data sampling methods in qualitative research

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Different Types of Sampling Techniques in Qualitative Research

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Key Takeaways:

• Sampling techniques in qualitative research include purposive, convenience, snowball, and theoretical sampling.
• Choosing the right sampling technique significantly impacts the accuracy and reliability of the research results.
• It’s crucial to consider the potential impact on the bias, sample diversity, and generalizability when choosing a sampling technique for your qualitative research.

Qualitative research seeks to understand social phenomena from the perspective of those experiencing them. It involves collecting non-numerical data such as interviews, observations, and written documents to gain insights into human experiences, attitudes, and behaviors. While qualitative research can provide rich and nuanced insights, the accuracy and generalizability of findings depend on the quality of the sampling process. Sampling is a critical component of qualitative research as it involves selecting a group of participants who can provide valuable insights into the research questions.

This article explores different types of sampling techniques used in qualitative research. First, we’ll provide a comprehensive overview of four standard sampling techniques used in qualitative research. and then compare and contrast these techniques to provide guidance on choosing the most appropriate method for a particular study. Additionally, you’ll find best practices for sampling and learn about ethical considerations researchers need to consider in selecting a sample. Overall, this article aims to help researchers conduct effective and high-quality sampling in qualitative research.

In this Article:

• Purposive Sampling
• Convenience Sampling
• Snowball Sampling
• Theoretical Sampling

Factors to Consider When Choosing a Sampling Technique

Practical approaches to sampling: recommended practices, final thoughts, get expert guidance on your sample needs.

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4 Types of Sampling Techniques and Their Applications

Sampling is a crucial aspect of qualitative research as it determines the representativeness and credibility of the data collected. Several sampling techniques are used in qualitative research, each with strengths and weaknesses. In this section, let’s explore four standard sampling techniques used in qualitative research: purposive sampling, convenience sampling, snowball sampling, and theoretical sampling. We’ll break down the definition of each technique, when to use it, and its advantages and disadvantages.

1. Purposive Sampling

Purposive sampling, or judgmental sampling, is a non-probability sampling technique commonly used in qualitative research. In purposive sampling, researchers intentionally select participants with specific characteristics or unique experiences related to the research question. The goal is to identify and recruit participants who can provide rich and diverse data to enhance the research findings.

Purposive sampling is used when researchers seek to identify individuals or groups with particular knowledge, skills, or experiences relevant to the research question. For instance, in a study examining the experiences of cancer patients undergoing chemotherapy, purposive sampling may be used to recruit participants who have undergone chemotherapy in the past year. Researchers can better understand the phenomenon under investigation by selecting individuals with relevant backgrounds.

Purposive Sampling: Strengths and Weaknesses

Purposive sampling is a powerful tool for researchers seeking to select participants who can provide valuable insight into their research question. This method is advantageous when studying groups with technical characteristics or experiences where a random selection of participants may yield different results.

One of the main advantages of purposive sampling is the ability to improve the quality and accuracy of data collected by selecting participants most relevant to the research question. This approach also enables researchers to collect data from diverse participants with unique perspectives and experiences related to the research question.

However, researchers should also be aware of potential bias when using purposive sampling. The researcher’s judgment may influence the selection of participants, resulting in a biased sample that does not accurately represent the broader population. Another disadvantage is that purposive sampling may not be representative of the more general population, which limits the generalizability of the findings. To guarantee the accuracy and dependability of data obtained through purposive sampling, researchers must provide a clear and transparent justification of their selection criteria and sampling approach. This entails outlining the specific characteristics or experiences required for participants to be included in the study and explaining the rationale behind these criteria. This level of transparency not only helps readers to evaluate the validity of the findings, but also enhances the replicability of the research.

2. Convenience Sampling  

When time and resources are limited, researchers may opt for convenience sampling as a quick and cost-effective way to recruit participants. In this non-probability sampling technique, participants are selected based on their accessibility and willingness to participate rather than their suitability for the research question. Qualitative research often uses this approach to generate various perspectives and experiences.

During the COVID-19 pandemic, convenience sampling was a valuable method for researchers to collect data quickly and efficiently from participants who were easily accessible and willing to participate. For example, in a study examining the experiences of university students during the pandemic, convenience sampling allowed researchers to recruit students who were available and willing to share their experiences quickly. While the pandemic may be over, convenience sampling during this time highlights its value in urgent situations where time and resources are limited.

Convenience Sampling: Strengths and Weaknesses

Convenience sampling offers several advantages to researchers, including its ease of implementation and cost-effectiveness. This technique allows researchers to quickly and efficiently recruit participants without spending time and resources identifying and contacting potential participants. Furthermore, convenience sampling can result in a diverse pool of participants, as individuals from various backgrounds and experiences may be more likely to participate.

While convenience sampling has the advantage of being efficient, researchers need to acknowledge its limitations. One of the primary drawbacks of convenience sampling is that it is susceptible to selection bias. Participants who are more easily accessible may not be representative of the broader population, which can limit the generalizability of the findings. Furthermore, convenience sampling may lead to issues with the reliability of the results, as it may not be possible to replicate the study using the same sample or a similar one.

To mitigate these limitations, researchers should carefully define the population of interest and ensure the sample is drawn from that population. For instance, if a study is investigating the experiences of individuals with a particular medical condition, researchers can recruit participants from specialized clinics or support groups for that condition. Researchers can also use statistical techniques such as stratified sampling or weighting to adjust for potential biases in the sample.

3. Snowball Sampling

Snowball sampling, also called referral sampling, is a unique approach researchers use to recruit participants in qualitative research. The technique involves identifying a few initial participants who meet the eligibility criteria and asking them to refer others they know who also fit the requirements. The sample size grows as referrals are added, creating a chain-like structure.

Snowball sampling enables researchers to reach out to individuals who may be hard to locate through traditional sampling methods, such as members of marginalized or hidden communities. For instance, in a study examining the experiences of undocumented immigrants, snowball sampling may be used to identify and recruit participants through referrals from other undocumented immigrants.

Snowball Sampling: Strengths and Weaknesses

Snowball sampling can produce in-depth and detailed data from participants with common characteristics or experiences. Since referrals are made within a network of individuals who share similarities, researchers can gain deep insights into a specific group’s attitudes, behaviors, and perspectives.

4. Theoretical Sampling

Theoretical sampling is a sophisticated and strategic technique that can help researchers develop more in-depth and nuanced theories from their data. Instead of selecting participants based on convenience or accessibility, researchers using theoretical sampling choose participants based on their potential to contribute to the emerging themes and concepts in the data. This approach allows researchers to refine their research question and theory based on the data they collect rather than forcing their data to fit a preconceived idea.

Theoretical sampling is used when researchers conduct grounded theory research and have developed an initial theory or conceptual framework. In a study examining cancer survivors’ experiences, for example, theoretical sampling may be used to identify and recruit participants who can provide new insights into the coping strategies of survivors.

Theoretical Sampling: Strengths and Weaknesses

One of the significant advantages of theoretical sampling is that it allows researchers to refine their research question and theory based on emerging data. This means the research can be highly targeted and focused, leading to a deeper understanding of the phenomenon being studied. Additionally, theoretical sampling can generate rich and in-depth data, as participants are selected based on their potential to provide new insights into the research question.

Participants are selected based on their perceived ability to offer new perspectives on the research question. This means specific perspectives or experiences may be overrepresented in the sample, leading to an incomplete understanding of the phenomenon being studied. Additionally, theoretical sampling can be time-consuming and resource-intensive, as researchers must continuously analyze the data and recruit new participants.

To mitigate the potential for bias, researchers can take several steps. One way to reduce bias is to use a diverse team of researchers to analyze the data and make participant selection decisions. Having multiple perspectives and backgrounds can help prevent researchers from unconsciously selecting participants who fit their preconceived notions or biases.

Another solution would be to use reflexive sampling. Reflexive sampling involves selecting participants aware of the research process and provides insights into how their biases and experiences may influence their perspectives. By including participants who are reflexive about their subjectivity, researchers can generate more nuanced and self-aware findings.

Choosing the proper sampling technique is one of the most critical decisions a researcher makes when conducting a study. The preferred method can significantly impact the accuracy and reliability of the research results.

For instance, purposive sampling provides a more targeted and specific sample, which helps to answer research questions related to that particular population or phenomenon. However, this approach may also introduce bias by limiting the diversity of the sample.

Conversely, convenience sampling may offer a more diverse sample regarding demographics and backgrounds but may also introduce bias by selecting more willing or available participants.

Snowball sampling may help study hard-to-reach populations, but it can also limit the sample’s diversity as participants are selected based on their connections to existing participants.

Theoretical sampling may offer an opportunity to refine the research question and theory based on emerging data, but it can also be time-consuming and resource-intensive.

Additionally, the choice of sampling technique can impact the generalizability of the research findings. Therefore, it’s crucial to consider the potential impact on the bias, sample diversity, and generalizability when choosing a sampling technique. By doing so, researchers can select the most appropriate method for their research question and ensure the validity and reliability of their findings.

Tips for Selecting Participants

When selecting participants for a qualitative research study, it is crucial to consider the research question and the purpose of the study. In addition, researchers should identify the specific characteristics or criteria they seek in their sample and select participants accordingly.

One helpful tip for selecting participants is to use a pre-screening process to ensure potential participants meet the criteria for inclusion in the study. Another technique is using multiple recruitment methods to ensure the sample is diverse and representative of the studied population.

Ensuring Diversity in Samples

Diversity in the sample is important to ensure the study’s findings apply to a wide range of individuals and situations. One way to ensure diversity is to use stratified sampling, which involves dividing the population into subgroups and selecting participants from each subset. This helps establish that the sample is representative of the larger population.

Maintaining Ethical Considerations

When selecting participants for a qualitative research study, it is essential to ensure ethical considerations are taken into account. Researchers must ensure participants are fully informed about the study and provide their voluntary consent to participate. They must also ensure participants understand their rights and that their confidentiality and privacy will be protected.

A qualitative research study’s success hinges on its sampling technique’s effectiveness. The choice of sampling technique must be guided by the research question, the population being studied, and the purpose of the study. Whether purposive, convenience, snowball, or theoretical sampling, the primary goal is to ensure the validity and reliability of the study’s findings.

By thoughtfully weighing the pros and cons of each sampling technique, researchers can make informed decisions that lead to more reliable and accurate results. In conclusion, carefully selecting a sampling technique is integral to the success of a qualitative research study, and a thorough understanding of the available options can make all the difference in achieving high-quality research outcomes.

If you’re interested in improving your research and sampling methods, Sago offers a variety of solutions. Our qualitative research platforms, such as QualBoard and QualMeeting, can assist you in conducting research studies with precision and efficiency. Our robust global panel and recruitment options help you reach the right people. We also offer qualitative and quantitative research services to meet your research needs. Contact us today to learn more about how we can help improve your research outcomes.

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BEFORE YOU GO

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Chapter 5. Sampling

Introduction.

Most Americans will experience unemployment at some point in their lives. Sarah Damaske ( 2021 ) was interested in learning about how men and women experience unemployment differently. To answer this question, she interviewed unemployed people. After conducting a “pilot study” with twenty interviewees, she realized she was also interested in finding out how working-class and middle-class persons experienced unemployment differently. She found one hundred persons through local unemployment offices. She purposefully selected a roughly equal number of men and women and working-class and middle-class persons for the study. This would allow her to make the kinds of comparisons she was interested in. She further refined her selection of persons to interview:

I decided that I needed to be able to focus my attention on gender and class; therefore, I interviewed only people born between 1962 and 1987 (ages 28–52, the prime working and child-rearing years), those who worked full-time before their job loss, those who experienced an involuntary job loss during the past year, and those who did not lose a job for cause (e.g., were not fired because of their behavior at work). ( 244 )

The people she ultimately interviewed compose her sample. They represent (“sample”) the larger population of the involuntarily unemployed. This “theoretically informed stratified sampling design” allowed Damaske “to achieve relatively equal distribution of participation across gender and class,” but it came with some limitations. For one, the unemployment centers were located in primarily White areas of the country, so there were very few persons of color interviewed. Qualitative researchers must make these kinds of decisions all the time—who to include and who not to include. There is never an absolutely correct decision, as the choice is linked to the particular research question posed by the particular researcher, although some sampling choices are more compelling than others. In this case, Damaske made the choice to foreground both gender and class rather than compare all middle-class men and women or women of color from different class positions or just talk to White men. She leaves the door open for other researchers to sample differently. Because science is a collective enterprise, it is most likely someone will be inspired to conduct a similar study as Damaske’s but with an entirely different sample.

This chapter is all about sampling. After you have developed a research question and have a general idea of how you will collect data (observations or interviews), how do you go about actually finding people and sites to study? Although there is no “correct number” of people to interview, the sample should follow the research question and research design. You might remember studying sampling in a quantitative research course. Sampling is important here too, but it works a bit differently. Unlike quantitative research, qualitative research involves nonprobability sampling. This chapter explains why this is so and what qualities instead make a good sample for qualitative research.

Quick Terms Refresher

• The population is the entire group that you want to draw conclusions about.
• The sample is the specific group of individuals that you will collect data from.
• Sampling frame is the actual list of individuals that the sample will be drawn from. Ideally, it should include the entire target population (and nobody who is not part of that population).
• Sample size is how many individuals (or units) are included in your sample.

The “Who” of Your Research Study

After you have turned your general research interest into an actual research question and identified an approach you want to take to answer that question, you will need to specify the people you will be interviewing or observing. In most qualitative research, the objects of your study will indeed be people. In some cases, however, your objects might be content left by people (e.g., diaries, yearbooks, photographs) or documents (official or unofficial) or even institutions (e.g., schools, medical centers) and locations (e.g., nation-states, cities). Chances are, whatever “people, places, or things” are the objects of your study, you will not really be able to talk to, observe, or follow every single individual/object of the entire population of interest. You will need to create a sample of the population . Sampling in qualitative research has different purposes and goals than sampling in quantitative research. Sampling in both allows you to say something of interest about a population without having to include the entire population in your sample.

We begin this chapter with the case of a population of interest composed of actual people. After we have a better understanding of populations and samples that involve real people, we’ll discuss sampling in other types of qualitative research, such as archival research, content analysis, and case studies. We’ll then move to a larger discussion about the difference between sampling in qualitative research generally versus quantitative research, then we’ll move on to the idea of “theoretical” generalizability, and finally, we’ll conclude with some practical tips on the correct “number” to include in one’s sample.

Sampling People

To help think through samples, let’s imagine we want to know more about “vaccine hesitancy.” We’ve all lived through 2020 and 2021, and we know that a sizable number of people in the United States (and elsewhere) were slow to accept vaccines, even when these were freely available. By some accounts, about one-third of Americans initially refused vaccination. Why is this so? Well, as I write this in the summer of 2021, we know that some people actively refused the vaccination, thinking it was harmful or part of a government plot. Others were simply lazy or dismissed the necessity. And still others were worried about harmful side effects. The general population of interest here (all adult Americans who were not vaccinated by August 2021) may be as many as eighty million people. We clearly cannot talk to all of them. So we will have to narrow the number to something manageable. How can we do this?

First, we have to think about our actual research question and the form of research we are conducting. I am going to begin with a quantitative research question. Quantitative research questions tend to be simpler to visualize, at least when we are first starting out doing social science research. So let us say we want to know what percentage of each kind of resistance is out there and how race or class or gender affects vaccine hesitancy. Again, we don’t have the ability to talk to everyone. But harnessing what we know about normal probability distributions (see quantitative methods for more on this), we can find this out through a sample that represents the general population. We can’t really address these particular questions if we only talk to White women who go to college with us. And if you are really trying to generalize the specific findings of your sample to the larger population, you will have to employ probability sampling , a sampling technique where a researcher sets a selection of a few criteria and chooses members of a population randomly. Why randomly? If truly random, all the members have an equal opportunity to be a part of the sample, and thus we avoid the problem of having only our friends and neighbors (who may be very different from other people in the population) in the study. Mathematically, there is going to be a certain number that will be large enough to allow us to generalize our particular findings from our sample population to the population at large. It might surprise you how small that number can be. Election polls of no more than one thousand people are routinely used to predict actual election outcomes of millions of people. Below that number, however, you will not be able to make generalizations. Talking to five people at random is simply not enough people to predict a presidential election.

In order to answer quantitative research questions of causality, one must employ probability sampling. Quantitative researchers try to generalize their findings to a larger population. Samples are designed with that in mind. Qualitative researchers ask very different questions, though. Qualitative research questions are not about “how many” of a certain group do X (in this case, what percentage of the unvaccinated hesitate for concern about safety rather than reject vaccination on political grounds). Qualitative research employs nonprobability sampling . By definition, not everyone has an equal opportunity to be included in the sample. The researcher might select White women they go to college with to provide insight into racial and gender dynamics at play. Whatever is found by doing so will not be generalizable to everyone who has not been vaccinated, or even all White women who have not been vaccinated, or even all White women who have not been vaccinated who are in this particular college. That is not the point of qualitative research at all. This is a really important distinction, so I will repeat in bold: Qualitative researchers are not trying to statistically generalize specific findings to a larger population . They have not failed when their sample cannot be generalized, as that is not the point at all.

In the previous paragraph, I said it would be perfectly acceptable for a qualitative researcher to interview five White women with whom she goes to college about their vaccine hesitancy “to provide insight into racial and gender dynamics at play.” The key word here is “insight.” Rather than use a sample as a stand-in for the general population, as quantitative researchers do, the qualitative researcher uses the sample to gain insight into a process or phenomenon. The qualitative researcher is not going to be content with simply asking each of the women to state her reason for not being vaccinated and then draw conclusions that, because one in five of these women were concerned about their health, one in five of all people were also concerned about their health. That would be, frankly, a very poor study indeed. Rather, the qualitative researcher might sit down with each of the women and conduct a lengthy interview about what the vaccine means to her, why she is hesitant, how she manages her hesitancy (how she explains it to her friends), what she thinks about others who are unvaccinated, what she thinks of those who have been vaccinated, and what she knows or thinks she knows about COVID-19. The researcher might include specific interview questions about the college context, about their status as White women, about the political beliefs they hold about racism in the US, and about how their own political affiliations may or may not provide narrative scripts about “protective whiteness.” There are many interesting things to ask and learn about and many things to discover. Where a quantitative researcher begins with clear parameters to set their population and guide their sample selection process, the qualitative researcher is discovering new parameters, making it impossible to engage in probability sampling.

Looking at it this way, sampling for qualitative researchers needs to be more strategic. More theoretically informed. What persons can be interviewed or observed that would provide maximum insight into what is still unknown? In other words, qualitative researchers think through what cases they could learn the most from, and those are the cases selected to study: “What would be ‘bias’ in statistical sampling, and therefore a weakness, becomes intended focus in qualitative sampling, and therefore a strength. The logic and power of purposeful sampling like in selecting information-rich cases for study in depth. Information-rich cases are those from which one can learn a great deal about issues of central importance to the purpose of the inquiry, thus the term purposeful sampling” ( Patton 2002:230 ; emphases in the original).

Before selecting your sample, though, it is important to clearly identify the general population of interest. You need to know this before you can determine the sample. In our example case, it is “adult Americans who have not yet been vaccinated.” Depending on the specific qualitative research question, however, it might be “adult Americans who have been vaccinated for political reasons” or even “college students who have not been vaccinated.” What insights are you seeking? Do you want to know how politics is affecting vaccination? Or do you want to understand how people manage being an outlier in a particular setting (unvaccinated where vaccinations are heavily encouraged if not required)? More clearly stated, your population should align with your research question . Think back to the opening story about Damaske’s work studying the unemployed. She drew her sample narrowly to address the particular questions she was interested in pursuing. Knowing your questions or, at a minimum, why you are interested in the topic will allow you to draw the best sample possible to achieve insight.

Once you have your population in mind, how do you go about getting people to agree to be in your sample? In qualitative research, it is permissible to find people by convenience. Just ask for people who fit your sample criteria and see who shows up. Or reach out to friends and colleagues and see if they know anyone that fits. Don’t let the name convenience sampling mislead you; this is not exactly “easy,” and it is certainly a valid form of sampling in qualitative research. The more unknowns you have about what you will find, the more convenience sampling makes sense. If you don’t know how race or class or political affiliation might matter, and your population is unvaccinated college students, you can construct a sample of college students by placing an advertisement in the student paper or posting a flyer on a notice board. Whoever answers is your sample. That is what is meant by a convenience sample. A common variation of convenience sampling is snowball sampling . This is particularly useful if your target population is hard to find. Let’s say you posted a flyer about your study and only two college students responded. You could then ask those two students for referrals. They tell their friends, and those friends tell other friends, and, like a snowball, your sample gets bigger and bigger.

Researcher Note

Gaining Access: When Your Friend Is Your Research Subject

My early experience with qualitative research was rather unique. At that time, I needed to do a project that required me to interview first-generation college students, and my friends, with whom I had been sharing a dorm for two years, just perfectly fell into the sample category. Thus, I just asked them and easily “gained my access” to the research subject; I know them, we are friends, and I am part of them. I am an insider. I also thought, “Well, since I am part of the group, I can easily understand their language and norms, I can capture their honesty, read their nonverbal cues well, will get more information, as they will be more opened to me because they trust me.” All in all, easy access with rich information. But, gosh, I did not realize that my status as an insider came with a price! When structuring the interview questions, I began to realize that rather than focusing on the unique experiences of my friends, I mostly based the questions on my own experiences, assuming we have similar if not the same experiences. I began to struggle with my objectivity and even questioned my role; am I doing this as part of the group or as a researcher? I came to know later that my status as an insider or my “positionality” may impact my research. It not only shapes the process of data collection but might heavily influence my interpretation of the data. I came to realize that although my inside status came with a lot of benefits (especially for access), it could also bring some drawbacks.

—Dede Setiono, PhD student focusing on international development and environmental policy, Oregon State University

The more you know about what you might find, the more strategic you can be. If you wanted to compare how politically conservative and politically liberal college students explained their vaccine hesitancy, for example, you might construct a sample purposively, finding an equal number of both types of students so that you can make those comparisons in your analysis. This is what Damaske ( 2021 ) did. You could still use convenience or snowball sampling as a way of recruitment. Post a flyer at the conservative student club and then ask for referrals from the one student that agrees to be interviewed. As with convenience sampling, there are variations of purposive sampling as well as other names used (e.g., judgment, quota, stratified, criterion, theoretical). Try not to get bogged down in the nomenclature; instead, focus on identifying the general population that matches your research question and then using a sampling method that is most likely to provide insight, given the types of questions you have.

There are all kinds of ways of being strategic with sampling in qualitative research. Here are a few of my favorite techniques for maximizing insight:

• Consider using “extreme” or “deviant” cases. Maybe your college houses a prominent anti-vaxxer who has written about and demonstrated against the college’s policy on vaccines. You could learn a lot from that single case (depending on your research question, of course).
• Consider “intensity”: people and cases and circumstances where your questions are more likely to feature prominently (but not extremely or deviantly). For example, you could compare those who volunteer at local Republican and Democratic election headquarters during an election season in a study on why party matters. Those who volunteer are more likely to have something to say than those who are more apathetic.
• Maximize variation, as with the case of “politically liberal” versus “politically conservative,” or include an array of social locations (young vs. old; Northwest vs. Southeast region). This kind of heterogeneity sampling can capture and describe the central themes that cut across the variations: any common patterns that emerge, even in this wildly mismatched sample, are probably important to note!
• Rather than maximize the variation, you could select a small homogenous sample to describe some particular subgroup in depth. Focus groups are often the best form of data collection for homogeneity sampling.
• Think about which cases are “critical” or politically important—ones that “if it happens here, it would happen anywhere” or a case that is politically sensitive, as with the single “blue” (Democratic) county in a “red” (Republican) state. In both, you are choosing a site that would yield the most information and have the greatest impact on the development of knowledge.
• On the other hand, sometimes you want to select the “typical”—the typical college student, for example. You are trying to not generalize from the typical but illustrate aspects that may be typical of this case or group. When selecting for typicality, be clear with yourself about why the typical matches your research questions (and who might be excluded or marginalized in doing so).
• Finally, it is often a good idea to look for disconfirming cases : if you are at the stage where you have a hypothesis (of sorts), you might select those who do not fit your hypothesis—you will surely learn something important there. They may be “exceptions that prove the rule” or exceptions that force you to alter your findings in order to make sense of these additional cases.

In addition to all these sampling variations, there is the theoretical approach taken by grounded theorists in which the researcher samples comparative people (or events) on the basis of their potential to represent important theoretical constructs. The sample, one can say, is by definition representative of the phenomenon of interest. It accompanies the constant comparative method of analysis. In the words of the funders of Grounded Theory , “Theoretical sampling is sampling on the basis of the emerging concepts, with the aim being to explore the dimensional range or varied conditions along which the properties of the concepts vary” ( Strauss and Corbin 1998:73 ).

When Your Population is Not Composed of People

I think it is easiest for most people to think of populations and samples in terms of people, but sometimes our units of analysis are not actually people. They could be places or institutions. Even so, you might still want to talk to people or observe the actions of people to understand those places or institutions. Or not! In the case of content analyses (see chapter 17), you won’t even have people involved at all but rather documents or films or photographs or news clippings. Everything we have covered about sampling applies to other units of analysis too. Let’s work through some examples.

Case Studies

When constructing a case study, it is helpful to think of your cases as sample populations in the same way that we considered people above. If, for example, you are comparing campus climates for diversity, your overall population may be “four-year college campuses in the US,” and from there you might decide to study three college campuses as your sample. Which three? Will you use purposeful sampling (perhaps [1] selecting three colleges in Oregon that are different sizes or [2] selecting three colleges across the US located in different political cultures or [3] varying the three colleges by racial makeup of the student body)? Or will you select three colleges at random, out of convenience? There are justifiable reasons for all approaches.

As with people, there are different ways of maximizing insight in your sample selection. Think about the following rationales: typical, diverse, extreme, deviant, influential, crucial, or even embodying a particular “pathway” ( Gerring 2008 ). When choosing a case or particular research site, Rubin ( 2021 ) suggests you bear in mind, first, what you are leaving out by selecting this particular case/site; second, what you might be overemphasizing by studying this case/site and not another; and, finally, whether you truly need to worry about either of those things—“that is, what are the sources of bias and how bad are they for what you are trying to do?” ( 89 ).

Once you have selected your cases, you may still want to include interviews with specific people or observations at particular sites within those cases. Then you go through possible sampling approaches all over again to determine which people will be contacted.

Content: Documents, Narrative Accounts, And So On

Although not often discussed as sampling, your selection of documents and other units to use in various content/historical analyses is subject to similar considerations. When you are asking quantitative-type questions (percentages and proportionalities of a general population), you will want to follow probabilistic sampling. For example, I created a random sample of accounts posted on the website studentloanjustice.org to delineate the types of problems people were having with student debt ( Hurst 2007 ). Even though my data was qualitative (narratives of student debt), I was actually asking a quantitative-type research question, so it was important that my sample was representative of the larger population (debtors who posted on the website). On the other hand, when you are asking qualitative-type questions, the selection process should be very different. In that case, use nonprobabilistic techniques, either convenience (where you are really new to this data and do not have the ability to set comparative criteria or even know what a deviant case would be) or some variant of purposive sampling. Let’s say you were interested in the visual representation of women in media published in the 1950s. You could select a national magazine like Time for a “typical” representation (and for its convenience, as all issues are freely available on the web and easy to search). Or you could compare one magazine known for its feminist content versus one antifeminist. The point is, sample selection is important even when you are not interviewing or observing people.

Goals of Qualitative Sampling versus Goals of Quantitative Sampling

We have already discussed some of the differences in the goals of quantitative and qualitative sampling above, but it is worth further discussion. The quantitative researcher seeks a sample that is representative of the population of interest so that they may properly generalize the results (e.g., if 80 percent of first-gen students in the sample were concerned with costs of college, then we can say there is a strong likelihood that 80 percent of first-gen students nationally are concerned with costs of college). The qualitative researcher does not seek to generalize in this way . They may want a representative sample because they are interested in typical responses or behaviors of the population of interest, but they may very well not want a representative sample at all. They might want an “extreme” or deviant case to highlight what could go wrong with a particular situation, or maybe they want to examine just one case as a way of understanding what elements might be of interest in further research. When thinking of your sample, you will have to know why you are selecting the units, and this relates back to your research question or sets of questions. It has nothing to do with having a representative sample to generalize results. You may be tempted—or it may be suggested to you by a quantitatively minded member of your committee—to create as large and representative a sample as you possibly can to earn credibility from quantitative researchers. Ignore this temptation or suggestion. The only thing you should be considering is what sample will best bring insight into the questions guiding your research. This has implications for the number of people (or units) in your study as well, which is the topic of the next section.

What is the Correct “Number” to Sample?

Because we are not trying to create a generalizable representative sample, the guidelines for the “number” of people to interview or news stories to code are also a bit more nebulous. There are some brilliant insightful studies out there with an n of 1 (meaning one person or one account used as the entire set of data). This is particularly so in the case of autoethnography, a variation of ethnographic research that uses the researcher’s own subject position and experiences as the basis of data collection and analysis. But it is true for all forms of qualitative research. There are no hard-and-fast rules here. The number to include is what is relevant and insightful to your particular study.

That said, humans do not thrive well under such ambiguity, and there are a few helpful suggestions that can be made. First, many qualitative researchers talk about “saturation” as the end point for data collection. You stop adding participants when you are no longer getting any new information (or so very little that the cost of adding another interview subject or spending another day in the field exceeds any likely benefits to the research). The term saturation was first used here by Glaser and Strauss ( 1967 ), the founders of Grounded Theory. Here is their explanation: “The criterion for judging when to stop sampling the different groups pertinent to a category is the category’s theoretical saturation . Saturation means that no additional data are being found whereby the sociologist can develop properties of the category. As he [or she] sees similar instances over and over again, the researcher becomes empirically confident that a category is saturated. [They go] out of [their] way to look for groups that stretch diversity of data as far as possible, just to make certain that saturation is based on the widest possible range of data on the category” ( 61 ).

It makes sense that the term was developed by grounded theorists, since this approach is rather more open-ended than other approaches used by qualitative researchers. With so much left open, having a guideline of “stop collecting data when you don’t find anything new” is reasonable. However, saturation can’t help much when first setting out your sample. How do you know how many people to contact to interview? What number will you put down in your institutional review board (IRB) protocol (see chapter 8)? You may guess how many people or units it will take to reach saturation, but there really is no way to know in advance. The best you can do is think about your population and your questions and look at what others have done with similar populations and questions.

Here are some suggestions to use as a starting point: For phenomenological studies, try to interview at least ten people for each major category or group of people . If you are comparing male-identified, female-identified, and gender-neutral college students in a study on gender regimes in social clubs, that means you might want to design a sample of thirty students, ten from each group. This is the minimum suggested number. Damaske’s ( 2021 ) sample of one hundred allows room for up to twenty-five participants in each of four “buckets” (e.g., working-class*female, working-class*male, middle-class*female, middle-class*male). If there is more than one comparative group (e.g., you are comparing students attending three different colleges, and you are comparing White and Black students in each), you can sometimes reduce the number for each group in your sample to five for, in this case, thirty total students. But that is really a bare minimum you will want to go. A lot of people will not trust you with only “five” cases in a bucket. Lareau ( 2021:24 ) advises a minimum of seven or nine for each bucket (or “cell,” in her words). The point is to think about what your analyses might look like and how comfortable you will be with a certain number of persons fitting each category.

Because qualitative research takes so much time and effort, it is rare for a beginning researcher to include more than thirty to fifty people or units in the study. You may not be able to conduct all the comparisons you might want simply because you cannot manage a larger sample. In that case, the limits of who you can reach or what you can include may influence you to rethink an original overcomplicated research design. Rather than include students from every racial group on a campus, for example, you might want to sample strategically, thinking about the most contrast (insightful), possibly excluding majority-race (White) students entirely, and simply using previous literature to fill in gaps in our understanding. For example, one of my former students was interested in discovering how race and class worked at a predominantly White institution (PWI). Due to time constraints, she simplified her study from an original sample frame of middle-class and working-class domestic Black and international African students (four buckets) to a sample frame of domestic Black and international African students (two buckets), allowing the complexities of class to come through individual accounts rather than from part of the sample frame. She wisely decided not to include White students in the sample, as her focus was on how minoritized students navigated the PWI. She was able to successfully complete her project and develop insights from the data with fewer than twenty interviewees. [1]

But what if you had unlimited time and resources? Would it always be better to interview more people or include more accounts, documents, and units of analysis? No! Your sample size should reflect your research question and the goals you have set yourself. Larger numbers can sometimes work against your goals. If, for example, you want to help bring out individual stories of success against the odds, adding more people to the analysis can end up drowning out those individual stories. Sometimes, the perfect size really is one (or three, or five). It really depends on what you are trying to discover and achieve in your study. Furthermore, studies of one hundred or more (people, documents, accounts, etc.) can sometimes be mistaken for quantitative research. Inevitably, the large sample size will push the researcher into simplifying the data numerically. And readers will begin to expect generalizability from such a large sample.

To summarize, “There are no rules for sample size in qualitative inquiry. Sample size depends on what you want to know, the purpose of the inquiry, what’s at stake, what will be useful, what will have credibility, and what can be done with available time and resources” ( Patton 2002:244 ).

How did you find/construct a sample?

Since qualitative researchers work with comparatively small sample sizes, getting your sample right is rather important. Yet it is also difficult to accomplish. For instance, a key question you need to ask yourself is whether you want a homogeneous or heterogeneous sample. In other words, do you want to include people in your study who are by and large the same, or do you want to have diversity in your sample?

For many years, I have studied the experiences of students who were the first in their families to attend university. There is a rather large number of sampling decisions I need to consider before starting the study. (1) Should I only talk to first-in-family students, or should I have a comparison group of students who are not first-in-family? (2) Do I need to strive for a gender distribution that matches undergraduate enrollment patterns? (3) Should I include participants that reflect diversity in gender identity and sexuality? (4) How about racial diversity? First-in-family status is strongly related to some ethnic or racial identity. (5) And how about areas of study?

As you can see, if I wanted to accommodate all these differences and get enough study participants in each category, I would quickly end up with a sample size of hundreds, which is not feasible in most qualitative research. In the end, for me, the most important decision was to maximize the voices of first-in-family students, which meant that I only included them in my sample. As for the other categories, I figured it was going to be hard enough to find first-in-family students, so I started recruiting with an open mind and an understanding that I may have to accept a lack of gender, sexuality, or racial diversity and then not be able to say anything about these issues. But I would definitely be able to speak about the experiences of being first-in-family.

—Wolfgang Lehmann, author of “Habitus Transformation and Hidden Injuries”

Examples of “Sample” Sections in Journal Articles

Think about some of the studies you have read in college, especially those with rich stories and accounts about people’s lives. Do you know how the people were selected to be the focus of those stories? If the account was published by an academic press (e.g., University of California Press or Princeton University Press) or in an academic journal, chances are that the author included a description of their sample selection. You can usually find these in a methodological appendix (book) or a section on “research methods” (article).

Here are two examples from recent books and one example from a recent article:

Example 1 . In It’s Not like I’m Poor: How Working Families Make Ends Meet in a Post-welfare World , the research team employed a mixed methods approach to understand how parents use the earned income tax credit, a refundable tax credit designed to provide relief for low- to moderate-income working people ( Halpern-Meekin et al. 2015 ). At the end of their book, their first appendix is “Introduction to Boston and the Research Project.” After describing the context of the study, they include the following description of their sample selection:

In June 2007, we drew 120 names at random from the roughly 332 surveys we gathered between February and April. Within each racial and ethnic group, we aimed for one-third married couples with children and two-thirds unmarried parents. We sent each of these families a letter informing them of the opportunity to participate in the in-depth portion of our study and then began calling the home and cell phone numbers they provided us on the surveys and knocking on the doors of the addresses they provided.…In the end, we interviewed 115 of the 120 families originally selected for the in-depth interview sample (the remaining five families declined to participate). ( 22 )

Was their sample selection based on convenience or purpose? Why do you think it was important for them to tell you that five families declined to be interviewed? There is actually a trick here, as the names were pulled randomly from a survey whose sample design was probabilistic. Why is this important to know? What can we say about the representativeness or the uniqueness of whatever findings are reported here?

Example 2 . In When Diversity Drops , Park ( 2013 ) examines the impact of decreasing campus diversity on the lives of college students. She does this through a case study of one student club, the InterVarsity Christian Fellowship (IVCF), at one university (“California University,” a pseudonym). Here is her description:

I supplemented participant observation with individual in-depth interviews with sixty IVCF associates, including thirty-four current students, eight former and current staff members, eleven alumni, and seven regional or national staff members. The racial/ethnic breakdown was twenty-five Asian Americans (41.6 percent), one Armenian (1.6 percent), twelve people who were black (20.0 percent), eight Latino/as (13.3 percent), three South Asian Americans (5.0 percent), and eleven people who were white (18.3 percent). Twenty-nine were men, and thirty-one were women. Looking back, I note that the higher number of Asian Americans reflected both the group’s racial/ethnic composition and my relative ease about approaching them for interviews. ( 156 )

How can you tell this is a convenience sample? What else do you note about the sample selection from this description?

Example 3. The last example is taken from an article published in the journal Research in Higher Education . Published articles tend to be more formal than books, at least when it comes to the presentation of qualitative research. In this article, Lawson ( 2021 ) is seeking to understand why female-identified college students drop out of majors that are dominated by male-identified students (e.g., engineering, computer science, music theory). Here is the entire relevant section of the article:

Method Participants Data were collected as part of a larger study designed to better understand the daily experiences of women in MDMs [male-dominated majors].…Participants included 120 students from a midsize, Midwestern University. This sample included 40 women and 40 men from MDMs—defined as any major where at least 2/3 of students are men at both the university and nationally—and 40 women from GNMs—defined as any may where 40–60% of students are women at both the university and nationally.… Procedure A multi-faceted approach was used to recruit participants; participants were sent targeted emails (obtained based on participants’ reported gender and major listings), campus-wide emails sent through the University’s Communication Center, flyers, and in-class presentations. Recruitment materials stated that the research focused on the daily experiences of college students, including classroom experiences, stressors, positive experiences, departmental contexts, and career aspirations. Interested participants were directed to email the study coordinator to verify eligibility (at least 18 years old, man/woman in MDM or woman in GNM, access to a smartphone). Sixteen interested individuals were not eligible for the study due to the gender/major combination. ( 482ff .)

What method of sample selection was used by Lawson? Why is it important to define “MDM” at the outset? How does this definition relate to sampling? Why were interested participants directed to the study coordinator to verify eligibility?

Final Words

I have found that students often find it difficult to be specific enough when defining and choosing their sample. It might help to think about your sample design and sample recruitment like a cookbook. You want all the details there so that someone else can pick up your study and conduct it as you intended. That person could be yourself, but this analogy might work better if you have someone else in mind. When I am writing down recipes, I often think of my sister and try to convey the details she would need to duplicate the dish. We share a grandmother whose recipes are full of handwritten notes in the margins, in spidery ink, that tell us what bowl to use when or where things could go wrong. Describe your sample clearly, convey the steps required accurately, and then add any other details that will help keep you on track and remind you why you have chosen to limit possible interviewees to those of a certain age or class or location. Imagine actually going out and getting your sample (making your dish). Do you have all the necessary details to get started?

Table 5.1. Sampling Type and Strategies

Further Readings

Fusch, Patricia I., and Lawrence R. Ness. 2015. “Are We There Yet? Data Saturation in Qualitative Research.” Qualitative Report 20(9):1408–1416.

Saunders, Benjamin, Julius Sim, Tom Kinstone, Shula Baker, Jackie Waterfield, Bernadette Bartlam, Heather Burroughs, and Clare Jinks. 2018. “Saturation in Qualitative Research: Exploring Its Conceptualization and Operationalization.”  Quality & Quantity  52(4):1893–1907.

• Rubin ( 2021 ) suggests a minimum of twenty interviews (but safer with thirty) for an interview-based study and a minimum of three to six months in the field for ethnographic studies. For a content-based study, she suggests between five hundred and one thousand documents, although some will be “very small” ( 243–244 ). ↵

The process of selecting people or other units of analysis to represent a larger population. In quantitative research, this representation is taken quite literally, as statistically representative.  In qualitative research, in contrast, sample selection is often made based on potential to generate insight about a particular topic or phenomenon.

The actual list of individuals that the sample will be drawn from. Ideally, it should include the entire target population (and nobody who is not part of that population).  Sampling frames can differ from the larger population when specific exclusions are inherent, as in the case of pulling names randomly from voter registration rolls where not everyone is a registered voter.  This difference in frame and population can undercut the generalizability of quantitative results.

The specific group of individuals that you will collect data from.  Contrast population.

The large group of interest to the researcher.  Although it will likely be impossible to design a study that incorporates or reaches all members of the population of interest, this should be clearly defined at the outset of a study so that a reasonable sample of the population can be taken.  For example, if one is studying working-class college students, the sample may include twenty such students attending a particular college, while the population is “working-class college students.”  In quantitative research, clearly defining the general population of interest is a necessary step in generalizing results from a sample.  In qualitative research, defining the population is conceptually important for clarity.

A sampling strategy in which the sample is chosen to represent (numerically) the larger population from which it is drawn by random selection.  Each person in the population has an equal chance of making it into the sample.  This is often done through a lottery or other chance mechanisms (e.g., a random selection of every twelfth name on an alphabetical list of voters).  Also known as random sampling .

The selection of research participants or other data sources based on availability or accessibility, in contrast to purposive sampling .

A sample generated non-randomly by asking participants to help recruit more participants the idea being that a person who fits your sampling criteria probably knows other people with similar criteria.

Broad codes that are assigned to the main issues emerging in the data; identifying themes is often part of initial coding . 

A form of case selection focusing on examples that do not fit the emerging patterns. This allows the researcher to evaluate rival explanations or to define the limitations of their research findings. While disconfirming cases are found (not sought out), researchers should expand their analysis or rethink their theories to include/explain them.

A methodological tradition of inquiry and approach to analyzing qualitative data in which theories emerge from a rigorous and systematic process of induction.  This approach was pioneered by the sociologists Glaser and Strauss (1967).  The elements of theory generated from comparative analysis of data are, first, conceptual categories and their properties and, second, hypotheses or generalized relations among the categories and their properties – “The constant comparing of many groups draws the [researcher’s] attention to their many similarities and differences.  Considering these leads [the researcher] to generate abstract categories and their properties, which, since they emerge from the data, will clearly be important to a theory explaining the kind of behavior under observation.” (36).

The result of probability sampling, in which a sample is chosen to represent (numerically) the larger population from which it is drawn by random selection.  Each person in the population has an equal chance of making it into the random sample.  This is often done through a lottery or other chance mechanisms (e.g., the random selection of every twelfth name on an alphabetical list of voters).  This is typically not required in qualitative research but rather essential for the generalizability of quantitative research.

A form of case selection or purposeful sampling in which cases that are unusual or special in some way are chosen to highlight processes or to illuminate gaps in our knowledge of a phenomenon.   See also extreme case .

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

The accuracy with which results or findings can be transferred to situations or people other than those originally studied.  Qualitative studies generally are unable to use (and are uninterested in) statistical generalizability where the sample population is said to be able to predict or stand in for a larger population of interest.  Instead, qualitative researchers often discuss “theoretical generalizability,” in which the findings of a particular study can shed light on processes and mechanisms that may be at play in other settings.  See also statistical generalization and theoretical generalization .

A term used by IRBs to denote all materials aimed at recruiting participants into a research study (including printed advertisements, scripts, audio or video tapes, or websites).  Copies of this material are required in research protocols submitted to IRB.

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

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In This Article Expand or collapse the "in this article" section Qualitative, Quantitative, and Mixed Methods Research Sampling Strategies

Introduction.

• Sampling Strategies
• Sample Size
• Qualitative Design Considerations
• Discipline Specific and Special Considerations
• Sampling Strategies Unique to Mixed Methods Designs

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Qualitative, Quantitative, and Mixed Methods Research Sampling Strategies by Timothy C. Guetterman LAST MODIFIED: 26 February 2020 DOI: 10.1093/obo/9780199756810-0241

Sampling is a critical, often overlooked aspect of the research process. The importance of sampling extends to the ability to draw accurate inferences, and it is an integral part of qualitative guidelines across research methods. Sampling considerations are important in quantitative and qualitative research when considering a target population and when drawing a sample that will either allow us to generalize (i.e., quantitatively) or go into sufficient depth (i.e., qualitatively). While quantitative research is generally concerned with probability-based approaches, qualitative research typically uses nonprobability purposeful sampling approaches. Scholars generally focus on two major sampling topics: sampling strategies and sample sizes. Or simply, researchers should think about who to include and how many; both of these concerns are key. Mixed methods studies have both qualitative and quantitative sampling considerations. However, mixed methods studies also have unique considerations based on the relationship of quantitative and qualitative research within the study.

Sampling in Qualitative Research

Sampling in qualitative research may be divided into two major areas: overall sampling strategies and issues around sample size. Sampling strategies refers to the process of sampling and how to design a sampling. Qualitative sampling typically follows a nonprobability-based approach, such as purposive or purposeful sampling where participants or other units of analysis are selected intentionally for their ability to provide information to address research questions. Sample size refers to how many participants or other units are needed to address research questions. The methodological literature about sampling tends to fall into these two broad categories, though some articles, chapters, and books cover both concepts. Others have connected sampling to the type of qualitative design that is employed. Additionally, researchers might consider discipline specific sampling issues as much research does tend to operate within disciplinary views and constraints. Scholars in many disciplines have examined sampling around specific topics, research problems, or disciplines and provide guidance to making sampling decisions, such as appropriate strategies and sample size.

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Qualitative Research Sampling Methods: Pros and Cons to Help You Choose

Your choice of sampling strategy can deeply impact your research findings, especially in qualitative studies, where every person counts.

There’s so much written on methods that it can sometimes feel overwhelming when you’re first discovering what’s out there. Even if you’re well into your research career, you may find yourself sticking with the same methodology again and again.

Many researchers focus on quantitative methodology. But they can greatly benefit from knowing qualitative methodology for use in mixed-methods studies and to better understand other studies.

This article aims to help you dive into the most widely recognized qualitative sampling strategies shortly and objectively.

What you ’ ll learn in this post

• All the most common types of qualitative research sampling methods.

• When to use each method.

• Pros and cons of each method.

• Specific examples of these qualitative sampling methods in use.

• Where to get your research both critiqued and edited, be it qualitative, quantitative, or mixed methods.

Your first step in choosing a qualitative sampling strategy

So, where do you start when you know you need to do more than grab students walking by your office? One of the first and most important decisions you must make about your sampling strategy is defining a clear sampling frame .

The cases you choose for your sample need to cover the various issues and variables you want to explore in your research. A fundamental aspect of your sample is that it should always contain the cases most likely to provide you with the richest data (Gray, 2004).

Owing to time and expense, qualitative research often works with small samples of people, cases, or phenomena in particular contexts. Therefore, unlike in quantitative research, samples tend to be more purposive (using your judgment) than they are random (Flick, 2009). This post will cover those main purposive sampling strategies.

It’s also important to keep in mind that qualitative samples are sometimes predetermined ­– what’s known as a priori determination, and other times follow more flexible determination (Flick, 2009).

So this article is organized based on those two parameters: a priori and more flexible determination.

And take note that in certain strategies it’s possible to start with a predetermined sample and end up extending it, or even varying it, for a valid reason.

Qualitative research is much more flexible than quantitative research. You iterate, you run another round, you seek saturation.

OK? Let’s see what’s on the qualitative menu. Hope you find something tasty.

A priori determination

Comprehensive sampling.

Comprehensive (or total population) sampling is a strategy that examines every case or instance of a given population that has specific characteristics (e.g., attributes, traits, experience, knowledge) you’re interested in for your study (Gray, 2004).

This sampling strategy is somewhat unusual because it’s often hard to sample the entire population of interest.

When to use it

It’s ideal for studies that focus on a specific organization or people with such specific characteristics that it’s possible to contact the whole population that has them (Gray, 2004).

Basically, two aspects are key to using this method

• population size being somewhat small
• having uncommon characteristics

One example would be studying perceptions about leadership within a small company (e.g., 10–30 people), where your sample could easily be every employee within the company.

• Ideal for further analyzing, differentiating, and perhaps testing (Flick, 2009).
• It might facilitate confidence in the validity of the results of research that use this method because it covers every case in a given population.
• Reduced risk of missing valuable insights.
• Only applicable to very specific studies because it requires the targeted population to be small and have uncommon characteristics.
• Very limited potential for generalizability.

Practical example: Gerhard (as cited in Flick, 2009, p. 117) used this strategy to study the careers of patients with chronic renal failure. The sample was a complete collection of all patients with predetermined characteristics (male, married, age 30­–50 years, at the start of treatment at five hospitals in the UK).

Note that for this particular study, sampling was limited to several criteria: a specific sex, disease, marital status, age, region, and a limited period.

These predetermined characteristics were what allowed the researchers to achieve a comprehensive (total population) sample.

Extreme/deviant sampling

Extreme/deviant sampling is intentionally selecting extremes and trying to identify the factors that affect them (Gray, 2004).

It’s usually used to focus on special or uncommon cases such as noteworthy successes or failures. For instance, if you’re conducting a study about a reform program, you can include particularly successful examples and/or cases of big failures – these are two extremes, which is where the “extreme/deviant” name comes from (Flick, 2009).

It’s ideal for studying special/unusual cases in a particular context.

• Allows you to collect focused information on a very particular phenomenon.
• It’s sometimes regarded as producing the “purest” form of insight into a particular phenomenon.
• Lets you collect insights from two very distinct perspectives, which will help you get an understanding of the phenomena as a whole.
• The danger of mistakenly generalizing from extreme cases.
• Selection bias

Practical example: Perhaps one of the most widely recognized studies that used this sampling method was Waterman and Peters’ In Search of Excellence: Lessons from America’s Best-Run Companies , published in 1982.

The researchers chose 62 companies based on their outstanding (extreme) success in terms of innovation and excellence (see Peters & Waterman [2004]).

Intensity sampling

Intensity sampling fundamentally involves the same logic as extreme/deviant case sampling, but it has less emphasis on the extremes.

Cases chosen for an intensity sample should be information-rich, manifesting the phenomenon intensely but not extremely; therefore capturing more typical cases compared with those at the extremes (Patton, 2002; Gray, 2004; Benoot, Hannes & Bilsen, 2016).

Patton (2002) argues that ideally, you should use this when you already have prior information about the variation of the subject you want to study. Some exploratory research might be needed depending on what you are researching.

• Great for heuristic research/inquiry (Patton, 2002).
• By choosing intensive cases that aren’t extreme/deviant, you can avoid the distortion that extreme cases sometimes bring (Patton, 2002).
• Involves some prior information and considerable judgment. The researcher must do some exploratory work to grasp the nature of the variation of the specific situation he is researching about (Patton, 2002)
• It requires an extended knowledge of the phenomena being studied to not mix cases that have sufficient intensity with the ones at the extremes (Patton, 2002).

Practical example: Researching above average/below average students would be a time to use this sampling method. This is because they experience the educational system intensely but aren’t extreme cases.

Maximum variation sampling

The maximum variation sampling strategy aims at capturing and describing a wide range of variations and that cut across what you want to research (Patton, 2002; Gray, 2004). How can you proceed to guarantee that you capture a high level of variation?

You can start by setting specific characteristics where you’ll look for variation that the literature (or you) identify as relevant for the phenomenon you’re researching. These may be education level, ethnicity, age, or socioeconomic status.

For small samples, having too much heterogeneity can be a problem because each case may be very different from the other.

But according to Patton (2002), this method might turn that weakness into a strength.

It does so by applying this logic: any common pattern that emerges from this kind of sample is of particular interest and value in capturing the core experiences and central, shared dimensions of a setting or phenomenon.

When to use it: Whenever you want to explore the variation of perceptions/practices concerning a broad phenomenon.

• Allows the researcher to capture all variations of a phenomenon (Patton, 2002; Schreier, 2018).
• Finds detailed insights about each variation (Patton, 2002; Schreier, 2018).
• In small samples, sometimes cases are so different from one another that no common patterns emerge (Patton, 2002).

Practical example: Ziebland et al. (2004) was about how the internet affects patients’ experiences with cancer. It used a maximum variation sample to maximize the variety of insights.

The researchers purposively looked for people that differed in: type of cancer they had, stage of cancer, age, and sex.

Homogenous sampling

The homogenous sampling strategy can be seen as the exact opposite of maximum variation sampling because it seeks homogenous groups of people, settings, or contexts to be studied in-depth.

With this kind of sample, using focus group interviewing might prove extremely productive (Gray, 2004).

Use it if your research aims to specifically focus on a group with shared characteristics.

• Produces highly detailed insights regarding a specific group (Patton, 2002).
• Highly compatible with focus group interviews (Patton, 2002).
• Can simplify the analysis (Patton, 2002).
• Doesn’t let the researcher capture much variation (Patton, 2002).

Practical example: Nestbitt et al. (2012) was a study about Canadian adolescent mothers’ perceptions of influences on breastfeeding decisions. The researchers purposefully collected 16 homogenous cases of adolescent mothers (15­–19 years) that lived in the Durham region and had children up to 12 months old.

Other criteria included speaking English fluently and breastfeeding their infant at least once.

The aim of the researchers by using this method was to produce an in-depth look at this very specific group.

Theory-based sampling

Theory-based sampling is basically a more formal type of criterion sampling, it’s more conceptually oriented, and the cases are chosen on the basis that they represent a theoretical construct (Patton, 2002; Gray, 2004).

The researcher samples incidents, periods of someone’s life, time periods, or people based on the potential manifestation or representation of important theoretical constructs.

Use this one when you want to study a pre-existing theory-derived concept that is of interest to your research.

• Elaborating on previous theoretical and established concepts can facilitate the analysis.
• Working on established theoretical concepts allows you to contribute new insights for an established theory.
• The odds of finding out something entirely “new” are somewhat limited.
• It might be harder to determine the population of interest because it’s hard to find people, programs, organizations, or communities of interest to a specific theoretical construct. This is unlike what happens when sampling based on determined people’s characteristics (Patton, 2002).

Practical example: Buckhold (as cited in Patton [2002, p. 238]) researched people who met specific theory-derived criteria for being “resilient.” She aimed to analyze the resilience of women who were victims of abuse and were able to survive.

Stratified purposive sampling

In stratified purposive sampling, decisions about the sample’s composition are made before data collection .

Schreier (2018) notes that it can be done in four steps:

• Deciding which factors are known or likely to cause variation in the phenomenon of interest.
• Selecting from two to a maximum of four factors for constructing a sampling guide.
• Combining the factors of choice in a cross-table, though when picking more than two factors, it might be impossible to conduct sampling for all factor combinations.
• Deciding on how many units for each cell/or factor combination.

Use this method when you want to explore known factors that influence the phenomenon of your interest.

These might be hypothesized in theory while having no empirical data supporting them. You can also purpose a factor and by including it on your sampling you might grasp its importance regarding the phenomena you’re researching.

• Allows you to focus on several known factors that of interest for your research (Schreier, 2018).
• Predetermining the composition of your sample might facilitate finding the cases/people/groups to research.
• Sticking to the predetermined composition might have trouble with new factors discovered from your first cases that are left unresearched.
• Finding the cases with the factors that are of most interest for your research might be challenging.

Practical example: Palacic (2017) examined entrepreneurial leadership and business performance in “gazelles” and “MICE” (business/market terms to describe a type of company). The sample was purposively constituted to contain cases from both types of companies that were involved in three major industrial sectors – manufacturing, sales, and services.

More flexible determination

Theoretical sampling.

Theoretical sampling was developed in the context of grounded theory methodology.

Fundamentally, it’s a process of data collection that aims to generate theory. It takes place in a constant interrelation between data collection and data analysis, and it’s guided by the concepts and/or theory emerging from the research process (Gray, 2004; Flick, 2009).

The sample is usually composed of heterogeneous cases that allow comparison of different instantiations (Schreier, 2018).

You can use this when you’re aiming to generate a new theory about a certain phenomenon.

• May bring more innovation to your research (Schreier, 2018).
• Your sample is more flexible compared with many other methods because there are no “static” criteria for your sample’s population.
• Not ideal for inexperienced researchers because generating a new theory is very challenging.
• Very time-consuming and complex.

Practical example: Glaser and Strauss (as cited in Flick, 2009, pp. 118–119) famously used this method to research awareness of dying in hospitals.

The researchers chose to conduct participant observation in different hospitals to develop a new theory about the way dying in a hospital is organized as a social process.

They built their sample through a step-by-step process while in direct contact with the field. First they studied awareness of dying in conditions that minimized patient awareness (e.g., comatose). Then they moved to situations where staff’s and patients’ awareness was high and death often was quick (e.g., intensive care). Then to situations where staff expectations of terminality were high, but dying tended to be slow (e.g., cancer). And ultimately to situations where death was unforeseen and rapid (e.g., emergency services).

Snowball sampling

Snowball sampling (or, chain referral sampling) is a method widely used in qualitative sociological research (Biernacki & Waldorf, 1981; Gray, 2004; Flick, 2009; Heckathorn, 2011). It’s used a lot because it’s effective at getting numbers. It’s premised on the idea that people know people similar to themselves.

Snowballing especially useful for studying hard-to-reach populations. Snowball sampling has been most applicable in studies where the focus relies on a sensitive issue, something that might be a private matter that requires knowing insiders so you can locate, contact, and receive consent from the true target population (Biernacki & Waldorf, 1981; Heckathorn, 2011).

The researcher forms a study sample through referrals made among people who are acquainted with others who have the characteristics of interest for the research. It begins through a convenience sample of someone of a hard-to-reach population.

After successfully interviewing/communicating with this person, the researcher will ask them to introduce other people with the same characteristics. After acquiring contacts, the research proceeds in the same way (Heckathorn, 2011).

As hard-to-reach groups are, well, hard to reach, snowball sampling is effective when you need an inroad and cannot easily recruit and sample.

• Ideal for studying hard-to-reach groups (Biernacki & Waldorf, 1981; Gray, 2004; Flick, 2009; Heckathorn, 2011).
• Able to produce highly detailed insights regarding a specific group through the sampling of, in principle, information-rich cases (Patton, 2002).
• If the researcher is studying a topic that involves moral, legal, or socially sensitive issues (e.g., prostitution, drug addiction) and does not know anyone from this group, it might be hard to start the first “chain” that bring in more recruits.
• Very limited generalization potential.

Practical example: Cloud and Granfield (1994) used snowball sampling to study drug and alcohol addicts who beat their addictions without resorting to a treatment.

Using the snowballing method was fundamental to the authors because they were researching a widely distributed population (unlike those who participate in self-help groups or in treatment), and because the participants did not wish to expose their past as former drug addicts (i.e., sensitive issue).

Convenience sampling

Convenience sampling is a strategy that involves simply choosing cases in a way that is fast and convenient.

It’s probably the most common sampling strategy and, according to Patton (2002), the least desirable because it can’t be regarded as purposeful or strategic.

Many researchers choose this method thinking that their sample size is too small to generalize anyway, so they might as well pick cases that are easy to access and inexpensive to study (Patton, 2002).

This is a very common strategy among master’s students ­– asking fellow students to be part of the sample of their dissertation. That’s convenience sampling (Schreier, 2018). Also notable is that online surveying makes convenience sampling even simpler, beyond geographic limitations.

When you have few resources (mainly time and money) for your qualitative research, this is the go-to method. This is why so many studies are conducted on university students – they’re literally all over the place, whether you’re a student or researcher. As students, they’re also easier to incentivize with small compensation and they often are in the same boat.

• Saves time, money, and effort (Patton, 2002).
• Might be optimal for unfinanced and strictly timed qualitative research (often in master’s theses and in many doctoral dissertations).
• Something of a “bad reputation” (Schreier, 2018).
• Lowest credibility (Patton, 2002).
• Might yield information-poor cases (Patton, 2002).

Practical example: Augusto and Simões (2017) used a convenience sampling strategy to capture perceptions and prevention strategies on Facebook surveillance.

As the original fieldwork was part of a master’s dissertation, convenience sampling was chosen because of the main author’s limited time and resources. This is in no way to discredit the study and findings – it was simply the most feasible way to get the research done.

Confirming and disconfirming cases

Confirming and disconfirming cases is frequently a second-stage sampling strategy.

Cases are chosen on the premise that they can confirm or disconfirm emerging patterns from the first stage of sampling (Gray, 2004).

After an exploratory process, one might consider testing ideas, confirming the importance and/or meaning of eventual patterns, and ultimately the viability of the findings through collecting new data and/or sampling additional cases (Patton, 2002).

As the name indicates, generally, it’s ideal for testing emergent findings from your data.

• Strengthens emergent findings.
• Allows you to identify possible “exceptions that prove the rule” or exceptions that might disconfirm a finding (Patton, 2002).
• Usually requires a “first stage” of sampling.
• While definitely useful, one can certainly make an argument about quantitative research being better able to test certain findings.

Practical example: If you were researching students’ motives for applying for college, and on the first interviews you found out the interviewees’ main reason for pursuing their education was to avoid having a routine day-job, this might be a good sampling method to use. The findings, however, would have to carefully look at trends and check for outliers.

So, how’s your research going?

Here’s hoping you find the right qualitative sampling method(s) that work for you. Putting this together was a lesson for me as well.

And when you’re ready for a professional edit or scientific review, check out Edanz’s author-guidance services , which have been leading the way since 1995. Good luck with your research!

This is a guest post from Adam Goulston, PsyD, MBA, MS, MISD, ELS. Adam runs science marketing firm Scize and has worked an in-house Senior Language Editor, as well as a manuscript editor, with Edanz.

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Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research

• Original Article
• Published: 06 November 2013
• Volume 42 , pages 533–544, ( 2015 )

Cite this article

• Lawrence A. Palinkas 1 ,
• Sarah M. Horwitz 2 ,
• Carla A. Green 3 ,
• Jennifer P. Wisdom 4 ,
• Naihua Duan 5 &
• Kimberly Hoagwood 2  

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Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest. Although there are several different purposeful sampling strategies, criterion sampling appears to be used most commonly in implementation research. However, combining sampling strategies may be more appropriate to the aims of implementation research and more consistent with recent developments in quantitative methods. This paper reviews the principles and practice of purposeful sampling in implementation research, summarizes types and categories of purposeful sampling strategies and provides a set of recommendations for use of single strategy or multistage strategy designs, particularly for state implementation research.

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Optimal Design and Purposeful Sampling: Complementary Methodologies for Implementation Research

Naihua Duan, Dulal K. Bhaumik, … Kimberly Hoagwood

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Acknowledgments

This study was funded through a Grant from the National Institute of Mental Health (P30-MH090322: K. Hoagwood, PI).

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School of Social Work, University of Southern California, 669 W. 34th Street, Los Angeles, CA, 90089-0411, USA

Lawrence A. Palinkas

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Sarah M. Horwitz & Kimberly Hoagwood

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Carla A. Green

George Washington University, Washington, DC, USA

Jennifer P. Wisdom

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Palinkas, L.A., Horwitz, S.M., Green, C.A. et al. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health 42 , 533–544 (2015). https://doi.org/10.1007/s10488-013-0528-y

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10 17. Qualitative data and sampling

Chapter outline.

• Ethical responsibility and cultural respectfulness (7 minute read)
• Critical considerations (8 minute read)
• Find the right qualitative data to answer my research question (17 minute read)
• How to gather a qualitative sample (21 minute read)
• What should my sample look like? (9 minute read)

Content warning: examples in this chapter contain references to substance use, ageism, injustices against the Black community in research (e.g. Henrietta Lacks and Tuskegee Syphillis Study), children and their educational experiences, mental health, research bias, job loss and business closure, mobility limitations, politics, media portrayals of LatinX families, labor protests, neighborhood crime, Batten Disease (childhood disorder), transgender youth, cancer, child welfare including kinship care and foster care, Planned Parenthood, trauma and resilience, sexual health behaviors.

Now let’s change things up! In the previous chapters, we were exploring steps to create and carry out a quantitative research study. Quantitative studies are great when we want to summarize data and examine or test relationships between ideas using numbers and the power of statistics. However, qualitative research offers us a different and equally important tool. Sometimes the aim of research is to explore meaning and experience. If these are the goals of our research proposal, we are going to turn to qualitative research. Qualitative research relies on the power of human expression through words, pictures, movies, performance and other artifacts that represent these things. All of these tell stories about the human experience and we want to learn from them and have them be represented in our research. Generally speaking, qualitative research is about the gathering up of these stories, breaking them into pieces so we can examine the ideas that make them up, and putting them back together in a way that allows us to tell a common or shared story that responds to our research question. Back in Chapter 7 we talked about different paradigms.

Before plunging further into our exploration of qualitative research, I would like to suggest that we begin by thinking about some ethical, cultural and empowerment-related considerations as you plan your proposal. This is by no means a comprehensive discussion of these topics as they relate to qualitative research, but my intention is to have you think about a few issues that are relevant at each step of the qualitative process. I will begin each of our qualitative chapters with some discussion about these topics as they relate to each of these steps in the research process. These sections are specially situated at the beginning of the chapters so that you can consider how these principles apply throughout the proceeding discussion. At the end of this chapter there will be an opportunity to reflect on these areas as they apply specifically to your proposal. Now, we have already discussed research ethics back in Chapter 8 . However, as qualitative researchers we have some unique ethical commitments to participants and to the communities that they represent. Our work as qualitative researchers often requires us to represent the experiences of others, which also means that we need to be especially attentive to how culture is reflected in our research. Cultural respectfulness suggests that we approach our work and our participants with a sense of humility. This means that we maintain an open mind, a desire to learn about the cultural context of participants’ lives, and that we preserve the integrity of this context as we share our findings.

17.1 Ethical responsibility and cultural respectfulness

Learning objectives.

Learners will be able to…

• Explain how our ethical responsibilities as researchers translate into decisions regarding qualitative sampling
• Summarize how aspects of culture and identity may influence recruitment for qualitative studies

Representation

Representation reflects two important aspects of our work as qualitative researchers, who is present and how are they presented. First, we need to consider who we are including or excluding in or sample. Recruitment and sampling is especially tied to our ethical mandate as researchers to uphold the principle of justice under the Belmont Report [1] (see Chapter 6   for additional information). Within this context we need to:

• Assure there is fair distribution of risks and benefits related to our research
• Be conscientious in our recruitment efforts to support equitable representation
• Ensure that special protections to vulnerable groups involved in research activities are in place

As you plan your qualitative research study, make sure to consider who is invited and able to participate and who is not. These choices have important implications for your findings and how well your results reflect the population you are seeking to represent. There may be explicit exclusions that don’t allow certain people to participate, but there may also be unintended reasons people are excluded (e.g. transportation, language barriers, access to technology, lack of time).

The second part of representation has to do with how we disseminate our findings and how this reflects on the population we are studying. We will speak further about this aspect of representation in Chapter 21 , which is specific to qualitative research dissemination. For now, it is enough to know that we need to be thoughtful about who we attempt to recruit and how effectively our resultant sample reflects our population.

Being mindful of history

As you plan for the recruitment of your sample, be mindful of the history of how this group (and/or the individuals you may be interacting with) has been treated – not just by the research community, but by others in positions of power. As researchers, we usually represent an outside influence and the people we are seeking to recruit may have significant reservations about trusting us and being willing to participate in our study (often grounded in good historical reasons—see Chapter 6 for additional information). Because of this, be very intentional in your efforts to be transparent about the purpose of your research and what it involves, why it is important to you, as well as how it can impact the community. Also, in helping to address this history, we need to make concerted efforts to get to know the communities that we research with well, including what is important to them.

Stories as sacred: How are we requesting them?

Finally, it is worth pointing out that as qualitative researchers, we have an extra layer of ethical and cultural responsibility. While quantitative research deals with numbers, as qualitative researchers, we are generally asking people to share their stories. Stories are intimate, full of depth and meaning, and can reveal tremendous amounts about who we are and what makes us tick. Because of this, we need to take special care to treat these stories as sacred. I will come back to this point in subsequent chapters, but as we go about asking for people to share their stories, we need to do so humbly.

Key Takeaways

• As researchers, we need to consider how our participant communities have been treated historically, how we are representing them in the present through our research, and the implications this representation could have (intended and unintended) for their lives. We need to treat research participants and their stories with respect and humility.
• When conducting qualitative research, we are asking people to share their stories with us. These “data” are personal, intimate, and often reflect the very essence of who our participants are. As researchers, we need to treat  research participants and their stories with respect and humility.

17.2 Critical considerations

• Assess dynamics of power in sampling design and recruitment for individual participants and participant communities
• Create opportunities for empowerment through early choice points in key research design elements

Related to the previous discussion regarding being mindful of history, we also need to consider the current dynamics of power between researcher and potential participant. While we may not always recognize or feel like we are in a position of power, as researchers we hold specialized knowledge, a particular skill set, and what we do can with the data we collect can have important implications and consequences for individuals, groups, and communities. All of these contribute to the formation of a role ascribed with power. It is important for us to consider how this power is perceived and whenever possible, how we can build opportunities for empowerment that can be built into our research design. Examples of some strategies include:

• Recruiting and meeting in spaces that are culturally acceptable
• Finding ways to build participant choice into the research process
• Working with a community advisory group during the research process (explained further in the example box below)
• Designing informative and educational materials that help to thoroughly explain the research process in meaningful ways
• Regularly checking with participants for understanding
• Asking participants what they would like to get out of their participation and what it has been like to participate in our research
• Determining if there are ways that we can contribute back to communities beyond our research (developing an ongoing commitment to collaboration and reciprocity)

While it may be beyond the scope of a student research project to address all of these considerations, I do think it is important that we start thinking about these more in our research practices. As social work researchers, we should be modeling empowerment practices in the field of social science research, but we often fail to meet this standard.

Example. A community advisory group can be a tremendous asset throughout our research process, but especially in early stages of planning, including recruitment. I was fortunate enough to have a community advisory group for one of the projects I worked on. They were incredibly helpful as I considered different perspectives I needed to include in my study, helping me to think through a respectful way to approach recruitment, and how we might make the research arrangement a bit more reciprocal so community members might benefit as well.

Intersectional identity

As qualitative researchers, we are often not looking to prove a hypothesis or uncover facts. Instead, we are generally seeking to expand our understanding of the breadth and depth of human experience. Breadth is reflected as we seek to uncover variation across participants and depth captures variation or detail within each participants’ story. Both are important for generating the fullest picture possible for our findings. For example, we might be interested in learning about people’s experience living in an assisted living facility by interviewing residents. We would want to capture a range of different residents’ experiences (breadth) and for each resident, we would seek as much detail as possible (depth). Do note, sometimes our research may only involve one person, such as in a case study . However, in these instances we are usually trying to understand many aspects or dimensions of that single case.

To capture this breadth and depth we need to remember that people are made of multiple stories formed by intersectional identities . This means that our participants never just represent one homogeneous social group. We need to consider the various aspects of our population that will help to give the most complete representation in our sample as we go about recruitment.

Identify a population you are interested in studying. This might be a population you are working with at your field placement (either directly or indirectly), a group you are especially interested in learning more about, or a community you want to serve in the future. As you formulate your question, you may draw your sample directly from clients that are being served, others in their support network, service providers that are providing services, or other stakeholders that might be invested in the well-being of this group or community. Below, list out two populations you are interested in studying and then for each one, think about two groups connected with this population that you might focus your study on.

Next, think about what would kind of information might help you understand this group better. If you had the chance to sit down and talk with them, what kinds of things would you want to ask? What kinds of things would help you understand their perspective or their worldview more clearly? What kinds of things do we need to learn from them and their experiences that could help us to be better social workers? For each of the groups you identified above, write out something you would like to learn from their experience.

Finally, consider how this group might perceive a request to participate. For the populations and the groups that you have identified, think about the following questions:

• How have these groups been represented in the news?
• How have these groups been represented in popular culture and popular media?
• What historical or contemporary factors might influence these group members’ opinions of research and researchers?
• In what ways have these groups been oppressed and how might research or academic institutions have contributed to this oppression?

Our impact on the qualitative process

It is important for qualitative research to thoughtfully plan for and attempt to capture our own impact on the research process. This influence that we can have on the research process represents what is known as researcher bias . This requires that we consider how we, as human beings, influence the research we conduct. This starts at the very beginning of the research process, including how we go about sampling. Our choices throughout the research process are driven by our unique values, experiences, and existing knowledge of how the world works. To help capture this contribution, qualitative researchers may plan to use tools like a reflexive journal , which is a research journal that helps the researcher to reflect on and consider their thoughts and reactions to the research process and how these may influence or shape a study (there will be more about this tool in Chapter 20 when we discuss the concept of rigor ). While this tool is not specific to the sampling process, the next few chapters will suggest reflexive journal questions to help you think through how it might be used as you develop a qualitative proposal.

Example. To help demonstrate the potential for researcher bias, consider a number of students that I work with who are placed in school systems for their field experience and choose to focus their research proposal in this area. Some are interested in understanding why parents or guardians aren’t more involved in their children’s educational experience. While this might be an interesting topic, I would encourage students to consider what kind of biases they might have around this issue.

• What expectations do they have about parenting?
• What values do they attach to education and how it should be supported in the home?
• How has their own upbringing shaped their expectations?
• What do they know about the families that the school district serves and how did they come by this information?
• How are these families’ life experiences different from their own?

The answers to these questions may unconsciously shape the early design of the study, including the research question they ask and the sources of data they seek out. For instance, their study may only focus on the behaviors and the inclinations of the families, but do little to investigate the role that the school plays in engagement and other structural barriers that might exist (e.g. language, stigma, accessibility, child-care, financial constraints, etc.).

• As researchers, we wield (sometimes subtle) power and we need to be conscientious of how we use and distribute this power.
• Qualitative study findings represent complex human experiences. As good as we may be, we are only going to capture a relatively small window into these experiences (and need to be mindful of this when discussing our findings).

In the early stages of your research process, it is a good idea to start your reflexive journal . Starting a reflexive journal is as easy as opening up a new word document, titling it and chronologically dating your entries. If you are more tactile-oriented, you can also keep your reflexive journal in paper bound journal.

To prompt your initial entry, put your thoughts down in response to the following questions:

• What led you to be interested in this topic?
• What experience(s) do you have in this area?
• What knowledge do you have about this issue and how did you come by this knowledge?
• In what ways might you be biased about this topic?

Don’t answer this last question too hastily! Our initial reaction is often—”Biased!?! Me—I don’t have a biased bone in my body! I have an open-mind about everything, toward everyone!” After all, much of our social work training directs us towards acceptance and working to understand the perspectives of others. However, WE ALL HAVE BIASES . These are conscious or subconscious preferences that lead us to favor some things over others. These preferences influence the choices we make throughout the research process. The reflexive journal helps us to reflect on these preferences, where they might stem from, and how they might be influencing our research process. For instance, I conduct research in the area of mental health. Before I became a researcher, I was a mental health clinician, and my years as a mental health practitioner created biases for me that influence my approach to research. For instance, I may be biased in perceiving mental health services as being well-intentioned and helpful. However, participants may well have very different perceptions based on their experiences or beliefs (or those of their loved ones).

17.3 Finding the right qualitative data to answer my research question

• Compare different types of qualitative data
• Begin to formulate decisions as they build their qualitative research proposal, specially in regards to selecting types of data that can effectively answer their research question

Sampling starts with deciding on the type of data you will be using. Qualitative research may use data from a variety of sources. Sources of qualitative data may come from interviews or focus groups , observations , a review of written documents, administrative data, or other forms of media, and performances. While some qualitative studies rely solely on one source of data, others incorporate a variety.

You should now be well acquainted with the term triangulation . When thinking about triangulation in qualitative research, we are often referring to our use of multiple sources of data among those listed above to help strengthen the confidence we have in our findings. Drawing on a journalism metaphor, this allows us to “fact check” our data to help ensure that we are getting the story correct. This can mean that we use one type of data (like interviews), but we intentionally plan to get a diverse range of perspectives from people we know will see things differently. In this case we are using triangulation of perspectives. In addition, we may also you a variety of different types of data, like including interviews, data from case records, and staff meeting minutes all as data sources in the same study. This reflects triangulation through types of data.

As a student conducting research, you may not always have access to vulnerable groups or communities in need, or it may be unreasonable for you to collect data from them directly due to time, resource, or knowledge constraints. Because of this, as you are reviewing the sections below, think about accessible alternative sources of data that will still allow you to answer your research question practically, and I will provide some examples along the way to get you started. In the above example, local media coverage might be a means of obtaining data that does not involve vulnerable directly collecting data from potentially vulnerable participants.

Verbal data

Perhaps the bread an d butter of t he qualitative researche r, we often rely on what people  tell us as a primary source of information for qualitative studies in the form of verbal data. The researcher who schedules interviews with recipients of public assistance to capture their experience after legislation drastically changes requirements for benefits relies on the communication between the researcher and the impacted recipients of public assistance. Focus groups are another frequently used method of gathering verbal data. Focus groups bring together a group of participants to discuss their unique perspectives and explore commonalities on a given topic. One such example is a researcher who brings together a group of child welfare workers who have been in the field for one to two years to ask them questions regarding their preparation, experiences, and perceptions regarding their work. 

A benefit of utilizing verbal data is that it offers an opportunity for researchers to hear directly from participants about their experiences, opinions, or understanding of a given topic. Of course, this requires that participants be willing to share this information with a researcher and that the information shared is genuine. If groups of participants are unwilling to participate in sharing verbal data or if participants share information that somehow misrepresents their feelings (perhaps because they feel intimidated by the research process), then our qualitative sample can become biased and lead to inaccurate or partially accurate findings.

As noted above, participant willingness and honesty can present challenges for qualitative researchers. You may face similar challenges as a student gathering verbal data directly from participants who have been personally affected by your research topic. Because of this, you might want to gather verbal data from other sources. Many of the students I work with are placed in schools. It is not feasible for them to interview the youth they work with directly, so frequently they will interview other professionals in the school, such as teachers, counselors, administration, and other staff. You might also consider interviewing other social work students about their perceptions or experiences working with a particular g roup. 

Again, because it may be problematic or unrealistic for you to obtain verbal data directly from vulnerable groups as a student researcher, you might consider gathering verbal data from the following sources:

• Interviews and focus groups with providers, social work students, faculty, the general public, administrators, local politicians, advocacy groups
• Public blogs of people invested in your topic
• Publicly available transcripts from interviews with experts in the area or people reporting experiences in popular media

Make sure to consult with your professor to ensure that what you are planning will be realistic for the purposes of your study.

Observational data

As researcher s, we sometimes rely on our own powers of observation to gather data on a particular topic. We may observe a person’s behavior, an interaction, setting, context, and maybe even our own reactions to what we are observing (i.e. what we are thinking or feeling). When observational data is used for quantitative purposes, it involves a count, such as how many times a certain behavior occurs for a child in a classroom. However, when observational data is used for qualitative purposes, it involves the researcher providing a detailed description. For instance, a qualitative researcher may conduct observations of how mothers and children interact in child and adolescent cancer units, and take notes about where exchanges take place, topics of conversation, nonverbal information, and data about the setting itself – what the unit looks like, how it is arranged, the lighting, photos on the wall, etc.

Observational data can provide important contextual information that may not be captured when we rely solely on verbal data. However, using this form of data requires us, as researchers, to correctly observe and interpret what is going on. As we don’t have direct access to what participants may be thinking or feeling to aid us (which can lead us to misinterpret or create a biased representation of what we are observing), our take on this situation may vary drastically from that of another person observing the same thing. For instance, if we observe two people talking and one begins crying, how do we know if these are tears of joy or sorrow? When you observe someone being abrupt in a conversation, I might interpret that as the person being rude while you might perceive that the person is distracted or preoccupied with something. The point is, we can’t know for sure. Perhaps one of the most challenging aspects of gathering observational data is collecting neutral, objective observations, that are not laden with our subjective value judgments placed on them. Students often find this out in class during one of our activities. For this activity, they have to go out to public space and write down observations about what they observe. When they bring them back to class and we start discussing them together, we quickly realize how often we make (unfounded) judgments. Frequent examples from our class include determining the race/ethnicity of people they observe or the relationships between people, without any confirmational knowledge. Additionally, they often describe scenarios with adverbs and adjectives that often reflect judgments and values they are placing on their data. I’m not sharing this to call them out, in fact, they do a great job with the assignment. I just want to demonstrate that as human beings, we are often less objective than we think we are! These are great examples of research bias.

Again, gaining access to observational spaces, especially private ones, might be a challenge for you as a student. As such, you might consider if observing public spaces might be an option. If you do opt for this, make sure you are not violating anyone’s right to privacy. For instance, gathering information in a narcotics anonymous meeting or a religious celebration might be perceived as offensive, invasive or in direct opposition to values (like anonymity) of participants. When making observations in public spaces be careful not to gather any information that might identify specific individuals or organizations. Also, it is important to consider the influence your presence may have on a community, particularly if your observation makes you stand out among those typically present in that setting. Always consider the needs of the individual and the communities in formulating a plan for observing public behavior. Public spaces might include commercial spaces or events open to the public as well as municipal parks. Below we will have an expanded discussion about different varieties of non-probability sampling strategies that apply to qualitative research. Recruiting in public spaces like these may work for strategies such as convenience sampling or quota sampling , but would not be a good choice for snowball sampling or purposive sampling .

As with the cautionary note for student researchers under verbal data, you may experience restricted access to spaces in which you are able to gather observational data. However, if you do determine that observational data might be a good fit for your student proposal, you might consider the following spaces:

• Shopping malls
• Public parks or beaches
• Public meetings or rallies
• Public transportation

Artifacts (documents & other media)

Existing artifacts can also be very useful for the qualitative researcher. Examples include newspapers, blogs, websites, podcasts, television shows, movies, pictures, video recordings, artwork, and live performances. While many of these sources may provide indirect information on a topic, this information can still be quite valuable in capturing the sentiment of popular culture and thereby help researchers enhance their understanding of (dominant) societal values and opinions. Conversely, researchers can intentionally choose to seek out divergent, unique or controversial perspectives by searching for artifacts that tend to take up positions that differ from the mainstream, such as independent publications and (electronic) newsletters. While we will explore this further below, it is important to understand that data and research, in all its forms, is political. Among many other purposes, it is used to create, critique, and change policy; to engage in activism; to support and refute how organizations function; and to sway public opinion.

When utilizing documents and other media as artifacts, researchers may choose to use an entire source (such as a book or movie), or they may use a segment or portion of that artifact (such as the front-page stories from newspapers, or specific scenes in a television series). Your choice of which artifacts you choose to include will be driven by your question, and remember, you want your sample of artifacts to reflect the diversity of perspectives that may exist in the population you are interested in. For instance, perhaps I am interested in studying how various forms of media portray substance use treatment. I might intentionally include a range of liberal to conservative views that are portrayed across a number of media sources.

As qualitative researchers using artifacts, we often need to do some digging to understand the context of said artifact. We do this because data is almost always affiliated or aligned with some position (again, data is political). To help us consider this, it may be helpful to reflect on the following questions:

• Who owns the artifact or where is it housed
• What values does the owner (organization or person) hold
• How might the position or identity of the owner influence what information is shared or how it is portrayed
• What is the purpose of the artifact
• Who is the audience for which the artifact is intended

Answers to questions such as these can help us to b etter under stand and give meaning to the content of the artifacts. Content is the substance of the artifact (e.g. the wor ds, picture, scene). While c ontext is the circumstances surrounding content. Both work together to help provide meaning, and further understanding of what can be derived from an artifact. As an example to illustrate this point, let’s say that you are including meeting minutes from an organizing network as a source of data for your study. The narrative description in these minutes will certainly be important, however, they may not tell the whole story. For instance, you might not know from the text that the organization has recently voted in a new president and this has created significant division within the network. Knowing this information might help you to interpret the agenda and the discussion contained in the minutes very differently. 

As student researchers, using documents and other artifacts may be a particularly appealing source of data for your study. This is because this data already exists (you aren’t creating new data) and depending on what you select, it might be relatively easy to access. Examples of utilizing existing artifacts might include studying the cultural context of movie portrayals of Latinx families or analyzing publicly available town hall meeting minutes to explore expressions of social capital. Below is a list of sources of data from documents or other media sources to consider for your student proposal:

• Movies or TV shows
• Music or music videos
• Public blogs
• Policies or other organizational documents
• Meeting minutes
• Comments in online forums
• Books, newspapers, magazines, or other print/virtual text-based materials
• Recruitment, training, or educational materials
• Musical or artistic expressions

Finally, Photovoice is a technique that merges pictures with narrative (word or voice) data that helps interpret the meaning or significance of the visual. Photovoice is often used for qualitative work that is conducted as part of Community Based Participatory Research (CBPR), wherein community members act as both participants and as co-researchers. These community members are provided with a means of capturing images that reflect their understanding of some topic, prompt or question, and then they are asked to provide a narrative description or interpretation to help give meaning to the image(s). Both the visual and n arrative information are used as qualitative data to include in the study. Dissemination of Photovoice projects often involve a public display of the works, such as through a demonstration or art exhibition to raise awareness or to produce some specific change that is desired by participants. Because this form of study is often intentionally persuasive in nature, we need to recognize that this form of data will be inherently subjective. As a student, it may be particularly challenging to implement a Photovoice project, especially due to its time-intensive nature, as well as the additional commitments of needing to engage, train, and collaborate with community partners.

How many kinds of data?

You will need to consider whether you will rely on one kind of data or multiple. While many qualitative studies solely use one type of data, such as interviews or focus groups, others may use multiple sources. The decision to use multiple sources is often made to help strengthen the confidence we have in our findings or to help us to produce a richer, more detailed description of our results. For instance, if we are conducting a case study of what the family experience is for a child with a very rare disorder like Batten Disease , we may use multiple sources of data. These can include observing family and community interactions, conducting interviews with family members and others connected to the family (such as service providers,) and examining journal entries families were asked to keep over the course of the study. By collecting data from a variety of sources such as this, we can more broadly represent a range of perspectives when answering our research question, which will hopefully provide a more holistic picture of the family experience. However, if we are trying to examine the decision-making processes of adult protective workers, it may make the most sense to rely on just one type of data, such as interviews with adult protective workers. 

• There are numerous types of qualitative data (verbal, observational, artifacts) that we may be able to access when planning a qualitative study. As we plan, we need to consider the strengths and challenges that each possess and how well each type might answer our research question.
• The use of multiple types of qualitative data does add complexity to a study, but this complication may well be worth it to help us explore multiple dimensions of our topic and thereby enrich our findings.

Reflexive Journal Entry Prompt

For your next entry, consider responding to the following:

• What types of data appeal to you?
• Why do you think you are drawn to them?
• How well does this type of data “fit” as a means of answering your question? Why?

17.4 How to gather a qualitative sample

• Compare and contrast various non-probability sampling approaches
• Select a sampling strategy that ideologically fits the research question and is practical/actionable

Before we launch into how to plan our sample, I’m going to take a brief moment to remind us of the philosophical basis surrounding the purpose of qualitative research—not to punish you, but because it has important implications for sampling.

Nomothetic vs. idiographic

As a quick reminder, as we discussed in Chapter 8   idiographic research aims to develop a rich or deep understanding of the individual or the few. The focus is on capturing the uniqueness of a smaller sample in a comprehensive manner. For example, an idiographic study might be a good approach for a case study examining the experiences of a transgender youth and her family living in a rural Midwestern state. Data for this idiographic study would be collected from a range of sources, including interviews with family members, observations of family interactions at home and in the community, a focus group with the youth and her friend group, another focus group with the mother and her social network, etc. The aim would be to gain a very holistic picture of this family’s experiences.

On the other hand, nomothetic research is invested in trying to uncover what is ‘true’ for many. It seeks to develop a general understanding of a very specific relationship between variables. The aim is to produce generalizable findings, or findings that apply to a large group of people. This is done by gathering a large sample and looking at a limited or restricted number of aspects. A nomothetic study might involve a national survey of heath care providers in which thousands of providers are surveyed regarding their current knowledge and comp etence in treating transgender individuals. It would gather data from a very large number of people, and attempt to highlight some general findings across this population on a very focused topic.

Idiographic and nomothetic research represent two different research categories existing at opposite extremes on a continuum.  Qualitative research generally exists on the idiographic end of this continuum. We are most often seeking to obtain a rich, deep, detailed understanding from a relatively small group of people.

Non-probability sampling

Non-probability sampling refers to sampling techniques for which a person’s (or event’s) likelihood of being selected for membership in the sample is unknown. Because we don’t know the likelihood of selection, we don’t know whether a sample represents a larger population or not. But that’s okay, because representing the population is not the goal of nonprobability samples. That said, the fact that nonprobability samples do not represent a larger population does not mean that they are drawn arbitrarily or without any specific purpose in mind. We typically use nonprobability samples in research projects that are qualitative in nature. We will examine several types of nonprobability samples. These include purposive samples, snowball samples, quota samples, and convenience samples.

Convenience or availability

Convenience sampling, also known as availability sampling, is a nonprobability sampling strategy that is employed by both qualitative and quantitative researchers. To draw a convenience sample, we would simply collect data from those people or other relevant elements to which we have the most convenient access. While convenience samples offer one major benefit—convenience—we should be cautious about generalizing from research that relies on convenience samples because we have no confidence that the sample is representative of a broader population. If you are a social work student who needs to conduct a research project at your field placement setting and you decide to conduct a focus group with the staff at your agency, you are using a convenience sampling approach – you are recruiting participants that are easily accessible to you. In addition, if you elect to analyze existing data that your social work program has collected as part of their graduation exit surveys, you are using data that you readily have access to for your project; again, you have a convenience sample. The vast majority of students I work with on their proposal design rely on convenience data due to time constraints and limited resources.

To draw a purposive sample, we begin with specific perspectives or purposive criteria in mind that we want to examine. We would then seek out research participants who cover that full range of perspectives. For example, if you are studying mental health supports on your campus, you may want to be sure to include not only students, but mental health practitioners and student affairs administrators as well. You might also select students who currently use mental health supports, those who dropped out of supports, and those who are waiting to receive supports. The “purposive” part of purposive sampling comes from selecting specific participants on purpose because you already know they have certain characteristics—being an administrator, dropping out of mental health supports, for example—that you need in your sample.

Note that these differ from inclusion criteria , which are more general requirements a person must possess to be a part of your sample; to be a potential participant that may or may not be sampled. For example, one of the inclusion criteria for a study of your campus’ mental health supports might be that participants had to have visited the mental health center in the past year. That differs from purposive sampling. In purposive sampling, you know characteristics of individuals and recruit them because of those characteristics. For example, I might recruit Jane because she stopped seeking supports this month, because she has worked at the center for many years, and so forth.

Also, it’s important to recognize that purposive sampling requires you to have prior information about your participants before recruiting them because you need to know their perspectives or experiences before you know whether you want them in your sample. This is a common mistake that many students make. What I often hear is, “I’m using purposive sampling because I’m recruiting people from the health center,” or something like that. That’s not purposive sampling. In most instances they really mean they are going to use convenience sampling-taking whoever they can recruit that fit the inclusion criteria (i.e. have attended the mental health center). Purposive sampling is recruiting specific people  because of the various characteristics and perspectives they bring to your sample. Imagine we were creating a focus group. A purposive sample might gather clinicians, patients, administrators, staff, and former patients together so they can talk as a group. Purposive sampling would seek out people that have each of those attributes.

If you are considering using a purposive sampling approach for your research proposal, you will need to determine what your purposive criteria involves. There are a range of different purposive strategies that might be employed, including: maximum variation , typical case , extreme case , or political case , and you want to be thoughtful in thinking about which one(s) you select and why.

  It can be a bit tricky determining how to approach or formulate your purposive cases. Below are a couple additional resources to explore this strategy further.

For more information on purposive sampling consult this webpage from Laerd Statistics on purposive sampling and this webpage from the University of Connecticut on education research .

When using snowball sampling , we might know one or two people we’d like to include in our study but then we have to rely on those initial participants to help identify additional participants. Thus, our sample builds and grows as the study continues, much as a snowball builds and becomes larger as it rolls through the snow. Snowball sampling is an especially useful strategy when you wish to study a stigmatized group or behavior. These groups may have limited visibility and accessibility for a variety of reasons, including safety. 

Malebranche and colleagues (2010) [5] were interested in studying sexual health behaviors of Black, bisexual men. Anticipating that this may be a challenging group to recruit, they utilized a snowball sampling approach. They recruited initial contacts through activities such as advertising on websites and distributing fliers strategically (e.g. barbershops, nightclubs). These initial recruits were compensated with $50 and received study information sheets and five contact cards to distribute to people in their social network that fit the study criteria. Eventually the research team was able to recruit a sample of 38 men who fit the study criteria.

Snowball sampling may present some ethical quandaries for us. Since we are essentially relying on others to help advertise for us, we are giving up some of our control over the process of recruitment. We may be worried about coercion, or having people put undue pressure to have others’ they know participate in your study. To help mitigate this, we would want to make sure that any participant we recruit understands that participation is completely voluntary and if they tell others about the studies, they should also make them aware that it is voluntary, too. In addition to coercion, we also want to make sure that people’s privacy is not violated when we take this approach. For this reason, it is good practice when using a snowball approach to provide people with our contact information as the researchers and ask that they get in touch with us, rather than the other way around. This may also help to protect again potential feelings of exploitation or feeling taken advantage of. Because we often turn to snowball sampling when our population is difficult to reach or engage, we need to be especially sensitive to why this is. It is often because they have been exploited in the past and participating in research may feel like an extension of this. To address this, we need to have a very clear and transparent informed consent process and to also think about how we can use or research to benefit the people we work in the most meaningful and tangible ways.

Quota sampling is another nonprobability sampling strategy. This type of sampling is actually employed by both qualitative and quantitative researchers, but because it is a nonprobability method, we’ll discuss it in this section. When conducting quota sampling, we identify categories that are important to our study and for which there is likely to be some variation. Subgroups are created based on each category and the researcher decides how many people (or whatever element happens to be the focus of the research) to include from each subgroup and collects data from that number for each subgroup. To demonstrate, perhaps we are interested in studying support needs for children in the foster care system. We decide that we want to examine equal numbers (seven each) of children placed in a kinship placement, a non-kinship foster placement, group home, and residential placements. We expect that the experiences and needs across these settings may differ significantly, so we want to have good representation of each one, thus setting a quota of seven for each type of placement.

As you continue to plan for your proposal, below you will find some of the strengths and challenges presented by each of these types of sampling.

Wait a minute, we need a plan!

Both qualitative and quantitative research should be planful and systematic. We’ve actually covered a lot of ground already and before we get any further, we need to start thinking about what the plan for your qualitative research proposal will look like. This means that as you develop your research proposal, you need to consider what you will be doing each step of the way: how you will find data, how you will capture it, how you will organize it, and how you will store it. If you have multiple types of data, you need to have a plan in place for each type. The plan that you develop is your data collection protocol . If you have a team of researchers (or are part of a research team), the data collection protocol is an important communication tool, making sure that everyone is clear what is going on as the research proceeds. This plan is important to help keep you and others involved in your research consistent and accountable. Throughout this chapter and the next ( Chapter 18 —qualitative data gathering) we will walk through points you will want to include in your data collection protocol. While I’ve spent a fair amount of time talking about the importance of having a plan here, qualitative design often does embrace some degree of flexibility. This flexibility is related to the concept of emergent design that we find in qualitative studies. Emergent design is the idea that some decision in our design will be dynamic and fluid as our understanding of the research question evolves. The more we learn about the topic, the more we want to understand it thoroughly.

A research protocol is a document that not only defines your research project and its aims, but also comprehensively plans how you will carry it out. If this sounds like the function of a research proposal, you are right, they are similar. What differentiates a protocol from a proposal is the level of detail. A proposal is more conceptual; a protocol is more practical (right down to the dollars and cents!). A protocol offers explicit instructions for you and your research team, any funders that may be involved in your research, and any oversight bodies that might be responsible for overseeing your study. Not every study requires a research protocol, but what I’m suggesting here is that you consider constructing at least a limited one to help though the decisions you will need to make to construct your qualitative study.

Al-Jundi and Sakka (2016) [6] provide the following elements for a research protocol :

• What is the question? (Hypothesis) What is to be investigated?
• Why is the study important (Significance)
• Where and when will it take place?
• What is the methodology? (Procedures and methods to be used).
• How are you going to implement it? (Research design)
• What is the proposed time table and budget?
• What are the resources required (technical, scientific, and financial)?

While your research proposal in its entirety will focus on many of these areas, our attention for developing your qualitative research protocol will hone in on the two highlighted above. As we go through these next couple chapters, there will be a number of exercises that walk you though decision points that will form your qualitative research protocol.

To begin developing your qualitative research protocol:

• Select the question you have decided is the best to frame your research proposal.
• Write a brief paragraph about the aim of your study, ending it with the research question you have selected.

Here are a few additional resources on developing a research protocol:

Cameli et al., (2018) How to write a research protocol: Tips and tricks .

Ohio State University, Institutional Review Board (n.d.). Research protocol .

World Health Organization (n.d.). Recommended format for a research protocol .

Decision Point: What types of data will you be using?

• Why is this a good choice, given your research question?
• If so, provide support for this decision.

Decision Point: Which non-probability sampling strategy will you employ?

• Why is this is a good fit?
• What steps might your take to address these challenges?

Recruiting strategies

Much like quantitative research, recruitment for qualitative studies can take many different approaches. When considering how to draw your qualitative sample, it may be helpful to first consider which of these three general strategies will best fit your research question and general study design: public, targeted, or membership-based. While all will lead to a sample, the process for getting you there will look very different, depending on the strategy you select.

Taking a public approach to recruitment offers you access to the broadest swath of potential participants. With this approach, you are taking advantage of public spaces in an attempt to gain the attention of the general population of people that frequent that space so that they can learn about your study. These spaces can be in-person (e.g. libraries, coffee shops, grocery stores, health care settings, parks) or virtual (e.g. open chat forums, e-bulletin boards, news feeds). Furthermore, a public approach can be static (such as hanging a flier), or dynamic (such as talking to people and directly making requests to participate). While a public approach may offer broad coverage in that it attempts to appeal to an array of people, it may be perceived as impersonal or easily able to be overlooked, due to the potential presence of other announcements that may be featured in public spaces. Public recruitment is most likely to be associated with convenience or quota sampling and is unlikely to be used with purposive or snowball sampling, where we would need some advance knowledge of people and the characteristics they possess.

As an alternative, you may elect to take a targeted approach to recruitment. By targeting a select group, you are restricting your sampling frame to those individuals or groups who are potentially most well-suited to answer your research question. Additionally, you may be targeting specific people to help craft a diverse sample, particularly with respect to personal characteristics and/or opinions.

You can target your recruitment through the use of different strategies. First, you might consider the use of knowledgeable and well-connected community members. These are people who may possess a good amount of social capital in their community, which can aid in recruitment efforts. If you are considering the use of community members in this role, make sure to be thoughtful in your approach, as you are essentially asking them to share some of their social capital with you. This means learning about the community or group, approaching community members with a sense of humility, and making sure to demonstrate transparency and authenticity in your interactions. These community members may also be champions for the topic you are researching. A champion is someone who helps to draw the interest of a particular group of people. The champion often comes from within the group itself. As an example, let’s say you’re interested in studying the experiences of family members who have a loved one struggling with substance use. To aid in your recruitment for this study, you enlist the help of a local person who does a lot of work with Al-Anon, an organization facilitating mutual support groups for individuals and families affected by alcoholism.

A targeted approach can certainly help ensure that we are talking to people who are knowledgeable about the topic we are interested in, however, we still need to be aware of the potential for bias. If we target our recruitment based on connection to a particular person, event, or passion for the topic, these folks may share information that they think is viewed as favorable or that disproportionately reflects a particular perspective. This phenomenon is due to the fact that we often spend time with people who are like-minded or share many of our views. A targeted approach may be helpful for any type of non-probability sampling, but can be especially useful for purposive, quota, or snowball sampling, where we are trying to access people or groups of people with specific characteristics or expertise.

Membership-based

Finally, you might consider a membership-based approach . This approach is really a form of targeted recruitment, but may benefit from some individual attention. When using a membership-based approach, your sampling frame is the membership list of a particular organization or group. As you might have guessed, this organization or group must be well-suited for helping to answer your research question. You will need permission to access membership, and the identity of the person authorized to grant permission will depend on the organizational structure. When contacting members regarding recruitment, you may consider using directories, newsletters, listservs or membership meetings. When utilizing a membership-based approach, we often know that members possess specific inclusion criteria we need, however, because they are all associated with that particular group or organization, they may be homogenous or like-minded in other ways. This may limit the diversity in our sample and is something to be mindful of when interpreting our findings. Membership-based recruiting can be helpful when we have a membership group that fulfills our inclusion criteria. For instance, if you want to conduct research with social workers, you might attempt to recruit through the NASW membership distribution list (but this access will come with stipulations and a price tag). Membership-based recruitment may be helpful for any non-probability sampling approach, given that the membership criteria and study inclusion criteria are a close fit. Table 17.5 offers some additional considerations for each of these strategies with examples to help demonstrate sources that might correspond with them.

• Qualitative research predominately relies on non-probability sampling techniques. There are a number of these techniques to choose from (convenience/availability, purposive, snowball, quota), each with advantages and limitations to consider. As we consider these, we need to reflect on both our research question and the resources we have available to us in developing a sampling strategy.
• As we consider where and how we will recruit our sample, there are a range of general approaches, including public, targeted, and membership-based.

Decision Point: How will you recruit or gain access to your sample?

• If you are recruiting people, how will you identify them? If necessary (and it often is), how will gain permission to do this?
• If you are using documents or other artifacts for your study, how will you gain access to these? If necessary (and it often is), how will gain permission to do this?

17.5 What should my sample look like?

• Explain key factors that influence the makeup of a qualitative sample
• Develop and critique a sampling strategy to support their qualitative proposal

Once you have started your recruitment, you also need to know when to stop. Knowing when to stop recruiting for a qualitative research study generally involves a dynamic and reflective process. This means that you will actively be involved in a process of recruiting, collecting data, beginning to review your preliminary data, and conducting more recruitment to gather more data. You will continue this process until you have gathered enough data and included sufficient perspectives to answer your research question in rich and meaningful way.

The sample size of qualitative studies can vary significantly. For instance, case studies may involve only one participant or event, while some studies may involve hundreds of interviews or even thousands of documents. Generally speaking, when compared to quantitative research, qualitative studies have a considerably smaller sample. Your decision regarding sample size should be guided by a few considerations, described below.

Amount of data

When gathering quantitative data, the amount of data we are gathering is often specified at the start (e.g. a fixed number of questions on a survey or a set number of indicators on a tracking form). However, when gathering qualitative data, we are often asking people to expand on and explore their thoughts and reactions to certain things. This can produce A LOT of data. If you have ever had to transcribe an interview (type out the conversation while listening to an audio recorded interview), you quickly learn that a 15-minute discussion turns into many pages of dialogue. As such, each interview or focus group you conduct represents multi-page transcripts, all of which becomes your data. If you are conducting interviews or focus groups, y ou will know you have collected enough data from each interaction when you have covered all your questions and allowed the participant(s) to share any and all ideas they have related to the topic. If you are using observational data, you need to spend sufficient time making observations and capturing data to offer a genuine and holistic representation of the thing you are observing (at least to the best of your ability). When using documents and other sources of media, again, you want to ensure that diverse perspectives are represented through your artifact choices so that your data reflects a well-rounded representation of the issue you are studying. For any of these data sources, this involves a judgment call on the researcher’s part. Your judgment should be informed by what you have read in the existing literature and consultation with your professor. 

As part of your analysis, you will likely eventually break these larger hunks of data apart into words or small phrases, giving you potentially thousands of pieces of data. If you are relying on documents or other artifacts, the amount of data contained in each of these pieces is determined in advance, as they already exist. However, you will need to determine how many to include. With interviews, focus groups, or other forms of data generation (e.g. taking pictures for a photovoice project), we don’t necessarily know how much data will be generated with each encounter, as it will depend on the questions that are asked, the information that is shared, and how well we capture it.

Type of study

A variety of types of qualitative studies will be discussed in greater detail in Chapter 22 . While you don’t necessarily need to have an extensive understanding of them all at this point in time, it is important that you understand which of the different design types are best for answering certain research questions. For instance, if our question involves understanding some type of experience, that is often best answered by a phenomenological design. Or, if we want to better understand some process, a grounded theory study may be best suited. While there are no hard and fast rules regarding qualitative sample size, each of these different types of designs has different guidelines for what is considered an acceptable or reasonable number to include in your sample. So drawing on the previous examples, your grounded theory study might include 45 participants because you need more people to gain a clearer picture of each step of the process, while your phenomenological study includes 20 because that provides a good representation of the experience you are interested in. Both would be reasonable targets based on the respective study design type. So as you consider your research question and which specific type of qualitative design this leads you to, you will need to do some investigation to see what size samples are recommended for that particular type of qualitative design.

Diversity of perspectives

As you consider your research question, you also may want to think about the potential variation in how your study population might view this topic. If you are conducting a case study of one person, this obviously isn’t a concern, but if you are interested in exploring a range of experiences, you want to plan to intentionally recruit so this level of diversity is reflected in your sample. The level of variation you seek will have direct implications for how big your sample might be. In the example provided above in the section on quota sampling, we wanted to ensure we had equal representation across a host of placement dispositions for children in foster care. This helped us define our target sample size: (4) settings a quota of (7) participants from each type of setting = a target sample size of (28).

In Chapter 18 , we will be talking about different approaches to data gathering, which may help to dictate the range of perspectives you want to represent. For instance, if you conduct a focus group, you want all of your participants to have some experience with the thing that you are studying, but you hope that their perspectives differ from one another. Furthermore, you may want to avoid groups of participants who know each other well in the same focus group (if possible), as this may lead to groupthink or level of familiarity that doesn’t really encourage differences being expressed. Ideally, we want to encourage a discussion where a variety of ideas are shared, offering a more complete understanding of how the topic is experienced. This is true in all forms of qualitative data, in that your findings are likely to be more well-rounded and offer a broader understanding fo the issue if you recruit a sample with diverse perspectives.

Finally, the concept of saturation has important implications for both qualitative sample size and data analysis. To understand the idea of saturation, it is first important to understand that unlike most quantitative research, with qualitative research we often at least begin the process of data analysis while we are still actively collecting data. This is called an iterative approach to data analysis. So, if you are a qualitative researcher conducting interviews, you may be aiming to complete 30 interviews. After you have completed your first five interviews, you may begin reviewing and coding (a term that refers to labeling the different ideas found in your transcripts) these interviews while you are still conducting more interviews. You go on to review each new interview that you conduct and code it for the ideas that are reflected there. Eventually, you will reach a point where conducting more interviews isn’t producing any new ideas, and this is the point of saturation. Reaching saturation is an indication that we can stop data collection. This may come before or after you hit 30, but as you can see, it is driven by the presence of new ideas or concepts in your interviews, not a specific number.

This chapter represents our transition in the text to a focus on qualitative methods in research. Throughout this chapter we have explored a number of topics including various types of qualitative data, approaches to qualitative sampling, and some considerations for recruitment and sample composition. It bears repeating that your plan for sampling should be driven by a number of things: your research question, what is feasible for you, especially as a student researcher, best practices in qualitative research. Finally, in subsequent chapters, we will continue the discussion about reflexivity as it relates to the qualitative research process that we began here.

• The composition of our qualitative sample comes with some important decisions to consider, including how large should our sample be and what level and type of diversity it should reflect. These decisions are guided by the purposes or aims of our study, as well as access to resources and our population.
• The concept of saturation is important for qualitative research. It helps us to determine when we have sufficiently collected a range of perspectives on the topic we are studying.

Decision Point(s): What should your sample look like (sample composition)?

• If so, how many?
• How was this number determined?
• OR will you use the concept of saturation to determine when to stop?
• What supports your decision in regards to the previous question?

This isn’t so much a decision point, but a chance for you to reflect on the choices you’ve made thus far in your protocol with regards to your: (1) ethical responsibility, (2) commitment to cultural humility, and (3) respect for empowerment of individuals and groups as a social work researcher. Think about each of the decisions you’ve made thus far and work across this grid to identify any important considerations that you need to take into account.

You have been prompted to make a number of choices regarding how you will proceed with gathering your qualitative sample. Based on what you have learned and what you are planning, respond to the following questions below.

• What are the strengths of your sampling plan in respect to being able to answer your qualitative research question?
• How feasible is it for you, as a student researcher, to be able to carry out your sampling plan?
• What reservations or questions do you still need to have answered to adequately plan for your sample?
• What excites you about your proposal thus far?
• What worries you about your proposal thus far?
• National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html ↵
• Patel, J., Tinker, A., & Corna, L. (2018). Younger workers’ attitudes and perceptions towards older colleagues.  Working with Older People, 22 (3), 129-138. ↵
• Veenstra, A. S., Iyer, N., Hossain, M. D., & Park, J. (2014). Time, place, technology: Twitter as an information source in the Wisconsin labor protests. Computers in Human Behavior, 31, 65-72. ↵
• Ohmer, M. L., & Owens, J. (2013). Using photovoice to empower youth and adults to prevent crime.  Journal of Community Practice, 21 (4), 410-433. ↵
• Malebranche, D. J., Arriola, K. J., Jenkins, T. R., Dauria, E., & Patel, S. N. (2010). Exploring the “bisexual bridge”: A qualitative study of risk behavior and disclosure of same-sex behavior among Black bisexual men . American Journal of Public Health, 100( 1), 159-164. ↵
• Al-Jundi, A., & SakkA, S. (2016). Protocol writing in clinical research. Journal of Clinical and Diagnostic Research: JCDR, 10 (11), ZE10. ↵

Research that involves the use of data that represents human expression through words, pictures, movies, performance and other artifacts.

One of the three ethical principles in the Belmont Report. States that benefits and burdens of research should be distributed fairly.

Case studies are a type of qualitative research design that focus on a defined case and gathers data to provide a very rich, full understanding of that case. It usually involves gathering data from multiple different sources to get a well-rounded case description.

the various aspects or dimensions that come together in forming our identity

The unintended influence that the researcher may have on the research process.

A research journal that helps the researcher to reflect on and consider their thoughts and reactions to the research process and how it may be shaping the study

Rigor is the process through which we demonstrate, to the best of our ability, that our research is empirically sound and reflects a scientific approach to knowledge building.

A form of data gathering where researchers ask individual participants to respond to a series of (mostly open-ended) questions.

A form of data gathering where researchers ask a group of participants to respond to a series of (mostly open-ended) questions.

Observation is a tool for data gathering where researchers rely on their own senses (e.g. sight, sound) to gather information on a topic.

Triangulation of data refers to the use of multiple types, measures or sources of data in a research project to increase the confidence that we have in our findings.

sampling approaches for which a person’s likelihood of being selected for membership in the sample is unknown

A convenience sample is formed by collecting data from those people or other relevant elements to which we have the most convenient access. Essentially, we take who we can get.

A quota sample involves the researcher identifying a subgroups within a population that they want to make sure to include in their sample, and then identifies a quota or target number to recruit that represent each of these subgroups.

For a snowball sample, a few initial participants are recruited and then we rely on those initial (and successive) participants to help identify additional people to recruit. We thus rely on participants connects and knowledge of the population to aid our recruitment.

In a purposive sample, participants are intentionally or hand-selected because of their specific expertise or experience.

Content is the substance of the artifact (e.g. the words, picture, scene). It is what can actually be observed.

Context is the circumstances surrounding an artifact, event, or experience.

Photovoice is a technique that merges pictures with narrative (word or voice data that helps that interpret the meaning or significance of the visual artifact. It is often used as a tool in CBPR.

A rich, deep, detailed understanding of a unique person, small group, and/or set of circumstances.

Inclusion criteria are general requirements a person must possess to be a part of your sample.

A purposive sampling strategy where you choose cases because they represent a range of very different perspectives on a topic

A purposive sampling strategy where you select cases that represent the most common/ a commonly held perspective.

A purposive sampling strategy that selects a case(s) that represent extreme or underrepresented perspectives. It is a way of intentionally focusing on or representing voices that may not often be heard or given emphasis.

A purposive sampling strategy that focuses on selecting cases that are important in representing a contemporary politicized issue.

A plan that is developed by a researcher, prior to commencing a research project, that details how data will be collected, stored and managed during the research project.

Emergent design is the idea that some decision in our research design will be dynamic and change as our understanding of the research question evolves as we go through the research process. This is (often) evident in qualitative research, but rare in quantitative research.

approach to recruitment where participants are sought in public spaces

approach to recruitment where participants are based on some personal characteristic or group association

approach to recruitment where participants are members of an organization or social group with identified membership

To type out the text of recorded interview or focus group.

A qualitative research design that aims to capture and describe the lived experience of some event or "phenomenon" for a group of people.

A type of research design that is often used to study a process or identify a theory about how something works.

The point where gathering more data doesn't offer any new ideas or perspectives on the issue you are studying.  Reaching saturation is an indication that we can stop qualitative data collection.

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Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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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: Methods

• Getting Started
• Focus Groups
• Observation
• Case Studies
• Data Collection
• Cleaning Text
• Analysis Tools
• Institutional Review

Table of Contents: Methods Section

Duke resources.

Duke's Office of Assessment:

Assessment Resources (qualitative and quantitative)

Qualitative Research Methods: A Data Collector's Field Guide Downloadable how-to guide covers the mechanics of data collection for applied qualitative research; appropriate for novice and experienced researchers.

In qualitative research, only a sample (subset) of a population is selected for any given study.Three of the most common sampling methods are:

• Purposive sampling Participants are grouped according to preselected criteria relevant to a particular research question; sample sizes often determined by theoretical saturation (new data doesn't bring additional insights)
• Quota sampling While designing a study, it is determined how many people with which characteristics need to be included as participants
• Snowball sampling Participants or informants use their social networks to refer the researcher to other people who could potentially participate in the study, often used to find and recruit “hidden populations"

Choosing a Method for Collecting Qualitative Data

Table was adapted from the Basic Guide to Program Evaluation, http://www.managementhelp.org/evaluatn/fnl_eval.htm#anchor1585345

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• Last Updated: Mar 1, 2024 10:13 AM
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Open Access

Peer-reviewed

Research Article

Use of antimicrobials and other medical products in an ethnic minority context of South-Central Vietnam: A qualitative study of vulnerability

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium

Roles Conceptualization, Formal analysis, Investigation, Project administration, Writing – original draft, Writing – review & editing

Affiliations Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium, Department of Malaria Epidemiology, National Institute of Malariology, Parasitology, and Entomology, Hanoi, Vietnam

Roles Project administration, Supervision, Writing – review & editing

Affiliation Department of Malaria Epidemiology, National Institute of Malariology, Parasitology, and Entomology, Hanoi, Vietnam

Roles Validation, Writing – review & editing

Roles Writing – review & editing

Roles Supervision

Roles Conceptualization, Methodology, Supervision, Validation, Writing – review & editing

Affiliation Department of Anthropology, Philosophy and Social Work, Rovira i Virgili, Tarragona, Spain

Contributed equally to this work with: Charlotte Gryseels, Koen Peeters Grietens

Roles Conceptualization, Supervision, Validation, Writing – review & editing

Roles Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing

• Maya Ronse, 
• Thuan Thi Nguyen, 
• Xa Xuan Nguyen, 
• Brecht Ingelbeen, 
• Mira Leonie Schneiders, 
• Duong Thanh Tran, 
• Joan Muela Ribera, 
• Charlotte Gryseels, 
• Koen Peeters Grietens

• Published: April 9, 2024
• https://doi.org/10.1371/journal.pgph.0002982
• Reader Comments

Despite the global threat of antimicrobial resistance (AMR), evidence on the use and quality of medicines at community level is limited, particularly in impoverished, rural areas where prevalence of (bacterial) infections is high. To better understand the processes that drive vulnerability to AMR’ effects, this study aimed to assess social factors underpinning access to–and use of–medical products and healthcare, among people from the Raglai ethnic minority in Ninh Thuan Province, Vietnam. We conducted ethnographic research in eight villages in 2018–2019, using interviewing and participant observation methods for data collection. Different types of informants (including community members and healthcare providers) were selected using purposive sampling strategies and analysis was retroductive. Our findings show that, despite the existence of a government-funded health insurance scheme, Raglai people’s flexible therapeutic itineraries did not systematically start with formal healthcare. Different types of care (private/informal, public, shamanic) were combined in parallel or in alternation, determined by distance to the provider, cost, workload, perceived diagnostic capacity, perceived severity and aetiology of the illness, and trust in the provider. Available medicines were often tablets dispensed in plastic bags containing labelled tablets, unlabelled tablets (in bulk) or tablets ground to powder. Treatment was often considered effective when it relieved symptoms, which led to abandonment of the treatment course. When symptoms did not speedily abate, the illness aetiology would be reinterpreted, and “stronger” medicines would be sought. The precarious socio-economic status of some Raglai drove them in cycles of severe poverty when additional unforeseen factors such as illness, animal disease or loss of crops arose, hampering access to (in)formal healthcare providers and/or appropriate diagnosis and treatment. We conclude that Raglai communities are structurally unable to buffer themselves against the threat and consequences of AMR. Despite this vulnerability, they are among the least targeted by efforts to optimize antibiotic use, which are concentrated in secondary and tertiary healthcare facilities targeted at urban populations.

Citation: Ronse M, Nguyen TT, Nguyen XX, Ingelbeen B, Schneiders ML, Tran DT, et al. (2024) Use of antimicrobials and other medical products in an ethnic minority context of South-Central Vietnam: A qualitative study of vulnerability. PLOS Glob Public Health 4(4): e0002982. https://doi.org/10.1371/journal.pgph.0002982

Editor: Muhammad Asaduzzaman, University of Oslo Faculty of Medicine: Universitetet i Oslo Det medisinske fakultet, NORWAY

Received: March 20, 2023; Accepted: February 9, 2024; Published: April 9, 2024

Copyright: © 2024 Ronse et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data supporting the findings of this study are retained at the Institute of Tropical Medicine, Antwerp and will not be made openly accessible due to confidentiality concerns as the dataset cannot be fully anonymised given the nature of the research. Data can, however, be made available after approval of a motivated and written request to the Institute of Tropical Medicine at [email protected] .

Funding: This work was supported by the London School of Hygiene & Tropical Medicine (ITDCZL84 to MR) and the Multi-year Programme agreement (2017-2021) between the Belgian Directorate of Development Cooperation (DGD) and the Institute of Tropical Medicine, Belgium (to XXN, TTN). TTN was funded with a PhD scholarship from the DGD. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Antimicrobial resistance (AMR) is a public health threat of global importance. Exposure to antimicrobial (AM) substances contributes to the emergence and spread of AMR microorganisms (bacteria, viruses, parasites and fungi) [ 1 ]. The dynamic interaction between people (social actors such as patients and healthcare providers), health systems (access to healthcare and to AM treatment, infection prevention and control measures, policy and political context), and the environment (AM exposure in livestock, food, plants, water, soil and other household products) affects exposure to antimicrobials and therefore the biological emergence and spread of AMR. In addition to human AM use, use in animals, and exposure through agriculture also contribute to increasing rates of AMR [ 2 – 5 ].

In terms of antibiotic resistance (ABR) specifically, absence of hygiene and sanitation measures in resource-limited settings result in higher incidence of bacterial infections [ 6 – 10 ] and consequently in higher consumption of antibiotics. In resource-constrained settings, access to hospitals is often limited and antibiotics are frequently used at community-level. However, while antibiotic resistant blood-stream infections may be largely community-acquired, most reports and interventions to address ABR in these settings are hospital-based [ 11 – 14 ].

Inappropriate use of antimicrobials at community level can accelerate the emergence and spread of AMR, by increasing pathogen and commensal bacterias’ exposure to antimicrobials, out-selecting resistant bacteria, which are then more frequently transmitted [ 1 , 3 , 15 – 20 ]. Inappropriate use of antimicrobials is not limited to misuse or overuse [ 21 ], but also underdosing, related for instance to poor treatment adherence, poor storage of antimicrobials, poor quality antimicrobials, non-prescription, and certain treatment preferences [ 22 , 23 ].

The use of medicines has been shown to be related to socio-cultural factors. These factors range from patients’ perceptions of healthcare providers and of the efficacy and quality of medicine, perceptions of illness severity and recovery, the choice for public or private providers, as well as an understanding of side effects and fears thereof. Additionally, broader contextual factors such as accessibility and quality of healthcare [ 24 – 26 ], (partially) influenced by the political and historical context, are other factors to consider. In addition, some broader socio-cultural factors also affect the context in which healthcare is sought and provided: actions and perceptions of governments and healthcare providers, healthcare sector regulations (e.g. over-the-counter dispensing of antibiotics), gaps between health policy and implementation, and between intended and actual service delivery, availability of different medicine dispensers in the public-private sector mix and medical pluralism practices, financial or geographical barriers to appropriate diagnosis and treatment, waiting times at providers, quality of medical training, and availability of medical personnel [ 25 , 27 – 29 ]. Several of these factors also affect trust in the health system, the emergence of rumours regarding public health campaigns, and more general conceptions on health and illness [ 25 , 27 – 29 ]. In addition, factors affecting access, such as financial constraints to pay for antimicrobials, or public stock outs, have also been described as barriers to appropriate antimicrobial use, resulting in an inverse association between income and AMR [ 27 , 30 , 31 ].

South-East Asia represents an important setting in terms of antimicrobial drug resistance due to a unique convergence of sociocultural, political-economic, ecological and biological factors. The region faces high levels of bacterial resistance to antibiotics [ 32 – 36 ], largely attributable to higher incidence of community-acquired infections [ 8 – 10 ] and has repeatedly been the epicentre of the emergence of antimalarials parasite resistance [ 33 , 37 – 39 ].

In Vietnam particularly, increasing ABR has been documented in human and animal health [ 40 – 44 ]. A recent study in a rural community found that 80.6% of households had members carrying colistin-resistant E. coli [ 45 ]. Despite government regulations, antibiotics are generally dispensed without medical prescription [ 46 ]. Recent studies in Vietnam estimated the share of antibiotics dispensed without prescription between 55.2% and 91% [ 24 , 47 ]. For mild illness, healthcare is reported to be mainly (72.5%) sought at drug stores, of which the majority are non-licensed, whereas for severe illness, care is sought at public facilities (74.1%) [ 24 ]. Vietnam has developed a national AMR action plan, including an antibiotic stewardship programme, but has not yet reported results to WHO’s Global Antimicrobial Resistance Surveillance System (GLASS) [ 48 ].

AMR is clearly shaped by the interaction between biological and human social processes [ 49 , 50 ]. Our qualitative study therefore aimed to explore the social processes that drive vulnerability to the effects of AMR generally and to the suboptimal use of medical products specifically. As exposure to a range of infectious diseases as well as reduced access to appropriate healthcare often cluster in remote and sometimes marginalized ethnic minority populations in South-East Asia, our study focused on Raglai people’s access to healthcare and use of medical products. This study is part of a longstanding collaboration on health-related research in the area since 2004.

Although the initial objective was to assess perceptions and use of antibiotics and ABR, we found that the concepts of antibiotics and ABR as defined in a biomedical framework were not part of the language or reference framework of the study population. We therefore moved the focus of the research to the use of medical products and experiences of treatment failure in general, while keeping an analytical lens on AMR. This particular study aimed to assess social factors underpinning access to–and use of–medical products and healthcare, among people from the Raglai ethnic minority in Ninh Thuan Province, Vietnam.

Materials and methods

Study design.

Our study consisted of a qualitative emergent-theory design based on ethnographic fieldwork [ 51 ].

Study site and population

This study was carried out in eight villages of Bac Ai and Ninh Son districts, situated in the hilly and forested part of the Ninh Thuan province (South-Central Vietnam). In 2022, Bac Ai counted a population of approximately 31,000 inhabitants, predominantly of Raglai ethnicity, in addition to Cham and Kinh ethnicities, the latter being the Vietnamese majority population [ 52 ]. According to 2022 local statistics, the Ninh Son district had a population of over 61,000 inhabitants, predominantly of Kinh ethnicity in addition to various other ethnic groups including Cham, Raglai, Co Ho, and Nung [ 52 ]. Ninh Son is approximately 28 km from Bac Ai district.

Our interviews and observations were in majority with people who identified as being from Raglai ethnicity and refered to themselves as (the) “Raglai”. The Raglai are a diverse group of people, and when we will mention “(the) Raglai” in this work, we only refer to the study population we interviewed. Our Raglai informants took a certain pride in saying they were Raglai, and always asked us from where we came. Therefore, in referring to these informants and their communities in that way, we are trying to respect their identity.

People of Raglai ethnicity are categorized by the government as an ethnic minority group. Despite the government’s socio-economic interventions in the past 20 years, people of Raglai ethnicity are among the poorest groups in Vietnam [ 53 ]. Raglai people engage in small-scale subsistence slash-and-burn agriculture in the forests on the mountains, occasionally combined with livestock, hunting, and logging [ 54 , 55 ]. In the last two decades, Raglai were relocated from ‘old villages’ in their traditional forested territory to ‘new villages’ constructed by the government as part of its policy for resettlement and socio-economic development of ethnic minority groups [ 56 ]. Public healthcare and schools are made available in ‘new villages’. Despite the government’s interventions and the gradual integration with the market economy, more than half of the district’s population–estimated at 58,6%–lives under the national poverty line [ 57 ].

Health studies found that people of Raglai ethnicity had a higher risk of malaria infection and malnutrition rates among children under 5 years of age in comparison to those who were of Kinh ethnicity [ 54 , 58 – 60 ].

District hospital data from 2016–2018 reported an increasing trend of dispensed antibiotics at public health facilities [ 61 ]. Although there are no granular AMR data from Bac Ai district, a small hospital-based study at the provincial reference hospital for our study setting reported a high prevalence of ABR amongst bloodstream infections in 2017 (e.g. 100% resistance to ampicillin, 92.7% to trimethoprim/sulfamethoxazole, 72.7% to ciprofloxacin, and 72.0% to ceftriaxone in 144 E. coli bloodstream infections, preserving only carbapenems to treat these infections) [ 62 ]. Malaria parasite resistance was found in some provinces in south-central Vietnam including Ninh Thuan [ 63 ] and delayed parasite clearance has been spreading [ 64 – 66 ].

Positionality

The research team was composed of two field researchers (TTN–female, MR–female). The Vietnamese researcher (TTN) was from Kinh ethnicity and had already been conducting fieldwork among predominantly Raglai communities for several months, acquiring familiarity with informants of Raglai ethnicity, gatekeepers in the field, the Raglai culture, and the Raglai accent in Vietnamese. Prior to the study, TTN conducted four periods of fieldwork in the study sites, between July 2016 and April 2018, as part of her PhD research on malaria transmission among Raglai population. Each fieldwork was between four and six weeks. Being from Kinh ethnicity, TTNs ethnographic approach was a requirement to gain trust and allow proper data collection among this ethnic minority. With the exception of a few people who only spoke Raglai, TTN could communicate directly with most informants in Vietnamese. The second Belgian researcher (MR) faced language barriers, needing translation, and initial increased socio-cultural distance. The prolonged stays in the communities, in combination with MR’s precedence from a “neutral” country–not involved in the Vietnamese war–and not part of inter-cultural socio-political tensions at national level, helped to gradually build trust and lead to informants opening-up about certain topics in a different way. Members of the larger study team (XXN and KPG) have been doing research embedded in this study area and population since 2004.

Data collection

Two researchers conducted ethnographic fieldwork between April-August 2018 (MR and TTN) and May-July 2019 (TTN). Collected data consisted of semi-structured in-depth interviews (IDI), (focus) group discussions, and participant observation including informal conversations. The field researchers participated in everyday activities including observations at communal health centres and private practices as well as residing with community members. This allowed to build rapport and trust, and gain insights into living conditions, socio-cultural practices, people’s health-seeking behaviours, as well as their perceptions, use, and/or prescription of medicines. When IDIs and group discussions were recorded, this was done using a dictaphone. Sometimes only notes could be taken. For informal conversations, notes were written down as soon as possible after the conversation. All data were transcribed in either English or Vietnamese by TTN and MR with the assistance of a local field assistant.

We selected informants following theoretical and snowball sampling strategies. Both communities and participants were gradually selected within the study area on the basis of emerging information. Informants included community members (both from “old” and “new” villages); human health service providers (public and private sector, as well as informal providers); animal health service providers (public, private sector, and informal); representatives of local government (local authorities, forest protection guards etc.); and traditional power structures (shaman, respected “wise” persons). We aimed for maximum variation in occupational profiles (farmers, doctors, informal providers, grocery shop owners); ethnicities (Raglai, Cham, and Kinh); gender (female, male); and age groups (older people, adults, and children). Further details on the categories of informants are provided in S1 Table . Data collection resulted in 43 informal conversations in combination with participant observation, 71 IDIs, and 10 group discussions.

Analysis followed the principles of retroductive analysis [ 67 ]. We analysed data intermittently during, between, and after data collection phases. We carried out thematic content analysis and analysed transcribed data with the help of NVivo (11) software (QSR International Pty Ltd. Cardigan UK), based on themes pre-identified from the initial research questions in addition to new themes that emerged during intermittent analysis [ 68 ]. Data was coded and analysed by two authors (TTN and MR). A theoretical framework on vulnerability underpinned this work (cf. discussion).

Ethical approvals

Ethical approval was granted by the Institutional Review Board of the Institute of Tropical Medicine (ITM), Antwerp (Belgium)–Ref 1234/18 –in addition to the Ministry of Health and the National Institute of Malariology, Entomology, and Parasitology (NIMPE), Hanoi (Vietnam)–IRB decisions 1648/QD-VSR and 3731, QD-BYT. We obtained oral consent from all informants. Participants had the opportunity to ask questions, voice concerns, or withdraw from participation at any time during the research. Specific attention was given by the researchers to detecting culturally specific “polite/indirect” signs of refusal to answer questions and/or to participation, in which cases researchers stopped the data collection. As an example, some individuals responded "I do not speak Vietnamese" as a means of declining to participate in the study, even though they had basic knowledge of the language. In other situations, people expressed interest in hearing our introduction, but politely declined when invited to participate in the study.

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the S1 Checklist .

The findings presented hereunder are categorised in four main types of factors influencing either directly or indirectly access to–and use of–medical products and healthcare: factors influencing (1) patients’ access to healthcare; (2) patients’ choice of providers; (3) patients’ choice and use of medical products; and (4) factors driving diagnosis and prescribing practices of providers.

Factors influencing patients’ access to healthcare

Subsistence strategies and financial resources..

In our study setting, farming land assigned to Raglai people in the new villages was limited in size and prone to droughts. The economic pressure, escalating government regulations and control over forest resources (i.e. ban on creating new fields, extraction of timber products, and hunting in the protected areas) has led to changes in subsistence and mobility strategies of many informants, resulting in a combination of slash-and-burn agriculture in their old villages, rice farming in the new villages, and seasonal forest and plantation work. Key informants reported being constantly short of cash for essential needs and experienced seasonal food shortage as a result of severe droughts over the past few years. Forest extraction activities (vegetation, flowers, honey etc.) provided some income in between harvests, but also led to tensions between local (Raglai) community members and forest management authorities. To meet the demands of a changed lifestyle in the new villages, many informants took loans from the government and private lenders. Some people entered cycles of severe poverty when additional unforeseen factors such as illness, animal disease or loss of crops arose, hampering access to (in)formal healthcare providers and/or appropriate diagnosis and treatment.

Marginalization.

Raglai were often sceptical and/or scared of people from the dominant ethnic group. Despite being proud of the traditions originating from Raglai culture and cosmology, including spiritual shamanism and the advantages of a matrilineal kinship system, Raglai informants often showed signs of low self-esteem when comparing themselves to other ethnic groups or foreigners. When being asked about their culture, Raglai informants often repeated the stereotypes developed by mainstream society, i.e. being “backward”, maintaining a forest-based lifestyle, practicing “backward” traditions such as shamanism, being physically “ugly” (i.e. having a darker skin tone compared to the ideal standards of fair skin tone in dominant Kinh ethnicity), wearing dirty working outfits, speaking with an unusual accent in Vietnamese (i.e. Kinh), being poor, and having low education.

These degrading stereotypes also play a role in the healthcare encounter. Health information materials available to Raglai people at health centers portrayed Kinh “ideals”, implying fairer skin tone, a small family size and signs of belonging to the “industrial” world (e.g. having an industrial job). References to local culture and people were sometimes used in promotion materials, such as representing people in traditional outfits, with forest-going/nomadic lifestyles, living in bamboo stilt-houses. However, these can be ambiguously interpreted as depicting stereotypes of ethnic minorities in Vietnam.

Accessibility of health information.

Most of Raglai people could hold basic conversations in Kinh language but few could read or write. At health facilities, all printed health education materials were in Kinh. With the majority of health staff also being of Kinh ethnicity, communication between health staff and patients was mostly in Kinh, which many Raglai only partly comprehended. Communication was further complicated by the inter-ethnic hierarchy and the pressure on health professionals to shorten time spent on each patient in order to control waiting times. It was observed and shared in interviews that both public and private prescribers often did not provide clear information on diagnosis, aetiology, and instructions on treatment, especially when receiving mixed-medicine bags containing different types of tablets with different posologies.

Incongruent conceptualizations of pathogens and medicines.

Biomedical causations of diseases and associated explanations provided by health staff often were difficult to translate into a locally adapted reference framework, with the absence of existing similar terms or concepts in Raglai language. As an example, in Raglai language, specific terms for antibiotics and bacteria, viruses, or parasites were non-existent and commonly referred to as ‘medicine’ (jrãu) and ‘worms’ ( ana hula ) respectively. In terms of symptoms for Raglai, fever (sot) and headache (dau dau) were considered interchangeable terms as they related to similar symptoms. It was suggested by a Raglai nurse that only Raglai with more medical literacy would be able to make out the difference. From a biomedical point of view, this added a level of complexity in explaining differences between these biomedical concepts and causations in diagnosis, and general health communication for Raglai.

Factors driving patients’ choice of providers

Even though more than 90% of the population in the studied villages was estimated to have access to a basic health insurance provided by the government to populations living in poverty and remote areas [ 69 ], public health facilities were not always the first choice of care. Therapeutic itineraries for one health problem commonly combined several types of care, either in parallel or in alternation, which was influenced by a complex interplay of factors.

In this study setting, the range of healthcare options was relatively wide, offering many therapeutic options to communities, ranging from primary and secondary biomedical healthcare–including public and private commune health centres (CHC); hospitals; home practices by nurses, doctors, pharmacy technicians; sole dispensing of medical products by private pharmacies, grocery shops, and mobile sellers–to shamanic healing. See Table 1 for an overview of the available therapeutic options and the perceived comparative advantages in our study context.

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https://doi.org/10.1371/journal.pgph.0002982.t001

Time and work

In subsistence farming, which determined most Raglai’s life rhythm, time meant money and resources. As such, seeking care became a priority only when the symptoms compromised the ability to work. In this case, striving for time efficiency appeared to weigh most heavily in the decision where and with which provider to seek healthcare. Consequently, waiting lines in public health centres were perceived as an important impediment. In addition, while in theory there should always be staff on duty, in some health centres staff occupied post-office hours for emergencies only, and not for minor healthcare problems. For some community members, however, the perception of what was urgent or not was different from staff’s perceptions, leading to occasional disagreements that impacted on the relationship of trust between provider and patient. These experiences would then influence subsequent health-seeking itineraries.

Distance and geographical accessibility

The time required to travel to a health facility was particularly important in remote and old villages where it takes a considerable amount of time to get out of the forest, down the mountain, on bad quality roads, to a pharmacy or a public health centre. Home practices, grocery shops, and mobile sellers provided a comparative advantage in this regard. Poorest families had to mainly travel by foot, while better off families had motorbikes. The motorbikes were often owned and used by men, which sometimes made it difficult for women to access care quickly in case of emergencies.

To evaluate the affordability of a provider the following needed to be taken into account: (i) direct non-medical costs such as the financial costs of transport, (ii) direct medical costs of healthcare and medicines, as well as (iii) indirect costs such as the loss of income and food due to not being able to work; as well as the missed chores and (temporary) abandonment of relatives (children, older people, disabled) in need of care at home. All Raglai communities were entitled to free basic health insurance provided by the government due to their designation as ‘poor’ and remote residence, covering selective medical services in the public sector [ 70 ]. To obtain a health insurance card, people needed to officially register for a new card annually, except for children under six years of age who were exempt from the renewal requirement). Given the Raglai’s poverty, families that for various reasons did not obtain a health insurance card or did not go to the public health sector needed to use a high proportion of their total income to purchase medicines and health services. This sometimes led to the need to sell domestic animals, to borrow money from relatives or to take an individual loan from a grocery shop (often owned by someone from Kinh ethnicity) as a financial coping mechanism, which would subsequently become a major burden on the household. In such a context, the option of buying partial drug regimens, according to the means of the patient, or having the option of paying at a later time, were considered important advantages for health providers to attract clientele.

Perceived diagnostic capacities of the provider

The possibility for receiving a diagnosis, an explanation for the cause of the disease and a description of the problem itself, was a valued advantage of biomedical healthcare providers, both in health centres and in private practices. Nevertheless, the speed of recovery was often deemed to be more important and therefore previous experiences relating to speed of service and recovery prognosis often outweighed the benefits of receiving a concrete diagnosis. People therefore often sought out those drug dispensers that were perceived to be more accessible and were known to have more effective and fast-acting drugs, regardless of their diagnostic capacities.

Provider-patient relationship

Being welcoming, taking time to listen to the patient and giving clear information in a respectful way and comprehensible language (preferably Raglai), showing cultural proximity or sensitivity (more likely to be achieved by Raglai staff) were elements that were seen to foster trust from the patients and contribute to a good reputation of the healthcare provider. These perceptions were often circulated and fed back within the community, leading to a reputation of a provider which would either attract more patients in the future, or to the contrary, lead to avoidance by patients in case of negative experiences. Anecdotes were shared of patients being addressed by staff in disrespectful ways, such as being asked to sit further away during a consultation because of their unpleasant smell. References were also made to unequal inter-ethnic relations as healthcare workers were often from a different ethnicity than the Raglai patients in our study.

“ …In general the instructions [given by the district health centre] are easy for patients to understand . I am Raglai and they can understand what I say… Patients find your people [Kinh] annoying . My people rarely raise our tone when we speak to the patient, we always handle the conversations with them gently, we explain every little detail to them. Your people [Kinh] often give short explanations to the patients [which makes them] think they were being scolded.” (IDI, healthcare worker at a public health centre, 16/05/2018)

Perceived aetiology of the illness symptoms

In Raglai cosmology, humans are intrinsically connected to the environment they are born in, to the land that hosts living beings as well as their ancestors. All these connected elements are believed to have spirits. These spirits, including the own spirit of a person, can be offended in case of antisocial behaviour or disrespect towards essential traditional values, unnecessary destruction of natural resources, and trespassing of sacred spaces. Such behaviours can trigger ill health. “Bad” shamans were believed to be able to afflict illness as well. Both biomedical and spiritual aetiologies allowed for biomedical (“western”) treatment and/or spiritual shamanic healing (involving rituals, prayers, offerings/sacrifices) as appropriate courses of action as both could be intertwined. Herbal medicine is also part of traditional care, though it was mentioned that a lot of this knowledge was being lost among the younger generations. Biological diseases could be associated with “worms” in the body (imagery stemming from biomedical healthcare personnel ranging from viewable to invisible organisms in the body causing illness). Additionally, sudden ecological changes (e.g. in the weather and climate) in combination with intensive working conditions were also perceived to place a heavy burden on the body, leading to sickness or other disruptions in a natural balance such as changes in diets etc. Sudden changes in weather could refer to sudden rain, wind, and cold or on the contrary, to very high temperatures and sun exposure. However, this was also associated to perceptions of climate change, showing increasingly unpredictable changes in weather and seasons which was said to have a significant impact on agriculture practices and working conditions in the fields. Spiritual illness could be associated with conflicts between spirits and people (e.g. offenses to the ancestors) or between people (e.g. jealousy). The longer biomedical treatments remained ineffective in relieving symptoms, the higher the probability that people perceived either the medicines not to be appropriate in relation to the severity or the “strength” of the disease; or interpreted the illness to be caused by something which “Western medicine” could not solve. This was the case for complicated, relapsing, and chronic diseases, where aetiological associations with spirits and/or sorcery often became the final diagnosis, dedicating all efforts towards spiritual healing.

Factors influencing patients’ choice and use of medical products

Administration route..

Parenteral medical products, such as transfusions and injections seemed widely preferred as routes of administration by patients, as they were thought to lead to rapid symptom improvement and required more dedicated care from healthcare workers, which in turn fed into the perceived well-being of a patient. These options were also prescribed by both private and public health practitioners as they believed these administration routes could enhance the patient’s ability to recover. Nevertheless, they were more expensive and therefore the most common type of medical products consumed were oral medicine, in tablets or more seldom in instant powder. Clear distinctions were made between medication for children and for adults. Tablets were often delivered in mixed-medicine plastic bags and could contain (a combination of) labelled tablets (from cut blister packages), unlabelled tablets (in bulk), or all ground to powder, depending on the dispensers. Some dispensers (e.g. at CHCs) prepared different sachets for each type of medicine, with separate instructions per type of drug (and sachet). All these medicines were then grouped into a bigger plastic bag that was given to each patient. Other dispensers packed the mixed drugs in sachets per daily intake, while others again combined all drugs purchased with different instructions in one bag ( Fig 1 ). Patients often had little or no idea which medicines were included in the package as it was often referred to as “medicine bag to treat fever”, “belly pain”, or “headache”, etc.

Image credit: TTN.

https://doi.org/10.1371/journal.pgph.0002982.g001

Perceived efficacy to treat illness symptoms

The efficacy of a treatment was judged in relation to the speed with which symptoms were alleviated. Raglai informants often explained this in terms of “fast” or “strong” medicines versus “slow” or “mild” medicines. When medication was started, patients tended to take medication for one to three days in line with their capacity to pay and the other factors described hereabove. During this period, the patient evaluated the drug efficacy against the rapidity of symptom relief. If symptoms abated, treatment was considered effective and pursued (with the potential purchase of additional dosages when means allowed) until symptoms were experienced to have sufficiently decreased. The course was then considered complete and further doses were stored for future use. Treatment failure was often interpreted initially as a “bad prescription”, i.e. the wrong answer to the problem. Such a “bad prescription” could be associated with (i) poor quality of the drugs; (ii) a wrong diagnosis, i.e. the prescribed/purchased regimen was inappropriate for the disease the patient actually had; (iii) the disease being too “strong” for the prescribed medicine. The latter explanation was often linked to spiritual aetiologies, such as the spirit of the sick person being too weak or travelling too far from the physical body for the medicine to take effect.

"… At the communal health centre, they gave me medicines, but sometimes I would still be sick after taking them for a week . I am not sure why, but I think the medicines they prescribed were too mild. Unfortunately, I could not afford to buy stronger medications, so I had to rely on the ones provided at the communal health centre . Occasionally, they would refer me to the district health centre, where they have stronger medicines and highly trained health professionals." (IDI, patient, 11/08/2018)

Perceived quality of medical products

Informants sometimes referred to medicines sold in grocery shops as thuốc bậy bạ or “nonsense medicine” implying that this kind of medicine was considered a temporary solution while waiting to see if symptoms would decline or preparing to seek care from a private or public provider further away. Informants and shop owners named these medicines “fever medicine” or “belly pain medicines”.

Among both Raglai and Kinh people, the quality of drugs from public health centres was often perceived to be lower than in private practices or pharmacies. While some people believed that the health centre medicines healed at a slower pace, others also believed these medicines could only partially heal the disease. The perception about “slow”-working domestic medicines in health centres versus “strong” and “fast”-working imported (foreign) medicines in private pharmacies or healthcare practices was shared by some staff working in health centres, pharmacies, and Raglai key informants with higher socio-economic status. These perceived benefits of foreign medicines were promoted by private providers and used as an argument to justify the higher costs.

Factors driving diagnosis and prescribing practices of providers

Access to diagnostic tools..

At the lowest level of care, the CHC staff reported to have limited diagnostic tools with limited staff training to use diagnostic equipment with the exception of malaria. For any signs of complication or severe illness, CHC staff (often headed by a nurse or more exceptionally a medical doctor) had to refer the patient to district or provincial levels of care, where better diagnostic technologies and trained/specialized staff were available. Private practitioners could also be found in Ninh Son who offered diagnostics capacities such as laboratory testing, medical imaging etc.

In Bac Ai district, the current public health system did not offer routine bacterial surveillance testing nor antibiotic susceptibility testing at commune- and district-level, which limited the possibility of diagnosis to clinical diagnosis and consequent prescription. Laboratory surveillance and antibiotic susceptibility testing was only possible at provincial hospital level, which was one of the least accessible/accessed levels of healthcare for Raglai due to the factors mentioned above.

"… The communal and district health centres are required to refer suspected cases of antibiotic resistance to the provincial hospital . The patient must be admitted to the hospital in Phan Rang City for an antibiotic susceptibility test, which takes two days to obtain results. We rarely have patients of Raglai ethnicity, as the majority of them did not survive long enough to seek medical help from us. Raglai patients often try multiple types of antibiotics at communal health centres or private pharmacies . If these treatments prove ineffective, they often abandon western medicine due to its high cost." (IDI, provincial laboratory director, 18/05/2018)

Access to supplies and storage.

Procurement of medical products varied depending on the type of providers. Medical products (including antibiotics) at public providers were mostly manufactured locally, in Vietnam. Public structures had procedures in place for the procurement, storage, and disposal of expired drugs. Informants explained that CHC and district health centres had to submit requests for medical supplies at higher levels (from commune, to district, to provincial level) which were then procured at provincial level within the available funding following public bidding regulations. Medicine storage rooms were equipped with fans. At home practices, pharmacies or grocery shops, drugs were purchased from wholesale suppliers at district-level and storage conditions were left solely in the hand of the individual provider. Informants explained that procuring their supplies at Bac Ai district was more expensive then at Ninh Son, which was a bigger and central city, and better connected to different districts. Pharmacies could also procure supplies from large pharmaceutical companies or distributors. At grocery shops, drugs were often left in the open, with direct sunlight exposure and without measures in place to manage the expiration dates (as tablets were often stripped off or removed from their protective strips).

Clinical training and competence.

Empirical therapy was mainly prescribed based on clinical diagnosis and seemed to commonly include prophylactic prescription of antibiotics (from observations and conversations). Trained providers from health centres, private practices, and hospitals had to compete with other prescribers, who did not necessarily have (appropriate) training in diagnosis, dispensing, storage, and use, nor imposed limitations on the types of medicines they could prescribe. Private home practitioners were often public healthcare providers with some nursing or medical training, even though the training background could vary substantially from one practitioner to another (for instance pharmacists and laboratory technicians were observed to also have home practices).

Perceived relevance of ABR.

In public structures, regulated lists of medicines to supply and prescribe existed and seemed to be followed according to our observations. However for private/informal providers, prescription medicines were sometimes observed to be sold over-the-counter (i.e. without the customer/patient presenting a relevant prescription). Dispensers (pharmacies, grocery shops, mobile sellers) assessed which medicines to sell based on the described symptoms and known/supposed coinciding medicines as well as the financial means of the client.

Despite having heard about ABR, the interviewed healthcare workers in public structures and private pharmacies commonly shared the perception that while ABR was an issue in big cities, it was not a problem in rural areas because people living there were too poor to buy different types of antibiotics (or medicines in general) and ‘old’ first-line antibiotic treatments were still very effective in patients from rural areas. This contrasts nevertheless with the fact that ampicillin was removed from the list of medicines used by communal and district health centres a few years ago, though it was still sold in pharmacies or distributed as part of incentives for clinical studies or charity medicines donations in the study area.

In light of the current AMR global health threat this study explored several aspects underpinning Raglai people’s access to–and use of medical products. A theoretical framework on vulnerability underpinned this work and was further complemented by work done by Okeke, highlighting that antimicrobial use, prophylactic use, diagnostic imprecision, and interpersonal spread are key factors in the selection and dissemination of resistant strains, which can be related to poverty at the individual patient, health system, and national levels [ 71 ].

With regard to medicine use, we described different factors that impact (timely) access to care and quality medicines, as well as the logics underlying the use of medicines relating to perceived quality and type of medical products, perceived efficacy, and the explanatory logics behind treatment failure. These factors shaped the re-interpretation of the aetiology and associated re-evaluation of the therapeutic trajectory along the course of the illness [ 27 , 30 , 72 – 74 ]. In such a context, the medicine use that might be described as “irrational” from a biomedical perspective (see WHO’s definition of rational medicine use e.g. [ 75 ]) appears logical and rational from a contextualized consumer perspective [ 76 ].

The socio-cultural, economic, political, and structural context in which Raglai are embedded reveals the structural vulnerability they face. Structural vulnerability can be defined as “[a]n individual’s or a population groups’ condition of being at risk for negative health outcomes through their interface with socioeconomic, political and cultural/normative hierarchies. Patients are structurally vulnerable when their location in their society’s multiple overlapping and mutually reinforcing power hierarchies (e.g., socioeconomic, racial, cultural) and institutional and policy-level statuses […] constrain their ability to access healthcare and pursue healthy lifestyles” [ 77 ]. Our study highlights the precarious socio-economic situation of some Raglai communities, which is partially linked to their position in society as “ethnic minority” people [ 78 , 79 ], leading to marginalization and sometimes even self-discrimination. This position as an “ethnic minority” affects the inter-ethnic encounter in health-seeking itineraries of ethnic minority groups in Vietnam as has been shown in other studies [ 80 – 85 ]. Chambers describes how the body is the most crucial asset of the poorest (referring to the body’s role in manual labour, which is often the main subsistence strategy of the poorest), yet it is more vulnerable compared to the less poor and therefore physical disabilities comprise higher personal costs [ 86 ]. Similarly, for Raglai informants the ability to do productive work was regarded as the highest priority in life, i.e. doing manual labour in the fields and everyday chores in the household.

The confluence of the above-mentioned driving factors of medical products’ use are also key for understanding the cumulative processes of (structural) vulnerability that keep the Raglai in “spirals of vulnerability” [ 87 ]. Such vulnerability can be expected to influence exposure to AMR as (i) resistant-promoting activities of some may have consequences for others; (ii) poor people are more susceptible to acquiring an infection–they have low immunity due to malnutrition and repeated and chronic infection (for example due to less access to clean water and food). Structural vulnerability will thus also have an impact on Raglai’s coping mechanisms for facing AMR: (i) people living in poverty are least able to buffer themselves from the consequences of resistance even if they may contribute less to the problems in terms of selective pressure; (ii) the burden of resistant infection is disproportionally shouldered by the less privileged who are (iii) less likely to be able to access appropriate care, ABR control interventions (as not necessarily accessible to poor people), antimicrobials, good diagnostics, good prescribers; (iv) more likely to acquire and consume partial doses, and self-medicate, as well as more likely to access substandard and counterfeit drugs originating from less regulated supply chains [ 71 ].

Raglai people’s “defencelessness” [ 86 ] to “buffer” themselves against the consequences of (resistant) infections illustrates how vulnerable populations need to be actively integrated in multisectoral interventions, policies, and research targeting AMR [ 76 ]. Raglai communities are at hightened risk of resistant infections, yet they are among the least targeted by antimicrobial use interventions, which are mostly set up in secondary and tertiary healthcare facilities and target urban populations. In addition, our findings illustrate that over-the-counter procurement and dispensing of (prescription) medicines in the private and informal sphere not only compounds to Raglai’s precarious situation but also undermines the global effort to combat suboptimal use of antimicrobials (including prescription and broader access).

Limitations

While we looked at several social factors underlying use of medicines and potentially impacting AMR, more data on social factors related to antibiotic use in animals, prescription practices and more specific data on antibiotics is needed to gain a more holistic understanding, especially if combined with interdisciplinary data on AMR in this context (e.g., microbiological and epidemiological data). However, given the current scarcity of AMR data from this context and the time and budget limitations, this was not achievable within the scope of the current study.

Conclusions

The precarity experienced by populations like the Raglai show the need to gather more evidence on the prevalence of AMR among vulnerable populations, as well as its underlying biological and social processes at the community level. In the meantime, access to and use of quality care and medical products could already be improved by focusing on interventions that (i) train (community) care providers and dispensers in AMR and on the risks of suboptimal (poor quality) antibiotic dispensing and use in communities and (ii) organise contextualized community sensitisation activities on these same topics; and (iii) improve active monitoring of compliance to policies regulating the procurement of medical products and their quality assurance, especially in the private sector. Nonetheless, our findings also underline the need for broader structural interventions that address the root causes of poverty and marginalisation of the Raglai people which constitute an essential dimension to tackle.

Supporting information

S1 checklist. inclusivity in global research..

https://doi.org/10.1371/journal.pgph.0002982.s001

S1 Table. Categories of informants.

https://doi.org/10.1371/journal.pgph.0002982.s002

Acknowledgments

Our deep gratitude goes to our informants and all the people met along the way who were of tremendous help to guide us, to find information, and to get a better understanding of the Raglai culture and clues that we couldn’t make sense of. Without important logistical support received from staff at health centres in Phuoc Thang, Phuoc Chien, Phuoc Binh and Ninh Thuan Provincial Centre for Malaria Control, it would have been impossible for us to access the field. We would also like to thank Mai Thi Lim, Patau Asa Ong, Kator Thi Tuyet, Ho Quang Phuc, Truong Hieu M. and Vu Dung K.A. for accompanying/assisting us in different phases of the fieldwork.

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• Open access
• Published: 09 April 2024

A qualitative study on the health system-related needs in women survivors of rape

• Leila Asadi 1 , 2 ,
• Mahnaz Noroozi 3 ,
• Hajar Salimi 4 ,
• Sara Jambarsang 5 &
• Fardin Mardani 6  

BMC Health Services Research volume  24 , Article number:  443 ( 2024 ) Cite this article

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Metrics details

Rape, as an adverse incidence, leads to irreparable complications and consequences in women. Provision of health services to women survivors of rape requires catering for their real needs and identifying current deficits as well as barriers. The present study aimed to explore health system-related needs in women survivors of rape.

In the present qualitative study, the participants consisted of 39 individuals, including 19 women survivors of rape and 20 individuals with work experience in providing services to women survivors of rape. The participants were selected using the purposive sampling method with a maximum variation in Isfahan, Iran. Data were collected through in-depth interviews as well as field notes and were concurrently analyzed via conventional qualitative content analysis method.

After analyzing the interviews, the health system-related needs of women survivors of rape were classified into two main categories: 1- The need for efficient medical care services with three sub-categories, namely “receiving services with respect for privacy and confidentiality”, “non-judgmental behavior and approach”, and “the need to receive empathy and the feeling of not being alone”, and 2- The need for desirable conditions and structure to provide services with two sub-categories, namely “the need to receive comprehensive and integrated services”, and “establishing specialized centers for providing services to survivors”.

Conclusions

Overall, explaining and highlighting the health system-related needs of women survivors of rape could provide a suitable basis for policy-making and planning according to their real needs. Receiving continuous services in separate centers with confidentiality and empathy could reduce the worries and concerns of women survivors of rape and help improve their health.

Peer Review reports

Rape, as a violation of health and human rights, affects numerous women worldwide [ 1 ]. The prevalence of rape is different in every region in the world. Dworkin et al., who studied the prevalence of rape based on studies in the last 10 years, reported a mean rape prevalence of 29% in women in different countries, and 59% in some countries, including South Africa, indicating a very high prevalence of rape in this region [ 2 ]. Statistics related to rape in many countries are not accurate for various reasons such as lack of reporting by survivors. It is believed that about 80% of rape cases go unreported for various reasons [ 3 , 4 ]. In Iran, as with many countries in the world, due to the taboo and fear of social stigma, there are no accurate and reliable statistics on rape cases. Nevertheless, the lack of statistics is not a reason for the absence of such a problem. In some studies, incest rates are reported to be about 22–25% [ 5 ].

Women survivors of rape experience a large number of short and long-term consequences in different aspects of health [ 6 ]. The most important psychological consequences include post-traumatic stress disorder (PTSD), as well as other anxiety disorders, depression, and suicide [ 7 , 8 , 9 , 10 , 11 ]. Other implications include sexually transmitted infections (STIs), HIV/AIDS, chronic diseases, physical injuries to the body and genital area, unwanted pregnancy, and unsafe abortion [ 12 , 13 , 14 , 15 ].

Even though rape is a very important threat to the health of many women, the use of health services is very low among survivors in many societies [ 16 , 17 ]. The provision of health services to survivors of gender-based violence, including rape, has been significantly developed since 2000 thanks to the extensive activity of reproductive health activists. Based on a global evaluation of sexual and reproductive health in 2004, the clinical management of rape in humanitarian settings is associated with many deficits, but such services were more widely available 10 years later [ 18 ]. Despite the considerable developments, the provision of suitable services to survivors faces problems owing to several reasons, including insufficient budgets of countries, lack of correct referral of survivors, limited supply and stock of drugs, and gender biases in societies [ 19 , 20 ]. The survivors also seldom use these services even in countries where such barriers have been removed [ 19 ]. Women survivors of rape face numerous barriers to receiving health services, including stigma, rejection, and non-confidentiality, leading to under usage of health services by survivors [ 20 ]. Meanwhile, the needs of women survivors of rape should be recognized and they should receive suitable services and support according to their needs. Providing services while neglecting their needs will cause them to be re-victimized and suffer more injuries [ 21 ].

Knowledge about perceptions and experiences of women survivors of rape regarding services, as well as the existing barriers and deficits in healthcare systems is significantly important in comprehensive and cultural-based interventions for improving health services, and ultimately, their health. There is little research on the proper and desirable services of this group of women, and it is not yet clear whether the existing services are fully tailored to their needs. Qualitative research is an approach to discovering and describing the experiences of participants and conceptualizing them. It could enhance insight, perception, and knowledge of human experiences [ 22 ]. Considering the differences in the social and cultural context of Iran with other countries as well as the importance of sexual and reproductive health of women survivors of rape, this qualitative study aimed to explore the health system-related needs of women survivors of rape.

This research was part of a large mixed-methods study conducted with a content analysis approach from November 2021 to August 2022.

Settings, sample, and recruitment

The participants of the study included women survivors of rape ( n  = 19) and individuals with work experience in providing services to them ( n  = 20) in Isfahan, Iran. The selection of rape survivors began through purposive sampling and then continued with a strategy of maximum variation regarding age, job, education level, marital status, number of pregnancies and deliveries, and length of time after rape. Subsequently, a number of participants were included in the research using the snowball method based on the introduction of the primary participants. The inclusion criteria for women survivors of rape were informed consent and willingness to participate in the interview, being able to communicate and express experiences of rape, Iranian nationality (due to the difference in the needs of rape survivors according to cultural and social conditions and background), being 21 years old or older during the research [ 23 ], a minimum of 6 months and a maximum of 2 years past the rape [ 10 , 24 ], lack of well-known psychological disorders and a history of psychiatric treatment before rape or now (based on the participant’s report), no previous experience of rape, and no experience of adverse incidents in life (death of a family member, etc.) over the past three months. Exclusion criteria included reluctance to continue participation in the study at any stage of the study. Service providers were also first selected via purposive sampling, and then sampling continued with a strategy of maximum variation in terms of work experience. Inclusion criteria for service providers included willingness to participate in the study plus having expertise and work experience in the field of rape.

In the present study, access to the participants was done through the special counseling centers for vulnerable women, Drop in Centers (DIC), addiction treatment centers, social emergency, together with women’s rehabilitation centers, midwives and reproductive health specialists’ offices, counseling and midwifery service centers, emergency and women’s and midwifery clinics of hospitals, legal medicine centers, counseling centers for behavioral diseases, private offices of general practitioners and specialists (obstetrics and gynecology, infectious diseases and psychiatry), psychology and counseling centers, guidance and counseling centers at universities, social deputy of the Law Enforcement Force, and Crime Prevention Unit (affiliated to the judicial system) of Isfahan city. In these centers, participants were invited to the study through phone calls. In order to maintain confidentiality, phone calls were made to the women survivors of rape and the criteria for their entry into the research were checked by the service providers working in the centers; the researcher was able to access their contact information only after obtaining informed consent from the survivors. In the present study, no one refused to participate or dropped out of this study once they were recruited to participate. The first author (L.A) had no previous relationship with the participants and centers.

Data collection

In the present study, data collection methods included semi-structured in-depth interviews and field notes. The first author (L.A) conducted the interviews and filed notes. She had 11 years of working experience in midwifery and was a Ph.D. candidate in reproductive health in Isfahan University of Medical Sciences. Four other authors had previous experience in qualitative paper/report writing and interviewing. Prior to data collection, the first author (L.A) wrote down initial preconceptions about the study topic based on her previous working experience and from literature review. Questions, prompts, and guides were provided and this was piloted in two pilot interviews. Interviews with women survivors of rape began with the general questions: “What problems have you faced in receiving health services since this incident (rape)? What needs did you feel in this regard? Please explain it.“ , and then the participants’ open and interpretative answers guided the process. The interviews with service providers began with the general question: “ What do you think women, who have experienced rape, need about the healthcare system? Please explain it.“ , and then the participants’ open and interpretative answers guided the process. All interviews were digitally recorded using an MP4 device. In this research, 39 interviews (lasting 45 to 60 min) were conducted in participants’ preferred places (such as parks). No one else was present at the interview besides the participants and the researchers. The interviews continued until data saturation was reached by interviewing 36 persons, with no new code being formed, and all codes previously obtained and duplicated. However, to avoid false data saturation, the researchers conducted another three interviews after repletion of codes in interview NO.36, to be more confident of achieving accurate data saturation, with no new data in the next three interviews. At this point, the researchers concluded that they would stop the data collection and analysis since data saturation had been obtained. In the present study, the first author (L.A) recorded observations of participants’ non-verbal behavior and interaction in field notes.

Data analysis

In the present study, conventional qualitative content analysis based on the method by Graneheim and Lundman was used to analyze the data [ 25 ]. Data analysis was performed manually where no software was used. The data were regularly transcribed after each interview. Then, the interviews were read repeatedly to obtain a complete understanding of them. Sentences and expressions were coded by the first author (L.A) and after the formation of codes by the inductive method, similar codes were merged; those with similar meanings were placed in one category and created sub-categories. Thereafter, the conceptually similar categories were placed in a main category and constituted the main categories.

Rigor and trustworthiness

A variety of methods, including in-depth interviews at different times and places, field notes, and selecting participants with a maximum variation were utilized to validate the results. In the present study, the results were presented to three women survivors of rape with the same characteristics as the participants, who did not participate in the study, to judge the similarity of the study results with their own experiences so that the transferability could improve. To enhance the confirmability of the data, coded interviews were discussed with five participants in other meetings and their final comments were summarized to achieve a review by participants. To augment the dependability of the results, the opinions of five experts were used to match and ensure the consistency of the results with the participants’ statements.

Ethical considerations

The research was approved by the ethics committee of Isfahan University of Medical Sciences (approval code: IR.MUI.NUREMA.REC.1400.133). Informed consent, right to withdraw at any time, confidentiality, and preservation of anonymity were respected in this research. The objectives for the study were explained prior to each individual interview.

The demographic characteristics of the participants are reported in Table  1 . A total of 34 inferential codes, five sub-categories, and two main categories were extracted after data analysis. The two main categories included “The need for efficient medical care services” and “The need for desirable conditions and structure to provide services” (Table  2 ).

1-The need for efficient medical care services

According to the participants, the health services provided to the survivors were inefficient and did not meet their needs. Many of the participating survivors expressed their discomfort with the lack of respect for privacy and confidentiality while receiving services, recording personal information when providing services, wrong behaviors and judgments, and lack of understanding, acceptance, and empathy. Further, many of these women faced such issues when going to the centers, then left the center or gave up receiving health services. This main category was composed of three sub-categories, namely “receiving services with respect for privacy and confidentiality”, “non-judgmental behavior and approach”, and “the need to receive empathy and the feeling of not being alone”.

A-Receiving services with respect for privacy and confidentiality

Participating rape survivors were worried about the disclosure of their names and identity when visiting healthcare centers. They expressed that they needed special attention from service providers to maintain confidentiality and non-disclosure of their identity information at all stages. For this reason, many of them had refused to go to pharmacies and health centers owing to being worried about their identity information being revealed.

“I was frightened to go to the doctor. I was afraid that someone might know my name. For example, I used to say (to myself) that they would know my name and recognize me, lest they wrote my name in a list.” (A 37-year-old survivor) . “… I was worried that if I go to the pharmacy to buy pills or go to the doctor, my information would be read and they would record what medicine I took.” (A 35-year-old survivor) .

The service providers narrated that most survivors of rape were worried about the disclosure of their identity when they were in healthcare centers, and thus they often refused to continue attending those centers and received incomplete services.

“… When the result of their HIV or HBS Ag tests are positive and we inform them, either they don’t come to receive medication and continue treatment and we have to follow up regularly, or they insist on not recording their test results in their files.” (Midwife) .

B-Non-judgmental behavior and approach

According to most participating survivors, when they received healthcare services, they face service providers’ judgmental behavior which was very annoying for them. They were dissatisfied with the fact that they were considered guilty in the incident of rape and the behavior of health service providers that made them feel guilty. Therefore, they did not express real health problems and needs due to the worry and embarrassment of being judged.

“… When I went to the pharmacy and took pills, that man looked at me in an unsatisfactory way. In these cases, society looks at girls very badly. They always think that it is often due to girls’ fault. “(A 37-year-old survivor) . “… When I went to the laboratory, they didn’t treat me well. They never talked to me. I gave the doctor’s prescription to take a specimen from me. After reading, he looked at me and just said: Go sit in the room. His behavior was annoying.” (A 25-year-old survivor) .

The service providers argued that behavior with judgment and blame could be barriers to receiving correct healthcare services in survivors. When survivors were faced with such blaming behavior combined with judgment, they would have doubts about disclosing the rape, leading them to postpone receiving healthcare services.

“… I had clients who came with other complaints, including anxiety and stress. When they received empathy and non-judgment, they slowly started to reveal the rape and ask for help.” (Psychiatrist) .

C-The need to receive empathy and the feeling of not being alone

The participating rape survivors narrated that they needed to receive empathy from service providers due to the bitter experience of rape. Many of them expressed that they needed service providers to understand their situation and empathize so that they felt they were not the only people who were raped. They needed to receive the necessary support resources to disclose the rape incidence in the healthcare system. Many of them were annoyed by the lack of empathy. An important negative experience of these women about not receiving empathy was during the virginity examination.

“… Here (The Forensic Medicine Organization), they didn’t pay attention to my feelings, nor to my voice and cries, and said like a normal patient, go upstairs and sleep. I had never been examined. My hands and legs were shaking.” (A 21-year-old survivor) .

The service providers argued that if rape survivors received empathy and support from service providers, they would attend diagnostic and treatment processes more favorably and make more efforts to improve their health status.

“Our behavior in the first meetings definitely has a great effect on not abandoning the person. When a person finds out we understand her and that she is not alone, it will definitely facilitate her future visits. In these women, not leaving care and follow-up is very important, where understanding and empathy with the surviving person should be a high priority for us.” (Psychiatrist) .

2-The need for desirable conditions and structure to provide services

According to the results, healthcare services must be provided in optimal conditions and structures to meet the maximum needs of rape survivors. According to the participants, the current structure of health services did not fully cover the rape survivors’ needs and it required changes. This main category was obtained from the two sub-categories, namely “the need to receive comprehensive and integrated services”, and “establishing specialized centers for providing services to survivors”.

A-The need to receive comprehensive and integrated services

The participating rape survivors narrated that they were referred to different centers (including private clinics and offices, behavioral disease centers, medical centers, and centers affiliated with the welfare organization) to receive health services, and in each center, they received separate services that sometimes overlapped with other services. Based on the results, not only this issue led to spending a lot of time and money for the survivors, the lack of integrated services caused failure in receiving some essential services (e.g. diagnosis and treatment of STIs, contraception, supportive and psychological services). The impossibility of follow-up, failure to examine the survivors’ real needs at different stages after the rape, and providing interrupted services regardless of personal records were the most important disadvantages of such services.

“… After my presence in the Forensic Medicine Organization, I went to the gynecologist’s office, and she gave me medicine for the infection. After some time, I still had a vaginal discharge. With my friend’s advice, I went to the infectious disease specialist and now I am taking a new medicine, but I still haven’t seen any difference.” (A 38-year-old survivor) .

According to participating service providers, survivors of rape needed to receive comprehensive and integrated services provided by a team with different specialists comprising a gynecologist, a forensic medicine specialist, a psychiatrist, a social worker, and a psychologist to enhance their access to all necessary services and prevent long-term complications. They also recommended the establishment of centers for survivors of rape to provide services to them with long-term continuous follow-up.

“The services and support for these women should be presented by a more specialized organization or group; hence, when these women visit, they know that the services are provided in a package, and all of their issues will be resolved without any problems.” (A forensic medicine specialist) . “… The services for these women need to be presented by a team. Comprehensive, complete, and timely services should be provided, and this team should consist of gynecologists, social workers, psychologists, forensic medicine specialists, and psychiatrists.” (Psychiatrist) .

B- establishing specialized centers for providing services to survivors

The lack of specialized centers to provide services to women survivors of rape is another deficiency of the healthcare systems which was taken into account and stated by the participating rape survivors.

“… In my opinion, I wish the Forensic Medicine Organization would follow up on the issue. I wish they had a consultant here who would follow up on our bad situation and we could follow up on the spot because we don’t like to talk about this issue everywhere.” (A 23-year-old survivor) .

The participating service providers argued that due to the rape survivors’ need to visit psychological, gynecological, midwifery, and laboratory centers to receive a variety of services, many of them did not present to these centers and missed necessary services due to the lack of special service centers. Also, they emphasized consideration of centers specialized in providing services to women survivors of rape.

“… Most of the visiting survivors finally reach us after wandering around and visiting different centers and places.” (Gynecologist) . “The (health) system should move towards a separate center for these women to receive necessary procedures and consultations so that when the examination is conducted (legally), this person knows that she does not need to go elsewhere to prevent pregnancy and infections.” (A forensic medicine specialist) .

The present study aimed to explore the health system-related needs of women survivors of rape. The results indicated that women survivors of rape needed desirable, structured, and efficient care as well as treatment services. Survivors participating in the present study had experiences of non-preserved confidentiality, non-respected privacy, and blaming behaviors far from empathy in receiving healthcare services. There is a belief that women survivors of rape have many unmet physical and psychological needs making them dependent on health care systems. These needs should be identified and resolved in cultural contexts [ 26 ]. In this regard, the results of a systematic review by Bach et al. indicated that service providers’ insufficient knowledge about the way of empathizing with rape survivors without judgment and preserving confidentiality was an important barrier to survivors receiving healthcare services [ 27 ]. Conducting an exploratory descriptive qualitative study through interviews with survivors of rape, Sebaeng et al. reported that health service providers should be sensitive to problems experienced by women survivors of rape, not consider them as survivors of the crime scene, nor think of just collecting medical and legal evidence as their duties [ 28 ]. Polite et al. also confirmed that physicians and service providers not only must comply with medical and judicial guidelines and perform their therapeutic duties, but also should provide support and build trust through understanding, empathy, and non-judgment of the survivors [ 29 ]. Munala et al. reported that survivors of rape were concerned about the attitude of physicians and healthcare providers, normalization of rape, and blaming them [ 30 ]. Ferdowsian et al. found that profession was significantly associated with beliefs and attitudes about sexual violence and survivors. Law enforcement professionals were more likely than health professionals and lawyers to indicate that survivors should feel ashamed [ 31 ]. Thus, women survivors of rape need to receive survivor-based healthcare services which include non-judgmental and empathic behaviors. Health service providers should be supportive, not judge the survivors, and consider survivors’ dignity while providing services to bring aobut an efficient service procedure. It seems that the existing health services for women survivors of rape in Iran need detailed policies and plans based on women , s needs, since the absence or incomplete health services can re-victimize and have many consequences for them. The results of the present study emphasized providing survivor-based medical care services for women survivors of rape since the way of providing services to survivors greatly contributed to the process of incident disclosure by survivors and their presence in the next meetings and follow-ups. Also, our findings suggest a need for interventions that adequately address potentially harmful beliefs as well as attitudes of some professionals serving women survivors of rape.

The present study also found that the necessary services for women survivors of rape should be comprehensive, integrated, and be provided by a team. Furthermore, these services should be provided in specialized centers that were specific to women survivors of rape. In this way, they would be assured of the provision of necessary and efficient services with long-term continuous follow-up. Sebaeng et al. study also indicated that survivors of rape needed to receive healthcare services through integrated specialized “Sexual Assault Response Teams (SART)” which provide all integrated services in teams by different specialists in separate centers to enhance the survivors’ access to all essential services and prevent long-term complications [ 28 ]. Shahali evaluated the healthcare providers’ experiences in dealing with survivors of rape and reported that two important barriers for survivors to receive health services included the lack of a single center for the provision of essential healthcare services to survivors of rape and the lack of organized guidelines for interdepartmental interaction [ 32 ]. Sepeng et al. in a study in Africa reported that most rape survivors received managed care for acute psychological health problems, injuries, pregnancy, STIs, and HIV; however, few survivors of rape received managed psychological healthcare during follow-up care sessions. They attributed the low attendance of survivors in psychological follow-up sessions to the lack of an integrated and continuous medical care system [ 33 ]. Ades et al. observed that even though patients with a history of sexual assault often had essential health needs, which continued long after the traumatic incident, most of the available services to survivors of rape only focused on acute care immediately after the violence, and a few clinics managed long-term medical outcomes and consequences of rape in a specialized trauma center [ 34 ]. Bougard et al. evaluated the quality of service provision in comprehensive multi-specialty centers for providing integrated rape services in South Africa and reported that the quality of service provision was satisfactory in these specialized centers, and survivors were highly satisfied with the available services as they received all services in a specialized center [ 35 ]. The results of the present study emphasized women survivors of rape need care and treatment services according to their basic needs in such a way that continuous services and long-term follow-up are provided with respect for confidentiality and privacy without judgment, stigma, and blame. Also, establishing specialized centers, which provide all required healthcare services to women survivors of rape, is particularly important in improving the quality of care for these women in Iran.

Practical implications

Recognizing health system-related needs in women survivors of rape could facilitate evidence-based policymaking, planning, and making necessary changes in the health system. In addition, the results of the present study can help service providers understand, evaluate, and recognize the needs of women survivors of rape so that they can try to meet these needs and solve existing problems to improve women’s health. It is expected that the results of the present study will be utilized as a basis for conducting wider and more comprehensive studies about women survivors of rape and result in the identification of newer research domains. Future studies are suggested to design, conduct, and evaluate effective survivor-based health programs for women survivors of rape in Iran.

Strengths and limitations

Through presenting an image of health system-related needs in women survivors of rape for the first time in Iran, the present study could contribute to designing the necessary interventions to improve health of these women. The most important limitation of the present study was the survivors’ shame or modesty to talk about the rape due to cultural and social taboos in Iran. Therefore, attempts were made to build the participants’ trust by providing explanations about the importance of the issue, committing the researchers to preserve confidentiality, as well as providing a safe and calm space for effective communication. Furthermore, researchers faced difficulties in obtaining permission to access participants in a number of research environments. In this sense, the researchers had to attend the centers that had issued sampling permits as well as reached the participants using the snowball sampling method.

Based on the results of the present study, necessary measures should be taken to provide efficient medical care services to women survivors of rape and develop a desirable structure for providing health services in such a way that they can receive necessary services continuously in special centers with confidentiality and empathy. These results can be helpful for policy-making, planning, designing successful interventions, as well as providing basic and comprehensive care programs to improve women’s health.

Data availability

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

Abbreviations

Post-Traumatic Stress Disorder

Sexually Transmitted Infections

Drop-in Centers

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Acknowledgements

We should thank the Vice-chancellor for Research of Isfahan University of Medical Sciences for their support.

Financial support by Isfahan University of Medical Sciences, Research proposal No: 3400527.

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Leila Asadi

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Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Mahnaz Noroozi

Behavioral Sciences Research Center, Department of Psychiatry, Isfahan University of Medical Sciences, Isfahan, Iran

Hajar Salimi

Research Center of Prevention and Epidemiology of Non-Communicable Disease, Department of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

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All the authors contributed to the conception and design of the study. L.A drafted the first version of the manuscript. M.N, H.S, F.M and S.J revised the manuscript. M.N critically reviewed the manuscript for important intellectual content. All authors approved the final version.

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Correspondence to Mahnaz Noroozi .

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The Ethics Committee of the Isfahan University of Medical Sciences in Isfahan, Iran approved the protocol of this study (code number: IR.MUI.NUREMA.REC.1400.133). Written informed consent is taken from each participant. In this study, all methods were carried out in accordance with the Declaration of Helsinki.

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Asadi, L., Noroozi, M., Salimi, H. et al. A qualitative study on the health system-related needs in women survivors of rape. BMC Health Serv Res 24 , 443 (2024). https://doi.org/10.1186/s12913-024-10852-0

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Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

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• Open access
• Published: 11 April 2024

Pregnant and postpartum women’s experiences of the indirect impacts of the COVID-19 pandemic in high-income countries: a qualitative evidence synthesis

• Annie Tan 1 , 2 , 3 ,
• Amanda Blair 2 , 4 ,
• Caroline SE. Homer 1 , 2 ,
• Robin Digby 1 , 3 , 5 ,
• Joshua P. Vogel 1 , 2 &
• Tracey Bucknall 1 , 3 , 5  

BMC Pregnancy and Childbirth volume  24 , Article number:  262 ( 2024 ) Cite this article

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Pregnant and postpartum women’s experiences of the COVID-19 pandemic, as well as the emotional and psychosocial impact of COVID-19 on perinatal health, has been well-documented across high-income countries. Increased anxiety and fear, isolation, as well as a disrupted pregnancy and postnatal period are widely described in many studies. The aim of this study was to explore, describe and synthesise studies that addressed the experiences of pregnant and postpartum women in high-income countries during the first two years of the pandemic.

A qualitative evidence synthesis of studies relating to women’s experiences in high-income countries during the pandemic were included. Two reviewers extracted the data using a thematic synthesis approach and NVivo 20 software. The GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) was used to assess confidence in review findings.

Sixty-eight studies were eligible and subjected to a sampling framework to ensure data richness. In total, 36 sampled studies contributed to the development of themes, sub-themes and review findings. There were six over-arching themes: (1) dealing with public health restrictions; (2) navigating changing health policies; (3) adapting to alternative ways of receiving social support; (4) dealing with impacts on their own mental health; (5) managing the new and changing information; and (6) being resilient and optimistic. Seventeen review findings were developed under these themes with high to moderate confidence according to the GRADE-CERQual assessment.

Conclusions

The findings from this synthesis offer different strategies for practice and policy makers to better support women, babies and their families in future emergency responses. These strategies include optimising care delivery, enhancing communication, and supporting social and mental wellbeing.

Peer Review reports

As of February 2024 SARS-CoV-2 has infected over 774 million people, and 7 million deaths have been attributed to coronavirus 19 (COVID-19) infection [ 1 ]. Maternal and newborn health services are essential for pregnant and postpartum women, and the COVID-19 pandemic significantly altered provision and access to routine care. Reduced services, limited face-to-face care, transition to virtual and remote care, and limited access to maternity care providers were commonly cited as barriers to accessing quality care by pregnant and postpartum women [ 2 , 3 , 4 , 5 , 6 ]. Additionally, reduced lengths of stay within hospitals and restrictions on support people imposed by health facilities have impacted women receiving care and placed an additional burden on nursing and midwifery staff [ 7 , 8 , 9 ]. This had significant impacts on pregnant and postpartum women’s emotional and psychosocial wellbeing.

Pregnant women and their babies were at an increased risk of adverse effects if she contracted SARS-CoV-2 [ 10 , 11 ]. The direct impacts of the COVID-19 pandemic were largely focused on the clinical manifestations of SARS-CoV-2 such as symptoms, risk factors, management and treatment, as well as adverse maternal and newborn outcomes [ 12 , 13 , 14 , 15 ]. However, at a wider level, the impacts of policy changes, health system reforms and changes to maternity care services indirectly affected the provision of care for all women giving birth over this time period. Women’s experiences of the transition from pregnancy to motherhood were also impacted. For example, in many countries, pregnant women were encouraged to homestay at home, receive care through telehealth rather than face-to-face and reduce face-to-face education [ 16 , 17 ]. Isolation from family, friends and peers has negatively impacted women’s mental health, with increased levels of anxiety, depression and stress globally [ 18 , 19 , 20 , 21 ].

Since the beginning of the pandemic, there has been a plethora of qualitative studies on women’s experiences [ 19 , 22 , 23 , 24 , 25 , 26 ] – the significant volume of papers highlights the need for a clear synthesis. Reviews of qualitative evidence have reported pregnant women’s experiences of social support [ 27 ], as well as highlighting the challenges they faced as they embraced motherhood during the pandemic [ 28 ]. Collating the evidence in a systematic and transparent manner will allow policymakers to consider the indirect implications of public health restrictions on the physical, emotional, and psychosocial health and wellbeing of pregnant and postpartum women.

Qualitative evidence synthesis (QES) is an approach that can systematically collate qualitative data in a transparent manner to inform policy and practice [ 29 ]. Findings from a QES can enable a richer interpretation of a particular phenomenon and enable a greater understanding of individual experiences, views and beliefs [ 30 ]. This QES aimed to explore, describe and synthesise the experiences of pregnant and postpartum women living in high-income countries during the first two years of the COVID-19 pandemic. This research method allows a deeper understanding of their views and experiences during this time. It also facilitates identification of areas of improvement for maternity care services, to ensure high-quality care is available at all times.

A QES was undertaken to identify, evaluate and summarise findings from qualitative studies providing a cohesive and transparent documentation of the contextual variations, stakeholder preferences and experiences to ultimately influence policy and practice [ 31 , 32 ]. This type of synthesis integrates diverse perspectives, which is needed to capture the complexity of the indirect impacts of the COVID-19 pandemic on pregnant and postpartum women’s experiences. This QES was structured to include findings from qualitative studies, as well as qualitative findings from mixed-methods studies. Emphasis was placed on including different types of qualitative evidence that can potentially enrich a synthesis, such as narrative data from qualitative components of mixed-methods studies or free-text from questionnaires [ 29 ].

We followed the relevant Cochrane guidelines [ 29 ] and used the “Enhancing transparency in reporting the synthesis of qualitative research” (ENTREQ) statement to guide our approach and reporting (Supplementary 1 , S1) [ 33 ]. In addition, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting the different phases of identifying studies was used as recommended by the ENTREQ statement (S 2 ) [ 34 ]. The protocol and systematic review were not registered.

Eligibility criteria

We defined “indirect impacts of the pandemic on women”, to mean the impact of regulations, recommendations and public health measures enforced by governments as a response to the COVID-19 pandemic had on pregnant and postpartum women and their newborns. We adopted the World Health Organization’s definition of the postpartum period beginning immediately after birth of the baby and extending to six weeks (42 days) after birth [ 35 ].

Participants within these studies were those who were pregnant or within the postpartum period, of childbearing age (15-49 years), and received any type of maternity care during the COVID-19 pandemic. Studies of women with pre-existing comorbidities were also eligible, as well as those focused on migrants, refugee populations or ethnic minority groups. To facilitate exploration of findings from women of diverse backgrounds we have used the term ‘culturally and linguistically diverse (CALD) populations’. We focussed on women living in high-income countries (HICs). Studies were included if they were conducted in countries listed in the Organisation for Economic Co-operation and Development (OECD) [ 36 ] and Human Development Index (HDI) list of “Very high human development” list [ 37 ]. This allowed for similar contexts and countries to be compared.

Eligible study designs were those that addressed the indirect impact of COVID-19 using qualitative methodologies, including phenomenology, ethnography, grounded theory studies and case studies. We also included any study that obtained data through qualitative methods for data collection such as, interviews, focus groups, online forums and document analysis.

The decision to limit the eligibility based on year of publication, to only include studies published in the first two years of the COVID-19 pandemic (1 st Jan 2020 – 1 st Jan 2022) was to emphasise the impact of the stricter restrictions and lockdowns during this time period. Globally, public health measures to reduce spread and transmission included, mandatory quarantine, limiting movement, lockdowns, closure of schools and workplaces and shielding of vulnerable populations. These measures were significantly harsher during the first two years and subsequently relaxed as vaccine roll-outs occurred and infection rates began to decline [ 38 , 39 ]. The Oxford Coronavirus Government Response Tracker reported a stringency index which reiterates the trend of harsher restrictions implemented by governments throughout 2020-2022 time period and reflects the gradual decline after this date [ 40 ].

Search strategy

Six electronic databases (EBSCO Medline, Embase, APA PsycInfo, CINAHL and Maternity and Infant Care (MIDIRS)) were searched to identify all qualitative research articles published between 1 st January 2020 – 1 st January 2022. Search strategy included terms such as, “pregnan*”, “postpartum”, “mother”, “views”, “experiences”, “opinion*”, “indirect”, “COVID-19”, “coronavirus”. The search strategy was reviewed by a university librarian (S 3 ). Search hits from each of the databases were imported into Endnote 20 which was then used as our reference library. References were imported into Covidence for screening [ 41 ].

Study selection and sampling framework

Two review authors (AT, AB) independently screened titles, abstracts and full texts for inclusion, with any conflicts resolved by discussion or consulting a third author. Reasons for exclusion are described within PRISMA flowchart (Fig. 1 ). Sixty-eight studies were included following full-text review. The Cochrane guidelines for QES highlight that for reviews with large amounts of primary studies (50 or more) can result in a high volume of data, which can threaten quality of the synthesis. In such situations, a sampling framework can enhance the quality and diversity of the papers and ensure the number of studies and amount of data are manageable [ 42 , 43 , 44 ]. A QES worked example by Ames et al., 2019 was used as a guide to develop the sampling framework for data richness [ 45 ]. Two independent reviewers scored included studies from 1 to 5 based on the criteria outlined in Table 1 , to ensure that the sampling framework was reliable and replicable. Any conflicts were resolved by discussion, or a third review author was consulted. Studies with a score ≥4 were included for data extraction and are referred to as ‘sampled’ studies (S 4 ).

Reporting of adapted PRISMA flowchart of included and sampled studies in accordance with PRISMA and ENTREQ guidelines [ 33 ]

Quality assessment

The Critically Appraisal Skills Program (CASP) tool for qualitative research was used by two independent review authors (AT, AB) to assess methodological limitations of sampled studies (S 5 ) [ 46 ]. Any disagreements were resolved through discussion, or when required, a third review author was consulted. Sampled studies were graded as no or very minor, minor, moderate or severe concerns with methodological limitations.

Data extraction and synthesis

A “Characteristics of sampled studies” table was created in Excel and details are reported in Table 2 . Two independent reviewers familiarised themselves with the sampled studies and extracted key themes using Braun and Clarke’s reflexive approach to inductive and deductive thematic analysis [ 47 ]. Data were managed using NVivo 20 [ 48 ]. This was an iterative process as many of the themes and sub-themes overlapped and were relevant in many aspects throughout the perinatal period (Table 3 ). The findings were developed iteratively, and periodically shared with the broader team to evolve our interpretation. Any quotes taken from studies were selected as they reiterated findings, and provided additional depth and meaning to review findings.

Extracted data were populated into two tables for analysis. The first table collated quotes and author interpretations of findings (S 6 ), whilst the second table summarised these into review findings (Table 4 ).

Assessment of confidence in the review findings (GRADE-CERQual)

The GRADE-CERQual tool assesses the confidence in review findings from qualitative evidence syntheses [ 83 ]. Lewin et al., 2018 state that that “the approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation” [ 83 ]. The GRADE-CERQual Interactive Summary of Qualitative Findings (iSoQ) online platform was used to manage and assess confidence in review findings [ 84 ].

Confidence in review findings was determined based on four criteria: methodological limitations, coherence, adequacy and relevance [ 83 ]. For each criterion, review authors determined if there were no or very minor, minor, moderate or serious concerns. An overall GRADE-CERQual assessment of confidence was placed on the findings, levels included: high, moderate, low and very low confidence. Review findings are considered at the highest confidence level and downgraded as there are greater concerns for each individual criterion (Table 4 ). This process was conducted by two authors, with any disagreements resolved through discussion and consulting other authors.

Managing our own reflexivity

Throughout the conceptualisation, data collection and analytical process, the authors considered their own individual views and beliefs about maternity care during the COVID-19 pandemic. As clinicians and researchers working on maternity care (including during the pandemic), we recognised that the COVID-19 period impacted indirectly on women and babies, including their experiences of care, their own anxieties and worries. We are public health professionals with diverse backgrounds including nursing and midwifery, maternal and newborn health, epidemiology and qualitative health research. We met regularly, both to explore the findings and the processes but also to ensure that we separated our individual experiences and beliefs on the interpretation of the analysis and the findings. Employing a systematic and transparent approach to the analytical process, such as including reflection notes after analysing each sampled paper, facilitated collaborative discussions, ensure objectivity and reduced the impact of personal biases.

A total of 36 studies contributed to the synthesis of qualitative evidence to understand pregnant and postpartum women’s experiences during the first two years of the pandemic. There were six over-arching themes: (1) dealing with public health restrictions; (2) navigating changing health policies; (3) adapting to alternative ways of receiving social support; (4) dealing with impacts on their own mental health; (5) managing the new and changing information; and (6) being resilient and optimistic. Seventeen sub-themes were developed within these 6 themes and illustrative quotes are presented in Table 3 to demonstrate theme development. Themes were categorised to differentiate major disruptors to the pregnancy and postpartum period and sub-themes aimed to categorise the indirect impacts that occurred within the major themes.

Characteristics of contributing studies

After applying the sampling framework (data richness score ≥4), 36 sampled studies were included for data extraction and analysis. Thirteen out of 36 studies had a score of 5 [ 49 , 52 , 57 , 58 , 61 , 62 , 63 , 66 , 68 , 69 , 71 , 77 , 82 ], with the remainder scoring 4 [ 9 , 16 , 50 , 51 , 53 , 54 , 55 , 56 , 59 , 60 , 64 , 65 , 67 , 70 , 72 , 73 , 74 , 75 , 76 , 78 , 79 , 80 , 81 , 82 ] (S 5 ). Most studies ( N =27/36, 75%) used specific qualitative methodologies, six were mixed-methods studies, two were cross-sectional studies, and one was a case series report.

Studies were conducted across nine countries, almost one-third ( N =10/36, 28%) of studies published from the UK, Canada ( N =7) and the USA ( N =7) (Table 2 ). Country-specific responses to the pandemic largely included border closures, mandatory lockdowns and restrictions on movement; it is interesting to note that Sweden did not mandate this but instead enforced social distancing practices [ 68 ]. Additionally, some studies reported on a specific sub-population of pregnant and postpartum women, for example women from ethnic minority groups, those with pre-existing comorbidities, and those who were COVID-19 positive. Some studies also included results from women with babies who were greater than 6 months of age, and any findings directly from these participants were omitted from analysis where possible.

The number of participants in studies that conducted interviews ranged from 3 to 84, and studies using qualitative data from open-ended questions or survey data included responses from 16 to 4,611 participants. Where demographic data were available, approximately 1,192 women were primiparous (having their first baby) and approximately 8,017 women were surveyed or interviewed postpartum. Sampled studies were generally of high quality and assessment of methodological limitations indicated that 29 studies were assigned “no or very minor concerns”, six studies were assigned “minor concerns”, and one study was assigned “moderate concerns”. When available, quotes obtained from studies have included additional demographic data. Factors included pregnant or postpartum status at time of data collection, parity and geographical location.

Theme 1: Dealing with public health restrictions

The rapid introduction of public health restrictions has had adverse effects on mental health, social isolation, and the pregnancy experience. Women had to navigate these restrictions and adapt accordingly, realising quickly that their pregnancy and postpartum experience was going to be very different from their expectations.

Sub-theme 1.1. Limited support networks from health care system and providers (High confidence)

Support networks were limited. Women felt that they were “on their own”, “unimportant or irrelevant” or treated as “second class citizens” after birth, because of a lack of physical supports from healthcare providers [ 51 , 60 , 61 , 62 , 70 , 72 , 74 ]. Limited or no access to physical and social support networks was commonly cited as a reason for deteriorating mental health.

Sub-theme 1.2. Balancing exposure risk and need for healthy behaviours (High confidence)

Women balanced COVID-19 exposure risks by shielding, either because of health providers recommendations [ 16 , 69 ] or because they felt it was needed to protect their baby [ 50 , 68 , 71 , 77 , 81 ]. Women delayed or postponed antenatal appointments [ 50 , 57 , 69 , 72 , 82 ], opted for induction of labour [ 74 ], or waited until labour was quite advanced before attending hospital [ 60 , 61 , 77 ]. These decisions were due to pandemic-induced fear, and the perceived risk of infection in a high-risk environment such as the hospital [ 16 , 56 , 80 ].

Sub-theme 1.3: Missing out on social opportunities (High confidence)

Women felt sad, unseen and heartbroken that they were not able to have social opportunities, especially sharing their newborns with family and friends [ 9 , 54 , 56 , 61 , 66 , 70 , 71 , 75 , 76 ]. On postnatal wards, women with older children were disappointed that their nuclear families could not visit and bond with their newborn in the early postpartum period [ 56 , 59 , 80 , 82 ]. While this was disappointing for many, one woman described still feeling well-supported, “ we were supposed to have a baby shower, the weekend after everything shut down … definitely got a lot of gifts in the mail and people who drop things off …. [we] feel like even though he’s being born in this super crazy time and he doesn’t necessarily get to meet people in person, that they are excited about him and want to support us” (USA) [ 52 ]. Primiparous women felt that they missed the opportunity to share many “firsts” with extended families - one woman said, “ this is my family’s first grandchild so it just breaks my heart they will miss her whole babyhood” (postpartum, Canada) [ 64 ].

Sub-theme 1.4 : Breastfeeding challenges and triumphs (High confidence)

Women that struggled with the lack of support around breastfeeding said, " when it came time for breastfeeding, I had no idea what to do or any challenges that could come. There were so, so, so many questions and I felt so confused during everything” (postpartum, primiparous, UK) [ 60 ]. Lactation consultations through virtual remote care was considered inadequate by most women [ 51 , 66 , 71 , 73 , 75 ], especially when practical hands-on education and assistance was needed [ 51 , 53 , 72 , 77 ]. These challenges led some women to cease breastfeeding early [ 51 , 62 , 73 ].

Conversely, public health restrictions enforcing women to stay at home allowed some women to practice responsive breastfeeding, without concern for social obligations or visitors [ 51 , 62 , 64 , 71 , 75 , 79 ]. Some women valued this flexibility - “ there’s no right or wrong way. You know, at the end of the day the ultimate goal is that my baby needs to be fed.… you know, feed him breast milk, breast milk, or formula. He’s fed. He’s happy. Sweet. That’s done. Job done! The important thing is actually [to] be kind to yourself, you know?” (postpartum, primiparous, UK) [ 62 ].

Challenges and triumphs were felt by both multiparous and primiparous women [ 51 ]. The difference between experienced and first-time mothers was stark in some studies, highlighted by multiparous women who felt ‘knowledgeable’ and ‘had the experience’, and sharing empathetic messages towards primiparous women with limited breastfeeding support [ 62 , 78 ].However, the lack of face-to-face breastfeeding support meant that first-time mothers and experienced mothers also faced hardships. As one mother recounts her sadness: “ I had virtual appointments [with lactation consultants], which I found totally useless… I was devastated that it wasn’t working with [the new baby] because it was something I was really looking forward to” (postpartum, multiparous, Canada)  [ 73 ].

Theme 2: Navigating changing health policies

The ever-changing nature of the pandemic created periods of uncertainty. Women and their families were expected to accept and adapt to changing health policies which directly impacted their antenatal, labour and birth and postnatal experiences.

Sub-theme 2.1: A birthing experience filled with uncertainty and unknowns (High confidence)

Many women reported that, given the constantly changing policies, they were unsure what to expect for their labour and birth [ 9 , 49 , 60 , 75 , 77 ]. Limitations included not being able to have a water birth, use a bath or the shower, access nitrous oxide gas during labour [ 49 , 74 , 82 ] and others could not have their desired support people present [ 60 , 77 ]. In some cases, women opted for medicalised interventions to retain a sense of control - choosing a caesarean birth to ensure their partner was present at birth [ 60 , 74 ]. Women struggled with the prospect of early discharge, lacking confidence and fearing reduced support at home, with some feeling pushed out of the hospital [ 49 , 53 , 60 , 74 ]. Some women chose to leave hospital early due to the lack of support or poor experiences while in hospital [ 60 ]. Conversely, some women welcomed early discharge, wanting to be away from the hospital and to be reunited with family members [ 62 , 80 ]. Women who tested positive to COVID-19 early in the pandemic described additional challenges, such as a lack of certainty on how care was going to be managed [ 77 ]. They felt this restricted their autonomy over their labour and birth choices.

Sub-theme 2.2: Reduced support and partner presence healthcare settings (High confidence)

Due to the public health restrictions in hospitals, women often missed having their partner and family supports [ 16 , 49 , 57 , 66 , 71 ]. For example, “ one of my coping mechanisms is having my partner there to hear the same things I am hearing because I kind of shut down sometimes when I get too upset. It’s always good to have that second person listening… and walking out with strength of unity ” (pregnant, primiparous, Australia) [ 49 ]. The inability for some women to have their partners present negatively impacted women’s birthing experience [ 53 , 70 , 79 , 80 ], confidence on the postnatal ward and many expressed the sense of being “ robbed of this experience ” (pregnant, UK) [ 75 ].

Sub-theme 2.3: Transitioning to telehealth, virtual and remote care (Moderate confidence)

Public health restrictions limited face-to-face health care appointments with a maternity care provider [ 54 ]. Negative telehealth experiences were expressed predominantly by first-time mothers [ 71 ], with many saying, “ over the phone just doesn’t do it… you don’t get to look into somebody’s eyes and to trust them and for them to say, you’re okay ” (postpartum, Ireland) , adding to their anxieties. This was felt similarly by CALD women as there was a disconnect with health care providers using virtual methods and this was exacerbated for women who were not able to access interpreters [ 80 ]. Positive encounters with telehealth were associated with the increased accessibility to health services and generally preferred by multiparous women [ 54 , 65 , 68 ]. Whilst many were glad that telehealth services were available, this woman highlighted the inequities, “ I think I would question the accessibility of that. Not everyone has a smartphone and expecting people to be able to receive a video call is not necessarily the most inclusive thing ” (postpartum, primiparous, UK) [ 77 ] indicating that some women may have fallen through the gaps of maternity care.

Sub-theme 2.4: Barriers to accessing health services (High confidence)

The closure of so-called non-essential services, such as, physiotherapists, chiropractors, pools and gyms indirectly impacted women [ 66 , 74 ]. This often increased women’s anxiety, stress, feelings of helplessness and frustration [ 16 , 54 , 60 , 74 ] and incidence of postnatal depression [ 82 ]. This also limited opportunities to receive reassurance from healthcare providers, reducing women’s confidence [ 49 , 71 , 72 , 77 ]. Typically, women accessed networks for information and support, such as, family and friends with midwifery clinical expertise, or referred to recent pregnancy experience [ 52 , 68 , 75 , 79 ]. Women had to advocate strongly for physical assessments for themselves and their newborns [ 74 ].

Additionally, women from CALD populations were challenged in accessing culturally appropriate care with changes to interpretation services, “it creates like a…a gap in communication where if something you express is not clearly understood so maybe they could be left with some misinterpretation” (UK) [ 63 ]. Another example of the inequities faced by CALD women was expressed by this woman who did not receive interpretation services during appointments, “ sometimes they explained things to me by using signs and I understand a little English but it’s hard to understand medical terms and they didn’t use an interpreter for this ” (postpartum, multiparous, Canada) [ 80 ].

Theme 3: Adapting to alternative ways of receiving social support

Support networks, such as, family and friends, peer support groups (e.g. mother’s groups), and formal support from maternity care providers provide the foundation for a healthy and positive pregnancy and postpartum period. The COVID-19 pandemic forced women to adapt and seek support in different ways.

Sub-theme 3.1: Accessing support through different avenues (Moderate confidence)

Support from family and friends was accessed in different ways, for example, utilising video call technologies to be able to see faces helped with the grief of not being able to be present [ 16 ]. Women who were able to establish pregnancy and mother’s groups during the pandemic were grateful that they had these supports. Alternatively, women created or sought support through online social media platforms [ 61 , 68 , 70 , 81 ], to share a sense of camaraderie that they were not alone in their experiences [ 52 , 77 ]. In these forums, women shared information about COVID-19 developments, updates to hospital policies, and utilised others as sounding boards for advice. Some women reported greater support from partners who had transitioned to working from home [ 51 , 62 , 64 , 66 , 75 ]. Although virtual technologies allowed women to bridge the gap of social distancing, they wanted the physical connection with others.

Sub-theme 3.2: Desiring connection with family and friends (High confidence)

Women felt they needed intergenerational support to raise their newborns, and this was especially important during difficult times. Many had planned for parents to come and support them [ 81 ], as they believed that, “ the older generation have more experience on what babies need or what they feel… with my other two [children]… they knew exactly what would make them feel better ” (pregnant, multigravida, Australia) [ 49 ]. Some women struggled without the additional support, the lack of sleep impeded their physical wellbeing [ 61 , 73 , 75 ], and the isolation from family impacted their mental health [ 9 , 49 , 56 , 60 , 61 , 73 ]. In some cases, women were able to “ quarantine with family ”, providing women with a “ strong support network ” (postpartum, Canada) as they transitioned into motherhood [ 59 ]. Gradually, as public health restrictions eased, women from the UK felt government responses did not consider new mothers and babies and they called for “social bubbles” for families to receive the additional support [ 62 , 72 ]. The loss of informal support networks was apparent for some CALD women. As this woman said, “it was really hard during COVID. In Syria I had my family… but to give birth here with no one with me?! I needed someone with me, my neighbours, my friends… I felt like I was drowning” (postpartum, multiparous, Canada) [ 80 ].

Theme 4: Dealing with impacts on their own mental health

The COVID-19 pandemic placed a significant toll on pregnant and postpartum women’s mental health at all stages of the pandemic. Public health strategies failed to include protective measures for mental health, as such many women reported increased levels of fear, anxiety, stress, loneliness and depression.

Sub-theme 4.1: Managing anxiety due to virus-related fears and concerns (Moderate confidence)

Women often experienced anxiety exacerbated by the pandemic, for example, “ as a new mom you are already so nervous, so adding a pandemic to that pile of anxiety and worry ” (postpartum, Canada) [ 70 ]. This was related to possibility of infection, particularly in hospital and healthcare settings [ 9 , 56 , 57 , 69 , 82 ], and the need to protect their unborn or newborn baby [ 50 , 72 , 80 ]. Some faced additional challenges as migrants from another country, “ I found it very hard when you’re coming to the country without knowing anyone and the coronavirus, lockdown was very difficult, I was very depressed. I was very anxious… I feel worried a lot ” (UK) [ 63 ].

Sub-theme 4.2: Feeling lonely and isolated (High confidence)

Loneliness and isolation were commonly reported as women faced motherhood alone without their usual support systems. One woman said, “ it was quite sad that I couldn’t even share my pregnancy experience with anyone, and I feel like I missed out ” (postpartum, Australia) [ 54 ]. Feelings of loneliness was especially felt by mothers who were not able to have their partners present during birth or postnatally [ 61 ]. Women were not able to build supportive peer networks in their antenatal and postnatal periods [ 49 , 62 , 73 , 74 , 75 , 78 , 81 ], with one woman saying, “ there’s nothing like just meeting people or, just naturally building friendships when you go to baby groups” (postpartum, multiparous, UK)  [ 62 ] emphasising the importance of developing social relationships. Cancellation of appointments and lack of face-to-face care added to feelings of “ abandonment ” and “ being forgotten ” [ 9 , 60 , 62 , 70 , 72 , 73 ].

Theme 5: Managing new and changing information

Due to the novelty of COVID-19 and lack of information about adverse effects, maternity care services had to rapidly adapt as new data came to light. Women described the need to search, access and filter useful information, a process which was challenging for many.

Sub-theme 5.1: Constantly changing advice and information (High confidence)

The constantly changing advice was distressing [ 82 ]. These changes meant a lot of uncertainty, one woman said, “ at 34 weeks I had a telephone appointment and I tried to ask what the changes in hospitals were, because of COVID and talk about the birth plan. She basically said, ‘everything is changing so quickly there is no point in us even talking about that now. Wait until your next appointment’ ” (postpartum, primiparous, UK) [ 77 ]. This limited women’s ability to adequately plan and prepare for the birth. Some women described following the updates from government officials and hospitals overwhelming [ 66 ]. As restrictions eased, women described the frustrations they had with the slow adaptations by health services, “ when I got to the hospital, they didn’t know about the restrictions having been lifted … That was really frustrating because I was like why? Why does this hospital not know?” (Australia) [ 82 ] and the differences between health services, “ restrictions have still not been lifted in ‘Hospital A’ whereas they have been eased in both ‘Hospital B’ and ‘Hospital C’ ” (pregnant, multiparous, Ireland) [ 9 ].

Sub-theme 5.2: Inadequate information from healthcare providers (Moderate confidence)

Women felt there was not enough information from healthcare providers, “ I think there was a lot of confusion; there was no good communication about what was happening to appointments. You weren’t really sure; were they happening on the phone [telehealth], when were you going to get the call? There was very little communication. So, I always felt a bit uneasy about that… ” (postpartum, primiparous, UK) [ 77 ]. Some information was contradictory [ 60 ] for example, “ I’ve found the disconnect between the information that my GP was getting and that the [hospital] was getting – they weren’t getting the same ” (Australia) [ 82 ]. Women wanted clear information that was easily accessed by the lay person [ 9 , 16 , 54 , 61 , 65 , 66 , 67 , 68 , 75 ]. They also wanted uncertainty to be acknowledged, “ it would have been useful to have some generic information that went out to women in that situation… statements from a medical professional to put people’s minds at ease ” (postpartum, Australia) [ 54 ].

Theme 6: Being resilient and optimistic

Many women were self-reliant and took it upon themselves to remain positive and proactive throughout the perinatal period.

Sub-theme 6.1: Self-help strategies to overcome challenges of the pandemic (High confidence)

Women developed their own strategies to find solace and support [ 77 ]. When asked what advice they had for other women in similar situations, advocacy for oneself was frequently reported [ 66 , 67 , 70 , 71 , 77 , 79 , 81 , 82 ]. In contrast, another woman regretted not voicing her concerns, “ I have naively trusted that the hospital gives me the information I need … Then I realized afterwards that there were many moms who were much angrier than me and said much more; insisted much more… and I simply did not; I regret it a bit ” (postpartum, Norway) [ 67 ]. Women reported coping using different strategies, such as being outdoors and active [ 16 , 52 , 54 ], limiting news and access to social media platforms [ 54 , 69 , 70 , 81 ], seeking professional help [ 58 , 73 ], informing themselves about the virus [ 58 , 71 ], drawing on their own faith and religion [ 52 , 69 ] and self-reassurance [ 50 , 52 , 62 ]. Many complied with public health restrictions, however there were some women that decided their mental health and physical wellbeing was more of a priority and broke public health restrictions to seek support from family and friends [ 62 , 66 , 73 ]. Despite the challenges faced during the pandemic, some women reported high resilience, positive childbirth and postnatal experiences, and feeling empowered by their ability to overcome challenging circumstances [ 54 , 58 , 74 ].

Sub-theme 6.2: Making the most out of the positive encounters (Moderate confidence)

The lack of visitors on the postnatal ward and in homes was described by women as “ pleasant ”, “ relaxing ” and a “ blessing in disguise ” as women were able to recover and establish undisrupted routines with their newborns [ 54 , 71 , 72 ]. A commonly reported positive outcome of limiting social obligations was the ability to establish successful breastfeeding, one woman said, “ I was inundated with visitors with my first child and often could not feed responsively… With my second child, there is none of that pressure and I can really see an enormous difference both is his feeding and in my mental health ” (postpartum, UK) [ 51 ]. Women also described health services as “ peaceful ”, as there were fewer people in waiting rooms, appointments were quick, social distancing was enforced and use of PPE limited the possibility of transmission [ 16 , 49 , 71 , 75 , 81 , 82 ].

Sub-theme 6.3: Information seeking and desire for more information (Moderate confidence)

Women obtained information from official government documents, guidelines released by professional bodies, the news, social media and platforms run by professional academics [ 53 , 66 , 68 , 72 , 81 ]. Reasons to seek information included: to clarify any uncertainties about risk and infection, keep up to date with COVID-19 guidelines and to be informed about changes to hospital policies [ 49 , 52 , 66 , 69 , 77 ]. Even once women were provided with information, poor communication and follow up left women feeling dissatisfied [ 54 ]. One woman shared advice about engaging with different information sources – “ you can’t just trust them – you’ve got to decipher through what’s true and what’s not… Is that actually having a positive influence on me, and my mental and physical health, or not? And if it’s a no, well why am I engaging in this ?” (Australia) [ 81 ].

This QES synthesised data from 36 sampled studies on pregnant and postpartum women’s experiences from high income countries during the COVID-19 pandemic. Findings were categorised under six overarching themes and 17 review findings to understand their experiences as the pandemic unfolded. Women had to navigate the transition from pregnancy to motherhood, whilst also adapting to the complexities of the COVID-19 pandemic. High to moderate confidence was placed in these review findings, indicating the strength of the evidence.

This review highlights that pregnant and postnatal women across high-income countries faced similar yet inherently unique experiences and challenges. During the pandemic, primiparous women faced moderate-to-high prenatal stress levels, as they recounted their first pregnancy experience during a time of significant uncertainty [ 85 , 86 , 87 ]. On the other hand, some evidence highlighted that multiparous women were ‘adaptive’ and felt ‘prepared’ [ 66 , 71 , 77 ]. However this was not experienced universally - many experienced mothers facing difficulties [ 9 , 73 , 80 ]. The COVID-19 pandemic and associated public health restrictions across high-income countries disrupted access and quality of care for many pregnant and postpartum women.

Reduced health service capacity and the transition to remote and virtual care due to pandemic restrictions have been heavily criticised [ 8 , 88 ]. In many contexts, women had not received high quality maternity care during the pandemic and described overtly negative experiences [ 35 , 89 , 90 ]. Women were unable to access usual supports, had limited birth choices and reduced postpartum care which resulted in stress and anxiety. These are clearly widespread experiences, regardless of context, and highlights some of the structural weaknesses and vulnerabilities of maternity care systems. This was evident in the findings for pregnant and postpartum women of culturally and linguistically diverse backgrounds. The lack of culturally appropriate care, including access to interpretation services, doulas and being unable to have their support person present are known to impair maternal health and wellbeing [ 56 , 63 , 80 ]. These factors are key elements of respectful maternity care as they help provide information, enable women’s agency and ensure emotional and social support is available [ 91 , 92 ]. Health restrictions should not limit this service for women during times of unrest, as women and babies thrive in culturally respectful maternity services [ 93 ]. We note however that CALD women continue to be an under-represented group - only three of the 36 sampled studies reported evidence specifically for CALD groups [ 56 , 63 , 80 ]. The lack of diverse perspectives included in the evidence base makes it more difficult for culturally sensitive and community-responsive policies to be developed. Further research with women from diverse backgrounds are warranted to ensure they are not unduly disadvantaged in future pandemics [ 94 ].

A key finding was the reduced presence of partner and social support throughout the pregnancy and postpartum periods. Partner support and strong connections with extended support networks reduces stress and anxiety, and can be a positive influence on the woman and her experience [ 95 , 96 , 97 ]. In the trade-off between the risk of transmission and spread of disease, expectant fathers and partners were frequently left out [ 98 , 99 ]. Similarly, studies of families and partners of intensive care unit patients during the COVID-19 pandemic reported being physically and emotionally unable to support partners and families [ 100 , 101 ]. Close family members are essential to the recovery of patients upon discharge and partners are integral to a safe and positive pregnancy, intrapartum and postpartum experience for mothers. To ensure that maternity care services can adequately respond in the future, recommendations for some degree of flexibility for women given the long-term psychosocial impact that a negative experience would have on the woman and family unit has been sought [ 8 , 87 , 88 ].

Pregnant and postpartum women’s experiences were not universally negative. Another key finding in this review highlights the resilience and optimism that some women felt. Some women perceived this time as a “blessing in disguise” – referencing the ability to stay at home, having fewer disruptions to breastfeeding, and embracing newfound time as a family unit [ 64 , 66 , 71 ]. Coping strategies reported in this study are supported by other evidence of protective factors against stressors of the COVID-19 pandemic [ 102 , 103 , 104 ].

Maternity care services need to continue delivering care during public health emergencies. There is no possibility of delaying or postponing care; and women require care over an extended period of time. Enforced lockdowns limited movement and fear of contracting the virus in hospitals lead to delays in healthcare seeking (e.g. when there is reduced fetal movements). The pandemic altered the provision of services and women’s access to care and, as a result, some countries have reported changes to the incidences of stillbirth and preterm birth [ 105 , 106 , 107 ].

Understanding women’s experiences, their preferences and satisfaction with maternity care services are essential to a safe and positive pregnancy, labour and childbirth and postpartum period. Many maternity models of care such as woman-centred and midwifery-led care places the woman at the centre of care and her experience, focusing on woman’s health needs, expectations and aspirations [ 108 , 109 ]. These models have proven to return high levels of satisfaction and are beneficial to the psychological and physiological recovery of the woman [ 110 , 111 ]. The COVID-19 pandemic has disrupted these models of care for women who were pregnant and gave birth during the pandemic. Pressures on the maternity care system and service delivery did not facilitate the midwife-woman relationship, resulting in poorer clinical outcomes [ 112 ]. Supporting women throughout their perinatal period is essential so women and their babies are able to emerge from the experience feeling prepared, safe and satisfied [ 113 , 114 ].

Moving forward, as maternity care systems adapt to a post-pandemic structure, considerations need to be made to ensure maternity services can adequately respond to future health crises. Our QES has shown that the impacts of COVID-19 went far beyond the direct impacts on women who were infected with SARS-COV2. All women giving birth over the pandemic, especially in the first two years, were indirectly impacted and as a result experienced a lack of autonomy during their pregnancy and childbirth, barriers to accessing face-to-face care and loss of social supports. This highlights the need to consider women’s views and experiences in developing policies for future responses to pandemics or public health emergencies.

We recommend that policy makers and maternity care services should: 1) optimise care delivery to maintain face-to-face care when possible and facilitate the presence of chosen support people; 2) enhance communication channels between maternity care services and women to minimise misinformation, stress and anxiety; and 3) support social and mental wellbeing to ensure women have access to adequate social support and mental health services are well resourced.

Strengths and limitations

The rigorous and systematic methodology of this QES in selecting studies for inclusion allowed us to analyse experiences of a heterogenous cohort of pregnant and postpartum women during the COVID-19 pandemic. When we started the review, the abundance of published work of women’s experiences was overwhelming, therefore strict eligibility criteria were used to ensure that findings could be obtained and compared across studies. This study was therefore limited to experiences of women in high-income countries and cannot be generalised to low- and middle-income countries.

Studies were subject to a sampling framework to ensure that a diverse, yet data rich sample of studies contributed to the development of review findings. This had its own set of limitations as the sampling framework is not a validated tool and may be biased by the user’s own interpretation. Additionally, the search strategy was limited to the first two years of the pandemic. While it is possible research was published outside of this two-year period, we felt that it was unlikely that different experiences would be reported. An updated search (December 2022) was conducted to determine if any new themes emerged, however no new themes emerged and therefore did not warrant the addition of any new studies. Almost all studies that used interviews to collect qualitative data did so via remote methods. Telephones and video conferencing tools were popular methods to conduct interviews, adhering to social distancing guidelines. Whilst this increased accessibility for participants from diverse geographical locations, there may be concerns about the depth of data obtained and exclusion of participants that are unable to access these technologies. A further consideration is the limited number of studies exploring the experiences of women from diverse backgrounds. This prevented us from more critically examining what factors and circumstances shape women’s experiences and responses.

Women’s pregnancy and postpartum experience during the COVID-19 pandemic showcased similarities despite different contexts. This QES has collated the experiences of women from high income countries sharing insight into the challenges faced and resilience of pregnant and postpartum women. The COVID-19 pandemic has exacerbated many systemic shortfalls of the maternal and newborn health system – a system that is essential to the health and wellbeing of women and babies. The review findings have highlighted areas within this period where strategies to inform policy and practice could be optimised to allow for better access to care and support for women in their journey to motherhood. Future pandemic preparedness strategies need to maximise face-to-face care, optimise communication channels to combat misinformation and anxiety, include a flexible approach to public health restrictions for women and their families by allowing formal and informal support networks to be readily available and accessible, and to ensure maternal mental health is a priority.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files]. Additional information is available from the corresponding author on reasonable request.

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The primary author is funded by Deakin University Postgraduate Research Scholarship as a PhD Candidate. AB is supported by the Australian Government Research Training Program, CSEH is supported by the Australian National Health and Medical Research Council Leadership Investigator Grant, and JPV is supported by the Australian National Health and Medical Research Council Emerging Leadership Investigator Grant. The funding bodies had no role in the conceptualisation of the study design and data collection, data analysis, interpretation and writing of the manuscript.

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Tan, A., Blair, A., Homer, C.S. et al. Pregnant and postpartum women’s experiences of the indirect impacts of the COVID-19 pandemic in high-income countries: a qualitative evidence synthesis. BMC Pregnancy Childbirth 24 , 262 (2024). https://doi.org/10.1186/s12884-024-06439-6

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Building public engagement and access to palliative care and advance care planning: a qualitative study

• Rachel Black   ORCID: orcid.org/0000-0001-8952-0501 1 ,
• Felicity Hasson   ORCID: orcid.org/0000-0002-8200-9732 2 ,
• Paul Slater   ORCID: orcid.org/0000-0003-2318-0705 3 ,
• Esther Beck   ORCID: orcid.org/0000-0002-8783-7625 4 &
• Sonja McIlfatrick   ORCID: orcid.org/0000-0002-1010-4300 5  

BMC Palliative Care volume  23 , Article number:  98 ( 2024 ) Cite this article

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Research evidence suggests that a lack of engagement with palliative care and advance care planning could be attributed to a lack of knowledge, presence of misconceptions and stigma within the general public. However, the importance of how death, dying and bereavement are viewed and experienced has been highlighted as an important aspect in enabling public health approaches to palliative care. Therefore, research which explores the public views on strategies to facilitate engagement with palliative care and advance care planning is required.

Exploratory, qualitative design, utilising purposive random sampling from a database of participants involved in a larger mixed methods study. Online semi-structured interviews were conducted ( n  = 28) and analysed using reflexive thematic analysis. Thematic findings were mapped to the social-ecological model framework to provide a holistic understanding of public behaviours in relation to palliative care and advance care planning engagement.

Three themes were generated from the data: “Visibility and relatability”; “Embedding opportunities for engagement into everyday life”; “Societal and cultural barriers to open discussion”. Evidence of interaction across all five social ecological model levels was identified across the themes, suggesting a multi-level public health approach incorporating individual, social, structural and cultural aspects is required for effective public engagement.

Conclusions

Public views around potential strategies for effective engagement in palliative care and advance care planning services were found to be multifaceted. Participants suggested an increase in visibility within the public domain to be a significant area of consideration. Additionally, enhancing opportunities for the public to engage in palliative care and advance care planning within everyday life, such as education within schools, is suggested to improve death literacy and reduce stigma. For effective communication, socio-cultural aspects need to be explored when developing strategies for engagement with all members of society.

Peer Review reports

It is estimated that globally only 14% of patients who require palliative support receive it [ 1 ]. The World Health Organisation (WHO) advocates for palliative care (PC) to be considered a public health issue and suggests earlier integration of PC services within the wider healthcare system is required [ 2 ]. However, research has shown that a lack of public knowledge and misconceptions about PC may deter people from accessing integrative PC services early in a disease trajectory [ 3 ]. Integral to good PC is the facilitation of choice and decision-making, which can be facilitated via advance care planning (ACP). Evidence suggests that ACP can positively impact the quality of end of life care and increase the uptake of palliative care services [ 4 ]. While ACP is commonly associated with end of life (EOL) care, it provides the opportunity for adults of any age to consider their wishes for future care and other financial and personal planning. However, there is evidence of a lack of active engagement in advance care planning (ACP) [ 5 ]. Recent research exploring knowledge and public attitudes towards ACP found just 28.5% of participants had heard the term and only 7% had engaged in ACP [ 6 ]. Barriers to engagement in ACP discussions have been found to include topics such as death and dying are considered a social taboo, posing an increased risk of distress for loved ones; and [ 6 ] a misconception that ACP is only for those at the end of life rather than future planning [ 7 ]. Therefore, there is a need for a public health approach to ACP, to enable and support individuals to engage in conversations about their wishes and make decisions surrounding their future care.

The need for a public health approach to PC, to tackle the challenges of equity and access for diverse populations, was noted in a recent Lancet paper [ 8 ]. This is further supported in a recent review, exploring inequalities in hospice care in the UK, Australia, New Zealand, and Canada which reported that disadvantaged groups such as those with non-cancer illnesses, people living in rural locations and homeless individuals had unequal access to palliative care [ 9 ]. They postulated that differing levels of public awareness in what hospice care provides, and to whom, was an influencing factor with variations in health literacy and knowledge of health services being present in both minority and socioeconomic groups [ 9 ].

Changes in how we experience death and dying have resulted in a shift away from family and community settings into healthcare settings. The Lancet commission exploring the ‘Value of Death’, suggests it has created an imbalance where the value of death is no longer recognised [ 10 ]. The commission’s report posits the need to rebalance death, dying and grieving, where changes across all death systems are required. This needs to consider how the social, cultural, economic, religious, and political factors that determine how death, dying, and bereavement are understood, experienced, and managed [ 10 ].

New public health approaches that aim to strengthen community action and improve death literacy, through increased community responsibility are reflected in initiatives, such as ‘Compassionate Communities’ and ‘Last Aid’ [ 11 , 12 ]. However, a suggested challenge is the management of potential tensions that are present when attempting to conceptualise death in a way that mobilises a whole community [ 13 ]. Whilst palliative care education (PCE) can be effective in improving knowledge and reducing misconceptions, many PCE intervention studies, have focused on carers and healthcare professionals [ 14 ]. Initiatives such as ‘Last Aid’ attempt to bridge this gap by focusing on delivering PCE to the public, however, they are not embedded into the wider social networks of communities. It can be argued that public health campaigns, such as these are falling short by neglecting to use the full range of mass media to suit different ages, cultures, genders and religious beliefs [ 15 ]. Consequently, to understand what is required to engage the public successfully, the voice of the public must lead this conversation. Therefore, this study sought to explore public views on strategies and approaches to enable engagement with palliative care and advance care planning to help share future debate and decision making.

Within the last decades the delivery of PC and ACP have been increasingly medicalised and viewed as a specialist territory, however in reality, the care of those with life-limiting conditions occurs not only within clinical settings but within a social structure that affects the family and an entire community [ 16 ]. Therefore, death, dying and bereavement involve a combination of social, physical, psychological and spiritual events, therefore, to frame PC and ACP within a public health approach the response requires a shift from the individual to understanding the systems and culture within which we live. The Social Ecological Model (SEM) recognises the complex interplay between individual behaviours, and organisational, community, and societal factors that shape our acceptance and engagement. SEM provides a framework to understand the influences affecting engagement with PC and ACP and has been utilised as a lens through which the data in this study is explored.

Qualitative research, using semi-structured interviews were adopted as this enabled an in-depth understanding of public views on strategies to enable engagement with PC. This research was part of a larger mixed-methods study [ 17 ]. Comprehensive Consolidated Criteria for Reporting Qualitative research (COREQ) were used [ 18 ](See Supplementary file 1 ).

A purposive random sampling method, using a random number generator, was adopted to recruit participants who consented to be contacted during data collection of a larger mixed methods study. Selected individuals were contacted by telephone and email to invite them to participate. Inclusion and exclusion criteria are outlined in Table  1 . Interested individuals were provided with a participant information sheet detailing the aims of the study and asked to complete a consent form and demographic questionnaire.

A total of 159 participants were contacted, 105 did not respond, 21 declined and three were ineligible to participate. A total of thirty participants consented, however, two subsequently opted to withdraw prior to the interview.

Data collection

Data was collected from December 2022 to March 2023 by RB. The qualitative interview schedule comprised four broad topic areas: (1) participants’ knowledge of PC and ACP; (2) sources of information on PC and ACP and current awareness of local initiatives for public awareness; (3) knowledge of accessibility to PC and ACP and (4) future strategies for promoting public awareness of PC and ACP, with a consideration of supporting and inhibiting factors. The interview schedule was adapted from a previous study on palliative care to incorporate the topic of ACP [ 3 ] (See Supplementary file 2 ). This paper reports on future strategies.

Participants were asked to complete a short demographic questionnaire prior to the interview to enable the research team to describe the characteristics of those who participated. These questions included variables such as age, gender, religion, marital status, behaviour relating to ACP and experience of PC.

Data was collected via online interviews conducted using the videoconferencing platform Microsoft Teams. Interviews lasted between 20 and 60 min and were recorded with participant consent. Data were stored on a secure server and managed through NVivo 12 Software.

Data analysis

Qualitative data were transcribed verbatim automatically by Microsoft Teams and the transcripts were reviewed and mistakes corrected by the interviewer. All identifying information was removed. Transcripts were analysed using reflexive thematic analysis which involved a six-step process: familiarisation, coding, generating initial themes, developing and reviewing themes, refining, defining and naming themes, and writing up [ 19 ]. Themes were derived by exploring patterns, similarities and differences within and across the data in relation to participant’s views on the promotion of PC and ACP and the best ways to engage the public in open discussions.

The study explored the data through a SEM lens to provide a holistic framework for understanding the influences surrounding health behaviour change in relation to palliative care and advance care planning by mapping the findings to each of the SEM constructs.

The SEM for public health was conceptualised by McLeroy et al. [ 20 ]., and was based on previous work by Bronfenbrenner’s ecological systems theory [ 21 ]. The SEM looks to identify social-level determinants of health behaviours [ 22 ]. Five factor levels have been identified within the SEM; (1) Intrapersonal factors (2) Interpersonal processes (3) Institutional factors (4) Community factors and (5) Public policy [ 20 ]. In short, the SEM suggests that the social factors that influence health behaviours on an individual level are nestled within a wider complex system of higher levels. Current research literature has explored SEM as a model for understanding barriers and facilitators to the delivery of PC, adults’ preferences for EOL care and older adults’ knowledge and attitudes of ACP within differing socioeconomic backgrounds [ 23 , 24 , 25 ]. It has demonstrated the importance of a multilevel approach within these populations. However, there is a scarcity of research exploring strategies for public engagement with PC and/or ACP which are underpinned by SEM theory.

To ensure rigour in the analysis four members of the research team (RB, SM, FH, EB) independently reviewed the transcripts and were involved in the analysis and development of themes as a method of confirmability [ 26 ].

Ethical approval was gained from the University Research Ethics Filter Committee prior to commencing data collection. Participants provided written informed consent prior to the commencement of the interviews. They were advised of their right to withdraw, and the confidentiality and anonymity of all data were confirmed. All data was kept in accordance with the Data Protection Act (2018) [ 27 ].

All participants were white; 70% were female (n-19) and 70% were either married or cohabiting (n-19). The largest proportion of the sample 44% was aged under 50 years (n-12), with 22% aged between 50 and 59 (n-6) and 33% (n-9) aged between 60 and 84. Over half of the sample was employed (n-15), 15% were self-employed [ 4 ] whilst 26% were retired (n-7). Demographic data were missing for one of the included participants (see Table  2 ).

Responses to questions relating to ACP knowledge and behaviours found just 12 participants had heard of the term ACP prior to completing the Northern Ireland Life and Times Survey. Furthermore, none of the participants had been offered the opportunity to discuss ACP and none had prepared a plan of their wishes and preferences.

Main findings

Three overarching themes were generated from the data: ‘Visibility and relatability’; ‘Embedding opportunities for engagement into everyday life’; ‘Societal and cultural barriers. These findings were then mapped to the five social ecological model (SEM) levels ( individual; interpersonal; institutional; community; and policy ) to demonstrate the importance of a multilevel approach when seeking to engage the public around PC and ACP. See Fig.  1 for SEM construct mapping.

Theme 1: visibility and relatability

This theme relates to the suggestion that social taboo was a barrier to awareness and the mechanism to ameliorate this was visibility – in turn promoting reduction of stereotypes and promoting understanding and engagement. This posits the idea that the lack of understanding of PC is the root cause of much of the stigma surrounding it. The SEM construct mapping suggests a multilevel approach is required with intrapersonal (increased individual understanding), interpersonal (openness in discussion with friends and family through media normalisation) and institutional (health service policies for promotion and support) levels being identified.

Participants discussed how there is a lack of knowledge on what PC is, with many assuming that it was for people in the latter stages of life or facing end of life care. This highlighted the lack of individual education with participants suggesting that there should be more visibility and promotion on PC and ACP so that individuals are better informed.

“So, it’s really um there needs to be more education, maybe, I think around it. So that people can view it maybe differently or you know talk about it a bit more. Yeah, probably demystifying what it is. This is this is what it is. This isn’t what it is. You know, this isn’t about um, ending your life for you, you know. And this is about giving you choices and ensuring that you know, you know people are here looking after you”(P37538F45) .

However, there was a recognition that individual differences play a part in whether people engage in discussions. A number of participants explored the idea that some people just don’t want to talk about death and that for some it was not a subject that they want to approach. Despite this, there was a sense that increasing visibility was considered important as there will still be many people who are willing to increase their knowledge and understanding of PC and ACP.

“I can talk about it, for example, with one of my sisters, but not with my mom and not with my other sister or my brothers. They just refuse point blank to talk about it…. some of them have done and the others have started crying and just shut me. Shut me off. And just. No, we don’t want to talk about that. So, it just depends on the personality, I suppose” (P14876F59) .

The lack of knowledge and awareness of PC and ACP was suggested to be the attributed to the scarcity of information being made available at a more institutional level. For some participant’s, this was felt to be the responsibility of the health service to ensure the knowledge is out there and being promoted.

“I think people are naive and they know they’re not at that stage and they don’t know what palliative care is, you know. It’s all like it’s ignorance. But our health service is not promoting this. Well in my eyes, they’re not promoting it whatsoever. And they should, they should, because it would help a hell of a lot of people ” (P37172M61). “I and I think it needs to be promoted by the point of contact, whether it’s a GP, National Health, whatever it might be, I think when they’re there, there needs to be a bit more encouragement to have that conversation” (P26495M43) .

The lack of visibility within the general practice was discussed by several participants who said that leaflets and posters would be helpful in increasing visibility. One participant went as far as to say that a member of staff within a GP surgery would be beneficial.

“I suppose the palliative care because it is a bit more personal. There should be even maybe a professional that you could talk to in your GP practice, or you know, like they have mental health practitioners now in GP practices. Maybe there are I don’t know if there is or not, but there should be maybe a palliative health practitioner that talks to people when they are at that stage of their life” (P21647F29).

Participants also noted how there were generational differences in how people accessed health information. Many of the participants suggested that they would turn to the internet and ‘google’ for information, however, the suggestion was made that care should be taken to target awareness campaigns to different age groups via different methods to reduce disparities in technology skills such as those with less computer literacy.

“ I think a certain proportion of society need the visibility because they’re not always going to be self-sufficient enough to jump on the Internet even though you know we’re getting to the point now where the generational thing is. The generation have been brought up with the Internet and they’re obviously they go to it as the first point of call. But we still got the generation at the moment that don’t”. (P25046F-)

One of the participants talked about ways to increase visibility via the use of the media, including social media, and the utilisation of famous faces.

“Yeah, I think you know, they need to discuss it on Loose Women. You know, morning TV need to get on the bandwagon….But you know. It only takes like that one celebrity to mention it and then the whole media is jumping on the bandwagon.” (P19874F-) .

The UK media coverage of other successful campaigns such as those highlighting mental health and bowel cancer were noted to have been particularly helpful in raising awareness.

“if I think myself about the whole exposure that we have and as a society at the minute about mental health in general, you know a lot of the work on that has been done via social media. You know, celebrities hash tagging and talked about their experience. It’s OK to not be OK etcetera. And I feel like that is responsible for a lot of people who are now discussing their mental health” (P21647F29) .

The sentiment expressed in the above quotes regarding increased visibility in the media also suggests that unless a topic seems relevant to an individual then they won’t engage with health promotion. This concept of relatability pertains to those aspects of human empathy where they can place themselves within a situation leading it to become more relevant to them.

Many participants discussed that using real-life stories on television and in campaigns would be an effective way to connect with the public and it would make PC and ACP more relatable and highlight the importance of thinking about it.

“I think always what tends to be most effective is when it’s somebody that we could all relate to telling their own story (…)……I’m not too sure I know enough about what it involves, but really, like the consequences, that the consequences that people have suffered from not having done that. Not knowing what the wishes were, not having planned for it”. (P32288F62)

Several participants discussed how the topics of PC and ACP were not something they would identify with as being relevant to them. The suggestion was that without it being an immediate concern, for example, if they were not approaching a certain age, then they would assume that they did not need to increase their knowledge about what PC or ACP involves.

“You have to be able to relate to it in order to think, oh, yeah, that applies to me. You need to have something in which you identify with”. (P13697F51)

Theme 2: embedding opportunities for engagement into everyday life

Throughout the discussions, there was evidence that participants felt that death literacy could be increased by providing more opportunities to gain knowledge about planning for future care and what PC involves. Education was highlighted as a potential pathway to engaging the public by targeting appropriate age groups and professions with relevant knowledge and skills. For some, this was thought to be best achieved through educating the youth and for others, the importance of educating those who are working in the healthcare profession was particularly salient. In addition, almost half of the participants suggested they would approach charity organisations for information, with participants advocating for education within secondary and tertiary levels and within community organisations. This data reflects an institutional-level construct within the SEM framework.

Educating younger generations on the topics of PC and ACP through open discussions in schools, and providing skills on how to have difficult conversations with loved ones were seen to be a valuable strategies.

“ young people don’t have that ability to accept and admit and bring it out into the open and I think they need to be perhaps encouraged more to do that through some kind of teaching in the school environment when they’re at a young and impressionable age ”. (P25046F-)

Due to the difficulties around having conversations about death, it was suggested that different healthcare professionals should be trained to have conversations with their patients.

“Yeah, it’s like you think the discussions are difficult to broach for maybe health care professionals that you know, a difficult topic even for them to bring up. Well, if you’re working with someone who’s you know with a family and where things are quite distressed and very often it can be either, it can be the stress can cause a lot of friction and you know, decision making can be very difficult for people…., but just at every level, there’s, you know, possibility to be having conversations like that with people.”(P37538F45) . “I suppose you could think about training some care professionals (…) there may be some way that as a second part of the person’s job or whatever that they’re trained so that people could go along and discuss ” (P19265F76) .

Further to education for young people and healthcare professionals, there was the recognition that community organisations are perfectly positioned to educate the public in PC and ACP. One participant highlighted the missed opportunity to educate family members and carers through an existing programme on dementia. This is particularly pertinent to ACP due to the impact of cognitive decline on decision-making.

“I went to zoom meetings for four weeks in a row with the Alzheimer’s Society. Umm regarding things to do with dementia. And you know, there was a week about your finances and things like that. I suppose. They never really talked about end of life care you know that sort of thing. Um I suppose it would have been useful had they you know, broached that subject as well. But it wasn’t, you know, there was more about looking after yourself, looking after the person. The symptoms of dementia and all this sort of thing, Alzheimer’s and then you know, um the financial and the help available to you. You know, but they didn’t mention about the end-of-life care and like the end result of dementia, I guess, is death. So, you know that that subject, you know, I was, I suppose to just those organizations that deal with um the issues of, like dementia or, as you say, all the rest for, you know, the rest of the diseases and that. You know to be up front and honest and say you know where this can lead and to make people you know, make people aware that there is a palliative care process that can be gone through.” (P19874F-) .

Furthermore, the option of a helpline was suggested with reference made to other successful charity helplines such as the National Society for the Prevention of Cruelty to Children (NSPCC) and The Samaritans. Whilst it was acknowledged there were specialist support services available for people living with a terminal diagnosis, there was a sense that a generic information support helpline would be helpful.

“You know, people need to be (aware)… they’re not alone. There is help out there. You know, you see your helpline, your children, NSPCC, your Samaritans. All on all these helplines, I have to think, I’ve never seen a helpline for palliative care or who you can contact. You don’t see things like that.” (P22964F52) .

In addition to education, the suggestion that embedding ACP discussions into other more common aspects of future planning such as will making, and organ donation was postulated as a potential way to engage the public. This demonstrated clear links to the policy and institutional level constructs within SEM. Changes within organisational policies and public law to support individuals to consider future planning would promote better engagement on a wider societal level.

Participants suggested that they would like to see some of the conversations surrounding ACP introduced into workplace policies and guidelines, as well as through other legal discussions. They noted that conversations surrounding future planning already occur when discussing legal wills and workplace pensions. The potential to expand these discussions to include ACP with solicitors and in workplaces was seen to be a missed opportunity.

“So maybe um around people who are making their wills and you know, you get will making services advertised and things like that. And I think once you get into your 30s and 40s, people start thinking about a will and things like that. So maybe aligned to something like that, you know would get younger people.” (P13790F67) . “when people talk about the pension, you know so retirement, you know, to make people aware about this as well. You know, I would say that’s probably good ways to reach people” (P21263M54) .

Current legislation and promotion regarding organ donation were discussed as being successful in engaging the public and therefore implied that the government should take a more active role in the promotion of ACP.

“If you look at the way, sort of, government have been promoting like organ donation and that. You know that sort of thing. And then people have really bought into it and you know, and there’s a lot of positivity around it. So, I think that’s sort of similar approach would be good”. (P29453F40) “You know, people talking about pension, pension plans and so on and it’s part of the natural life circle, you know. So, if it’s in connection with this, you know, so think about your future, make your plans …so probably in connection with organ donation and so on, you know, so I think they could be trigger points, you know,, people talking about this.” (P21263M54) .

Theme 3: societal and cultural barriers to open discussion

In conversations surrounding why there was a lack of openness in discussion, participants postulated that a potential factor was the influence of cultural and societal norms. This was found to overlap in the SEM levels of intrapersonal, interpersonal and community.

Rural farming communities were highlighted as potentially being more isolated and traditional in their views around death and dying, whilst those with strong religious beliefs were seen to be less likely to engage in discussions.

“You know, and there is a, I’m out in the countryside. Well, it’s (place name). So it’s a relatively rural sort of conservative place and it and it’s that… you know you’re tied to the land, you’re tied to the farm. This is your home and sending you away from it early it is seen as a bit of a shameful thing. So yeah, to try and educate folk and to try and speak into that I think would be really helpful because again, I’ve seen situations where probably the individual’s life, the end of life, has been made tougher because the family have fought to keep that person at home.…. We’re going to try and do it ourselves” (P26495M43) . “I think it’s probably a lot to do with religion more than likely because people just like to hear, because we still are very much, you know, a lot is dictated by religion. So, people just want to leave stuff in God’s hands so they don’t want to have like…that would be the kind of where my mom and dad are coming from, you know, don’t interfere with it, blah blah blah. So, it’s a very gentle like kind of reminding them, you know, well, I think we do need to think about it. And I think people are afraid that they’ll make again that um it’s kind of euthanasia you know what I mean” (P37538F45) .

Cultural differences between countries were also considered with some seeing other global communities approaching death as a celebration rather than something to shy away from.

“I think in Northern Ireland we are, and the UK and probably the world in general. We are really poor at talking about, about death, and it has to be a positive thing to be able to talk more about death. You look at other cultures where you know. Death is treated differently, you know, even in Africa things where, you know, it’s a real celebration, whereas it’s seen so differently in in Northern Ireland” (P31154F35) .

Furthermore, regions and countries that have experienced war and conflict were perceived by one participant as a potential barrier to engaging in subject matters which involve death.

“I don’t I don’t know about other countries, but those that grew up maybe during the conflict here, maybe it’s just something that, you know it’s it’s a completely different mindset to them” (P23609M39) .

Whilst it is unclear from the data why the participant felt the conflict might inhibit engagement with the subject of dying, it could be interpreted that the participant was suggesting that death is too morbid to engage with following a conflict period which saw numerous deaths. An alternative interpretation could be that people are desensitised to death and do not see death as something that an individual has autonomy over.

It was noted that in many modern societies communities are changing. People no longer interact with their neighbours in the way they used to which results in a reduced sense of community responsibility.

“I don’t know that everyone is as neighbourly as they used to be. Northern Ireland I always perceived as being open door policy and everybody looked out for everyone else. But I think as a society has changed and it has changed in Northern Ireland, and it’s become becoming more closed (…) So I think we need to try and encourage that community um experience back again so that people are mindful of their neighbours and share that responsibility and making sure that everyone’s OK” (P25046F) .

This sense of social isolation was discussed by one participant who referred to homeless people. They reflected on how current social structures may not be providing the information and support to this minority group and therefore should be considered when developing public health approaches to engaging them in PC and ACP education.

“And if you look at homeless people on the streets, where do they get the information from? Where do they get the care, the information, the attention. I know there are Street workers that work, but I don’t know again to what extent in Northern Ireland compared with the likes of London” (P25046F) .

Mapping the findings to a social ecological model framework

Following thematic analysis each of the resulting themes were mapped to the five socioecological levels identified by McLeroy et al. (1988) for health promotion programmes. Construct mapping can be found in Fig.  1 below.

Thematic interaction within the Social Ecological Model levels

The findings from this study highlight the complexity of current public perceptions of palliative care and their views on effective engagement with PC and ACP. Within medicalised western culture there is a tendency to focus on the preservation of life, with conversations about death avoided. This has resulted in death becoming a taboo, raising fear and stigma where death is equated with failure. These social taboos that exist around death, dying and bereavement are posited to stem from the lack of awareness and understanding of PC and ACP and the resulting stigma of approaching these discussions. There was evidence of influencing factors on all SEM levels, which demonstrates the need for a multifaceted public health approach that uses not only behaviour change communication but also social change communication, social mobilisation and advocacy. It can be argued this reflects the key aspects outlined in Lancet Commission report on ‘Valuing Death’, which advocated for a ‘systems approach’ [ 10 ]. This systems approach is aligned to differing levels within the SEM and the different approaches the public have identified when seeking to build public engagement and access to palliative care. Three key aspects were noted: visibility, embedding opportunities for engagement in everyday life and societal and cultural influences.

It was clear from the analysis that a major factor associated with poor public engagement was the lack of visibility within the public domain, which was hindering both the normalisation of death and understanding that PC was more than just end of life care. The findings demonstrated different ways to address the lack of visibility, such as the use of targeted social media and wider publicity campaigns. Research to date has demonstrated that palliative care education is a useful tool in improving knowledge of, confidence in and attitudes towards palliative care amongst healthcare professionals and carers [ 14 ]. Similar results have been noted for the public when exploring the potential to promote palliative care through various media challenges such as YouTube and social media [ 28 ]. This does, however, raise questions around the quality and accuracy of information offered via the media, taking cognisance of whether some of the messaging may inadvertently be adding to misunderstanding, and thus a lack of public engagement.

Secondly, the findings indicated that experience at the individual level within a social context was noted as an important element when seeking ways to increase public engagement with PC and ACP. The experience of illness, dying and loss is often overlooked, therefore, this points to the potential value of community-based education approaches, with peers enabling experience-based exchange. Such interventions have been noted in the literature on the role of volunteers and education [ 29 ]. This reflects the need for an overall public health palliative care approach that seeks to empower individuals, families and communities to draw on their own resources and community supports to adapt and cope with death and dying [ 6 , 30 ].

Thirdly, the findings from this study indicated the need for enhancing opportunities for engagement in PC and ACP within everyday life. Research indicates there is an appetite for people to talk about death, for example, in the UK, a recent YouGov ‘daily question’ survey reported 67% of adults who responded think the subject of death and dying should be talked about in schools [ 31 ]. This speaks to the need to consider schools, workplaces and key trigger points in life as times to consider engagement with PC and ACP. This reflects the overall need for death literacy in society to improve experiences at the end of life [ 10 ].

Finally, the importance of socio-cultural aspects for the public cannot be underestimated. Therefore, effective communication strategies need to be tailored to individuals, and communities and be culturally appropriate. This has been noted as an important aspect for specific communities, such as the Chinese diaspora, for example, but nuances around this for specific ethnic, political, religious, and geographical aspects need further consideration [ 32 ]. Cultural competence, defined as an understanding of how culture affects an individual’s beliefs, values and behaviour, is an important consideration [ 33 ]. A meta-analysis of 19 review articles, concluded that interventions to increase cultural competence in healthcare were effective in enhancing the knowledge, skills and attitudes of healthcare providers, leading to clinical benefits for patients/clients through improved access and utilization of healthcare [ 34 ]. The translation of such reviews for public engagement in PC and ACP warrants further exploration. It has been advocated that elements of cultural systems should be analysed with a socio-ecological framework [ 35 ]. Such consideration and integration of salient contextual cultural factors could assist public messaging and cultural communication, which would enhance more effective and sustainable public engagement in PC and ACP.

Limitations

When considering potential limitations, it is pertinent to note that due to the sensitive nature of the topic the exclusion criteria restricted the sample to those who had not experienced a recent bereavement. This may have limited the ability to gain a wider perspective, as the views of the recently bereaved may have provided further nuanced insights into how best to engage the public. Furthermore, the participant sample was limited to those involved in a larger mixed-methods study. This may have introduced bias in relation to true knowledge and attitudes due to the participants having completed the survey questionnaire prior to the interviews.

In conclusion, this qualitative study has provided insights into how the public would like to be engaged in PC and ACP. The findings highlighted that to build public engagement and access to palliative care and advance care planning a multifaceted public health approach is required. Discussions of death and dying remain difficult for many members of society, therefore, an increase in death literacy across all systems to reduce misperceptions surrounding PC and APC is needed, by increasing visibility and providing opportunities for the public to engage with PC and ACP within everyday life. Finally, socio-cultural aspects need consideration when developing strategies to ensure effective communication and engagement with all members of the community.

Data availability

The datasets analysed are not publicly available but are available from the corresponding author upon reasonable request.

Abbreviations

Advance care plan

• Palliative care

Palliative care education

Social ecological model

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Black, R., Hasson, F., Slater, P. et al. Building public engagement and access to palliative care and advance care planning: a qualitative study. BMC Palliat Care 23 , 98 (2024). https://doi.org/10.1186/s12904-024-01420-8

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Original research article, developing a community of inquiry using an educational blog in higher education from the perspective of bangladesh.

• 1 Institute of Education and Research (IER), University of Dhaka, Dhaka, Bangladesh
• 2 School of Education and Social Sciences, University of the West of Scotland, Paisley, United Kingdom

Web 2.0 tools such as blogs, wikis, social networking, and podcasting have received attention in educational research over the last decade. Blogs enable students to reflect their learning experiences, disseminate ideas, and participate in analytical thinking. The Community of Inquiry (CoI) framework has been widely used in educational research to understand and enhance online and blended learning platforms. There is insufficient research evidence to demonstrate the impact of educational blogging using the CoI model as a framework. This article explores how blogs can be used to support collaborative learning and how such an interaction upholds CoI through enhancing critical thinking and meaningful learning in the context of higher education (HE). An exploratory sequential mixed-method approach has been followed in this study. A convenience sampling method was employed to choose 75 undergraduate students from Dhaka University for a 24-week blogging project. Every publication on the blog was segmented into meaningful units. Whole texts of posts and comments are extracted from the blog, and the transcripts are analyzed in a qualitative manner considering the CoI framework, more specifically, through the lens of cognitive, social, and teaching presence. In addition, the semi-structured questionnaire is used to collect data from students irrespective of whether blogging expedited students' learning or not. The research findings indicate that cognitive presence, namely, the exploration component, is dominant in blog-based learning activity. Moreover, this research has demonstrated that blogs build reliable virtual connections among students through exchanging ideas and information and by offering opportunities for reflective practice and asynchronous feedback. This study also revealed challenges related to blogging in the context of developing countries, including lack of familiarity with blogs, restricted internet connectivity, limited access to devices, and low levels of social interaction. It is recommended that different stakeholders including policymakers, curriculum developers, and teachers take the initiative to synchronize the utilization of educational blogs with the formal curriculum, guaranteeing that blog activities supplement and improve traditional teaching–learning activities.

1 Introduction

The prevalence of online learning is rapidly expanding and has become more advanced due to ongoing technological improvements ( Seaman et al., 2018 ). Web 2.0 tools, such as blogs, wikis, social networking, media sharing, and podcasting, allow for self-directed, collaborative, and widespread learning by sharing resources, regardless of physical or geographical constraints ( Song and Bonk, 2016 ). For instance, blogs can be used in online and blended learning platforms to foster students' reflective learning ( Milad, 2017 ), developing learning communities through several strategies like posting students' work, exchanging hyperlinks, and so on ( Kerawalla et al., 2009 ). In this connection, several researchers added that blogging has obvious advantages to form the Community of Inquiry (CoI) framework and to trigger meaningful learning through improving the social, cognitive, and teaching presence ( Cameron and Anderson, 2006 ; Petit et al., 2023 ). In addition, effective instructional strategies and facilitation of discourse guided by teachers are more significant in creating CoI than any other approach ( Garrison and Akyol, 2013 ). Additionally, Jimoyiannis et al. (2012) argued that properly designed blog activities can help students achieve higher cognitive levels by enhancing their communication and collaboration skills and their critical thinking. However, despite the widespread excitement and curiosity around the learning design framework and online learning environments, there is a lack of research on the educational influence of learning designs ( Bower, 2017 ). Shifting to the reality of the COVID-19 pandemic and the widespread adoption of online learning, the pandemic has initiated a radical and rapid rethinking of the teaching–learning arrangement. The challenge was to provide guidance and support to educators to shift their curriculum to an online environment ( Garrison, 2020 ). The CoI framework may provide a coherent representation of relevant information and the means to navigate between theoretical and practical sources of information ( Garrison, 2020 ). Hence, it is vital to examine how CoI inquiry could be designed and implemented in online environments. Additionally, there is a lack of research evidence to demonstrate the impact of educational blogging when using the CoI model as a framework. Moreover, no research article on the use of educational blogs for a higher education level in Bangladesh has been found yet. The study aims to investigate the potential of the blogging environment in assisting higher education students in their learning process, focusing on key elements of the CoI framework. Hence, the following research questions will be addressed:

i. What is the nature of the students' interaction in the educational blogging practice?

ii. How does participating in blog-based learning activity support students' learning experience?

iii. What problems do the students confront while engaging in educational blogging?

2 Literature review

Blogs can be characterized as a web-based archive displaying contents in reverse chronological entry date. People with little technical knowledge can publish as well as share their thoughts, opinions, and emotions with others using blogs ( Pifarré et al., 2014 ). The use of blogging technologies by students in educational settings is on the rise globally ( Ifinedo, 2017 ). Blogs are commonly advocated as collaborative tools that facilitate active learning among students ( Jimoyiannis and Angelaina, 2012 ). However, the rate of users' participation can diverge from session to session and blog to blog ( Lawrence et al., 2010 ). Blogs can create an online collaborative portfolio for course-related resources, assignments, calendars, events, teaching experiences, open discussions, students' queries, and so on ( Kaya et al., 2012 ). Hence, blogs can play a vital role in establishing the learning community as well as encouraging interpersonal communication among teachers and students of higher education ( Kaçar, 2021 ).

The analysis of the educational use of blogs often involves various methods and frameworks to understand the dynamics, engagement, and impact of the blog content ( Kaul et al., 2018 ). The CoI model is a framework that is particularly relevant for analyzing the educational aspects of blog posts, especially in online learning platforms ( Kim and Gurvitch, 2020 ). CoI was initially developed as a conceptual framework to guide the practice of collaborative learning through asynchronous communication in online settings ( Garrison and Akyol, 2013 ; Shea et al., 2022 ). The origin of the CoI model is grounded in Vygotsky's theory of social development ( 1978 ) and Dewey's practical inquiry and critical thinking model ( 1933 ) ( Garrison and Akyol, 2013 ; Shea et al., 2022 ). The structure depicted in Figure 1 illustrates the three primary components (teaching, cognitive, and social presence) of CoI and their intersection, which are crucial for comprehending the dynamics of profound and significant online learning experiences ( Garrison et al., 2010a ). Subsequently, other research studies focused on collating data related to learning design as well as the evaluation process in the online learning experience to the cognitive dimension to identify and measure three constitutional components of the CoI framework, namely, social presence, teaching presence, and cognitive presence ( Garrison et al., 2010b ; Angeli and Schwartz, 2016 ).

Figure 1 . Community of Inquiry framework [adapted from Akyol and Garrison (2011) ].

Among the three elements of the CoI framework, the role of social presence has been investigated most extensively in online educational settings ( Garrison and Arbaugh, 2007 ). Research has claimed that social presence enhances the learner's satisfaction, while the internet is used as a medium to deliver education ( Cui et al., 2013 ). However, the positive social environments including affective expression, open discussion, and group cohesion lead toward a hidden curriculum of the technological aspects of distance or virtual education ( Moodley et al., 2022 ). In addition, Akyol and Garrison (2011) described cognitive presence as the extent to which learners can construct and confirm meaning through sustained reflection and discourse. Cognitive presence is considered a distinctive outcome of higher education since long rooted in Dewey's (1933) construction of practical inquiry and critical thinking ( Sadaf et al., 2021 ). Akyol and Garrison (2011) implemented cognitive presence in terms of a practical inquiry model and established a four-phase process including triggering, exploration, integration, and resolution in the context of educational settings. However, Marshall and Kostka (2020) emphasized the importance of teaching presence to ensure effective online learning rather than interactions among participants. Teaching presence has been conceptualized to comprise three components: instructional design and organization, facilitating discourse, and direct instruction. Several pieces of literature ( Chakraborty and Nafukho, 2015 ; Chakraborty, 2017 ; Bhatty, 2020 ) highlight the significance of teaching presence in online learning platforms to meet the needs of students, to ensure perceived learning, and to certify the sense of community.

Researchers were likely intrigued by the potential of blogs to foster a sense of community and social presence, which are essential elements of the CoI framework. The exploration of CoI in educational blogs is likely driven by a combination of theoretical considerations, gaps in current research, and practical implications. The research design was meticulously constructed to explicitly address these qualities and offer significant contributions to the field of online education.

3 Theoretical framework: Community of Inquiry (CoI) in educational blogs

Several researchers ( Pifarré et al., 2014 ; Jimoyiannis and Roussinos, 2017 ) have suggested the design of educational blogging activities applying the CoI model as an analysis framework considering students' engagement and presence. The primary approach underlying the design was to integrate an educational blog with both content space and discussion space. The content space encompasses blog posts, articles, multimedia elements, and other sources of information generated by the author or contributors. On the other hand, the discussion space refers to the section of the blog platform where readers and participants can actively participate in conversations, express opinions, ask questions, and offer feedback about the content presented in the content space. This design confirms the collaborative nature of the blog ( Jimoyiannis and Angelaina, 2012 ). Moreover, the CoI model determines indicators to recognize and measure each presence in an educational blog community. Basic components and indicators of CoI are presented in Table 1 considering educational blogs as a collaborative learning platform.

Table 1 . Indicators to recognize and measure each presence in an educational blog [modified from Garrison and Arbaugh (2007) ].

Table 1 provides a more explicit definition of CoI elements, using both indicators and instances. These characteristics have been employed to unambiguously ascertain social presence, cognitive presence, and instructional presence in a blog-assisted educational context. This mapping has been used in laying the groundwork for this research.

4 Methodology

4.1 research context.

Although technology-mediated learning has been introduced at the higher education level in Bangladesh in recent years ( Chowdhury et al., 2018 ), different online-based technologies have yet to be integrated into the curriculum and assessment process ( Arefin et al., 2023 ). In this study, the educational blog was created using Google Sites considering a project-based learning approach, which combines online and in-person instruction to enhance learning by offering guidance, resources, and feedback. The goal of this blog-based activity was to promote for blogs as additional resources in traditional teaching methods, with a focus on developing engaging and efficient instructional materials that are in line with specific learning objectives. This activity also aimed to foster collaborative learning and effective communication among students. However, there was no correlation between student involvement in the blog-based learning activity and the assessment process. Moreover, the curriculum did not provide any guidance on using alternative online platforms like blogs for instructional activities.

This study employed an exploratory sequential mixed-method approach. A convenience sampling method was employed to choose undergraduate students from Dhaka University for a 24-week blogging project. A total of 75 students enrolled in the “Introduction to Computer Course” of the B.Ed. program were invited to participate in this blog-based activities and were assessed on how collaborative learning opportunities contribute to the achievement of learning outcomes. A total of 65 students actively participated in collaborative blog discussions, contributing by uploading content and/or commenting to promote the discourse and reflection.

4.2 Data collection

This study collected both qualitative and quantitative data as part of an exploratory sequential mixed-method research design. Qualitative data were collected from the blogging activities of students and categorized into the following: content posts (e.g., text, image, audio, and video) and comments (e.g., questions, replies to or explanation of previous posts, and new notions). After completing a thorough analysis of the blog's activity, it was ascertained that there were 20 content postings and 71 comments made on the site during the research period. The low level of involvement can be ascribed to students' lack of familiarity with the blogging platform and the optional nature of their participation.

Furthermore, a semi-structured questionnaire, developed on existing research that used the CoI framework in online settings, was employed as an instrument to collect data from the students at the end of the semester to assess whether activities on educational blogs facilitate and contribute to students' learning. The participating students were required to assess quantitative items on a 5-point scale: (1 [strongly disagree], 2 [disagree], 3 [unsure], 4 [agree], and 5 [strongly agree]). They were also asked to provide qualitative responses in an open-text format, expressing their opinions on the effectiveness and challenges of educational blogs.

4.3 Data analysis

To address the first research question, qualitative data (content posts and comments) on the blog were segmented into meaningful units. A meaningful unit refers to a distinct and analyzable segment or component within a content post/comment on the blog. Each meaningful unit is segmented based on the specific characteristics related to cognitive, social, and teaching presence, as outlined in the CoI framework. Afterward, these meaningful data units were categorized according to 13 indicators associated with CoI elements (specified in Table 1 ). Both authors attempted to generate meaningful units from content posts and comments. To evaluate the consistency or agreement between the researchers while assessing the meaningful units, interrater reliability was measured ( Stemler, 2019 ). Subsequently, the researchers employed a consensus-building procedure to address and settle any differences, and this entailed collaborative evaluations of complex instances and deliberations to arrive at mutually acceptable decisions ( Stemler, 2019 ).

In the subsequent phase, students' responses were analyzed to address the second and third research questions. Quantitative data of students' responses were analyzed statistically using descriptive statistics methods (frequency, mean, and standard deviation), whereas qualitative data were analyzed thematically. The qualitative data about blog-based activities were integrated with the quantitative data concerning the students' perspective of blogging to have a more accurate comprehension of the research inquiries. Hence, the validity and reliability of the study were enhanced through cross-verification of results by using both qualitative and quantitative data.

4.4 Ethical consideration

Prior to participation as samples, the participants were provided with an informed consent form about the goal of the study. Subsequently, the participants provided written informed consent to ensure their complete understanding and enable them to make voluntary and well-informed decisions regarding their participation. This study used rigorous measures to guarantee absolute confidentiality and anonymity in both data collection and presentation, thereby safeguarding the privacy of the participants' data. There was no requirement for any type of student identification for the questionnaire. Moreover, the blog activities and analysis of blog publication did not need the use of individual student identities.

The findings were organized into three sections: students' engagement patterns on educational blogs, the impact of blog-based learning activities on students' learning, and the challenges associated with using educational blogs.

5.1 Nature of students' interaction in educational blogging

By converting each content posts and comments into distinct and significant components, a total of 100 meaningful units of units were found. In this specific study, the researchers reached a consensus on 90 out of 100 units, indicating a significant degree of interrater reliability. The results obtained by the researchers reveal a strong correlation across all sets of results, indicating a high level of interrater reliability for the test. Subsequently, after resolving the disagreements through a consensus, meaningful units were categorized in Table 2 according to the 13 indicators of the CoI model.

Table 2 . Blog's Community of Inquiry.

In Table 2 , the analysis of dissimilar proportions among three key presence factors—cognitive, social, and teaching—revealed significant variations. Cognitive presence dominated with 71%, surpassing both social presence (17%) and teaching presence (12%). The feeling of belonging enhanced social presence as individuals had a sense of connection to a collective with common interests and objectives. Within the cognitive domain, the aspect of exploration was prominent, accounting for 43% of the overall presence. Analyzing social presence revealed a fair distribution within this group. Teaching presence referred to a focus on the design and organization aspect, which accounts for 8% of this group. The comprehensive analysis of each category of presence offered a nuanced comprehension of the diverse factors influencing the CoI.

5.2 Blog-based learning activities to contribute and facilitate the way of students' learning

The following sections have highlighted students' responses regarding the blog-based experience.

5.2.1 Influencing factors of blogging experience in terms of perceived learning, community of practice and collaborative learning

The quantitative findings were categorized into perceived learning, community of practice, and collaborative learning and presented in the following sections:

• Perceived learning

It was revealed that students usually hold a favorable impression of using blogs for learning, exhibiting a strong consensus on statements pertaining to enjoyment, knowledge dissemination, and the efficacy of learning ( Table 3 ).

Table 3 . Perceived learning of blogs ( N = 65).

As given in Table 3 , 84.6% of students reported positive attitudes toward using blogs for educational purposes, with a mean score of 3.97 indicating a moderately positive perception and a low level of variability with a standard deviation of 0.59. Similarly, 81.5% of students derived enjoyment from reading and acquiring knowledge from publications on the blog. A significant majority (89.1%) hold the belief that blog conversations are beneficial for exchanging information and expertise with peers. However, a variation in the reactions to accessing the blog more than required was observed, with a significant number of students expressing a neutral position. The average score (M = 2.97) indicated a neutral-to-slightly negative sentiment, and there is a significant range of responses (SD = 0.98). In addition, 89.1% of students strongly asserted that using the blog has facilitated their learning, demonstrating a constant and favorable influence on their educational experience.

• Community of practice

Table 4 illustrated that students perceived positive perceptions of the impact of blog posts on enhanced connectivity, heightened motivation, and greater interaction.

Table 4 . Blogs as a community of practice ( N = 65).

As given in Table 4 , approximately 70.3% of students reported feeling connected when using the blog, suggesting a favorable emotional attachment to the learning environment. The data indicated that a substantial number of students (75.4%) demonstrated a desire to engage with supplementary materials pertaining to the issues mentioned on the blog. This pointed out that the blog can serve as an effective catalyst for encouraging further investigation and study. Approximately 70.4% of students hold the belief that the blog has a role in enhancing the interaction, promoting a feeling of involvement and cooperation within the learning community.

• Collaborative learning

Table 5 demonstrated that the data suggest favorable perceptions regarding the influence of blog posts on the enhancement of skills and the promotion of collaborative learning.

Table 5 . Collaborative learning through blogs ( N = 65).

Approximately 79.7% of students concurred that publications (posts/comments) from peers have been beneficial in enhancing their abilities and knowledge. Likewise, a significant majority of students (75.1%) held the belief that blogging enhances collaborative learning among their peers. Nevertheless, opinions differed regarding the idea that collaborative learning is time-consuming; 36.7% of individuals agreed, while 31.3% remained neutral. The average score was somewhat negative (M = 3.05), and there was a considerable degree of heterogeneity in the replies (SD = 1.06).

• Scale statistics

It was found that students preferred blogs as beneficial for perceived learning use (M = 19.00, SD = 2.078) in comparison to community of practice (M = 11.29, SD = 1.670) and collaborative learning platform (M = 10.63, SD = 1.386). In aggregation, positive experiences were revealed to continue teaching-learning practices using blogs among students ( Table 6 ).

Table 6 . Scale statistics ( N = 65).

5.2.2 Impact of blogging activities on learning experience

The following sections emphasized students' perception of the impact that blog-based learning activities had on their learning experience.

• Flexibility

It was found that more than 75% of the students have mentioned that it is convenient as blogs are easy to access and flexible in timing based on their personal preference even in leisure. However, some of them were worried about the availability of the internet. According to Student 1 ,

“ I can access blog 24/7 anywhere.”

Approximately two-thirds of the students mentioned that blogs give them an opportunity to share learning resources and access different thoughts of a community as well as to develop understanding. Some other students' responses are mentioned below:

“ People learn from reading the comments of different respondents.” (Student 2)     “ Blog helps to develop understanding.” ( Student 3)     “ Blog helps us to know thought of others.” ( Student 4)

Few students mentioned that blogs were a new way of learning collectively and are very fun and interactive. According to Student 5 ,

“ I think it is new way of learning collectively.”

• Feedback

Around half of the students mentioned that they can express themselves through writing, and at the same time, the feedback helps them be motivated as well as accumulate self-confidence. A few of the students reported that they were able to learn many new things through using blogs. According to Student 6 ,

“ Blog makes us confident as it creates opportunities to learn new things.”

• Motivation

Students also demonstrated favorable attitudes toward emotions of connection, motivation for further reading, and apparent enhancement in engagement when using the blog ( Table 4 ).

• Virtual learning communities

Nearly half of the students concurred that blogs had the potential to foster the development of virtual learning communities, facilitating student connectivity, the exchange of experiences, and the provision of mutual support. According to Student 7 ,

“ Blog promotes discussion.”

• Empowerment

Some of the students expressed the view that blogging enables students to assert their thoughts, communicate their viewpoints, and participate in discussions, hence fostering a sense of ownership in their learning experience. According to Student 8 ,

“ As blogs have different people with different perspectives, and I have personally found many thought-provoking ideas in different blogs.”

• Access to resources

A number of students contended that blogs could function as a means for disseminating knowledge, references, and supplementary content, thereby offering benefits to students.

5.3 Challenges of using educational blog

While educational blogs offered numerous benefits, there were also challenges associated with their use in the context of developing countries such as Bangladesh. The subsequent sections delineated several obstacles reported by the students during their use of educational blogs in this study:

• Unfamiliarity of blog

Several students expressed a lack of proficiency in using blogs, which impedes their capacity to successfully explore and use instructional blogs. According to Student 9 ,

“ The problem is that blogs are still unfamiliar.”

• Limited internet access

The majority of the students reported that limited and unreliable access to the internet can hinder the students' ability to participate in blog-based activities. According to Student 10 ,

“ Blogging activity needs internet, and internet is not available everywhere.”

• Limited access to device

The study revealed that several students do not have personal devices such as laptops or smartphones, which presents a difficulty for their involvement in blog activities that require digital interaction. This has the potential to create a digital divide, which could impact the equity of educational opportunities.

• Decreased socialization

It was found that blog users sometimes absorb information alone, not actively participating in social interactions. Furthermore, a few students indicated that, unlike face-to-face contacts, blogs may lack personal connection, resulting in a decreased sense of socialization. According to Student 11 ,

“ It can reduce the tendency of reading the contents carefully and reduce in-person interactions with people.”

6 Discussion

This study has demonstrated that the integration of cognitive, social, and teaching presence is necessary for meaningful learning in online platforms. The results of this investigation are consistent with the conclusions of a prior study ( Fiock, 2020 ). In addition, this study has confirmed that cognitive presence is highly observed in blogging activities, which is similar to the findings of a previous research ( Liu et al., 2022 ). On the contrary, several studies ( Garrison, 2007 ; Galikyan and Admiraal, 2019 ) have found difficulties to move toward higher cognitive and inquiry levels in asynchronous online discussions. This study has confirmed that teaching presence is the least observed in blogging activities, which is similar to the findings of previous research ( Angelaina and Jimoyiannis, 2011 ), where they reported that teaching presence is anticipated to be less tangible in blogging activities while analyzing students' posts using the CoI framework, and it cannot be assumed that all students will actively engage with and read the instructor's posts.

In addition, the majority of the students affirmed that they enjoyed using blogs as a learning tool and have been facilitated through blogs to share knowledge and experience with peers. Furthermore, they added that the presence of conducive academic environments for collaborative learning has spurred their inclination to explore relevant supplementary resources. Similarly, Bener and Yildiz (2019) found blogs as a reflective platform where participants can actively deliberate their thoughts about the topics discussed in the blogs. Students have also uttered that blogging leads toward effective collaboration by creating opportunities for diverse perspectives, which reflects the research outcome of a previous study ( Zawilinski, 2012 ).

The current study indicated that blogs are not familiar enough to the students and that ~15% of them are not interested in posting publications. In addition, approximately one-third of the students were found inattentive to take the maximum advantages of collaboration and feedback due to a lack of technological competency. However, Amichai-Hamburger et al. (2016) noted that individuals who only engage in reading rather than not interested in participating in online discussion may still get the opportunity to learn through passive or indirect participation. In addition, this study revealed that students need clear guidelines, argumentative posts, and constant feedback to optimize learning outcomes in the blogging environment. Similar issues have been mentioned by other research also ( Hansen, 2016 ). This study has revealed that providing constructive feedback can effectively steer students toward enhancing their level of engagement and the quality of their contributions. Additionally, Pifarré et al. (2014) used an exploratory sequential multi-method approach to investigate a blogging project in a secondary class and found that collaborative learning as well as a sense of community were important factors in predicting perceived learning in an online setting. The results of their research align with the results of this study. Hence, it is evident that a supportive community can inspire students to actively participate in the blogging environment and have a sense of belonging. Furthermore, one-third of the students worried about the unfamiliarity and technical difficulties of using blogs. It is to be noted here that this research did not provide any training on blogging. Farmer et al. (2008) emphasized conducting a fully scaffold lab session for ensuring enhanced accessibility as well as providing adequate technical support.

7 Recommendations

This study suggests the following recommendations to leverage students' engagement as well as to enhance learning outcomes through blogging activities:

• Establishing monitoring system: It is recommended to establish a monitoring system to detect the students who may be encountering difficulties with technology or experiencing a lack of involvement.

• Offering training, guidelines, and mentorship: It is imperative to establish comprehensive training programs that focus on technical competency for students, aiming to improve their proficiency in using online platforms. Explicit guidelines or online modules might aid students in comprehending the specific requirements, minimizing ambiguity, and augmenting their capacity to engage actively. Furthermore, offering supplementary aid through individualized guidance, peer mentorship, or supplementary materials can assist these students in surmounting barriers and engaging effectively.

• Fostering open communication: It is suggested to foster a positive environment that encourages students to freely voice their viewpoints, inquire, and engage with their peers, which can serve as a beneficial stimulus to promote active participation.

• Accommodating diverse learning preference: It recommended to focus on designing learning activities that accommodate different diverse learning preferences of the students, guaranteeing that both engaged and unengaged participants can benefit from the blogging platform.

• Redesigning curriculum: It is recommended to synchronize the use of educational blogs with the formal curriculum, guaranteeing that blog activities supplement and improve conventional teaching techniques.

• Redesigning assessment process: It is recommended to establish explicit assessment methods for blog-related tasks, ensuring they are in line with the goals of the course. This study suggests the design of collaborative projects that leverage the interactive features of blogs. Assignments that require group discussions, collaborative projects, or peer evaluations on the blogging platform can enhance collaborative learning and offer exposure to a wide range of ideas.

• Creating awareness: As a social media tool, blogs are still underrated and underutilized, so awareness needs to be created focusing on the impact of blogs to enhance teaching and learning practices.

8 Conclusion

Despite that most of the students were unfamiliar with using blogs, they showed enhanced enthusiasm to participate in the blog activities to boost online learning through posting content and resources, discussing ideas, making queries, and so on. Students' participation in educational blogging practices is characterized by asynchronous collaboration, information exchange, reflection, and constructive feedback. Engaging in a wider dialogue and receiving feedback frequently result in a stronger sense of personal responsibility for one's own learning. Using a blended learning philosophy, well-designed blogs can encompass the students' learning arena beyond the classroom boundaries by combining different approaches to learning. Overall, the findings of this study indicate that blogs are perceived by students as an effective collaborative learning tool. Hence, stakeholders and curriculum developers may emphasize aligning this tool with the existing curriculum to maximize and leverage the potential benefits of blogging. The small sample size and exploratory nature of the study are the major limitations of this study. Further research may be conducted to assess student perception with a larger study group to get a detailed idea about how blogs andragogically or pedagogically can be used to support the creation of a CoI framework that could lead to meaningful and collaborative learning.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

Ethical approval was not required for the study involving human participants in accordance with the local legislation and institutional requirements. Written informed consent was obtained from the individuals for participation in the study and for the publication of any potentially identifiable images or data included in this article.

Author contributions

SC: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Software, Visualization, Writing – original draft, Writing – review & editing. MS: Conceptualization, Methodology, Project administration, Supervision, Validation, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: web 2.0, Community of Inquiry (CoI), blog, collaborative learning, learning outcome

Citation: Chowdhury SA and Siddique MNA (2024) Developing a Community of Inquiry using an educational blog in higher education from the perspective of Bangladesh. Front. Educ. 9:1302434. doi: 10.3389/feduc.2024.1302434

Received: 26 September 2023; Accepted: 25 March 2024; Published: 09 April 2024.

Reviewed by:

Copyright © 2024 Chowdhury and Siddique. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Sabbir Ahmed Chowdhury, sabbir.ahmed@du.ac.bd

This article is part of the Research Topic

Psychological Transformation in Technology-Enhanced Learning Environments (TELEs): Focus on Teachers and Learners