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Critically appraising qualitative research

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  • Peer review
  • Ayelet Kuper , assistant professor 1 ,
  • Lorelei Lingard , associate professor 2 ,
  • Wendy Levinson , Sir John and Lady Eaton professor and chair 3
  • 1 Department of Medicine, Sunnybrook Health Sciences Centre, and Wilson Centre for Research in Education, University of Toronto, 2075 Bayview Avenue, Room HG 08, Toronto, ON, Canada M4N 3M5
  • 2 Department of Paediatrics and Wilson Centre for Research in Education, University of Toronto and SickKids Learning Institute; BMO Financial Group Professor in Health Professions Education Research, University Health Network, 200 Elizabeth Street, Eaton South 1-565, Toronto
  • 3 Department of Medicine, Sunnybrook Health Sciences Centre
  • Correspondence to: A Kuper ayelet94{at}post.harvard.edu

Six key questions will help readers to assess qualitative research

Summary points

Appraising qualitative research is different from appraising quantitative research

Qualitative research papers should show appropriate sampling, data collection, and data analysis

Transferability of qualitative research depends on context and may be enhanced by using theory

Ethics in qualitative research goes beyond review boards’ requirements to involve complex issues of confidentiality, reflexivity, and power

Over the past decade, readers of medical journals have gained skills in critically appraising studies to determine whether the results can be trusted and applied to their own practice settings. Criteria have been designed to assess studies that use quantitative methods, and these are now in common use.

In this article we offer guidance for readers on how to assess a study that uses qualitative research methods by providing six key questions to ask when reading qualitative research (box 1). However, the thorough assessment of qualitative research is an interpretive act and requires informed reflective thought rather than the simple application of a scoring system.

Box 1 Key questions to ask when reading qualitative research studies

Was the sample used in the study appropriate to its research question, were the data collected appropriately, were the data analysed appropriately, can i transfer the results of this study to my own setting, does the study adequately address potential ethical issues, including reflexivity.

Overall: is what the researchers did clear?

One of the critical decisions in a qualitative study is whom or what to include in the sample—whom to interview, whom to observe, what texts to analyse. An understanding that qualitative research is based in experience and in the construction of meaning, combined with the specific research question, should guide the sampling process. For example, a study of the experience of survivors of domestic violence that examined their reasons for not seeking help from healthcare providers might focus on interviewing a sample of such survivors (rather than, for example, healthcare providers, social services workers, or academics in the field). The sample should be broad enough to capture the many facets of a phenomenon, and limitations to the sample should be clearly justified. Since the answers to questions of experience and meaning also relate to people’s social affiliations (culture, religion, socioeconomic group, profession, etc), it is also important that the researcher acknowledges these contexts in the selection of a study sample.

In contrast with quantitative approaches, qualitative studies do not usually have predetermined sample sizes. Sampling stops when a thorough understanding of the phenomenon under study has been reached, an end point that is often called saturation. Researchers consider samples to be saturated when encounters (interviews, observations, etc) with new participants no longer elicit trends or themes not already raised by previous participants. Thus, to sample to saturation, data analysis has to happen while new data are still being collected. Multiple sampling methods may be used to broaden the understanding achieved in a study (box 2). These sampling issues should be clearly articulated in the methods section.

Box 2 Qualitative sampling methods for interviews and focus groups 9

Examples are for a hypothetical study of financial concerns among adult patients with chronic renal failure receiving ongoing haemodialysis in a single hospital outpatient unit.

Typical case sampling —sampling the most ordinary, usual cases of a phenomenon

The sample would include patients likely to have had typical experiences for that haemodialysis unit and patients who fit the profile of patients in the unit for factors found on literature review. Other typical cases could be found via snowball sampling (see below)

Deviant case sampling —sampling the most extreme cases of a phenomenon

The sample would include patients likely to have had different experiences of relevant aspects of haemodialysis. For example, if most patients in the unit are 60-70 years old and recently began haemodialysis for diabetic nephropathy, researchers might sample the unmarried university student in his 20s on haemodialysis since childhood, the 32 year old woman with lupus who is now trying to get pregnant, and the 90 year old who newly started haemodialysis due to an adverse reaction to radio-opaque contrast dye. Other deviant cases could be found via theoretical and/or snowball sampling (see below)

Critical case sampling —sampling cases that are predicted (based on theoretical models or previous research) to be especially information-rich and thus particularly illuminating

The nature of this sample depends on previous research. For example, if research showed that marital status was a major determinant of financial concerns for haemodialysis patients, then critical cases might include patients whose marital status changed while on haemodialysis

Maximum-variation sampling —sampling as wide a range of perspectives as possible to capture the broadest set of information and experiences)

The sample would include typical, deviant, and critical cases (as above), plus any other perspectives identified

Confirming-disconfirming sampling —Sampling both individuals or texts whose perspectives are likely to confirm the researcher’s developing understanding of the phenomenon under study and those whose perspectives are likely to challenge that understanding

The sample would include patients whose experiences would likely either confirm or disconfirm what the researchers had already learnt (from other patients) about financial concerns among patients in the haemodialysis unit. This could be accomplished via theoretical and/or snowball sampling (see below)

Snowball sampling —sampling participants found by asking current participants in a study to recommend others whose experiences would be relevant to the study

Current participants could be asked to provide the names of others in the unit who they thought, when asked about financial concerns, would either share their views (confirming), disagree with their views (disconfirming), have views typical of patients on their unit (typical cases), or have views different from most other patients on their unit (deviant cases)

Theoretical sampling —sampling individuals or texts whom the researchers predict (based on theoretical models or previous research) would add new perspectives to those already represented in the sample

Researchers could use their understanding of known issues for haemodialysis patients that would, in theory, relate to financial concerns to ensure that the relevant perspectives were represented in the study. For example, if, as the research progressed, it turned out that none of the patients in the sample had had to change or leave a job in order to accommodate haemodialysis scheduling, the researchers might (based on previous research) choose to intentionally sample patients who had left their jobs because of the time commitment of haemodialysis (but who could not do peritoneal dialysis) and others who had switched to jobs with more flexible scheduling because of their need for haemodialysis

It is important that a qualitative study carefully describes the methods used in collecting data. The appropriateness of the method(s) selected to use for the specific research question should be justified, ideally with reference to the research literature. It should be clear that methods were used systematically and in an organised manner. Attention should be paid to specific methodological challenges such as the Hawthorne effect, 1 whereby the presence of an observer may influence participants’ behaviours. By using a technique called thick description, qualitative studies often aim to include enough contextual information to provide readers with a sense of what it was like to have been in the research setting.

Another technique that is often used is triangulation, with which a researcher uses multiple methods or perspectives to help produce a more comprehensive set of findings. A study can triangulate data, using different sources of data to examine a phenomenon in different contexts (for example, interviewing palliative patients who are at home, those who are in acute care hospitals, and those who are in specialist palliative care units); it can also triangulate methods, collecting different types of data (for example, interviews, focus groups, observations) to increase insight into a phenomenon.

Another common technique is the use of an iterative process, whereby concurrent data analysis is used to inform data collection. For example, concurrent analysis of an interview study about lack of adherence to medications among a particular social group might show that early participants seem to be dismissive of the efforts of their local pharmacists; the interview script might then be changed to include an exploration of this phenomenon. The iterative process constitutes a distinctive qualitative tradition, in contrast to the tradition of stable processes and measures in quantitative studies. Iterations should be explicit and justified with reference to the research question and sampling techniques so that the reader understands how data collection shaped the resulting insights.

Qualitative studies should include a clear description of a systematic form of data analysis. Many legitimate analytical approaches exist; regardless of which is used, the study should report what was done, how, and by whom. If an iterative process was used, it should be clearly delineated. If more than one researcher analysed the data (which depends on the methodology used) it should be clear how differences between analyses were negotiated. Many studies make reference to a technique called member checking, wherein the researcher shows all or part of the study’s findings to participants to determine if they are in accord with their experiences. 2 Studies may also describe an audit trail, which might include researchers’ analysis notes, minutes of researchers’ meetings, and other materials that could be used to follow the research process.

The contextual nature of qualitative research means that careful thought must be given to the potential transferability of its results to other sociocultural settings. Though the study should discuss the extent of the findings’ resonance with the published literature, 3 much of the onus of assessing transferability is left to readers, who must decide if the setting of the study is sufficiently similar for its results to be transferable to their own context. In doing so, the reader looks for resonance—the extent that research findings have meaning for the reader.

Transferability may be helped by the study’s discussion of how its results advance theoretical understandings that are relevant to multiple situations. For example, a study of patients’ preferences in palliative care may contribute to theories of ethics and humanity in medicine, thus suggesting relevance to other clinical situations such as the informed consent exchange before treatment. We have explained elsewhere in this series the importance of theory in qualitative research, and there are many who believe that a key indicator of quality in qualitative research is its contribution to advancing theoretical understanding as well as useful knowledge. This debate continues in the literature, 4 but from a pragmatic perspective most qualitative studies in health professions journals emphasise results that relate to practice; theoretical discussions tend to be published elsewhere.

Reflexivity is particularly important within the qualitative paradigm. Reflexivity refers to recognition of the influence a researcher brings to the research process. It highlights potential power relationships between the researcher and research participants that might shape the data being collected, particularly when the researcher is a healthcare professional or educator and the participant is a patient, client, or student. 5 It also acknowledges how a researcher’s gender, ethnic background, profession, and social status influence the choices made within the study, such as the research question itself and the methods of data collection. 6 7

Research articles written in the qualitative paradigm should show evidence both of reflexive practice and of consideration of other relevant ethical issues. Ethics in qualitative research should extend beyond prescriptive guidelines and research ethics boards into a thorough exploration of the ethical consequences of collecting personal experiences and opening those experiences to public scrutiny (a detailed discussion of this problem within a research report may, however, be limited by the practicalities of word count limitations). 8 Issues of confidentiality and anonymity can become quite complex when data constitute personal reports of experience or perception; the need to minimise harm may involve not only protection from external scrutiny but also mechanisms to mitigate potential distress to participants from sharing their personal stories.

In conclusion: is what the researchers did clear?

The qualitative paradigm includes a wide range of theoretical and methodological options, and qualitative studies must include clear descriptions of how they were conducted, including the selection of the study sample, the data collection methods, and the analysis process. The list of key questions for beginning readers to ask when reading qualitative research articles (see box 1) is intended not as a finite checklist, but rather as a beginner’s guide to a complex topic. Critical appraisal of particular qualitative articles may differ according to the theories and methodologies used, and achieving a nuanced understanding in this area is fairly complex.

Further reading

Crabtree F, Miller WL, eds. Doing qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 1999.

Denzin NK, Lincoln YS, eds. Handbook of qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 2000.

Finlay L, Ballinger C, eds. Qualitative research for allied health professionals: challenging choices . Chichester: Wiley, 2006.

Flick U. An introduction to qualitative research . 2nd ed. London: Sage, 2002.

Green J, Thorogood N. Qualitative methods for health research . London: Sage, 2004.

Lingard L, Kennedy TJ. Qualitative research in medical education . Edinburgh: Association for the Study of Medical Education, 2007.

Mauthner M, Birch M, Jessop J, Miller T, eds. Ethics in Qualitative Research . Thousand Oaks, CA: Sage, 2002.

Seale C. The quality of qualitative research . London: Sage, 1999.

Silverman D. Doing qualitative research . Thousand Oaks, CA: Sage, 2000.

Journal articles

Greenhalgh T. How to read a paper: papers that go beyond numbers. BMJ 1997;315:740-3.

Mays N, Pope C. Qualitative research: Rigour and qualitative research. BMJ 1995;311:109-12.

Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ 2000;320:50-2.

Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res 1998;8:341-51.

Internet resources

National Health Service Public Health Resource Unit. Critical appraisal skills programme: qualitative research appraisal tool . 2006. www.phru.nhs.uk/Doc_Links/Qualitative%20Appraisal%20Tool.pdf

Cite this as: BMJ 2008;337:a1035

  • Related to doi: , 10.1136/bmj.a288
  • doi: , 10.1136/bmj.39602.690162.47
  • doi: , 10.1136/bmj.a1020
  • doi: , 10.1136/bmj.a879
  • doi: 10.1136/bmj.a949

This is the last in a series of six articles that aim to help readers to critically appraise the increasing number of qualitative research articles in clinical journals. The series editors are Ayelet Kuper and Scott Reeves.

For a definition of general terms relating to qualitative research, see the first article in this series.

Contributors: AK wrote the first draft of the article and collated comments for subsequent iterations. LL and WL made substantial contributions to the structure and content, provided examples, and gave feedback on successive drafts. AK is the guarantor.

Funding: None.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

  • ↵ Holden JD. Hawthorne effects and research into professional practice. J Evaluation Clin Pract 2001 ; 7 : 65 -70. OpenUrl CrossRef PubMed Web of Science
  • ↵ Hammersley M, Atkinson P. Ethnography: principles in practice . 2nd ed. London: Routledge, 1995 .
  • ↵ Silverman D. Doing qualitative research . Thousand Oaks, CA: Sage, 2000 .
  • ↵ Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ 2000 ; 320 : 50 -2. OpenUrl FREE Full Text
  • ↵ Lingard L, Kennedy TJ. Qualitative research in medical education . Edinburgh: Association for the Study of Medical Education, 2007 .
  • ↵ Seale C. The quality of qualitative research . London: Sage, 1999 .
  • ↵ Wallerstein N. Power between evaluator and community: research relationships within New Mexico’s healthier communities. Soc Sci Med 1999 ; 49 : 39 -54. OpenUrl CrossRef PubMed Web of Science
  • ↵ Mauthner M, Birch M, Jessop J, Miller T, eds. Ethics in qualitative research . Thousand Oaks, CA: Sage, 2002 .
  • ↵ Kuzel AJ. Sampling in qualitative inquiry. In: Crabtree F, Miller WL, eds. Doing qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 1999 :33-45.

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  • Volume 25, Issue 1
  • Critical appraisal of qualitative research: necessity, partialities and the issue of bias
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  • http://orcid.org/0000-0001-5660-8224 Veronika Williams ,
  • Anne-Marie Boylan ,
  • http://orcid.org/0000-0003-4597-1276 David Nunan
  • Nuffield Department of Primary Care Health Sciences , University of Oxford, Radcliffe Observatory Quarter , Oxford , UK
  • Correspondence to Dr Veronika Williams, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; veronika.williams{at}phc.ox.ac.uk


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  • qualitative research


Qualitative evidence allows researchers to analyse human experience and provides useful exploratory insights into experiential matters and meaning, often explaining the ‘how’ and ‘why’. As we have argued previously 1 , qualitative research has an important place within evidence-based healthcare, contributing to among other things policy on patient safety, 2 prescribing, 3 4 and understanding chronic illness. 5 Equally, it offers additional insight into quantitative studies, explaining contextual factors surrounding a successful intervention or why an intervention might have ‘failed’ or ‘succeeded’ where effect sizes cannot. It is for these reasons that the MRC strongly recommends including qualitative evaluations when developing and evaluating complex interventions. 6

Critical appraisal of qualitative research

Is it necessary.

Although the importance of qualitative research to improve health services and care is now increasingly widely supported (discussed in paper 1), the role of appraising the quality of qualitative health research is still debated. 8 10 Despite a large body of literature focusing on appraisal and rigour, 9 11–15 often referred to as ‘trustworthiness’ 16 in qualitative research, there remains debate about how to —and even whether to—critically appraise qualitative research. 8–10 17–19 However, if we are to make a case for qualitative research as integral to evidence-based healthcare, then any argument to omit a crucial element of evidence-based practice is difficult to justify. That being said, simply applying the standards of rigour used to appraise studies based on the positivist paradigm (Positivism depends on quantifiable observations to test hypotheses and assumes that the researcher is independent of the study. Research situated within a positivist paradigm isbased purely on facts and consider the world to be external and objective and is concerned with validity, reliability and generalisability as measures of rigour.) would be misplaced given the different epistemological underpinnings of the two types of data.

Given its scope and its place within health research, the robust and systematic appraisal of qualitative research to assess its trustworthiness is as paramount to its implementation in clinical practice as any other type of research. It is important to appraise different qualitative studies in relation to the specific methodology used because the methodological approach is linked to the ‘outcome’ of the research (eg, theory development, phenomenological understandings and credibility of findings). Moreover, appraisal needs to go beyond merely describing the specific details of the methods used (eg, how data were collected and analysed), with additional focus needed on the overarching research design and its appropriateness in accordance with the study remit and objectives.

Poorly conducted qualitative research has been described as ‘worthless, becomes fiction and loses its utility’. 20 However, without a deep understanding of concepts of quality in qualitative research or at least an appropriate means to assess its quality, good qualitative research also risks being dismissed, particularly in the context of evidence-based healthcare where end users may not be well versed in this paradigm.

How is appraisal currently performed?

Appraising the quality of qualitative research is not a new concept—there are a number of published appraisal tools, frameworks and checklists in existence. 21–23  An important and often overlooked point is the confusion between tools designed for appraising methodological quality and reporting guidelines designed to assess the quality of methods reporting. An example is the Consolidate Criteria for Reporting Qualitative Research (COREQ) 24 checklist, which was designed to provide standards for authors when reporting qualitative research but is often mistaken for a methods appraisal tool. 10

Broadly speaking there are two types of critical appraisal approaches for qualitative research: checklists and frameworks. Checklists have often been criticised for confusing quality in qualitative research with ‘technical fixes’ 21 25 , resulting in the erroneous prioritisation of particular aspects of methodological processes over others (eg, multiple coding and triangulation). It could be argued that a checklist approach adopts the positivist paradigm, where the focus is on objectively assessing ‘quality’ where the assumptions is that the researcher is independent of the research conducted. This may result in the application of quantitative understandings of bias in order to judge aspects of recruitment, sampling, data collection and analysis in qualitative research papers. One of the most widely used appraisal tools is the Critical Appraisal Skills Programme (CASP) 26 and along with the JBI QARI (Joanna Briggs Institute Qualitative Assessment and Assessment Instrument) 27 presents examples which tend to mimic the quantitative approach to appraisal. The CASP qualitative tool follows that of other CASP appraisal tools for quantitative research designs developed in the 1990s. The similarities are therefore unsurprising given the status of qualitative research at that time.

Frameworks focus on the overarching concepts of quality in qualitative research, including transparency, reflexivity, dependability and transferability (see box 1 ). 11–13 15 16 20 28 However, unless the reader is familiar with these concepts—their meaning and impact, and how to interpret them—they will have difficulty applying them when critically appraising a paper.

The main issue concerning currently available checklist and framework appraisal methods is that they take a broad brush approach to ‘qualitative’ research as whole, with few, if any, sufficiently differentiating between the different methodological approaches (eg, Grounded Theory, Interpretative Phenomenology, Discourse Analysis) nor different methods of data collection (interviewing, focus groups and observations). In this sense, it is akin to taking the entire field of ‘quantitative’ study designs and applying a single method or tool for their quality appraisal. In the case of qualitative research, checklists, therefore, offer only a blunt and arguably ineffective tool and potentially promote an incomplete understanding of good ‘quality’ in qualitative research. Likewise, current framework methods do not take into account how concepts differ in their application across the variety of qualitative approaches and, like checklists, they also do not differentiate between different qualitative methodologies.

On the need for specific appraisal tools

Current approaches to the appraisal of the methodological rigour of the differing types of qualitative research converge towards checklists or frameworks. More importantly, the current tools do not explicitly acknowledge the prejudices that may be present in the different types of qualitative research.

Concepts of rigour or trustworthiness within qualitative research 31

Transferability: the extent to which the presented study allows readers to make connections between the study’s data and wider community settings, ie, transfer conceptual findings to other contexts.

Credibility: extent to which a research account is believable and appropriate, particularly in relation to the stories told by participants and the interpretations made by the researcher.

Reflexivity: refers to the researchers’ engagement of continuous examination and explanation of how they have influenced a research project from choosing a research question to sampling, data collection, analysis and interpretation of data.

Transparency: making explicit the whole research process from sampling strategies, data collection to analysis. The rationale for decisions made is as important as the decisions themselves.

However, we often talk about these concepts in general terms, and it might be helpful to give some explicit examples of how the ‘technical processes’ affect these, for example, partialities related to:

Selection: recruiting participants via gatekeepers, such as healthcare professionals or clinicians, who may select them based on whether they believe them to be ‘good’ participants for interviews/focus groups.

Data collection: poor interview guide with closed questions which encourage yes/no answers and/leading questions.

Reflexivity and transparency: where researchers may focus their analysis on preconceived ideas rather than ground their analysis in the data and do not reflect on the impact of this in a transparent way.

The lack of tailored, method-specific appraisal tools has potentially contributed to the poor uptake and use of qualitative research for informing evidence-based decision making. To improve this situation, we propose the need for more robust quality appraisal tools that explicitly encompass both the core design aspects of all qualitative research (sampling/data collection/analysis) but also considered the specific partialities that can be presented with different methodological approaches. Such tools might draw on the strengths of current frameworks and checklists while providing users with sufficient understanding of concepts of rigour in relation to the different types of qualitative methods. We provide an outline of such tools in the third and final paper in this series.

As qualitative research becomes ever more embedded in health science research, and in order for that research to have better impact on healthcare decisions, we need to rethink critical appraisal and develop tools that allow differentiated evaluations of the myriad of qualitative methodological approaches rather than continuing to treat qualitative research as a single unified approach.

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  • ↵ CASP (Critical Appraisal Skills Programme). date unknown . http://www.phru.nhs.uk/Pages/PHD/CASP.htm .
  • ↵ The Joanna Briggs Institute . JBI QARI Critical appraisal checklist for interpretive & critical research . Adelaide : The Joanna Briggs Institute , 2014 .
  • Stephens J ,

Contributors VW and DN: conceived the idea for this article. VW: wrote the first draft. AMB and DN: contributed to the final draft. All authors approve the submitted article.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Correction notice This article has been updated since its original publication to include a new reference (reference 1.)

Read the full text or download the PDF:

Qualitative Studies

Phillips-Wangensteen Building.

Qualitative Research Studies: Introduction


Research design decides how research materials will be collected. One or more research methods, for example -- experiment, survey, interview, etc. -- are chosen depending on the research objectives. In some research contexts, a survey may be suitable. In other instances, interviews or case studies or observation might be more appropriate. Research design actually provides insights into “how” to conduct research using a particular research methodology. Basically, every researcher has a list of research questions that need to be assessed that can be done with research design.

So research design can be defined as a framework of research methods and techniques applied by a researcher to incorporate different elements & components of research in a systematic manner. Most significantly, research design provides insights into how to Conduct Research using a particular research methodology. 

Qualitative Methods try to gather detailed, rich data allowing for an in-depth understanding of research phenomena.  Seeks the “why” rather than the “how.”

Qualitative Data Collection

Data obtained using qualitative data collection methods can be used to find new ideas, opportunities, and problems, test their value and accuracy, formulate predictions, explore a certain field in more detail, and explain the numbers obtained using quantitative data collection techniques.

Since qualitative data collection methods usually do not involve numbers and mathematical calculations, qualitative data is often seen as more subjective, but at the same time, it allows a greater depth of understanding.

Aspers, P., Corte, U. What is Qualitative in Qualitative Research .  Qual Sociol   42 , 139–160 (2019). 

Types of Qualitative Studies

Qualitative study methods are semi-structured or unstructured, usually involve small sample sizes and lack strong scientific controls.

Qualitative Study Methods

Qualitative study methods employ many of the same methods as quantitative data collection, except that instead of structured or closed, they are semi- or unstructured and open-ended.  Some of the most common qualitative  study techniques include open-ended surveys and questionnaires, interviews, focus groups, observation, case studies, and so on.

There is generally five types of qualitative data collection:

  • Ethnography research: Involves semi-structure or unstructured interviews with open-ended questions; participant and non-participant observation; collected materials including documents, books, papers, audio, images, videos etc.
  • Phenomenological research : I n-depth interviewing which involves conducting intensive individual interviews with a small number of respondents to explore their perspectives on a particular idea, program, or situation.  The participant interviews may be structured, semi-structured or unstructured; it also includes reflective journals; written oral self-reports; and participant’s aesthetic expressions.
  • Grounded theory research: Data collection methods often include in-depth interviews using open-ended questions. Questions can be adjusted as theory emerges. Participant observation and focus groups may also be used as well as collecting and studying …  including documents, books, papers, audio, images, artifacts; videos etc. used by participants in their daily lives.
  • Narrative: Participant or non-participant interview, aesthetic expressions; one’s own and other’s observation; storytelling; letter writing; autobiographic writing; collected materials …..; personal information such as values. Narrative analysis focuses on different elements to make diverse but equally substantial and meaningful interpretations and conclusions. It is a genre of analytical frames used by researchers to interpret information with the context of research shared by all in daily life. 
  • Case study : Focus groups; semi-structured or unstructured interviews with open-ended questions; participant and non-participant observation; collected materials

Nayar, S., & Stanley, D. M. (Eds.). (2015).  Qualitative research methodologies for occupational science and therapy . London: Routledge.

Frank, G., & Polkinghorne, D. (2010). Qualitative Research in Occupational Therapy: From the First to the Second Generation . OTJR (Thorofare, N.J.), 30(2), 51-57.

How To Search for Qualitative Studies

Databases categorize their records using subject terms or controlled vocabularies. These Subject Headings vary for each database.

Medline/PubMed : MeSH Subject Headings

  • Qualitative Research : Any type of research that employs nonnumeric information to explore individual or group characteristics, producing findings not arrived at by statistical procedures or other quantitative means.  Includes Document Analysis & Hermaneutics.
  • Interviews as Topic:  Works about conversations with an individual or individuals held in order to obtain information about their background and other personal biographical data, their attitudes and opinions, etc. It includes works about school admission or job interviews.
  • Focus Groups : A method of data collection and a QUALITATIVE RESEARCH tool in which a small group of individuals are brought together and allowed to interact in a discussion of their opinions about topics, issues, or questions.
  • Grounded Theory : The generation of theories from analysis of empirical data.
  • Nursing Methodology Research :  Research carried out by nurses concerning techniques and methods to implement projects and to document information, including methods of interviewing patients, collecting data, and forming inferences. The concept includes exploration of methodological issues such as human subjectivity and human experience.
  • Anecdotes As Topic : Works about brief accounts or narratives of an incident or event.
  • Narration : The act, process, or an instance of narrating, i.e., telling a story. In the context of MEDICINE or ETHICS, narration includes relating the particular and the personal in the life story of an individual.
  • Personal Narratives As Topic:  Works about accounts of individual experience in relation to a particular field or of participation in related activities.
  • Observational Studies As Topic : Works about clinical studies in which participants may receive diagnostic, therapeutic, or other types of interventions, but the investigator does not assign participants to specific interventions (as in an interventional study).

CINAHL (Cumulative Index to Nursing & Allied Health) : CINAHL Subject Headings 

  • Action Research: Research in which problem definition, data collection, factor formulation, planned change, data analysis, and problem redefinition continue in an ongoing cycle.
  • Ethnographic Research: Research which seeks to uncover the symbols and categories that members of a given culture use to interpret their world.
  • Ethnological Research: Comparison and contrasting of cultures and societies as a whole.
  • Ethnonursing Research: The study and analysis of a designated culture's viewpoints, beliefs, and practices about nursing care behavior.
  • Grounded Theory: A qualitative method developed by Glaser and Strauss to unite theory construction and data analysis.
  • Naturalist Inquiry: The use of the natural setting in research to enable understanding the whole rather than only part of the reality being studied.
  • Phenomenological Research: Research designed to discover and understand the meaning of human life experiences.
  • Focus Groups : Small groups of individuals brought together to discuss their opinions regarding specific issues, topics, and questions.
  • Interviews:  Face-to-face or telephone meetings with subjects for the purpose of gathering information.
  • Narratives : Descriptions or interpretations of events, usually in an informal manner. Often used as a data collection method for research. Do not confuse with STORYTELLING, a form of literature or telling a real or imagined story to an audience or listener.
  • Descriptive Research : Research studies that have as their main objective the accurate portrayal of the characteristics of persons, situations, or groups, and the frequency with which certain phenomena occur.
  • Observational Methods:  Methods of data collection in which the investigator witnesses and records behaviors of interest.
  • Projective Techniques : A variety of methods for measuring by providing respondents with unstructured stimuli to which to respond.

In CINHAL, on the Advanced Search page, there are Search Options.  Scroll down to the Clinical Queries drop down box and choose to limit the search to  Qualitative-High Sensitivity; Qualitative-High Specificity ; Qualitative-Best Balance . High Sensitivity is the broadest search, to include ALL relevant material, but may also include less relevant materials. High Specificity is the most targeted search to include only the most relevant result set, but may miss some relevant materials. Best Balance retrieves the best balance between Sensitivity and Specificity.

PsycINFO: Subject Headings

  • Grounded Theory
  • Narrative Analysis
  • Thematic Analysis : A qualitative research strategy for identifying, analyzing, and reporting identifiable patterns or clusters within data.
  • Focus Grou p
  • Focus Group Interview
  • Semi-Structured Interview
  • Interpretive Phenomenological Analysis : A systematic qualitative approach in which a researcher explores how individual's make sense of particular experiences, events, and states, primarily through the analysis of data from structured and semi-structured interviews.
  • Qualitative Measures : Measures or tests employing qualitative methods and/or data, such as narratives, interviews, and focus groups.

As with CINAHL, you can limit to Methodology.  Click on Additional Limits, scroll down to "Methodology" and choose "Qualitative Study", "Focus Groups" or "Interview".

NOTE!: Be aware of  Inconsistent indexing. The above subject headings as not always indexed (i.e. added to articles) for qualitative research nor is the publication type/methodology.  So, to successfully find qualitative articles you also need to add keywords to your search strategy or if you are getting too few results, leave off the Clinical Queries or Methodology filters.

Free text keywords

Use selective free text keywords to search in Titles, Abstracts or Keywords of records held in the databases to identify Qualitative Research.  Examples:

When searching, do a combination of subject terms and keywords depending on the type of qualitative study you are looking for:

Qualitative Research [MeSH] OR (qualitative AND (research OR study OR method))

(Grounded Theory[MeSH] OR "grounded theory")

then combine it with your topic of interest

post-traumatic stress disorder OR PTSD

brain injury, OR BTI OR "traumatic, brain injury"

How to Critically Analyze Qualitative Studies

 A critical analysis of a qualitative study considers the “fit” of the research question with the qualitative method used in the study. There are many checklists available for the assessment of qualitative research studies.  Here are a few:

  • The Johanna Briggs Institute: The Joanna Briggs Institute Critical Appraisal tools  for use in JBI Systematic Reviews Checklist for  Qualitative Research  
  • CASP:  CASP Checklist: 10 questions to help you make sense of a Qualitative research
  • McMaster University:  Guidelines for Critical Review Form:  Qualitative Studies (Version 2.0) © Letts, L., Wilkins, S., Law, M., Stewart, D., Bosch, J., & Westmorland, M., 2007  

NOTE:  When using these checklists, be sure to use them critically and with careful consideration of the research context.  In other words, use the checklists as the beginning point in assessing the article and then re-assess the article based on whether the findings can be applied in your setting/population/disease/condition.

Additional Resources

Moorley, C., & Cathala, X. (2019). How to appraise qualitative research .  Evidence-Based Nursing ,  22 (1), 10-13.    ( open access)

Stenfors, T., Kajamaa, A. and Bennett, D. (2020), How to … assess the quality of qualitative research . Clin Teach, 17: 596-599.

Greenhalgh, T., & Taylor, R. (1997). How to read a paper: Papers that go beyond numbers (qualitative research).   BMj ,  315 (7110), 740-743. 

Jeanfreau, S. G., & Jack, L., Jr (2010). Appraising qualitative research in health education: guidelines for public health educators.   Health promotion practice ,  11 (5), 612–617. 

Research Series - Critical appraisal of qualitative research when reading papers Jul 22, 2022 Virtual Tutor; Research Series (Elsevier Health Education) YouTube Video 10:04 min [ This episode Professor Dall'Ora will be looking at qualitative research in more detail. In particular how to critically appraise qualitative studies.]

Hanes K. Chapter 4: Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, Lockwood C (editors), Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions. Version 1 (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011. 

David Tod, Andrew Booth & Brett Smith (2022)  Critical appraisal ,  International Review of Sport and Exercise Psychology, 15:1, 52-72  (open access)

Validity & Reliability in Qualitative Studies

Validity & Reliability

Validity in qualitative research means the “appropriateness” of the tools, processes, and data -- are the tools, processes and data measuring what it is intended to measure to answer the research question?  Assessing for validity is looking to see if the research question is "valid" for the desired outcome -- whether the choice of of the methodology used was appropriate for answering the research question, was the study design valid for the methodology, were the appropriate sampling and data analysis used and finally, were the results and conclusions valid for the sample and within the context of the research question. 

In contrast, reliability concerns the degree of consistency in the results if the study, using the same methodology, can be repeated over and over.

The Basics of Validity and Reliability in Research by Joe O'Brian & Anders Orn, Research Collective.com

Brewer, M., & Crano, W. (2014). Research Design and Issues of Validity. In H. Reis & C. Judd (Eds.),  Handbook of Research Methods in Social and Personality Psychology  (pp. 11-26). Cambridge: Cambridge University Press. 

Golafshani, N. (2003). Understanding Reliability and Validity in Qualitative Research.   The Qualitative Report ,  8 (4), 597-606. 

Cypress, Brigitte S. EdD, RN, CCRN. Rigor or Reliability and Validity in Qualitative Research: Perspectives, Strategies, Reconceptualization, and Recommendations . Dimensions of Critical Care Nursing 36(4):p 253-263, 7/8 2017. 

Leung L. (2015). Validity, reliability, and generalizability in qualitative research .  Journal of family medicine and primary care ,  4 (3), 324–327. 

Understanding Reliability and Validity . Writing@CSU

Rosumeck, S., Wagner, M., Wallraf, S., & Euler, U. (2020). A validation study revealed differences in design and performance of search filters for qualitative research in PsycINFO and CINAHL.   Journal of clinical epidemiology ,  128 , 101–108. 

Wagner, M., Rosumeck, S., Küffmeier, C., Döring, K., & Euler, U. (2020). A validation study revealed differences in design and performance of MEDLINE search filters for qualitative research .  Journal of clinical epidemiology ,  120 , 17–24.

Franzel, B., Schwiegershausen, M., Heusser, P.  et al.   How to locate and appraise qualitative research in complementary and alternative medicine.   BMC Complement Altern Med   13 , 125 (2013). 

Finfgeld-Connett, D. and Johnson, E.D. (2013), Literature search strategies for conducting knowledge-building and theory-generating qualitative systematic reviews. Journal of Advanced Nursing, 69: 194-204. 

Rogers, M, Bethel, A, Abbott, R.  Locating qualitative studies in dementia on MEDLINE, EMBASE, CINAHL, and PsycINFO: A comparison of search strategies.   Res Syn Meth . 2018; 9: 579– 586. 

Booth, A. Searching for qualitative research for inclusion in systematic reviews: a structured methodological review .  Syst Rev   5 , 74 (2016). 

Noyes, J., Hannes, K., Booth, A., Harris, J., Harden, A., Popay, J., ... & Pantoja, T. (2015). Qualitative research and Cochrane reviews .

Citing Sources

Citations are brief notations in the body of a research paper that point to a source in the bibliography or references cited section.

If your paper quotes, paraphrases, summarizes the work of someone else, you need to use citations.

Citation style guides such as APA, Chicago and MLA provide detailed instructions on how citations and bibliographies should be formatted.

Health Sciences Research Toolkit

Resources, tips, and guidelines to help you through the research process., finding information.

Library Research Checklist Helpful hints for starting a library research project.

Search Strategy Checklist and Tips Helpful tips on how to develop a literature search strategy.

Boolean Operators: A Cheat Sheet Boolean logic (named after mathematician George Boole) is a system of logic to designed to yield optimal search results. The Boolean operators, AND, OR, and NOT, help you construct a logical search. Boolean operators act on sets -- groups of records containing a particular word or concept.

Literature Searching Overview and tips on how to conduct a literature search.

Health Statistics and Data Sources Health related statistics and data sources are increasingly available on the Internet. They can be found already neatly packaged, or as raw data sets. The most reliable data comes from governmental sources or health-care professional organizations.

Evaluating Information

Primary, Secondary and Tertiary Sources in the Health Sciences Understand what are considered primary, secondary and tertiary sources.

Scholarly vs Popular Journals/Magazines How to determine what are scholarly journals vs trade or popular magazines.

Identifying Peer-Reviewed Journals A “peer-reviewed” or “refereed” journal is one in which the articles it contains have been examined by people with credentials in the article’s field of study before it is published.

Evaluating Web  Resources When searching for information on the Internet, it is important to be aware of the quality of the information being presented to you. Keep in mind that anyone can host a web site. To be sure that the information you are looking at is credible and of value.

Conducting Research Through An Anti-Racism Lens This guide is for students, staff, and faculty who are incorporating an anti-racist lens at all stages of the research life cycle.

Understanding Research Study Designs Covers case studies, randomized control trials, systematic reviews and meta-analysis.

Qualitative Studies Overview of what is a qualitative study and how to recognize, find and critically appraise.

Writing and Publishing

Citing Sources Citations are brief notations in the body of a research paper that point to a source in the bibliography or references cited section.

Structure of a Research Paper Reports of research studies usually follow the IMRAD format. IMRAD (Introduction, Methods, Results, [and] Discussion) is a mnemonic for the major components of a scientific paper. These elements are included in the overall structure of a research paper.

Top Reasons for Non-Acceptance of Scientific Articles Avoid these mistakes when preparing an article for publication.

Annotated Bibliographies Guide on how to create an annotated bibliography.

Writing guides, Style Manuals and the Publication Process in the Biological and Health Sciences Style manuals, citation guides as well as information on public access policies, copyright and plagiarism.

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Methods for the synthesis of qualitative research: a critical review

Elaine barnett-page.

1 Evidence for Policy and Practice Information and Co-ordinating (EPPI-) Centre, Social Science Research Unit, 18 Woburn Square, London WC1H 0NS, UK

James Thomas

Associated data.

In recent years, a growing number of methods for synthesising qualitative research have emerged, particularly in relation to health-related research. There is a need for both researchers and commissioners to be able to distinguish between these methods and to select which method is the most appropriate to their situation.

A number of methodological and conceptual links between these methods were identified and explored, while contrasting epistemological positions explained differences in approaches to issues such as quality assessment and extent of iteration. Methods broadly fall into 'realist' or 'idealist' epistemologies, which partly accounts for these differences.

Methods for qualitative synthesis vary across a range of dimensions. Commissioners of qualitative syntheses might wish to consider the kind of product they want and select their method – or type of method – accordingly.

The range of different methods for synthesising qualitative research has been growing over recent years [ 1 , 2 ], alongside an increasing interest in qualitative synthesis to inform health-related policy and practice [ 3 ]. While the terms 'meta-analysis' (a statistical method to combine the results of primary studies), or sometimes 'narrative synthesis', are frequently used to describe how quantitative research is synthesised, far more terms are used to describe the synthesis of qualitative research. This profusion of terms can mask some of the basic similarities in approach that the different methods share, and also lead to some confusion regarding which method is most appropriate in a given situation. This paper does not argue that the various nomenclatures are unnecessary, but rather seeks to draw together and review the full range of methods of synthesis available to assist future reviewers in selecting a method that is fit for their purpose. It also represents an attempt to guide the reader through some of the varied terminology to spring up around qualitative synthesis. Other helpful reviews of synthesis methods have been undertaken in recent years with slightly different foci to this paper. Two recent studies have focused on describing and critiquing methods for the integration of qualitative research with quantitative [ 4 , 5 ] rather than exclusively examining the detail and rationale of methods for the synthesis of qualitative research. Two other significant pieces of work give practical advice for conducting the synthesis of qualitative research, but do not discuss the full range of methods available [ 6 , 7 ]. We begin our Discussion by outlining each method of synthesis in turn, before comparing and contrasting characteristics of these different methods across a range of dimensions. Readers who are more familiar with the synthesis methods described here may prefer to turn straight to the 'dimensions of difference' analysis in the second part of the Discussion.

Overview of synthesis methods


In their seminal work of 1988, Noblit and Hare proposed meta-ethnography as an alternative to meta-analysis [ 8 ]. They cited Strike and Posner's [ 9 ] definition of synthesis as an activity in which separate parts are brought together to form a 'whole'; this construction of the whole is essentially characterised by some degree of innovation, so that the result is greater than the sum of its parts. They also borrowed from Turner's theory of social explanation [ 10 ], a key tenet of which was building 'comparative understanding' [[ 8 ], p22] rather than aggregating data.

To Noblit and Hare, synthesis provided an answer to the question of 'how to "put together" written interpretive accounts' [[ 8 ], p7], where mere integration would not be appropriate. Noblit and Hare's early work synthesised research from the field of education.

Three different methods of synthesis are used in meta-ethnography. One involves the 'translation' of concepts from individual studies into one another, thereby evolving overarching concepts or metaphors. Noblit and Hare called this process reciprocal translational analysis (RTA). Refutational synthesis involves exploring and explaining contradictions between individual studies. Lines-of-argument (LOA) synthesis involves building up a picture of the whole (i.e. culture, organisation etc) from studies of its parts. The authors conceptualised this latter approach as a type of grounded theorising.

Britten et al [ 11 ] and Campbell et al [ 12 ] have both conducted evaluations of meta-ethnography and claim to have succeeded, by using this method, in producing theories with greater explanatory power than could be achieved in a narrative literature review. While both these evaluations used small numbers of studies, more recently Pound et al [ 13 ] conducted both an RTA and an LOA synthesis using a much larger number of studies (37) on resisting medicines. These studies demonstrate that meta-ethnography has evolved since Noblit and Hare first introduced it. Campbell et al claim to have applied the method successfully to non-ethnographical studies. Based on their reading of Schutz [ 14 ], Britten et al have developed both second and third order constructs in their synthesis (Noblit and Hare briefly allude to the possibility of a 'second level of synthesis' [[ 8 ], p28] but do not demonstrate or further develop the idea).

In a more recent development, Sandelowski & Barroso [ 15 ] write of adapting RTA by using it to ' integrate findings interpretively, as opposed to comparing them interpretively' (p204). The former would involve looking to see whether the same concept, theory etc exists in different studies; the latter would involve the construction of a bigger picture or theory (i.e. LOA synthesis). They also talk about comparing or integrating imported concepts (e.g. from other disciplines) as well as those evolved 'in vivo'.

Grounded theory

Kearney [ 16 ], Eaves [ 17 ] and Finfgeld [ 18 ] have all adapted grounded theory to formulate a method of synthesis. Key methods and assumptions of grounded theory, as originally formulated and subsequently refined by Glaser and Strauss [ 19 ] and Strauss and Corbin [ 20 , 21 ], include: simultaneous phases of data collection and analysis; an inductive approach to analysis, allowing the theory to emerge from the data; the use of the constant comparison method; the use of theoretical sampling to reach theoretical saturation; and the generation of new theory. Eaves cited grounded theorists Charmaz [ 22 ] and Chesler [ 23 ], as well as Strauss and Corbin [ 20 ], as informing her approach to synthesis.

Glaser and Strauss [ 19 ] foresaw a time when a substantive body of grounded research should be pushed towards a higher, more abstract level. As a piece of methodological work, Eaves undertook her own synthesis of the synthesis methods used by these authors to produce her own clear and explicit guide to synthesis in grounded formal theory. Kearney stated that 'grounded formal theory', as she termed this method of synthesis, 'is suited to study of phenomena involving processes of contextualized understanding and action' [[ 24 ], p180] and, as such, is particularly applicable to nurses' research interests.

As Kearney suggested, the examples examined here were largely dominated by research in nursing. Eaves synthesised studies on care-giving in rural African-American families for elderly stroke survivors; Finfgeld on courage among individuals with long-term health problems; Kearney on women's experiences of domestic violence.

Kearney explicitly chose 'grounded formal theory' because it matches 'like' with 'like': that is, it applies the same methods that have been used to generate the original grounded theories included in the synthesis – produced by constant comparison and theoretical sampling – to generate a higher-level grounded theory. The wish to match 'like' with 'like' is also implicit in Eaves' paper. This distinguishes grounded formal theory from more recent applications of meta-ethnography, which have sought to include qualitative research using diverse methodological approaches [ 12 ].

Thematic Synthesis

Thomas and Harden [ 25 ] have developed an approach to synthesis which they term 'thematic synthesis'. This combines and adapts approaches from both meta-ethnography and grounded theory. The method was developed out of a need to conduct reviews that addressed questions relating to intervention need, appropriateness and acceptability – as well as those relating to effectiveness – without compromising on key principles developed in systematic reviews. They applied thematic synthesis in a review of the barriers to, and facilitators of, healthy eating amongst children.

Free codes of findings are organised into 'descriptive' themes, which are then further interpreted to yield 'analytical' themes. This approach shares characteristics with later adaptations of meta-ethnography, in that the analytical themes are comparable to 'third order interpretations' and that the development of descriptive and analytical themes using coding invoke reciprocal 'translation'. It also shares much with grounded theory, in that the approach is inductive and themes are developed using a 'constant comparison' method. A novel aspect of their approach is the use of computer software to code the results of included studies line-by-line, thus borrowing another technique from methods usually used to analyse primary research.

Textual Narrative Synthesis

Textual narrative synthesis is an approach which arranges studies into more homogenous groups. Lucas et al [ 26 ] comment that it has proved useful in synthesising evidence of different types (qualitative, quantitative, economic etc). Typically, study characteristics, context, quality and findings are reported on according to a standard format and similarities and differences are compared across studies. Structured summaries may also be developed, elaborating on and putting into context the extracted data [ 27 ].

Lucas et al [ 26 ] compared thematic synthesis with textual narrative synthesis. They found that 'thematic synthesis holds most potential for hypothesis generation' whereas textual narrative synthesis is more likely to make transparent heterogeneity between studies (as does meta-ethnography, with refutational synthesis) and issues of quality appraisal. This is possibly because textual narrative synthesis makes clearer the context and characteristics of each study, while the thematic approach organises data according to themes. However, Lucas et al found that textual narrative synthesis is 'less good at identifying commonality' (p2); the authors do not make explicit why this should be, although it may be that organising according to themes, as the thematic approach does, is comparatively more successful in revealing commonality.

Paterson et al [ 28 ] have evolved a multi-faceted approach to synthesis, which they call 'meta-study'. The sociologist Zhao [ 29 ], drawing on Ritzer's work [ 30 ], outlined three components of analysis, which they proposed should be undertaken prior to synthesis. These are meta-data-analysis (the analysis of findings), meta-method (the analysis of methods) and meta-theory (the analysis of theory). Collectively, these three elements of analysis, culminating in synthesis, make up the practice of 'meta-study'. Paterson et al pointed out that the different components of analysis may be conducted concurrently.

Paterson et al argued that primary research is a construction; secondary research is therefore a construction of a construction. There is need for an approach that recognises this, and that also recognises research to be a product of its social, historical and ideological context. Such an approach would be useful in accounting for differences in research findings. For Paterson et al, there is no such thing as 'absolute truth'.

Meta-study was developed to study the experiences of adults living with a chronic illness. Meta-data-analysis was conceived of by Paterson et al in similar terms to Noblit and Hare's meta-ethnography (see above), in that it is essentially interpretive and seeks to reveal similarities and discrepancies among accounts of a particular phenomenon. Meta-method involves the examination of the methodologies of the individual studies under review. Part of the process of meta-method is to consider different aspects of methodology such as sampling, data collection, research design etc, similar to procedures others have called 'critical appraisal' (CASP [ 31 ]). However, Paterson et al take their critique to a deeper level by establishing the underlying assumptions of the methodologies used and the relationship between research outcomes and methods used. Meta-theory involves scrutiny of the philosophical and theoretical assumptions of the included research papers; this includes looking at the wider context in which new theory is generated. Paterson et al described meta-synthesis as a process which creates a new interpretation which accounts for the results of all three elements of analysis. The process of synthesis is iterative and reflexive and the authors were unwilling to oversimplify the process by 'codifying' procedures for bringing all three components of analysis together.


Greenhalgh et al [ 32 ]'s meta-narrative approach to synthesis arose out of the need to synthesise evidence to inform complex policy-making questions and was assisted by the formation of a multi-disciplinary team. Their approach to review was informed by Thomas Kuhn's The Structure of Scientific Revolutions [ 33 ], in which he proposed that knowledge is produced within particular paradigms which have their own assumptions about theory, about what is a legitimate object of study, about what are legitimate research questions and about what constitutes a finding. Paradigms also tend to develop through time according to a particular set of stages, central to which is the stage of 'normal science', in which the particular standards of the paradigm are largely unchallenged and seen to be self-evident. As Greenhalgh et al pointed out, Kuhn saw paradigms as largely incommensurable: 'that is, an empirical discovery made using one set of concepts, theories, methods and instruments cannot be satisfactorily explained through a different paradigmatic lens' [[ 32 ], p419].

Greenhalgh et al synthesised research from a wide range of disciplines; their research question related to the diffusion of innovations in health service delivery and organisation. They thus identified a need to synthesise findings from research which contains many different theories arising from many different disciplines and study designs.

Based on Kuhn's work, Greenhalgh et al proposed that, across different paradigms, there were multiple – and potentially mutually contradictory – ways of understanding the concept at the heart of their review, namely the diffusion of innovation. Bearing this in mind, the reviewers deliberately chose to select key papers from a number of different research 'paradigms' or 'traditions', both within and beyond healthcare, guided by their multidisciplinary research team. They took as their unit of analysis the 'unfolding "storyline" of a research tradition over time' [[ 32 ], p417) and sought to understand diffusion of innovation as it was conceptualised in each of these traditions. Key features of each tradition were mapped: historical roots, scope, theoretical basis; research questions asked and methods/instruments used; main empirical findings; historical development of the body of knowledge (how have earlier findings led to later findings); and strengths and limitations of the tradition. The results of this exercise led to maps of 13 'meta-narratives' in total, from which seven key dimensions, or themes, were identified and distilled for the synthesis phase of the review.

Critical Interpretive Synthesis

Dixon-Woods et al [ 34 ] developed their own approach to synthesising multi-disciplinary and multi-method evidence, termed 'critical interpretive synthesis', while researching access to healthcare by vulnerable groups. Critical interpretive synthesis is an adaptation of meta-ethnography, as well as borrowing techniques from grounded theory. The authors stated that they needed to adapt traditional meta-ethnographic methods for synthesis, since these had never been applied to quantitative as well as qualitative data, nor had they been applied to a substantial body of data (in this case, 119 papers).

Dixon-Woods et al presented critical interpretive synthesis as an approach to the whole process of review, rather than to just the synthesis component. It involves an iterative approach to refining the research question and searching and selecting from the literature (using theoretical sampling) and defining and applying codes and categories. It also has a particular approach to appraising quality, using relevance – i.e. likely contribution to theory development – rather than methodological characteristics as a means of determining the 'quality' of individual papers [ 35 ]. The authors also stress, as a defining characteristic, critical interpretive synthesis's critical approach to the literature in terms of deconstructing research traditions or theoretical assumptions as a means of contextualising findings.

Dixon-Woods et al rejected reciprocal translational analysis (RTA) as this produced 'only a summary in terms that have already been used in the literature' [[ 34 ], p5], which was seen as less helpful when dealing with a large and diverse body of literature. Instead, Dixon-Woods et al adopted a lines-of-argument (LOA) synthesis, in which – rejecting the difference between first, second and third order constructs – they instead developed 'synthetic constructs' which were then linked with constructs arising directly from the literature.

The influence of grounded theory can be seen in particular in critical interpretive synthesis's inductive approach to formulating the review question and to developing categories and concepts, rejecting a 'stage' approach to systematic reviewing, and in selecting papers using theoretical sampling. Dixon-Woods et al also claim that critical interpretive synthesis is distinct in its 'explicit orientation towards theory generation' [[ 34 ], p9].

Ecological Triangulation

Jim Banning is the author of 'ecological triangulation' or 'ecological sentence synthesis', applying this method to the evidence for what works for youth with disabilities. He borrows from Webb et al [ 36 ] and Denzin [ 37 ] the concept of triangulation, in which phenomena are studied from a variety of vantage points. His rationale is that building an 'evidence base' of effectiveness requires the synthesis of cumulative, multi-faceted evidence in order to find out 'what intervention works for what kind of outcomes for what kind of persons under what kind of conditions' [[ 38 ], p1].

Ecological triangulation unpicks the mutually interdependent relationships between behaviour, persons and environments. The method requires that, for data extraction and synthesis, 'ecological sentences' are formulated following the pattern: 'With this intervention, these outcomes occur with these population foci and within these grades (ages), with these genders ... and these ethnicities in these settings' [[ 39 ], p1].

Framework Synthesis

Brunton et al [ 40 ] and Oliver et al [ 41 ] have applied a 'framework synthesis' approach in their reviews. Framework synthesis is based on framework analysis, which was outlined by Pope, Ziebland and Mays [ 42 ], and draws upon the work of Ritchie and Spencer [ 43 ] and Miles and Huberman [ 44 ]. Its rationale is that qualitative research produces large amounts of textual data in the form of transcripts, observational fieldnotes etc. The sheer wealth of information poses a challenge for rigorous analysis. Framework synthesis offers a highly structured approach to organising and analysing data (e.g. indexing using numerical codes, rearranging data into charts etc).

Brunton et al applied the approach to a review of children's, young people's and parents' views of walking and cycling; Oliver et al to an analysis of public involvement in health services research. Framework synthesis is distinct from the other methods outlined here in that it utilises an a priori 'framework' – informed by background material and team discussions – to extract and synthesise findings. As such, it is largely a deductive approach although, in addition to topics identified by the framework, new topics may be developed and incorporated as they emerge from the data. The synthetic product can be expressed in the form of a chart for each key dimension identified, which may be used to map the nature and range of the concept under study and find associations between themes and exceptions to these [ 40 ].

'Fledgling' approaches

There are three other approaches to synthesis which have not yet been widely used. One is an approach using content analysis [ 45 , 46 ] in which text is condensed into fewer content-related categories. Another is 'meta-interpretation' [ 47 ], featuring the following: an ideographic rather than pre-determined approach to the development of exclusion criteria; a focus on meaning in context; interpretations as raw data for synthesis (although this feature doesn't distinguish it from other synthesis methods); an iterative approach to the theoretical sampling of studies for synthesis; and a transparent audit trail demonstrating the trustworthiness of the synthesis.

In addition to the synthesis methods discussed above, Sandelowski and Barroso propose a method they call 'qualitative metasummary' [ 15 ]. It is mentioned here as a new and original approach to handling a collection of qualitative studies but is qualitatively different to the other methods described here since it is aggregative; that is, findings are accumulated and summarised rather than 'transformed'. Metasummary is a way of producing a 'map' of the contents of qualitative studies and – according to Sandelowski and Barroso – 'reflect [s] a quantitative logic' [[ 15 ], p151]. The frequency of each finding is determined and the higher the frequency of a particular finding, the greater its validity. The authors even discuss the calculation of 'effect sizes' for qualitative findings. Qualitative metasummaries can be undertaken as an end in themselves or may serve as a basis for a further synthesis.

Dimensions of difference

Having outlined the range of methods identified, we now turn to an examination of how they compare with one another. It is clear that they have come from many different contexts and have different approaches to understanding knowledge, but what do these differences mean in practice? Our framework for this analysis is shown in Additional file 1 : dimensions of difference [ 48 ]. We have examined the epistemology of each of the methods and found that, to some extent, this explains the need for different methods and their various approaches to synthesis.


The first dimension that we will consider is that of the researchers' epistemological assumptions. Spencer et al [ 49 ] outline a range of epistemological positions, which might be organised into a spectrum as follows:

Subjective idealism : there is no shared reality independent of multiple alternative human constructions

Objective idealism : there is a world of collectively shared understandings

Critical realism : knowledge of reality is mediated by our perceptions and beliefs

Scientific realism : it is possible for knowledge to approximate closely an external reality

Naïve realism : reality exists independently of human constructions and can be known directly [ 49 , 45 , 46 ].

Thus, at one end of the spectrum we have a highly constructivist view of knowledge and, at the other, an unproblematized 'direct window onto the world' view.

Nearly all of positions along this spectrum are represented in the range of methodological approaches to synthesis covered in this paper. The originators of meta-narrative synthesis, critical interpretive synthesis and meta-study all articulate what might be termed a 'subjective idealist' approach to knowledge. Paterson et al [ 28 ] state that meta-study shies away from creating 'grand theories' within the health or social sciences and assume that no single objective reality will be found. Primary studies, they argue, are themselves constructions; meta-synthesis, then, 'deals with constructions of constructions' (p7). Greenhalgh et al [ 32 ] also view knowledge as a product of its disciplinary paradigm and use this to explain conflicting findings: again, the authors neither seek, nor expect to find, one final, non-contestable answer to their research question. Critical interpretive synthesis is similar in seeking to place literature within its context, to question its assumptions and to produce a theoretical model of a phenomenon which – because highly interpretive – may not be reproducible by different research teams at alternative points in time [[ 34 ], p11].

Methods used to synthesise grounded theory studies in order to produce a higher level of grounded theory [ 24 ] appear to be informed by 'objective idealism', as does meta-ethnography. Kearney argues for the near-universal applicability of a 'ready-to-wear' theory across contexts and populations. This approach is clearly distinct from one which recognises multiple realities. The emphasis is on examining commonalities amongst, rather than discrepancies between, accounts. This emphasis is similarly apparent in most meta-ethnographies, which are conducted either according to Noblit and Hare's 'reciprocal translational analysis' technique or to their 'lines-of-argument' technique and which seek to provide a 'whole' which has a greater explanatory power. Although Noblit and Hare also propose 'refutational synthesis', in which contradictory findings might be explored, there are few examples of this having been undertaken in practice, and the aim of the method appears to be to explain and explore differences due to context, rather than multiple realities.

Despite an assumption of a reality which is perhaps less contestable than those of meta-narrative synthesis, critical interpretive synthesis and meta-study, both grounded formal theory and meta-ethnography place a great deal of emphasis on the interpretive nature of their methods. This still supposes a degree of constructivism. Although less explicit about how their methods are informed, it seems that both thematic synthesis and framework synthesis – while also involving some interpretation of data – share an even less problematized view of reality and a greater assumption that their synthetic products are reproducible and correspond to a shared reality. This is also implicit in the fact that such products are designed directly to inform policy and practice, a characteristic shared by ecological triangulation. Notably, ecological triangulation, according to Banning, can be either realist or idealist. Banning argues that the interpretation of triangulation can either be one in which multiple viewpoints converge on a point to produce confirming evidence (i.e. one definitive answer to the research question) or an idealist one, in which the complexity of multiple viewpoints is represented. Thus, although ecological triangulation views reality as complex, the approach assumes that it can be approximately knowable (at least when the realist view of ecological triangulation is adopted) and that interventions can and should be modelled according to the products of its syntheses.

While pigeonholing different methods into specific epistemological positions is a problematic process, we do suggest that the contrasting epistemologies of different researchers is one way of explaining why we have – and need – different methods for synthesis.

Variation in terms of the extent of iteration during the review process is another key dimension. All synthesis methods include some iteration but the degree varies. Meta-ethnography, grounded theory and thematic synthesis all include iteration at the synthesis stage; both framework synthesis and critical interpretive synthesis involve iterative literature searching – in the case of critical interpretive synthesis, it is not clear whether iteration occurs during the rest of the review process. Meta-narrative also involves iteration at every stage. Banning does not mention iteration in outlining ecological triangulation and neither do Lucas or Thomas and Harden for thematic narrative synthesis.

It seems that the more idealist the approach, the greater the extent of iteration. This might be because a large degree of iteration does not sit well with a more 'positivist' ideal of procedural objectivity; in particular, the notion that the robustness of the synthetic product depends in part on the reviewers stating up front in a protocol their searching strategies, inclusion/exclusion criteria etc, and being seen not to alter these at a later stage.

Quality assessment

Another dimension along which we can look at different synthesis methods is that of quality assessment. When the approaches to the assessment of the quality of studies retrieved for review are examined, there is again a wide methodological variation. It might be expected that the further towards the 'realism' end of the epistemological spectrum a method of synthesis falls, the greater the emphasis on quality assessment. In fact, this is only partially the case.

Framework synthesis, thematic narrative synthesis and thematic synthesis – methods which might be classified as sharing a 'critical realist' approach – all have highly specified approaches to quality assessment. The review in which framework synthesis was developed applied ten quality criteria: two on quality and reporting of sampling methods, four to the quality of the description of the sample in the study, two to the reliability and validity of the tools used to collect data and one on whether studies used appropriate methods for helping people to express their views. Studies which did not meet a certain number of quality criteria were excluded from contributing to findings. Similarly, in the example review for thematic synthesis, 12 criteria were applied: five related to reporting aims, context, rationale, methods and findings; four relating to reliability and validity; and three relating to the appropriateness of methods for ensuring that findings were rooted in participants' own perspectives. Studies which were deemed to have significant flaws were excluded and sensitivity analyses were used to assess the possible impact of study quality on the review's findings. Thomas and Harden's use of thematic narrative synthesis similarly applied quality criteria and developed criteria additional to those they found in the literature on quality assessment, relating to the extent to which people's views and perspectives had been privileged by researchers. It is worth noting not only that these methods apply quality criteria but that they are explicit about what they are: assessing quality is a key component in the review process for both of these methods. Likewise, Banning – the originator of ecological triangulation – sees quality assessment as important and adapts the Design and Implementation Assessment Device (DIAD) Version 0.3 (a quality assessment tool for quantitative research) for use when appraising qualitative studies [ 50 ]. Again, Banning writes of excluding studies deemed to be of poor quality.

Greenhalgh et al's meta-narrative review [ 32 ] modified a range of existing quality assessment tools to evaluate studies according to validity and robustness of methods; sample size and power; and validity of conclusions. The authors imply, but are not explicit, that this process formed the basis for the exclusion of some studies. Although not quite so clear about quality assessment methods as framework and thematic synthesis, it might be argued that meta-narrative synthesis shows a greater commitment to the concept that research can and should be assessed for quality than either meta-ethnography or grounded formal theory. The originators of meta-ethnography, Noblit and Hare [ 8 ], originally discussed quality in terms of quality of metaphor, while more recent use of this method has used amended versions of CASP (the Critical Appraisal Skills Programme tool, [ 31 ]), yet has only referred to studies being excluded on the basis of lack of relevance or because they weren't 'qualitative' studies [ 8 ]. In grounded theory, quality assessment is only discussed in terms of a 'personal note' being made on the context, quality and usefulness of each study. However, contrary to expectation, meta-narrative synthesis lies at the extreme end of the idealism/realism spectrum – as a subjective idealist approach – while meta-ethnography and grounded theory are classified as objective idealist approaches.

Finally, meta-study and critical interpretive synthesis – two more subjective idealist approaches – look to the content and utility of findings rather than methodology in order to establish quality. While earlier forms of meta-study included only studies which demonstrated 'epistemological soundness', in its most recent form [ 51 ] this method has sought to include all relevant studies, excluding only those deemed not to be 'qualitative' research. Critical interpretive synthesis also conforms to what we might expect of its approach to quality assessment: quality of research is judged as the extent to which it informs theory. The threshold of inclusion is informed by expertise and instinct rather than being articulated a priori.

In terms of quality assessment, it might be important to consider the academic context in which these various methods of synthesis developed. The reason why thematic synthesis, framework synthesis and ecological triangulation have such highly specified approaches to quality assessment may be that each of these was developed for a particular task, i.e. to conduct a multi-method review in which randomised controlled trials (RCTs) were included. The concept of quality assessment in relation to RCTs is much less contested and there is general agreement on criteria against which quality should be judged.

Problematizing the literature

Critical interpretive synthesis, the meta-narrative approach and the meta-theory element of meta-study all share some common ground in that their review and synthesis processes include examining all aspects of the context in which knowledge is produced. In conducting a review on access to healthcare by vulnerable groups, critical interpretive synthesis sought to question 'the ways in which the literature had constructed the problematics of access, the nature of the assumptions on which it drew, and what has influenced its choice of proposed solutions' [[ 34 ], p6]. Although not claiming to have been directly influenced by Greenhalgh et al's meta-narrative approach, Dixon-Woods et al do cite it as sharing similar characteristics in the sense that it critiques the literature it reviews.

Meta-study uses meta-theory to describe and deconstruct the theories that shape a body of research and to assess its quality. One aspect of this process is to examine the historical evolution of each theory and to put it in its socio-political context, which invites direct comparison with meta-narrative synthesis. Greenhalgh et al put a similar emphasis on placing research findings within their social and historical context, often as a means of seeking to explain heterogeneity of findings. In addition, meta-narrative shares with critical interpretive synthesis an iterative approach to searching and selecting from the literature.

Framework synthesis, thematic synthesis, textual narrative synthesis, meta-ethnography and grounded theory do not share the same approach to problematizing the literature as critical interpretive synthesis, meta-study and meta-narrative. In part, this may be explained by the extent to which studies included in the synthesis represented a broad range of approaches or methodologies. This, in turn, may reflect the broadness of the review question and the extent to which the concepts contained within the question are pre-defined within the literature. In the case of both the critical interpretive synthesis and meta-narrative reviews, terminology was elastic and/or the question formed iteratively. Similarly, both reviews placed great emphasis on employing multi-disciplinary research teams. Approaches which do not critique the literature in the same way tend to have more narrowly-focused questions. They also tend to include a more limited range of studies: grounded theory synthesis includes grounded theory studies, meta-ethnography (in its original form, as applied by Noblit and Hare) ethnographies. The thematic synthesis incorporated studies based on only a narrow range of qualitative methodologies (interviews and focus groups) which were informed by a similarly narrow range of epistemological assumptions. It may be that the authors of such syntheses saw no need for including such a critique in their review process.

Similarities and differences between primary studies

Most methods of synthesis are applicable to heterogeneous data (i.e. studies which use contrasting methodologies) apart from early meta-ethnography and synthesis informed by grounded theory. All methods of synthesis state that, at some level, studies are compared; many are not so explicit about how this is done, though some are. Meta-ethnography is one of the most explicit: it describes the act of 'translation' where terms and concepts which have resonance with one another are subsumed into 'higher order constructs'. Grounded theory, as represented by Eaves [ 17 ], is undertaken according to a long list of steps and sub-steps, includes the production of generalizations about concepts/categories, which comes from classifying these categories. In meta-narrative synthesis, comparable studies are grouped together at the appraisal phase of review.

Perhaps more interesting are the ways in which differences between studies are explored. Those methods with a greater emphasis on critical appraisal may tend (although this is not always made explicit) to use differences in method to explain differences in finding. Meta-ethnography proposes 'refutational synthesis' to explain differences, although there are few examples of this in the literature. Some synthesis methods – for example, thematic synthesis – look at other characteristics of the studies under review, whether types of participants and their context vary, and whether this can explain differences in perspective.

All of these methods, then, look within the studies to explain differences. Other methods look beyond the study itself to the context in which it was produced. Critical interpretive synthesis and meta-study look at differences in theory or in socio-economic context. Critical interpretive synthesis, like meta-narrative, also explores epistemological orientation. Meta-narrative is unique in concerning itself with disciplinary paradigm (i.e. the story of the discipline as it progresses). It is also distinctive in that it treats conflicting findings as 'higher order data' [[ 32 ], p420], so that the main emphasis of the synthesis appears to be on examining and explaining contradictions in the literature.

Going 'beyond' the primary studies

Synthesis is sometimes defined as a process resulting in a product, a 'whole', which is more than the sum of its parts. However, the methods reviewed here vary in the extent to which they attempt to 'go beyond' the primary studies and transform the data. Some methods – textual narrative synthesis, ecological triangulation and framework synthesis – focus on describing and summarising their primary data (often in a highly structured and detailed way) and translating the studies into one another. Others – meta-ethnography, grounded theory, thematic synthesis, meta-study, meta-narrative and critical interpretive synthesis – seek to push beyond the original data to a fresh interpretation of the phenomena under review. A key feature of thematic synthesis is its clear differentiation between these two stages.

Different methods have different mechanisms for going beyond the primary studies, although some are more explicit than others about what these entail. Meta-ethnography proposes a 'Line of Argument' (LOA) synthesis in which an interpretation is constructed to both link and explain a set of parts. Critical interpretive synthesis based its synthesis methods on those of meta-ethnography, developing an LOA using what the authors term 'synthetic constructs' (akin to 'third order constructs' in meta-ethnography) to create a 'synthesising argument'. Dixon-Woods et al claim that this is an advance on Britten et al's methods, in that they reject the difference between first, second and third order constructs.

Meta-narrative, as outlined above, focuses on conflicting findings and constructs theories to explain these in terms of differing paradigms. Meta study derives questions from each of its three components to which it subjects the dataset and inductively generates a number of theoretical claims in relation to it. According to Eaves' model of grounded theory [ 17 ], mini-theories are integrated to produce an explanatory framework. In ecological triangulation, the 'axial' codes – or second level codes evolved from the initial deductive open codes – are used to produce Banning's 'ecological sentence' [ 39 ].

The synthetic product

In overviewing and comparing different qualitative synthesis methods, the ultimate question relates to the utility of the synthetic product: what is it for? It is clear that some methods of synthesis – namely, thematic synthesis, textual narrative synthesis, framework synthesis and ecological triangulation – view themselves as producing an output that is directly applicable to policy makers and designers of interventions. The example of framework synthesis examined here (on children's, young people's and parents' views of walking and cycling) involved policy makers and practitioners in directing the focus of the synthesis and used the themes derived from the synthesis to infer what kind of interventions might be most effective in encouraging walking and cycling. Likewise, the products of the thematic synthesis took the form of practical recommendations for interventions (e.g. 'do not promote fruit and vegetables in the same way in the same intervention'). The extent to which policy makers and practitioners are involved in informing either synthesis or recommendation is less clear from the documents published on ecological triangulation, but the aim certainly is to directly inform practice.

The outputs of synthesis methods which have a more constructivist orientation – meta-study, meta-narrative, meta-ethnography, grounded theory, critical interpretive synthesis – tend to look rather different. They are generally more complex and conceptual, sometimes operating on the symbolic or metaphorical level, and requiring a further process of interpretation by policy makers and practitioners in order for them to inform practice. This is not to say, however, that they are not useful for practice, more that they are doing different work. However, it may be that, in the absence of further interpretation, they are more useful for informing other researchers and theoreticians.

Looking across dimensions

After examining the dimensions of difference of our included methods, what picture ultimately emerges? It seems clear that, while similar in some respects, there are genuine differences in approach to the synthesis of what is essentially textual data. To some extent, these differences can be explained by the epistemological assumptions that underpin each method. Our methods split into two broad camps: the idealist and the realist (see Table ​ Table1 1 for a summary). Idealist approaches generally tend to have a more iterative approach to searching (and the review process), have less a priori quality assessment procedures and are more inclined to problematize the literature. Realist approaches are characterised by a more linear approach to searching and review, have clearer and more well-developed approaches to quality assessment, and do not problematize the literature.

Summary table

N.B.: In terms of the above dimensions, it is generally a question of degree rather than of absolute distinctions.

Mapping the relationships between methods

What is interesting is the relationship between these methods of synthesis, the conceptual links between them, and the extent to which the originators cite – or, in some cases, don't cite – one another. Some methods directly build on others – framework synthesis builds on framework analysis, for example, while grounded theory and constant comparative analysis build on grounded theory. Others further develop existing methods – meta-study, critical interpretive synthesis and meta-narrative all adapt aspects of meta-ethnography, while also importing concepts from other theorists (critical interpretive synthesis also adapts grounded theory techniques).

Some methods share a clear conceptual link, without directly citing one another: for example, the analytical themes developed during thematic synthesis are comparable to the third order interpretations of meta-ethnography. The meta-theory aspect of meta-study is echoed in both meta-narrative synthesis and critical interpretive synthesis (see 'Problematizing the literature, above); however, the originators of critical interpretive synthesis only refer to the originators of meta-study in relation to their use of sampling techniques.

While methods for qualitative synthesis have many similarities, there are clear differences in approach between them, many of which can be explained by taking account of a given method's epistemology.

However, within the two broad idealist/realist categories, any differences between methods in terms of outputs appear to be small.

Since many systematic reviews are designed to inform policy and practice, it is important to select a method – or type of method – that will produce the kind of conclusions needed. However, it is acknowledged that this is not always simple or even possible to achieve in practice.

The approaches that result in more easily translatable messages for policy-makers and practitioners may appear to be more attractive than the others; but we do need to take account lessons from the more idealist end of the spectrum, that some perspectives are not universal.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

Both authors made substantial contributions, with EBP taking a lead on writing and JT on the analytical framework. Both authors read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:


Supplementary Material

Dimensions of difference . Ranging from subjective idealism through objective idealism and critical realism to scientific realism to naïve realism


The authors would like to acknowledge the helpful contributions of the following in commenting on earlier drafts of this paper: David Gough, Sandy Oliver, Angela Harden, Mary Dixon-Woods, Trisha Greenhalgh and Barbara L. Paterson. We would also like to thank the peer reviewers: Helen J Smith, Rosaline Barbour and Mark Rodgers for their helpful reviews. The methodological development was supported by the Department of Health (England) and the ESRC through the Methods for Research Synthesis Node of the National Centre for Research Methods (NCRM). An earlier draft of this paper currently appears as a working paper on the National Centre for Research Methods' website http://www.ncrm.ac.uk/ .

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  • What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

  • Flexibility

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

  • Natural settings

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

  • Meaningful insights

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

  • Generation of new ideas

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

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

  • Unreliability

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

  • Subjectivity

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

  • Limited generalizability

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

  • Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Critical Appraisal for Health Students

  • Critical Appraisal of a qualitative paper
  • Critical Appraisal: Help
  • Critical Appraisal of a quantitative paper
  • Useful resources

Appraisal of a Qualitative paper : Top tips


  • Introduction

Critical appraisal of a qualitative paper

This guide aimed at health students, provides basic level support for appraising qualitative research papers. It's designed for students who have already attended lectures on critical appraisal. One framework  for appraising qualitative research (based on 4 aspects of trustworthiness) is  provided and there is an opportunity to practise the technique on a sample article.

Support Materials

  • Framework for reading qualitative papers
  • Critical appraisal of a qualitative paper PowerPoint

To practise following this framework for critically appraising a qualitative article, please look at the following article:

Schellekens, M.P.J.  et al  (2016) 'A qualitative study on mindfulness-based stress reduction for breast cancer patients: how women experience participating with fellow patients',  Support Care Cancer , 24(4), pp. 1813-1820.

Critical appraisal of a qualitative paper: practical example.

  • Credibility
  • Transferability
  • Dependability
  • Confirmability

How to use this practical example 

Using the framework, you can have a go at appraising a qualitative paper - we are going to look at the following article: 

Step 1.  take a quick look at the article, step 2.  click on the credibility tab above - there are questions to help you appraise the trustworthiness of the article, read the questions and look for the answers in the article. , step 3.   click on each question and our answers will appear., step 4.    repeat with the other aspects of trustworthiness: transferability, dependability and confirmability ., questioning the credibility:, who is the researcher what has been their experience how well do they know this research area, was the best method chosen what method did they use was there any justification was the method scrutinised by peers is it a recognisable method was there triangulation ( more than one method used), how was the data collected was data collected from the participants at more than one time point how long were the interviews were questions asked to the participants in different ways, is the research reporting what the participants actually said were the participants shown transcripts / notes of the interviews / observations to ‘check’ for accuracy are direct quotes used from a variety of participants, how would you rate the overall credibility, questioning the transferability, was a meaningful sample obtained how many people were included is the sample diverse how were they selected, are the demographics given, does the research cover diverse viewpoints do the results include negative cases was data saturation reached, what is the overall transferability can the research be transferred to other settings , questioning the dependability :, how transparent is the audit trail can you follow the research steps are the decisions made transparent is the whole process explained in enough detail did the researcher keep a field diary is there a clear limitations section, was there peer scrutiny of the researchwas the research plan shown to peers / colleagues for approval and/or feedback did two or more researchers independently judge data, how would you rate the overall dependability would the results be similar if the study was repeated how consistent are the data and findings, questioning the confirmability :, is the process of analysis described in detail is a method of analysis named or described is there sufficient detail, have any checks taken place was there cross-checking of themes was there a team of researchers, has the researcher reflected on possible bias is there a reflexive diary, giving a detailed log of thoughts, ideas and assumptions, how do you rate the overall confirmability has the researcher attempted to limit bias, questioning the overall trustworthiness :, overall how trustworthy is the research, further information.

See Useful resources  for links, books and LibGuides to help with Critical appraisal.

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The Oxford Handbook of Qualitative Research (2nd edn)

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The Oxford Handbook of Qualitative Research (2nd edn)

9 Critical Approaches to Qualitative Research

Kum-Kum Bhavnani, Department of Sociology, University of California at Santa Barbara

Peter Chua, Department of Sociology, San José State University

Dana Collins, Department of Sociology, California State University, Fullerton

  • Published: 02 September 2020
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This chapter reflects on critical strategies in qualitative research. It examines the meanings and debates associated with the term critical , in particular, contrasting liberal and dialectical notions and practices in relation to social analysis and qualitative research. The chapter also explores how critical social research may be synonymous with critical ethnography in relation to issues of power, positionality, representation, and the production of situated knowledges. It uses Bhavnani’s framework to draw on Dana Collins’s research as a specific case to suggest how the notion of the critical relates to ethnographic research practices: ensuring feminist and queer accountability, resisting reinscription, and integrating lived experience.

Qualitative research is now ubiquitous and fairly well respected throughout the human sciences. That Oxford University Press is producing this much-needed volume is further testament to that notion and one that we applaud. However, although there are different approaches to conducting qualitative research, what is often not addressed are the philosophical notions underlying such research. And that is where the critical enters. Indeed, critical, used as an adjective and applied, within the academy, to methods of research, is also a familiar phrase. The question is, therefore, what does critical mean, and how might it be translated such that present and future researchers could draw on some of its fundamentals as they plan their research studies in relation to progressive political activism?

The popularity of critical research is not predictable. Although the 1960s and early 1970s did offer a number of publications that engaged with critical research traditions (e.g., Gouldner, 1970 ) and the 1990s also led to a resurgence of interest in this area (e.g., L. Harvey, 1990 ; Thomas, 1993 ), it has now been 2 decades since explicit discussions of critical research have been widely discussed within the social sciences (see Madison, 2012 ; L. T. Smith, 1999 , as exceptions).

In this chapter, we first outline meanings associated with critical. We then suggest that the narratives of critical ethnography are best suited for an overview chapter such as this. We consider critical ethnography virtually synonymous with critical social research as we discuss it in this chapter. In the final section of our chapter, we discuss Dana Collins’s specific research studies to suggest how her approach embraces the notion of critical (Collins, 2005 , 2007 , 2009 ).

The Critical in Critical Approaches

Critical is used in many ways. In everyday use, the term can refer, among other definitions, to an assessment that points out flaws and mistakes (“a critical approach to the design”) or to being close to a crisis (“a critical illness”). On the positive side, it can refer to a close reading (“a critical assessment of Rosa Luxembourg’s writings”) or as being essential (“critical for effective educational strategies”). A final definition is that the word can be used either to denote considerable praise (“the playwright’s work was critically acclaimed”) or to indicate a particular turning point (“this is a critical time to vote”). It is this last definition that is closest to our approach as we reflect on the use of the term critical in the context of qualitative research. That is, drawing from the writings of Marx, the Frankfurt school, and others (see Delanty, 2005 ; Marx, 1845 / 1976 ; Strydom, 2011 ), we suggest that critical approaches to qualitative methods do not signify just a particular way of thinking about the methods we use in our research studies; critical approaches also signify a turning point in how we think about the conduct of research across the human sciences, including its dialectical relations to the progressive and systematic transformation of social relations and social institutions.

The most straightforward notion of critical in this context is that it refers to (at the least) or insists (at its strongest) that research—and all ways by which knowledge is created—is firmly grounded within an understanding of social structures (social inequalities), power relationships (power inequalities), and the agency of human beings (an engagement with the fact that human beings actively think about their worlds). Critical approaches are most frequently associated with Marxist, feminist, antiracist, indigenous, and Third World perspectives. At its most succinct, therefore, we argue that critical in this context refers to issues of epistemology, power, micropolitics, and resistance.

What does this mean, both theoretically and for how we conduct our research? Most would agree that whereas qualitative research does not, by definition, insist on a nonpositivist way of examining the social world, for critical approaches to be truly critical, an antipositivist approach is the sine qua non of critical research. Furthermore, it is evident as we survey critical empirical research that issues of reflexive and subjective techniques in data collection and the researcher’s relationship with research subjects also frame both the practices and the theories associated with research.

The following section begins by drawing attention to developments and debates involving the more restricted use of the term critical as related to Marxism and then explores the ramifications for varying attempts to conduct critical qualitative research.

The Critical Debates

Karl Marx, Friedrich Engels, and their contemporaries (see Engels, 1877/1969 ; D. Harvey, 1996 ; Lenin, 1915/1977 ; Mao, 1990 ; Ollman, 2003 ) developed dialectical materialist notions of critique and critical that were substantively different from prior notions. They incorporated these dialectical materialist notions to develop Marxist theories and politics.

Dialectical materialism refers to an outlook on reality that emphasizes the importance of process and change that are inherent to things (such as objects, phenomena, and situations), as well as the importance of human practices in making change. Significantly, human struggle over existing conditions and contradictions creates not only new conditions, but also new contradictions. This outlook serves as an analytical tool over idealist and old-fashioned materialist worldviews and as a source of strength for exploited peoples in their struggle against ruling elites and classes. It emphasizes that correct ideas, knowledge, and theoretical abstractions are established initially, and perhaps inevitably, through practice.

Dialectical materialism may be used to examine two aspects of the research process and the production of academic knowledge. The first aspect involves the writing process as it is carried out among multiple authors. At the drafting phase, the authors craft their distinct ideas into textual form. Contradictions in ideas are bound to exist in the draft. In doing revisions, some contradictions may become intensified and remain unresolved, yet, most frequently (and hopefully!), many are addressed in the form of clearer, more solid, and coherent arguments, thus resolving the earlier contradictions in the text. Yet, new struggles and contradictions emerge. The synthesis of ideas and argument in the final manuscript may again, however, engage in new struggles with the prevailing arguments being discussed.

The second aspect involves the relationship and interaction between the researcher and the interviewee. As their relationship begins, contradictions and differences usually exist between them, for instance, in terms of their prior experiences and knowledge, their material interests in the research project, and their communication skills in being persuasive and forging consent. The struggle of these initial contradictions could result in new conditions and contradictions. For example, this could lead to

the establishment of quality rapport between them, allowing the interview to be completed while the researcher maintains control over the situation;

the abrupt end of the interview because of the interviewee refusing and asserting her or his right to comply with the interview process; or

an explicit set of negotiations that address the unevenness in power relations between them, along with an invitation for both to be part of the research team and to collaborate in the collection and analysis of data and in the forging of new theories and knowledges.

In the first possibility, the prevailing power relations in interviews remain, but shift beneath the surface of the relationship, under the guise of “rapport.” In the second possibility, power relations in the interview process and initial contradictions are heightened, resulting in new conditions and contradictions that the researcher and research participant must address, jointly and singly. In the third possibility, the research subject is transformed into a researcher as well, and the relationship between the two is transformed into a more active colearning and coteaching relationship. Still, new conflicts and contradictions may emerge as the research process continues to unfold. 1 In short, dialectical materialism stresses the analysis of change in the (a) essence, (b) practice, and (c) struggle. Such analyses are at the root of how change may be imagined within the practices of social research.

Dialectical materialism, which forms the basis of the concept of critical, emphasizes the need to engage with power, inequality, and social relations in the social, political, economic, cultural, and ideological arenas. Based on this status, it is argued that an analysis of societies and ways of life demands a more comprehensive approach, one that views society and social institutions not merely as a singular unit of analysis, but rather as being replete with history. Dialectical materialism directs its criticism against prevailing views or hegemonies and, within the context of academic endeavors, engages in debates against positivism and neo-Kantian forms of social inquiry. It is this basis of critical that defines it in the context of research as a deep questioning of science, objectivity, and rationality. Thus, the meaning of the term critical, based on the idea of critique , emerges from the practice and application of dialectical materialism.

Historical materialism emerges from and is based on dialectical materialism. That is, any application of the dialectic to material realities is historical materialism. For example, any study of human society, its history, its development, and its process of change demands a dialectical approach rooted in historical materialism. This involves delving deeper into past and present social phenomena to thereby determine how people change the essence of social phenomena and simultaneously transform their contradictions.

Dialectical materialism regards positivism as a crude and naive endeavor to seek knowledge and explain phenomena and as one that assumes it is the task of social researchers to determine the laws of social relationships by relying solely on observations (i.e., by assuming there is a primacy of external conditions and actions). In addition, positivism separates the subject (the seemingly unbiased, detached observer) and object (the phenomenon/a under consideration) of study. Dialectical materialism overcomes the shortcomings of positivism by offering a holistic understanding of (a) the essence of phenomena; (b) the processes of internal changes, the handling of contradictions, and the development of knowledge; (c) the unity of the subject and object in the making of correct ideas; and (d) the role of practice and politics in knowledge creation.

Dialectical materialism directs its criticism against dominant standpoints. These standpoints can offer a simplistic form of idealism and philosophical materialism. Within the context of academic endeavors, the methods of dialectical materialism engage in debates against positivism and neo-Kantian forms of social inquiry. This approach challenges assertions that science, objectivity, and rationality are the sine qua non of research and that skepticism and liberalism are the only appropriate analytical positionings by which a research project can be defined as critical.

For instance, Auguste Comte and Émile Durkheim, in developing sociological positivism, argued for a new science to study society, one that adopted the methods of the natural sciences, such as skeptical empiricism and the practices of induction. In adopting these methods, approaches relying on early positivism sought to craft knowledge based on seemingly affirmative verification rather than that based on judgmental evaluation and transformative distinctions.

Positivism and dialectical materialism were both developed in response to Kantian and idealist philosophy. In the context of the European Enlightenment, in the late 1700s, Immanuel Kant inaugurated the philosophy of critique. Positivism challenged Kant’s philosophy of critique as the basis for the theory of knowledge.

Kant developed his notion of critique to highlight the workings of human reason and judgment, to illuminate its limitations, and to consolidate its application in order to secure a stable foundation for morality, religion, and metaphysical concerns. Politically, Kantian philosophy provided justification for both a traditionalism derived from earlier periods and a liberalism developed during the ascendance of the Enlightenment.

Kant sought to settle philosophical disputes between a narrow notion of empiricism (that relies on pure observation, perception, and experience as the basis for knowledge) and a narrow notion of rationalism (that relies on pure reason and concepts as the basis for knowledge). He argued that the essence (termed thing-in-itself ) is unknowable, countering David Hume’s skeptical empiricism, and he was convinced that there is no knowledge outside innate conceptual categories. For Kant, “concepts without perceptions are empty; perceptions without concepts are blind” (1781/1965, p. A51/B75).

The method of dialectical materialism challenges Kant’s idealism for (what is claimed to be) its faulty assertion that correct ideas and knowing about the thing-in-itself can only emerge from innate conceptual categories, ones that are universal and transcendental. In Kantian philosophy, there is no reality (out there) to be known. Rather, it is the experience of reality itself that provides for human reason and consciousness.

Dialectical materialism overcomes Kant’s idealism with its recognition of the existence of concrete phenomena, outside and independent of human reason. Dialectical materialism stresses that social reality and concrete phenomena reflect on and determine the content of human consciousness (and also, we would argue, vice versa). Dialectical materialism also emphasizes the role of practice and politics in knowledge development, instead of merely centering the primacy of ideas and the meanings of objects.

In sum, the core debate against positivism centers on the practices of science. Dialectical materialism regards positivist approaches as crude and naive endeavors that seek to determine unchangeable laws of nature, rely solely on observations and “sense experience” of phenomena as the basis for knowledge, highlight the primacy of external conditions and actions to explain phenomena, and separate the subject from the object of study. That is, dialectical materialism views positivism as a form of mechanical, as distinct from historical, materialism.

This abridged account of dialectical materialism and the critiques it offers of Kantian idealism and sociological positivism can allow for the formation of a preliminary set of criteria for what may constitute the critical. We argue that qualitative research may be critical if it makes clear conceptually and analytically:

the essence and root cause of any social phenomena (e.g., youth and politics);

the relationship between the essence of the social phenomena under consideration to the general social totality (such as how youth and their views of politics are related to wider systems within society, such as education, age, exploitation);

the contradictions within this social phenomenon (such as how young people are expressing their discontent), and, therefore,

How to conduct more reflexive practices that interrelate data generation, data analysis, and political engagement that challenge existing relations of power.

Contemporary debates between neo-Kantian idealists and dialectical materialists have often been friendly regarding the direction for carving out what is meant by a critical project in qualitative social research. These debates bring to the fore issues of politics, ethics, research design, and the collection and analysis of data. They have also prompted a variety of ways in which critical may be used in relation to qualitative research. For the purposes of this chapter, we suggest four substantial ways in which critical is used in the context of qualitative research: (a) critical as a form of liberalism, (b) critical as a counterdisciplinary perspective, (c) critical as an expansion of politics, and (d) critical as a professionalized research endeavor and perspective.

Critical as a form of Kantian liberalism is one of the more conventional uses of the term in qualitative research. This use of critical is generally contrasted against the dogmatism of positivist approaches within social scientific research. Yet, to use critical in this way means that we embrace a liberalism that ends up promoting idealism in outlook and pluralism in practice. That is, Kantian liberalism presents itself as a critical and novel analysis by combining eclectic ideas and theories while not making known its political stand and its material interests. As a result, it supports prevailing modes of thinking that emphasize abstraction over concrete reality, and it succumbs to relativistist and pragmatist practices in research, such as “anything goes,” in collecting data. In terms of methods, this use of critical promotes looseness and leniency in ethics and data collection and analysis, often without a structured accountability to the many constituencies that underlie all social research. Furthermore, the use of, for example, phrases such as critical spaces , when applied to social research, may be better understood as a celebration of method above theory and metatheory and an engagement with some (of the often rather) excessive approaches to reflexivity and metareflexivity. In sum, this understanding of critical lacks appropriate structures of ethics and accountability and often tends to reject dialectic materialism.

The second use of critical in regard to qualitative research proposes a more analytical disagreement with conventional scholarly disciplines and, in so doing, seeks to take up counterdisciplinary positions (Burawoy, 1998 , 2003 ; Carroll, 2004 ; D. Smith, 2007 ). There are two main strands in this use of critical. One strand argues that critical is a means of exposing the weaknesses of conventional academic disciplines such as anthropology, political science, psychology, and sociology. At the same time, this strand maintains the viability of these core social science disciplines. For instance, academic feminists have continually highlighted the masculinist and heterosexist bias in what is considered top-tier scholarship and the need for these disciplines to be more inclusive in terms of perspectives and methodological techniques (e.g., Fonow & Cook, 1991 ; Harding, 1991 ; Ray, 2006 ). Yet such an approach may not inevitably focus on the fundamental problems, such as a neglect of the study of power inequalities (e.g., Boserup, 1970 ; and see examples in Reinharz & Davidman, 1992 ). This second strand seeks to carve out interdisciplinary and multidisciplinary fields such as women studies, cultural studies, and area studies to overcome the paradigmatic and fundamental crises within core disciplines (Bhavnani, Foran, & Kurian, 2003 ; Marchand, 1995 ; Mohanty, 2003 ). Many of these interdisciplinary and multidisciplinary fields have often been more historical and qualitative in their approaches, seeking to go beyond positivist limitations and present a more nuanced and thorough analysis. However, even these multi-, inter-, and antidisciplinary fields have an uneven impact on dominant and conventional knowledge.

Moreover, neither strand has been able to overcome the increasing corporatization and neoliberalization of academic institutions. This issue addresses the increasing restructuring of public education into a private domain, one that relies on privatized practices and funding of both teaching and research. The neoliberalization of the academy is found in the ties of academic research to corporate grants, individualized career advancement, excessive publishing demands and citation indices, and the use of outsourcing for transcription, interviewing, online education, and private research spaces that are “rented” by public institutions, to name a few. These neoliberal conditions of research usually push out those critical researchers who attempt to avoid such exploitative avenues for research, writing, and collaboration. This use of critical, however, does expose that critical research is taking shape within contemporary processes of neoliberalism and the increasing privatization of the academy (Giroux, 2009 ; Greenwood, 2012 ; Pavlidis, 2012 ).

The third and less familiar approach is to view critical as invigorating politics through the practices of feminist, antiracist, and participatory action research. This approach, for example, highlights the importance of analyzing power in research, as in terms of the conduct of inquiry, in political usefulness, and in affecting relations of power and material relations. Yet this view of critical is dogmatic because this approach demands that every research study meet all criteria of criticality comprehensively and perfectly.

A final use of critical emerges from the many scholarly and professionalized approaches that engage with the politics of academic knowledge construction while making visible the limits of positivism. Critical is used here as a means to focus primarily on revitalizing scholarship and research endeavors. However, we argue that even this use of critical ossifies the separation of the making of specialized knowledge from an active engagement to transform social life. Such a separation is antithetical to dialectical materialism. Often, this fourth form of the term critical is based on the logics of the Frankfurt school of critical theory (such as that of Adorno, 1973 ; Habermas, 1985 ; and Marcuse, 1968 ) and other Western neo-Marxisms (from Lukacs, 1971 ; and Gramsci, 1971 ; to Negri, 1999 ). Critical ethnographers and other critical social researchers, drawing from this tradition, often develop public intellectual persona by writing and talking about politics through scholarly and popular forms of publishing and speaking presentations and are even seen to take part in political mobilizations. Yet they can also shy away from infusing their research with a deep engagement in political processes outside the academy.

Later in this chapter, we discuss how to avoid some of the pitfalls of these four types of critical, but suffice it to say, in short, that it is the politics and the explicit situatedness of research projects that can allow research to remain critical.

Is Critical Ethnography the Same as Critical Research?

George Marcus ( 1998 ) argued that the ethnographer is a midwife who, through words, gives birth to what is happening in the lives of the oppressed. Beverley Skeggs ( 1994 ) proposed that ethnography is, in itself, “a theory of the research process,” and Asad ( 1973 ) offered the now-classic critique of anthropology as the colonial encounter. However, although many approaches to and definitions of ethnography abound, it is the case that they all agree on one aspect: namely, that ethnographies offer an “insider’s” perspective on the social phenomena under consideration. It is often suggested that the best ethnographies, whether defined as critical or not, offer detailed descriptions of how people see, and inhabit, their social worlds and cultures (e.g., Behar, 1993 ; Ho, 2009 ; Kondo, 1990 ; Zinn, 1979 ).

It is evident from our argument so far that we do not think of ethnographic approaches to knowledge construction as being, in and of themselves, critical. This is because an ethnographic study, although not in opposition to critical ethnography or to critical research in general, has practices rooted in social anthropology. Therefore, its assumptions are often in line with anthropological assumptions (see L. Harvey, 1990 , for a recounting of some of these assumptions). Concepts such as insider versus outsider, going native, gaining access , and even conceptualizations of a homogenized and/or exoticized “field” that is out there ready to be examined by research remain significant lenses of methodological conceptualization in much ethnographic research.

Despite, or perhaps because of, the move to reflexivity in ethnographic research, there remain enduring assumptions about best practices. As a result, a certain fetishization of research methods transpires, one that is often epitomized as reflexivity. In this instance, ethnographic and qualitative research become an ideal set of practices for extracting information. In sum, “best research practices,” as ways to extract information, reproduce core power dynamics of racism, gender, class, imperialism, and heteronormativity, which, in turn, reproduce the oppressive dynamics of noncritical qualitative research.

Furthermore, when presenting research merely as reflexive research, it is the case that the researcher can lose sight of the broader social structural and historical materialist context. In addition, a static notion of reflexivity can lead to the researcher not looking outward to assess the wider interconnections among the micropolitics of the research. That is, reflexivity is a dialectic among the researcher, the research process, and the analysis (Jordan & Yeomans, 1995 ), but it is often presented simply as a series of apparently unchangeable/essential facets of the researcher. Our final point is that for theory to be critical in the development of research paradigms, it must explicitly engage with lived experiences and cultures because, without that engagement, it remains formalism (see, e.g., the work of Guenther, 2009 ; and Kang, 2010 , as examples of critical qualitative research). We are very much in tune with Hesse-Biber and Leavy ( 2006 ), who suggested that (grounded) theory building is a “dynamic dance routine” in which “there is no one right dance, no set routine to follow. One must be open to discovery” (p. 76).

An example of the limitation of conventionally reflexive research is in the area of lesbian and gay research methods that focus on the experiences of gay men and lesbians conducting qualitative research. It also offers a commentary on the role that nonnormative sexuality plays in social research. By looking inward (see the earlier comment on reflexivity), these methodological frameworks focus on the researcher’s and participants’ lesbian or gay identifications. In so doing, this can fabricate a shared social structural positionality with research participants who have been labeled gay or lesbian. Such an approach to reflexivity overlooks the fabricated nature of positionalities and ignores the sometimes more significant divisions between researchers and participants that are expressed along the lines of race, class, gender, and nationality. Reflexivity is used only as a way to forge a connection for the exchange of information. A grave mistake is made in this rush to force similarity along the lines of how people practice nonnormative sexualities (Lewin & Leap, 1996 ; for a more successful engagement with queer intersectionality in research, see Browne & Nash, 2010 ).

The point to be made is that critical researchers should not merely ask, How does this knowledge engage with social structure? Critical researchers, when contemplating the question What is this? as they set up and analyze their research, could also ask, What could this be? (Carspecken, 1996 ; Degiuli, 2007 ; Denzin, 2001 ; Noblit, Flores, & Murillo, 2004 , all cited in Degiuli, 2007 ). Perhaps, borrowing from Karen O’Reilly’s ( 2009 ) thoughts on critical ethnography, one may think of critical research as “an approach that is overtly political and critical, exposing inequalities in an effort to effect change” (p. 51). That is, for qualitative research to be critical, it must be grounded in the material relationships of history, as may be seen in the work of Carruyo ( 2011 ), Chua ( 2001 , 2006 , 2007 , 2012 ), Collins ( 2005 , 2007 , 2009 ), Lodhia ( 2010 ), and Talcott ( 2010 ).

Quantz ( 1992 ), in his discussion of critical ethnography, suggests that five aspects are central to the discussion of critical research/ethnography: knowledge, values, society, history, and culture. So far in this chapter, we have discussed knowledge and its production, values/reflexivity and qualitative research/ethnography, society and unequal social relationships, and history as a method of historical and dialectical materialism to better understand social and institutional structures. What we have not discussed, however, is the notion of culture, or, indeed, the predicament of culture (Clifford, 1998 ): “Culture is an ongoing political struggle around the meaning given to actions of people located within unbounded asymmetrical power relations” (Quantz, 1992 , p. 483).

Quantz ( 1992 ) elaborated by stating that culture develops as people struggle together to name their experiences (see Comaroff & Comaroff, 2012 , for a sophisticated and elegant discussion of this thinking). For example, one key task of critical research is to tease out how disempowerment is achieved, undermined, or resisted. That is, the job of the researcher is to see how the disempowerment—economic, political, cultural—of subordinated groups manifests itself within culture and, indeed, whether the subordinated groups even recognize their disempowerment. For example, the statement “the hand that rocks the cradle rules the world” is one example of how the material disempowerment of many groups of women is presented, in fact, as a strength of women, and yet it takes the gaze away from seeing the subordination of women by ostensibly emphasizing women’s hidden social power.

It is critical qualitative research that must simultaneously analyze how our research can identify processes and expressions of disempowerment and can then lead to a restructuring of these relationships of disempowerment. At times, critical social researchers engage in long-term projects that involve policy advocacy and community solidarity to link community-driven research with social empowerment and community change (see Bonacich, 1998 ; Bonacich & Wilson, 2008 ; Hondagneu-Sotelo, 2007 ; Stoecker, 2012 ).

The key point is that critical qualitative research parts company with positivistic approaches because it is argued that positivism is only able to offer a superficial set of findings. Critical qualitative research hones research concepts, practices, and analyses into finer points of reference not only so that societal relationships may be understood, but also so that social power inequalities can be undermined. In short, critical social research has a Foucauldian notion of power at its very core and may thus be thought of as offering insights into people’s lived experiences (Williams, 1976 ) as they negotiate asymmetrical societal power relations (see e.g., Novelli, 2006 ).

The Practices of Critical Qualitative Research

Within our current era of enduring global inequalities, what could constitute a truly critical approach to qualitative research? More than 20 years ago, in “Tracing the Contours” (Bhavnani, 1993 ), it was argued that if all knowledge is historically contingent and, therefore, that the processes of knowledge production are situated, then this must apply to all research practices as well. 2 This argument was based on Haraway’s ( 1988 ) idea that the particularities of knowledge production do not lie in the characteristics of individuals. Rather, Haraway noted, knowledge production is “about communities, not about isolated individuals” (p. 590). Building on this, Haraway discussed the significance of partiality and its relationship to objectivity. She suggested that it is the researcher’s knowledge of his or her own “limited location” that creates objectivity. In other words, knowing the limitations of one’s structural position as a researcher contributes to objective research because there is no objectivity that is omniscient, one from which all can be revealed (Haraway discusses this as the “god trick,” which is like “seeing everything from nowhere,” p. 582).

It is from Haraway’s ( 1988 ) insights that we develop our argument that situated knowledges are not synonymous with the static reflexivity we describe earlier. This is because, in this latter scenario, the researcher implies that all research knowledge is based on and derives from an individual’s personal historical and biographical perspectives. That is, researchers note their racial/ethnic identity, sex/gender, sexuality, age, class, and ability (i.e., biographical aspects of themselves), which are presented as essential and unchanging factors and determine the knowledge created by the research. This has also been called absolute relativism (Bhavnani, 1993 ) or extreme relativism (Alcoff & Potter, 1993 ).

We suggest that the three elements central to research being critical are partiality, positionality, and accountability. Partiality leads to critical research interrogating prevailing representations as the research is conducted, and this builds on difference. Positionality is not about being reflexive, but about understanding the sociohistorical/political context from which research is created and thus engages with the micropolitics of a research endeavor. Accountability makes it evident that there are many constituencies to which all academic researchers are accountable—for example, their discipline, intellectual integrity, their institution and academic colleagues, the idea of rigorous scientific research, and academic freedom in research—as well as being accountable to the people with whom the research is being conducted. It is accountability that leads to a critical research project interrogating how the lived experiences and cultures of the research participants are inscribed within the research (see Stoecker, 2012 ).

What might the necessary elements be for ensuring that our research practices retain the criticality we have discussed earlier? We offer four possibilities that could form a filter through which one could decide if research is critical, using our definition of the term. First, all critical qualitative researchers should interrogate the history of ethnographic research that has led to the systematic domination of the poor: working classes; ethnic, racialized, sexual Others; women; and colonized peoples. That is, critical qualitative researchers must begin research with an understanding of how previous research, including their own, may continue to play a part in the subordination of peoples around the world, for example, by reinscribing them into predictable and stereotypical roles. Second, critical qualitative researchers should work to develop a consciousness of what might constitute critical research practices—without fetishizing methods—that challenge the system of domination often present in social research. Third, researchers who embrace critical qualitative approaches must develop comfort with the notion that they are conducting research with a purpose; that is, researchers grapple with and comprehend that critical research demands that they engage with the idea that they conduct research into research inequalities in order to undo these inequalities. Finally, critical qualitative researchers comprehend that their level of comfort can extend into the idea that research does not simply capture social realities; rather, the critical research approach is generative of narratives and knowledges. Once this last idea is accepted—namely, that knowledge is created in a research project and not merely captured—it is then a comparatively straightforward task to see the need for a researcher’s accountability for the narratives and knowledges he or she ultimately produces. In so doing, it is possible to recognize that all representations have a life of their own outside any intentions and that representations can contribute to histories of oppression and subordination.

We propose that it is the actual practice of research and, perhaps, even the idea of researcher as witness (Fernandes, 2003 ), and not a notion of best practices, that keeps the politics of research at the center of the work we do. This includes insights into the redistribution of power, representation, and knowledge production. We suggest that critical research is work that shifts research away from the production of knowledge for knowledge’s sake and edges or nudges it toward a more transformative vision of social justice (see Burawoy, 1998 ; Choudry, 2011 ; D’Souza, 2009 ; Hunter, Emerald, & Martin, 2013 ; Hussey, 2012 ).

Thoughts from the Field

Here, based on Collins’s fieldwork, we highlight a set of critical methodological lessons that became prominent while she was conducting her field research in Malate, in the city of Manila, the Philippines, currently a tourist destination but once famous as a sex district. We define her work as a critical research practice.

Since 1999, Dana Collins has conducted urban ethnographic work in Malate, exploring gay men’s production of urban sexual place. She has been interested in the role of desire in urban renewal and, in particular, how informal sexual laborers (whom she terms gay hospitality workers , a nomenclature drawn from their own understandings of their labor and lives) use desire to forge their place in a gentrifying district that is also displacing them. This displacement has involved analyzing urban tourism development, city-directed urban renewal, and gay-led gentrification, as well as informal sexual labor.

The research has involved her precarious immersion in an urban sexual field. She undertook participant observation of gay night life in the streets, as well as in private business establishments, and conducted in-depth and in-field interviews with gay business owners, city officials, conservationists, gay tourists, and gay-identified sexual laborers. In addition, she drew on insights from visual sociology and completed extensive archival work and oral history interviewing. In all this, she explored the collective memories of Malate as a freeing urban sexual space.

There exist multiple and shifting positionalities of power, knowledge, exchange, and resistance in her research. For example, she points out that she occupies multiple social locations as a White, lesbian-identified feminist ethnographer from a U.S. university, one who forges complicated relationships with urban sexual space, sex workers, and both gay Filipino men and gay tourists.

A critical research practice at heart involves the shifting of epistemological foundations of social science research by addressing core questions of how we know what we know, how power shapes the practices of research, how we can better integrate research participants and communities as central producers of knowledge in our research, and how we can better conceptualize the relationship between the research we do and the social justice we are working toward in this world. 3 Such questions function as a call to action for critical researchers not only to examine the power relations present in research, but also to generate new ways of researching that can confront the realities of racism, gender and class oppression, imperialism, and homophobia. This is about not only becoming better researchers, but also seeking ways to shift the very paradigm of qualitative research and ensuring its service to social change. We have learned to use these questions as a central and ongoing part of the research we do.

Feminist and Queer Accountability to the Micropolitics of the Field

One of the primary tenets of critical qualitative research is that researchers must work with a wider understanding and application of the politics of research. For Kum-Kum Bhavnani ( 1993 ), this means that one must be accountable to the micropolitics of research because such accountability destabilizes the tendency to conduct and present research from a transcendent position—the “all-knowing” ethnographer, the outsider going in to understand the point of view of insiders, the attempt to (avoid) go(ing) native, and the researcher who aims to gain access at all costs and in the interests of furthering research. Micropolitics is not only the axis of inequality that shapes contemporary field relations; it is also the historical materialist relationship that constitutes the field and informs the basis of critical qualitative research. Micropolitics, therefore, is a critical framework that questions the essentializing and power-laden perceptions of research spaces and people because it both encourages a reflexive inquiry into the limited locations of research and involves the more critical practice of the researcher turning outward, to comprehend what Bhavnani calls the interconnections among researcher, research participants, and the social structural spaces of the field.

Micropolitics illuminates how all research is conducted from the limited locations of gender, race, class, sexual identification, and nationality, as well as illuminating the interconnections among all these locations. This is not a simplistic reflexive practice of taking a moment in research to account for one’s positionality and then moving on to conduct normative fieldwork; Bhavnani has been critical of such moments of inward inspection that lack substantial accountability to the wider micropolitics of the field. Rather, this move requires an ongoing interrogation of the limited locations of research that show how knowledge is not transcendent. Furthermore, when used reflexively, limited locations offer a more critical framework from which to practice research.

Micropolitics encouraged Collins’s attention to the limited location of a global feminist ethnographer doing research on gay male urban sexual space in Manila. She moved among positionalities throughout her research—of woman, queer-identified, White, U.S. academic, tourist, ate (Tagalog term for older sister)—and none of these positions was either a transcendent or a more authentic standpoint from which to conduct ethnographic work. So, for instance, as a White tourist, she moved easily among the gentrifying gay spaces because these spaces were increasingly designed to encourage her movement around Malate. This limited location showed the increasing establishment of White consumer space, which encouraged the movement of consumers like herself, yet dissuaded the movement of the informal sexual laborers with whom she was also spending time—the gay hosts. Her limited location as a White woman researcher from a major U.S. university meant that gay hosts sometimes shared their spaces and meanings of urban gay life with her, yet many times those particular spaces and dialogues were closed—she was not allowed into the many public sexual spaces (parks and avenues for cruising and sex late at night), yet gay hosts treated her as an audience for their many romantic stories about the boyfriends they met in the neighborhood.

Hosts emphasized that they gained much from hosting foreigners in terms of friendship, love, desire, and cultural capital. Yet they monitored the information they shared because she remained to them a U.S. researcher who wielded the power of representation over their lives, despite her closeness with a group of five gay hosts. Hence, gay hosts often chose to remain silent about their difficult memories of sex work or any information that could frame them as one-dimensional “money boys,” as distinct from the gay-identified Filipino men who migrated to Malate to take part in a gay urban community.

Micropolitics challenges the authenticity of any one positionality over another; it was Collins’s movement among all of them, as well as her ongoing consideration of their social structural places, that provided her with a more critical orientation to the research. She suggests that she was not essentially a better “positioned” researcher to study gay life in Manila because she, too, is gay. Rather, she found that differences of race, class, gender, and nationality tended to serve as more enduring, limited locations that influenced relationships within this research and required ongoing critical reflexive engagement.

We want to add that a queer micropolitics of the field also offers critical insight into how identities are not stagnant, but rather can be fabricated and performative during the research process. This moves researchers away from an essentialist take on their standpoint because an essentialist mindset can lead to a search for the authentic insider and outsider. It can also lead to an essentialist social positionality that is more conducive for researching. Queer micropolitics show that research is made up of a collection of productive relations and identities. So, for example, her lesbian identification did not create a more authentic connection with gay hosts in Manila; rather, she often fabricated a shared gay positionality. This was a performance that served as a point of departure for her many conversations, from which she could proceed to share meanings of what it meant to be gay in Manila and the United States.

Some of the productive relations that arise in research are the continuum of intimacies that develop while doing research. So, like feminists before her, she chose to develop close friendships with hosts where they genuinely loved (in a familial way) as they spoke of love. While learning about gay life in Malate, she stroked egos, offered advice, cried over broken hearts and life struggles, and built and maintained familial relations. Queer micropolitics shows, however, the limitations of such intimacies because intimacy does not equal similarity—the differing social locations of class, race, gender, and nationality meant that the experiences of urban gay life varied immensely. Thus, building such intimacies across these differences requires both the recognition and the respect for boundaries that hosts constructed. She had to learn to see and know that when hosts became quiet and pulled away, these were acts of self-preservation as well as acts of defiance against the many misrepresentations of their lives that had taken shape in academic research and journalistic renderings of their place in “exotic” sex districts.

A queer micropolitics also shows how research is an embodied practice: Researchers are gendered, racialized, classed, and sexualized in the field. This became most apparent as she walked alone at night in the field and developed a keen awareness of the deeply gendered aspects of Malate’s urban spaces. Her embodiment was a peculiar presence because women in Manila do not walk alone at night. This includes women sex workers, who publicly congregate in groups or with clients and escorts; otherwise, they are subject to police harassment. Hence, her very movement in the field as a sole woman felt like a transgression into masculine urban space because her feminine body was treated as out of place in the public spaces of the streets at night—she was flirted with, called names, followed, and sexually handled as she walked to gay bars for her research. As much as her queer location afforded her an understanding of how gender is a discursive production on the body, replete with the possibility of her being able to transcend and destabilize the gendered body as a biological “reality,” she confronted the discomfort of being read as a real woman in what became predominantly men’s spaces at night.

Yet this gendered embodiment, in part, shaped her knowledge of the district as she developed quick and knowledgeable movement through the streets, a queer micropolitical reading of urban space that arose from this limited gender location. She was aware of the spacing of blocks, the alleys, the street lighting, and the time of night when crowds spilled out from the bars and onto the streets, allowing her to realize that a socially vibrant street life facilitated her movement. This queer micropolitical reading of urban space showed how both researchers and research participants do not simply exist in a neutral way in city space; rather, gender leads to our use and misuse of urban space. She has juxtaposed her experience with that of research participants in her study. The latter spoke at length about their exploratory and liberatory experiences of urban space, replete with their access to masculine sexual spaces—parks for cruising and sex, city blocks for meeting clients or picking up male sex workers, and alleys, movie theaters, and mall bathrooms for anonymous sex.

This queer micropolitical read of Malate’s gentrified space showed how very different was her access to the newly opening bars, restaurants, cafés, and lifestyle stores. Her Whiteness signaled assumptions of her class location and positioned her as part of the international presence that this gentrifying space was targeting and whose movement among establishments was encouraged. She received free entry, free drinks, exceptional hospitality, and invitations to private parties, and her movements were closely monitored as she entered and exited establishments for the sake of “protecting a foreign tourist from street harassment” (interview with bar owner).

Overall, she experienced Whiteness and class as equally embodied because these locations signaled her power as a “legitimate” consumer, allowing access to urban consumer sites and a privileged movement among gentrified spaces. This embodied experience of gentrified space differed from that of her gay hosts, who were often denied access to these establishments for being Filipino, young, working class, gay, and interested in foreigners. Contrarily, their bodies were constructed as a “threat” to urban renewal in the district.

Resisting Reinscription

Critical qualitative research is also concerned with the politics of representation in research. This requires a hard look at the implicit imperialisms of ethnographic work, including the tendency to go in and get out with abundant factual information, as well as the lasting impact of objectificatory research practices on fields of study. Such practices are evident in the now-global rhetoric about the so-called Third World prostitute, who in both academic and journalistic renderings tends to be sensationalized and sexually Othered. This rendering is part of a long history of exoticization that has denied subjectivity and rendered invisible the lived experiences of sexual laborers around the world.

Such failed representations are part of what Kum-Kum Bhavnani ( 1993 ) called reinscription —the tendency in research to freeze research participants and sites in time and space, thus rendering them both exotic and silenced. Reinscription denies agency to research participants and renders invisible the dynamic lived experiences of those same research participants. Doing research in both postcolonial and sexual spaces means that researchers must grapple with how our research participates in histories of reinscription—we both enter and potentially contribute to a field that has been already “examined,” overstudied, and often exoticized. Thus, a critical qualitative approach is one that begins with a thorough understanding of these histories of representation so that we are not entering fields naively, as spaces only of exploration. Rather, we enter with knowledge of how the field has already been constituted for us through reinscription. A critical orientation has a core objective of understanding how our representations of research at all levels of the research process could contribute to exoticization by reinscribing participants and sites.

The issue of reinscription became particularly apparent when Dana Collins interviewed gay hosts and grappled with what appeared to be their elaboration of a contradictory picture of their sexual labor, as well as of their lives. In short, hosts tended to “lie,” remain silent, embellish “truths,” and articulate contradictory allusions to their life and labor in Malate. When Collins began her interviewing, she held the implicit objective of obtaining the truth about hosts’ lives, which she believed resided in what they do in the tourism industry. She was concerned with the “facts” about their lives, even though gay hosts were more likely to express their desire—desire for relations with foreigners, desire to migrate to a gay urban district, desire for rewarding work, and desire for community and social change. She struggled with many uncertainties about the discussions: how could they hold a range of “jobs” and attend school, yet spend most of their days and nights in Malate? How could they understand gay tourists as both boyfriends and clients? Why resist the label sex worker , yet refer to themselves as working boys and claim to have “clients”? She struggled to make sense of the meanings that hosts offered even as she simultaneously felt misled concerning the “real” relations of hospitality.

Interviewing hosts about sexualized labor—as a way to produce a representation of sex work—did not facilitate the flow of candid information; hosts later expressed their view that sex work and their lives were already overstudied. Many researchers had previously descended on Malate to study sex work, and the district was a prime location for the outreach of HIV/AIDS organizations, some of which had breached the confidence of the gay host community. In short, Collins mistakenly started her research without the knowledge of Malate as a hyperrepresented field, and her research risked reinscribing gay hosts’ lives within that field as static and unchanging.

Importantly, those gay hosts who resisted becoming the “good research subjects” who give accurate and bountiful information prompted a radical shift in her research framework. They told her stories about their imagined social lives, which encouraged her to rethink her commitment to researching sex work because the transformation of the discourses offered another view of the district, their work, and lives, one that offered a more visionary perspective. She began to focus less on “misinformation” and instead followed how hosts framed their lives. She treated these framings as social imaginings in which Malate features prominently in their understandings of gay identity, community, belonging, and change. In short, their social imaginings functioned as counternarratives to reinscription and offered their lived experience of urban gay place. Such imaginations expressed hope, fear, critique, and desire—in short, they present a utopic vision of identity, community, and urban change.

Integrating Lived Experience

Finally, critical qualitative research is a call to study lived experience, which is a messy, contradictory realm, but a deeply important one if we as critical researchers are truly interested in working against a history of research that has silenced those “under study” (see Weis & Fine, 2012 ). Paying attention to lived experience allows us to better engage with the contradictions mentioned earlier because lived experience is about understanding the meanings that research participants choose to share with researchers, and it is also about respecting their silences. As Kum-Kum Bhavnani ( 1993 ) argued, silences can be as eloquent as words. Finally, integrating lived experience can take a critical qualitative project further because lived experience allows researchers to explore the epistemological relationship of the meanings and imaginings offered by research participants and to be explicit about the project of knowledge production. In other words, a central guiding question of critical qualitative research is, How can research participants speak and shape epistemology, rather than solely being spoken about or being the subjects of epistemology?

Collins used hosts’ social imaginings as an epistemological contribution because their imaginings showed how hosts draw from experiences of urban gay community to articulate their desires for change, despite their simultaneous experiences of inequality and exclusion. We read social imaginings as a subjective rendering of urban place—the hosts’ social imaginings expressed their history, identity, subversive uses of urban space, and, ultimately, the symbolic reconstitution of that urban space. In this way, hosts were refiguring transnational urban space by writing themselves and their labor back into the district’s meaning, even as the global forces of tourism and urban renewal threatened to displace them.

In conclusion, we seek to highlight how critical research insists on the interplay of reflexivity, process, and practice. In particular, we encourage critical researchers to be mindful of the multiple meanings and usages of the term critical so that we can make more explicit our political interests and stand within our disciplines, the academy, our community, and the world. We offer dialectical materialism as a distinct mode of critical analysis that emphasizes an analysis of change in essence, practice, and struggle. We also suggest that, for researchers to be critical in their research, they should strive to take up research questions and projects that study change, contradictions, struggle, and practice to counter dominant interests and advance the well-being of the world’s majority. We should strive to build new research relationships—such as overcoming the faulty divides between researchers and research participants and by promoting systems of community accountability—that dialectically fuse research, political activism, and progressive social change.

Furthermore, we suggest that critical research can agitate against the homogeneity of ethnographic representation, allowing the realities of people’s lives to come into view. Critical researchers recognize the contested fields of research, yet this requires our critical engagement with the research process as a reflexive, empathetic, collective, self-altering, socially transformative, and embedded exercise in knowledge production. Therefore, critical research can resist imperialist research practices that are disembodied and that assume a singular social positioning. We use an imperative here to say that we must conduct research as embodied subjects who shift between multiple and limited locations. We must also find more ways to remain accountable to our communities of research as a way to undo implicit imperialisms in social research. Critical research can work against the remnants of an objectivist and truth-seeking method that supports prevailing interests, classes, and groups while embracing research from social locations that offer situated knowledges and the possibility for greater shared understandings. Finally, critical research can engage the micropolitics of research and foreground the need for the accountability of researchers to resist reproducing epistemic violence.

This last is an idealist imagining of what should happen. However, a number of research projects have approximated these goals closely.

Parts of our argument have appeared in some of our earlier work (e.g., Bhavnani & Talcott, 2011 ; Chua, 2001 ; Collins, 2002 , 2009 ).

Although we, as the chapter’s three authors, do not usually use we in our writing as a general pronoun, it is the most direct way to offer our insights in this section.

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Critical Analysis in Qualitative and Quantitative methods

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Qualitative Methods provides a fitting occasion to reflect on this branch of methodology.1 Given that the other APSA organized section concerned with methodology2 is centrally fo-cused on quantitative methods, the additional issue arises of the relationship between the qualitative and quantitative traditions. Adopting a pragmatic approach to choices about concepts (Collier and Adcock 1999), we believe that the task here is not to seek the "true" meaning of the qualitative-quantitative distinction. Rather, the challenge is to use this distinction to focus on similarities and contrasts in research practices that pro

Kezang sherab

Zeinab NasserEddine

Dr. Mustapha Kulungu

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Ivan Steenkamp

Oriol Iglesias

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  • Published: 24 January 2024

Social determinants of health during and after coronavirus: a qualitative study

  • Farideh Izadi sabet 1 ,
  • Aliakbar Aminbeidokhti 2 &
  • Sakineh Jafari 3  

BMC Public Health volume  24 , Article number:  283 ( 2024 ) Cite this article

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Health has multiple dimensions influenced not only by individual factors but also by broader social, economic, cultural, and political structures. The widespread COVID-19 pandemic has multidimensional effects on people’s lives, which can have effects on individuals’ lifestyles after the COVID-19. This study aimed to speculate the social determinants of health during and after the COVID-19, which can lead to more effective planning for promoting community health.

The present study interviewed 21 experts in social and medical fields during four months. The sampling method was snowball. The interviews were semi-structured and administered in-person or electronic. All interviews were transcribed and analyzed according to the Brown and Clarke’s six-stage framework to extract themes.

the participants were 13 males, eight experts in social field, all had PhD, 17 were academic members, and 10 were members of the Social Determinants of Health Research Center. The qualitative content analysis induced seven different social themes that affect the health which included: justice (3 Subcategories), integration (4 Subcategories), acceptance (4 Subcategories), participation (2 Subcategories), adaptation (3 Subcategories), flourishing (4 Subcategories), and cohesion (3 Subcategories).


According to the present study, a grand plan to cover all positive and negative social effects of COVID-19 should have at least seven different dimensions. However, the present models of effective social determinants in health do not have such comprehensiveness. Future studies may provide a proper model to be used in clinical and research fields.

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Society is a group of people who live together and have various cultural, political, and economic interactions and exchanges, therefore the society has structure. Contemporary complex industrial societies and past simple societies have a common aspect: they are not simply the result of people coming together. But, each possesses its specific social structure, distinguishing them from other imagined social forms. The philosophy of social formation is based on the realization that only within a society, people can fulfill and satisfy specific fundamental needs or, at the very least, access them more easily [ 1 ]. Human societies are various interwoven factors including culture, social, economic, and politic. While these factors are distinct, they interact with each other, establishing tangible connections. The interactions of these factors can render the conditions of society critical and disordered or desirable and ideal. As creators of the constituents of human societies, humans assume various social roles, and the proper fulfillment of these roles enhances interactions within the community. Humans can effectively perform their social functions and continue their activities while they feel themselves healthy and their living environment is not disturbing their comfort. Currently, health is considered a multidimensional and multilayered phenomenon among fundamental human rights which is a necessary condition for fulfilling social roles. People can be fully active when they feel healthy and society considers them healthy. In this context, health will be categorized in the ranks of social values, and the biological variables will not be sufficing to provide a comprehensive definition of health. The World Health Organization (WHO) provided the definition of health in Geneva in 1948 that can still be used in health-related theories. This definition encompasses complete physical, mental, spiritual, and social well-being and not merely the absence of disease. For the first time in the world, this definition included social health alongside psychological and physical health. Moreover, the WHO describes differences in health status or the social determinants of health in various strata of society as inequalities. When these inequalities are avoidable, it refers to them as injustices [ 2 ].

Although the impact of social determinants of health has been recognized for centuries, the inherent and genuine interaction between social trends and health and disease has recently been raised [ 3 ]. The evidence suggests that the utmost burden of diseases and the most pronounced health inequalities in the world arise from social determinants [ 4 ]. The social conditions and determinants influencing people’s health are diverse and complex [ 5 ]. Social determinants of health can be defined as the conditions in which people are born, grow, live, work, and age, which are influenced by stronger forces such as economic factors, social policies, and political issues [ 6 ].

Social determinants of health contain the social factors that promote or weaken individuals’ health and the underlying processes of these factors [ 7 ]. The importance of social health is such that individuals who possess it can better cope with problems arising from fulfilling their primary social roles [ 8 ]. It must be acknowledged that communicable diseases are becoming more of a social problem than just healthcare issues [ 9 ]. Therefore, professionals should particularly consider the differences in social and economic factors and their impact on individuals’ health in emergency health conditions [ 10 ]; so that the disadvantaged population does not endure a heavier burden of health emergency as for example pandemics. It should be noted that people from low socioeconomic backgrounds experience worse health conditions and shorter lifespans than those counterparts from higher socioeconomic backgrounds [ 11 ].

One of the most significant pandemics in human history is the COVID-19 that has rapidly spread with a high mortality rate. The virus was first discovered in China in late 2019 and has since become one of the most challenging human trials in modern history. Studies have demonstrated the impact of this pandemic on human social factors. As the number of confirmed cases of COVID-19 continue to rise, the virus with negative effects on health systems and increasing the fatal rate has shaken the foundations of the global economy and led to sustainable geopolitical changes [ 12 ]. This infectious disease threatens the physical health of societies and, in some cases, leads to fatalities. It also affects both physical and mental determinants on health because it generates uncertainty and confusion among people. Consequently, it imposes unbearable psychological pressure, such as stress, anxiety, depression, and grief, on affected societies [ 13 ]. The emergence of a public health crisis like the COVID-19 pandemic can significantly represent roles of social determinants of health on contagious, spreading the infection, and the impact of the pandemic on social health factors. This health crisis even penetrates people’s living conditions and lifestyles to the extent that in-depth changes occur even after the pandemic ends. It is essential to acknowledge that lifestyle is directly related to people’s health [ 5 ], therefore, special considerations should be given to the changes of people’s lifestyles after the COVID-19 pandemic ends.

The review of the literature has revealed that most of the studies have considered the medical aspect of this pandemic such as background, prevention, symptoms, risks, complications, treatment, and the psychological and psychiatric effects of the disease [ 14 , 15 , 16 ]. Other studies in this field explored disease patterns based on social factors in an infected area [ 16 ], effects of bioenvironmental, social, and political approaches on the performance of some centers during the COVID-19 pandemic [ 17 ], and understanding of the disease and some social factors such as perceived social support [ 18 ]. To the best knowledge of the authors, there is not any study considered the social determinants of health comprehensively. While such study may enlighten the professionals of some hidden factors that could change the medical and health outcomes.

Considering the paucity that we felt in the studies, the research team decided to conduct a qualitative study to speculate the social determinants of health during and after the COVID-19. The main objective was to identify and analyze the various social factors impacting health and to recognize their subgroups. By determining these factors, this study may provide essential information to social and healthcare policymakers. They will be able to use this information in strategic planning to enhance society’s lifestyle and overall health indicators during and after the pandemic of COVID-19. The research team hypothesized that all social determinants on health are interacting with each other and a comprehensive perspective regarding the social determinants of health will provide effective solutions for improving community health.

Materials and methods

The present study had qualitative design. Qualitative research involves studying clients in their natural environments and interpreting phenomena based on the meanings that people attribute to them. In qualitative approach, often conducted through interviews, the aim is to obtain the perspectives and interpretations of the study participants and represent and convey these findings [ 19 ]. Regarding to the aim of the present study, the research team chose this method to examine and identify the social determinants of health during and after COVID-19. Therefore, the present study can be considered as a thematic analysis type. Thematic analysis is a method for analyzing qualitative data and is one of the cluster methods that focus on identifying patterns of meaning within a dataset. Unlike many other qualitative methods, thematic analysis is not tied to a specific epistemological or theoretical perspective, making it a flexible approach. The goal of thematic analysis is to identify themes that are patterns in the important and interesting data for the researcher. Braun and Clarke introduced a six-stage framework for conducting thematic analysis, which includes familiarizing oneself with data, generating initial codes, searching for themes, reviewing themes, defining themes, and writing the final analysis [ 20 , 21 ]. Since we chose to have thematic analysis, the research team followed Brown and Clarke’s six-stage framework. In diagram 1 , the steps toward aim of the present study have been displayed.

figure 1

The conceptual framework of the qualitative study of determinants of social factors affecting health during and after Covid-19

Design questions

With the aim of doing the study, the research team started by review of the related literature and upstream documents. In this review, factors, components, and indices of social determinants on health were identified and proper questions to be conducted in interviews were designed. three questions (and exploratory ones), as outlined in Table  1 , were used in this study.

To enrich and strengthen the data obtained from the literature, and to develop the conceptual model, expert opinions and specialists’ insights were collected through semi-structured interviews. The sampling method was started by purposeful and non-random (according to Teddlie & Tashakkori, 2023) [ 21 ]. To continue the study, the research team undertook the snowball method. Firstly, the research team started interviewing those experts who have been well-known in this field and had all inclusion criteria (to be familiar with Covid-19 and their previous research on the impact of social factors on the occurrence of disease). When the interview was finished, the interviewer asked each interviewee to introduce any other expert that had the mentioned inclusion criteria. Each interview was transcribed immediately by the interviewer. In both groups (scientific and clinical), the interviews were continued until in the last 2–3 interviews no further information was obtained (data/theoretical saturation). The statistical population were two groups. The first group (scientific) was those experts and specialists who had sufficient knowledge in the field of health, i.e., authored books or articles related to prevention, treatment, or health promotion, or those with academic qualifications in this field. The second group (clinical) included individuals who were active in the health field i.e., familiar with health issues, actively engaged in education, research, healthcare, or related fields for the preservation and promotion of health (details of each participant have been presented in Table  2 ).

All interviews were administered nationally (including Tehran, Semnan, Khorasan, Orumiyeh, Kashan), between November 2022 and February 2023. To make it possible, the interviewees were able to choose their mode: face-to-face or online (through social messaging apps). Each interview lasted for 45 to 60 min. In face-to-face interviews, the interviewer took notes and recorded whole sessions to be able to do a recheck and have a full transcription. However, for those who chose online mode, the interviewees wrote their answers and sent them back to the interviewer. In both conditions, the interviewers contacted the participants when any response was vague or problematic. Additionally, if a specific point was raised by a participant, in next interview, the interviewer would emphasize on that point to get a clearer response [ 22 ].

Braun and Clarke’s six-stage framework

When each interview was transcribed by the interviewer, the six-stage of thematic analysis was started. Main parts of this process were identifying and encoding semantic units (Basic level), classifying the units into broader categories (Organizing level), and finally, extracting main themes (Comprehensive level). The researchers conducted essential informant confirmations, expert reviews, and document analysis to enhance the data’s reliability. The researcher used manual coding to analyze data. Redundant and excessive codes were removed, and the process continued until broader categories and extensive components related to health were identified.

Evaluation of study rigor

The research team employed various methods to achieve credibility, dependability, confirmability, transferability, and authenticity. These included member checks, granting participants the opportunity to review and validate or remove interview data, assessing how coding was performed by the research team and individuals familiar with the research methodology (external check), obtaining informed consent, and providing transparent explanations of the research process for all participants, and providing rich data descriptions to ensure a clear understanding of the research process. A sampling method with maximum diversity was also used, and prolonged engagement in the field was maintained. The researcher tried to be accurate in sampling, documenting, data collecting and analyzing, and using the participant-feedback method in addition to quality criterion to make the obtained data valid and reliable.

Investigator triangulation

To evaluate the credibility of the findings, three people including a pulmonologist, an internal specialist, and a person active in social science studies transcribed the same 20% of all interviews independently. The main researcher asked them to analyze and interpret their transcriptions according to the Braun and Clarke’s approach without prior discussion or collaboration among them. The research team compared all transcriptions, resolved the discrepancies, and reached to a consensus through point-by-point method and reached approximately 90% of agreement among analyzers.

This study aimed to find social determinants of health during and after Covid-19 through a qualitative approach. Interviews were running with 21 experts with an average age of 44 years (eight were female). Eight had clinical experiences, 17 were academic staffs, and 18 married people. The thematic analysis of the transcriptions induced 10 themes, 33 subcategories, and 132 semantic units.

Q1: dimensions and components of the social determinants of health

All experts answered this question in full agreement that the conceptual framework of influential factors on health, as expressed by the WHO, is the best model to be used in evaluation of social determinants on health. In their opinions, the social concept mentioned in the WHO’s definition of health could be impressed by at least 10 different themes: (1) Individual factors, (2) Biological factors, (3) Social justice, (4) Social integration, (5) Social acceptance, (6) Social participation, (7) Social adaptation, (8) Social prosperity, (9) Social solidarity, and (10) Spiritual factors.

Individual and biological factors

Although in WHO’s definition of health, these factors have their special positions, most of experts in this study believed that age, gender, genetic factors, and mental status impact one’s social determinants on health. Yet, one expert has emphasized the effect of health literacy and media literacy on social determinants on health. They elaborated the mental status factors in different concepts such as the influence of self-efficacy, personality type, interpersonal relationships, and emotional well-being. Besides, the lifestyle of the people could significantly affect their health; even if all conditions for health were met, but then people were not following a healthy lifestyle, their health could still be in danger. Furthermore, most experts believe in the influence of biological factors, such as environmental conditions, on individuals’ health.

Social Justice

This themes was extracted from three different policies: economic, government, and societal general rules and regulations. In Table  3 , details of the basic units, organizing levels, and comprehensive theme have been presented.

Social Integration

The second theme was social integration which was a consolidation of four different organizers (level 2) as displayed in Table  4 . Experts ( 1 , 9 , and 11 ) said “the acceptance of the social norms, avoiding of breaking the law, and committed to obey the rules are effective in social health; social health is necessary for the health of the members of the society”. Experts 3 to 7 expressed: “family making is the cause of social health”. Even, expert 11 believed: “being employed is effective in health”.

Social Acceptance and Participation

According to the experts, “social judgment, whether in the form of acceptance, rejection, or neutrality, significantly impacts people’s health”. Also, “conformity and social influence of people has an effect on the health of society and consequently on the people’s health”. “The participation of individuals in society, both formally and informally, reflects the health and dynamism of the community”. In Table  5 , the thematic analysis regarding these two themes have been displayed.

Social Adaptation

To reach this theme, the basic units went through three levels of organizing (Table  6 ). Ps 2, 5 and 8 said: “Crime, aggression, superstitions, irresponsibility, breaking the law and people stress in society are the marks of lack of health in the society”. P13 said: “Charitable donations, being responsible, and law-abiding are those preventive factors that protect the health in the society”.

Social Flourishing

A society would flourish if “social happiness and vitality” according to Ps 3, 7, and 14 in addition to “meritocracy, the development of people’s self-esteem, and people’s welfare” Ps 10, 16 and 17 as well as “a sense of community security” based on the experts’ opinions existed. In Table  7 , this specific theme along with its subcategories and basic units have been presented.

Social Cohesion

P 9 said: “the unity among people and the attraction between the society members are the prerequisites of society health”. In Table  8 , this specific theme along with its subcategories and basic units have been presented.

Spiritual Factors

Considering the WHO’s definition of health, the spiritual aspect should also be considered as all experts said. P s 3, 10, 14, 19 and 20 believed that “spiritual and religious components have an important role in people’s health”. P 20 believed: “religious and spiritual aspects are subcategories of society’s culture and play roles in people’s health”.

The effective role of social determinants of health during COVID-19.

Most of the experts considered the factors affecting the health of the society during the outbreak of the Corona virus to be similar to the factors affecting health before the pandemic, however, they deemed social factors much more critical during the pandemic. They expressed the influence of appropriate social behavior, without stress and anxiety, a healthy diet, using helpful social media, and physical exercise in controlling the spread of COVID-19 disease (P 1, 2, and 3). P6, while emphasizing the prominent role of social factors in mitigating the pandemic and reducing its casualties, pointed out health education through media, legally mandated physical distancing, and mask-wearing as three main indices contributing to the success of societies in controlling the COVID-19 pandemic, which are all social determinants on health.

Also, some experts considered the pandemic of Corona virus effective on social factors and mentioned that a two-way relationship has been established during the pandemic of Corona virus between the disease and social determinants on health. This relationship could have positive effects including leading to increased empathy, compassion, and cooperative approaches among people; a surge in spiritual tendencies; an increase in respecting each other’s rights; evolution in attitudes of art communities and social science theorists; improvement in media literacy; enhancement of health literacy; an increase in preventive acts, and justifiable therapeutic support. On the other hand, it could have adverse effects, causing public fear; increased hopelessness, family and societal conflicts, and unemployment rate; reduced income, leisure activities, physical exercise, and social interactions; and dissemination of falsehoods. These positive and negative societal effects may result in changes in social factors, once again affecting people’s health (quoted by P 4,5, 6, 9, 11, 18, and 21).

The effective role of social determinants of health after COVID-19.

All experts referred to the specific impact of social determinants of health after COVID-19. P1 said “those who suffered more damages during the pandemic, such as those who lost their jobs, homes, or loved ones, or a decrease in income, are at risk of deteriorating health”. P3 mentioned some achievements would be perceived after COVID-19: “Health proceedings will continue. The use of new technology will persist, leading to reduced traffic, pollution, and road hazards. A transformation in economy, culture, and communications, which is not similar to the pre-COVID era, and these changes will give rise to new social factors affecting health. Individuals will focus on self-care and care for others.”

P4 emphasized: “According to the conditions and extent of crisis management during the pandemic, various psychological, communication, and educational abnormalities have emerged, which will continue for years. These [abnormalities] should be considered as social factors that can compromise health, and appropriate strategies should be devised to tackle them”. P6 said: “initial documentation of the experiences of the Corona era and turning them into artistic and literary works can make these experiences last, and the cooperation of the Ministry of Health and cultural institutions can create a fundamental basis for the introduction of social determinants that affect health in the society. It [the fundamental basis] causes the optimal management of all capacities to achieve justice in health and the mutation of these components”. According to P11 “if social, cultural, and economic factors are optimal, society can more easily return to the pre-COVID conditions”.

Social well-being refers to the ability to interact with others and the environment to establish satisfying interpersonal relationships. Capabilities such as sincere communication with others and managing conflicts in a proper way and ethically over an appropriate and acceptable period of time are among the indicators of social well-being. Respecting others, taking responsibility for the community, and being prepared to spend personal resources for the society and engage in healthy and balanced interactions with others (in a way that neither we nor others are exploited) are considered subcategories of social health. The present study, based on the expert opinions, identified seven social determinants on health, that interacting with personal factors additionally to spiritual factors. Those seven social determinants social justice, social integration, social acceptance, social participation, social adaptation, social flourishing, and social cohesion. Our findings were partially in line with the model presented by Keyes (1998). Keyes presented a multidimensional model for social health, which included social coherence, social acceptance, social contribution, social adaptation, and social actualization [ 23 ]. We found two more dimensions that Keyes’ model did not include: social justice and social cohesion. This difference might be a result of the methodology and the concept that each study searched for. Our study had qualitative design assigned to find social determinants of health during and after Covid-19; while Keyes tried to develop a proper scale to evaluate social well-being. It seems the differences of terms in these two studies are superficial, since the definitions and concepts that they include are similar.

The bio and psycho factors of each person can be affected during and after COVID-19, as the experts highlighted in the present study. This is in concert with findings reported by different studies [ 24 , 25 , 26 , 27 , 28 ]. For example, Sher (2021) reported that many COVID-19 survivors experience persistent physical symptoms such as cough, fatigue, dyspnea and pain after recovering from their initial illness; they also experience persistent psychiatric symptoms such as depression, anxiety, and post-traumatic symptoms as well as neurological impairment including anosmia, ageusia, dizziness, headache and seizure. He hypothesized that these symptoms may increase the possibility of suicide or suicidal ideation [ 24 ]. Obviously, in a society that a large number of people were and are struggling with bio-psycho symptoms of COVID-19, the social aspect of their lives would be in danger as well (as Einvik and colleagues showed in 2021) [ 29 ].

The present study indicated that during and after Covid-19, another dimension that has effects on social health is spiritual factors. These factors have been considered as an important dimension of health [ 30 ]. We found spiritual attitudes, spiritual connections, and spiritual behaviors as the most important subcategories that should be considered during and after COVID-pandemic. What the study revealed was in agreement with findings reported by Ghaderi and colleagues (2018). They tried to provide a definition for the spiritual health. By interviewing 21 experts, they were able to find at least three dimensions for spiritual health (including religious, individualistic, and material world-oriented). Their participants distinguished between spiritual health and spirituality; they believed following the spiritual health factors affects the bio-psycho- and social aspects of health [ 30 ]. At the time of pandemic, spirituality went through positive and negative perspectives. For example, Büssing and colleagues investigated a specific topic about spirituality “spiritual dryness” during COVID-19 in Iran. They found the spiritual struggle/dryness between 27 and 35% among their participants. The best and positive predictors were usage of mood-enhancing medications, loneliness/social isolation, and praying and negative predictor was being restricted in daily life concerns [ 31 ]. At the same time, there are some studies that showed patients with COVID-19 whose spiritual health was enhanced could effectively adapt to their illness [ 32 ].

The present study revealed that social determinants of health during COVID-19 were similar to those ones before the pandemic, however, their effects were intensified. Accordingly, Abrams and Szefler (2020) emphasized that the effect social determinants of health have been underestimated during COVID-19. They expand their commentary by the relying on the results of the studies on how the poverty, physical environment (such as, smoke exposure, homelessness), and race or ethnicity might increase the chance of morbidity and mortality with COVID-19. They stated while COVID-19 has been considered as a great equalizer, its outcomes brought up inequalities in social health [ 33 ]. Similarly, Singu and colleagues (2020) in a review article took a step further and highlighted the effect of social determinants of health on the outbreak of COVID-19. In a five-dimension model, they showed five social determinants health factors (health and health care, Economy stability, Education, Neighborhood & Built Environment, and social & community context). They also used documents and studies to show how these five factors put people in a hierarchy and vulnerable to the COVID-19 [ 9 ]. Hiscott and colleagues (2020) expanded what Abrams & Szefler or Singu and colleagues wrote and added up many details on how social determinants of health changed during COVID-19 and how effective these determinants were [ 34 ]. They discussed how strict social distancing measures and home quarantine have resulted in the bankruptcy and closure of many businesses worldwide [ 29 ]. Consequently, some individuals have turned to drugs, tobacco, alcohol, gambling, and online gaming to cope with stress, which, in turn, significantly increases domestic violence and sexual abuse [ 28 ]. Lifestyle changes during the COVID-19 pandemic, such as increased solidarity, attention to and adherence to health guidelines, and reduction in social gatherings (e.g., weddings), have been observed in various communities throughout the pandemic.

Regarding the influential role of social factors on health after COVID-19 pandemic, according to experts’ opinions, the changes that occurred during the pandemic may persist even after it ends. Studies from other countries reached to similar perspective that danger in social health inequity would last to the post-COVID-19 unless proper policies and interventions to tackle vulnerability in living, education, employment, and poverty design and implement [ 35 ]. Lukkahatai and colleagues (2023) took a conserving position about the persistence symptoms of COVID-19 and wrote that “the persistent symptoms of long COVID-19 are less clear”. To be able to provide a proper explanation about the effects of post-COVID-19 on social determinants of health, they used WHO’s model. In this model, to reach appropriate health outcomes two groups of determinants including structural and intermediary are interacting. Details on these two groups are in fact those seven themes that we found in our first step to define the social determinants of health during the COVID-19. The WHO defines socioeconomic and political context and socioeconomic position as the structural determinants and material circumstances, behaviors and biological factors, and psychosocial factors as intermediary determinants. The inter and inter relationship among all these factors and determinants will provide time to resolution of symptoms, health care utilization, quality of life (these three variables as a collection considered to be the ‘health outcomes’) [ 36 ]. During the post-COVID-19 period, the number of television viewers and the percentage of activity on social networks are expected to increase significantly [ 37 ]. Economic recession, a decline in marriage rates, increased anxiety, and a lack of confidence in the future will reduce fertility rates and lead to consequences such as family disintegration and increased financial pressure [ 30 ]. Both during COVID-19 and afterward, significant changes will be observed in social systems and norms.

Given the wide range of social factors affecting health and their mutual influence on biological and spiritual aspects, we assume each community must identify these factors and plan for their control to overcome social health challenges during and after crisis such as COVID-19. However, this complexity should not stop planners from acting and implementing comprehensive programs, as the effects of pandemics can lead to lifestyle changes during and after, significantly impacting social structures.

Research limitations

This study faced limitations, such as the lack of transparency in the division boundaries of the dimensions of social factors affecting health and the creation of interferences within each size. The impact of the coronavirus disease on increasing or decreasing the valuation of influential social factors on health (for example, the increased importance of social justice and decreased social participation due to medical quarantine) and access to scattered and fragmented results in global and national studies were also challenges. However, the researchers tried to identify the most influential health factors, particularly social ones, that are important for the Iranian community.

Application of the Research

The researchers hope that presenting the socially influential factors on health in the post-COVID-19 era can assist health policymakers in making more practical decisions.


Identifying and formulating an operational plan to reduce the adverse effects of the above interactions is recommended by specifying the areas relevant to long-term, medium-term, and short-term practical programs affected by social factors during the COVID-19 pandemic. Additionally, it will be interesting to find out what social determinants on health were reinforced and what was minored after the COVID-19 pandemic.

Data availability

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

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The authors express their utmost gratitude and appreciation to all the experts and clinical specialists who participated in the interviews and shared their experiences and opinions. The first author wishes to offer her special thanks to Dr. Masoomeh Salmani, respected associate professor in department of speech and language therapy, who cooperated with us in drafting and proofreading of this manuscript.

All costs of the present study have been paid by the first author.

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Aliakbar Aminbeidokhti

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FIS, SJ, and AMB conceived and designed the study. FIS and SJ collected and checked the data. FIS and SJ analyzed the data. FIS and SJ drafted the manuscript. FIS, SJ, and AMB revised the manuscript, and FIS submitted the manuscript. All authors read and approved the final manuscript.

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sabet, F.I., Aminbeidokhti, A. & Jafari, S. Social determinants of health during and after coronavirus: a qualitative study. BMC Public Health 24 , 283 (2024). https://doi.org/10.1186/s12889-024-17785-7

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  • Social Factors Influencing Health
  • Coronavirus

BMC Public Health

ISSN: 1471-2458

a critical analysis qualitative research

Forum: Qualitative Social Research / Forum Qualitative Sozialforschung

Doorways of Understanding: A Generative Metaphor Analysis

  • Katie Haus Indiana University
  • Jaclyn Hadfield Louisiana State University
  • Kathryn LaRoche Purdue University
  • Barbara Dennis Indiana University
  • Ronna Turner University of Arkansas
  • Brandon Crawford Indiana University
  • Wen-Juo Lo University of Arkansas
  • Kristen Jozkowski Indiana University

In this paper, we explore the use of a generative metaphor for analyzing qualitative interviews on abortion attitudes. U.S. abortion attitudes are notably complex and multidimensional, thus, requiring subtle, complex, and multidimensional tools of study. We used the generative metaphor of a "doorway" as an analytic tool to enable new understandings of abortion attitudes as expressed across 24 one-on-one semi-structured qualitative interviews with U.S. adults. The doorway metaphor gave us an understanding of the ways in which participants thought of their abortion attitudes as open to revision or change to some degree while also being closed to revision in other ways. This spectrum of openness and closedness does not come into view when examining abortion attitudes through the dichotomous framings. In this methodological paper, we thoroughly describe how we used the metaphor to explicate the complexities and multi-dimensionalities of a person's abortion attitudes.

Author Biographies

Katie haus, indiana university.

Katie HAUS is an advanced doctoral student working on a dual PhD in health behavior (School of Public Health) and qualitative and quantitative research methodology (School of Education) at Indiana University. She is currently integrating her interests in sexual health with her interests in creative epistemologies and critical methodologies to center human experience and outcomes in reproductive health.

Jaclyn Hadfield, Louisiana State University

Dr. Jaclyn HADFIELD is a multilingual cross-cultural behavioral scientist who specializes in mixed-methods, cross-cultural, and multilingual research (English/Spanish/Italian). Although in her research she explores various domains of public health, she predominantly focuses on social and behavioral determinants of health beliefs and behaviors among women within the domain of physical activity using theory-based methods with a translational and community-based approach. In her research, she aims to identify salient factors to inclusively influence intervention designs and improve women's physical activity behavioral engagement while reducing health disparities domestically and globally.

Kathryn LaRoche, Purdue University

Dr. Kathryn J. LaROCHE is an assistant professor in the Department of Public Health at Purdue University. As a public health social scientist and applied anthropologist, she carries out community-engaged, action- and intervention-oriented research about sexual and reproductive health with a focus on abortion and pregnancy.

Barbara Dennis, Indiana University

Dr. Barbara DENNIS is a professor in the Qualitative and Quantitative Research Methodology program at Indiana University. She studies methodological concepts such as validity and ethics in the context of critical qualitative research with a particular interest in methodological equity and justice. In her 2020 book, "Walking with strangers. Critical Ethnography and Educational Promise," nominated for several awards, she detailed the methodological inner workings of a long-term critical ethnography. In her most recent book, co-authored with Pengfei HAO, Karen ROSS, and Peiwei LI (2021), she advanced a practitioner/student centered approach to social science methodology.

Ronna Turner, University of Arkansas

Dr. Ronna C. TURNER is a professor in educational statistics and research methods and coordinator for the educational statistics and psychometrics concentration of the interdisciplinary Statistics and Analytics program at the University of Arkansas. She received her PhD in educational psychology from the University of Illinois, specializing in quantitative and evaluative research methodologies.

Brandon Crawford, Indiana University

Dr. Brandon CRAWFORD is a principal investigator on the Indiana University Abortion Attitudes Project (IUAPP) and an assistant professor in the Department of Applied Health Science in the School of Public Health at Indiana University Bloomington. His main areas of research include the measurement of attitudes regarding controversial social issues and examining the relationship between child maltreatment, child welfare experiences, and adverse life events throughout the life-course. He has expertise in the analysis of secondary data (including data with complex survey designs), survey development, and quantitative analyses.

Wen-Juo Lo, University of Arkansas

Dr. Wen-Juo LO is an associate professor and program co-coordinator in the Educational Statistics and Research Methodology (ESRM) program at the University of Arkansas. Before coming to the USA, he worked in a general hospital in Taiwan for five years and conducted inpatient and outpatient psychotherapy as well as psychological assessments. His research interests involve methodological issues related to latent factor modeling with a focus on psychometric methods in examining the validity and reliability of the psychological inventory.

Kristen Jozkowski, Indiana University

Dr. Kristen N. JOZKOWSKI  is a principal investigator for the Indiana University Abortion Attitudes Project (IUAPP). She is the William L. Yarber Endowed Professor in Sexual Health in the Department of Applied Health Science in the School of Public Health, a senior scientist with the Kinsey Institute for Research in Sex, Gender, and Reproduction, and affiliate faculty in gender studies at Indiana University. In her research, she focuses on sexual consent and refusal communication and abortion attitudes. She has expertise and training in mixed-methods and sexuality.

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CT features based preoperative predictors of aggressive pathology for clinical T1 solid renal cell carcinoma and the development of nomogram model

  • Keruo Wang 1   na1 ,
  • Liang Dong 1   na1 ,
  • Songyang Li 1   na1 ,
  • Yaru Liu 2 ,
  • Yuanjie Niu 1 &
  • Gang Li 1  

BMC Cancer volume  24 , Article number:  148 ( 2024 ) Cite this article

Metrics details

We aimed to identify preoperative predictors of aggressive pathology for cT1 solid renal cell carcinoma (RCC) by combining clinical features with qualitative and quantitative CT parameters, and developed a nomogram model.

We conducted a retrospective study of 776 cT1 solid RCC patients treated with partial nephrectomy (PN) or radical nephrectomy (RN) between 2018 and 2022. All patients underwent four-phase contrast-enhanced CT scans and the CT parameters were obtained by two experienced radiologists using region of interest (ROI). Aggressive pathology was defined as patients with nuclear grade III-IV; upstage to pT3a; type II papillary renal cell carcinoma (pRCC), collecting duct or renal medullary carcinoma, unclassified RCC or sarcomatoid/rhabdoid features. Univariate and multivariate logistic analyses were used to determine significant predictors and develop the nomogram model. To evaluate the accuracy and clinical utility of the nomogram model, we used the receiver operating characteristic (ROC) curve, calibration plot, decision curve analysis (DCA), risk stratification, and subgroup analysis.

Of the 776 cT1 solid RCC patients, 250 (32.2%) had aggressive pathological features. The interclass correlation coefficient (ICC) of CT parameters accessed by two reviewers ranged from 0.758 to 0.982. Logistic regression analyses showed that neutrophil-to-lymphocyte ratio (NLR), distance to the collecting system, CT necrosis, tumor margin irregularity, peritumoral neovascularity, and RER-NP were independent predictive factors associated with aggressive pathology. We built the nomogram model using these significant variables, which had an area under the curve (AUC) of 0.854 in the ROC curve.


Our research demonstrated that preoperative four-phase contrast-enhanced CT was critical for predicting aggressive pathology in cT1 solid RCC, and the constructed nomogram was useful in guiding patient treatment and postoperative follow-up.

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The use of cross-sectional imaging techniques has significantly increased the likelihood of incidental detection of cT1 renal tumors. In most cases, surgery is required to treat T1 RCC. PN is the preferred treatment measure because it can better preserve kidney function and provide similar oncologic outcomes compared to RN [ 1 ]. Although PN offers the chance of cure for T1 RCC patients, it is crucial to elucidate the impact of pathological aggressiveness on patient prognosis based on postoperative histological findings [ 2 ]. The aggressive pathological features, including nuclear grade III/IV, pT3a upstage, sarcomatoid dedifferentiation, and aggressive pathological subtypes are associated with advanced disease and poorer outcomes [ 3 , 4 ]. Apart from surgical treatment, active surveillance and tumor ablation have become important options for the management of T1 RCC patients [ 5 ]. Existing literature suggests that T1 RCC patients with complications or indolent pathology have low cancer-specific mortality. In such cases, active surgical treatment may not improve overall survival (OS) or cancer-specific survival (CSS) compared to active surveillance or tumor ablation [ 6 , 7 , 8 ]. As a consequence, the prediction of aggressive pathology for T1 RCC is essential to determine the patient’s treatment plan and follow-up schedule.

In general, most renal masses can be detected and characterized by imaging such as ultrasound, CT, and MRI. Abdominal contrast-enhanced CT scan is the most common imaging method used to evaluate renal tumors and is known for its predictive value in determining nuclear grade, pT3a upstage, and pathological subtypes of RCC [ 9 , 10 , 11 ]. Renal mass biopsy (RMB) has been performed in recent years to reveal histological characteristics of radiologically indeterminate renal masses. However, the accuracy and safety of RMB are of concern due to the possibility of intratumoral heterogeneity and biopsy tract seeding [ 12 , 13 ].

On four-phase contrast-enhanced CT, distinguishing between benign renal tumors and RCC is relatively straightforward based on features such as macroscopic fat, enhancement characteristics, necrosis, and others [ 14 ]. Most relevant studies have focused on differentiating specific subtypes of benign renal tumors, like fat-poor angiomyolipoma/oncocytomas, from RCC [ 14 ]. The choice of treatment for T1 RCC patients depends on the degree of pathological aggressiveness and the Bosniak grading system in determining the pathological malignancy and aggressiveness of cystic renal masses is accurate. Consequently, our study aimed at predicting the aggressive pathology of cT1 solid RCC and retrospectively enrolled cases with pathologically confirmed diagnoses of RCC. We analyzed the imaging characteristics of 776 cT1 solid RCC patients, including qualitative information such as tumor margin regularity, CT necrosis, calcification, etc., as well as quantitative parameters such as attenuation values of different ROI, and constructed a nomogram model.

Materials and methods

Our retrospective study consecutively enrolled 776 patients diagnosed with cT1 RCC treated in the Second Hospital of Tianjin Medical University between January 2018 and December 2022. To be eligible for our study, patients should meet the following inclusion criteria: (1) Renal mass ≤ 7 cm in maximum diameter; (2) Postoperative pathology confirmed RCC; (3) The patients who underwent contrast-enhanced CT scan, including pre-contrast phase (PCP), corticomedullary phase (CMP), nephrographic phase (NP), and excretory phase (EP) in our medical center. The exclusion criteria were as follows: (1) Renal mass with > 25% cystic component; (2) Presence of perinephric fat/sinus fat/renal vein invasion, local lymph node, or distant metastasis on CT images; (3) Lack of preoperative four-phase contrast-enhanced CT scan; (4) Without surgical treatment (Fig.  1 ).

figure 1

Flow chart of patient inclusion and exclusion criteria

Clinicopathological diagnosis

We collected the clinical factors of cT1 solid RCC patients, including age, gender, laterality, body mass index (BMI), ECOG performance status, symptomatic presentation, hypertension, diabetes, and smoking history. We also collected laboratory test results and surgical findings, including hemoglobin, NLR, surgical approach, and type of nephrectomy. Pathological findings included clinical tumor size, cT stage (AJCC 8th, 2017), histology subtype, surgical margin status, tumor nuclear grade (WHO/ISUP, 2022), pT3a upstage, and sarcomatoid/rhabdoid component. The aggressive pathology of cT1 solid RCC was defined as follows: (1) nuclear grade III-IV; (2) upstage to pT3a; (3) non-clear cell subtypes with adverse prognosis (type II pRCC, collecting duct or renal medullary carcinoma, unclassified RCC); (4) with sarcomatoid/rhabdoid features [ 15 , 16 , 17 ].

CT imaging evaluation

A GE Discovery 750 HD CT scanner was used to conduct renal contrast-enhanced CT from the top of the diaphragm to the anterior superior iliac spine. The CT scanning mode was used with the following parameters: the tube voltage was 120 kV, the tube current was 100 mA, and the reconstruction thickness and scanning thickness were both 1.25 mm. All patients performed PCP of the CT scan before CMP (25 ~ 30 s delay), NP (60 ~ 90 s delay), and EP (120 ~ 180 s delay). For the enhanced examination, 100 ml of the non-ionic contrast iodixitol (containing iodine 300 mg/ml) was injected through the cubital vein with an injection flow rate of 2.5 ml/s.

All CT images were analyzed at a picture archiving and communication system workstation (PACs) and assessed by two radiologists with 6 and 10 years of experience in urological imaging blinded to the pathological results. The qualitative CT features of RCC are as follows: maximal tumor diameter (≤ 4 cm/4 cm ~ 7 cm), exophytic/endophytic rate (≥ 50%/< 50%/Endophytic), distance to the collecting system (> 7 mm/4 mm ~ 7 mm/≤ 4 mm), polar location (entirely above or below the polar line/cross the polar line/> 50% cross the polar line, cross the axial renal midline or entirely between the polar lines) [ 11 ], necrosis [ 18 ], calcification [ 19 ], tumor margin regularity [ 10 ] and peritumoral neovascularity [ 20 ]. The examples of intratumoral necrosis, calcification, tumor margin irregularity, and peritumoral neovascularity are shown in Fig.  2 .

figure 2

Representative images on CT for cT1 solid RCC: ( A ) necrosis, ( B ) calcification, ( C ) peritumoral neovascularization, ( D ) tumor margin irregularity: nodular growth pattern, ( E ) tumor margin irregularity: blurred boundary between renal tumor and parenchyma, (F)tumor margin irregularity: completely non-elliptical shape.  RCC, renal cell carcinoma

The attenuation values [Hounsfeld units (HU)] of ROIs in four-phase contrast-enhanced CT were also recorded, which represented the radiodensity of tissues. The attenuation values of renal tumor (TAV) and renal cortex (TAC) were measured on the same axial image of contrast-enhanced CT. TAV PCP/CMP/NP/EP and TAC PCP/CMP/NP/EP represent the CT attenuation values of the renal tumor and adjacent renal cortex in PCP, CMP, NP, and EP, respectively. The final TAV and TAC are the averages measured by two radiologists. To eliminate the individual differences in CT images resulting from the metabolism of contrast agents, we additionally calculated the net enhancement value of renal tumor (TEV), the net enhancement value of renal cortex (CEV), and the relative enhancement ratio of renal tumor (RER). The TEV and CEV are calculated as follows: TEV CMP/NP/EP =TAV CMP/NP/EP -TAV PCP, CEV CMP/NP/EP =TAC CMP/NP/EP -TAC PCP . The RER is calculated as follows: RER CMP/NP/EP =TAV CMP/NP/EP /TAC CMP/NP/EP . Two radiologists selected ROIs based on the following principles: (1) The ROIs of both the renal tumor and normal renal cortex were consistent in size and location on four-phase contrast-enhanced CT images. (2) The circular or elliptical ROI should include the relatively homogeneous and maximum enhancing solid region of RCC while avoiding intratumoral necrosis, calcification, vasculature, and cystic component. (3) Each area should be measured twice, and if there is more than one solid enhancement region, they should be measured separately and take the average eventually. An example of selecting the ROI for measuring TAV and TAC is shown in Fig.  3 A-D. Furthermore, the heterogeneous degree of tumor (HDT) was determined based on the standard deviation (SD) of CT values. The selection criteria of ROI for measuring HDT are as follows (Fig.  3 E-H): (1) Since the margin of the tumor was most clearly in NP, it was first measured in NP. The ROIs of RCC in PCP, CMP, and EP should be placed refer to NP. (2) The circular or elliptical ROIs should cover the full RCC regions as much as possible, with the margins 2–3 mm medial to the tumor border. (3) Each tumor image should be measured twice, with the average values being recorded.

figure 3

The placement method of ROIs for measuring TAV and TAC: ( A ) PCP, ( B ) CMP, ( C ) NP, ( D ) EP, and for measuring HDT: ( E ) PCP, ( F ) CMP, ( G ) NP, ( H ) EP.  ROI: region of interest; PCP: precontrast phase; CMP: corticomedullary phase; NP: nephrographic phase; EP: excretory phase

Statistical analysis

Our research provided information on the qualitative and quantitative data, with frequency (percentage) and median [interquartile range (IQR)] used respectively. The ICC score was used to assess agreement between two radiologists, with a score > 0.75 regarded as good reproducibility. The comparisons between cT1 solid RCC patients with aggressive and non-aggressive pathology were used by the Student t-test or Mann–Whitney U test for the continuous variables, and the Chi-square test or Fisher’s exact test for the categorical variables. Logistic regressions were used to identify the independent predictors of aggressive pathology. P values in univariate logistic regression were adjusted by the Benjamini-Hochberg FDR method, and the variables with adjusted p values less than 0.05 were considered statistically significant. Variation Inflation Factors (VIF, < 5 being considered non-significant) were performed to evaluate the collinearity of combinations of variables. To evaluate the discrimination performance of the nomogram, a ROC curve was used, while the AUC, calibration plots, and DCA were calculated to assess the accuracy, goodness of fit, and clinical benefit. The risk score and linear predicted probability of individual aggressive pathology were calculated using the significant risk factors and their corresponding regression coefficients. Subsequently, the individual predicted probability was used for risk stratification and subgroup analysis. All statistical analyses were performed using SPSS 22.0 and R software (version 4.3.1), and p  < 0.05 was considered statistically significant.

Clinicopathological and radiologic features

The study analyzed 776 patients with cT1 solid RCC who underwent PN/RN. Out of these, 250 patients had aggressive pathology. The clinicopathological characteristics of all patients are summarized in Table  1 . The median age of the patients was 62.0 years and 72% were male. Among the 250 cT1 solid RCC patients with aggressive pathology, 210 (27.1%) had high nuclear grade, 58 (7.5%) had pT3a upstage, 25 (3.2%) had type II pRCC, collecting duct carcinoma, renal medullary carcinoma or unclassified RCC, and 4 (0.5%) had sarcomatoid/rhabdoid features. There were significant differences between the two groups in terms of age ( P  < 0.001), ECOG performance status ( P  = 0.005), hemoglobin ( P  < 0.001), NLR ( P  < 0.001), type of nephrectomy ( P  < 0.001), clinical tumor size ( P  < 0.001) and histology subtype ( P  < 0.001).

Table  2 displays the CT parameters of the patients who were enrolled in the study. The patients with aggressive pathology exhibited the following qualitative CT parameters: renal tumors located closer to the collecting system ( P  < 0.001), higher RENAL scores ( P  = 0.005), higher rates of CT necrosis ( P  < 0.001), calcification ( P  = 0.044), peritumoral neovascularity ( P  < 0.001), and irregular tumor margins ( P  < 0.001) in the image. We also evaluated quantitative CT data and determined that the ICC between the results measured by two reviewers was high, ranging from 0.758 to 0.982. Regarding TAV, TAC, and HDT, the ICC results were 0.824, 0.758, and 0.811 in PCP; 0.976, 0.982, and 0.895 in CMP; 0.951, 0.962, and 0.916 in NP; and 0.922, 0.963, and 0.914 in EP. Among all quantitative CT parameters, only TAV-CMP ( P  = 0.062) and HDT-NP ( P  = 0.058) were not statistically different between the two groups.

Determination of independent predictors

As illustrated in Table  3 , we included all clinicopathological and radiologic variables and completed the univariate and multivariate logistic regression analyses. The results of univariate analyses showed that age, ECOG performance status, clinical tumor size, hemoglobin, NLR, type of nephrectomy, distance to the collecting system, CT necrosis, tumor margin regularity, peritumoral neovascularity, TAV-PCP, TEV-CMP, RER-CMP, TAV-NP, TEV-NP, RER-NP, TEV-EP, RER-EP and HDT-EP were risk factors of aggressiveness for cT1 solid RCC (all P  < 0.05). Then, we performed a collinearity test for the 19 variables selected from the univariate logistic regression and excluded 4 variables with VIF > 5 (TAV-NP, TEV-NP, TEV-EP, HDT-EP). After incorporating the 15 variables into the multivariate analysis, the result showed that NLR ( P  < 0.001), distance to the collecting system ( P  = 0.036), CT necrosis ( P  < 0.001), tumor margin irregularity ( P  < 0.001), peritumoral neovascularity ( P  = 0.001) and RER-NP ( P  = 0.047) were independent predictors of aggressive pathology for cT1 solid RCC.

Construction and evaluation of the nomogram model

After identifying the independent predictors of aggressiveness for cT1 solid RCC, we constructed a nomogram model, shown in Fig.  4 A. The nomogram model had an AUC of 0.854 (95%CI: 0.826–0.882), with sensitivity and specificity of 0.808 and 0.751, respectively, indicating high discrimination of the model (Fig.  4 B). The calibration plot of the nomogram model presented in Fig.  4 C showed high consistency between the predicted and actual probability of aggressiveness for cT1 solid RCC. The Hosmer-Lemeshow test result was 0.645, revealing a good fit of the nomogram model. The DCA curve in Fig.  4 D indicated that the net benefit of the nomogram model was significantly higher than that of a single variable. Then, we calculated the risk score according to the result of multivariate logistic regression. Risk score = 0.092×NLR + 0 (“N score”=1) /-0.602 (“N score”=2)/+0.307 (“N score”=3) + 0(without CT necrosis)/1.793 (with CT necrosis) + 0 (tumor margin regularity)/2.084 (tumor margin irregularity) + 0 (without peritumoral neovascularity) /1.120 (with peritumoral neovascularity) -2.020×RER_NP -1.559. We also calculated the predicted probability of aggressive pathology for cT1 solid RCC patients according to the formula between risk score and linear predictive probability: ln (P/1−P)  = risk score. Finally, the individual probability of aggressive pathology is calculated as follows: P (aggressive pathology) = 1/(1 + exp −risk score ). We divided all cT1 solid RCC patients into the low-risk ( N  = 258), medium-risk ( N  = 259), and high-risk groups ( N  = 259) on average according to the P value, with the probability of aggressive pathology being 5.8% (15/258), 24.3% (63/259), and 66.4% (172/259), respectively. The cut-off P value was 0.105 between the low-risk and medium-risk groups and 0.400 between the medium-risk and high-risk groups. Subsequently, we performed subgroup analyses of cT1a and cT1b solid RCC patients according to the cut-off values of 0.105 and 0.400. The results showed that the probability of aggressive pathology was 6.2% (9/142), 26.9% (37/120), and 66.1% (84/127) for patients in the low-risk, medium-risk, and high-risk groups in the cT1a subgroup, and 5.3% (6/114),18.4% (26/141), and 66.7% (88/132) in the cT1b subgroup, respectively.

figure 4

A Nomogram, ( B ) ROC curve, ( C ) calibration plot, and ( D ) DCA curve of the model for predicting aggressive pathology of cT1 solid RCC.  RCC: renal cell carcinoma; ROC: receiver operating characteristic; DCA: decision curve analysis.  A straight line was plotted from the corresponding location on each predictor to the “Points” to determine the points of a single predictor. The points of each predictor were summed to obtain a total point, then a straight line was plotted from the “Total Point” to the “Rate” to obtain the probability of aggressive pathology

With the advancement of medical technology, there are now various treatment options available for T1 RCC patients, such as nephrectomy, active surveillance, RMB, radiofrequency ablation, cryoablation, and more. It is essential to provide personalized treatment plans for individuals with T1 RCC, taking into account their age, physical condition, and the anatomical and biological characteristics of their renal tumors. Research has shown that aggressive pathology of RCC is associated with a poor prognosis [ 3 , 4 , 21 , 22 ]. Diagnostic imaging has advantages in distinguishing pathological aggressiveness, and preoperative CT enhancement and texture features are crucial for clinical decision-making in RCC cases. Because of the high accuracy of the Bosniak grading system in stratifying cystic renal masses as to the probability of malignancy, our study developed a nomogram model to predict postoperative pathology in cT1 solid RCC patients.

In our study, we contained 776 patients, and 32.2% of them had aggressive pathology, which is in line with previous findings ranging from 21.1–49% [ 15 , 23 ]. We found that RCC patients with aggressive pathology were older, and had poorer ECOG performance status, higher NLR, higher rate of RN, higher clinical tumor size, and lower hemoglobin. The predictive value of tumor size has been confirmed in earlier reports, Ball et al. found tumor size to be an important risk factor for aggressive histology in cT1a RCC, and Bhindi et al. also reported tumor size-based risk stratification of the probability of adverse pathology in renal masses [ 8 , 24 ]. Aggressive pathology was more common in older patients and resulted in increased frailty and comorbidities [ 16 , 25 ]. In our study cohort, RCC patients with aggressive pathology had more complex tumor anatomy and consequently received a higher proportion of RN to reduce the likelihood of postoperative recurrence. The relationship between systemic inflammation markers and RCC pathology has been previously investigated, and hemoglobin and NLR have been confirmed as independent predictors of unfavorable pathology in cT1 RCC [ 23 ]. As the only clinical predictor included in our nomogram model, NLR is also a well-known prognostic biomarker in various solid tumors, such as RCC, lung cancer, gastric cancer, etc. [ 26 , 27 ]. 

In a recent study, Ficarra et al. summarized several qualitative CT features with a significant role in predicting aggressive pathology of RCC. They found that clinical tumor size, tumor growth rate, enhancement characteristics, tumor margins, CT necrosis, and distance to the renal sinus are relevant features in predicting the biological aggressiveness of RCC, and that peritumoral and intratumoral neovascularity are variables that need to be further accessed [ 18 ]. Our data confirmed that tumor margin irregularity, CT necrosis, distance to the collecting system, and peritumoral neovascularity were independent predictors of aggressive pathology for cT1 solid RCC. However, tumor growth rate could not be recorded in our study since all patients underwent nephrectomy without active surveillance. Although RCC patients with aggressive pathology had a significantly larger clinical tumor size, it was excluded from the final nomogram model after multivariate regression. This may be because our patients with cT1 RCC have other predictors that are more strongly associated with aggressiveness, as the relationship between tumor size and aggressiveness was stronger in T2 and advanced RCC. Radiologists recommend that renal tumor margins should be classified into “circumscribed” and “irregular” [ 28 ]. In our study, tumor margin irregularity includes three categories nodular growth pattern, blurred boundary between renal tumor and parenchyma, and completely non-elliptical shape, which are summarised by previous literature [ 10 , 16 , 29 ]. The presence of irregular renal tumor margins has been shown to be a strong predictor of perirenal/renal sinus fat invasion, pT3a upstage, and aggressive histology subtype [ 10 , 29 , 30 ]. Our findings align with previous literature and confirm that irregular renal tumor margin is an important independent risk factor of aggressive pathology for cT1 solid RCC. Moreover, as an important part of the RENAL nephrometry score, the distance of the renal tumor to the collecting system less than 4 mm in the image implies a higher rate of renal sinus fat invasion and upstaging to pT3a. Its potential role in predicting high nuclear grade and aggressive histological subtypes of RCC has also been reported and confirmed [ 30 , 31 ]. Interestingly, our results suggest that compared to the distance greater than 7 mm from the collecting system, cT1 RCC with a distance between 4 and 7 mm has a lower probability of aggressive pathology, due to its lower rate of perirenal fat invasion. Previous studies have demonstrated that CT necrosis of renal masses was closely related to pT3a RCC, high nuclear grade, sarcomatoid dedifferentiation, and aggressive histological subtypes [ 30 , 32 , 33 , 34 ]. Similarly, our study arrived at comparable outcomes. Peritumoral neovascularity was not routinely reported by radiologists, but it may have potential predictive value. Recently, Yanagi et al. reported that peritumoral neovascularity was a significant factor associated with tumor recurrence in patients with small renal masses, and Suo et al. found that RCC patients with peritumoral neovascularity had higher pT stage, nuclear grade, and shorter OS [ 20 , 35 ]. There is increasing evidence that the high level of peritumoral angiogenesis is associated with aggressiveness of RCC and our study confirmed that peritumoral neovascularity could be interpreted as a predictor of aggressiveness [ 36 ].

To our acknowledgment, several studies have utilized quantitative CT-derived parameters to differentiate histological subtypes, nuclear grade, and prognosis [ 37 , 38 , 39 ]. However, this is the first study to combine qualitative and quantitative CT parameters for the prediction of aggressive pathology in RCC. Coy et al. reported that clear cell RCC with high nuclear grade had lower enhancement values in NP and EP, and absolute enhancement < 52 HU was an independent predictor of high nuclear grade in NP [ 39 ]. Similarly, Zhu et al. identified age, irregular tumor margin, and low tumor enhancement as independent predictors of high tumor grade [ 37 ]. We also found statistically significant lower TAV, TEV, and RER of aggressive RCC in NP and EP, which may be due to the difference of microvessel density and micronecrotic areas between aggressive and non-aggressive RCC [ 37 , 39 , 40 ]. Because of the less enhancement of renal tumor compared to the surrounding renal cortex, the NP was commonly considered as the most sensitive phase for characterizing renal masses. We incorporated renal cortex enhancement as the reference and found that RER-NP was negatively correlated with aggressive pathology as an independent predictor in cT1 solid RCC. Furthermore, we found that HDT of RCC was higher in patients with aggressive pathology. The relatively high local necrosis and ischemic change of RCC with aggressiveness result in the decrease of attenuation value in this area, which exhibits enhanced heterogeneity in the ROI region. Additionally, the aggressive pathological features make the blood supply within RCC unbalanced, and the distribution degree of iodine agent within the tumor varies largely, leading to a significantly higher HDT value. Based on the previous literature review, we included as many variables as possible that may be relevant to aggressive pathology of RCC. No variables related to the EP were included in the final nomogram. Given that not all medical centers include the EP in contrast-enhanced CT when evaluating renal masses that do not invade the collecting system, our nomogram can be applied without limitations in these medical centers. Ultimately, our nomogram model had an AUC of 0.854, diagnostic sensitivity and specificity of 0.808 and 0.751, with good calibration and net clinical benefit. Our model outperforms other existing predictive methods for RCC aggressive pathology [ 8 , 23 , 24 , 30 ]. The individual predictive probability of aggressive pathology, based on our nomogram model, was also calculated and proved to be significant for guiding clinical treatment. Utilizing 0.105 and 0.400 as the cut-off values for the low-risk, medium-risk, and high-risk groups demonstrated excellent risk stratification capability in cT1 solid RCC patients, as well as within the cT1a and cT1b subgroups. Our results recommend active surveillance for cT1 solid RCC patients with linear predictive probability values less than 0.105, and PN/RN for patients with linear predictive probability values greater than 0.400.

There are certain limitations to our research. Firstly, our study was a retrospective analysis carried out in a single institution, which may cause selection bias. Our nomogram model still needs to be further validated with samples from other medical centers. Secondly, different patients have varying abilities to metabolize contrast agents, leading to individual differences in the enhanced scanning time, which may affect the quantitative CT parameters. Although we applied renal cortex CT values as the reference and correction, further research is needed to eliminate the impact of scanning time on the final diagnostic performance. Thirdly, our study only included cT1 RCC patients and focused on the impact of contrast-enhanced CT on pathology. In future studies, cT2 and locally advanced RCC patients should also be included. Other emerging imaging methods, such as radiomics texture analysis and 3D reconstruction, should also be applied and compared to explore the differences and correlations among these methods in imaging-based diagnosis.

In conclusion, based on CT features and clinical data, we have developed a nomogram model that can predict the risk of aggressive pathology in cT1 solid RCC patients accurately. Our nomogram model could be used to calculate the individualized risk of aggressive pathology and provide treatment decisions for cT1 solid RCC patients.

Availability of data and materials

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


Renal cell carcinoma

Partial nephrectomy

Radical nephrectomy

Region of interest

Receiver operating characteristic

Decision curve analysis

Interclass correlation coefficient

Neutrophil-to-lymphocyte ratio

Area under the curve

Computed tomography

Overall survival

Cancer-specific survival

Renal mass biopsy

Pre-contrast phase

Corticomedullary phase

Nephrographic phase

Excretory phase

Attenuation value of renal tumor

Attenuation value of renal cortex

Net enhancement value of renal tumor

Net enhancement value of renal cortex

Enhancement ratio

Heterogeneous degree of tumor

Body mass index

Standard deviation

Interquartile range

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This study was supported by the Tianjin Municipal Natural Science Foundation (grant no.21JCYBJC01690).

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Keruo Wang, Liang Dong and Songyang Li contributed equally to this work.

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Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, China

Keruo Wang, Liang Dong, Songyang Li, Yuanjie Niu & Gang Li

Department of Pulmonary & Critical Care Medicine, 8th Medical Center, Chinese PLA General Hospital, Beijing, China

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KRW raised conceptualization and drafted the manuscript; SYL and LD collected data and performed data analysis; YRL was responsible for data curation and critically revised the manuscript; YJN and GL administrated the whole project and critically revised the manuscript; All authors read and approved the final manuscript.

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Correspondence to Yuanjie Niu or Gang Li .

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This study was approved by the Institutional Review Board of Tianjin Medical University. All procedures followed were in accordance with the Helsinki Declaration of 1964 and later versions and informed consent was taken from all individual participants.

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Wang, K., Dong, L., Li, S. et al. CT features based preoperative predictors of aggressive pathology for clinical T1 solid renal cell carcinoma and the development of nomogram model. BMC Cancer 24 , 148 (2024). https://doi.org/10.1186/s12885-024-11870-1

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DOI : https://doi.org/10.1186/s12885-024-11870-1

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Qualitative and quantitative analysis of lipids in Exparel® injectable liposomal drug formulation

2023 FDA Science Forum

Application of liposomal formulations in drug delivery has gained popularity because of distinct advantages over traditional drug formulations in altered drug distribution, sustained delivery, and others. Exparel® is a multivesicular liposomal formulation (MVL) of bupivacaine, which provides sustained release at the site of injection resulting in prolong anesthetic effect. MVL possesses a unique structural assembly of multiple polyhedral chambers separated by lipid septal, providing prolonged release following the in vivo erosion of lipid membranes. Compared to univesicular liposomes, MVL use charge neutral triacylglycerols which serve as space fillers at the lipid membrane intersection, leading to structural stability of the MVLs. As the lipid composition leads to its unique structure, the quantification of major lipid constituents and identification of possible minor lipids, lipid degradation products, and cholesterol oxidation products are necessary for a complete evaluation of the formulation. We utilized a novel UHPLC-ESI-QTOF method and SimLipid® high throughput lipid identification software to identify and quantify all the major and minor lipids, cholesterol oxidation products, the active pharmaceutical ingredient (API) and its enantiomers in two batches of commercially available Exparel® injectable liposomal drug formulation. We identified 24 minor lipids and two cholesterol oxidation products in the formulation. Out of the 24 minor lipids identified, 22 were phospholipids and the others were triacylglycerols. The two batches of Exparel® were found to contain 4.264% and 3.699% of minor lipids content as compared to the total amounts of lipids. This approach has allowed us to analyze the major and minor lipid excipient content of an MVL drug formulation and could be used for comparison of different Exparel® batches as well as future generic and brand product comparison.

Qualitative and quantitative analysis of lipids in Exparel® injectable liposomal drug formulation

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