key informant interview in qualitative research

Key Informant Interviews: An In-Depth Guide for Researchers

Frankline kibuacha | feb. 02, 2024 | 8 min. read.

What are Key Informant Interviews?

Key Informant Interviews (KIIs) are specialized qualitative interviews conducted with individuals (key informants) recognized for their insider knowledge or unique perspectives on a specific topic. This method is distinct in its focus on depth rather than breadth, targeting information-rich sources.

Unlike surveys that seek quantitative data or focus groups that explore group dynamics, KIIs delve deeply into individual perspectives, offering a granular understanding of complex issues.

KIIs are invaluable for gaining insights into trends, motivations, perceptions, and experiences. They are particularly effective in sectors where in-depth, expert knowledge is crucial, such as public health, policy development, and market analysis.

The Importance of Key Informant Interviews in Research

Key Informant Interviews (KIIs) play a pivotal role in qualitative research, offering a depth of understanding often unattainable through other methods. Their significance in various research settings can be elaborated as follows:

• Access to Specialized Knowledge and Expert Insights: KIIs enable researchers to tap into the wealth of knowledge possessed by experts in specific fields. This is especially crucial in areas where specialized insights are vital to understanding complex issues. For instance, interviews with healthcare professionals in public health research can uncover nuances in patient care practices that surveys may not reveal.
• Understanding Context and Nuance: One of the primary strengths of KIIs is their ability to capture the context and nuances around a subject matter. Unlike quantitative methods that offer breadth, KIIs provide depth, uncovering the ‘why’ and ‘how’ behind observable trends. This depth is invaluable in fields like policy analysis, where understanding the rationale behind decisions can inform more effective policy development.
• Flexibility and Adaptability: KIIs offer unmatched flexibility, allowing researchers to explore new lines of inquiry as they emerge during the interview. This adaptability is critical in exploratory research or when dealing with emerging issues, where predefined survey questions might miss important aspects.
• Identifying Hidden or Sensitive Issues: Given their expertise and experience, key informants can provide insights into sensitive or hidden issues that might not be readily disclosed through other methodologies. In contexts such as humanitarian work or conflict research, KIIs can reveal underlying problems or needs that are not visible on the surface.
• Enhancing Other Research Findings: KIIs can complement and improve findings from quantitative research. They add depth to the statistical data by providing qualitative insights, offering a more comprehensive view of the research topic.
• Case Studies Illustrating Impact: Real-world examples further illustrate the impact of KIIs. For example, in environmental research, KIIs with local community leaders and environmental experts have been instrumental in understanding the impact of climate change at a local level, leading to more targeted and effective conservation strategies.

Key Informant Interviews are an indispensable tool in the researcher’s toolkit. They provide a level of detail and understanding crucial for fully grasping complex issues, influencing policy, and informing comprehensive and effective solutions.

Methodology and Best Practices for Key Informant Interviews

Effective Key Informant Interviews require a well-thought-out methodology and adherence to best practices. This section outlines the key steps and considerations for maximizing the value of KIIs.

• Criteria for Selection: The selection of key informants is a critical step. Ideal candidates are those who have in-depth knowledge or experience relevant to the research topic. This could include industry experts, community leaders, or individuals with unique experiences pertinent to the study.
• Diversity and Representation: It’s essential to ensure diversity in selecting informants. This includes diversity in profession, demographic characteristics, and perspectives to obtain a well-rounded understanding of the issue.
• Recruitment Strategies: Effective recruitment may involve formal invitations, leveraging professional networks, or recommendations from other experts in the field. It’s crucial to clearly communicate the purpose of the research and the informant’s role.
• Balancing Structure and Flexibility: While having a structured set of questions to guide the interview is important, flexibility is key. Researchers should be prepared to explore interesting avenues that emerge during the conversation.
• Question Types : A mix of open-ended questions (to explore opinions and experiences) and more specific questions (to gather detailed information) is recommended. Avoid leading questions to minimize bias.
• Piloting Questions: Before conducting the interviews, it’s advisable to pilot the questions with a small group to ensure they are clear and elicit the desired information.
• Building Rapport: The initial part of the interview should focus on building rapport with the informant. This can be achieved through a friendly demeanor, active listening, and genuine interest in the informant’s perspectives.
• Interview Techniques: Effective techniques include probing for details, paraphrasing to check understanding, and managing the pace of the interview. Non-verbal cues play a significant role in creating a comfortable environment.
• Recording and Note-Taking: It’s essential to accurately record the interviews, subject to the informant’s consent. This can be done through audio recordings or detailed note-taking. Clear, concise, and accurate notes are vital for accurate data analysis.
• Informed Consent: Informants should be fully informed about the purpose of the research, how their information will be used, and their rights, including the right to withdraw from the interview at any point.
• Confidentiality and Anonymity: Researchers must respect the confidentiality of the information provided and ensure anonymity if the informant requests it.
• Cultural Sensitivity: It is crucial to be culturally sensitive and respectful of the informant’s background and beliefs, especially when dealing with sensitive topics.
• Debriefing and Reflection: After each interview, a debriefing session can be helpful for the research team to discuss initial impressions and insights.
• Data Management: Organizing and securely storing interview data is crucial for analysis and future reference.

Challenges and Solutions in Key Informant Interviews

Key Informant Interviews, while invaluable in qualitative research, present unique challenges. Addressing these effectively is crucial for the integrity and utility of the data collected.

• Solution: Employing multiple interviewers and informants can provide diverse viewpoints, reducing individual bias. Establishing a clear, structured interview framework helps maintain objectivity. Regular team discussions can also aid in identifying and mitigating biases.
• Solution: Developing a detailed interview guide ensures consistency across interviews. Validity can be enhanced through careful selection of informants based on their expertise and through cross-verification of data with other sources.
• Solution: Flexibility in scheduling and using technology for remote interviews can alleviate logistical issues. Building rapport with informants beforehand can also ease scheduling difficulties. It is also important to have backup interviewees, for instance, someone in the same department with the same knowledge as the primary informant.
• Solution: Employing culturally aware and, where necessary, multilingual interviewers can mitigate these issues. Researching cultural norms and using interpreters when needed is also helpful.
• Solution : KIIs typically involve a small group of respondents, so your best bet is to attain a sample that is well knowledgeable of the topic at hand.
• Solution: Utilizing qualitative data analysis software can streamline coding and thematic analysis, reducing time and subjective biases. Engaging multiple team members in the analysis can provide a balance of perspectives.

While Key Informant Interviews pose specific challenges, these can be effectively addressed through careful planning, methodological rigor, and cultural sensitivity. Overcoming these challenges ensures the integrity and value of the insights gained from this qualitative research method.

Analyzing and Utilizing Data from Key Informant Interviews

Analyzing and utilizing data gathered from KIIs are as crucial as the interview process itself. This phase transforms raw, qualitative data into meaningful insights that can guide decision-making and policy formulation. It is worth noting that, due to their typically small sample sizes and qualitative nature, KIIs are almost never quantified.

• Transcribing Interviews: The first step is to transcribe the interviews verbatim. This process involves converting audio recordings into written text, capturing every word, and noting critical non-verbal cues.
• Data Cleaning: Transcripts should be reviewed and cleaned for clarity and accuracy. This includes removing irrelevant sections, correcting errors, and anonymizing data if required.
• Thematic Analysis: One of the most common approaches is thematic analysis, which involves identifying patterns and themes within the interview data. This process starts with reading through the transcripts multiple times to gain a deep understanding of the content.
• Coding: Coding involves labeling text segments with tags that summarize their content. This could be done manually or with the help of qualitative data analysis software. Initial codes are generated and then refined and grouped into broader themes.
• Interpreting Themes: Once themes are identified, the next step is to interpret them in the context of the research objectives. This involves understanding how these themes contribute to answering the research questions and what new insights they offer.
• Cross-Verification with Other Data Sources: To enhance the validity of the findings, it’s essential to cross-verify the insights from KIIs with other data sources, such as surveys, literature reviews, or observational studies.
• Triangulation: This process involves using multiple data sources or methods to corroborate the findings. Triangulation strengthens the credibility of the research conclusions.
• Developing Recommendations: The insights derived from KIIs should be translated into actionable recommendations. This involves considering how the findings can inform policy, influence strategies, or guide practical interventions.
• Reporting Findings: When reporting findings, it’s essential to present the data in a way that is accessible and understandable to the intended audience. This could include using quotes from informants to illustrate points, creating visual representations of themes, or developing case studies.
• Subjectivity: One of the challenges in analyzing qualitative data is the inherent subjectivity. It’s crucial to approach data interpretation with an awareness of potential biases and strive for objectivity.
• Complexity of Data: Qualitative data from KIIs can be complex and multifaceted. Researchers need to be methodical in their approach to ensure that the richness of the data is fully explored and understood.

In a nutshell, analyzing and utilizing data from Key Informant Interviews require meticulous attention to detail, rigorous methodological approaches, and a careful balance between subjective interpretation and objective analysis.

When to Use Key Informant Interviews in Research

Understanding when to utilize Key Informant Interviews (KIIs) is crucial for researchers to gather in-depth qualitative data effectively. KIIs are particularly advantageous in specific research contexts:

• Exploring Complex or Sensitive Issues: KIIs are ideal when researching topics that are complex, nuanced, or sensitive. They provide a safe environment for informants to share detailed insights and personal experiences that might not be captured through other methods.
• Gaining Expert Perspectives: When a study requires expert opinions or specialized knowledge, KIIs are an excellent choice. They allow researchers to tap into the wealth of experience and expertise of individuals who are well-versed in the subject matter.
• Developing or Refining Hypotheses: In the early stages of research, especially when hypotheses are being developed or refined, KIIs can offer valuable insights that inform the direction and focus of the study.
• Understanding Contextual and Cultural Dynamics: When research involves understanding the cultural or contextual nuances of a topic, KIIs with local experts or community leaders can provide depth and context that other methods may miss.
• Policy Development and Evaluation: For policy-oriented research, KIIs with policymakers, stakeholders, and those affected by the policy can provide insights into both the impact of existing policies and considerations for future policy development.
• Market Research and Consumer Insights: In market research , KIIs with industry experts, consumers, or other stakeholders can uncover trends, motivations, and attitudes that inform marketing strategies and product development.
• When Quantitative Data Needs Qualitative Support: KIIs are also valuable when quantitative data requires qualitative insights for a more comprehensive understanding. They can explain the ‘why’ behind the numbers, adding depth to quantitative findings.
• Resource-Limited Settings: In settings where resources for large-scale surveys are limited, KIIs can provide significant insights without the need for extensive logistics and infrastructure.

The decision to use KIIs should be guided by the research objectives, the nature of the research question, and the context in which the study is conducted. When used appropriately, KIIs can be a powerful tool in the researcher’s arsenal, providing nuanced insights that are vital for in-depth understanding and informed decision-making.

Master Key Informant Interviews with GeoPoll

Key Informant Interviews (KIIs) stand as an indispensable qualitative research tool, adept at uncovering deep insights and nuanced understandings in a wide array of research settings. From exploring complex and sensitive issues to refining hypotheses and informing policy decisions, KIIs offer a unique avenue for accessing expert knowledge and contextual information that other methods might miss.

This guide has journeyed through the intricacies of KIIs, highlighting their importance, methodology, challenges, solutions, and ideal usage scenarios. The careful planning, ethical considerations, and skilled execution required for effective KIIs underscore the need for experienced researchers and methodologists.

GeoPoll, with its vast experience and expertise in conducting KIIs across diverse sectors and regions, is uniquely positioned to help you leverage this powerful research method. Our seasoned professionals are adept at navigating the complexities of KIIs, ensuring that each interview is methodologically sound and rich in valuable insights. We offer a full spectrum of services, from designing the interview guide and selecting key informants to conducting the interviews and analyzing the data.

Contact us for further information on how Key Informant Interviews can enrich your specific research endeavors and how we can support you.

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Key informant interviews

Key informant interviews involve interviewing people who have particularly informed perspectives on an aspect of the program being evaluated.

Key informant interviews are "qualitative, in-depth interviews of 15 to 35 people selected for their first-hand knowledge about a topic of interest. The interviews are loosely structured, relying on a list of issues to be discussed. Key informant interviews resemble a conversation among acquaintances, allowing a free flow of ideas and information. Interviewers frame questions spontaneously, probe for information and take notes, which are elaborated on later" (USAID 1996).

USAID (1996) lists a number of situations in which key informant interviews are useful:

• When decision-making can be achieved through qualitative and descriptive information.
• When it is important to gain an understanding of the perspectives, behaviour and motivations of customers and partners of an activity or project in order to explain the shortcomings and successes of an activity.
• When generating recommendations is the key purpose.
• In order to interpret quantitative data by interviewing key informants about the how and why of the quantitative findings.
• In order to help frame the issues that are relevant before designing a quantitative study.

Advantages to this method include:

They are an affordable way to gain a big picture idea of a situation.

The information gathered comes from people who have relevant knowledge and insight.

They allow for new and unanticipated issues and ideas to emerge.

Limitations to this method include:

There is a potential for the interviewer to unwittingly influence the responses given by informants.

There is a potential bias if informants are not selected with care.

Systematic analysis of a large amount of qualitative data can be time-consuming.

The validity of the data can sometimes be difficult to prove.

Advice for using this method

When formulating study questions, limit the amount to five or fewer.

The interview should allow for free discussion by informants however, interviewers should be aware of what questions to ask and topics that should be covered. 

When preparing a guide for interview topics, items are usually limited to 12 items so as to allow for in-depth discussion. It is sometimes useful to prepare different guides for different groups of informants.

When selecting key informants, it is often a good idea to start with a smaller amount as initially unplanned informants are often added. The total number generally is no more than 35.

In selecting key informants, make sure to include a wide range of perspectives and points of view, including selecting from different groups of key stakeholders.

See Interviews for more general advice on interviewing.

This USAID document advises how to conduct and apply the rapid appraisal technique known as key informant interviews.

Pact, Inc. (2014),  Field Guide for Evaluation: How to Develop an Effective Terms of Reference.  Washington.

USAID Center for Development Information and Evaluation (1996) Conducting Key Informant Interviews   Performance Monitoring & Evaluation TIPS . Washington DC, USAID. Retrieved from  http://pdf.usaid.gov/pdf_docs/PNABS541.pdf  via  USAID

'Key informant interviews' is referenced in:

• Qualitative impact assessment protocol
• 52 weeks of BetterEvaluation: Week 4: Including unintended impacts

Framework/Guide

• Communication for Development (C4D) :  C4D Hub: Check the results support causal attribution (strategy 2)
• Communication for Development (C4D) :  C4D Hub: Investigate possible alternative explanations (strategy 3)
• Communication for Development (C4D) :  C4D: Collect and/or retrieve data (methods)
• Communication for Development (C4D) :  C4D: Identify potential unintended results
• Rainbow Framework :  Collect and/ or retrieve data
• Rainbow Framework :  Identify potential unintended results
• Footprint evaluation
• Sustained and Emerging Impacts Evaluation (SEIE)

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Principles of Social Research Methodology pp 389–403 Cite as

Key Informants’ Interviews

• Salma Akhter 4  
• First Online: 27 October 2022

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This chapter provides a short description of the key informant interview (KII), an important data collection method in qualitative research. Then, the chapter explains the suitability of this method in qualitative research. The chapter discusses the selection process of key informants with the roles of researcher and interviewer. The chapter gives important guidelines of the steps to conduct KII. The chapter also provides some guidelines about the data process, data presentation, and data analysis strategies of KII. The chapter ends with a description of the advantages and disadvantages of KII.

• Social research; Qualitative research; Interview; Key informants

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Adams, A., & Cox, A. L. (2008). Questionnaires, in-depth interviews and focus groups. In P. Cairns & A. L. Cox (Eds.), Research methods for human computer interaction (pp. 17–34). Cambridge University Press.

Chapter   Google Scholar  

Ali, M., David, M. K., & Lai, L. C. (2014). Using the Key Informants Interviews (KIIs) technique: A social sciences study with Malaysian and Pakistani respondents. Man and Society , 24 , 131–148

Google Scholar  

Bailey, C. A. (2017). A guide to qualitative field research. The Pine Forge Press series in research methods and statistics . Pine Forge Press. A Sage Publications Company.

Bryman, A. (2004). Social research methods , (2nd ed). Oxford university Press.

Douglas, J. (1985). Creating interviewing . Sage.

Henn, M., Weinstein, M., & Foard, N. (2006). A short introduction to social research . Sage Publications: California, USA.

Jones, C. (1993). Qualitative interviewing. In G. Allan, C. Skinner (Eds), Handbook for Research students in the social sciences . The Falmer Press: London.

Kumar, K. (1989). Conducting Key Informant Interviews in Developing Countries, A.I.D. Program Design and Evaluation Methodology Report No. 13, Center for Development Information and Evaluation, A.I.D, December 1989

Kvale, S. (1996). Interviews: An introduction to qualitative research interviewing . Sage Publications.

Lavrakas, Paul J., 2008, Encyclopaedia of Survey research Methods, Sage Publications.

Mack, N., Woodsong, C., Macqueen, K. M., Guest, G., & Namey, E. (2005). Qualitative research methods overview. Qualitative research methods: A data collector’s field guide , 1–12, Family Health International, USAID.

Marshall, M. N. (1996). The key informant technique, Family Practice , 13 (1), Oxford University Press.

Maxwell, J. (1996). Qualitative research design: An interactive approach, applied social research methods series . Vol. 41, Sage publication: Thousand Oaks, USA.

McKenna, S. A., & Main, D. S. (2013). The role and influence of key informants in community-engaged research: A critical perspective. Action Research . SAGE.

Needs assessment techniques. Using key informant interviews . Retrieved from. http://ppa.aces.uiuc.edu/pdf_files/Informant1.PDF

Neuman, W., & Lawrence. (1997). Social research methods. Qualitative and quantitative approaches (3rd ed), Allyn and Bacon: USA.

Oklahoma's Official Website. Key informant interview guidance document . Retrieved from. https://www.ok.gov/odmhsas/documents/Key%20Informant%20Interview%20Guidance%20Doc_Draft.pdf

Pact Inc. (2014). Field guide for evaluation: How to develop an effective terms of reference, Washington DC. Retrieved from. https://www.betterevaluation.org/sites/default/files/Field%20Guide%20for%20Evaluation_Final.pdf

Parsons, J., (2008). A Key Informant. Blackwell encyclopaedia of sociology, 2007 , Sage publications.

Punch, KF. (2001). Introduction to social research. Qualitative and quantitative approaches , Sage Publications: London.

Richardson, M. (1994). Writing: A method of inquiry. In N. K. Denzin, & Y. S. Lincoln (Eds), Handbook of qualitative research (pp. 516–529). Sage: Thousand Oaks, CA, USA.

Ritchie, J. & Lewis, J. (Eds.). (2013). Qualitative research practice: A guide for social science students and researchers . Sage.

Sanjari, M., Bahramnezhad, F., Fomani, F. K., Shoghi, M., & Cheraghi, M. A. (2014). Ethical challenges of researchers in qualitative studies: The necessity to develop a specific guideline. Journal of Medical Ethics and History of Medicine , 7 , 14.

Sofaer, S. (2002). Qualitative research matters. International Journal for Quality in Health Care, 18 (4), 329–336, International Society for Quality in health care and Oxford University Press.

Thakur, D. (2005). Research Methodology in Social Sciences . Deep and Deep Publications Pvt Ltd.

The center for substance abuse prevention’s northeast center for the application of prevention technologies. (2004). Key informant interviews , (NECAPT, 2004 Education Development Center, Inc.

Turney, L. & Pocknee, C. (2005). Virtual Focus Groups. New Frontiers in Research.

UCLA centre for health policy research, Key informant interviews .

University of Illinois Extension Service-Office of Program Planning and Assessment.

USAID centre for Development Information and Evaluation. (1996). Performance monitoring and evaluation TIPS . No. 2. Retrieved from. http://pdf.usaid.gov/pdf_docs/PNABS541.pdf

Washington University. Conducting key informant interviews guide. Key informant interview handbook . courses.washington.edu.

World Health organization (WHO). (2003). Description of the key informant survey . Retrieved from. http://www.who.int/evidence/KI-Survey

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Akhter, S. (2022). Key Informants’ Interviews. In: Islam, M.R., Khan, N.A., Baikady, R. (eds) Principles of Social Research Methodology. Springer, Singapore. https://doi.org/10.1007/978-981-19-5441-2_27

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The Key Informant Technique in Qualitative Research

• By: Denise Faifua
• Product: Sage Research Methods Cases Part 1
• Publisher: SAGE Publications, Ltd.
• Publication year: 2014
• Online pub date: January 01, 2014
• Discipline: Business and Management , Sociology
• DOI: https:// doi. org/10.4135/978144627305014540254
• Keywords: key informants , organizations Show all Show less
• Online ISBN: 9781473951853 Copyright: Contact SAGE Publications at http://www.sagepub.com More information Less information

As a PhD student, I was guided in my research by the methodological assumptions of a qualitative perspective in management and organisation. This case study highlights the importance of knowing the ontological and epistemological assumptions of the discipline from which one is researching. Importantly, it sheds light on the way methodological assumptions lead to and support decisions about the adopted research methods or tools. The main purpose of the case in this research context is to set out in practical detail the social and analytical processes required of the researcher when adopting the key informant technique. The key informant technique, often referred to as the in-depth interview, is characteristic of interpretative qualitative research and ethnographic field research more broadly.

Learning Outcomes

By the end of the case study, you should

• Understand the relationship of methodological assumptions to the decisions we make in adopting methods or tools of research
• Be able to assess the differences in interviewing approaches as employed in different fields and disciplines
• Have a better understanding of the use of the key informant technique in interpretative qualitative or ethnographic research
• Understand the flexible nature of selecting key informants
• Understand the role of funnelling and probing in the key informant technique
• Understand the pros and cons of key informant interviewing as a tool for collecting qualitative data

The Project

My research project concerning perspective in management and organisation was interpretative or qualitative. I studied four cases, each of which corresponded to a dominant form of industrial organisation. For practical reasons, these cases were Australian based. My first case was a government bureaucracy that underwent restructuring and corporatisation. It represented an organisation with community service obligations undergoing changes to accommodate market contestability. My second case was an entrepreneurial franchise that extended across New Zealand and Australia. It represents an organisation with a pure market agenda. My next case was a growers co-operative. This growers co-operative comprised three river sugar mills. It represented a social and economic community struggling to survive under market pressure and changing government legislation. My last case was a workers co-operative located in the suburbs of Western Sydney, New South Wales. At the time of my research, this social and economic community had maintained the same core staff and experienced 10 years of successful operation. Gathering data for my study involved both primary and secondary research. It was time-consuming and difficult to organise and involved travel in Queensland and New South Wales, Australia. Using the key informant technique – a technique for collecting information about social structures and situations by talking to a select number of participants and then analysing their convergent and divergent perspectives – I interviewed 35 people working in relevant government agencies or in the chosen organisations. I also sourced comparative documents that would provide background material on the institutional context of the organisations, documents pertaining to significant historical events that affected the organisations and documents on the contemporary structure of the organisations.

Research Methodology

For new researchers, there can be a great deal of confusion about methodology or ontology and epistemology, and its relationship to the method or tools of research (e.g. surveys, interviews). This confusion may stem from a tendency to overlook the importance of both becoming familiar with methodological assumptions and having a broader understanding of social science research. One common error is to adopt uncritically the idea that all qualitative research is ethnographic or all survey work is positivist. Morgan and Smircich (1980) call this the pendulum swing in abstract empiricism; that is, the swing from research based on quantitative and often survey methods to research based on qualitative methods. The point is, qualitative interviews are a common method or tool for gathering data in positivist, interpretative and critical research projects.

A challenge for new researchers is to recognise early in their research which paradigm they are adopting and then to question how the qualitative interview is best used. Positivist researchers will adopt either quantitative or qualitative research methods tools such as the survey or the interview, or a combination of both. However, they will justify their methodological assumptions and the use of methods or tools using different research criteria. From a positivist point of view, the qualitative interview is taken as a method for gathering qualitative data, and the responses are seen as the interviewees' perceptions of causality. These qualitative data are assumed to have significant weaknesses, given that the interviewees are open to bias and likely to give inaccurate responses. As a consequence, positivist researchers adopt many techniques to improve the validity and reliability of interviews, including the triangulation of data and the adoption of a structured interview approach (see Yin, 1994). As pointed out by Collins (1998), the research interview is generally divided into two types – the unstructured and the structured (e.g. Bernard, 1999; Bergers, 1984; Mason, 1996, cited in Collins). However, this can be a misleading and unhelpful dichotomy, given that unstructured interviews are used in conjunction with a structured interview guide and structured interviews often require the use of probes.

As qualitative research, my project spanned both the interpretative and critical paradigms and drew on an established bank of researchers who study management and organisation (e.g. Barnard, 1938; Chandler, 1962; Daft & Weick, 1984; Giddens, 1979; March & Simon, 1958; Pfeffer, 1981; Scott, 2003, 2008). Given the diversity of interpretative and critical paradigms within this field, my decision to adopt the key informant technique was based on a critical decision to study community, social structures, social actions and situations.

The Key Informant Technique

Because I had adopted an interpretative and critical, qualitative approach, the key informant technique was a natural inclusion for my research design. Gilchrist, Crabtree, and Miller (1992) point out the key informant technique is most commonly used by ethnographers; however, Tremblay (1982) has applied the key informant technique to non-ethnographic research. Although the key informant technique is commonly named the ethnographic or even anthropological technique, and also unstructured interviewing or in-depth interviewing, it is important to differentiate the technique from qualitative interviewing in general. A difficulty that researchers of organisations face is conducting comparative research when a small number of cases is involved. This is particularly challenging ‘when research is directed towards investigations of processes and actions that cannot readily be researched using available secondary data’ (Humphrey, 1986). The use of the key informant technique has become relatively common in organisational research because it is recognised as an approach appropriate for the study of processes and actions. The key informant technique when adopted in organisational research taps into ‘the ability of different types of informants to report on various aspects of the social system in which they perform role functions’ (Houston, 1975). Key informants who occupy specialised roles within a social structure can provide greater information on role-related aspects of the structure, than those who occupy unrelated positions (Houston, 1975). I chose the key informant technique because it fit with the methodology of my research, and it enabled a systematic selection of interviewees who occupied specialised roles within my four case studies.

The key informant technique has been critically evaluated by Humphrey (1986). Although I do not agree with Humphrey's choice of research criteria, his work is one of the few attempts to consider the strengths and weaknesses of this data collection technique and well worth reading. So too is the article by Young and Young (2008) in which they argue that if the key informant technique is associated with particular conditions of social research, then we can confidently predict its widespread use in exploratory, or unstructured situations, underdeveloped areas of research, and/or in the many new subfields of social science. Studies that have adopted the key informant technique include Anderson and Theodori (2009), Mataritta-Cascarte, Brennan, and Luloff (2010), and Shaw (1999).

Implementing the Key Informant Technique

The following subsections detail the research method decisions made at various stages of implementing the key informant technique. The way in which the key informant technique has been implemented here is specific to my PhD research, and I have therefore attempted to provide some reasoning behind why I implemented it in the way I did.

Choosing Key Informants

The key informants are ‘chosen not on a random basis, but because they possess special qualifications such as a particular status, wide communications, or even accurate information for the study’ (Young & Young, 2008). The key informants across the cases, by which I refer to as the range of key informants, were identified on the basis of position or status in the organisation from high to low (e.g. chief executive officer or managing director to electrical field worker) and/or on the basis of expertise (e.g. industrial relations managers, human resource manager, finance manager, occupational health and safety officer), the aim being to draw on a diverse range of competing perspectives. For example, in the bureaucracy, I identified the managerial staff, employees and union representatives including the industrial relations manager, the human resource manager, the finance manager, the occupational health and safety officer and others; in the franchise organisation, I identified the franchiser and the franchisees, but there were few employees as often these were husband and wife businesses; in the co-operative, I identified the cane-grower, the mill manager, the millers, the co-operative association president and others; and in the worker co-operative, the managerial and production workers.

Gaining Access

My initial goal was to gain access so I could begin interviewing people in the organisations. I had no difficulty gaining access to organisations A and B. In contrast, access to organisations C and D came only after numerous attempts to gain entry. To reassure key informants of the integrity of my work and the care that would be taken with the interview responses, I provided an overview of my research by reading a prescripted explanation of the areas of interest, and indicated the range of people I hoped to interview. I found gaining the approval of a senior person in the organisation made access to other people at comparable and/or lower levels easier.

Entering the Field

I contacted each key informant at least 1 week before the date of the interview. This was important because I needed to travel from Brisbane to Northern New South Wales and Sydney. I organised as many interviews as I could for the same or following days but had to be open to arranging further interviews on the basis of referral. On arrival at the interviews, I asked each person to fill out a fact sheet detailing their name, position in the organisation and the place of the interview. This produced a list of key informants for each of the organisations being studied and ensured a range of interests were represented.

The Interview Guide

The use of the key informant technique ensured the interviewees represented the range of professional interests in management and organisation. To complement the key informant technique, I used an interview guide to elicit from the interviewees what they considered to be important issues on a given topic; research (Cicourel, 1964; Denzin, 1978; Lincoln & Guba, 1985; Lofland, 1971; Minichiello, Aroni, Timewell, & Alexander, 1990) has shown this to be preferable for eliciting answers to pre-structured questions. The challenge in designing the interview guide was to be clear about the types of data sought from interviewees without limiting their responses (Tremblay, 1982). First, a general outline of the study was explained to each interviewee. The aim was to give all of the informants some common orientation. Following this, a brief overview of the topics was given, such as ‘institutional or regulatory context’, ‘the level of productive organisation’, ‘direct and indirect incentives to work’ or ‘other incentives’.

Funnelling and Probing

As the aim of the key informant technique is to compare and draw together the common and divergent perspectives ranging across the interviewees (Shaw, 1999), I complemented the approach with general qualitative interviewing funnelling and probing. The common orientation was used as a funnel in that it assisted interviewees to focus on specific topics. For each topic, there were further probes or questions on the same topic to draw out perspectives and in particular themes for the interview. Thus, I began each topic with a broad question, which was funnelled or based on the topic, and sequenced or followed by more specific probes (Lofland, 1971; Minichiello, 1990). In the interview process, I followed the recursive model where there is no attempt to maintain a tight ordering or wording of the questions but an attempt to stay focused on the topics.

The Recursive Process in Interviewing

The aim of the recursive process is to enrich both the understanding of the interviewer and the response of the interviewee (Minichiello et al., 1990). As my understanding of each topic increased, I found my questions became more focused and the interviewees' responses became more in-depth. The recursive model underpinning the key informant technique emphasises the progressive restructuring of the choice of informants and, if need be, the content of the interviews. I began with a general outline of key informants to interview; however, as most interviewees recommended people they believed were knowledgeable, I chose to follow their leads. This is similar to the snowballing approach of Patton (1990). Thus, while the skeletal framework of the interview guide was maintained, the content of the interviews varied according to the level of knowledge of the informants, their positions in the organisations and whether they adopted a managerial, employee, union, franchiser, franchisee, cane-grower, miller or worker co-operative perspective.

Background of Key Informants

Previous interviewees referred me to other people in the organisation on the basis of either position or expertise in a particular area. For instance, people were often recommended for their knowledge of the legal institutional or regulatory level, the productive or operations level or the human resources level. People were also recommended for the contrast of perspectives they could give on the organisation or for their retrospective, longitudinal or historical knowledge. As a result, the interviewees held a range of positions from senior executive, white-collar, to technical supervisory and blue-collar, and most had been with the organisation for a considerable number of years.

Thirty-Five Interviews

The number of interviews varied from case to case. This seemed reasonable given the very different structural configurations of the organisations. For instance, in the entrepreneurial unit, I was able to interview the franchiser and a number of his professional staff, but the franchisees operating the stores often had family members working for them. Consequently, at the franchise operation, I stopped the interviewing at the point the franchisee felt comfortable. I did not interview his wife or son. Similarly, the worker co-operative was small and not all of the workers wanted to participate in interviews. One of the workers was a migrant, and although he had been in Australia for many years, he felt the language barrier would be too difficult. Again, I stopped the interviewing at the point the members of the co-operative felt comfortable. Of the more than 40 interviewees I contacted, I successfully interviewed 35 individuals.

Secondary Source Data

The second source of data for my study was documentary evidence. This also was an important data source and involved the collection of a wide array of documents. Interviewees recommended public materials such as industry and government reports, legislation, industry or peak body journals, company brochures and annual reports. I searched for and read a number of published histories, in particular on the producer co-operative. I also searched for and read material on government organisations, franchises and on worker co-operatives. However, I found the published histories were theoretically tangential to my research interests and/or far too general. In the end, I relied on key informants' recommendations of historical documents perceived to be important, whether published or unpublished. Some of the historical documents were newspapers and magazines; others were in-house unpublished documents. Ultimately, the most useful documents were those that came through key informant recommendation.

Taping the Interviews

I taped all of the interviews. Most interviewees were comfortable with this. When they were not comfortable, they verbalised a legal disclaimer on to the tape so as to protect themselves and the organisation. Almost all of the interviews were long running, from 45 to 90 minutes. The interviews were transcribed verbatim. The transcription was an arduous process, as I spent a day or more completing each one, and in the weeks that followed, I went back over the tapes, checking for correctness of the material transcribed and for typing errors.

Field Notes

I also wrote field notes or interpretative observations about interviewees' responsiveness. This was my own process for reaching an understanding of how well I was doing with the funnelling and probing techniques. Miles and Huberman (1984), Pettigrew (1990) and Van de Ven and Poole (1990) all argue that in qualitative research, writing field notes is one way in which to provide an audit trail.

Data Analysis

I analysed the data in a number of ways. First, in each case, I analysed the internal working of the dominant worldview, as represented from the point of view of the dominant status groups. I explored economic rationalities in terms of rational economic interests in market, structure and technology, and internal political and human behaviour processes that sustained the dominant worldview. I also explored political rationalities in terms of political interests that buffered or deadened the impact of competing worldviews. I included the unexpected significance of industrial relations in my analyses. I explored social rationalities to determine whether the values sustaining the dominant worldview were instrumental or social. In sum, I took those rational configurations to comprise the dominant and competing views of the worlds of work I was studying.

Second, I analysed the cases more closely for the interface between dominant and competing worldviews. I explored the economic and political interests, and the values of competing status groups, comparing them with those of the dominant status groups. In particular, I revisited the success or otherwise of political buffering, looking additionally for political shoring by the dominant status groups, and for political reactions of the less dominant status groups. And, I examined the success or otherwise of the social rationality of the dominant status group, searching for any value misalignments in competing status groups. The significance of this analysis varied for each case.

Third, I analysed each case for a fit with my own worldview. I examined the cases in terms of the order of the ‘rational configurations of the world of work’ looking for the existence of any descending order of rationality (i.e. an economic rationality, buffered by a political rationality and sustained by an economic ethic or instrumental social rationality). I also examined each case looking for the existence of any ascending order of rationality (i.e. an economic rationality, buffered by a political rationality, but sustained by a broader social rationality).

In sum, the key informant technique provided data on common and divergent perspectives across the case studies. The key informants highlighted what they believed were the important issues based on their professional occupations in the organisations.

Methodological Soundness

The use of qualitative interviews is controversial, centring on the supposed superiority of positivist research over qualitative research, and the role and status of qualitative research in the social sciences. There are two general responses. The first argues qualitative research can be incorporated into an overall empiricist framework (Tsoukas, 1989). The second argues the positivist versus qualitative debate need not be an issue (Luthans & Davis, 1982) if there is an acknowledgement of the different methodological assumptions that underpin research. Given my use of the key informant technique, its uniqueness; its relevance to research on community, structures, process and action; and its limited evaluation at the time of my PhD, I adopted a pragmatic approach to methodological soundness. I agree with the argument that there is no single logic of science, so it is reasonable that the integrity or soundness of research should be assessed using appropriate criteria (Hunt, 1990; Marshall & Rossman, 1989). I adopted the approach of Lincoln and Guba (1985) who propose four criteria to evaluate the methodological soundness of non-empiricist research. They argue whereas logical empiricism is evaluated through the criteria of internal validity, external validity, reliability and objectivity, non-empiricist research should be evaluated through the criteria of confirmability, dependability, credibility and transferability.

Practical Lessons Learned

This final subsection complements the earlier discussion on the decisions made at various stages of implementing the key informant technique, by providing reflections on my aspects of the implementation that were particularly challenging.

Time was the enemy, as collecting qualitative data using the key informant technique was time-consuming. It took 2 years to reach the point at which I felt I had interviewed enough key informants to be able to answer my research questions. The interviews were long, from 60 to 90 minutes. It took another year to transcribe the interviews to produce the scripts that I would code using a qualitative data analysis technique. One time-saving solution is to hire a professional to type the transcripts. I didn't do this because I learned far more by doing the job myself. Thirty-five qualitative interviews is a lot of work!

Richness of Data

The key informant technique produced rich insights into the management structures of the organisations I was studying. The challenge was to work through the different perspectives offered by the line managers in different departments and different positions of authority. Often, the qualitative data collected from one interview would discredit the qualitative data from a previous interview and so on. Yes, the data are rich, but it takes quite a lot of interview triangulation and document triangulation to arrive at a commonly agreed upon synthesis of organisational knowledge.

Interviewees

Taking care of interviewees is an important consideration for the researcher. As the interviewer, I found that the interview process becomes easier with practice. However, for the interviewee, it can all be a bit of a shock. The use of the tape recorder can be intimidating simply because they are shy or nervous, or because they don't feel they are really the experts they are recommended to be. There were a few occasions where I had to put the tape recorder away. That being the case, I was unable to produce a usable transcript.

On reflection, the ethics of research is far more complicated than I had expected. I satisfied the research ethics committee, but found the information I gave to the key informants was not always sufficient to make them confident about their participation in the research. One reason for this is that as researchers, we don't always know the outcomes of the research we are conducting when we are in the process of interviewing (Wiles, Crow, Charles, & Heath, 2006). Another reason is that as researchers, we may have to convey too much information for people to be able to really understand the research.

Work–Life Balance

Most research requires a considerable commitment on the part of the researcher. Because this research project was a PhD project, it seemed to take up far too much of my personal life. It would have been better to have conducted it as a funded project with colleagues who could share the work load. That said, I'm guessing all PhD candidates may say the same. If you do interpretative qualitative research, it requires considerable life balance skills.

I believe in the integrity of aligning research methodology with methods and tools. As a student, I was fortunate to engage in research seminars with academics knowledgeable about methodology and also experienced in the use of surveys, interviews and data analysis techniques. In addition, the existing research methods literature outlined the arguments for and against the use of the key informant technique (regardless of which term was used: the key informant technique, the unstructured interview or the in-depth interview). My choice to adopt the key informant interview was without a doubt guided by researchers who write as sages and researchers who engage in practice.

The reality of undertaking the key informant technique was much harder than I expected. It was difficult and time-consuming to organise access to interviewees and obtain the data. Choosing key informants on the basis of position and knowledge turned out to be a very credible approach, but following up with referrals to similar informants who were unknown to me required a considerable degree of flexibility and patience on my part. It meant the project had a life span of its own rather than a discrete time frame beginning at date A and finishing at date B. The nature of the interviewing also meant considerable work in terms of triangulation of evidence.

What I did find rewarding was the richness of meaning that only those who worked in the organisations could impart and share with me. That, I think, is the real strength of the type of qualitative interviewing I undertook. I also enjoyed meeting people in professional positions and was always grateful for the contribution they made to the project.

Exercises and Discussion Questions

• 1. Do you believe the key informant technique is limited to ethnographic research? Explain your answer.
• 2. What is the most common interview type used by researchers in your research field? Do you believe the key informant technique can improve the quality of interview data in your particular field? Explain your answer.
• 3. What are the key challenges for the individual researcher in undertaking a key informant technique approach?
• 4. What is meant by the term recursive ? How does this relate to funnelling and probing in the key informant technique?
• 5. What are the pros and cons of adopting the key informant technique as an interview technique?

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How to analyze key informant interview data

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I’m your coffee-loving grant writing guru and founder of Upstream Consulting.

Melissa here.

Welcome to Part 3 of the 3-part series: Everything You Need to Know about Key Informant Interviews. Be sure to check out   6 Tips for Planning Successful Key Informant Interviews and How to Conduct a Successful Key Informant Interview before you read this post.

By this point, you have planned and conducted your key informant interviews. Now it’s time to gather all your notes and audio recordings to discover the stories behind your results. This post will provide tips on compiling, analyzing, and sharing the results of your interviews. Once you’ve analyzed your data, you’ll have an idea of what your informants collectively think about the community problem your interviews addressed.

THINK BACK TO YOUR GOAL & PURPOSE

Before you jump into organizing data, think back to your purpose for conducting key informant interviews. You decided to use this tool to gather information about a community issue from informed community leaders. Your results should explain community members’ perceptions and beliefs on the issue you were exploring.

Keep your purpose in mind as you begin reviewing your data. This will help you quickly identify the most important and relevant information your key informants shared. This will be especially helpful when you’re reviewing those interviews that got off track!

ORGANIZE & TRANSCRIBE THE DATA

Gather your notes and audio recordings from the interviews. Ensure your notes are legible and organized so you can reference important points or a specific informant’s responses in the future. If your notes are handwritten, you may want to type them in a word processing document to make your data analysis easier. Alternately, make multiple copies of your notes so you can add comments, highlights, etc. when you begin analyzing the data. Additionally, it will be helpful to summarize lengthy notes from your interviews in a separate document. This will help you more easily identify interview themes.

If you need a written record of the audio recordings, you’ll need to transcribe your audio files. You can either pay a professional transcription service or transcribe the files yourself. If you’re transcribing your own files, write or type exactly what you hear so the stories are not changed.

IDENTIFY THEMES

Once your notes are organized and audio files are transcribed, read back through all the data. As you’re reviewing, some common themes, or categories, should emerge. Take note of these themes.

If others also conducted interviews, ask them to add the themes that surfaced during their interviews to your list. For example, if you studied the decline of physical activity among youth in your community, you may notice that lack of infrastructure, safety concerns, and increased crime rates were common themes related to the reasons youth aren’t physically active. Trust your data as it will show common themes among all the interviews.

ANALYZE & SUMMARIZE THE DATA

Analyzing and summarizing your data are necessary to determine if and how the interviews answered your question(s). This step will also help you communicate your findings within your organization and community.

The simplest way to analyze your data is to go through your notes and/or audio transcriptions and categorize each informant’s responses by theme. This process will allow you to determine how often informants referenced a specific theme. You’ll also be able to use your categorized responses to find powerful quotes to use in your interview summaries.

Here’s an example of what a categorized list of responses might look like:

• Respondent 1: “I’ve been living here for 25 years. I used to see kids in the streets, playing, riding their bikes. Since those two shootings happened, I don’t see kids anymore. I guess now their parents make them stay inside, worried they’ll get shot too.”
• Respondent 2: “You know, my nephew, he’s only 11 years old, he was robbed a few weeks ago. He only had a cheap wallet and $10 on him but they still robbed him. He’s only a kid. My sister won’t even let him leave the driveway now.”

Once you’ve categorized all your responses, you can begin to summarize the results. Your summary might include:

• The most common themes that emerged throughout your interviews.
• The most common themes that emerged for each interview question.
• Any differences in responses based on demographics (e.g., age, gender, time living in community, position in community).
• Specific quotes or responses that support the problem(s) being addressed.
• An overall summary that captures your community members’ thoughts, beliefs, and recommendations.

IDENTIFY LIMITATIONS

It’s important to identify limitations that may have impacted your results or conclusions. Some limitations to consider when conducting key informant interviews include:

• It may be difficult to tell how reliable a person’s responses are. People may not quite understand your questions, may have unique opinions about a topic, or may simply tell you what they think you want to hear.
• The informants’ responses may vary greatly due to confusing questions, poor interview skills, or lack of participant knowledge about the topic. You can avoid these issues by thoroughly planning your interviews .
• Analyzing qualitative data can be hard! If you don’t have staff or volunteers who can analyze your data, hire an external evaluator to consolidate, analyze, and summarize your data.
• Bias may occur if the interviewers or data analysts know or work closely with your key informants. Avoid bias by working with a diverse set of trained, objective interviewers and analysts.

SHARE THE DATA

Sharing your results is the most exciting part! Instead of writing a lengthy report, use visual data representations such as diagrams or infographics to present and summarize key findings. These techniques will allow your partners and community members to easily see connections among themes. Using data visualizations will also make it more likely that your community members will share the results of your interviews.

You might also want to share your results through:

• A one-pager to share with partners, community members, or elected officials.
• Social media posts that highlight major findings.
• Formal community meetings to provide more details on your findings.

Sharing your results is a great way to share resources. It will benefit your organization, engage partners, and encourage collaboration within the community. Sharing your results is also an important step as you build upon the work of others. Most importantly, widely disseminated information can lead to more informed community decision-making regarding funding, programs, and policy changes.

We’ve covered a lot in our 3-part series on key informant interviews! I hope by now you feel comfortable planning, conducting, and analyzing key informant interviews.

Until next time!

Do you have any tips to share for analyzing and using key informant interview data? Please share your experience below!

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• Open access
• Published: 26 March 2024

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

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

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

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Metrics details

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

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

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

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

Peer Review reports

Introduction

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

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

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

Materials and methods

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

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

Participant and sampling

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

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

Data curation and processing

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

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

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

Data analysis

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

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

Tax-based strategies

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

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

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

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

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

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

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

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

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

Policy-based strategies

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

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

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

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

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

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

Need-based strategies

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

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

Implementation-based strategies

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

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

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

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

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

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

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

Support of religious groups

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

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

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

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

Funding through adolescent sporting activities

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

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

Summary of findings

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

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

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

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

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

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

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

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

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

Data availability

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

Liang M, Simelane S, Fortuny Fillo G, Chalasani S, Weny K, Salazar Canelos P, Jenkins L, Moller AB, Chandra-Mouli V, Say L, Michielsen K, Engel DMC, Snow R. The state of adolescent sexual and Reproductive Health. J Adolesc Health. 2019;65(6S):3–S15. https://doi.org/10.1016/j.jadohealth.2019.09.015 .

Article   Google Scholar  

United Nations, Department of Economic and Social Affairs PD. World population prospects 2019. Available at: https://population.un.org/wpp/ , Accessed July 21, 2023.

Melesse DY, Mutua MK, Choudhury A, Wado YD, Faye CM, Neal S, Boerma T. Adolescent sexual and reproductive health in sub-saharan Africa: who is left behind? BMJ Glob Health. 2020;5(1):e002231. https://doi.org/10.1136/bmjgh-2019-002231 .

Article   PubMed   PubMed Central   Google Scholar  

Chandra-Mouli V, Armstrong A, Amin A, Ferguson J. A pressing need to respond to the needs and sexual and reproductive health problems of adolescent girls living with HIV in low‐and middle‐income countries. J Int AIDS Soc. 2015;18:20297.

United Nations. Special edition to the sustainable development goals progress report. Report of the Secretary-General, Supplementary Information. New York. 2019.

Institute for Health Metrics and Evaluation (IHME). GBD database. Available at: http://ghdx.healthdata.org/gbd-results-tool , Accessed July 20, 2023.

Ganchimeg T, Ota E, Morisaki N, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicounty study. BJOG. 2014;121:40e8.

Ghana Statistical Service. (2021). Ghana 2021 population and housing census report: General report volume 3B. https://statsghana.gov.gh/gssmain/fileUpload/pressrelease/2021%20PHC%20General%20Report%20Vol%203B_Age%20and%20Sex%20Profile_181121.pdf .

Ghana Broadcasting Corporation. 36% of adolescents in Ghana are sexually active, study reveals. GBC, Accra. 2023. Available at: https://www.gbcghanaonline.com/general/36-of-adolescents/2023/ , Accessed July 19, 2023.

World Health Organization. Universal health coverage for sexual and reproductive health in Ghana, WHO, Geneva, Switzerland. 2021. Available at: https://apps.who.int/iris/bitstream/handle/10665/350888/WHO-SRH-21.17-eng.pdf , Accessed July 25, 2023.

Engel DMC, Paul M, Chalasani S, Gonsalves L, Ross DA, Chandra-Mouli V, Cole CB, de Carvalho Eriksson C, Hayes B, Philipose A, Beadle S, Ferguson BJ. A Package of sexual and Reproductive Health and rights interventions-what does it Mean for adolescents? J Adolesc Health. 2019;65(6S):41–S50. https://doi.org/10.1016/j.jadohealth.2019.09.014 .

Ravindran TKS, Govender V. Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries. Sex Reprod Health Matters. 2020;28(2):1779632. https://doi.org/10.1080/26410397.2020.1779632 .

World Health Organization. Universal health coverage for sexual and reproductive health, Geneva WHO, Switzerland. 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/331113/WHO-SRH-20.1-eng.pdf , Accessed July 25, 2023.

Otieku E, Fenny AP, Achala DM, Ataguba JE, Obse AG. 2023. Funding strategies, gaps, and sustainable resource mobilization for adolescent sexual and reproductive health interventions in Ghana. Evidence Brief . August 2023. Available at: https://afhea.org/en/ecasarh-project-policy-briefs/ .

Otieku E, Fenny AP, Achala DM, Ataguba JE, Obse AG. 2023. Understanding the implication cost of priority adolescent sexual and reproductive health interventions in Ghana. Evidence Brief , August 2023. Available at: https://afhea.org/en/ecasarh-project-policy-briefs/ .

Salam RA, Das JK, Lassi ZS, Bhutta ZA. Adolescent Health interventions: conclusions, evidence gaps, and Research priorities. J Adolesc Health. 2016;59(4S):88–S92. https://doi.org/10.1016/j.jadohealth .

Morse JM. Simultaneous and sequential qualitative mixed method designs. Qualitative Inq. 2010;16(6):483–91.

Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. India: Sage; 2014.

Google Scholar  

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. https://doi.org/10.1093/intqhc/mzm042 .

Article   PubMed   Google Scholar  

Hamilton J, Ivker R. Donor fatigue hits family planning in developing world. Lancet. 1997;349(9064):1530.

Awadari AC. Donor fatigue phenomenon: Trend and circumvention in Northern Ghana. Int J Financial Acc Manage. 2020;1(4):191–8.

Gilbert K, Tenni B, Lê G. Sustainable transition from donor grant financing: what could it look like? Asia Pac J Public Health. 2019;31(6):485–98. https://doi.org/10.1177/1010539519870656 .

Republic of Ghana. Mid-year fiscal policy review of the 2023 budget statement and economic policy of the government of Ghana. July 31, 2023. https://mofep.gov.gh/sites/default/files/budget-statements/2023-Mid-Year-Policy-Review_1.pdf .

Republic of Ghana. The budget statement and economic policy of the government of Ghana for the 2024 financial year, November 2023, https://mofep.gov.gh/publications/budget-statements .

Kephart G, Asada Y. Need-based resource allocation: different need indicators, different results? BMC Health Serv Res. 2009;9:122. https://doi.org/10.1186/1472-6963-9-122 .

Kaufman BG, Jones KA, Greiner MA, Giri A, Stewart L, He A, Clark AG, Taylor DH Jr, Bundorf MK, Whitaker RG, Van Houtven CH, Higgins A. Health Care use and spending among need-based subgroups of Medicare beneficiaries with full Medicaid benefits. JAMA Health Forum. 2023;4(5):e230973. https://doi.org/10.1001/jamahealthforum.2023.0973 .

Radinmanesh M, Ebadifard Azar F, Hashjin aghaei. A review of appropriate indicators for need-based financial resource allocation in health systems. BMC Health Serv Res. 2021;21:674. https://doi.org/10.1186/s12913-021-06522-0 .

Paul E, Bodson O, Ridde V. What theories underpin performance-based financing? A scoping review. J Health Organ Manag . 2021;ahead-of-print(ahead-of-print). https://doi.org/10.1108/JHOM-04-2020-0161 .

Waithaka D, Cashin C, Barasa E. Is performance-based financing A pathway to Strategic Purchasing in Sub-saharan Africa? A synthesis of the evidence. Health Syst Reform. 2022;8(2):e2068231. https://doi.org/10.1080/23288604.2022.2068231 .

Witter S, Bertone MP, Diaconu K, Bornemisza O. Performance-based Financing versus unconditional direct facility financing - false dichotomy? Health Syst Reform. 2021;7(1):e2006121. https://doi.org/10.1080/23288604.2021.2006121 .

Fretheim A, Witter S, Lindahl AK, Olsen IT. Performance-based financing in low- and middle-income countries: still more questions than answers. Bull World Health Organ. 2012;90(8):559–559A. https://doi.org/10.2471/BLT.12.106468 .

Ghana Web. Auditing of pandemic expenditure needed for transparency and accountability. https://www.ghanaweb.com/GhanaHomePage/NewsArchive/Auditing-of-pandemic-expenditure-needed-for-transparency-and-accountability-1420021 , Accessed August 6, 2023.

COVID Transparency and Accountability Project. Ghana’s COVID-19 Fund Management lack transparency. https://myjoyonline.com/ghanas-covid-19-funds-management-lack-transparency-ctap/ , Accessed August 6, 2023.

Schaaf M, Boydell V, Van Belle S, Brinkerhoff DW, George A. Accountability for SRHR in the context of the COVID-19 pandemic. Sex Reprod Health Matters. 2020;28(1):1779634. https://doi.org/10.1080/26410397.2020.1779634 .

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Acknowledgements

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

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

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

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

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

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

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Cara B Safon, Lois McCloskey, Maria Guadalupe Estela, Sarah H Gordon, Megan B Cole, Jack Clark, Access to perinatal doula services in Medicaid: a case analysis of 2 states, Health Affairs Scholar , Volume 2, Issue 3, March 2024, qxae023, https://doi.org/10.1093/haschl/qxae023

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Doula services support maternal and child health, but few Medicaid programs reimburse for them. Through qualitative interviews with key policy informants ( n = 20), this study explored facilitators and barriers to Medicaid reimbursement through perceptions of doula-related policies in 2 states: Oregon, where doula care is reimbursed, and Massachusetts, where reimbursement is pending. Five themes characterize the inclusion of doula services in Medicaid. In Theme 1, stakeholders recognized an imperative to expand access to doula services. Subsequent themes represent complications in accomplishing that imperative. In Theme 2, perceptions that doula services were not valued by health care providers resulted in conflict between doulas and the health care system. In Theme 3, complex billing processes created friction and impeded reimbursement. In Theme 4, internal conflict presented barriers to policymaking. In Theme 5, structural fragmentation between state government and doula communities was prominent in Massachusetts, presenting tensions during policymaking. Informants reported on problems demanding resolution to establish equitable and robust doula care policies. Medicaid coverage of doula services requires ongoing collaboration with doulas, providers, and health care advocates.

Maternal health indicators in the United States are highly inequitable. In 2021, the maternal mortality rate among non-Hispanic Black pregnant and postpartum people (PPP) was 2.6 times that among non-Hispanic White PPP. 1 Severe maternal morbidity (SMM), a composite of 21 indicators reflecting end-organ dysfunction such as diabetes, high blood pressure, or infections, 2 is prevalent among PPP, affecting over 50 000 US individuals every year 3 and disproportionately affecting PPP of color. 4 Evidence illuminating the positive impact of perinatal doula care on maternal health outcomes is strong and mounting. Yet, doulas are underutilized—in part, due to Medicaid reimbursement challenges. 5 The goal of this study was to elucidate the complex process of adopting and sustaining policies covering doula care as a reimbursed health service in Medicaid.

Doulas are nonclinical health care personnel who provide physical and emotional support to PPP during labor and childbirth, 6 as well as during the postpartum period. Doulas offer information about possible pregnancy-, childbirth-, or postpartum-related complications; provide continuous companionship during labor; offer physiological pain-management techniques; and provide approaches to infant care and parental coping skills. 7 Doulas can facilitate communication between patients and maternal health providers, empowering PPP to advocate for their health care preferences. 8

Despite the benefits, nationwide utilization is low—around 6% annually. 9 , 10 While many individuals desire doula care, 11 low usage rates may be due, in part, to high out-of-pocket costs of doula care, precluding many low-income PPP from accessing it. Low rates may also relate to a low supply of culturally congruent, 12 community-based doula care, which is important in achieving the aforementioned positive outcomes. 13 Low supply may be partially attributable to the fact that doulas, who are typically paid on a fee-for-service basis and lack access to the benefits that salaried employees often have, may spend up to 11 times more time with clients than other providers 14 and are not compensated for transportation costs and time spent “on call.” 14

Medicaid and doula services

Medicaid is the primary payer for 42% of US births, including 65% of births among Black PPP and 59% of births among Hispanic PPP. 15 Moreover, Medicaid enrollees are more than 80% more likely than those with private health insurance coverage to experience SMM. 3 Including doula care as a Medicaid-covered benefit could improve access to a critical maternal care intervention.

Public and private payers infrequently reimburse for doula services. 13 , 16 , 17 As of 2023, only 10 states reimbursed for doula services in Medicaid, and at varying rates. Challenges in state-level approaches to reimbursing for doula services remain, 18 , 19 including determining doulas' scope of services (ie, identifying and defining prenatal vs postpartum vs full-spectrum doulas, as well as the extent to which doulas are perceived to express opinions or offer advice to their clients during labor and delivery and while in the presence of their provider[s]), ensuring accessibility of training, implementing standards for credentialing (ie, licensing or certification), addressing burdensome administrative requirements when enrolling as a Medicaid provider, and establishing and implementing equitable compensation rates. 13

A recent scoping review by our research team identified 5 key policy issues related to the implementation of Medicaid reimbursement for doula services: increasing doula workforce diversity, reducing administrative barriers to doulas' service provision, determining the value of doula services and facilitating adequate compensation, developing sustainable funding models, and strengthening partnerships between policymakers and the doula community. 20 Resolving these issues is integral to implementing and sustaining Medicaid reimbursement for doula care but is complicated by the exigencies of policymaking in each state. To understand how the policy issues identified in the scoping review are playing out, we examined the implementation of Medicaid reimbursement for doula services in 2 states: Oregon, the state with the longest-standing Medicaid reimbursement policy, and Massachusetts, where, at the time of writing, a policy was about to be implemented. In terms of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, 21 the states represent 2 phases of implementation: Sustainment and Preparation, respectively. The definition of EPIS phases framed the sampling and comparison of the 2 state case studies.

In this study, EPIS defines external factors, relationships among stakeholders, and inner contextual factors that affect the implementation of social policies in complex settings, such as Medicaid, at successive stages. In the first, Exploration, multiple interested parties—state agencies, independent health policy groups, and service providers—define a new policy as they become aware of an unmet need as well as a policy option addressing it. 21 Exploration may lead to Preparation to adopt that policy, ascertaining barriers and facilitators of implementation, assessing adaptation needs, and developing a plan to mitigate potential barriers and capitalize on potential facilitators. 21 In Implementation, implementers discover whether efforts made during Preparation addressed potential issues; in Sustainment, the policy becomes engrained, a process that typically involves funding and ongoing monitoring and evaluation. 21 Each phase is affected by the outer context, or policy environment; the inner context, or stakeholders' diverse interests and prior relationships; bridging factors, including the involvement of intermediary stakeholders or agreements to manage diverse interests; and innovation factors, characteristics of the policy and the policy's compatibility with established practices.

The settings: Oregon and Massachusetts

Oregon was the first state to include doula care in Medicaid coverage, passing HB 3311 in 2011, which required the Oregon Health Authority (OHA) to consider prenatal, childbirth, and postpartum doula benefits. Thereafter, Oregon passed additional legislation to establish the Traditional Health Worker Commission, an entity that advises the OHA in matters related to the implementation of traditional health worker (THW) services as those covered by Medicaid. Traditional health workers are trusted members of their communities and are trained in at least 1 of 6 worker types, including doulas. Then, in 2014, policy implementation of doula coverage began. 22 (Additional information on Oregon's policy is provided in Appendix S1 .)

The policy in Massachusetts was in development as of November 2023. Following a succession of bills since 2018, Massachusetts' Medicaid program (MassHealth) began reimbursing for doula services in late 2023. H. 1182 was proposed in 2018, with legislation updated to H. 2372 in 2021, although that bill never moved past the House Committee on Ways and Means. A revised bill proposed in 2023 was referred to the Committee on Healthcare Financing. 23 Around the same time, the Betsy Lehman Center for Patient Safety issued a report outlining policy change efforts to increase access to doula care. 24 Among major findings, the report highlighted barriers to access to doula care at the client and doula levels. 24 At the client level, there was a lack of awareness of doula services; at the doula level, doulas sought affordable training and credentialing requirements, as well as fair and equitable compensation for their services. 24 In addition, doulas seeking to support clients faced resistance from maternity care teams and burdensome certification requirements. 24 (Additional information is provided in Appendix S1 .)

To examine preparation for policy implementation and policy sustainment in our 2 states of interest, we conducted a qualitative study consisting of semi-structured interviews with key policy informants. We followed Kingdon’s Multiple Streams Approach, 25 which posits that various solutions exist to resolve a given policy issue given the ambiguity of policy problems, 26 in defining the sample of informants representing diverse perspectives and solutions in resolving policy issues. We identified informants based on their roles in the policymaking process in the 2 states and via snowball sampling, guided by informants' referrals and the primary investigator's professional connections. The sample ( n = 20) included state legislators and representatives from state Medicaid agencies, state departments of health, and community doula organizations ( Appendix S2 ).

Data collection

We developed 2 semi-structured interview guides, 1 tailored to each state ( Appendix S3 ). After the first 3 interviews, we revised the guides to improve question clarity and sharpen the interview focus. We conducted the interviews, lasting 20 to 90 minutes, between April and December 2022.

We focused on informants' perceptions of barriers and facilitators to expanded access to doula services through Medicaid. The primary investigator, who conducted all the interviews, practiced reflexivity, whereby researchers acknowledge the carrying of their own experiences, expertise, and biases to the work. 27 , 28 While she identifies as a White woman without current doula training and is therefore unable to speak to the experiences of practicing or aspiring doulas of color, she is an experienced researcher on the topic of Medicaid reimbursement for doula care. After obtaining oral consent to participate and record the interviews, she conducted the interviews and transcribed transcripts using Microsoft Teams, storing data on a secure cloud server.

We received Institutional Review Board (IRB) approval from the Boston University Medical Campus IRB (H-42376). We report data in compliance with the Standards for Reporting Qualitative Research. 29

Analytic approach

The primary investigator and a research assistant used a combined inductive and deductive approach to identify emergent themes. Each of them open-coded 3 interviews, reflecting 10% of the sample. This enabled the development of a "coding frame", intended to capture "analytically significant features of the data". 30 We derived an initial code list based on that subset of interviews before expanding it to generate a draft codebook. To establish intercoder reliability, each of the 2 analysts coded each of the remaining transcripts using Dedoose (SocioCultural Research Consultants), 31 resolving discrepancies in coding applications by consensus. During this process, we also iteratively refined the codebook ( Appendix S4 ). Next, we grouped codes by category to identify themes. We drew upon EPIS to inform the interpretation of our analysis. Finally, we member-checked 32 with informants to ensure collaboration as we drew inferences from their responses.

We interviewed 8 key informants (KIs) based in Oregon and 12 in Massachusetts. Across both states, 13 were public sector informants: legislators, Medicaid agency employees, and state department of health employees; and 7 were private sector informants: local doula organization members, obstetrician-gynecologists, and employees of local health care organizations ( Table 1 ). Five themes characterize the barriers and facilitators in policy Preparation and Sustainment ( Figure 1 ).

Conceptual Framework. Source: Authors.

Informant characteristics.

Abbreviations: MA, Massachusetts; OR, Oregon.

Source: Authors.

a Informants categorized according to Kingdon-identified sector may also identify as doulas and/or as doula care advocates.

b In Oregon, may include local billing hubs, Independent Physician Associations (IPAs), health care providing organizations, and local Coordinated Care Organizations (CCOs) in OR, or Accountable Care Organizations (ACOs) in MA.

Theme 1. Expansion of Medicaid coverage of doula care was an imperative, but its accomplishment was challenging

Inherent in the fact that Oregon had pursued and Massachusetts was in the midst of pursuing Medicaid reimbursement for doula care, public insurance coverage of doula services was a critical goal for all stakeholders. Yet, while stakeholders agreed about the need to include doula services as a covered Medicaid benefit, Oregon-based informants reported issues with both doula care service implementation and Medicaid policy sustainment. One informant noted challenges in identifying fair and equitable reimbursement rates for doulas, lamenting, “it’s hard to be a leader when you don’t have someone to look up to sometimes” (KI 7—state government, Oregon).

In Massachusetts, informants were challenged with pressures to create comprehensive doula care policy. One informant described the low likelihood of including full-spectrum doula care—care provided prenatally, during labor and delivery, and postpartum, as well as for pregnancies that do not result in live births—as a MassHealth-covered benefit from the outset, implying that it would take time to solidify the policy to make it inclusive of all pregnancy outcomes. She said, “Sometimes it’s easier to kind of get an imperfect policy through the door first and build onto it afterwards” (KI 6—state government, Massachusetts).

Another stakeholder noted the nuances of developing an appropriate credentialing system for doulas when no roadmap detailing the process exists: “there’s not much of a blueprint” so developing “a doula initiative and a reimbursement pathway…it's…a beast of a thing” (KI 8— state government, Massachusetts).

Theme 2. In Oregon and Massachusetts, perceptions that doula services were not valued resulted in conflict between doulas and the health care system, specifically related to doulas’ ability to attend births

I hear a lot of the gripes from the nurses about the doulas. Yeah, those doulas show up, and they just sit in the corner and they don’t do anything or, you know, like they’re worthless…just sitting there doing nothing. (KI 5—local doula organization, Massachusetts)

We are not your enemy here…don’t kick us out of the room during the epidural. Don’t kick us out of the room and from the OR…Don’t kick us out at the most critical moments.

I’m being very extra mindful of my role [in the hospital] and how I’m interacting with people because I’m like, I don’t want, you know, the provider to feel uncomfortable and be like, ‘why are you saying these things now?’ You can’t be like kicking me out of the room. (KI 1—local doula organization, Oregon)

…that is not fair that it’s the doula who’s carrying the burden of that loss [of compensation] exclusively. That loss needs to be shared by the hospital, by MassHealth…[the loss] needs to be somehow equally divided so that it’s not just the doula who’s responsible to pay for her training…not the doula who’s trying to make a living by doing her best effort to show up. (KI 5—local doula organization, Massachusetts)

[Earlier doula-client engagement]…leads to the likelihood that that client will call their doula when the time comes to go to the hospital. However, you know there is a ceiling to the number of allowable visits in most contracts, so…the doula needs to find a way to keep the momentum going outside of those visits. (KI 7—local doula organization, Massachusetts)

I think the state is going to have to take on some responsibility for making sure that those hospitals and providers, not only are, you know, welcoming of doulas but are prepared, in terms of like having consistent policies and, you know, having infrastructure for feedback loops both from the doulas and the providers. (KI 1—local health care organization, Massachusetts)

Theme 3. Complex billing processes created friction and impeded reimbursement

…requiring a form be faxed is creating barriers so and then of course, you know, not only supporting the doula and figuring out where can she go to find a fax machine…but also, and by the way, she can’t afford the FedEx, you know, going to a FedEx Office. It’s like $2.50 a page and it’s like 15 pages. (KI 5—local health care organization, Oregon)

…a doctor…has a 5-minute phone call with somebody about a prescription refill. You better believe that there’s a billing specialist somewhere in his department that’s gonna bill for that. But right now, because doulas are operating outside of the medical system…nobody’s looking over their shoulder to flag things that are billable. (KI 7—local doula organization, Massachusetts)

I’m the one calling them and kind of nagging them like, ‘hey, where’s our payment or what happened here?’… I should not be having to prove that this is the rate that we agreed, you know, for you guys to pay. (KI 1—local doula organization, Oregon)

…you never know if [the birth is] gonna be 3 hours or 20 hours….I think that there should be an hourly rate for every hour worked and that includes phone time, text time, travel time, some compensation for being on call that's the time either virtual or in person. (KI 5—local doula organization, Massachusetts)

…it makes us look bad as an organization that we’re not paying people and so that discourages doulas…to work with OHP patients or clients. (KI 6—local doula organization, Oregon)

Theme 4. Stakeholders' feelings of internal conflict presented barriers to policymaking

I constantly felt like I was walking a tightrope of not being able to be transparent with doulas because of confidentiality reasons, and then feeling like I had to protect doulas when I was advocating for the policy. (KI 6—state government, Massachusetts)

Financially, in terms of structures and support, I understand professionally why [the stipulated number of prenatal and postpartum visits] are what they are…as a practicing doula, as someone who has…been to over 100 births…I think that there’s no possible way to put a quantitative number to that support. (KI 8—state government, Massachusetts)

[The rate increase] is going to bring people who were mostly serving private pay clients into the Medicaid space…and I just think that that could breed a workforce that is more adept at serving a higher income population. And so do they understand basic things like where food banks are and the needs of folks who don’t have transportation? (KI 5—local doula organization, Oregon).

…in my ideal world, there would be more paths to covering doula services through like foundations or through grant-based programs that have less of these, like, hoops you have to jump through as a provider and so I just worry that there’s like so much focus on Medicaid, and I don’t know if Medicaid is the right answer for improving perinatal health and increasing access to doula services. I think we’ve seen in a lot of states it kind of does the opposite. (KI 6—state government, Massachusetts)

I’ve definitely learned…what kinds of concerns doulas tend to have, especially when you talk about integrating doula care into the health care system or into these larger institutions, which is not the way the traditional doula role has looked. And there’s not always agreement across doulas in terms of…what this should look like. (KI 1—local health care organization, Massachusetts)

…there’s a huge spectrum of how people look at themselves as a doula. It's hard for other health professionals to understand what that doula is if they can’t come together and define that themselves. (KI 3—state government, Massachusetts)

Theme 5. In Massachusetts, structural fragmentation between state government and doula communities was prominent, presenting tensions during the policymaking process

In Massachusetts, lack of cohesion within and between groups of stakeholders, such as within the state and among doulas, as well as between the state and doulas, was present. This often bred misinformation, misunderstanding, or misalignment of operations between groups of stakeholders.

…most [legislators] have never worked in government before, they’ve never designed programs or policies directly before. So they just don’t understand the level of detail needed to think through these things. (KI 6—state government, Massachusetts)

…the way state government works is often very siloed…we’ve tried to pull together meetings and get everybody in the room and kind of say, ‘all right, so our end goal is the same. So how do we make sure that the legislative branch and the executive branch are working together and we’re keeping each other in the loop about what we’re doing?’ (KI 2—state government, Massachusetts)

Zero dollars have been allocated to doula training and workforce development. Everybody wants the perfect outcome. But where’s the money to invest in actually getting it right? (KI 5—local health care organization, Massachusetts)

I think a big part of feeling comfortable [as a client]…is to have congruent identities with [doulas]…and I worry about creating a doula workforce that's predominantly White women who have the money to do a DONA training but have never been on Medicaid themselves. (KI 6—state government, Massachusetts)

We explored challenges and facilitators of Preparing to implement policy and Sustaining policy related to Medicaid coverage of doula services in 2 states that were at different stages of policymaking as characterized by EPIS. We identified 5 themes. First, underpinning all other themes, stakeholders in Oregon (Sustainment) and Massachusetts (Preparation) sought expanded access to doula care, although achieving that expansion presenting many challenges (Theme 1). Themes 2–5 reflect those challenges. Those issues related to the value of doula services as determined by providers and other health care professionals already integrated into maternity care teams (Theme 2) and the bureaucratic exclusion of doulas via complex and costly billing and reimbursement processes (Theme 3). Internal conflict also arose among various stakeholders: as informants reported, policy preparation and sustainment involved tradeoffs between what informants considered ideal (ie, coverage of unlimited prenatal and postpartum visits by doulas) vs practical (ie, caps on those visits) (Theme 4). Finally, structural fragmentation within and between informants in Massachusetts presented tensions that stifled policymaking (Theme 5). Because that fragmentation, manifested by a lack of uniformity as a doula workforce, likely stymied recognition of doulas' value, it may have also stymied their political effectiveness. The EPIS framework's Bridging factors, discussed further below, serve as one way to reduce such fragmentation.

In Oregon, sustaining reimbursement entailed establishing mechanisms for doulas to be paid, but doulas were disadvantaged by complex bureaucratic procedures and their lack of resources to manage them, such as fax machines and billing departments. In Massachusetts, doulas faced conflicts with clinicians in labor and delivery rooms, where doulas saw their own work as acutely valuable. In Massachusetts, preparing also entailed resolving barely tractable problems of the value of doula services. In both states, these problems can be characterized as issues among players both within and between EPIS' inner and outer context, as described by a table outlining EPIS constructs and domains as depicted by the cases of Oregon (Sustainment phase) and Massachusetts (Preparation phase) ( Appendix S5 ). Conflict emerged in integrating doulas into maternity care teams (the inner context), and was shaped by factors like the service environment (eg, stakeholders' perceptions of doula care), and billing and reimbursement processes designed for established providers, not doulas (the outer context).

These issues highlight the significance of EPIS' Bridging factors: arrangements for resolving the conflicts inherent in the adoption of a policy innovation. They represent an investment in partnerships among policymakers, between policymakers and doulas, and between doulas and doula care advocates. 5 , 8 , 13 , 18 , 20 , 22 , 34-40 In Massachusetts, the Department of Public Health's Doula Partner Advisory Group convenes monthly to discuss ongoing legislative efforts, as well as doula–health care facility partnership and doula workforce strengthening. California stakeholders held similar meetings prior to implementation of their state's policy, and continue to hold their legislatively required Doula Implementation Workgroup. 41 Such meetings in these and other states, as supported by a "stakeholder-engaged process" in California, 42 provide opportunities to develop the “blueprint” for doula policy deemed necessary by an Oregon-based informant to refine implementation and sustain policy.

Yet, as we found, refinement of the blueprint does not end with Preparation: Sustainment inevitably involves ongoing negotiations. In Oregon, THW liaisons, who assist doulas with submitting Medicaid claims and billing support on behalf of CCOs, 43 have been deployed to facilitate partnership both among and between players in the inner context of service delivery and its outer context. In other states considering adoption of doula care policy, entities such as the Doula Network, a national program providing billing and other support to doulas, can unite health plans, providers, and community members 44 to enable consensus-building. Prior research using EPIS to explain policy processes demonstrates how Bridging factors to facilitate facets of the reimbursement process are needed. 45 , 46

The significance of bridges is prominent in promoting doula workforce diversity. Informants believed that racial diversity was a necessary component of maternal empowerment, particularly for PPP of color. 47 It is vital that policies stipulate a focus on recruiting, training, and retaining a diverse workforce to address strengthen the broken maternity care system.

Limitations

We examined policies in only 2 states, limiting our ability to draw conclusions transferrable to others. However, our findings are consistent with the research and policy literature and current national debates surrounding the integration of doula care in health care. 20 States may refer to existing resources 48 as they consider the various components of state support for community doula services. In addition, in an effort to focus this study on key policy informant perspectives, we did not interview PPP and birthing families; their perspective and partnership in any state's doula care policymaking process are urgently needed.

Implications

State Medicaid policies around doula care may complement other policies that benefit PPP. The American Rescue Plan Act of 2021 (ARPA) offers states the option to extend postpartum coverage of Medicaid from 60 to 365 days. Expanding Medicaid eligibility to nonelderly adults, as enabled under the Affordable Care Act, may result in more PPP being enrolled and engaged in care earlier, and therefore, more likely to utilize doula services. In states with the postpartum ARPA policy, 49 which offers PPP 365 instead of 60 days to take advantage of the benefits of Medicaid enrollment during the postpartum period, the extension of benefits means that Medicaid-enrolled PPP could have more time to take advantage of the doula care benefit in the postpartum period. State decisions to expand postpartum Medicaid eligibility could motivate those states to expand access to postpartum doula services in Medicaid and in commercial insurance carriers, especially given recent findings about the health benefits and cost savings of doula care. 50

Despite stakeholders sharing a policy agenda, doula care policymaking generated conflict during policy sustainment in Oregon and in policy implementation in Massachusetts. We found that, consistent with extant literature on doula care coverage for doula services, regardless of policy adoption stage, developing equitable and robust doula care requires collaboration with doulas, providers, and maternal health care advocates.

The authors thank all of the study participants for their time.

Supplementary material is available at Health Affairs Scholar online.

Hoyert DL . Maternal Mortality Rates in the United States, 2021 . Health E-Stats, National Center for Health Statistics, Centers for Disease Control and Prevention ; 2023 .

Centers for Disease Control and Prevention . How does CDC identify severe maternal morbidity? 2019. Accessed January 28, 2022. https://www-cdc-gov.ezproxy.bu.edu/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm

Declercq ER and Zephyrin L . Severe maternal morbidity in the United States: a primer. 2021. Accessed March 4, 2022. https://www.commonwealthfund.org/publications/issue-briefs/2021/oct/severe-maternal-morbidity-united-states-primer#:∼:text=Severe%20maternal%20morbidity%2C%20defined%20by, consequences%20to%20a%20woman's%20health.%E2%80%9D

Anderson B , Shapiro L , Camaliche A , Marshall M . Investing in Our Moms: Three Ways State Medicaid Programs Can Improve Maternal Health . Families USA ; 2023 .

Google Scholar

Google Preview

Safon CB , McCloskey L , Ezekwesili C , Feyman Y , Gordon SH . Doula care saves lives, improves equity, and empowers mothers. State Medicaid programs should pay for it . Health Affairs Forefront . 2021 . https://doi.org/10.1377/forefront.20210525.295915

Cleveland Clinic . Obstetric health care providers: choosing one right for you. 2017. Accessed October 4, 2019. https://my.clevelandclinic.org/health/articles/9698-obstetric-health-care-providers-choosing-one-right-for-you

Oregon Doulas . Core competencies for birth doulas. No date. Accessed July 6, 2022. https://static1.squarespace.com/static/55e60182e4b09fb565b2eb88/t/589155e0579fb38e735efa17/1485919712471/Core+Competencies.pdf

Strauss N , Sakala C , Corry MP . Overdue: Medicaid and private insurance coverage of doula care to strengthen maternal and infant health . J Perinat Educ. 2016 ; 25 ( 3 ): 145 – 149 .

Kozhimannil KB , Hardeman RR . How Medicaid coverage for doula care could improve birth outcomes, reduce costs, and improve equity, in Health Affairs blog . Health Afffairs Forefront . 2015 . https://doi.org/10.1377/forefront.20150701.049026

Declercq ER , Sakala C , Corry MP , Applebaum S , Herrlich A . Major survey findings of listening to mothers (SM) III: new mothers speak out: report of national surveys of women’s childbearing experiences conducted October-December 2012 and January-April 2013 . J Perinat Educ . 2014 ; 23 ( 1 ): 17 – 24 .

Kozhimannil KB , Attanasio LB , Jou J , Joarnt LK , Johnson PJ , Gjerdingen DK . Potential benefits of increased access to doula support during childbirth . Am J Manag Care . 2014 ; 20 ( 8 ): e340 – e352 .

Karbeah J , Hardeman R , Almanza J , Kozhimannil KB . Identifying the key elements of racially concordant care in a freestanding birth center . J Midwifery Womens Health . 2019 ; 64 ( 5 ): 592 – 597 .

Bey A . Brill A , Porchia-Albert C , Gradilla M , Strauss N . Advancing birth justice: community-based doula models as a standard of care for ending racial disparities. 2019. Accessed March 25, 2019. https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf

Bey A , Brill A , Porchia-Albert C , Gradilla M , Strauss N . Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities . Ancient Song Doula Services, Village Birth International, Every Mother Counts ; 2019 .

Osterman M , Hamilton B , Martin JA , Driscoll AK , Valenzuela CP . Births: final data for 2020 . Natl Vital Stat Rep . 2021 ; 70 ( 17 ): 1 – 50 .

Gomez AM , Arteaga S , Arcara J , et al.  “My 9 to 5 job is birth work”: a case study of two compensation approaches for community doula care . Int J Environ Res Public Health . 2021 ; 18 ( 20 ): 10817 .

Hardeman RR , Kozhimannil KB . Motivations for entering the doula profession: perspectives from women of color . J Midwifery Womens Health . 2016 ; 61 ( 6 ): 773 – 780 .

Chen A . Routes to Success for Medicaid Coverage of Doula Care, in Doula Medicaid Project . National Health Law Program ; 2018 .

Hasan A . State Medicaid approaches to doula service benefits. State trackers. 2023. Accessed September 19, 2023. https://nashp.org/state-medicaid-approaches-to-doula-service-benefits/? utm_source=Nashp+Enews&utm_campaign=2963d252ec-EMAIL_CAMPAIGN_August_29_2023_COPY_01&utm_medium=email&utm_term=0_afe3b8a6e2-2963d252ec-520359625

Safon CB , McCloskey L , Gordon SH , Brahim MBC , Clark J . Medicaid reimbursement for doula care: policy considerations from a scoping review . Med Care Res Rev . 2023 . https://doi.org/10.1177/10775587231215221

EPIS Framework . Home page. 2022. Accessed April 27, 2022. https://episframework.com/

Everson CL , Crane C , Nolan R . Advancing Health Equity for Childbearing Families in Oregon: Results of a Statewide Doula Workforce Needs Assessment . Oregon Doula Association ; 2018 . https://malegislature.gov/Bills/193/HD2452

An Act relative to Medicaid coverage for doula services. 2023 .

Betsy Lehman Center for Patient Safety . Expanding Doula Support Services in Massachusetts: Considerations for Successful Implementation . The Betsy Lehman Center for Patient Safety; 2022 .

Kingdon JW . Agendas, Alternatives, and Public Policies . 2nd ed. Addison-Welsey ; 2003 .

Hoefer R . The multiple streams framework: understanding and applying the problems, policies, and politics approach . J Policy Pract Res . 2022 ; 3 ( 1 ): 1 – 5 .

Charmaz K . Constructing Grounded Theory . Sage ; 2014 .

Dodgson JE . Reflexivity in qualitative research . J Hum Lact . 2019 ; 35 ( 2 ): 220 – 222 .

O’Brien BC , Harris IB , Beckman TJ , Reed DA , Cook DA . Standards for reporting qualitative research: a synthesis of recommendations . Acad Med . 2014 ; 89 ( 9 ): 1245 – 1251 .

O’Connor C , Joffe H . Intercoder reliability in qualitative research: debates and practical guidelines . Int J Qual Methods. 2020 ; 19 : 2 .

SocioCultural Research Consultants LLC . Dedoose Version 8.3.41, Web Application for Managing, Analyzing, and Presenting Qualitative and Mixed Method Research Data . SocioCultural Research Consultants; 2020 .

Birt L , Scott S , Cavers D , Campbell C , Walter F . Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res . 2016 ; 26 ( 13 ): 1802 – 1811 .

DONA International . Home page. 2024. Accessed January 29, 2024. https://www.dona.org/

HealthConnect One, National Health Law Program, National Partnership for Women and Families, and TEWA Women United . Improving Our Maternity Care Now: Four Care Models Decisionmakers Must Implement for Healthier Moms and Babies . HealthConnect One ; 2020 .

HealthConnect One, National Health Law Program, National Partnership for Women and Families, TEWA Women United . Improving Our Maternity Care Now Through Doula Support . 2022 .

HRSAtube . Impact of Community Doulas on Reducing Health Disparities in Maternal and Child Health Populations . EnRICH Webinar Series . Health Services and Resources Administration ; 2022 .

Institute for Medicaid Innovation and Every Mother Counts . Doulas and Perinatal Community Health Workers in Medicaid: A Learning Series on Leveraging Community-Based Support Services in Medicaid ., 2022 .

Kozhimannil K , Hardeman R . How Medicaid coverage for doula care could improve birth outcomes, reduce costs, and improve equity . Health Affairs Forefront . 2015 . https://doi.org/10.1377/forefront.20150701.049026

National Partnership for Women and Families . “Our Communities Hold the Solutions”: The Importance of Full-Spectrum Doulas to Reproductive Health and Justice . National Partnership for Women and Families ; 2022 .

Platt T , Kaye N . Four State Strategies to Employ Doulas to Improve Maternal Health and Birth Outcomes in Medicaid . National Academy for State Health Policy ; 2020 .

California Department of Healthcare Services (DHS) . Doula services as a medical benefit. 2023. Accessed October 13, 2023. https://www.dhcs.ca.gov/provgovpart/Pages/Doula-Services.aspx

Marshall CJ , Nguyen A , Arteaga S , et al.  Building capacity for research on community doula care: a stakeholder-engaged process in California. Matern Child Health J. 2024 . https://doi.org/10.1007/s10995-023-03883-2

Doula Series Footnotes . Coordinated care organizations and traditional health worker liaisons. Doula Series Footnotes. 2021. Accessed January 31, 2024. https://doulaseriesfootnotes.com/CCOs-and-THW-liaisons.html

The Doula Network . Home page. 2023. Accessed July 17, 2023. https://thedoulanetwork.com/

Crable EL , Benintendi A , Jones DK , Walley AY , Hicks JM , Drainoni ML . Translating Medicaid policy into practice: policy implementation strategies from three US states' experiences enhancing substance use disorder treatment . Implement Sci . 2022 ; 17 ( 1 ): 3 .

Cunningham PJ , O’Malley AS . Do reimbursement delays discourage Medicaid participation by physicians? Health Aff (Millwood) . 2009 ; 28 ( 1 ): w17 – w28 .

Prenatal-to-3 Policy Impact Center . Prenatal-to-3 Policy Clearinghouse Evidence Review: Community-Based Doulas . ER 23A.0423 . Peabody College of Education and Human Development, Vanderbilt University ; 2023 .

Prenatal-to-3 Policy Impact Center . State Policy Lever Checklist: Community-Based Doulas . Vanderbilt Peabody College ; 2023 .

Centers for Medicare and Medicaid Services . Center for Medicaid and CHIP Services, Increasing Access, Quality, and Equity in Postpartum Care in Medicaid and CHIP . Centers for Medicare and Medicaid Services ; 2023 .

Eastburn A . Hubbard E , Mitchell A . A Cost-Benefit Analysis of Doula Care from a Public Health Framework. Bixby Center for Global Reproductive Health and the National Health Law Program. 2024. Accessed March 4, 2024. https://healthlaw.org/resource/a-cost-benefit-analysis-of-doula-care-from-a-publichealth-framework/

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

Qualitative research method-interviewing and observation

Shazia jamshed.

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

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

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

Interviewing

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

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

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

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

Observation

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

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