systematically and objectively [ 41 ]. In this study, data analysis was performed using the Graneheim and Lundman’s approach, which involves five steps for analyzing qualitative data: (1) transcribing the interview completely immediately after each interview, (2) multiple readings of the entire transcripts to gain a general understanding of the content, (3) Identifying meaning units and basic codes, (4) categorizing initial codes into broader categories, (5) determining the main theme of the categories [ 42 ]. To understand and immerse in the data, the transcripts were read multiple times to develop a comprehensive understanding. Each section of the text was then assigned a name or code, and notes were made in the margin. The codes were then compared for similarities and differences, and codes that were similar or had similar meanings and concepts were grouped together. Based on this process, initial categories of codes were developed, and all categories were compared and classified. The classification process continued, and in the end, subcategories and main categories were derived. The coding and categorization process of categories and subcategories was reviewed and revised in multiple research group sessions. This process continued until the group reached agreement on coding and categories, and ultimately, by repeated examination of the categories and contemplation of the overall concept derived from each of them, the underlying meaning of the text and the main category were extracted. we used MAXQDA 2020 for managing codes, themes and memos. Memos were written throughout the analysis process to capture thoughts and reflections of the spouses of veterans with PTSD statements.

Trustworthiness of data

In this study, the four criteria of Lincoln and Guba including credibility, transferability, confirmability, and dependability were used to check the validity of the data [ 43 ]. To ensure the credibility of the findings, we used debriefing by peer and member check methods. In the case of peer debriefing, we had a request to peers who were not researchers on the study but had critique expertise in the field of Veterans PTSD including Psychiatrist and psychiatric nurse. The research team committed themselves to adhere to the topics of the peers and take their opinions into account in the final conclusions. In order to member check, a summary of the interview was returned to the participants to confirm or refute the accuracy of the researcher’s perception. In cases of disagreement between the perception of researchers and the opinion of the participant, we tried to reach a common understanding about the subject through interaction with participants. To improve the transferability of the findings, purposeful and heterogeneous sampling was used in terms of Age, education, Employment status, Income. Audit trial and peer review were used to control the dependability of data. Our research team with different expertise reviewed, revised, and confirmed all encoded data and determined subcategories and categories to confirm the confirmability of the data.

Initially, the study objectives were explained to the participants, and written informed consent was obtained from those who were willing to participate in the study. Additionally, permission was obtained to record the interviews using an audio recording device. Furthermore, the participants were assured of the principles of confidentiality, anonymity, voluntary participation in the study, and the freedom to withdraw at any time without any consequences. The participants were actively involved in determining the time and location of the interviews, ensuring a collaborative approach.

Based on the findings, the mean age of the participants in the study was 56.72 ± 6.34 years. Furthermore, 33.33% of the individuals had a primary education, 60.00% were housewives, and 66.66% had 1 to 3 children. Additionally, 53.33% of the participants expressed that their income was not sufficient for a decent life. More details are presented in Table  1 .

The analysis of the interviews led to the extraction of 721 initial codes, which were further reduced to 172 codes through repeated reviews of the codes and comparison of their differences and similarities. Finally, these codes were categorized into sixteen sub-categories and seven main categories related to the spouses’ perspectives on the challenges of living with a veteran diagnosed with PTSD. These categories included burnout, apathy towards self-care and caring for the veteran, depression, Crushed and ignored, relationship disturbances, financial burden, and declining social status, as shown in Table  2 .

Given that the spouses of veterans are constantly in the role of caregivers and repeatedly face the challenges associated with the veterans, and considering the significant responsibilities they have within the veterans’ families, caring for these individuals can lead to burnout over the years, both physically and mentally.

In this study, the burnout category included two subcategories: sleep disturbances and feelings of exhaustion.

Sleep Disturbances The spouses of the veterans stated that due to the sleep disorder, which is one of the common problems in the veterans suffering from post-traumatic stress disorder, they also experienced sleep problems such as low-quality sleep, difficulty falling asleep, chronic insomnia, and a sense of insecurity.

The participants expressed their experiences in this regard, “I can’t sleep due to the intensity of stress. I may sleep for about 4 to 5 hours during the whole day, but I never have a deep sleep within that duration.” (P. 5)
I wake up at the slightest sound during sleep. Sometimes, I wake up multiple times during the night and go back to sleep. When I wake up in the morning, it feels like I haven’t slept all night. (P. 7)

Feelings of exhaustion A number of participants stated that they have experienced constant feeling of tiredness, inability to do household chores, lack of strength and energy, aggravation of physical problems caused by the maintenance and care of veterans.

One of the participants expressed it as follows, “I constantly have headaches, back pain, and leg pain all the time. My lower back bones have deteriorated, and I have taken many medications, but I don’t get better. Even though I’m not really old, because I have been doing heavy work since a young age and taking care of my spouse, I have ended up like this. I’m always tired, I have no motivation or energy for anything.” (P. 2)
I feel that in recent years, I have become very incapable. It’s not that I’m being lazy, no, I just don’t have enough energy and strength to get up and do my work. Most of the time, my tasks remain unfinished, and it frustrates me. (P. 13)

Apathy towards self-care and caring for the veteran

In addition to caring for their husbands, the spouses of veterans with PTSD are also responsible for raising children and attending to all daily life tasks and responsibilities. These responsibilities signify the challenging roles these spouses have in their lives. Over time, these factors can lead to indifference and neglect towards self-care and the care of the veteran.

This category contained two subcategories: neglecting self-care and lack of interest in continuing care.

Neglecting self-care The spouses of veterans with PTSD, due to their continuous engagement in caring for their spouse and fulfilling multiple responsibilities, often neglect their own health, both physical and mental. This self-neglect can put these spouses at risk of developing physical and mental illnesses. Ignoring physical problems, disregarding their own mental well-being, lack of self-care, lack of motivation for self-care, and neglecting oneself were other challenges of living with a veteran diagnosed with PTSD. In this study, the participants believed that they lacked sufficient time, motivation, and conviction for self-care.

They expressed their experiences as follows, “…… I went to several doctors, and most of them said I needed surgery. But I wonder, if I undergo surgery, I’ll have to spend some time in bed. Then who will take care of this life and the children? Who will do my tasks? My husband is also unwell so I can’t expect him to help.” (P. 4)
I’ve given up on myself, may God protect me. Just being able to manage the issues and problems of my life is a lot. I don’t have time for myself anymore.” (P. 5)

Lack of interest in continuing care Feeling annoyed with the veteran and children, lack of appreciation from the veteran, and experiencing a sense of indifference towards continuing caring for the veteran were among the challenges of living with veterans suffering from PTSD. In this study, some of the participants believed that they had become disinterested in continuing to take care of the veteran, which could be attributed to emotional detachment and the veteran’s lack of appreciation for their efforts and sacrifices.

The participants expressed their experiences as follows, “I try my best to take good care of him, show him love, and give him his medications on time. But who appreciates it? Who knows the value of these hands that are worn out?” (P. 14)
I have always sacrificed so much to take care of him, neglecting my own needs and interests, just to ensure I can take good care of my husband. But it’s a shame that he doesn’t even recognize my love and care. There have been times when, due to his aggressive behavior that threatened my life, I had to leave home, but my heart couldn’t stay away, and I came back.” (P. 9)

Since veterans with PTSD themselves face significant psychological and social challenges, it is highly likely that their family members are also at risk of experiencing psychological harm [ 44 ]. Among them, the spouse of the veteran is the primary emotional and psychological support for the veteran and is the first person directly exposed to secondary trauma and cognitive difficulties [ 45 ] According to the interviews, the spouses of veterans with PTSD have been involved in some psychological problems due to the problems and hardships of their husbands.

This category included two subcategories: feelings of hopelessness and being at the end of the line, decreased self-confidence,

Feelings of hopelessness (being at the end of the line) Lack of enjoyment in life, improper mental state, boredom, suicidal thoughts, death wishes, meaninglessness of life, decreased motivation, and insufficient emotional connection were among the challenges experienced by most participants in living with veterans suffering from PTSD.

Also The participants stated that they experienced a lack of hope in life, a sense of being defeated, and a lack of purpose. They argued that due to long-term exposure to the challenges of living with a veteran suffering from PTSD, they had lost their hope.

The participants expressed their experiences in this regard, “I ask my spouse if he mistreats me because he thinks I am his prisoner. Sometimes, I pray to God for death to find peace.” (P. 4)
To be honest, life has no meaning for me anymore. I have no motivation to continue living. Sometimes I ask myself how I’m still alive with all these problems. I should have died a hundred times by now, but…” (P. 15)
The participants shared their experiences in this regard, “I feel like a lifeless being. I just go through the days without any meaning. There is no joy, no purpose, no aspiration. I simply have nothing anymore.” (P. 8)

Decreased self-confidence The loss of self-confidence means lack of trust in one’s abilities and difficulty expressing opinions, which were among the challenges of living with a veteran suffering from PTSD, as expressed by some of the spouses in this study.

In this regard, one of the participants stated, “He made me stay at home all the time. I had become so secluded and my self-confidence had deteriorated to the point that I couldn’t even utter a single word outside or in family gatherings.“(P. 1)

Crushed and ignored

Despite their significant efforts to meet the needs of the veterans with PTSD and their families and juggling multiple roles simultaneously such as being a spouse and a mother, these spouses are unfortunately often overlooked and not given the appreciation they deserve. Not only are their efforts unacknowledged by the family members and the veterans themselves, but also they are mistreated and beaten by the veterans in many cases. This leads to a feeling of being alongside a sense of being overlooked.

In this study, this category had three subcategories: being mistreated, having multiple roles and having a sense of self-sacrifice.

Being mistreated Veterans suffering from PTSD are more sensitive than ordinary individuals due to the chronic nature of the illness and their mental engagement with traumatic war memories and psychological challenges. They are quick-tempered people who react very quickly to environmental stimuli and become aggressive [ 46 ]. Violent behavior is one of the consequences of veterans being placed in complex situations, which makes family members, especially their spouses, experience physical violence and psychological insecurity [ 47 ]. In this study, being mistreated refers to physical assault by the veteran, lack of physical safety, and fear and anxiety, with the spouses of veterans being the primary victims.

In this regard, the participants shared their experiences as follows, “My husband once physically assaulted me over a trivial matter. He hit me so hard that two of my teeth broke. Since then, I’m afraid to argue with him because when he gets angry, he loses control over his behavior.” (P. 12)

Having multiple roles , the participants stated that due to their spouse’s problems, they play multiple roles that sometimes conflict with each other.

In this regard, one of the participants said, “I’m exhausted from doing everything myself. Most household responsibilities, such as grocery shopping, clothing, etc. are on my shoulders. Although I make a great effort to manage everything well, sometimes I feel overwhelmed and on the verge of collapse.” (P. 6)
I was both the homemaker and the breadwinner. I had to carry the entire burden of life on my shoulders and handle both household and external tasks alone. Moreover, my spouse required constant care, and I had to take care of many personal matters on his behalf. (P. 4)

Having a sense of self-sacrifice One of the forms of emotional support that the spouses of veterans offered to them was self-sacrifice in various ways. They selflessly dedicated themselves physically, emotionally, and mentally to their spouses. However, due to the lack of recognition and understanding of their sacrifices and selflessness, these spouses developed a sense of self-neglect in their own lives. Their comprehensive caregiving, enduring suffering, self-sacrifice, concealing their pains, maintaining appearances, disregarding their own interests, sacrificing to preserve the family’s life, and letting go of the arguments were among the experiences shared by the participants.

In this regard, one of the participants said, “With all his anger and our arguments, I sacrificed myself for this life.” (P. 12)
Many people tell me that I have dedicated myself to my husband and children, that I am a generous and compassionate person who has managed to live all these years in such circumstances. (P. 3)

Relationship disturbances

Given the hardships that spouses of veterans with PTSD endure and the neglect they face from both family and society, Especially the veteran, they gradually experience disruptions in their intrapersonal and interpersonal relationships(including husband and wife relationships), as well as in their relationship with God [ 48 ].

This category had three subcategories, including Dissatisfaction with marital relationship, Isolation and limited social interactions and disconnection from God.

Dissatisfaction with marital relationship in a healthy marriage, the presence of a satisfying sexual relationship plays a significant role in maintaining the stability of the family unit. In veterans, sexual relationships and functioning may vary depending on the type and severity of their trauma [ 49 ]. Some spouses experienced a lack of desire for sexual intimacy and a decrease in the quantity and quality of their marital relationship, which, in turn, resulted in marital dissatisfaction and a growing distance between the husband and wife.

The Participants in this study expressed their experiences in this regard, “The mental condition of my spouse has also affected our intimate relationship to the point that I have no desire or patience for sexual intercourse.” (P. 14)
My spouse and I haven’t had any sexual relationship for about 5 years or more, and it all goes back to the psychiatric medications that he takes. (P. 8)

Isolation and limited social interactions Isolation and relationship disturbances were among the challenges mentioned by the majority of participants. In fact, one of the problems and hardships that spouses of veterans with PTSD endure is a sense of loneliness, which leads to a lack of connections with others.

In this regard, one of the participants said, “My interactions with relatives and friends have become limited. Relatives don’t drop by because of my spouse’s bad behavior, and I and my children are hesitant to visit relatives because he might suddenly cause a scene there.” (P. 6)
For several years, I have lost interest in socializing and connecting with others. This man has taken away all my motivation. (P. 11)

Disconnection from God based on the interview findings, the spouses, due to living with a veteran suffering from PTSD for a long time, experience a disconnection from God in various forms. Feelings of being abandoned, lack of peace, and anger towards God were expressed by the participants. This disconnection from God is experienced as a sense of unrest in these individuals.

In this regard, one of the participants said, “Every day I pray and ask God to help this man get on the right path, to bring his senses back so that our life can improve. But when I realized that God didn’t listen to my voice, I became very angry with Him, and I kept asking why He treated me this way, as I haven’t been a bad servant.” (P. 7)”

Financial burden

The participants stated that the absence or lack of money caused them to experience many financial problems. Veterans suffering from PTSD who are unable to work and have high medical expenses because the families of these veterans experience many financial problems in addition to physical illness due to the veteran’s mental illness. In this study, financial burden was classified into two subcategories, including heavy costs of care and lack of insurance support.

Heavy costs of care Many participants complained about the high cost of treatment and counseling fees as well as inadequate income. Veterans suffering from PTSD not only experience the physical and psychological effects of the illness but also suffer from the financial burden of their care. Their families are also concerned about the high medical expenses in addition to the challenges of caring for the veteran.

In this regard, one of the participants said, “Our income is meager, and it all goes for medication and treatment for my spouse. There’s nothing left for us.” (P. 13)
These veterans are in great need of counseling services. For each half-hour session my spouse attended, we had to pay 70,000 tomans. We had to go at least twice a week. I took my spouse for a few sessions, but I couldn’t afford to continue the treatment. My spouse only has a retirement pension, which barely covers our living expenses amidst these high costs. (P. 8)

Lack of insurance support Insufficient insurance support was among the issues mentioned by the majority of participants. According to the data, insurance only covers limited services such as occupational therapy, physiotherapy, and physician visits. However, it does not fully cover many services needed by these veterans, including medication costs. The participants stated, this issue has made their life situation worse. One of the participants said,

It’s true that my spouse has supplementary insurance, but most of the time, when we take my spouse for treatment, either it’s not covered by the supplementary insurance, or we have to pay out of pocket and then submit the invoices to receive a small percentage of the expenses several months later. It’s very difficult for us in this situation. (P. 13)

Declining social status

This category refers to how the valor and sacrifices of veterans were initially valued while the values have diminished over time.

This category encompassed two subcategories, namely negative attitude of the society, and suffering from discrimination and inequality.

Negative attitude of the society The reduction in the social status, unfair judgments, and negative attitude of the society were among the experiences reported by the majority of participants. They believed that Veterans suffering from PTSD due to many psychological problems and their families are considered as distinct social groups whose social status and respect are not adequately by some individuals. They had experienced negative treatment from some people towards veterans and their families.

In this regard, one of the participants said, “People keep their distance and say, ‘You’re lucky, the government takes care of everything for you. What worries do you have?’ But they don’t know that we are burning from within ourselves, regardless of how others perceive us…” (P. 3)
People don’t know how much we struggle. They think we have no worries or problems in our lives. They say, ‘You went to the frontlines once in your life, so what? It’s nothing now.’ But it lasts a lifetime. They think being a veteran is a ladder to your own and your children’s progress. (P. 1)

Suffering from discrimination and inequality The sense of discrimination among Families of veterans suffering from PTSD disorder refers to the feeling of injustice and in receiving privileges related to these people and their families, as well as the lack of proper access to resources and services in the society.

One of the participants said, “Because my spouse’s disability rating is below 25%, we don’t qualify for many benefits and resources, neither for us nor for our children. We don’t even have the right to object. It sometimes feels like we are being insulted.” (P. 14)
I strongly disagree with these percentage-based classifications. I know people whose situations are much better than my spouse’s, but they managed to get a higher rating through favoritism. It’s okay. I always tell my spouse that you went to war for the sake of God, entrust everything to Him. (P. 9)

The purpose of this study was to explore the challenges of living with a veteran suffering from PTSD from the perspective of their spouses. The identified challenges were categorized into seven categories, burnout, apathy towards self-care and caring for the veteran, depression, Crushed and ignored, relationship disturbances, financial burden, and declining social status.

After the war and the return of veterans to their families, the stressors arising from the war and their negative impact on the physical and mental well-being of the veterans and the family members, especially the spouses who repeatedly experience the turmoil of the afflicted person, persist [ 50 ]. These experiences lead to a reduction in the quality of life of the family members, particularly the spouses of these veterans [ 51 ]. The family acts like a system because the behavior of the members of a family is a function of the behavior of other family members, and if there is a problem in the behavior and states of one of the members, the balance of the family is disrupted. The influence of one member of the family on another member is obvious and clear, so that it is not possible for a person to have a problem in a family and this problem does not affect other family members [ 52 ]. Therefore, the families of PTSD patients are in a more difficult and unstable situation emotionally, which leads to burnout in the functioning of the family and presents challenges and crises over time [ 4 ]. These challenges were clearly observed in the findings of the present study, which were based on the interviews with participants (spouses of veterans with PTSD).

Sleep disturbance is one of the primary and most common complaints among spouses of veterans PTSD. Because veterans have behaviors such as nightmares, frequent waking up, severe insomnia, etc., they cause suffering and discomfort to their spouses and as a result, sleep disorders in them [ 53 ]. According to the findings of a study by Hojjati et al. in Iran (2017),the lived experiences of the spouses of veterans indicate a decrease in their sleep quality. These spouses, due to marital commitment, are concerned about the condition of their spouse even during sleep and unconsciously wake up at night to be present beside them [ 51 ]. These findings are consistent with the results of the present study, as the participants expressed that due to the unique and specific circumstances of their spouses, they were lacking sufficient, suitable, and quality sleep for a long time and suffered from chronic insomnia. This sleep disturbance, in turn, exacerbates the challenges they face in various aspects of their lives, including physical dimensions.

Nursing and caring for disabled people such as veterans, especially veterans suffering from post-traumatic stress disorder, causes the caregiver, who in most cases is the spouse of a veteran, to suffer from many physical problems. Some of these physical problems have psychological roots and others are caused directly by the patient [ 54 ]. The results of the present study revealed that the Conditions of veterans with PTSD veterans with PTSD had an impact on the physical and psychological well-being of family members, especially their spouses, who have continuous and long-term contact with these stressors, leading to feelings of fatigue, inability to perform household tasks, lack of capacity and energy to engage in activities, and consequently, exacerbation of physical problems. Polenick et al.in United States (2017) showed that living with physically and mentally disabled people causes physical problems in the spouse [ 55 ] and Akhoondzadeh et al.in Iran (2017) showed that the spouses of veterans with PTSD experienced significant physical, emotional, and psychological challenges due to their continuous and repeated interaction with the veterans [ 56 ]. These results are in line with the results of the present study.

Furthermore, Braš et al.in Croatia (2019) found that the spouses of veterans were significantly affected by the physical disabilities and psychological consequences experienced by the veterans [ 57 ]. These challenges, over the long term, disrupt family functioning and give rise to common issues such as shame, guilt, mistrust, and reduced intimacy within the family [ 19 ]. The enduring nature of these challenges can not only give rise to physical problems but also have an impact on the mental well-being of spouses, resulting in distress and the development of psychological disorders [ 58 ] The results of a study by Owens-King et al. (2019) revealed that the spouses of these veterans can be considered among the at-risk groups in terms of mental health [ 59 ]. The highest prevalence of psychological problems among these spouses is related to depression and anxiety [ 60 ]. Additionally, the findings of a study by Heydari et al.in Iran (2022) showed that the spouses of veterans with PTSD experienced more psychological consequences of post-traumatic events compared to other family members, since the hyperarousal symptoms of veterans contribute to serious impairments, such as stress and depression, in their spouses, leading to high levels of distress [ 61 ]. These findings are consistent with the results of the present study, highlighting that these spouses experience challenges such as hopelessness, reduced self-confidence, and a sense of sacrifice, which they struggle to cope with.

Beks et al.in Canada (2018) found that the level of violence and aggression, particularly domestic violence towards spouses, was significantly higher in families of veterans with psychological injuries compared to other families, which could be attributed to the heightened irritability of the veterans [ 62 ]. These findings are in line with the results of the present study, where the spouses expressed that despite their significant sacrifices in caring for the veterans, accepting additional caregiving roles alongside other heavy responsibilities, financial concerns, reduced social support, adaptation to adverse life circumstances, they experienced repeated physical abuse and violence from the veterans. They added that these experiences not only created feelings of insecurity, fear, and anxiety but also contributed to a sense of being sacrificed in life and ultimately led to disinterest in self-care and caring for the veteran. The persistence of these issues and challenges results in a sense of neglect and feeling overwhelmed, leading to impaired functioning of these spouses within the family. These findings are consistent with a study by Borjali et al. in Iran (2021) in this regard [ 63 ].

One of the challenges expressed by these spouses was that the veteran’s condition had affected intimate relationships within the extended family. These spouses must constantly play the role of a mediator between the veteran and the children and always maintain a support role for both parties, which creates additional pressure. Moreover, these veterans exhibit behaviors such as lack of interest and motivation in socializing with others, and they also face difficulties in their communication with others. As a result, the spouses of these veteran’s experience limitations in their interactions with others and subsequently become isolated. These findings are consistent with the results of a study by Khodabakhshi et al. in Iran (2019), which indicate that the pressures arising from providing psychological and physical care to the veteran also have negative effects on the relationship between the mother or spouse as the primary caregiver and the children and acquaintances [ 64 ].

Post-traumatic stress disorder may cause a veteran to be unable to perform his marital duties and tasks, and on the other hand, due to inefficient behaviors, may create conditions that cause problems in married life [ 65 ]. Allen et al. in United States (2018) found that the spouses of elderly veterans with PTSD had lower marital intimacy compared to other couples [ 25 ],which is consistent with the findings of the present study. The majority of participants expressed dissatisfaction with their marital relationship, which led to reduced life satisfaction, loss of hope in life, and decreased individual, psychological, and social functioning of the spouses over time. However, it should be noted that not all participants mentioned this issue; they neither explicitly reported a lack of satisfaction with their marital relationship, nor did they highlight a decrease in emotional and psychological intimacy between them and their veteran spouses.

The majority of the participants stated that when they faced challenges in life, they found solace in their spiritual and religious beliefs, which in turn created motivation and hope for them. They believed that the spiritual rewards of such practices were significant to them, rather than worldly rewards. As a result, they never surrendered to difficulties. However, some others expressed that sometimes the problems and issues were greater than what could be solely addressed by these religious beliefs. Consequently, it can be argued that individuals may exhibit different reactions. Some may resort to spirituality and seek help from God, accepting these challenges as divine tests, while others may reduce or sever their connection with God. These findings were evident in the results of the present study and are consistent with the findings of a study by Yahyazadeh et al. in Iran (2016) [ 18 ].

One of the challenges found in the present study was the financial burden, which is in line with the results of the study by Mitter et al. (2017), which showed that living with a disabled adult imposes additional costs on the family [ 66 ]. Evans et al. (2019) concluded that homelessness among combat soldiers and veterans has increased and needs a plan to improve [ 67 ]. Although veteran’s affairs covers some of the expenses of these people, many veterans do not use these privileges and medical expenses Excess creates problems for them. The results of the present study showed that one of the bothersome challenges for the veterans’ spouses was that the support available in the society for veterans and their families, in addition to being inadequate, also created an inappropriate psychological atmosphere and even led to social exclusion for these families. The attitude of the society and even some governmental institutions towards the phenomenon of veteran and being subjected to unjust judgments constantly offended these families. This, in turn, has caused suffering for the veterans and their children. These findings are consistent with the results of a study by Shafiei et al.in Iran (2022), which indicated that the general public’s stereotypical view towards the financial benefits and social privileges of veterans was often accompanied by bias due to their lack of awareness of the deeper realities. Sometimes, these issues become so intense that these families prefer not to mention their “father being a veteran” because they are faced with unrealistic and unjust judgments from others [ 68 ].

The overall belief was that the social status of these veterans has declined, which is consistent with the findings of a study by Khalili et al. in Iran (2018), who stated that the literature on veterans has undergone changes, and in many cases, the sanctity and social status of being a veteran have been diminished to a set of compliments as well as advertising and media discourse [ 69 ]. According to the findings of Khodabakhshi et al.in Iran (2019), there have been transformations in the values and perceptions associated with being a veteran and self-sacrifice, leading to a materialistic and livelihood-oriented approach to the extent that, in the overall societal perspective, the material and economic outlook has prevailed over the cultural outlook [ 64 ]. This is in line with the findings of the present study and reflects the complaints of the spouses, indicating that despite the limited and insufficient benefits and allocations considered for veterans and the heavy costs of their care, the negative attitudes of individuals in the society persist, leading to a sense of discrimination, humiliation, and deprivation of respect.

Furthermore, feelings of alienation and lack of organizational belonging towards service-providing institutions have led to a sense of deprivation of organizational identity. This dissatisfaction with service-providing institutions is consistent with the results of a study by Shariati et al.in Iran [ 70 ], indicating that veterans have gone to war and accepted its consequences due to their special values and beliefs. In other words, the value of self-sacrifice accompanies the insignificance of material rewards for them. This transformation has also added to the cultural concerns and the scope of separation and social isolation among veterans and some family members, especially their spouses and children [ 71 ]. Overall, the above factors indicate that the psychological and physical condition of veterans with PTSD casts a shadow over their entire lives, particularly their family life, has led to dissatisfaction among family members, especially the spouses of these veterans, and has created deep wounds in the economic, social, and cultural dimensions of their lives.

Limitations

The present study, similar to other studies, has limitations. One of the limitations was the trust of the participants, the spouses of the veterans did not have enough trust to express their challenges at first. The researcher tried to control this limitation by interacting with the spouses for a long time and gaining their trust so that they can express their behavior freely. Furthermore, another limitation of this study due to the nature of qualitative studies is that the generalization of the results cannot be considered with certainty.

The results of the present study demonstrated that the consequences of PTSD-related injuries in veterans directly and indirectly affect the overall living conditions of their spouses. These spouses experience emotional detachment and constant rejection, leading to a decrease in their resilience against existing stressors and exposing them to disruptive and challenging issues in physical, psychological, and social dimensions of life. The spouses of these veterans are at the center of the family and serve as a refuge in the face of life difficulties. In addition to fulfilling their spousal duties, they shoulder the responsibilities of motherhood and other roles, often prioritizing the needs of others over their own physical and mental well-being, in order to regulate the relationships within the family and with the community. Therefore, the identification of these life challenges is considered essential because it enables the implementation of beneficial and constructive measures to empower them in psychological, emotional, and physical aspects. It also allows them to benefit from social support in educational, caregiving, therapeutic, and supportive dimensions, such as counseling and providing appropriate information.

Since the spouses of veterans with PTSD have an important role in maintaining and maintaining the cohesion of the family environment, and with their flexibility and adaptability, they can play an important role in finding family balance and reducing stress and tensions in life. Therefore, support systems such as counseling and providing appropriate information can improve the quality of life of veterans’ spouses and subsequently improve the quality of life of veterans. In the meantime, teaching life skills and communication skills and stress management methods and increasing understanding and social support can be helpful ultimately leading to positive impacts on the society. it is essential to develop precise plans to address and facilitate the challenges faced by these spouses and to empower family members, especially the spouse directly involved in dealing with the difficulties arising from the veteran’s injury. Additionally, it creates the necessary environment and motivation for further research in this field for researchers.

Data availability

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

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Acknowledgements

This study was part of a PhD thesis approved by Tehran University of Medical Sciences, Tehran, Iran. We would like to thank the Research Administration of this university (Code: 63051), Community Based Participatory Research Center, Tehran University of Medical Sciences, Tehran, Iran and authorities of Veterans Affairs Center and all the spouses of veterans with PTSD who assist us in this study.

This study was funded and supported Tehran University of Medical Sciences and Health Services, Iran. The funding source had no role in the design of the study, the collection, analysis and interpretation of the data, and the writing of the manuscript.

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ZM and ShP: design of study and acquisition of data; ZM, RN, SR and ShP: drafting the manuscript. ZM, RN, ShP: data analysis; All authors assisted in revising the text and approved the final manuscript.

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The study was carried out in accordance with the Declaration of Helsinki. Study was approved by the Ethics Committee of Tehran University of Medical Sciences with the ethical code.IR.TUMS.FNM.REC.1400.225. Initially, the study objectives were explained to the participants, and written informed consent was obtained from those who were willing to participate in the study.

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Maddah, Z., Negarandeh, R., Rahimi, S. et al. Challenges of living with veterans with post-traumatic stress disorder from the perspective of spouses: a qualitative content analysis study. BMC Psychiatry 24 , 151 (2024). https://doi.org/10.1186/s12888-024-05572-y

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DOI : https://doi.org/10.1186/s12888-024-05572-y

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In the United States, culturally responsive computing is a framework that aims to support broadening the participation of racially and linguistically diverse children in computing and technology education through bottom-up interventions that are community-oriented, technology rich, and culturally dynamic. Despite the important role that youth sports play in many local neighborhoods and communities across demographic groups there is only a small amount of research on developing culturally responsive computing education that incorporates these activities. We report findings from a culturally responsive computing collaboration between computing education researchers and coaches, mentors, and academic staff who ran a youth boxing program that predominantly served African American children. The purpose of the collaboration was to learn about and represent the adults’ expertise and knowledge in the co-development of culturally responsive computing activities. Using an emergent mixed methods research design, we collected qualitative data (i.e., interviews and group discussions) and quantitative data (i.e., pre- and post-surveys) throughout the collaboration. We analyzed these data to study how coaches, mentors, and staff members brought their knowledge and expertise to bear on the co-development of culturally responsive computing activities for the youth boxing program. Our findings show how the coaches, mentors, and academic staff used their expertise and knowledge in ways that leveraged boxing culture to go beyond boxing itself in the co-development of the activities. In addition, even when connections between computing and boxing did not appear authentically motivated this did not negate the adults’ engagement with the culturally responsive computing project. These findings have implications for anti-deficit theorizing about authenticity and inauthenticity in the co-development of culturally responsive computing in youth sports contexts. The construction of authenticity in culturally responsive computing might be less understood as a direct translation from community into education and more so as a negotiation between locally defined demarcations of what is considered authentic and inauthentic.

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This study was funded by Science + Society @ State, Michael Lachney, and the Joe L. Byers and Lucy Bates-Byers Endowment for Technology and Curriculum, Michael Lachney.

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Lachney, M., Green, B., Yadav, A. et al. Sparring with technology: collaborating with coaches, mentors, and academic staff to develop culturally responsive computing education for a youth boxing program. Education Tech Research Dev (2024). https://doi.org/10.1007/s11423-024-10344-2

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