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• Qualitative vs. Quantitative Research | Differences, Examples & Methods

Qualitative vs. Quantitative Research | Differences, Examples & Methods

Published on April 12, 2019 by Raimo Streefkerk . Revised on June 22, 2023.

When collecting and analyzing data, quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings. Both are important for gaining different kinds of knowledge.

Common quantitative methods include experiments, observations recorded as numbers, and surveys with closed-ended questions.

Quantitative research is at risk for research biases including information bias , omitted variable bias , sampling bias , or selection bias . Qualitative research Qualitative research is expressed in words . It is used to understand concepts, thoughts or experiences. This type of research enables you to gather in-depth insights on topics that are not well understood.

Common qualitative methods include interviews with open-ended questions, observations described in words, and literature reviews that explore concepts and theories.

Table of contents

The differences between quantitative and qualitative research, data collection methods, when to use qualitative vs. quantitative research, how to analyze qualitative and quantitative data, other interesting articles, frequently asked questions about qualitative and quantitative research.

Quantitative and qualitative research use different research methods to collect and analyze data, and they allow you to answer different kinds of research questions.

Quantitative and qualitative data can be collected using various methods. It is important to use a data collection method that will help answer your research question(s).

Many data collection methods can be either qualitative or quantitative. For example, in surveys, observational studies or case studies , your data can be represented as numbers (e.g., using rating scales or counting frequencies) or as words (e.g., with open-ended questions or descriptions of what you observe).

However, some methods are more commonly used in one type or the other.

Quantitative data collection methods

• Surveys :  List of closed or multiple choice questions that is distributed to a sample (online, in person, or over the phone).
• Experiments : Situation in which different types of variables are controlled and manipulated to establish cause-and-effect relationships.
• Observations : Observing subjects in a natural environment where variables can’t be controlled.

Qualitative data collection methods

• Interviews : Asking open-ended questions verbally to respondents.
• Focus groups : Discussion among a group of people about a topic to gather opinions that can be used for further research.
• Ethnography : Participating in a community or organization for an extended period of time to closely observe culture and behavior.
• Literature review : Survey of published works by other authors.

A rule of thumb for deciding whether to use qualitative or quantitative data is:

• Use quantitative research if you want to confirm or test something (a theory or hypothesis )
• Use qualitative research if you want to understand something (concepts, thoughts, experiences)

For most research topics you can choose a qualitative, quantitative or mixed methods approach . Which type you choose depends on, among other things, whether you’re taking an inductive vs. deductive research approach ; your research question(s) ; whether you’re doing experimental , correlational , or descriptive research ; and practical considerations such as time, money, availability of data, and access to respondents.

Quantitative research approach

You survey 300 students at your university and ask them questions such as: “on a scale from 1-5, how satisfied are your with your professors?”

You can perform statistical analysis on the data and draw conclusions such as: “on average students rated their professors 4.4”.

Qualitative research approach

You conduct in-depth interviews with 15 students and ask them open-ended questions such as: “How satisfied are you with your studies?”, “What is the most positive aspect of your study program?” and “What can be done to improve the study program?”

Based on the answers you get you can ask follow-up questions to clarify things. You transcribe all interviews using transcription software and try to find commonalities and patterns.

Mixed methods approach

You conduct interviews to find out how satisfied students are with their studies. Through open-ended questions you learn things you never thought about before and gain new insights. Later, you use a survey to test these insights on a larger scale.

It’s also possible to start with a survey to find out the overall trends, followed by interviews to better understand the reasons behind the trends.

Qualitative or quantitative data by itself can’t prove or demonstrate anything, but has to be analyzed to show its meaning in relation to the research questions. The method of analysis differs for each type of data.

Analyzing quantitative data

Quantitative data is based on numbers. Simple math or more advanced statistical analysis is used to discover commonalities or patterns in the data. The results are often reported in graphs and tables.

Applications such as Excel, SPSS, or R can be used to calculate things like:

• Average scores ( means )
• The number of times a particular answer was given
• The correlation or causation between two or more variables
• The reliability and validity of the results

Analyzing qualitative data

Qualitative data is more difficult to analyze than quantitative data. It consists of text, images or videos instead of numbers.

Some common approaches to analyzing qualitative data include:

• Qualitative content analysis : Tracking the occurrence, position and meaning of words or phrases
• Thematic analysis : Closely examining the data to identify the main themes and patterns
• Discourse analysis : Studying how communication works in social contexts

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.

In mixed methods research , you use both qualitative and quantitative data collection and analysis methods to answer your research question .

The research methods you use depend on the type of data you need to answer your research question .

• If you want to measure something or test a hypothesis , use quantitative methods . If you want to explore ideas, thoughts and meanings, use qualitative methods .
• If you want to analyze a large amount of readily-available data, use secondary data. If you want data specific to your purposes with control over how it is generated, collect primary data.
• If you want to establish cause-and-effect relationships between variables , use experimental methods. If you want to understand the characteristics of a research subject, use descriptive methods.

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 .

A research project is an academic, scientific, or professional undertaking to answer a research question . Research projects can take many forms, such as qualitative or quantitative , descriptive , longitudinal , experimental , or correlational . What kind of research approach you choose will depend on your topic.

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Qualitative vs Quantitative Research Methods & Data Analysis

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What is the difference between quantitative and qualitative?

The main difference between quantitative and qualitative research is the type of data they collect and analyze.

Quantitative research collects numerical data and analyzes it using statistical methods. The aim is to produce objective, empirical data that can be measured and expressed in numerical terms. Quantitative research is often used to test hypotheses, identify patterns, and make predictions.

Qualitative research , on the other hand, collects non-numerical data such as words, images, and sounds. The focus is on exploring subjective experiences, opinions, and attitudes, often through observation and interviews.

Qualitative research aims to produce rich and detailed descriptions of the phenomenon being studied, and to uncover new insights and meanings.

Quantitative data is information about quantities, and therefore numbers, and qualitative data is descriptive, and regards phenomenon which can be observed but not measured, such as language.

What Is Qualitative Research?

Qualitative research is the process of collecting, analyzing, and interpreting non-numerical data, such as language. Qualitative research can be used to understand how an individual subjectively perceives and gives meaning to their social reality.

Qualitative data is non-numerical data, such as text, video, photographs, or audio recordings. This type of data can be collected using diary accounts or in-depth interviews and analyzed using grounded theory or thematic analysis.

Qualitative research is multimethod in focus, involving an interpretive, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Denzin and Lincoln (1994, p. 2)

Interest in qualitative data came about as the result of the dissatisfaction of some psychologists (e.g., Carl Rogers) with the scientific study of psychologists such as behaviorists (e.g., Skinner ).

Since psychologists study people, the traditional approach to science is not seen as an appropriate way of carrying out research since it fails to capture the totality of human experience and the essence of being human.  Exploring participants’ experiences is known as a phenomenological approach (re: Humanism ).

Qualitative research is primarily concerned with meaning, subjectivity, and lived experience. The goal is to understand the quality and texture of people’s experiences, how they make sense of them, and the implications for their lives.

Qualitative research aims to understand the social reality of individuals, groups, and cultures as nearly as possible as participants feel or live it. Thus, people and groups are studied in their natural setting.

Some examples of qualitative research questions are provided, such as what an experience feels like, how people talk about something, how they make sense of an experience, and how events unfold for people.

Research following a qualitative approach is exploratory and seeks to explain ‘how’ and ‘why’ a particular phenomenon, or behavior, operates as it does in a particular context. It can be used to generate hypotheses and theories from the data.

Qualitative Methods

There are different types of qualitative research methods, including diary accounts, in-depth interviews , documents, focus groups , case study research , and ethnography.

The results of qualitative methods provide a deep understanding of how people perceive their social realities and in consequence, how they act within the social world.

The researcher has several methods for collecting empirical materials, ranging from the interview to direct observation, to the analysis of artifacts, documents, and cultural records, to the use of visual materials or personal experience. Denzin and Lincoln (1994, p. 14)

Here are some examples of qualitative data:

Interview transcripts : Verbatim records of what participants said during an interview or focus group. They allow researchers to identify common themes and patterns, and draw conclusions based on the data. Interview transcripts can also be useful in providing direct quotes and examples to support research findings.

Observations : The researcher typically takes detailed notes on what they observe, including any contextual information, nonverbal cues, or other relevant details. The resulting observational data can be analyzed to gain insights into social phenomena, such as human behavior, social interactions, and cultural practices.

Unstructured interviews : generate qualitative data through the use of open questions.  This allows the respondent to talk in some depth, choosing their own words.  This helps the researcher develop a real sense of a person’s understanding of a situation.

Diaries or journals : Written accounts of personal experiences or reflections.

Notice that qualitative data could be much more than just words or text. Photographs, videos, sound recordings, and so on, can be considered qualitative data. Visual data can be used to understand behaviors, environments, and social interactions.

Qualitative Data Analysis

Qualitative research is endlessly creative and interpretive. The researcher does not just leave the field with mountains of empirical data and then easily write up his or her findings.

Qualitative interpretations are constructed, and various techniques can be used to make sense of the data, such as content analysis, grounded theory (Glaser & Strauss, 1967), thematic analysis (Braun & Clarke, 2006), or discourse analysis .

For example, thematic analysis is a qualitative approach that involves identifying implicit or explicit ideas within the data. Themes will often emerge once the data has been coded .

Key Features

• Events can be understood adequately only if they are seen in context. Therefore, a qualitative researcher immerses her/himself in the field, in natural surroundings. The contexts of inquiry are not contrived; they are natural. Nothing is predefined or taken for granted.
• Qualitative researchers want those who are studied to speak for themselves, to provide their perspectives in words and other actions. Therefore, qualitative research is an interactive process in which the persons studied teach the researcher about their lives.
• The qualitative researcher is an integral part of the data; without the active participation of the researcher, no data exists.
• The study’s design evolves during the research and can be adjusted or changed as it progresses. For the qualitative researcher, there is no single reality. It is subjective and exists only in reference to the observer.
• The theory is data-driven and emerges as part of the research process, evolving from the data as they are collected.

Limitations of Qualitative Research

• Because of the time and costs involved, qualitative designs do not generally draw samples from large-scale data sets.
• The problem of adequate validity or reliability is a major criticism. Because of the subjective nature of qualitative data and its origin in single contexts, it is difficult to apply conventional standards of reliability and validity. For example, because of the central role played by the researcher in the generation of data, it is not possible to replicate qualitative studies.
• Also, contexts, situations, events, conditions, and interactions cannot be replicated to any extent, nor can generalizations be made to a wider context than the one studied with confidence.
• The time required for data collection, analysis, and interpretation is lengthy. Analysis of qualitative data is difficult, and expert knowledge of an area is necessary to interpret qualitative data. Great care must be taken when doing so, for example, looking for mental illness symptoms.

Advantages of Qualitative Research

• Because of close researcher involvement, the researcher gains an insider’s view of the field. This allows the researcher to find issues that are often missed (such as subtleties and complexities) by the scientific, more positivistic inquiries.
• Qualitative descriptions can be important in suggesting possible relationships, causes, effects, and dynamic processes.
• Qualitative analysis allows for ambiguities/contradictions in the data, which reflect social reality (Denscombe, 2010).
• Qualitative research uses a descriptive, narrative style; this research might be of particular benefit to the practitioner as she or he could turn to qualitative reports to examine forms of knowledge that might otherwise be unavailable, thereby gaining new insight.

What Is Quantitative Research?

Quantitative research involves the process of objectively collecting and analyzing numerical data to describe, predict, or control variables of interest.

The goals of quantitative research are to test causal relationships between variables , make predictions, and generalize results to wider populations.

Quantitative researchers aim to establish general laws of behavior and phenomenon across different settings/contexts. Research is used to test a theory and ultimately support or reject it.

Quantitative Methods

Experiments typically yield quantitative data, as they are concerned with measuring things.  However, other research methods, such as controlled observations and questionnaires , can produce both quantitative information.

For example, a rating scale or closed questions on a questionnaire would generate quantitative data as these produce either numerical data or data that can be put into categories (e.g., “yes,” “no” answers).

Experimental methods limit how research participants react to and express appropriate social behavior.

Findings are, therefore, likely to be context-bound and simply a reflection of the assumptions that the researcher brings to the investigation.

There are numerous examples of quantitative data in psychological research, including mental health. Here are a few examples:

Another example is the Experience in Close Relationships Scale (ECR), a self-report questionnaire widely used to assess adult attachment styles .

The ECR provides quantitative data that can be used to assess attachment styles and predict relationship outcomes.

Neuroimaging data : Neuroimaging techniques, such as MRI and fMRI, provide quantitative data on brain structure and function.

This data can be analyzed to identify brain regions involved in specific mental processes or disorders.

For example, the Beck Depression Inventory (BDI) is a clinician-administered questionnaire widely used to assess the severity of depressive symptoms in individuals.

The BDI consists of 21 questions, each scored on a scale of 0 to 3, with higher scores indicating more severe depressive symptoms. 

Quantitative Data Analysis

Statistics help us turn quantitative data into useful information to help with decision-making. We can use statistics to summarize our data, describing patterns, relationships, and connections. Statistics can be descriptive or inferential.

Descriptive statistics help us to summarize our data. In contrast, inferential statistics are used to identify statistically significant differences between groups of data (such as intervention and control groups in a randomized control study).

• Quantitative researchers try to control extraneous variables by conducting their studies in the lab.
• The research aims for objectivity (i.e., without bias) and is separated from the data.
• The design of the study is determined before it begins.
• For the quantitative researcher, the reality is objective, exists separately from the researcher, and can be seen by anyone.
• Research is used to test a theory and ultimately support or reject it.

Limitations of Quantitative Research

• Context: Quantitative experiments do not take place in natural settings. In addition, they do not allow participants to explain their choices or the meaning of the questions they may have for those participants (Carr, 1994).
• Researcher expertise: Poor knowledge of the application of statistical analysis may negatively affect analysis and subsequent interpretation (Black, 1999).
• Variability of data quantity: Large sample sizes are needed for more accurate analysis. Small-scale quantitative studies may be less reliable because of the low quantity of data (Denscombe, 2010). This also affects the ability to generalize study findings to wider populations.
• Confirmation bias: The researcher might miss observing phenomena because of focus on theory or hypothesis testing rather than on the theory of hypothesis generation.

Advantages of Quantitative Research

• Scientific objectivity: Quantitative data can be interpreted with statistical analysis, and since statistics are based on the principles of mathematics, the quantitative approach is viewed as scientifically objective and rational (Carr, 1994; Denscombe, 2010).
• Useful for testing and validating already constructed theories.
• Rapid analysis: Sophisticated software removes much of the need for prolonged data analysis, especially with large volumes of data involved (Antonius, 2003).
• Replication: Quantitative data is based on measured values and can be checked by others because numerical data is less open to ambiguities of interpretation.
• Hypotheses can also be tested because of statistical analysis (Antonius, 2003).

Antonius, R. (2003). Interpreting quantitative data with SPSS . Sage.

Black, T. R. (1999). Doing quantitative research in the social sciences: An integrated approach to research design, measurement and statistics . Sage.

Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology . Qualitative Research in Psychology , 3, 77–101.

Carr, L. T. (1994). The strengths and weaknesses of quantitative and qualitative research : what method for nursing? Journal of advanced nursing, 20(4) , 716-721.

Denscombe, M. (2010). The Good Research Guide: for small-scale social research. McGraw Hill.

Denzin, N., & Lincoln. Y. (1994). Handbook of Qualitative Research. Thousand Oaks, CA, US: Sage Publications Inc.

Glaser, B. G., Strauss, A. L., & Strutzel, E. (1968). The discovery of grounded theory; strategies for qualitative research. Nursing research, 17(4) , 364.

Minichiello, V. (1990). In-Depth Interviewing: Researching People. Longman Cheshire.

Punch, K. (1998). Introduction to Social Research: Quantitative and Qualitative Approaches. London: Sage

Further Information

• Mixed methods research
• Designing qualitative research
• Methods of data collection and analysis
• Introduction to quantitative and qualitative research
• Checklists for improving rigour in qualitative research: a case of the tail wagging the dog?
• Qualitative research in health care: Analysing qualitative data
• Qualitative data analysis: the framework approach
• Using the framework method for the analysis of
• Qualitative data in multi-disciplinary health research
• Content Analysis
• Grounded Theory
• Thematic Analysis

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Is it Quantitative... or Qualitative?

Quantitative research is:.

• The dominant 'research framework' in the social sciences and the hard sciences
• It's a set of strategies, techniques and assumptions used to study phenomena and answer questions through the  exploration of numeric patterns
• Quantitative research includes methodologies such as questionnaires, structured observations or experiments
• Used to generate knowledge and create understanding about the world by using scientific inquiry and data that are observed or measured  to examine questions / hypotheses about our reality

Allen, M. (2017).  The SAGE encyclopedia of communication research methods  (Vols. 1-4). Thousand Oaks, CA: SAGE Publications, Inc doi: 10.4135/9781483381411 Coghlan, D., Brydon-Miller, M. (2014).  The SAGE encyclopedia of action research  (Vols. 1-2). London, : SAGE Publications Ltd doi: 10.4135/9781446294406

Qualitative Research is:

• A process of 'naturalistic inquiry' that seeks an in-depth understanding of social phenomena within their natural setting .
• It focuses on the "why" rather than the "what" of social phenomena and relies on the direct experiences of human beings as meaning-making agents in their every day lives.
• Rather than by logical and statistical procedures, qualitative researchers use multiple systems of inquiry for the study of human phenomena including biography, case study, historical analysis, discourse analysis, ethnography, grounded theory, and phenomenology.

From: University of Utah College of Nursing, (n.d.).  What is qualitative research?  [Guide] Retrieved from  https://nursing.utah.edu/research/qualitative-research/what-is-qualitative-research.php#what 

Compare the Two

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The Fundamental Difference Between Qualitative and Quantitative Data in Mixed Methods Research

• Judith Schoonenboom University of Vienna

Mixed methods research is commonly defined as the combination and integration of qualitative and quantitative data. However, defining these two data types has proven difficult. In this article, I argue that qualitative and quantitative data are fundamentally different, and this difference is not about words and numbers but about condensation and structure. As qualitative data are analyzed with qualitative methods and quantitative data with quantitative methods, we cannot analyze one type of data with the other type of method. Quantitative data analysis can reveal new patterns, but these are always related to the existing variables, whereas qualitative data analysis can reveal new aspects that are hidden in the data. To consider data as quantitative or qualitative, we should judge these data as end products, not in terms of the process through which they come into being. Thus, quantitizing qualitative data results in quantitative data and the analysis thereof is quantitative, not mixed, data analysis. For mixed data analysis, both real , non-quantitized qualitative data and quantitative data are needed. As these quantitative data may be quantitized qualitative data, the implication is that, contrary to a common view, mixed methods research does not necessarily involve quantitative data collection.

Author Biography

Judith schoonenboom, university of vienna.

Judith SCHOONENBOOM is professor of empirical pedagogy at the University of Vienna, Austria. She has extensive experience in designing and evaluating innovations in education, especially those involving educational technology. Her research interests include mixed methods design and the foundations of mixed methods research. Judith is an associate editor of the Journal of Mixed Methods Research and a past president (2020-2021) of the Mixed Methods International Research Association (MMIRA).

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Bergman, Manfred M. (2008). The strawmen of the qualitative-quantitative divide and their influence on mixed methods research. In Manfred M. Bergman (Ed.), Advances in mixed methods research (pp.11-21). Los Angeles, CA: Sage.

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Bryman, Alan (2008). Why do researchers integrate/combine/mesh/blend/mix/merge/fuse quantitative and qualitative research?. In Manfred M. Bergman (Ed.), Advances in mixed methods research (pp.87-100). Los Angeles, CA: Sage.

Caracelli, Valerie J. & Greene, Jennifer C. (1993). Data analysis strategies for mixed-method evaluation designs. Educational Evaluation and Policy Analysis, 15(2), 195-207.

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SYSTEMATIC REVIEW article

A rapid review of the barriers and facilitators of mental health service access among veterans and their families.

• 1 MacDonald Franklin OSI Research and Innovation Centre, Lawson Health Research Institute, London, ON, Canada
• 2 Department of Psychiatry, Western University, London, ON, Canada
• 3 Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
• 4 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
• 5 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
• 6 St. Joseph’s OSI Clinic, St. Joseph’s Health Care London, London, ON, Canada

Introduction: Transitioning to civilian life after military service can be challenging for both Veterans and their families. Accessible mental health services are crucial during this period to provide support. The objective of this review was to conduct a rapid review to capture the barriers and identify facilitators that influence access to mental health services for Veterans and their families during the post-service transition period.

Methods: This review was conducted using the Cochrane Handbook for Systematic Reviews of Interventions as a methodological framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Rapid Review (PRISMA-RR).

Results: A total of 60 articles and 67 independent samples were included in the final data analyses. Across the included articles, this review identified 23 barriers and 14 facilitator themes. Issues navigating the mental health care system was identified as the main challenge among Veterans and their families, and those who received support navigating the system identified this as a significant facilitator. Applying the Theoretical Domains Framework, most of the identified barriers and facilitators were categorized into environmental context and resources domain.

Discussion: The heterogeneity in Veterans' and Veteran families' experiences with mental health care-seeking may suggest that access to mental health care for Veterans and Veteran families cannot be solved by addressing one type of barrier alone. Instead, coordinated efforts to address prioritized systemic, logistical, social, and inter-/intrapersonal obstacles are essential for improving access and optimizing mental health care outcomes. These insights underscore the complexity of considerations for Veterans and families accessing mental health care.

Introduction

For some Veterans, the post-service period is characterized by complex challenges ( 1 , 2 ). Indeed, over one-third of Canadian Armed Forces (CAF) Veterans report a moderate or very difficult transition to civilian life ( 3 ). The reintegration experience involves significant changes to one's physical environment (e.g., work, housing) and identity (e.g., role within the family, relationships), which impose new duties, expectations, and stressors. A difficult transition to civilian life has been associated with poor mental health outcomes ( 2 ), including an increased risk of mental disorders and suicide ( 4 , 5 ). Importantly, these changes are embedded within larger socio-ecological contexts and are amplified by existing health disparities and inequities.

While the perceived need for mental health care increases following the transition from the military to civilian life, St. Cyr et al. ( 6 ) found that a similar percentage of active members of the CAF and Canadian Veterans report accessing mental health care in the previous year. However, Veterans may experience different barriers to mental health care than actively serving military personnel, including geographical barriers to care (vs. having health care services readily available on base) and a lack of resources or knowledge of available support for Veterans [e.g., ( 7 – 9 )]. Further, certain aspects of military culture, such as a strong emphasis on self-reliance, may be integrated into Veterans' core beliefs ( 10 , 11 ) and deter help seeking. Additionally, the interpersonal, psychological, and behavioural difficulties that may be experienced during the post-service transition may also serve as barriers to treatment-seeking in this population ( 9 , 12 ). Finally, it is important to note that following the transition to civilian life, access to certain services and supports (e.g., unit support, military-specific mental health care) may become more limited or stop ( 13 , 14 ). Importantly, research has found a positive relation between mental health care access and health status among Veteran population [see ( 15 )], which may also extend to the families of transitioning Veterans given the experiential link between Veterans and their family members [e.g., ( 9 )]. Indeed, Schwartz et al. ( 9 ) note that many of the aforementioned barriers also impact Veteran family members, although the severity of their impact may vary with respect to various individual and environmental factors ( 9 ). Further, Maguire et al. ( 16 ) found that many health and wellbeing needs of Veteran families are amplified during the transition from military service to civilian life, and these families often face challenges navigating civilian systems of care. Indeed, Veterans and their families may encounter additional difficulties relative to active duty military personnel, especially related to continuity of care following release from the military when sources of health care and benefits change as a result of Veteran status [e.g., from the Department of Defense to Veterans Affairs; ( 17 )]. It is therefore critical to elucidate existing barriers and facilitators to mental health care among Veterans and Veteran families to understand gaps in service access or experiences [including across demographic characteristics, such as gender; see Cornish et al., ( 12 )].

To inform health care planning and policies within Canada, it is necessary to explore contemporary literature which describes experiences among similar populations of Veterans and families. As such, examining literature from across the Five Eyes nations (i.e., Australia, Canada, New Zealand, United Kingdom, United States), which are all Westernized countries sharing important similarities such as governmental structure and historical and military alliances [as noted in ( 18 )], broadens the scope of available information when considering experiences of miliary personnel and families. Further, a representative sample across these countries allows for examinations of certain between-country nuances (e.g., health care delivery systems) in a review context [e.g., ( 19 )]. For example, one report [see ( 20 )] noted high discrepancies in budgets for expenditures, and the number of case managers and staff available to Veterans across various allied nations, among other findings.

Given the complexity of barriers and facilitators affecting mental health service access for Veterans and their families, there is a need for a structured, theory-based approach to identify and address these critical factors effectively. The Theoretical Domains Framework [TDF; ( 21 , 22 )] offers a particularly effective method for this purpose. The TDF an integrative framework used to support implementation objectives by providing a sound theoretical basis for assessing behavioural influences and promoting behavioural change to improve outcomes in various clinical contexts. The TDF outlines 14 domains (e.g., knowledge, skills, optimism, beliefs about consequences, goals, etc.) which include 84 component constructs that further specify aspects of each domain [e.g., within the domain of knowledge: procedural knowledge, knowledge of task environment, and other relevant knowledge; ( 22 )]. These domains, in turn, influence physical, psychological, social, automatic, and reflective sources of behaviours that contribute to one's capability, opportunity, and motivation, which interact to produce behaviour ( 21 ). Notably, the TDF can be applied both deductively (e.g., as a preliminary framework for content analysis) and inductively [e.g., to generate themes relative to domains; ( 21 )]. In the present review, the inductive utility of TDF was applied to identify barriers and facilitators which might influence treatment-seeking behaviours among Veterans and their families. The TDF has been successfully used to assess barriers and facilitators across different areas of health care [e.g., ( 23 , 24 )]; this review extends its use to specifically address the empirical literature concerning mental health service access by Veterans and families, providing a novel insight into this context.

Existing systematic reviews examining health-related behaviours among Veterans either focus exclusively on quantitative research ( 25 ) or were specific to help-seeking behaviours ( 26 ) which are distinct from actual access to care. Further, existing reviews do not contextualize findings within a validated framework. Taken together, the aim of this review is to identify barriers and facilitators to mental health care by examining the lived experiences (via qualitative and quantitative data) of Veterans and their families accessing mental health care during the post-service period, through the lens of the TDF. Findings from this review can be used to highlight considerations or inform actionable recommendations related to health policy for Canadian Veterans. Specifically, this review aimed to address the following research questions: (1) How do Veterans and family members articulate barriers and facilitators to access to and reception of mental health services during the post-service period?; (2) What factors may optimize access to and reception of mental health services for Veterans and families during the post-service period?; (3) What considerations may need to be in place at the policy level to facilitate changes to better promote mental health access and care for Veterans and their families during the post-service period?; and (4) How does mental health interact with other domains of wellbeing (as represented in the TDF)?

This review was conducted using the Cochrane Handbook for Systematic Reviews of Interventions as a methodological framework ( 27 ). Cochrane guidelines were chosen as they are internationally regarded for their transparency, standardized and replicable methodologies, and methodological rigour across a variety of health and health related disciplines synthesizing both quantitative and qualitative data [e.g., ( 28 – 30 )]. Indeed, one survey of Moseley et al. ( 31 ) found that reviews implementing Cochrane Collaboration procedures demonstrated higher rigour and overall quality. The review process included deploying a search strategy across multiple databases, two levels of screening (title and abstract and full text) against inclusion and exclusion criteria, resolving conflicts at each level, as well as data extraction, data analyses, and data synthesis. This review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis - Rapid Review (PRISMA-RR) guidelines for standards of reporting findings ( 32 ).

Search strategy

We conducted a preliminary search for ten relevant articles that should be included in a systematic literature search. These articles served as “benchmark articles” to ensure our search strategy was accurate and comprehensive across a number of indexing databases ( 33 ). Our team then consulted with an academic librarian at Western University to confirm the following search strategy. In light of optimizing databases across the benchmarking articles and meeting the minimum number of searched databases required for systematic reviews [e.g., ( 34 , 35 )], we selected three databases to perform our search: Scopus, Medline (OVID), and PsycINFO (ProQuest). The following keywords were identified: military, “armed forces”, soldier, RCMP, Veteran*, transiti*, retir*, resources, “mental health care”, programs, “mental health service use”, “mental health services use”, “mental health care”, “mental health support”, “mental health treatment”, “mental health use”, “psychiatr* service use”, “utili*ation”, “help-seeking”, and “mental health” (see Supplementary Material for string terms). We imposed a date restriction of 10 years from the search date (i.e., 2013–2023), which was conducted on December 18, 2023, in order to focus on contemporary barriers and facilitators of mental health care. In addition, the Veterans Affairs Canada (VAC) Research Directorate webpage was scanned to identify any potentially relevant grey literature.

Inclusion and exclusion criteria

Articles were included if they:

(1) focused on military Veterans who have been released from service for any reason,

(2) focused on families of Veterans,

(3) reported on post-service experiences and mental health service use, and

(4) described barriers and/or facilitators to accessing and/or using mental health services.

Articles were excluded if they:

(1) did not differentiate between active duty and Veteran populations,

(2) reported the occurrence of a barrier or facilitator without any context of any specific barrier or facilitator,

(3) exclusively focused on medical services, including chronic pain,

(4) were non-study papers (e.g., books, news articles),

(5) not available in English or French,

(6) were not from the Five Eyes Countries [Canada, United States, United Kingdom (UK), Australia, New Zealand], and

(7) were published before 2013.

With respect to exclusion criterion ( 7 ), the goal of this review was to be able to provide actionable policy recommendations related to mental health service use by Veterans and their families. As such, this review will focus on capturing relatively contemporary barriers and facilitators to mental health care. Further, given that rapid reviews are often conducted to support policy-focused work [e.g., ( 36 )], a 10-year search restriction allowed for the requisite timely execution of this style of review in consideration of the scope of available literature.

Study selection

Following the deduplication of database outputs, two screeners independently reviewed each article against the inclusion and exclusion criteria for title and abstract review and full-text review. Across the entire body of citations, seven screeners participated in the screening process. Interrater reliability was good for title and abstract review [using percent agreement (97.2%), and Kappa (Fleiss and Conger; 0.742)] and full-text review [using percent agreement (90.4%), and Kappa (Fleiss and Conger; 0.705)]. At the data extraction stage, two raters extracted relevant information from included articles. Conflicts were resolved at each level of screening by study authors until a consensus was reached (see Figure 1 ). SWIFT-Active Screener, a web-based, collaborative review software that accelerates the screening processes, was used for the title and abstract and full-text review stages. SWIFT enlists a proprietary machine-learning algorithm to prioritize relevant articles for screening with a high degree of accuracy ( 37 ). Using this approach, our review and screening times were reduced without risk or loss of accuracy.

Figure 1 Preferred reporting items for systematic reviews and meta-analysis.

Data extraction

The following information was extracted from each article (1): article and demographic information, and (2) barriers and facilitators to mental health service use reported by Veterans or their family members. For article and demographic information, the following data were extracted: type of article (i.e., empirical article or dissertation/theses, further broken down by qualitative, quantitative or mixed data), country of study (i.e., Canada, United Kingdom, United States, New Zealand, Australia), age, gender/sex (i.e., mixed, women/female, men/male, transgender, not specified), race (i.e., White/European, Black/African/Caribbean, East Asian, Southeast Asian, Hawaiian/Pacific Islander, Indigenous Peoples, Latin American/Hispanic, Multiracial/Multiethnic, other, mixed, not specified), income (i.e., less than $40,000, $40,000–$59,999, $60,000–$79,999, $80,000–$99,999, $100,000–$119,999, $120,000 or more, mixed, not specified), education (i.e., less than high school, high school, college, undergraduate, graduate/professional degree, mixed, not specified), length of service, type of release (i.e., honourably discharged, dishonourably discharged, not specified), number of years since release, and Veteran vs. family perspective (i.e., Veteran, family, both).

Barrier and facilitator information associated with mental health service use (as reported by Veteran or their family members) was extracted from each article. To be considered a barrier, the results of the study must have explicitly stated an obstacle, difficulty, or challenge Veterans and/or their family members experienced during access to mental health service use. To be considered a facilitator, the results of the study must have explicitly stated a factor that eased the access to mental health service use for Veterans and/or their family members. As such, two independent reviewers extracted the data in the following stages:

○ Step 1. Extracted direct quotes or empirical outcome data from the article and categorized as being experienced by a Veteran or family member.

○ Step 2. Examined the raw data and identified common, repeated themes from a policy informed lens and categorized into barriers or facilitators within the dataset.

○ Step 3. Systematically grouped the emerging themes and subsequently organized them into relevant categories (e.g., Barriers–Veterans; Barriers–family members; Facilitators–Veterans; Facilitators–family members; see Table 1 for descriptive information about the emerging themes). For the primary analysis, a thematically-driven approach was used to classify barriers and facilitators to mental health care, rather than a pre-existing theoretical framework, to ensure a good fit of the data. For the secondary analysis, we mapped barriers and facilitators onto the domains of the TDF.

Table 1 Definition of emerging themes across barriers and facilitators.

Risk of bias assessment

The Mixed Method Appraisal Tool [MMAT; ( 58 )] was used to evaluate the risk of bias among articles. The MMAT is a valid and efficient quality assessment tool that allows for simultaneous appraisal of qualitative, quantitative, and mixed methods studies. Each article was categorized by study type (i.e., qualitative, quantitative, or mixed methods). Studies were then rated based on the MMAT criteria corresponding to the respective study type. Criteria included five specific appraisal questions assessing methodological characteristics (e.g., appropriate and effectively executed methodological approach) relative to the type of study conducted. Criteria were evaluated with “yes”, “no”, and “can’t tell” answer options.

Data analysis

Smartsheet and Microsoft Excel were used for data analyses. Demographic information was examined using descriptive statistics (i.e., frequencies; means and standard deviations). The themes emerged through deductive analysis based on our own binning process. Initially, themes were identified and categorized as either barriers or facilitators. These themes were then thematically organized into socio-ecological domains. This organization was based on the structural, environmental, or individual level at which these barriers and facilitators were described as relevant: (1) Systemic which refers to the obstacles or benefits that are embedded within the structure, policies, or practices of a system that impacts one's access to mental health services, (2) Inter-/Intrapersonal which refers to obstacles or benefits arising from interactions between individuals or within an individual's own thoughts, beliefs, or behaviors which influence help-seeking for mental health care, (3) Logistical which refers to obstacles or benefits that arise from practical considerations such as transportation, scheduling, or infrastructure limitations related to accessing mental health services, and (4) Social Environment which refers to obstacles or benefits originating from an individual's physical surroundings, social interactions, or external influences, which influence help-seeking for mental health care. While an emerging theme may recur throughout an article, our results are focused on the identification of unique themes within each article, rather than the frequency with which themes are repeated within an article.

Barriers and facilitators were then thematically organized across the 14 domains of the TDF: (1) Knowledge w hich refers to being aware of the existence of something, (2) Skills which refer to abilities or proficiencies acquired through practice, (3) S ocial/Professional Role and Identity which refers to the behaviours and qualities that individuals display in social or work settings, (4) Beliefs about Capabilities which refers to the level of acceptance of an ability that a person can put to use, (5) Optimism which refers to the level of belief that a goal can be attained or that something will happen for the best, (6) Beliefs about Consequences which refers to the level of acceptance for the outcomes of a behaviour in a particular setting, (7) Reinforcement which refers to the arrangement of a dependent relationship or contingency between a stimulus and response which increases the odds of that given response, (8) Intentions which refers to the decision that one makes to perform a behaviour in a certain manner, (9) Goals which refers to a mental representation of an end-state that an individual seeks to achieve, (10) Memory, Attention, and Decision Processes which refers to the ability to focus selectively, retain information, or make a choice between alternatives, (11) Environmental Context and Resource which refers to circumstances of an individual's environment or situation that either promote or discourage the development of abilities, independence, or adaptive behaviours, (12) Social Influences which refers to interpersonal processes that can lead individuals to change their behaviours, thoughts, or feelings, (13) Emotion which refers to reactionary patterns involving experiential, behavioural, and physiological elements to deal with a significant matter or event, and (14) Behavioural Regulation which refers to anything that is aimed at changing or managing measured or observed actions.

MMAT scoring to assess the risk of bias was calculated based on the percentage of MMAT criteria met (i.e., number of “yes” responses). Hong et al. ( 58 ) noted that calculating an overall score is not advisable. As such, studies were rated based on the percentage of criteria met [i.e., 20, 40, 60, 80, 100; per ( 58 )].

Study characteristics

The final sample consisted of 60 articles (denoted with N ) with 67 independent samples (denoted with k ; Figure 1 ; see Supplementary Material for raw data and reference list of included articles). The samples mostly included Veteran ( k  = 58) perspectives, with a few from family perspectives ( k  = 9). Across all included articles, this review identified 23 barriers and 14 facilitator themes. It is important to note that the demographic characteristics reported in Table 2 do not fully represent the participants across samples due to inconsistencies in the information reported across the included samples (see Table 2 for characteristic information). Notably, across all samples, 11 articles discussed topics related to military sexual trauma.

Table 2 Study characteristics ( N  = 60).

Examination of barrier and facilitator themes across socio-ecological domains

Veteran perspective.

Across all samples that captured the Veteran's perspective ( k  = 58), the most common type of barrier experienced was systemic in nature ( n  = 146; in this section, n denotes the total number of barriers or facilitators reported across all included articles within a respective domain as per Table 3 ). Within this domain, the most commonly identified theme was difficulty navigating the system (e.g., difficulty completing forms; k  = 38; 66%), followed by health care provider (i.e., physician, clinical psychologist, or psychotherapist) unfamiliar with military culture and patient condition (e.g., provider lacks knowledge about military life; k  = 25; 43%), and lack of service preference (e.g., lacking patient choice of care; k  = 24; 41%). The second most common domain was inter-/intrapersonal ( n  = 112). The most common theme identified within this domain was negative preexisting attitudes and beliefs towards mental health (e.g., stigma; k  = 35; 60%), followed by gaps in mental health knowledge (e.g., not understanding the early signs of mental health issues; k  = 32; 55%), and lack of trust in the system (e.g., belief that the mental health care system cannot ease mental health conditions; k  = 21; 36%). The third most common domain was logistical ( n  = 47). In this domain, the identified themes exhibited relatively equal prevalence: transportation challenges (e.g., location of mental health service is too far away; k  = 16; 28%), lifestyle disruptions (e.g., not able to take time off from work; k  = 16; 28%) and costly services and travel (e.g., cost of service is too expensive; k  = 15; 26%). Social environment was the least identified domain ( n  = 46). Within this domain, the most common theme was a military culture of stoicism (e.g., a culture creating a “tough it out” attitude; k  = 22; 38%), followed by fear of repercussions (e.g., fear of negative consequences such as losing out of job opportunities; k  = 12; 21%), and gender stereotypes ( k  = 12; 21%).

Table 3 Characteristics of barriers and facilitators across Veterans and their families ( k  = 67).

As for facilitators reported by Veterans, similarly, the most common domain was systemic ( n  = 58). Specifically, support navigating the system was the most prominent theme ( k  = 16; 28%), followed by service availability ( k  = 14; 24%), and health care provider familiarity with military culture and patient condition ( k  = 12; 21%). The second common domain was inter-/intrapersonal ( n  = 21). In particular, the most common themes were mental health knowledge ( k  = 12; 21%), followed by trust in the system ( k  = 5; 9%), and trust in provider (e.g., feeling the provider has their best interest in mind; k  = 4; 7%). The third most common domain was social environment, with social support being the only emerging theme ( k  = 17; 29%). Lastly, logistical was the least prevalent domain ( n  = 6). Within this domain, the reported themes included convenience (e.g., mental health service is close; k  = 3; 5%), childcare/transportation availability ( k  = 2; 4%), and affordable cost ( k  = 1; 2%; see Table 3 for reported themes within each domain across barriers and facilitators, as experienced by Veterans).

Family perspective

Similarly, across all samples that captured the Veteran family's perspective ( k  = 9), the most common barrier was systemic ( n  = 12). Specifically, difficulty navigating the system was reported as the most prominent theme ( k  = 5; 56%), followed by lack of service preference ( k  = 3; 33%) and provider unfamiliar with military culture and patient condition ( k  = 2; 22%). The inter-/intrapersonal domain was reported with almost equal frequency ( n  = 11). Within this domain, gaps in mental health knowledge was the most prominent barrier ( k  = 4; 44%), while negative preexisting attitudes and beliefs ( k  = 3; 33%), trust in provider ( k  = 2; 22%), and trust in the system ( k  = 2; 22%) were equally common. The third most common domain was logistical ( n  = 8). In particular, lifestyle disruptions were most common ( k  = 4; 44%), followed by transportation challenges ( k  = 2; 22%) and costly service and travel ( k  = 2; 22%) reported as equally common. The final domain, social environment, was not a prominent domain within the family literature ( n  = 1).

With regards to facilitators, the most prominent domain was inter-/intrapersonal ( n  = 6). Within this domain, the only repeated theme was mental health knowledge ( k  = 4; 44%). The next most common domain was systemic ( n  = 5), with service availability ( k  = 2; 22%) being the only repeatedly reported theme. Importantly, the social environment domain found social support was the only theme reported ( k  = 4; 44%). Lastly, the logistical domain was not prominent ( n  = 2; see Table 3 for reported themes within each domain across barriers and facilitators, as experienced by families).

Examination of the barriers and facilitators within the Theoretical Domains Framework

When examining the themes within the TDF framework, six of the domains were captured by the data in this review: knowledge, social/professional role and identity, beliefs about capabilities, beliefs about consequences, environmental context and resources, and social influences. Most of the 23 identified barriers were categorized into environmental context and resources ( n  = 10; 43%; in this section, n denotes the number of barrier or facilitator themes across TDF domains per Table 4 ), followed by social influences ( n  = 4; 17%), knowledge ( n  = 3; 13%) and beliefs about consequences ( n  = 3; 13%), social/professional role and identity ( n  = 2; 9%), and beliefs about capabilities ( n  = 1; 4%). As for facilitators, most of the 14 identified facilitators were embedded into the environmental context and resources ( n  = 7; 50%), followed by knowledge ( n  = 3; 21%), beliefs about consequences ( n  = 2; 14%), social/professional role and identity ( n  = 1; 7%) and social influences ( n  = 1; 7%).

Table 4 Barrier and facilitators themes embedded into Theoretical Domains Framework.

Risk of bias (Mixed Method Appraisal Tool)

Overall, the methodological quality of the included articles ( N  = 60) varied: 52% of the articles met ≤60% of MMAT criteria (31/60; 20% [ n  = 3], 40% [ n  = 12], 60% [ n  = 16]), while 48% of the articles met >60% of MMAT criteria (29/60; 80% [ n  = 28], 100% [ n  = 1]). Notably, the most common criterion was a quality threshold of 80% (see Supplementary Material for MMAT scores of all included articles).

Emerging barrier and facilitator themes within the socio-ecological domains

Veterans and Veteran family members identified a number of common barriers and facilitators across systemic, interpersonal/intrapersonal, logistical, and social environmental domains.

Systemic barriers were the most cited barriers to accessing mental health care with issues navigating the system reported by over half of the Veteran samples. Upon retirement, Veterans move from a military-specific health care system to the provincial or territorial health care system in their province or territory of residence, with additional VAC health care benefits being available for Veterans who have service-related injuries ( 59 ). This change can pose new difficulties such as not completing the necessary paperwork to access the benefits available to them [see ( 10 , 60 )], which may prohibit Veterans from initiating or continuing mental health care in the post-service period. Additionally, Veteran samples noted a lack of military cultural competence and/or unfamiliarity with treating mental health conditions among providers. Veterans represent a distinct cultural group which may have different health care needs relative to non-Veterans. Tam-Seto et al. ( 61 ) notes that a lack of cultural awareness, sensitivity, knowledge, and skills required to meet the unique mental health needs of Veterans can diminish the quality of the therapeutic relationship and impact wellbeing. This finding highlights the importance of the therapeutic alliance in this group [see ( 62 )]. A lack of service preferences (e.g., requests for a female mental health service provider or individual therapy vs. group therapy) was also identified as a prominent barrier by Veterans. Distinct from barriers which impede access to services, service preferences may be equally as important in determining Veteran engagement ( 63 ).

Findings also revealed that when these barriers are rectified, these themes can function as significant facilitators. For example, while difficulties navigating the system were the most common barriers, support navigating the system was the most common facilitator. In this sample, Veterans noted the importance of receiving assistance from fellow Veterans, health care providers, and staff members. Similarly, service availability and having health care providers with military cultural competence were other prominent facilitators of receiving mental health care. Indeed, having a variety of mental health services and treatment modalities available is important in addressing individual differences in needs [especially among minority groups such as women Veterans; ( 49 )]. Further, access to providers educated in the unique occupational stressors that are associated with a military career can help to facilitate the transition to the civilian health care system and ensures access to relevant resources ( 61 , 64 ).

Families of Veterans identified having difficulty navigating the system as the most common systemic barrier to care. Schwartz et al. ( 9 ) found that family members of Veterans are often unaware of the formal mental health resources available to them and are unclear on the administrative processes required to access these supports. Service availability was the most reported systemic facilitator; however, the representation of samples is too small to reliably interpret.

Interpersonal/intrapersonal

Negative pre-existing attitudes and beliefs were reported among many of the Veteran samples in the review. One review exploring the association between mental health beliefs and service use in military populations found that personal beliefs (about mental health, including stigma) are an important predictor of mental health service use [see ( 65 )]. Veterans also frequently reported gaps in mental health knowledge related to mental health symptoms and the potential treatments available to address them [see ( 66 )]. Increasing mental health knowledge may increase help-seeking and service use by minimizing the impact of other barriers. For example, a study of female Veterans in the U.S. found that increasing mental health knowledge reduced stigma and, thus, indirectly increased mental health treatment-seeking behaviours ( 67 ). Veterans also reported a lack of trust in the system, including but not limited to federally operated Veterans Affairs health organizations. One qualitative study found that lack of trust in the U.S. Veterans Affairs (VA) health care system acted as a significant barrier to mental health care-seeking, because of concerns it would be “nonresponsive, ineffective, and uncaring” [see ( 11 )]. Concerns over confidentiality or the ability to provide high-quality services in a timely manner also contribute to a lack of trust in Veteran health organizations ( 22 ). Relatedly, a lack of trust in their mental health care provider was also reported as a barrier among some samples. Consistent with the previous themes, mental health knowledge was identified as the most common facilitator among the Veteran samples. This aligns with previous research suggesting that increased mental health knowledge is inversely associated with negative attitudes towards mental health and mental health treatment ( 68 ). As in the Veteran samples, gaps in mental health knowledge were the most commonly reported intra-/interpersonal barrier among Veteran family samples while having mental health knowledge was the most frequently reported facilitator. Family members who are more aware of the impact that living with a Veteran experiencing mental health issues can have on their own mental health may be more inclined to seek mental health treatment themselves.

Transportation challenges were identified as the most prominent logistical barrier in Veteran samples. This encompasses the distance to the closest mental health care provider (i.e., too far to travel) or a lack of a reliable mode of transportation to reach these services. This may be a particular concern for Veterans residing in rural areas, where there are fewer mental health care providers and resources available ( 11 ). Lifestyle disruptions, such as needing to request time off work or finding a childcare provider to attend treatment ( 69 ), were also reported as barriers to mental health care in this review. It is important to note that these barriers may carry additional costs that render mental health care unaffordable, particularly for Veterans who may not have additional benefits or health care coverage. Convenience was the most reported logistical facilitator in this sample. Convenience may encompass living near mental health services, accessing services remotely, or being able to receive mental health services in the same location as physical health services. Previous research indicates that logistical barriers are frequently reported barriers to health care among military spouses ( 70 ). Among the samples of Veteran families included in this review, lifestyle disruptions–such as needing to take time off work or finding childcare–was the most reported barrier. Indeed, Maguire et al. ( 16 ), notes that care coordination can be particularly challenging among Veteran families with complex mental health needs (i.e., those impacting more than one domain of functioning), as may be the case during the post-service period. Logistical facilitators to mental health care were not widely commented on by the Veteran families included in the review.

Social environmental

The stereotypical military characteristics of stoicism and self-reliance were the most commonly reported social environmental barriers to seeking mental health care among the Veteran samples included in this review. One study exploring barriers to mental health care among U.S. Veterans found that self-reliance and stoicism were the most common attitudinal barriers to mental health care, with many Veterans reported enduring their mental health systems without complaint until the need for mental health treatment became undeniable ( 11 ). Indeed, another study found that Veterans delayed seeking mental health care for almost twelve years following their release from the military [see ( 71 )]. Concerns about the potential consequences mental health care-seeking might have on their military careers were also identified as a common barrier. Some of these concerns may include being treated differently by military leadership ( 72 ) or adverse military career implications ( 73 ). Additionally, gender stereotypes were identified as a barrier to mental health care in some studies. Previous research shows that men and women Veterans experience different barriers to mental health care, with women being more likely to indicate that their gender itself, as well as gender-based discrimination experienced during their military service, act as barriers to seeking mental health services ( 74 ). Female Veterans may also feel uncomfortable in male- dominated health service environments, such as VA mental health clinics ( 75 ).

Social support was the only social environmental facilitator cited in the Veteran samples included in this review. Positive social support (from partners, civilian communities, peers, etc.) has been identified as a motivator for seeking mental health care in a number of studies involving military Veterans [e.g., ( 11 , 25 , 55 )]. Further, research suggests that mentor/mentee-like relationships with other Veterans who have experienced and successfully sought help for a mental health concern may be a particularly valuable source of social support for Veterans contemplating mental health treatment initiation ( 11 ).

Few Veteran family members identified any social environmental barriers to mental health care: only lack of social support was identified in one of the Veteran family samples as a barrier to mental health care. Previous research has identified lack of social support as a generalized barrier to mental health care ( 16 ); however, it may be possible that this is significantly less of a concern for Veteran family members than it appears to be for Veterans themselves.

Positive social support was the only social environmental facilitator of mental health care identified in the Veteran family samples. Recent research suggests that family involvement in treatment for military-related posttraumatic stress disorder is, for some, motivated by social relationships [e.g., improving family life; protecting familial relationships; ( 52 )]. This may be a unique form of social support that motivates Veteran family members to engage in mental health care.

Mapping barrier and facilitator themes onto the Theoretical Domains Framework

The barriers and facilitators to mental health care identified in this review mapped on to 6 out of 14 TDF constructs: knowledge, social/professional role and identity, beliefs about capabilities, beliefs about consequences, environmental context and resources, and social influences (see Table 4 ).

Most of the barriers identified in this review reflected the environmental context and resources, and social influences related to mental health care experiences. According to the TDF Behaviour Change Wheel [see ( 21 )], environmental context and resources and social influences jointly contribute to opportunity. Barriers within these domains limit opportunity and influence both physical and social sources of behaviour. In the context of this review, Veterans and Veteran families reported how their engagement in mental health care services are limited by numerous barriers affecting access and availability (e.g., cost, service preferences), and the social contexts they are embedded within (e.g., military culture of stoicism, gender stereotypes). Per the TDF these barriers are inhibiting both physical and social components of treatment-seeking behaviours. These findings highlight specific areas (i.e., enhancing opportunity via environmental and social strategies) for policy recommendations or interventions aimed at engendering behavioural change related to help-seeking in these populations.

Notably, the environmental context and resources domain also emerged as an important facilitator of mental health care experiences. As previously noted, these facilitators often reflect the inverse of barriers (e.g., service availability vs. lack of service availability), highlighting the importance of rectifying prominent barriers to optimize experience and outcomes. Further, this finding serves to help refine our examination of gaps in services and supports with respect to the TDF. While environmental factors detract from opportunity, most facilitators also fell into this category, while facilitators with respect to social influences were very limited (i.e., social support only). Taken together, it may be that social influences are disproportionately detracting from opportunity relative to environmental factors; however, the representation of facilitators was relatively limited, and this review did not determine the magnitude of the effect of these barriers and facilitators beyond reported frequency. The knowledge domain also emerged as an important factor in facilitating experiences of Veterans and Veteran families' experiences with mental health care services. With respect to the TDF Behaviour Change Wheel, knowledge (e.g., mental health knowledge, and support navigating the system) bolsters capability and positively influences psychological sources of help-seeking behaviours.

Implications for research and policy

The findings of this review of qualitative and quantitative research align well with a rapid review conducted by Randles & Finnegan ( 26 ), as well as Hitch et al.'s ( 25 ) systematic review of quantitative research exploring barriers and facilitators to health care-seeking. Despite differences in the types of studies included across all three reviews, the consistency of findings increases confidence in the reliability and accuracy of our findings.

The heterogeneity in reported experiences observed across barriers and facilitators included in this review suggests that perhaps access to the system is not standardized or is based on other factors, such as reason for release from the military or familiarity with the system. Additionally, variability in structure, availability, and cost of mental health services between and within countries (e.g., state to state) may account for some of the variability with respect to thematic valence. However, these variations (i.e., experiencing a systemic factor as a barrier or facilitator) can be used to identify opportunities to create equitable policies that increase access to mental health services. The use of objective measures of barriers to mental health care (e.g., wait time from referral to support) may help to disentangle some of the heterogeneity observed in this review.

Findings of this review may also be used to inform relevant policy recommendations at the federal and provincial/community level. Concerted efforts to address the systemic, logistical, social environmental, and intra-/interpersonal barriers to mental health care should occur conjointly in order to maximize their benefit. For example, this might include building upon recent efforts by the CAF to increase mental health awareness and reduce stigma. Reducing stigma around service-related mental health concerns may promote help-seeking behaviours in military (and subsequently Veteran) populations. Federal agencies should aim to ensure the availability of culturally competent providers within their networks while also exploring avenues to decrease logistical and demand barriers to mental health care, such as providing childcare support and offering women-only hours in their mental health clinics. Nevertheless, access to mental health care for Veterans and Veteran families cannot be solved through addressing one type of barrier alone. For example, efforts to decrease stigma will not get more Veterans into treatment if supply issues are not addressed or the system remains difficult to navigate.

Similar steps could be taken at the provincial health care level. The civilian health care system is not always well equipped to treat the mental health needs of Veterans, particularly in areas without a large military or Veteran population. Efforts to identify the root cause(s) of insufficient military cultural competency, such as lack of training, could help address the paucity of community-based mental health providers with military cultural competence, while targeted recruitment efforts could be used to increase the number of mental health care providers in rural regions.

Limitations and strengths

The findings of this review should be interpreted in consideration of a few limitations. First, we were unable to conduct subgroup analyses. As such, the overall findings of this review disproportionately reflect experiences of mental health care for an American Veteran population via qualitative experiential accounts relative to mixed methods designs and do not adequately reflect the experiences of Veterans from other Five Eyes nations, and Veterans with intersectional identities. While these countries share important similarities, the inclusion of samples from Australia and New Zealand in addition to a more robust representation of Canadian and UK samples in this review may have allowed us to capture meaningful trends in access across various types of health care delivery systems (e.g., public vs. private), which would have provided important contextual nuance with respect to these experiential findings especially as they related to barriers associated with cost. Further efforts to disentangle whether the systemic barriers and facilitators to mental health care vary across nations and health care systems would help solidify our understanding of the specific barriers and facilitators faced by Canadian Veterans and families. Second, most studies did not provide information about the amount of time between data collection and end of participants' military service. The military to civilian transition period, which can be a period of increased need for mental health services, may have different barriers or facilitators to mental health care than in the years following this transitional period. Finally, our review contained only a few samples of Veteran families. This review adds to a growing body of literature attempting to elucidate and contextualize experiences of mental health care for Veteran families and calling for additional research within this population.

This review also had several strengths. First, this review provides a much-needed synthesis of literature in this area and summarizes available information on barriers and facilitators to mental health care for both Veterans and Veteran families. Importantly, this review highlighted that when Veteran health organizations address barriers to mental health care, these barriers became facilitators, enabling access to mental health services. Second, the quality of the studies included in the review were adequate, as measured by the MMAT, indicating that information included in this review was collected and analyzed with rigour. Finally, the findings of this review, in conjunction with the context provided by the TDF, highlight opportunities for future research, intervention approaches, and policy changes.

Considerations for future directions

Future studies in this field should aim to pinpoint specific behavioural determinants of health-seeking via primary data collection with Veterans and Veteran families. Using a structured framework such as the TDF would provide a more comprehensive context-specific understanding, and capture data that is reflective of current policies and community attitudes. Second, studies should implement conjoint analyses to empirically examine the relative importance of specific barriers and facilitators to treatment-seeking. Similarly, given that these results are based on mostly qualitative studies, future studies should seek to understand how themes related to help-seeking and service use among these populations are represented in both qualitative and quantitative data. For example, if themes related to stigma are more commonly captured in qualitative research, then it becomes important to identify the best way to capture these themes in a quantitative capacity as well. Third, studies should aim to capture the unique barriers and facilitators to mental health care for Veterans' and their families in a Canadian context. Relatedly, future studies should attempt to better understand help-seeking behaviours with respect to individual differences and across social identities (e.g., gender, age, sexual orientation, etc.). Finally, families represent a broad group, and future research should consider the barriers and facilitators for different kinds of family members and dynamics (e.g., spouses, children).

This review identified several barriers and facilitators to mental health care for Veterans and Veteran families. While systemic barriers, such as difficulty navigating systems were commonly reported by Veterans and Veteran families, these factors were also identified as facilitators to mental health care when addressed. These findings highlight the heterogeneity in Veterans' and Veteran families' experiences with mental health care-seeking, and the need to understand the effects of barriers on help-seeking behaviours and experiences to implement the appropriate modifications to remove them. In doing so, Veteran health and well-being organizations can provide relevant and accessible mental health care and, subsequently, improve mental health outcomes for Veterans and Veteran families.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author.

Author contributions

NE: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Visualization, Writing – original draft, Writing – review & editing. JG: Formal Analysis, Investigation, Writing – original draft, Writing – review & editing. KS: Writing – original draft, Writing – review & editing. JL: Conceptualization, Funding acquisition, Methodology, Resources, Visualization, Writing – review & editing. CB: Data curation, Investigation, Writing – original draft, Writing – review & editing. AN: Writing – review & editing. JR: Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article.

This work was supported by the Atlas Institute for Veterans and Families.

Acknowledgments

The authors would like to thank the following individuals who contributed to the screening and data extraction stages of this rapid review: Michelle Birch, Vanessa Soares, Ilyana Kocha, Akshitha Ereddy, Rishika Bhogadi, William Younger, and Jieun Jung. We would also like to thank Dominic Gargala for data analytic support.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frhs.2024.1426202/full#supplementary-material

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Keywords: mental health services, Veterans, Veteran families, wellbeing, mental health

Citation: Ein N, Gervasio J, St. Cyr K, Liu JJW, Baker C, Nazarov A and Richardson JD (2024) A rapid review of the barriers and facilitators of mental health service access among Veterans and their families. Front. Health Serv. 4 : 1426202. doi: 10.3389/frhs.2024.1426202

Received: 30 April 2024; Accepted: 25 June 2024; Published: 22 July 2024.

Reviewed by:

© 2024 Ein, Gervasio, St. Cyr, Liu, Baker, Nazarov and Richardson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Natalie Ein, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 23 July 2024

First-aid training for primary Healthcare providers on a remote Island: a mixed-methods study

• Ninh Do Thi 1 , 2 ,
• Giang Hoang Thi 2 ,
• Yoonjung Lee 3 ,
• Khue Pham Minh 2 ,
• Hai Nguyen Thanh 2 ,
• Jwa-Seop Shin 3 &
• Tuyen Luong Xuan 4  

BMC Medical Education volume  24 , Article number:  790 ( 2024 ) Cite this article

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Ensuring ongoing first-aid training for primary healthcare providers (PHPs) is one of the critical strategies for providing quality health services and contributing to achieving universal health coverage. However, PHPs have received insufficient attention in terms of training and capacity building, especially in the remote areas of low-to-middle-income countries. This study evaluated the effectiveness of a first-aid training program for PHPs on a Vietnamese island and explored their perspectives and experiences regarding first-aid implementation.

A mixed-methods study was conducted among 39 PHPs working in community healthcare centers. The quantitative method utilized a quasi-experimental design to evaluate participants’ first-aid knowledge at three time points: pre-training, immediately post-training, and three months post-training. Sixteen of the PHPs participated in subsequent semi-structured focus group interviews using the qualitative method. Quantitative data were analyzed using repeated measures analysis of variance (ANOVA), while qualitative data were subjected to thematic analysis.

The quantitative results showed a significant improvement in both the overall mean first-aid knowledge scores and the subdimensions of the first-aid knowledge scores among healthcare providers post-training. There was a statistically significant difference between the baseline and immediate posttest and follow-up knowledge scores ( p  < 0.001). However, the difference in knowledge scores between the immediate posttest and three-month follow-up was not significant ( p  > 0.05). Three main themes emerged from the focus group discussions: perception of first-aid in remote areas, facilitators and barriers. Participants identified barriers, including infrastructure limitations, shortage of the primary healthcare workforce, inadequate competencies, and insufficient resources. Conversely, receiving considerable support from colleagues and the benefits of communication technologies in implementing first aid were mentioned as facilitators. The training bolstered the participants’ confidence in their first-aid responses, and there was a desire for continued education.

Conclusions

Implementing periodic first-aid refresher training for PHPs in a nationwide resource-limited setting can contribute significantly to achieving universal health coverage goals. This approach potentially enhances the preparedness of healthcare providers in these areas to deliver timely and effective first aid during emergencies, which may lead to more consistent primary healthcare services despite various challenges.

Peer Review reports

Introduction

The World Health Organization (WHO) has determined that Universal Health Coverage is a fundamental goal for strengthening healthcare systems and achieving better health outcomes worldwide [ 1 ]. Universal Health Coverage ensures that all people have access to quality health services without the financial hardships associated with paying for care [ 2 ]. Primary healthcare (PHC) plays a crucial role in attaining universal health coverage because the majority of healthcare needs can be met through PHC interventions [ 3 ]. Therefore, strengthening the quality of PHC at the grassroots level is essential for all countries. Additionally, the WHO emphasizes the central role of the primary health workforce in emergency situations, life-threatening responses, and injury management, along with highlighting the importance of training these frontline staff [ 4 ]. However, PHPs have received insufficient attention in terms of training and capacity building, particularly in the remote areas of low- and middle-income countries, including in Vietnam [ 5 ].

Vietnam’s healthcare system consists of public and private healthcare sectors, with the public system predominantly providing preventive and curative healthcare services to the population [ 6 ]. The public healthcare system is classified into four hierarchical levels with different roles and functions [ 6 ]. The two higher levels, central and provincial, deliver tertiary and secondary healthcare services through specialized hospitals and professionals [ 7 ]. The two lower levels, district and commune, provide PHC services via healthcare centers that function as the foundation of the national health system and contribute significantly to implementing the nation’s health program [ 7 , 8 ]. Although PHC services at health centers are free or low-priced for the nationwide population with public health insurance, many people skip these facilities and reach provincial or central hospitals expecting higher-quality healthcare services [ 9 ]. Providing health services through less-qualified health staff has accounted for these issues at health centers for decades, primarily because of inadequate professional knowledge and clinical practice skills [ 9 , 10 ]. These challenges are particularly evident in the rural and remote communities [ 11 ]. Literature indicates that contextual factors, such as geographic conditions and limited resources, contribute to these issues, creating substantial barriers to accessing healthcare, supporting a skilled workforce, and implementing training programs at the grassroots level in Vietnam [ 5 ].

Providing first-aid training to healthcare providers at community health centers is one of the initial steps to compensate for these deficiencies in primary healthcare workforce development [ 12 ]. First-aid training equips PHPs with the necessary knowledge and skills to respond immediately and effectively to sudden, life-threatening, or common emergencies, thereby increasing the likelihood of successful treatment and safe living for residents [ 13 ]. Although previous studies have focused on first-aid training, most concentrated on the effectiveness of cardiopulmonary resuscitation in various subjects without focusing on healthcare providers [ 14 , 15 , 16 , 17 ]. Moreover, other critical first-aid skills, such as choking, burning, stroke, trauma, and hemorrhage, have rarely been studied [ 13 , 18 ]. Furthermore, healthcare providers repeatedly encounter challenges associated with inadequate basic lifesaving skills, insufficient training, limited opportunities for practice and skill development, and inefficient and short retention of skills [ 19 , 20 , 21 , 22 ] that may reduce healthcare quality. Importantly, first-aid training programs specifically designed for PHPs in remote areas, particularly islands, are lacking. Therefore, developing a tailored first-aid training program for PHPs in resource-limited settings is necessary to enhance their knowledge and skills and ultimately improve the quality of primary care.

This study aimed to evaluate the effectiveness of first-aid training programs for PHPs on a remote island in Vietnam. Additionally, we sought insights into the experiences and perceptions of island PHPs regarding the implementation of first aid. These findings provide evidence supporting the expansion of comprehensive first-aid training programs for PHPs in remote areas, both nationally and in low-to-middle-income countries. The conceptual framework for this study was developed based on the General Systems Theory [ 23 , 24 ], which comprises three elements: input, throughput, and output (Fig.  1 ).

Conceptual framework based on General Sytem Theory of Ludwig Von Bertalanffy (1986)

Study design

This study used a mixed-methods approach. Quantitative data were collected using a quasi-experimental design to investigate the effectiveness of the first-aid training program for PHPs. Qualitative data were obtained through group interviews to gain insights into the perceptions and experiences of PHPs regarding the implementation of first aid.

The quantitative study

Setting and participants.

This study was conducted in an island district in northern Vietnam. The district has an area of 325,6 sq. km, 12 communities, and approximately 32,090 residents. The healthcare system in the island district is similar to that in other provinces throughout Vietnam; however, differences in geographical and settlement conditions have resulted in remarkable disparities in health needs between the island and mainland populations and limited access to diverse health services for the island population. Healthcare providers encounter various challenges in delivering healthcare services to island residents.

The participants were PHPs (nurses, midwives, and physicians) in community health centers recruited using convenience sampling. PHPs were eligible to participate if they directly provided healthcare services in a healthcare setting, completed the theoretical and practical training program, and participated in the data collection before and after the program. A recruitment letter was sent to all thirteen community health centers on the island to recruit participants, and the sample size was reached according to the order of registration. The sample size was calculated using the G* Power 3.1.9.7. program with an effect size of 0.25, alpha level of 0.05, correlation among repeated measures of 0.5, and power of 0.90. Accordingly, the required sample size for the repeated-measures analysis of variance (ANOVA) was 36. To account for potential dropouts during the follow-up period, 39 PHPs with at least one year of experience voluntarily participated in the training.

The intervention

The first-aid training program was conducted face-to face over two days. The educational content comprised theoretical and practical training covering five dimensions: basic life support, drowning, bleeding, fractures, and burns. The theoretical components were delivered through didactic lectures, videos, and case studies. For practical training, 39 participants were divided into seven groups, each consisting of five people and one group comprising four people. Each group engaged in hands-on practice of first-aid procedures using manikins, learning devices, and equipment. Lecturers with experience teaching first aid at hospitals and medical universities guided and supported the participants throughout the training sessions. The participants were provided books, videos, audio materials, and slides two weeks in advance to enhance their teaching and learning outcomes. They were expected to review and study these resources before the training began. After training, first-aid skills were immediately evaluated using scenario-based assessments and checklists. This ensured that all participants were adept at and ready to apply first-aid techniques in real-life emergencies.

Instruments

Based on a needs assessment of first-aid training among island Primary Health Practitioners (PHPs) and a synthesized review of first-aid literature, a questionnaire was developed. This tool is organized into two parts to collect participants’ demographic information and assess their knowledge across five dimensions covered during the training. The first part included demographic information, such as age, gender, job titles, participation in a previous first-aid program, and working experience. The second part consisted of 30 multiple choice questions on knowledge of first aid, including nine items on fractures, seven on basic life support, seven on bleeding, four on drowning, and three on burns, with a higher score indicating a better level of first aid knowledge (Supplementary file 1 ). The questions specifically focused on common emergencies encountered by PHPs in communities and assessed the participants’ understanding of appropriate responses to these emergencies. The questionnaire content validity includes the item content validity index (I-CVI), and the overall scale content validity index (S-CVI), which was analyzed based on the proportion of ratings from a expert panel. The I-CVI value of each item ranged from 0.67 to 1.00, and the S-CVI was 0.97, indicating that the scale had good content validity. The reliability of the first aid scale was assessed using KR20, was 0.75. Therefore, the instrument demonstrated sufficient reliability and validity in this study.

Data collection and analysis

Participants’ knowledge of first aid was evaluated at three different time points: before training (pretest), immediately after training (posttest), and three months later (follow-up). Data were collected between September 2022 and May 2023. The collected data were analyzed using SPSS version 26.0. Descriptive statistics were used to calculate the mean (SD) for continuous variables and frequencies for categorical variables. Friedman’s ANOVA test was employed to assess within-subject differences in participants’ knowledge between the pretest, posttest, and follow-up. Statistical significance was defined as a p-value less than 0.05.

The qualitative study

The qualitative study employed group interviews led by researchers experienced in qualitative research methods. Sixteen PHPs from the quantitative sample willing to participate in the interview were organized into three focus groups. The first two groups contained five participants, whereas the third comprised six. Each interview was conducted immediately after the training session, ranging from 45 to 60 minutes. With the consent of the participants, the interviews were audio-recorded and transcribed verbatim to ensure the accuracy of the analysis. The interview questions included “ How do you perceive the implementation of first aid in your area?“, “How did you handle first-aid situations in your center?” and “What factors influence your first-aid implementation?“. The data were analyzed using the content analysis approach described by Elo and Kyngas [ 25 ]. After each session, the interview contents were transcribed word-for-word to retain accuracy and prevent distortions or misinterpretations. The researcher repeatedly read the interview transcripts to become familiar with the context. A meticulous, line-by-line examination pinpointed meaningful units, ranging from single words to whole sentences, that convey distinct insights from the interview data. After identifying these units, subsequent discussions among the authors categorized them into larger units. Finally, overarching themes were derived and presented as barriers and facilitators of implementing first-aid on the island.

This study was approved by the Research Ethics Committee of the Haiphong University of Medicine and Pharmacy (Approval No. 01/HDDD). Written consent for the participation and recording of interviews was obtained from the trainees.

Participant characteristics

Thirty-nine PHPs participated in training and completed the pretest, posttest, and follow-up test. The results revealed that the participants had a mean age of 38.77 years (SD = 7.93), and 61.5% were female. Additionally, 61.5% of the participants had more than nine years of experience, while 76.9% had previously attended courses related to first aid. Additionally, from the initial pool of 39 participants, 16 trainees voluntarily participated in the group interviews. Details of the participants are presented in Table  1 .

Results of the quantitative components

The results indicated a significant improvement in the overall mean knowledge scores after the training ( p  < 0.001). Specifically, there was a statistically significant difference between the baseline knowledge score and both the immediate posttest and follow-up knowledge scores, with p  < 0.001. However, no significant difference was observed in knowledge scores between the immediate posttest and follow-up ( p  > 0.05) (Fig.  2 ).

Comparing knowledge scores pretest/posttest, pretest/follow-up, and posttest /follow-up ( N  = 39)

This study evaluated the knowledge scores across five first-aid dimensions: basic life support, bleeding, fractures, drowning, and burns. Friedman’s ANOVA demonstrated a significant increase in knowledge scores across all dimensions after the intervention ( p  < 0.001). Specifically, the immediate posttest scores for basic life support and burns surged significantly from baseline, although they were marginally lower than the scores at the three-month follow-up ( X 2  = 31.70, p  < 0.001; X 2  = 37.48, p  < 0.001, respectively). Similarly, the immediate posttest scores for bleeding, fracture, and drowning saw a significant rise compared to pretest scores, but they edged out the scores at the follow-up ( X 2  = 41.90, p  < 0.001; X 2  = 42.24, p  < 0.001; X 2  = 25.29, p  < 0.05, respectively) (Table  2 ).

Results of the qualitative components

Three main themes emerged during the data analysis, including perception of first-aid in remote areas, barriers and facilitators, which represented the actual issues in delivering first aid on the island by PHPs.

The perception of first-aid in remote areas

Primary healthcare providers recognize the critical role of first aid as a first line of response in medical emergencies. Due to the potential delays in accessing advanced medical care in remote areas, first aid not only becomes a crucial skill set but also a vital component of community health strategy. They commonly express a strong belief in the need for comprehensive first aid training that is regularly updated and tailored to the specific challenges and risks of their community. They highlight the relevance of first aid in their daily practice, noting its impact on patient outcomes and community confidence in the healthcare system. There is a prevalent attitude that effective first aid training enhances their capability to manage emergencies more efficiently and provides a buffer time that can be critical for patient survival before professional medical help arrives.

In remote healthcare , first aid isn’t just an added skill—it’s often the difference between life and death. We are the first and sometimes the only line of defence when an emergency strikes. Regular , hands-on training in first aid is essential for us to keep up with the best ways to respond… . …Everyone in healthcare here knows that these skills are absolutely crucial. We need training that considers the specifics of our settings—like dealing with sea injuries, downing or snake bites , which are common in our area . …The training we receive has to mirror the realities we face—long distances , limited resources , and high reliance on each other’s skills. Enhanced first aid training that’s recurrent and comprehensive is not negotiable; it’s vital .

Participants identified geographic location and transportation infrastructure as substantial barriers to accessing emergencies and transferring patients to advanced medical facilities. As there is no public transportation on the island, calling an ambulance increases the waiting time for patients to receive healthcare delivery from a higher level of care. Therefore, PHPs utilize the available vehicles to manage patient transfers and minimize delays in reaching advanced care facilities.

…moving to the mainland is difficult. For example , many days there are storms and winds , and transporting patients across the ferry and over the ship is terrifying. The boats are tiny , but we still had to transfer the patient. It takes time to wait for an ambulance , so we often transfer directly to the district center… .

In addition to transportation, deficiencies and maldistribution of resources, such as financial resources, necessary equipment, and medications, contribute to ineffective first aid. Many healthcare centers have insufficient medical devices and essential medicines listed in the insurance drug formulary.

The government also provides equipment , but it is still very poor and small number , not able to provide many things. Also sometimes , we apply to get equipment from the agency , but the agencys’ funding is still limited. Most patients who received first aid or emergency , such as trauma or fracture , did not return after being transferred; the medical equipment used during the initial treatment is lost , and we have to purchase it again using our own money.

According to most participants, severe shortages of human resources and inadequate skills and knowledge were identified as significant barriers to healthcare and the implementation of first-aid. The lack of practical training programs and impractical working conditions due to the limited number of patients were cited as reasons for the staff’s insufficient competencies.

Due to low wages and isolated locations , fewer people want to work here , leading to a lack of staff. Many night shifts have only one staff member , so when there is an emergency , the staff cannot handle it…. I was only trained when studying at medical school and have not received any further training since. Some short courses were not related to first aid…. In a case of fall , the staff only injected the patient and sent him home. However , the patient’s family took him to a higher level because of concerns about his condition. He died before reaching the hospital because of internal injuries sustained during the fall… . Here , just few cases a month , they bypass the community to go directly to the city… .

Facilitators

The participants highlighted the most notable advantage of companionship from colleagues and upper-level staff who readily responded and provided support in times of necessity.

It was 10 p.m. , and I was alone at the health station; the patient came because of a thigh fracture after an accident. I called my colleague to help. We gave the patient first aid and then moved him to the city hospital. My colleague stayed on duty. Last time I had to call the director of the district healthcare center to ask for advice on curing a patient with a neck fracture , he provided his personal phone number as a hotline.

Participants also emphasized the importance and convenience of communication technologies in connecting patients, PHC providers, and higher healthcare levels. Patients can contact community staff beforehand in cases of unexpected situations, and primary healthcare staff can quickly seek consultation from provincial or district doctors for treatment guidance through mobile phones.

When we received a call from a patient or their relatives informing of an accident , we immediately went to the scene or prepared to pick the patient up at the health center .

Crucially, all participants expressed increased confidence in handling emergencies after the training. Additionally, they expressed a wish to undergo regular first-aid training every three to six months to update their knowledge. They showed interest in various types of first-aid training, with an emphasis on procedures specific to coastal regions, such as poisoning, snakebites, and patient transport via boats and ships. Furthermore, they expected all PHPs at island health centers to receive regular training.

After training , I am more confident and can teach other staff in my centers… . To be honest , we would like to study many things because of the lack of opportunities to update knowledge; if possible every three to six months , every staff receives training is good… . We want to learn more about typical first aid here , for example , poisoning , snakebite , patient transportation by boats , ships… .

This mixed-methods study investigated the effectiveness of a first-aid training program that aimed to improve PHPs’ knowledge and explore their perceptions and experiences regarding implementing first-aid on a remote Vietnamese island. The quantitative results showed a significant increase in the total and sub-dimensional mean knowledge scores of PHPs after training. The qualitative data revealed threemain themes: perception of firs-aid in remote area, barriers and facilitators.

In this study, the mean knowledge scores among healthcare providers significantly increased after training, which is consistent with findings from previous studies conducted on different subjects [ 19 , 20 , 22 , 26 ]. Despite the differences in research subjects across these studies, the results are comparable as they all underwent a first-aid learning experience [ 27 ].

The study identified a significant difference between the baseline and knowledge scores obtained in the posttest and after the three-month follow-up. However, no statistically significant difference in knowledge scores was observed between the post-test and the three-month follow-up, although the mean knowledge score slightly decreased after three months of training. This finding contrasts with an intervention conducted on PHPs in the USA [ 28 ], and other previous studies [ 29 , 30 ] on different research subjects, which showed substantial deterioration of knowledge after initial training. This disparity could be explained by the extended evaluation period, which is longer than the duration of our study. This result emphasizes the need for repeated interventions or follow-ups to help maintain the knowledge gained during training sessions.

The qualitative analysis revealed that primary healthcare providers in remote areas perceive first aid as a critical component of their response to medical emergencies, given the frequent delays in accessing advanced care. They emphasize the necessity of comprehensive, regularly updated first aid training tailored to their specific community challenges, such as sea injuries, drownings, and snake bites. This training significantly impacts patient outcomes and enhances community confidence in the healthcare system. The insights suggest that any intervention aimed at improving primary healthcare in remote areas should prioritize context-specific first aid training to ensure healthcare providers are well-prepared for the unique emergencies they face, ultimately improving patient outcomes [ 12 ].

Like other low- and middle-income countries, the Vietnamese primary healthcare system has been facing numerous challenges that impede the quality of healthcare services, including a lack of workforce and competencies, and limitations in infrastructure and resources [ 9 , 31 ]. This situation becomes even more complex in remote and island areas. The Ministry of Health’s Joint Annual Health Review [ 32 ] has highlighted the unequal distribution of financial resources between higher- and primary-level care, with insufficient investments in PHC to meet the demands. Vietnam has recently been striving towards achieving UHC through national programs aimed at strengthening and improving the quality of primary care, with a specific focus on enhancing infrastructure and staff competence at the grassroots level [ 7 , 8 ]. Although community health centers have a higher capacity to provide health services, UHC has not yet been fully realized [ 33 ].

A lack of human resources and competencies is related to geographic locations, low salaries, and inadequate training and promotion opportunities, which prevent young healthcare professionals from entering and engaging in the primary healthcare system. Issues related to recruitment and retention of the primary healthcare workforce have been documented in the literature in Vietnam and other countries worldwide [ 5 , 9 , 34 , 35 ]. Moreover, PHC providers’ competency deficiency might be explained by the recent reduction in the number of patients examined at health centers, which has led to a lack of clinical practice experience. Patients bypass primary healthcare centers to reach secondary and tertiary hospitals, which are expected to provide higher-quality healthcare services. The Ministry of Health [ 32 ] revealed that 54–65% of patients seeking care at central hospitals have health conditions that can be diagnosed and treated at lower levels of care. Furthermore, our findings indicated that one-fourth of the participants had not been retrained in first aid since graduating from medical school despite serving in the healthcare sector for almost nine years of mean working experience. This suggests a potential requirement for periodic refresher training for PHPs.

Regardless of the barriers to first aid, PHPs received support from their colleagues and benefited from communication technologies. In emergencies, teamwork and interprofessional collaboration play crucial roles in ensuring effective PHC through interactive efforts, communication, respect, and support among team members [ 36 , 37 , 38 ]. Therefore, it is essential to continually emphasize collaboration and inter-professional training in first-aid programs for PHPs. Furthermore, the PHC staff confirmed the usefulness of communication technologies in carrying out first aid. This finding aligns with previous studies that have demonstrated the crucial role of technologies in healthcare, as they serve as the foundation for services aimed at preventing, diagnosing, and treating illness and diseases, thereby enhancing the quality and safety of healthcare delivery systems [ 39 , 40 ]. However, our findings revealed that PHC staff primarily relied on smartphones for communication during emergencies, modern technologies, such as remote consultations, digital platforms for data sharing, digital non-invasive care, and interconnected medical decision support, are extensively and broadly used as tools to deliver a wide range of services to remote areas and PHC settings in many countries [ 41 ]. They also include continuous education, lifelong learning, and telehealth [ 39 ]. Therefore, periodic first-aid refresher training for PHC staff, using modern approaches that combine both online and offline methods, can offer diverse content while ensuring training quality and cost-effectiveness.

PHPs recognized the importance of periodic first-aid refresher training and were willing to pursue new training opportunities to improve their competencies. They also emphasized the significance of regular training for all island staff to ensure quality care for islanders. Previous studies have underscored the necessity of continuing professional development opportunities for healthcare workers to enhance the quality of the work environment [ 42 ]. Investment in knowledge and skill development has been linked to increased retention [ 43 ], higher job satisfaction [ 44 ], and improved self-confidence among staff nurses [ 45 ]. These positive outcomes can lead to reduced vacancy rates and increased retention [ 46 ], that is one of the key strategies for achieving UHC in remote areas.

The findings of this study highlight the importance of periodic first-aid refresher training. In addition to common first-aid skills, it emphasizes specific first-aid procedures tailored to coastal areas and interdisciplinary collaborative training to enhance the effectiveness of emergency responses and ensure the quality and safety of primary healthcare services. The study also emphasizes the need to address the challenges related to recruiting and retaining the primary healthcare workforce to achieve universal health coverage. Overall, this study provides valuable insights for policymakers, healthcare providers, and educators to enhance the quality and accessibility of PHC services in Vietnam and other low- and middle-income countries.

Limitations

This study has several limitations. First, while participants were confident and ready to apply first-aid techniques in real-life emergencies after immediate evaluation following the training, this study did not assess the first-aid skills at baseline. Further research should evaluate the participant’s skills and attitudes before and after the intervention. Additionally, utilizing an existing first-aid self-efficacy instrument would aid in predicting trainees’ behavior in certain situations. Second, the follow-up period was only three months, which may not be sufficient to assess the long-term impact of the first-aid training program. Third, this study was conducted in the specific context of an isolated island in Vietnam, which may limit the generalizability of the findings to other settings. Fourth, self-administered measures may introduce the potential for social desirability response bias. Finally, there may be potential for errors and misunderstandings resulting from the primary author’s cultural background and language limitations. However, this risk was minimized through an iterative research process and by collaborating with colleagues involved in various stages of the study, including developing study materials, collecting data, interpreting participants’ input, and co-authoring this paper.

Data availability

Data are available upon request from the author at the following email [email protected].

Abbreviations

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World Health Organization

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Acknowledgements

The authors would like to express their sincere thanks to the staff of the healthcare center and the participation of all healthcare providers.

This study was funded by a grant as support for KGA (KOFIH Global Alumni) Activities.

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Contributions

Conceptualization and Methodology: NDT, KPM, JWS, JYL, GHT, HNT; Investigation: NDT, KPM, GHT, HNT, TLX; Data Curation: NDT, GHT; Formal analysis: NDT; Writing- Original Draft: NDT; Review & Editing: NDT, KPM, JWS, JYL, GHT, HNT, TLX.

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This study was approved by the Research Ethics Committee of the Haiphong University of Medicine and Pharmacy (Approval No. 01/HDDD). Written informed consent for participation and the recording of interviews was obtained from all trainees involved in the study.

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Do Thi, N., Thi, G.H., Lee, Y. et al. First-aid training for primary Healthcare providers on a remote Island: a mixed-methods study. BMC Med Educ 24 , 790 (2024). https://doi.org/10.1186/s12909-024-05768-6

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Received : 11 September 2023

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DOI : https://doi.org/10.1186/s12909-024-05768-6

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