article for qualitative research

About Journal

American Journal of Qualitative Research (AJQR)  is a quarterly peer-reviewed academic journal that publishes qualitative research articles from a number of social science disciplines such as psychology, health science, sociology, criminology, education, political science, and administrative studies. The journal is an international and interdisciplinary focus and greatly welcomes papers from all countries. The journal offers an intellectual platform for researchers, practitioners, administrators, and policymakers to contribute and promote qualitative research and analysis.

ISSN: 2576-2141

Call for Papers- American Journal of Qualitative Research

American Journal of Qualitative Research (AJQR) welcomes original research articles and book reviews for its next issue. The AJQR is a quarterly and peer-reviewed journal published in February, May, August, and November.

We are seeking submissions for a forthcoming issue published in February 2024. The paper should be written in professional English. The length of 6000-10000 words is preferred. All manuscripts should be prepared in MS Word format and submitted online: https://www.editorialpark.com/ajqr

For any further information about the journal, please visit its website: https://www.ajqr.org

Submission Deadline: November 15, 2023

Announcement 

Dear AJQR Readers, 

Due to the high volume of submissions in the American Journal of Qualitative Research , the editorial board decided to publish quarterly since 2023.

Volume 8, Issue 1

Current issue.

Social distancing requirements resulted in many people working from home in the United Kingdom during the COVID-19 pandemic. The topic of working from home was often discussed in the media and online during the pandemic, but little was known about how quality of life (QOL) and remote working interfaced. The purpose of this study was to describe QOL while working from home during the COVID-19 pandemic. The novel topic, unique methodological approach of the General Online Qualitative Study ( D’Abundo & Franco, 2022a), and the strategic Social Distancing Sampling ( D’Abundo & Franco, 2022c) resulted in significant participation throughout the world (n = 709). The United Kingdom subset of participants (n = 234) is the focus of this article. This big qual, large qualitative study (n >100) included the principal investigator-developed, open-ended, online questionnaire entitled the “Quality of Life Home Workplace Questionnaire (QOLHWQ)” and demographic questions. Data were collected peak-pandemic from July to September 2020. Most participants cited increased QOL due to having more time with family/kids/partners/pets, a more comfortable work environment while being at home, and less commuting to work. The most cited issue associated with negative QOL was social isolation. As restrictions have been lifted and public health emergency declarations have been terminated during the post-peak era of the COVID-19 pandemic, the potential for future public health emergencies requiring social distancing still exists. To promote QOL and work-life balance for employees working remotely in the United Kingdom, stakeholders could develop social support networks and create effective planning initiatives to prevent social isolation and maximize the benefits of remote working experiences for both employees and organizations.

Keywords: qualitative research, quality of life, remote work, telework, United Kingdom, work from home.

(no abstract)

This essay reviews classic works on the philosophy of science and contemporary pedagogical guides to scientific inquiry in order to present a discussion of the three logics that underlie qualitative research in political science. The first logic, epistemology, relates to the essence of research as a scientific endeavor and is framed as a debate between positivist and interpretivist orientations within the discipline of political science. The second logic, ontology, relates to the approach that research takes to investigating the empirical world and is framed as a debate between positivist qualitative and quantitative orientations, which together constitute the vast majority of mainstream researchers within the discipline. The third logic, methodology, relates to the means by which research aspires to reach its scientific ends and is framed as a debate among positivist qualitative orientations. Additionally, the essay discusses the present state of qualitative research in the discipline of political science, reviews the various ways in which qualitative research is defined in the relevant literature, addresses the limitations and trade-offs that are inherently associated with the aforementioned logics of qualitative research, explores multimethod approaches to remedying these issues, and proposes avenues for acquiring further information on the topics discussed.

Keywords: qualitative research, epistemology, ontology, methodology

This paper examines the phenomenology of diagnostic crossover in eating disorders, the movement within or between feeding and eating disorder subtypes or diagnoses over time, in two young women who experienced multiple changes in eating disorder diagnosis over 5 years. Using interpretative phenomenological analysis, this study found that transitioning between different diagnostic labels, specifically between bulimia nervosa and anorexia nervosa binge/purge subtype, was experienced as disempowering, stigmatizing, and unhelpful. The findings in this study offer novel evidence that, from the perspective of individuals diagnosed with EDs, using BMI as an indicator of the presence, severity, or change of an ED may have adverse consequences for well-being and recovery and may lead to mischaracterization or misclassification of health status. The narratives discussed in this paper highlight the need for more person-centered practices in the context of diagnostic crossover. Including the perspectives of those with lived experience can help care providers working with individuals with eating disorders gain an in-depth understanding of the potential personal impact of diagnosis changing and inform discussions around developing person-focused diagnostic practices.

Keywords: feeding and eating disorders, bulimia nervosa, diagnostic labels, diagnostic crossover, illness narrative

Often among the first witnesses to child trauma, educators and therapists are on the frontline of an unfolding and multi-pronged occupational crisis. For educators, lack of support and secondary traumatic stress (STS) appear to be contributing to an epidemic in professional attrition. Similarly, therapists who do not prioritize self-care can feel depleted of energy and optimism. The purpose of this phenomenological study was to examine how bearing witness to the traumatic narratives of children impacts similar helping professionals. The study also sought to extrapolate the similarities and differences between compassion fatigue and secondary trauma across these two disciplines. Exploring the common factors and subjective individual experiences related to occupational stress across these two fields may foster a more complete picture of the delicate nature of working with traumatized children and the importance of successful self-care strategies. Utilizing Constructivist Self-Development Theory (CSDT) and focus group interviews, the study explores the significant risk of STS facing both educators and therapists.

Keywords: qualitative, secondary traumatic stress, self-care, child trauma, educators, therapists.

This study explored the lived experiences of residents of the Gulf Coast in the USA during Hurricane Katrina, which made landfall in August 2005 and caused insurmountable destruction throughout the area. A heuristic process and thematic analysis were employed to draw observations and conclusions about the lived experiences of each participant and make meaning through similar thoughts, feelings, and themes that emerged in the analysis of the data. Six themes emerged: (1) fear, (2) loss, (3) anger, (4) support, (5) spirituality, and (6) resilience. The results of this study allude to the possible psychological outcomes as a result of experiencing a traumatic event and provide an outline of what the psychological experience of trauma might entail. The current research suggests that preparedness and expectation are key to resilience and that people who feel that they have power over their situation fare better than those who do not.

Keywords: mass trauma, resilience, loss, natural disaster, mental health.

Women from rural, low-income backgrounds holding positions within the academy are the exception and not the rule. Most women faculty in the academy are from urban/suburban areas and middle- and upper-income family backgrounds. As women faculty who do not represent this norm, our primary goal with this article is to focus on the unique barriers we experienced as girls from rural, low-income areas in K-12 schools that influenced the possibilities for successfully transitioning to and engaging with higher education. We employed a qualitative duoethnographic and narrative research design to respond to the research questions, and we generated our data through semi-structured, critical, ethnographic dialogic conversations. Our duoethnographic-narrative analyses revealed six major themes: (1) independence and other   benefits of having a working-class mom; (2) crashing into middle-class norms and expectations; (3) lucking and falling into college; (4) fish out of water; (5) overcompensating, playing middle class, walking on eggshells, and pushing back; and (6) transitioning from a working-class kid to a working class academic, which we discuss in relation to our own educational attainment.

Keywords: rurality, working-class, educational attainment, duoethnography, higher education, women.

This article draws on the findings of a qualitative study that focused on the perspectives of four Indian American mothers of youth with developmental disabilities on the process of transitioning from school to post-school environments. Data were collected through in-depth ethnographic interviews. The findings indicate that in their efforts to support their youth with developmental disabilities, the mothers themselves navigate multiple transitions across countries, constructs, dreams, systems of schooling, and services. The mothers’ perspectives have to be understood against the larger context of their experiences as citizens of this country as well as members of the South Asian diaspora. The mothers’ views on services, their journey, their dreams for their youth, and their interpretation of the ideas anchored in current conversations on transition are continually evolving. Their attempts to maintain their resilience and their indigenous understandings while simultaneously negotiating their experiences in the United States with supporting their youth are discussed.  

Keywords: Indian-American mothers, transitioning, diaspora, disability, dreams.

This study explored the influence of yoga on practitioners’ lives ‘off the mat’ through a phenomenological lens. Central to the study was the lived experience of yoga in a purposive sample of self-identified New Zealand practitioners (n=38; 89.5% female; aged 18 to 65 years; 60.5% aged 36 to 55 years). The study’s aim was to explore whether habitual yoga practitioners experience any pro-health downstream effects of their practice ‘off the mat’ via their lived experience of yoga. A qualitative mixed methodology was applied via a phenomenological lens that explicitly acknowledged the researcher’s own experience of the research topic. Qualitative methods comprised an open-ended online survey for all participants (n=38), followed by in-depth semi-structured interviews (n=8) on a randomized subset. Quantitative methods included online outcome measures (health habits, self-efficacy, interoceptive awareness, and physical activity), practice component data (tenure, dose, yoga styles, yoga teacher status, meditation frequency), and socio-demographics. This paper highlights the qualitative findings emerging from participant narratives. Reported benefits of practice included the provision of a filter through which to engage with life and the experience of self-regulation and mindfulness ‘off the mat’. Practitioners experienced yoga as a self-sustaining positive resource via self-regulation guided by an embodied awareness. The key narrative to emerge was an attunement to embodiment through movement. Embodied movement can elicit self-regulatory pathways that support health behavior.

Keywords: embodiment, habit, interoception, mindfulness, movement practice, qualitative, self-regulation, yoga.

Historically and in the present day, Black women’s positionality in the U.S. has paradoxically situated them in a society where they are both intrinsically essential and treated as expendable. This positionality, known as gendered racism, manifests commonly in professional environments and results in myriad harms. In response, Black women have developed, honed, and practiced a range of coping styles to mitigate the insidious effects of gendered racism. While often effective in the short-term, these techniques frequently complicate Black women’s well-being. For Black female clinicians who experience gendered racism and work on the frontlines of community mental health, myriad bio-psycho-social-spiritual harms compound. This project provided an opportunity for Black female clinicians from across the U.S. to share their experiences during the dual pandemics of COVID-19 and anti-Black violence. I conducted in-depth interviews with clinicians (n=14) between the ages of 30 and 58. Using the Listening Guide voice-centered approach to data generation and analysis, I identified four voices to help answer this project’s central question: How do you experience being a Black female clinician in the U.S.? The voices of self, pride, vigilance, and mediating narrated the complex ways participants experienced their workplaces. This complexity seemed to be context-specific, depending on whether the clinicians worked in predominantly White workplaces (PWW), a mix of PWW and private practice, or private practice exclusively. Participants who worked only in PWW experienced the greatest stress, oppression, and burnout risk, while participants who worked exclusively in private practice reported more joy, more authenticity, and more job satisfaction. These findings have implications for mentoring, supporting, and retaining Black female clinicians.

Keywords: Black female clinicians, professional experiences, gendered racism, Listening Guide voice-centered approach.

The purpose of this article is to speak directly to the paucity of research regarding Dominican American women and identity narratives. To do so, this article uses the Listening Guide Method of Qualitative Inquiry (Gilligan, et al., 2006) to explore how 1.5 and second-generation Dominican American women narrated their experiences of individual identity within American cultural contexts and constructs. The results draw from the emergence of themes across six participant interviews and showed two distinct voices: The Voice of Cultural Explanation and the Tides of Dominican American Female Identity. Narrative examples from five participants are offered to illustrate where 1.5 and second-generation Dominican American women negotiate their identity narratives at the intersection of their Dominican and American selves. The article offers two conclusions. One, that participant women use the Voice of Cultural Explanation in order to discuss their identity as reflected within the broad cultural tensions of their daily lives. Two, that the Tides of Dominican American Female Identity are used to express strong emotions that manifest within their personal narratives as the unwanted distance from either the Dominican or American parts of their person.

Keywords: Dominican American, women, identity, the Listening Guide, narratives

• Open access
• Published: 27 May 2020

How to use and assess qualitative research methods

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

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

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

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Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Qualitative Study

Affiliations.

• 1 University of Nebraska Medical Center
• 2 GDB Research and Statistical Consulting
• 3 GDB Research and Statistical Consulting/McLaren Macomb Hospital
• PMID: 29262162
• Bookshelf ID: NBK470395

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. Instead of collecting numerical data points or intervene or introduce treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and application of qualitative research.

Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’. Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is. One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify and it is important to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Examples of Qualitative Research Approaches

Ethnography

Ethnography as a research design has its origins in social and cultural anthropology, and involves the researcher being directly immersed in the participant’s environment. Through this immersion, the ethnographer can use a variety of data collection techniques with the aim of being able to produce a comprehensive account of the social phenomena that occurred during the research period. That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc. through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded Theory

Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.” As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences. In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is defined as the “study of the meaning of phenomena or the study of the particular”. At first glance, it might seem that Grounded Theory and Phenomenology are quite similar, but upon careful examination, the differences can be seen. At its core, phenomenology looks to investigate experiences from the perspective of the individual. Phenomenology is essentially looking into the ‘lived experiences’ of the participants and aims to examine how and why participants behaved a certain way, from their perspective . Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources whereas Phenomenology focuses on describing and explaining an event or phenomena from the perspective of those who have experienced it.

Narrative Research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called ‘thick’ or ‘rich’ description and is a strength of qualitative research. Narrative research is rife with the possibilities of ‘thick’ description as this approach weaves together a sequence of events, usually from just one or two individuals, in the hopes of creating a cohesive story, or narrative. While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be “opportunities for innovation”.

Research Paradigm

Research paradigms are the assumptions, norms, and standards that underpin different approaches to research. Essentially, research paradigms are the ‘worldview’ that inform research. It is valuable for researchers, both qualitative and quantitative, to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontology and epistemologies . Ontology is defined as the "assumptions about the nature of reality” whereas epistemology is defined as the “assumptions about the nature of knowledge” that inform the work researchers do. It is important to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a full understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, it is crucial that researchers understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist vs Postpositivist

To further understand qualitative research, we need to discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social as well as natural sciences. Essentially, positivist thinking insists that the social sciences should use natural science methods in its research which stems from positivist ontology that there is an objective reality that exists that is fully independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained but it could be approximated. Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world” and therefore postpositivist philosophy is often associated with qualitative research. An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are constructivist as well, meaning they think there is no objective external reality that exists but rather that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. “Constructivism contends that individuals’ views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality”. Essentially, Constructivist thought focuses on how ‘reality’ is not a fixed certainty and experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike in positivist views, that there is not necessarily an ‘objective’ reality we all experience. This is the ‘relativist’ ontological view that reality and the world we live in are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.”

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have and can even change the role of the researcher themselves. For example, is the researcher an ‘objective’ observer such as in positivist quantitative work? Or is the researcher an active participant in the research itself, as in postpositivist qualitative work? Understanding the philosophical base of the research undertaken allows researchers to fully understand the implications of their work and their role within the research, as well as reflect on their own positionality and bias as it pertains to the research they are conducting.

Data Sampling

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors at play. The following are examples of participant sampling and selection:

Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

Snowball sampling- the selection is by referral from other participants or people who know potential participants.

Extreme case sampling- targeted selection of rare cases.

Typical case sampling-selection based on regular or average participants.

Data Collection and Analysis

Qualitative research uses several techniques including interviews, focus groups, and observation. [1] [2] [3] Interviews may be unstructured, with open-ended questions on a topic and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one on one and is appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be a participant-observer to share the experiences of the subject or a non-participant or detached observer.

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo.

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. Results also could be in the form of themes and theory or model development.

Dissemination

To standardize and facilitate the dissemination of qualitative research outcomes, the healthcare team can use two reporting standards. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research.

Examples of Application

Many times a research question will start with qualitative research. The qualitative research will help generate the research hypothesis which can be tested with quantitative methods. After the data is collected and analyzed with quantitative methods, a set of qualitative methods can be used to dive deeper into the data for a better understanding of what the numbers truly mean and their implications. The qualitative methods can then help clarify the quantitative data and also help refine the hypothesis for future research. Furthermore, with qualitative research researchers can explore subjects that are poorly studied with quantitative methods. These include opinions, individual's actions, and social science research.

A good qualitative study design starts with a goal or objective. This should be clearly defined or stated. The target population needs to be specified. A method for obtaining information from the study population must be carefully detailed to ensure there are no omissions of part of the target population. A proper collection method should be selected which will help obtain the desired information without overly limiting the collected data because many times, the information sought is not well compartmentalized or obtained. Finally, the design should ensure adequate methods for analyzing the data. An example may help better clarify some of the various aspects of qualitative research.

A researcher wants to decrease the number of teenagers who smoke in their community. The researcher could begin by asking current teen smokers why they started smoking through structured or unstructured interviews (qualitative research). The researcher can also get together a group of current teenage smokers and conduct a focus group to help brainstorm factors that may have prevented them from starting to smoke (qualitative research).

In this example, the researcher has used qualitative research methods (interviews and focus groups) to generate a list of ideas of both why teens start to smoke as well as factors that may have prevented them from starting to smoke. Next, the researcher compiles this data. The research found that, hypothetically, peer pressure, health issues, cost, being considered “cool,” and rebellious behavior all might increase or decrease the likelihood of teens starting to smoke.

The researcher creates a survey asking teen participants to rank how important each of the above factors is in either starting smoking (for current smokers) or not smoking (for current non-smokers). This survey provides specific numbers (ranked importance of each factor) and is thus a quantitative research tool.

The researcher can use the results of the survey to focus efforts on the one or two highest-ranked factors. Let us say the researcher found that health was the major factor that keeps teens from starting to smoke, and peer pressure was the major factor that contributed to teens to start smoking. The researcher can go back to qualitative research methods to dive deeper into each of these for more information. The researcher wants to focus on how to keep teens from starting to smoke, so they focus on the peer pressure aspect.

The researcher can conduct interviews and/or focus groups (qualitative research) about what types and forms of peer pressure are commonly encountered, where the peer pressure comes from, and where smoking first starts. The researcher hypothetically finds that peer pressure often occurs after school at the local teen hangouts, mostly the local park. The researcher also hypothetically finds that peer pressure comes from older, current smokers who provide the cigarettes.

The researcher could further explore this observation made at the local teen hangouts (qualitative research) and take notes regarding who is smoking, who is not, and what observable factors are at play for peer pressure of smoking. The researcher finds a local park where many local teenagers hang out and see that a shady, overgrown area of the park is where the smokers tend to hang out. The researcher notes the smoking teenagers buy their cigarettes from a local convenience store adjacent to the park where the clerk does not check identification before selling cigarettes. These observations fall under qualitative research.

If the researcher returns to the park and counts how many individuals smoke in each region of the park, this numerical data would be quantitative research. Based on the researcher's efforts thus far, they conclude that local teen smoking and teenagers who start to smoke may decrease if there are fewer overgrown areas of the park and the local convenience store does not sell cigarettes to underage individuals.

The researcher could try to have the parks department reassess the shady areas to make them less conducive to the smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk population their perceptions of the changes, what factors are still at play, as well as quantitative research that includes teen smoking rates in the community, the incidence of new teen smokers, among others.

Copyright © 2024, StatPearls Publishing LLC.

• Introduction
• Issues of Concern
• Clinical Significance
• Enhancing Healthcare Team Outcomes
• Review Questions

Publication types

• Study Guide

• Open access
• Published: 15 March 2024

Young people's experiences of physical activity insecurity: a qualitative study highlighting intersectional disadvantage in the UK

• Caroline Dodd-Reynolds 1 ,
• Naomi Griffin 2 ,
• Phillippa Kyle 3 ,
• Steph Scott 2 ,
• Hannah Fairbrother 4 ,
• Eleanor Holding 5 ,
• Mary Crowder 5 ,
• Nicholas Woodrow 5 &
• Carolyn Summerbell 1  

BMC Public Health volume  24 , Article number:  813 ( 2024 ) Cite this article

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Intersecting socioeconomic and demographic reasons for physical activity (PA) inequalities are not well understood for young people at risk of experiencing marginalisation and living with disadvantage. This study explored young people’s experiences of PA in their local area, and the associated impacts on opportunities for good physical and emotional health and wellbeing.

Seven local youth groups were purposefully sampled from disadvantaged areas across urban, rural and coastal areas of England, including two that were specifically for LGBTQ + young people. Each group engaged in three interlinked focus groups which explored young people’s perceptions and lived experience of PA inequalities. Data were analysed using an inductive, reflexive thematic approach to allow for flexibility in coding.

Fifty five young people aged 12–21 years of different sexualities, gender and ethnicity took part. Analysis yielded four themes: PA experiences across spaces; resigned to a lack of inclusivity and ‘belonging’; safety first; complexities in access and accessibility. Young people felt more comfortable to be active in spaces that were simpler to navigate, particularly outdoor locations largely based in nature. In contrast, local gyms and sports clubs, and the school environment in general, were spoken about often in negative terms and as spaces where they experienced insecurity, unsafety or discomfort. It was common for these young people to feel excluded from PA, often linked to their gender and sexuality. Lived experiences or fears of being bullied and harassed in many activity spaces was a powerful message, but in contrast, young people perceived their local youth club as a safe space. Intersecting barriers related to deprivation, gender and sexuality, accessibility, disability, Covid-19, affordability, ethnicity, and proximity of social networks. A need emerged for safe spaces in which young people can come together, within the local community and choose to be active.

Conclusions

The overarching concept of ‘physical activity insecurity’ emerged as a significant concern for the young people in this study. We posit that PA insecurity in this context can be described as a limited or restricted ability to be active, reinforced by worries and lived experiences of feeling uncomfortable, insecure, or unsafe.

Peer Review reports

Three in four adolescents do not meet global physical activity (PA) guidelines [ 1 ] and the annual global cost of inactivity is estimated to be in excess of $67·5 billion [ 2 ]. Adolescent inactivity is unequally distributed between nations, as well as within societies [ 3 ] and in England, only 47% of 13–16 year-olds met national PA guidelines in 2022/23 [ 4 ]. Physical activity is linked to 13 of the 2030 UN sustainable development goals (SDGs) including SDG3 good health and well-being, SDG4 quality education, and SDG10 reduced inequalities [ 1 ]. Through their global action plan, the World Health Organisation (WHO) [ 1 ] presents a mission to ensure access to safe and enabling environments along with diverse opportunities for PA, targeting a 15% relative reduction in inactivity for adults and adolescents by 2030. Despite this global focus, clear gaps in knowledge around policy development and implementation have been highlighted [ 3 ] with a need for supportive policies, environments, and opportunities [ 5 ] for children and young people to be active.

In this paper, we define physical activity as “people moving, acting and performing within culturally specific spaces and contexts, and influenced by a unique array of interests, emotions, ideas, instructions and relationships” ([ 6 ], p. 5). Like health, PA is heavily influenced by intersecting socioeconomic and demographic factors [ 7 , 8 ], yet PA has the potential to improve health equity [ 9 ]. In England, epidemiological data show that children and young people are less likely to meet PA guidelines according to low affluence, gender (girls and 'other'), and ethnicity (Black, Asian, Mixed and Other non-white/non-white British) [ 4 ]. Evidence suggests, however, that individual determinants of young people’s PA are variable and diverse and include previous PA, PE/school sports, independent mobility and active transport, education level and other health behaviours such as alcohol consumption [ 10 , 11 ]. A comprehensive systematic review of over 18-year-olds [ 12 ] reported 117 correlates of PA across a range of demographic, biological, psychological, behavioural, social and environmental factors.

The direct relationship between socioeconomic status (SES) and children’s PA is particularly unclear, with umbrella systematic review evidence [ 13 ] suggesting mixed findings in terms of whether SES is a determinant of PA, though the same study demonstrated a positive association between SES and PA for adults. Individual factors such as parental income and parental occupation, along with payment of fees/equipment did, however, show some evidence of an association with children and adolescent PA [ 13 ]. Whilst the authors note the small number of studies available for children and adolescents, a lack of causal evidence and differing measurement tools which might contribute to the uncertainty around SES and PA, we suggest also that quantitative evidence may well fail to capture the complexity of children and young people’s PA in different spaces. Indeed, a qualitative review of limited extant literature concerning socioeconomic position and experiences of barriers to PA [ 14 ] highlighted issues such as social support, accessibility and environment, and experiences (particularly gendered) of health and other behaviours, but importantly noted that those in low socioeconomic position areas had a good understanding of PA benefits. Better understanding is required regarding the complexity of PA experiences for children and young people living with disadvantage.

Within the PA literature, systems approaches are evolving to map and understand networks and mechanisms within complex systems, ultimately aiming to reduce health inequalities [ 15 , 16 ], and a systems-based framework for action forms a key component of the WHO’s global strategy [ 1 ]. To support this work, better understanding is needed regarding the dynamic, contextual mechanisms which underpin various agents in local systems [ 17 ], for example through understanding better young people’s personal, or direct ‘lived experiences’ of PA. Engaging in dialogue with young people at the heart of local communities, offers a deeper and more nuanced understanding of place-based PA challenges and opportunities.

In general, individuals transitioning from childhood to adulthood are underserved in PA research, yet experiences earlier in life have a lasting effect on adult health and health behaviours [ 7 ]. The 2016 Lancet Commission on adolescent Health and Wellbeing [ 18 ] recommended setting clear objectives for change, based on local needs, and highlighted a gap for young people at risk of being socially and economically marginalised, including LGBT + (lesbian, gay, bisexual, trans and others) groups. Adolescents and those on the fringes of adulthood (hereafter referred to as young people) therefore present a critical but wide-ranging group with whom we must seek to better understand PA inequalities, particularly in the context of widening place-based inequality and deprivation and the syndemic 'shock' of the COVID-19 pandemic [ 19 , 20 ]. Accordingly, we have applied the concept of intersectionality [ 21 , 22 ] to explore the complex and intersecting factors which influence access to, and experiences of, PA.

We have recently reported young people’s nuanced understandings of the malleable and dynamic relationships between socioeconomic circumstance and health [ 23 ] and in this paper, we focused on PA specifically. We explored young people’s experiences of PA in their local area, and the associated impacts on opportunities for good physical and emotional health and wellbeing. In doing so we worked with young people who were already at risk of experiencing social and health inequalities across England, UK.

This paper drew on data from a larger project [ 23 ] where a series of three interlinked qualitative focus groups were undertaken with six groups of young people who attended local community youth groups between February and June 2021. For the present study, we recruited a further group (December 2021) to ensure diversity in terms of gender and sexual orientation. In total, 55 participants aged 12–21 years, from seven youth groups across three regions of England took part. Each youth group took part in three interlinked focus groups exploring health and health inequalities (21 focus groups in total). Two regions were in the north of England (South Yorkshire (SY) n  = 2; North East (NE) n  = 3; one region was in the south of England (London (L) n  = 2). All regions fell within the most deprived quintile based on 2019 English indices of multiple deprivation (IMD) in England, with closer to 1 being more deprived. At participant-level, IMD quintile ranged from 1–3. The project commenced during the Covid-19 pandemic, where the UK experienced several lock-down periods. Due to social distancing restrictions, all focus groups were conducted online except for two youth groups which were in-person (one due to digital exclusion and another recruited once restrictions lifted sufficiently). Focus groups lasted approximately 1.5 h. Further details on methodological and ethical challenges and full procedures are described elsewhere [ 23 , 24 ]. Ethical approval was granted by the School of Health and Related Research (ScHARR) Ethics Committee at the University of Sheffield and the Department of Sport and Exercise Sciences Ethics Committee at Durham University.

We adopted a purposive sampling strategy, designed to encapsulate maximum variation in perspectives and diversity [ 25 ]. Our sample was guided by the breadth and focus of the research question(s); demands placed on participants; depth of data likely to be generated; pragmatic constraints; and the analytic goals and purpose of the overall project [ 25 , 26 ]. Our final sample included young people of different sexualities, gender and ethnicity across urban and rural and coastal areas (see Table  1 ).

Youth workers invited group members to participate and shared an information video and project overview before researchers attended youth group sessions to discuss the study, build rapport and provide more detailed information sheets.These sessions were all held online during lockdown, except for two in-person groups, which were visited by the researchers. Written consent was gathered for all participants and, where under 16 years, opt-in consent from parents/guardians was also gained. Participants were asked to provide basic demographic information including postcode to calculate IMD.

Data generation

Topic guides were developed [ 23 ], giving careful consideration to activities and language used around health inequalities. These were piloted and revised with two other partner youth organisations through early public involvement and engagement work. Youth workers helped facilitate sessions and at least four and two researchers were present for online and in-person sessions, respectively (NG, NW, MC, EH, HF, CDR, VE). The same groups of researchers worked across the 21 focus groups in different sites, to ensure consistency in process. All focus groups began with introductions and a warmup activity, followed by the main activity (in smaller breakout groups) and finally close and a cool-down activity. The three interlinked focus groups held with each youth group explored: (1) children and young people's understandings of health and wellbeing as a human right (via participatory concept mapping, see Jessiman [ 27 ] for an example), (2) children and young people's perceptions of the social determinants of health (sharing ideas about contemporary news articles relevant to health inequalities) and (3) children and young people's understandings of the ways young people can take action in their local area. Focus groups were recorded via encrypted Dictaphones and transcribed verbatim, with data anonymised at the point of transcription. Contextual field notes were taken by researchers.

Thematic analysis is a well-established approach to qualitative inquiry in health-related research that allows for the depth and richness of qualitative data to guide analysis [ 28 ]. We used an inductive, reflexive thematic approach to allow for flexibility in coding [ 26 ] and the desire to make sure our analysis was adequately capturing views of the young people themselves [ 29 ]. The approach was rigorously tested through the piloting of methods, regular analysis meetings, and sense-checking sessions (with participants) to validate themes [ 30 ]. For a full description of the original reflexive thematic analysis process [ 26 , 31 ] please see Fairbrother et al. [ 23 ]. In brief, an initial coding frame was developed, with key codes and overarching themes discussed (linked to young people’s perspectives on the relationship between socioeconomic circumstances and health) and agreed upon by the wider research team. Once these core themes were established, an additional in-depth phase of reflexive analysis was undertaken (NH, PK, CDR, CS) to specifically explore PA, which had arisen continually, but not been developed as a theme, across the initial analysis. As before [ 23 ], we emphasised a creative and active approach to the analysis which followed an inherently ‘interpretative reflexive process’ ([ 26 ], p. 334). CDR, PK and NG were immersed in the data, continually reflecting upon, questioning and revisiting during the analysis process Regular analysis meetings took place to reflect and discuss and a new coding framework was developed and agreed by CDR, PK and NG, from which with themes were developed. The qualitative data management software system NVivo-12 was used to support data management.

Our analysis yielded four central themes: (1) PA experiences across spaces; (2) Resigned to a lack of inclusivity and ‘belonging’; (3) Safety first; (4) Complexities in access and accessibility. Nevertheless, themes naturally interrelate and the overarching concept of ‘PA insecurity’ emerged as a significant concern for the young people who generously shared their personal experiences with us. Here each interlinked focus group session is denoted S1, S2, S3.

Physical activity experiences across spaces

The types of spaces in which young people felt able, or not able, to be active were crucial and formed the backdrop to their PA-related experiences and interactions with others. These are contextually linked here to later themes which provide further depth on how PA might or might not be enacted by young people within those spaces.

Across sites, there were differential responses in terms of ‘things to do’ in the local area. Inner city areas had fewer green and blue spaces but presented more organised opportunities in the locality. In rural areas young people had to travel to engage in social activities. Whilst in general there were positive attitudes towards PA, in the NE and SY, there was a perceived lack of things to do where they lived that did not cost money, or require private or unreliable public transport. A salient sub-theme developed around local opportunities for activity, with one group highlighting the resulting ease with which sedentary activities displaced other activities:

Facilitator : ‘Do you prefer to play on consoles or do you prefer to go outside and run around and have exercise’? NE2, S2 : ‘If there’s nothing to do, then I will stay in the house, but if there is something to do, then I might as well just go outside’.

At first glance, this apathy perhaps represents a lack of self-efficacy, often described as an individual-level determinant of PA. However, being physically active was far from simplistic and the young people described many associated challenges including closure of local amenities such as bowling and trampoline parks, with investment instead made in a nearby seaside town. For example, they described complexities around access to the nearest swimming pool. This was free in summer but not in the immediate locality, and thus required adult facilitation to enable the young people to travel to and access the pool, resulting in a structural barrier preventing them from taking part in something which was important to them within their existing social networks:

NE2,S2: ‘ Well just going out with friends and my dad saw that – I don’t know where – but he said, “Do you want to go?” “Yeah.” So he’ll get on the bus and he’ll go around and he got us in the baths ’. NE2,S2: ‘ He goes around…and picks up children ’.

Spaces that were simpler to navigate included outdoor locations, largely based in nature, which for a number of the young people evoked a sense of freedom and well-being: ‘ there’s a big, massive field and a couple of times a week I take my dog there so he can meet other dogs. Take him for a big walk… is good for your health. It’s good for my dog .’ (NE2, S1.)

Blue spaces were perceived similarly by those living near the coast: ‘ I like going to the beach… I just like the sea. It’s calm and obviously there’s a long way to walk as well ’ (NE2, S1).

Some indoor PA spaces, particularly swimming pools, were also described as places which evoked calmness and wellbeing. The following young person reflected on this in relation to how they felt in water:

‘ And it’s funny because when I first thought about the swimming pool, I didn’t think about it in terms of the physical exercise being good for me but obviously that is good. It’s much more that when I’m just completely submerged in water I feel very calm and I think it’s a bit of a shock to the system which can be nice, to be cold, suddenly very cold, and then get warmed up afterwards. So it’s kind of the pool and then also having a nice cup of tea when I get home after. For my mind and body I’d say… ’. (S1, S1).

Other indoor spaces such as gyms and sports clubs were spoken of in terms of being more for purposeful PA (i.e. exercise or sport) however the young people tended to speak less positively about their experiences, highlighting feelings of discomfort and of feeling self-conscious. In doing so, gender-based concerns often intersected: ‘ I did trampolining competitively…I was just getting to a point where I wasn’t comfortable. Because I was still having to wear the girl’s uniform …when you look at the differences between the uniforms, it's really stark ’. (NE1, S2). Similarly, in the gym setting, young people highlighted a perceived lack of security: ‘ Because gyms are enclosed spaces, there’s like dodgy blokes who are all like pumped and I’d rather not be around them. It’s just not my idea of fun ’ (SY2, S3). The ‘gym’ was repeatedly referred to in one focus group as negatively impacting upon self-esteem: ‘ I just hate it because like if you’re 16, the gym I used to go to had like a lot of older body building people so I’d feel like they were just watching me and I’d feel really uncomfortable about it’ , (SY1, S1). Conversations however also spoke of a need for inclusivity in the gym environment, noting feelings of pressure (as a female) ‘…if there’s guys looking at them they might not want them looking because obviously they’ll be looking in places they don’t want them looking. But also…we shouldn’t have to have girl-only gyms, everyone should be like integrated. ’ In the same conversation, concerns of racist behaviour were linked directly to the local area by another young person: ‘ And also racism as well, you could experience a lot of racism in gyms if you’re living in predominantly a white town.’ (SY2, S3).

The final space that permeated discussions, was an institutional one: the school or college environment. For the most part, narratives drew on personal experiences, often negative. For some, opportunities to be active in the institutional space had been removed altogether, something which was beyond their control: ‘ we didn’t do PE for about, a good three years because…we now needed to concentrate on our GCSEs… ’ (NE1,S3). Here, decisions made by adults in school, created barriers and the young people were aware of the gravity of lost opportunities to be active in the institutional space: ‘ …a lot of kids were missing out on that physical education and a way to exercise. That might have been students’ only way of exercise ’. This highlights how a lack of support from adults in positions of power can affect young people’s engagement in PA. Conversely, this could be positive intervention, illustrating how unequal distribution of support from teachers can impact significantly on young people’s PA experience in the education setting. In this example, one young person clearly highlighted a link between PA and psychological wellbeing:

‘ I managed to convince the teachers to let me do double rugby… two outside of school, one in school, like one club in school, two clubs outside of school and then two PE’s… because it’s an aggressive sport, I can get out all my aggression…I’m good with my team and I’m friends with all the people in it’ , (NE3, S3).

This theme illustrates that the young people were well aware of physical spaces in which they might be active but highlights the importance that young people attach to feelings of safety, security, and freedom, and how these can intersect with other characteristics. Physical activity spaces may be more conducive to positive mental health if they are larger and open, without interference from other people and where young people might feel less threatened by a perceived, or actual, need to conform.

Resigned to a lack of inclusivity and ‘belonging’

For many of the young people, there was a commentary around feeling excluded from PA, particularly sport, linked to gender and sexuality. This appeared to evoke a sense of resignation, even at such a young age, of having had to give up trying to access certain types of PA due to feeling a lack of inclusivity.

‘ If you feel that you can’t participate in a sport, then your physical health is going to decline, just from the sake of a trans person just trying to negotiate – if you go to a game. Which dressing room are you going to use? You avoid that completely to keep yourself safe or you have then out yourself to people. ’ (NE1, S2).

Such experiences extended to PE lessons, sometimes with a sense of finality and relief, with one trans young person seemingly ‘owning’ that exclusion:

‘ Participant 2: I’m not doing P.E…I also have it on my notes saying that I can’t do PE after going through physiotherapy. Facilitator 2: And is that good, do you think, because you don’t really want to do it? Participant 2: Yeah. ’ (NE3, S3).

For some trans and non-binary young people who were engaging with PA at school, there appeared to be some support and understanding from staff, but this was not enough on its own: ‘ teachers keep coming and talking to me about joining in with the boys and I’ve finally got my mum to agree to let me go. But the teachers keep saying they’ll talk to her, but then my mum keeps saying she’ll ring the school but she never does ’ (NE3, S3). Another young person who had not ‘ come out’ as non-binary fully yet in school further illustrated negative experiences with gendered PE lessons: ‘ So I go into the girls’ PE and I’m sick of it because I go in and it’s just like, “hi girls!!” and I’m just like just kill me now ’. (NE3, S3).

For others, non-gendered opportunities in PE were desirable, avoiding traditional school curriculum activities that implied boys and girls taking part separately. One participant admitted to having hidden in the toilets to avoid PE because: ‘ I despise football but it was the only thing we did for about six months ’ and suggested a need for more ‘ variety ’ and ‘ more inclusive sports .’ (NE1, S3).

Safety first

Young people’s access to and engagement with PA in certain spaces, was foregrounded by a need to feel safe in those spaces both in terms of physical and emotional safety. For many this was linked to fear of crime and substance abuse in the local park: ‘ You could literally go…and it’s probably got either a bag that’s had something in it, alcohol bottles or needles. It’s quite terrifying ’ (SY1, S2). Others highlighted particular situations which required avoidance: ‘… the dealing’s worse…that’s where all the fights happen…that basically…makes it more dangerous for people to be outside’ (L2, S2). When referring to the end of lockdown, and people buying drinking supermarket-bought alcohol ‘… outside in the open, like, and in huge groups…’ one participant noted a fear for safety outdoors which intersected with worries of racist behaviour…’ so, like, that’s one of the things that makes me a little bit, like, scared, like, I wonder, like, would they, like, say something, like, racist to me?’ (SY1, S2).

Active travel was also explained as problematic, but for some a necessity which required precautions for ‘girls’ who it was suggested (by a group of boys) should ‘ Put a key in their fingers ’. (NE2, S2) and careful planning for one participant: ‘ I had to find a whole new route home so I didn’t get harassed and beat up ’. (NE3, S3.5). For one group, avoidance of crimes in progress was critical: ‘ people constantly starting fires ’ (NE2, S1). Fear of harassment outdoors seemed entrenched for many, sometimes linked to gender: ‘ Catcalling, and being followed… harder to feel safe… even in…broad daylight ’ (L2, S3), and other times a generational influence on feelings of fear in the local area: ‘… after a certain time, 4 or 5 o’clock, my nan used to say “time to go back now” because she knew that that’s when all the dodgy people would come out really, even if it wasn’t necessarily dark earlier. ’ (SY1, S1).

For some, fears were more nuanced and centred around avoidance of bullying and transphobia: ‘ I think, particularly for trans and LGBTQ people, it’s difficult to feel secure in a sport … I don’t feel safe going to the club because if they find out I’m trans, they’ll just pick me out ’ (NE1, S2). This extended from access to sports clubs, to open spaces where young people in one LGBTQ + youth group were in agreement about fears of harassment based on their gender or sexuality:

Facilitator 2: When you’re walking around and you’re out and about, how do you feel? Participant 5: I feel like I’m in danger and scared….who feels unsafe out and about? Participant 2: I do. Participant 1: I do too. (NE3, S3)

Together, these points exemplify a need for safe spaces in which young people at risk of marginalisation and living with deprivation can come together, connect within the local community and choose to be active: ‘ Like, because you can be at a park and then you can get harassed easily… You could barely go [to a park] without that [harassment] happening…Makes me not want to leave my house .’ (NE1, S1). The youth groups themselves were seen as places of familiarity ‘ I’ve been here for ages ’, where young people can ‘ socialise, have fun, play a range of games, [make] new friends and bonding[sic] ’(NE2, S1) in a safe environment where social connections can be made. As such, youth groups might be pivotal in providing the kind of leadership and support required for PA access and engagement, perhaps even just in terms of open space provision: ‘ Even though we have the consoles, we don’t really use them that often. We’re mostly just outside… ’ (NE2, S1), as well as facilitating the social networks needed for young people to even consider PA.

Complexities in access & accessibility

Whilst intersecting elements of PA access feature throughout other themes, it is important to draw specific attention to intersecting barriers relating to accessibility, including disability, Covid-19, affordability, and proximity of social networks with whom to engage in PA. In illustrating this, we draw on some of the issues highlighted in earlier themes.

Provision of physically accessible green spaces with appropriate facilities and equipment was an intersecting issue linked to crime and affordability, in the experience of one young person living in an area of poverty:

‘ …where I live and work, like football is huge. We've got a few football pitches, you’ve got to pay to play certain places especially for young people, so it's very, very difficult and what they tend to do, they’ll climb the cage gates and that leads to trouble and…stuff. If we had access to open free football pitches, that would be quite beneficial…I don’t think there’s…enough active stuff. Over the last couple of years, I've noticed they put in like monkey bars and other gym stuff [in parks]. ’ (L1, S1).

In some discussions, disability was an intersecting issue, adding to the complexity of PA access and highlighting affordability and a desire to be active with peers:

Participant 4: It’s not easy [to get about town with transport] if you have a hearing impairment and I know that from experience Participant 1: But it can be easy though, depends on who your friends are, so me and my friends kind of live close [ind] and with covid, we have friends that kind of live further an it’s a little bit harder [ind] Facilitator so why it is harder, what stops that Participant 1: It’s probably either their parents not letting them go out further to come meet us [ind] and they may not be able to afford to…go out (NE2, S1)

This theme illustrates that complexity of intersecting barriers to PA appears particularly pronounced and nuanced for some of these young people. As a result, solutions are likely to be similarly complex..

Considering the naturally intersecting themes in this study, we posit that the overarching concept of ‘physical activity insecurity’ emerged as a significant concern for the young people who generously shared their personal experiences (see Fig.  1 ). Physical activity insecurity is not an established term within the literature. To date and to the best of our knowledge, just one paper has linked it to families’ low readiness to provide opportunities for PA, where food insecurity was already being experienced: an “inability to provide sufficient health-promoting MVPA for children” ([ 32 ], p. 41). We note the distinction with food insecurity, which is well-recognised and formally defined as “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways.” ([ 33 ], p. 193). Here, we propose a new conceptualisation for PA insecurity, beyond simply providing a space for PA to be ‘secure’ and in recognition of the complexity of PA as a behaviour which is navigated cerebrally, socially, and politically within a situated space [ 6 ]. Young people in our study were very much aware of the spaces and opportunities for PA and associated potential benefits but were challenged by how the wider social and physical environment responded to them and reinforced feelings of inaccessibility. Here we draw on Friere’s concept of critical consciousness [ 34 ], which refers to an individual’s awareness of oppressive systemic forces in society, a sense of efficacy to work against oppression, to illustrate that instead of internalising the inaccessibility of certain spaces, young people actively highlighted the ways in which spaces were not set up with their access needs in mind. We thus define PA insecurity as a limited or restricted ability to be active, reinforced by worries and experiences of feeling uncomfortable, emotionally or physically unsafe. We suggest this can be as a result of oppressive practices, lack of inclusion and disadvantage. Our findings suggest that PA insecurity can be experienced by any young person at risk of experiencing marginalisation and living with disadvantage, particularly where intersectional barriers overlap. However it seems is particularly nuanced for transgender and non-binary young people, for example in dealing with harassment and/or exclusion due to gender discrimination. We suggest that the young people in our study may not ever be able to contemplate PA until they feel safer, supported and included by society. We explore this further, later on the discussion, in terms of existing theory related to feelings of oppression and discrimination in disablism [ 35 , 36 ].

Physical activity insecurity experienced by young people

Challenges linked to gender and sexuality within a sporting context have been widely documented in the sociology literature, for example Anderson’s [ 37 ] inclusive masculinity theory suggests a trend towards reduced sexism and “homohysteria” in recent years. However, Pope [ 38 ] argues that though men’s attitudes to women in sport may be slowly changing for the better, overtly misogynistic masculinities are still prominent. Whilst our work was not grounded in theories of gender and sexuality, our sample comprised one trans masculine, one gender-fluid, four non-binary, nine trans males, 19 female and 21 male participants (Table  1 ) and our data certainly highlight that non cis-gendered individuals felt unable to be their true authentic self around PA. Little else is understood about the lived experiences of LGBTQ + youths in the PA domain, and what exists tends to consider school PE/sport provision [ 39 ]. Research does however support the notion that sexual and gender minority youths, particularly transgender young people, avoid PA settings due to feeling unsafe and uncomfortable [ 40 , 41 ]. Herrick and Duncan [ 42 ] similarly highlight a need for safe, inclusive PA spaces for LGBTQ + adults, and also a need for an intersectional approach to explore PA complexity along with avoidance of elitist and inaccessible terms such ‘athlete’.

Intersectionality highlights the multiple intersecting identities of individuals and groups and how they interact and can compound each other in relation to oppression and inequality [ 21 , 22 ]. In our findings, intersecting socioeconomic and demographic challenges raised by participants included deprivation (as per our sampling strategy), ablesim, crime and safety, affordability, and racism, as well as inequalities related to gender and sexuality. The young people in our study were cognisant to the ways in which different vulnerabilities can interact and compound each other, for example, exclusions related to homophobia, transphobia and ableism being further compounded by income inequality. They also discussed the links between accessibility and place, where some young people have greater opportunities to be involved in PA due to where they live, with closer proximity meaning greater access and affordability. Participants also reflected on how experiences of racism, sexism and/or homophobia in PA spaces increased the likelihood of disengagement. The young people who accessed LGBTQ + specific youth groups reflected on opportunities afforded to them to play or be active with others like them in a safe space, but highlighted that those space are not accessible to all, due to limited capacity and often a need to travel (affordability). Further insight into wider health inequalities as experienced by the LGBTQ + groups can be found in our linked paper by Griffin et al. [ 43 ]. In the present paper, we highlight a need to understand the complex ways in which intersectional disadvantages can intersect and compound each other, and in doing so, exacerbate PA insecurity.

We suggest that our findings of largely internalised feelings of insecurity, discomfort and a lack of safety represent facets of oppression and undermined psycho-emotional wellbeing. As such, there appear to be parallels with the concept of ‘psycho-emotional disablism and internalised oppression’ [ 35 , 36 , 44 , 45 ] where “internalised oppression…can undermine someone’s psycho-emotional well-being and sense of self” ([ 44 ] p. 24). Reeve [ 44 ] further notes that the emphasis on removing psycho-emotional barriers should not lie with the individual, but rather with society. We posit that this has important implications for our findings. Reeve [ 45 , 46 ] describes how indirect psycho-social disablism can reflect experiences of structural barriers, for example the “experience of being faced with an inaccessible building can evoke an emotional response such as anger or hurt at being excluded” ([ 46 ], p. 106). In our study such barriers are described by young people as e.g. changing rooms and uniforms which (drawing on Reeve [ 47 ]) alone might be characterised as solely socio-structural barriers to PA, if we did not have insight into how these experiences made the young people feel marginalised or resigned to inactivity. We suggest that the young people in our study similarly evoked elements of internalised oppression and discrimination in relation to PA, particularly in terms of feeling resigned to a lack of inclusivity and belonging. Importantly, we did not ask the young people in our study about their disability status, and therefore do not apply this theory through a disability lens per se. Rather, we consider here how psycho-emotional disablism might be applied through an intersectional lens, given the sharp similarities in challenges experienced and internalised by our young people. Given this, we suggest that simply adapting or removing structural barriers is insufficient to enable safe PA access for these young people, particularly those identifying as LGBTQ + . Researchers, practice partners and policy-makers need to work with young people to better understand their experiences, and to facilitate trustworthy relationships with PA within society.

Our findings also suggest that compassion, understanding and allyship of a trusted adult, may be critical for young people to feel safe and secure and thus give their trust and permission to engage in PA. Support from adults in positions of power had a strong influence on young people’s (lack of) engagement in PA, for example teachers in the institutional space. This point is supported by work which explored the relationship between a trusted adult and adolescent health and education outcomes [ 48 ], where young people outlined the need for mutual respect, patience and willingness of an adult to go the ‘extra mile’ in enabling them to engage in positive health behaviours. One US-based group has gone as far as to develop bespoke physical education teacher support around inclusive athletics for LGBTQ youth [ 49 ], though how this might work in practice across multiple PA settings needs yet to be explored. We suggest that young people, particularly those experiencing intersectional barriers to PA, should be included in decisions relating to PA policy and design of PA spaces themselves. This may in the longer-term reduce reliance on trusted adults.

Understanding what a secure PA space might actually look like for young people with shared challenges and/or protected characteristics is a clearly needed next step. Yet there exists a dearth of contextual evidence around how young people at risk of experiencing marginalisation and living with disadvantage experience PA in their local environment. More broadly, we acknowledge a need for whole system action to improve young people’s PA experiences in the spaces that they have access to. This extends beyond provision of what might be perceived physically safe spaces (e.g. safe playing, walking or cycling infrastructure) to inclusive language and action linked to changing facilities, clothing, and creating opportunities for PA within existing trusted networks such as youth groups. Though, as we have noted, responsibility for inclusivity should not lie with the individual, hearing the voices of young people in terms of who is needed, where they are needed and how spaces could be made more inclusive, is critical in this respect [ 50 , 51 ].

In the UK, the PA landscape is driven by ‘top-down’ national policy agendas [ 52 ] and responsibility for young people’s PA provision is devolved across numerous sectors at local level. Given gaps in knowledge of PA policy development and implementation for young people [ 3 ] and the need for supportive policies, environments and opportunities to strengthen those national policy efforts [ 5 ] we suggest that further work might look to local groups and networks to co-produce, with young people at risk of marginalisation and living with disadvantage [ 53 ], guidance on what secure PA spaces might look like and who is required to facilitate them. Such work must carefully consider the views of young people, trusted adults (e.g. youth workers) and others involved in provision of PA such as service providers, teachers and local authorities.

Limitations

Fieldwork took place during periods of Covid-related lockdown, and some comments from participants may reflect challenges which were exacerbated at this point in time. Though there was ethnic diversity across the overall sample, this was largely limited to the southern sites. We also acknowledge potential limitations of recruitment through existing youth organisations, which may exclude the voices of young people who are unable to engage with this provision. Nevertheless, as noted by Fairbrother et al. [ 23 ], working with youth groups enabled us to have the support of Youth Workers in refining topic guides and facilitating participant engagement, as well as providing an invaluable source of trusted support for participants [ 24 ].

Young people were recruited through youth groups and trusted youth leaders were very much part of the process. In each sampling site, the same group of young people engaged in three focus groups, and the building of rapport through this process provided open and honest reflections. We note the rigour of analysis as a strength in this work, particularly the sense-checking of themes with the young people.

Future research

Future research should build on these findings and work with young people at risk of experiencing marginalisation and living with disadvantage to explore what safe PA spaces and associated PA policies might consist of. Further diversity in sampling is also important. Finally, consideration should be paid to whether PA insecurity can be measured, for example via an assessment tool.

We argue that the voices of young people at risk of marginalisation and living with deprivation, including LGBTQ + youths, must be heard in the context of their own embodied PA experiences, in order to mediate PA inequalities. Young people articulated a clear and in-depth understanding of the spaces in which they experience (or do not) PA. They provided a powerful narrative which suggests PA insecurity as central to their lived experiences of PA, often highlighting intersecting barriers to PA which resulted in feelings of internalised oppression and undermined psycho-emotional well-being. We highlight a need for accessible and affordable safe spaces within the local community, where young people can come together and have the ability to be active. Such safe spaces will likely require facilitation and support of trusted adults in terms of helping to manage the complexity of challenges associated with PA for these young people.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due to privacy reasons but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to thank the members of our stakeholder steering group for their support and input throughout the project. We thank members of the youth organisations who piloted and provided feedback on our data generation tools and methods. We also thank Emily Tupper and Vanessa Er who provided support for some of the focus groups and Matt Egan for his involvement in the wider project. Finally, we thank the young people and youth organisations that took part in the research for their contributions, insights and enthusiasm.

This project was funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR) (grant reference number PD-SPH-2015). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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CDR was involved in conception and design of the study, data collection and analysis, drafting of manuscript; NG was involved in data collection and analysis; PK was involved in data analysis; SS was involved in data analysis; HF was involved in conception and study design, data analysis; EH was involved in data collection; MC was involved in data collection and analysis; NW was involved in data collection and analysis. CS was involved in conception and design of the study, data analysis, drafting of manuscript. All authors edited drafts and agreed the final submitted manuscript.

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Dodd-Reynolds, C., Griffin, N., Kyle, P. et al. Young people's experiences of physical activity insecurity: a qualitative study highlighting intersectional disadvantage in the UK. BMC Public Health 24 , 813 (2024). https://doi.org/10.1186/s12889-024-18078-9

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Julia Rosenberg, Patricia McDonough Ryan, Camille Brown, Rachel Schaffer, Caroline O’Brien, Fereshteh Ganjavi, Mona Sharifi, Exploring the determinants of successful implementation of a preventive mental health and wellness intervention for Afghan refugee families: a qualitative analysis, Health Education Research , Volume 39, Issue 2, April 2024, Pages 119–130, https://doi.org/10.1093/her/cyad034

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Many refugee children experience trauma in early childhood. Effective, tailored interventions are needed to improve refugee children’s access to preventive mental health. We interviewed refugee-serving stakeholders and parents participating in an evidence-based preventive mental health and wellness intervention adapted for Afghan refugee children and families who may have experienced trauma. Interview guide development was informed by two implementation science frameworks: the Consolidated Framework for Implementation Research and the Model for Adaptation Design and Impact. A three-person team coded transcripts via rapid qualitative analysis, and the study team reached consensus on themes. Six refugee-serving facilitators and five refugee parents discussed key determinants of successful implementation. Themes included: (i) modeling cultural humility to promote communication about emotions; (ii) needed linguistic support and referral networks to avoid miscommunications and missed communications; (iii) bridging connections between children, families and schools; (iv) different takeaways, or differing goals and expectations between facilitators and participants; and (v) timely, specific cultural considerations to overcome participation barriers. Overall, we found key determinants of successful implementation of a preventive mental health and wellness intervention for refugee children and families included adaptations to enhance cultural humility and sensitivity to cultural context while strengthening communication among facilitators, children and families.

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Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study

• Maxine Kuczawski   ORCID: orcid.org/0000-0002-0774-8113 1 ,
• Suzanne Ablard 1 ,
• Fiona Sampson 1 ,
• Susan Croft 1 , 2 ,
• Joanna Sutton-Klein 1 , 3 &
• Suzanne Mason 1  

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Advanced Clinical Practitioners (ACPs) are a new role that have been established to address gaps and support the existing medical workforce in an effort to help reduce increasing pressures on NHS services. ACPs have the potential to practice at a similar level to mid-grade medical staff, for example independently undertaking assessments, requesting and interpreting investigations, and diagnosing and discharging patients. These roles have been shown to improve both service outcomes and quality of patient care. However, there is currently no widespread formalised standard of training within the UK resulting in variations in the training experiences and clinical capabilities of ACPs. We sought to explore the training experiences of ACPs as well as their views on role identity and future development of the role.

Five online focus groups were conducted between March and May 2021 with trainee and qualified advanced clinical practitioners working in a range of healthcare settings, in the North of England. The focus groups aimed to explore the experiences of undertaking ACP training including supervision, gaining competence, role identity and career progression. Thematic analysis of the focus group transcripts was performed, informed by grounded theory principles.

Fourteen advanced clinical practitioners participated. Analysis revealed that training was influenced by internal and external perceptions of the role, often acting as barriers, with structural aspects being significant contributory factors. Key themes identified (1) clinical training lacked structure and support, negatively impacting progress, (2) existing knowledge and experience acted as both an enabler and inhibitor, with implications for confidence, (3) the role and responsibilities are poorly understood by both advanced clinical practitioners and the wider medical profession and (4) advanced clinical practitioners recognised the value and importance of the role but felt changes were necessary, to provide security and sustainability.

Conclusions

Appropriate structure and support are crucial throughout the training process to enable staff to have a smooth transition to advanced level, ensuring they obtain the necessary confidence and competence. Structural changes and knowledge brokering are essential, particularly in relation to role clarity and its responsibilities, sufficient allocated time to learn and practice, role accreditation and continuous appropriate supervision.

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Introduction

Advanced Clinical Practitioners (ACPs) are a relatively new role in the National Health Service (NHS), introduced to address the increasing complexity of healthcare needs and the growing demand for skilled professionals. They are becoming increasingly embedded within a wide range of NHS healthcare settings spanning community services, mental health wards and hospitals. ACPs play a vital role in expanding the scope of practice within healthcare teams, take on more advanced and complex levels of clinical work, including tasks historically carried out by doctors, with an aim to help alleviate the strain on medical professionals and enhance the efficiency of healthcare delivery. Their integration into the workforce has been shown to enhance patient care by providing timely access to high-quality services while also fostering interdisciplinary collaboration [ 1 ]. Studies have shown that ACPs contribute to improved patient outcomes, increased patient satisfaction, and cost-effective healthcare delivery [ 2 , 3 ]. Additionally, their presence supports the development of junior staff by providing mentorship and guidance, thus ensuring a sustainable healthcare workforce for the future [ 1 , 4 ]. As non-medical healthcare professionals, ACPS are required to undertake further education (Masters degree) and extended training in specific clinical areas such as nursing, pharmacy, or allied health professions to qualify as an ACP. According to the multi-professional framework advanced clinical practice, this training is underpinned by four pillars: clinical practice, leadership and management, education, and research [ 5 ]. However, there is wide variability in this practice and training of ACPs across the UK [ 6 ].

Recent years have seen attempts to standardise the training and practice of ACPs. A framework for advanced clinical practice in England was authored in 2017 by Health Education England (HEE) (NHS England) [ 5 ], which set out standards for advanced clinical practice. Within this framework, advanced clinical practitioners should be able to deliver care with a high degree of autonomy and undertake complex decision making. The knowledge and skills should be underpinned by a Master’s level award (or equivalent) that incorporates the Four Pillars of Practice: Clinical Practice, Leadership and Management, Education and Research [ 5 ]. In 2020, The Centre for Advancing Practice ( https://advanced-practice.hee.nhs.uk/ ) began accrediting some of the many advanced clinical practice Masters programmes available in the UK, which it deemed to have met the standards laid out in HEE’s framework [ 7 ]. This process of defining common standards remains in its early stages, and there remains little research on ACP training programmes and their structures or governance. In a further effort to improve and standardise advanced clinical practice, The Centre for Advancing Practice additionally created guidance on workplace supervision for ACPs, noting the crucial need for high-quality supervision [ 8 ]. The Nursing and Midwifery Council (NMC) published their 2020-25 corporate strategy also in 2020, and committed to explore the need for regulation in a comprehensive review of advanced nurse practice [ 9 ]. The review is still in progress but research undertaken in the early stages by The Nuffield Trust and BritainThinks as part of the review reported inconsistency in definitions, outcomes, standards of education and proficiency in advance practice [ 10 ], and support for regulation by health professionals [ 11 ]. Despite calls for improvements in the supervision of ACPs, there has been limited research in this area.

Studies have shown that ACPs have historically struggled with the transition from their previous career to their advanced practice roles [ 12 , 13 , 14 , 15 ]. The challenges of the transition have been exacerbated by a lack of clear professional identity for ACPs, which has been noted to be a source of tension and confusion, impacting on training, development and ultimately patient safety [ 6 , 16 , 17 , 18 , 19 , 20 ]. Recognising the importance of successful integration into the workforce will help ACPs to realise their full potential [ 21 , 22 ], impacting on role satisfaction [ 23 ], staff retention [ 24 ] and ultimately, building a more sustainable workforce.

As efforts to standardise and develop the ACP role continue, ACPs are becoming more widespread within the NHS. The proliferation of ACPs brings a need for a better understanding of all aspects of ACP training, both during and after qualification. We sought to explore the training experiences of ACPs with the aim of informing future models of education and support.

Theoretical framework

The theoretical framework of this study is based on the theories of Bourdieu, particularly his concept of Habitus [ 25 ], as it offers a valuable lens for examining the multifaceted identities, roles, and positionalities of ACPs. Habitus, ingrained dispositions and cultural knowledge shaped by social experiences, acts as a bridge between individual practitioners and the complex healthcare field they navigate. It influences how ACPs perceive and enact their roles, shaped by their educational background, professional training, and prior clinical experiences. Furthermore, Habitus interacts with the “field,” the social space within which ACPs operate, characterized by power dynamics, established hierarchies, and competing ideologies. This interaction influences the capital, both symbolic and material, that ACPs possess and wield within the field. Through this lens, we can understand how ACPs negotiate complex power dynamics within the healthcare system, navigate tensions between professional autonomy and institutional constraints, and ultimately construct their own sense of meaning and purpose within their evolving roles. By analyzing these interactions between Habitus, field, and capital, Bourdieu’s framework offers a rich and nuanced understanding of the experiences and challenges faced by ACPs, paving the way for further research and dialogue on optimizing their practice and impact.

We sought to explore the training experiences of ACPs as well as their perceptions on role identity, gaining clinical competency and future development of the role.

This exploratory study used a qualitative design to conduct focus groups with a purposive sample of ACPs currently working in South Yorkshire and Bassetlaw in the North of England. In 2022 there were 585 trainee ACPs and approximately 1200 qualified ACPs working in this region.

Participants

Qualified ACPs or trainee ACPs that have completed at least 1 year’s full time equivalent of Advanced Care Practitioners clinical training, and currently work in this role within either Mental Health, Community or Secondary Care within the South Yorkshire and Bassetlaw region. It was felt 12-month minimum training experience would ensure trainees were sufficiently embedded in the clinical and educational programmes.

Recruitment

The NHS England Regional Faculty for Advancing Practice– North East and Yorkshire (FACP-NEY) acted as gatekeepers for the recruitment, contacting all qualified and trainee Advanced Care Practitioners working in the region with an invitation to participate by email. The email included a brief outline of the study, dates and times of the focus groups, details of an incentive payment of £30 for participation, a participant information sheet and, a web link to a short online questionnaire and contact details form. Additionally, the study was also advertised on social media platforms (Twitter, Facebook), with those who expressed an interest sent the same study invitation email, documentation and web link. Recruitment was open between February and May 2021, with one reminder email sent from the FACP-NEY during this time.

ACPs that wished to participate in the study were required to complete the short online questionnaire built using the survey tool, Qualtrics ( www.qualtrics.com ). After confirming eligibility, basic details were recorded about the participant and their ACP training including name, contact details, gender, age group, ethnicity, length of experience in the ACP role, supervision routine, portfolio status and supernumerary time. A variety of dates and times (morning, afternoon and evening) were provided for the focus groups to maximise recruitment, and participants were asked to indicate their preference. A total of 14 participants took part across five focus groups.

Data collection

Focus groups took place online using the Google Meets platform, with a maximum of 3 participants per group. To ensure participants were confident in using the Google Meets platform, the focus group began with an overview of the main functions and how to use them, for example clicking the ‘hand-up’ icon to indicate a wish to speak and chat facility. A focus group schedule was designed and used to guide the discussion similar to that used by Macnaghten and Jacobs (1997) [ 26 ] with an emphasis on each topic followed by discussion amongst the participants. The topics covered included experiences of undertaking ACP training (including gaining competence), role identity and career progression. Data collection was discontinued once it was felt there was no new contributions to the analysis, and there had been full investigation of the developed themes.

Participants provided written informed consent prior to attending the focus group, and consent was also acquired verbally at the start of each focus group. Each focus group was facilitated by one of the two authors (SA and MK), both of whom are experienced qualitative researchers with no clinical background or experience. Google Meets was used to video and audio-record the focus groups. The focus groups were transcribed verbatim by a third party, and quality checked against the recordings for accuracy. The duration of the focus groups was 2 h with a 15-minute comfort break. On completion of the focus groups, participants were sent a £30 shopping voucher to compensate them for their time.

Data analysis

The data was thematically analysed by three researchers (MK, SA and JSK) following the six-phrase process of Braun and Clarke, commencing with familiarisation of the data and then line by line coding to identify preliminary categories [ 27 , 28 ]. The data was then ordered and synthesised, combining similar categories and exploring the relationships between them [ 29 ]. This process was repeated for three of the five transcripts at which point the main themes and sub-themes were identified forming a test model, this was then applied to the final two transcripts. Following discussion amongst the research team, the main themes and sub-themes were agreed. NVIVO Release 1.3 (QSR International) [ 30 ] was used to help organise the data. The Standards for Reporting Qualitative Research (SRQR) checklist was used to report the findings (see Additional file 1).

The focus groups highlighted significant variability in the training experience of ACPs, dependent on their role and place of work. Table  1 provides an overview of the participant characteristics of each of the focus groups, and an overview of the overarching themes and sub-themes that were developed are displayed in Table  2 .

Overarching themes

A number of overarching themes were identified in our analysis that appeared to be strongly linked to role identity. We found the experiences of the ACP training were influenced by internal and external perceptions of the ACP role, often acting as barriers, with structural aspects being significant contributory factors. These findings were revealed in four key themes - lack of structure and support in the clinical training, existing experience and knowledge as enablers and inhibitors to progress with implications for confidence, the poorly understood nature of the ACP role and associated responsibilities, and a need for change to provide security to the ACP role in the future.

Clinical training lacked structure and support

The data revealed a stark contrast between the academic and clinical training, with clinical training found to be lacking in structure and support. Experiences of the clinical training were often expressed negatively due to the lack of structure which was heavily reliant on supervision and placements. As a result, ACPs often had to take the lead on their training and having to identify their own supervisor(s) and/ or placements was felt to be challenging. Consequently, some ACPs reported they had no dedicated medical supervisor at all. Where supervisors were in place, the quality of supervision varied, from being ad hoc (p41) and chaotic (p52) to great ( p53). Some of the supervision issues raised by the ACPs included lack of supervisor knowledge in relation to the ACP training and their required responsibilities, accessibility of supervisor (available time) and little direct clinical oversight. ACPs felt they needed an experienced medical professional as their supervisor, providing similar support and advice to that received by junior doctors.

We have nursing supervision from the lead community matron who is our line manager, but we do miss that sort of medical supervision (p22, Trainee ACP– Primary care) . I’m line managed by a nurse who is the operational lead for the service. He is the right person, but I don’t go to him for clinical support. It would be nice to have a medical supervisor (p. 41, Trainee ACP– Community care) .

Good supportive supervision appeared to enhance the ACP training, conversely poor, unsuitable or no supervision was perceived to have a serious negative impact on training and well-being, with suggestions that ACPs had left during training because of it.

I’ve had free reign over my own training, and planned everything myself, and that’s a positive for me (p41, Trainee ACP– Community care) . So the positives, um, I think the academic and educational supervision’s been, err, accessible and supportive. So we have, um, supervision from [regional] ACP lead,…and then there’s, um, the course unit lead, which she’s there and she’s supportive. So yeah, the academic, err, supervision is good (p52, Trainee ACP– Secondary care) . I think, um, something that I haven’t touched upon is, which I realised, so I’ve got a, um, clinical supervisor, she’s a consultant *****, and…the module I’ve just done which is minor illness, you had to do like a learning log, so they had to see you do….a load of things. And it made me laugh cos they turned around and said, look, I haven’t assessed anybody’s abdomen in ten years…. (p53, Trainee ACP– Secondary care)

Similar to supervision, clinical placements were highly valued by the ACPs and recognised as an important part of the training to achieve competence and consolidate their academic learning. All of the ACPs reported obstacles in organising and undertaking such placements, with those working in the community or mental health facing particular difficulties due to placements needing to be in a different clinical setting to where they worked. Competition with other trainees, the need to ‘ beg ’ (p7) and insufficient time from trainers were highlighted as ongoing problems. Conflict with junior doctors was also described as a competition for training opportunities.

Completely unsupported by the Trust because they just weren’t set up for it, there was no one leading on it, there were no one for us to contact really to talk. And then, like you said, I got my placements from begging on a, on a forum on Facebook and a nurse set me up (p16, Trainee ACP– Secondary care) . To kind of fulfil the module requirements, it was pretty much, for minor illness basically phoning up GP surgeries, practice nurses, beg stealing and borrowing, you know, begging people can you help me out, to try and get the amount of hours that you needed (p7, Trainee ACP– Secondary care) . But sometimes, it’s a little bit of a fight to get to what you need when you need because there’s so many junior doctors that also need that same training. So, there are occasions where you have to sort of step up and say we are training the same as these guys, we also need to be able to have these opportunities and you kind of have to have a little bit of a voice to say, we’re here (p17, Trainee ACP– Secondary care) .

In contrast to the clinical training, the academic learning followed a traditional format of taught lessons which ACPs felt covered a wide breadth of knowledge. There was some feeling that modules might have been more useful if they had been tailored towards individuals’ specialisms such as mental health or physiotherapy, however on the whole it was described as a positive learning experience with good supportive academic supervision.

I found the dissection labs quite alien but they have really helped to develop my practice (p24, Qualified ACP– Secondary care) . It feels a lot like there’s university, which is one day a week, and you do that, and it’s really supportive, and I’ve made some really good friends there, and everybody supports each other. But then at work, it’s a bit of a try and find your own way (p53, Trainee ACP– Secondary care) .

ACPs did describe the two learning environments (clinical and academic) as disconnected, separate and discrete, even though the ACP training is a combination of academic and clinical learning.

From the course point of view it’s pretty straightforward but it’s marrying that up with the expectations of the employer. Willingness of the employer to be able to give you the time you need to do what you need to do (p. 38, Qualified ACP– Secondary care) . They’d learn something at University (e.g. Cardiology) but there was no way this could be built on within the Trust. They just don’t deal with the physical health side of things (p. 7, Trainee ACP– Community mental health) .

Existing knowledge and experience appeared to act as both an enabler and inhibitor for ACPs, with implications for confidence

As existing experienced clinical practitioners, ACPs felt they were able to recognise their knowledge gaps and work quickly towards filling them, however the training approach also led to declines in confidence when deficiencies in knowledge and skills were highlighted. ACPs reported learning ‘backwards’ compared to junior doctors, using pattern recognition rather than pathology as a starting point, for example, being able to identify the treatment based on a diagnosis, but not necessarily knowing how the diagnosis was made originally. Not being able to adequately answer questions sufficiently on such subjects when tested by clinicians, and as experienced clinical practitioners, ACPs perceived themselves as lacking competence with a subsequent drop in confidence.

ACPs are trained ‘bottom-up’– we learn pattern recognition and then work our way back, whereas doctors know the diseases better (p41, Trainee ACP– Community care) . I think about cases backwards compared to doctors– as they think about pathology first and then build on that (p9, Trainee ACP– Primary care) .

A comparison between the clinical training processes of junior doctors and ACPs was a common discussion between ACPs with suggestions that it would be more beneficial if ACPs were recognised in a similar manner to junior doctors. For example, ACPs felt they should not be ‘counted in the nursing numbers’ when working on a ward, and as a consequence should not be expected to undertake a dual role of managing a nursing shift and practicing as an advanced practitioner:-

So say for example, you’re sat with somebody talking about their prescription and trying, you know, looking to see if there needs to be a change made, and then you’ve got other people banging on the door saying, I want to go out on leave, and I need this and I need that, and you’re the nurse in charge and need to be doing that. The people that usually do those jobs, so say for example the doctors in the week, when they’re having those sorts of consultations with people, they’ve not got that stress, the pressure, the disruption and the responsibility of running a nursing shift or a completely other shift. So, us as novices, it just doesn’t make sense to me (p. 52, Trainee ACP– Secondary care)

ACPs spoke of being unsure of when they had reached clinical competency, and how they would maintain this. They worried that if they were not given sufficient time to practise the new clinical skills, their confidence would decline and that they would ultimately feel unsafe in their clinical practice. ACPs emphasised the importance of having sufficient time to practice new skills and consolidate knowledge, enabling autonomy and confidence building. It was also felt this provided essential opportunities for colleagues to observe progress.

I’ve got most of my competencies but I still wouldn’t see myself as an expert practitioner (p41, Trainee ACP– Community care) .

The ACP role and associated responsibilities are poorly understood by ACPs and the wider medical profession

Exploring the experiences of training and the process of developing clinical competence with ACPs revealed there was a lack of clarity regarding the job role depending on where the ACP worked, and this applied to the ACPs themselves as well as their colleagues. This uncertainty impacted the responsibilities the ACP undertook within the clinical environment, and the expectations on them from the staff that they worked with.

ACPs that worked within the Emergency Department reported that colleagues understood the ACP role and utilised the advanced skillset the ACPs gained as the training progressed. They described feeling fully immersed within the department as an advanced practitioner, yet they were also recognised as being in a transitional stage with appropriately allocated time to undertake the necessary training.

ACPs working in other areas of healthcare such as acute wards, outpatients, mental health and community care discussed a general lack of awareness about the advanced practitioner role by both healthcare staff and patients. It was felt this led to a lack of utilisation of the advanced skills of the ACPs and expectations that the ACP should fulfil multiple job roles, creating feelings of intense pressure and demoralisation. ACPs reported hearing discouraging comments from colleagues about their abilities and felt a need to justify their role. Some ACPs described struggling with how to introduce themselves to both staff and patients, with their uniform described as an important part of their identity and how they were perceived by others. Adding to these external perceptions, ACPs revealed their job description was not necessarily updated to reflect their ACP role and where it was, the job description could be vague further undermining their role identity and leading to feelings of conflict between their original healthcare professional role (e.g., nurse) and working at an advanced level.

There’s been a lot of ambiguity around the job description for ACPs and trainee ACPs, so that’s left wriggle room for everybody making their own assumptions about what you’re supposed to do and what you should be doing, and therefore you’re pulled into all different things that don’t tie in to on paper in terms of national, regional frameworks……. there’s just pressure on the role being categorised as an extension of the nursing team, and taking on classic nursing tasks, it’s what people are familiar with, it’s what they assume (p52, Trainee ACP– Secondary care) . The challenge is with our role, is the ACP is tagged on to the end of our existing job. So, we have all of our normal nursing duties, we’re bed managers, we triage nurse, we run the hospital. And then you’ve got ACP tagged on the end. (p25, Qualified ACP– Secondary care)

Inconsistencies in awareness of the role, experience, training and clinical practice were felt to be a reflection of the different professions undertaking ACP training, a lack of standardised job role and unclear expectations. The variation in financial remuneration within and across different organisations for ACPs was also felt to be a contributing factor to these identity issues.

The ACP role is important, but changes are required to provide security to the role in the future

There was consensus that the combination of experience and advanced skills made the ACP a unique and valued role in the NHS, fulfilling an important gap in patient care. ACPs reported uncertainty about their future in the role, and the need for change structurally to ensure the ACP role has a future. Accreditation was felt to be necessary as this would legitimise the ACP role and apply some professional control in respect to the role title. ACPs viewed this as an existing issue with ‘advanced’ used by a multitude of health professions that have not undertaken the accredited training.

I kind of feel that, certainly as an ACP title, it should be some sort of standardised title, and then people would probably understand it a little bit more. I think our colleagues would understand it, and I think you won’t get so much resistance, from some medical colleagues, maybe, if people were sort, if it were a bit more regulated. I mean, if there were talking about credentialing and looking at a directory for ACPs anyway, it should be a registered regulated title (p54, Qualified ACP– Primary care) . I think everybody should be under the same governing body and there should be a bit of standardised, training placement (p41, Trainee ACP– Community care) .

As well as increased knowledge and skills, ACPs discussed the additional benefits of the training including the broad range of opportunities offered both during and after the training, and the potential boost in future prospects. A key attraction to the ACP training route that was repeatedly highlighted was the fact that it offers career progression whilst maintaining clinical responsibilities, progressing through more traditional routes into a managerial role appears to involve considerably less clinical duties and contact with patients. However, there was also some feelings of insecurity regarding the future of the ACP role because of the general lack of awareness of how ACPs fitted and could contribute to the NHS. It was felt that the deficiency in formal structure for the ACP role contributed to this; ensuring job descriptions existed and reflected the responsibilities of the role, and there was a structure for career progression was proposed as a good starting point to improve understanding amongst staff.

In terms of where I see myself in five to ten years’ time, I’m not sure, it depends how that organisation I work for pans out, because…. I won’t be sat here in five years’ time saying the same stuff. If it’s still the same I won’t be there, I will have gone somewhere else cos there are places that fulfil the role (p52, Trainee ACP– Secondary care) . I don’t see much career progression within ACPs other than to become a lead ACP and there is nothing to define progression within that role from a banding point of view (p1, Trainee ACP– Secondary care) .

On the whole, the ACPs felt the role had great future potential but this was often caveated, that changes were needed in formalisation of the training and particularly, wider recognition of the role and its responsibilities. Without these changes, a number of ACPs felt they would not be in the ACP role in 5 years’ time.

The one thing that I do know is that I love the job, I love the role (p38, Qualified ACP– Secondary care) .

This qualitative study collected the perspectives of 14 ACPs from different specialties and at different stages of their career. The findings suggest that ACPs continue to face significant barriers, undermining their development, transition and integration into the healthcare workforce.

ACPs described a number of challenges experienced in their training within the clinical environment, notably with placements and supervision. Both of these elements appeared to suffer from a lack of formal structure; where some ACPs experienced a supportive clinical environment making their training experience ‘phenomenal’, others reported unsuitable supervision and having to identify their own supervisors and/ or placements. This lack of support was felt to have a serious negative impact on ACP training and well-being, which has been reported nationally and internationally [ 17 , 31 , 32 ]. It is recognised that a supportive environment is a healthy environment, aiding not only ACPs in their competency, role transition and job satisfaction but also helping to optimise quality patient care, recruitment and retention [ 13 , 24 ]. Additionally, a disconnect between academic and clinical training was highlighted. This lack of ‘joined-up’ working between educators, healthcare staff and managers has been described previously with suggestions that it can impede the development of ACPs and their fulfilment of the role [ 22 , 33 ].

The knowledge and experience already held by ACPs from their original professional training was perceived as both a strength and weakness. Whilst the ACPs felt they could provide improved holistic patient care and identify gaps in their own training, it influenced their approach to learning which was described as ‘bottom-up’ and ‘backwards’ compared to how junior doctors learnt. This had implications for confidence as ACPs often felt they could not adequately answer questions posed during training. Furthermore, if they were not given sufficient time to consolidate their new knowledge, this led to an additional drop in confidence and doubts about their competence. This was reported by MacLellan, Higgins and Levett-Jones (2017) [ 34 ] and has been referred to as Imposter Syndrome [ 35 ]. It links closely with role transition and identity which has been widely researched within the advanced practitioner community [ 12 , 13 , 14 ]. Increasing autonomy and responsibility is part of the transition for ACPs and whilst some of the ACPs in this study found this experience exciting, the majority conveyed mixed emotions including feeling stressed, pressured and uncertain. This was more prominent for those ACPs in areas where the role appeared to be less established and a lack of awareness among healthcare staff of the ACP role. For a smooth and successful transition, Barnes (2015) [ 12 ] identified a number of defining attributes including a shift from provider of care to prescriber of care, straddling two identities and mixed emotions. The experiences of our ACPs covered all of these attributes and suggest they have not experienced a smooth transitional journey.

Inconsistencies in the ACP training and lack of structure in relation to the clinical job role were discussed as contributing factors to role identity issues, which impacted their daily working lives. It appears the ACPs in our study are still experiencing the consequences of a role which was introduced without clear definition, standardisation, skills and scope [ 20 ], even though there has been significant development in recent years within advanced practice [ 5 ] of the ACP training. As a role introduced to work alongside doctors, nurses, pharmacists, and other healthcare professionals to deliver comprehensive and patient-centred care, ACPs play a pivotal role in fostering interprofessional collaboration within healthcare teams. However, with blurred definitions regarding the ACP role and responsibilities, it is unsurprising our ACPs reported a lack of understanding of their expertise and respect from their colleagues. Such barriers to interprofessional collaboration not only prevents ACPs from working to the full extent of their education and training [ 36 ] but impacts patients, on their outcomes and access to specialist care [ 21 , 37 , 38 ]. A review of 64 studies undertaken by Schot, Tummers and Noordegraaf (2020) of interprofessional collaboration among healthcare professionals described this as being multifaceted, and that for change to occur, individuals needs to work daily on tasks such as bridging gaps, negotiating overlaps and creating spaces [ 39 ].

There was agreement between the ACPs that accreditation of the role would help address some of the issues around role identity. The use of ‘advanced practice’ is widely applied within healthcare with little relationship to education level, often leading to confusion [ 18 ]. Accreditation would help protect the role by providing professional identity as well as providing more clarity to ACPs and those in the wider healthcare setting about the role and scope of practice [ 6 , 17 , 18 ]. It may also alieve fears of insecurity which were raised by the ACPs in relation to the future of the role. Improving and promoting knowledge brokering at both the individual and collective (system) levels would improve the transition process [ 40 ], whilst also encouraging change in an environment that is traditionally intransigent.

Although the ACPs reported challenges in their training and felt changes were necessary to ensure wider recognition of the ACP role, there was consensus among the ACPS that participated in this study that the training ‘boosted’ opportunities and allowed career progression whilst maintaining clinical responsibilities, an important factor to many of the ACPs in this study. Surprisingly, there was little discussion regarding the impact of the COVID-19 pandemic on ACP training, even though the focus groups took place during the pandemic. When it was discussed, it was generally in the context of placements and how they had been further limited.

This qualitative insight into the training experience of ACPs has highlighted that there are many challenges still to be overcome to ensure ACPs feel supported through their role transition journey and are recognised appropriately for their skills and experience in the healthcare workforce. These findings are not new [ 13 , 14 , 20 , 22 ] but after the release of the 2017 HEE multi-professional framework for advanced clinical practice [ 5 ], it would be expected that there would have been more clarity and structure in the ACP training and role, benefitting ACPs, wider healthcare professionals and employers. Progress may improve as a result of the NMC review on regulation of advanced nursing practice that is due in the next 12 months [ 9 ], however, at the time of this study, the ACPs appeared to feel progress was slow and more work was needed.

Strengths and limitations

The opinions and experiences provided in this study were from a group of ACPs, either during (> 1 year FTE) or post training, working in the South Yorkshire and Bassetlaw region. It is reasonable to suggest therefore that the results are not generalisable to other populations. Qualified and trainee ACPs were contacted about the study by email through the regional FACP-NEY who acted as gate keepers, as well as the study being advertised on social media platforms. It is assumed that this broad recruitment strategy helped to reach a wider population, although most respondents appeared to be as a result of the direct email. This approach may have introduced some bias but using a purposive sampling approach, participants from different specialties, professions and career stages were included. Information about the local ACP workforce such as size and individual characteristics was requested from the regional FACP-NEY but this was not provided thus an exact response rate cannot be calculated nor can any inferences be made regarding how representative the sample of ACPs were that participated in the study. The number of males that registered an interest in the study was low (three) and only one male participated in the focus groups; this is a limitation as there may be different perspectives and experiences of ACP training related to gender. Due to the COVID-19 pandemic focus groups had to be undertaken online. Adaptions were made to accommodate for this such as reducing the number of participants per focus group and creating time to build rapport [ 41 ]. One participant did experience technical issues, however using a digital approach did not appear to impede the participant-researcher interaction and compared favourably with traditional face to face focus groups [ 41 , 42 ]. There is a risk that views from participants were oversimplified due to the limited number of ACPs involved in the focus groups but findings from this study appear to align with previously published literature [ 6 , 17 , 19 , 21 ] providing some confidence in the results.

Future work

This was a small exploratory study in a rapidly evolving field, providing insights on ACP training, role identity and competence at one point in time. ACPs did report differences in their experiences due to their specialty thus a much larger study would provide an opportunity to explore this further and allow for more in-depth comparisons. The multi-professional framework was relatively new when this study was undertaken and since its publication, there has been much development in the guidance and practice of ACPs including the Royal College of Emergency Care ACP training [ 43 ] and the merger of Health Education England with NHS England. It would be useful to explore what impact, if any, these developments may have had on ACPs and if similar issues around role identity and competence still exist.

The ACP role is now integrated across many specialties both nationally and internationally, however challenges continue to persist in training, impacting on transition into the role. At a collective level, there remains a lack of structure and clarity around the ACP role, and individually ACPs appear to experience issues with supervision and support. This study has highlighted that the journey to advanced level practice is often turbulent, and changes are required to further embed the ACP training and role into the workplace. Ensuring ACPs have appropriate continuous support, allocated sufficient time to learn and practice, and wider recognition of the ACP role through accreditation would aid the training experience and a successful role transition.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the participants privacy being compromised but are available from the corresponding author on reasonable request.

Abbreviations

Advanced Clinical Practitioner

Faculty for Advanced Clinical Practice

Health Education England

National Health Service

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Acknowledgements

The authors would like to thank the Sheffield Emergency Care Forum (SECF) PPI group ( https://secf.org.uk/ ) for their helpful feedback on the recruitment materials (email invitation, information sheet and consent form) developed for this study to ensure they were suitable for a lay audience. For helping with the recruitment, we would also like to thank the Faculty of Advanced Practice, particularly Fran Mead. Lastly, we would like to thank our participants for giving up their valuable free time to share with us their experiences of developing clinical competence as an Advanced Clinical Practitioner, and for their opinions on role identity.

This manuscript is independent research funded by the National Institute for Health and Care Research, Yorkshire and Humber Applied Research Collaborations (NIHR200166). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health and Care Research or the Department of Health and Social Care.

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Made substantial contributions to conception and design, or acquisition of data: MK, SA and JSK; Analysis and interpretation of data: MK, SA, SC and JSK; Manuscript draft: MK, SA and JSK; Manuscript critical revisions: MK; SA; SC; JSK; FS; SM. All authors approved the final version of the manuscript.

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Kuczawski, M., Ablard, S., Sampson, F. et al. Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study. BMC Nurs 23 , 185 (2024). https://doi.org/10.1186/s12912-024-01843-x

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What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

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If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research is multimethod in focus, involving an interpretative, 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. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

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Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

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Something felt ‘off’ – how AI messed with our human research, and what we learned

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All levels of research are being changed by the rise of artificial intelligence (AI). Don’t have time to read that journal article? AI-powered tools such as TLDRthis will summarise it for you.

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Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study

• Easter Olwanda 1 ,
• Kennedy Opondo 2 ,
• Dorothy Oluoch 1 ,
• Kevin Croke 2 ,
• Justinah Maluni 1 ,
• Joyline Jepkosgei 1 &
• Jacinta Nzinga 1  

BMC Women's Health volume  24 , Article number:  181 ( 2024 ) Cite this article

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Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women’s ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women’s processes of decision-making in seeking maternal health care and how these affect women’s ability to access and use antenatal, delivery, and post-natal services.

We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of “female autonomy”, and “women’s agency” with the latter incorporating ‘voice’, ‘choice’ and ‘power’. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12.

The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women’s agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare.

Conclusions

Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women’s decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women’s voices for sustained use.

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Globally, the provision of health care is evolving towards providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions [ 1 ]. Patient-centered care, in relation to clinical decision-making, is grounded in concepts of intrinsic values, personal preferences, and partnership [ 2 ]. A patient-centered approach, empowers women by involving them in decision-making processes and respecting their choices [ 3 ]. Women’s empowerment, in turn, enhances their autonomy and ability to seek appropriate and timely maternal health care [ 4 ], ultimately affording women agency for their overall well-being. When women are not empowered or lack autonomy, they may face barriers to accessing quality care, resulting in adverse maternal health outcomes [ 5 ].

Research on patient-centered care for women shows that women’s autonomy (i.e., the freedom of women to exercise their judgment in order to act for their own interests) influences reproductive, maternal, and child health outcomes [ 6 , 7 , 8 , 9 , 10 , 11 ]. Conversely, the absence of women’s autonomy in decision-making results in delays and poor utilization of maternal health services and ultimately increased maternal morbidity and mortality [ 12 ]. Thus, empowered women can make informed decisions about their reproductive health, including family planning, timing and spacing of pregnancies, and the type of care they receive during pregnancy and childbirth [ 13 , 14 , 15 , 16 ].

Freedom of mobility, participation in household decision-making, and self-efficacy are key dimensions of women’s empowerment [ 17 , 18 ]. Empowering women to make their own decisions, pursue goals, and control their lives and resources is a crucial aspect of Sustainable Development Goal (SDG) 5, which seeks to attain gender equality and empower all women and girls [ 19 ]. Moreover, empowering women in reproductive and sexual matters is crucial, as intimate relationships often involve significant power imbalances that can limit women’s ability to negotiate with their partners on sexual issues [ 20 ].

The International Centre for Research on Women (ICRW) has developed a conceptual framework for reproductive empowerment merging “female autonomy” and “women’s agency”, which includes ‘voice’, ‘choice’, and ‘power’. This framework is relevant to women’s autonomy in Kakamega as it provides a comprehensive approach to understanding the factors influencing women’s agency and empowerment, informing targeted interventions and policies in the region. Women’s individual agency involves expressing opinions, making decisions about their lives, and pursuing their aspirations, which empowers them to assert their voices and seek personal and professional growth. Immediate relational agency focuses on the influence of close relationships such as family, friends, and intimate partners on an individual’s agency [ 21 ]. These relationships can either support or restrict a woman’s ability to exercise her voice, make choices, and pursue empowerment. Supportive relationships enable women to exercise their agency freely, while oppressive ones may limit their ability to make decisions and assert their voice, hindering empowerment. Distant relational agency refers to the broader social, cultural, and institutional influences that shape women’s agency and empowerment [ 22 ]. Societies that prioritize gender equality, offer legal protections, ensure access to education and healthcare, and promote women’s participation in decision-making enhance women’s agency. Conversely, gender inequalities and limited opportunities hinder women’s agency and empowerment.

The relationship between individual, immediate, and distant relational agency is complex and interconnected, with individual agency influenced by both immediate and distant relational agency. Supportive immediate relationships and equitable social structures can enhance individual agency, enabling women to exercise their voice and make choices while repressive immediate relationships and restrictive social structures can limit women’s agency [ 23 ]. Aligning all three levels of agency positively leads to women’s voice, choice, power, and empowerment. These concepts are illustrated in Fig.  1 below.

Borrowed from the Conceptual Framework of Reproductive Empowerment by the International Center for Research on Women (ICRW)

Evidence suggests that increasing women’s mobility can empower them to exercise greater control over their lives by increasing their access to healthcare, education, markets and information [ 6 , 24 ]. Additionally, women with strong sense of self-efficacy have the potential to anticipate different success scenarios, persevere in the face of obstacles, take action against the existing social norms [ 25 ], and navigate complicated healthcare contexts to receive care [ 26 ]. Relative to maternal and child health, increased postpartum maternal self-efficacy been has associated with improved functional status in the postpartum period [ 27 ]. Furthermore, women’s control over resources and decision-making within a household plays a crucial role in enhancing healthcare-seeking behaviors and maternal and child health outcomes [ 28 ]. Changes in women’s intra-household bargaining power, also increases a woman’s status and impacts her decision-making ability [ 29 , 30 ]. All these are key considerations in determining the implementation process and success of maternal and child health interventions and reforms. Existing literature primarily emphasizes the impact of women’s choice and agency on health decision-making and service use, but there is limited documentation on how women’s autonomy experiences can inform the implementation of improved maternal and child health interventions.

The implementation context

Kakamega County was selected due to its high maternal mortality rate of 316 per 100,000 live births and neonatal mortality rate of 19 per 1,000 live births, alongside approximately 70,000 births in 2018, distributed with 35% at home, 28% in primary care facilities, and 37% in hospitals. Part of recommendations from the Lancet Global Health Commission on High Quality Health Systems for improving quality of care is the implementation of “Service Delivery Redesign for Maternal and Newborn Health”, (SDR) reform. Kakamega County started the phased implemention of SDR in 2021 and is currently in its improvement phase.

During the SDR implementation period, improvements were made to health facilities, including the commissioning of a new Maternity wing and an increase in bed capacity at Malava. The Linda Mama health scheme provides affordable maternal and child health services, and Malava sub-county hospital increased its claims from 34 to 79%. Additionally, a newborn unit was constructed, and the facility currently has a resident pediatrician, surgeon and gynecologist supported by nurses, clinicians, and medical officers.

Similarly, Lumakanda sub-county hospital has reorganized its infrastructure at the maternity wing and the newborn unit, introduced emergency evacuation services, implemented pseudo-facility improvement fund (FIF) disbursements, enhanced accountability and visibility of blood resources through a blood tracker dashboard, enrolled women for pregnancy care text prompts, and provided Emergency obstetric and newborn care (EmONC) training to its staff while also training health workers from primary health care facilities. A summary of the SDR related implementation activities can be found in the Supplementary file 1 .

This paper aimed at examining how women’s processes of decision-making in seeking maternal and neonatal health care both influences and is influenced by the implementation of SDR in Kakamega county. It is anticipated that the learning from this paper will inform the implementation of SDR by highlighting patient voice in reforming delivery of MCH services.

Study setting

The study took place in Malava and Lumakanda sub-County hospitals which are maternity centers of excellence where the Kakamega Service Delivery Redesign (SDR) is being implemented. The Kakamega maternal and child health Service Delivery Redesign (SDR) is a structural reform that aims to reorganize the maternal and newborn health services by shifting deliveries for all women to advanced facilities that offer definitive care for complications. The reform is now being implemented by the Kakamega County government with the aim of improving the quality of antenatal, delivery and postnatal care. It purposes to ensure that all women can give birth in safe environments, with skilled providers that have the tools and competencies to care for women during uncomplicated birth and who can detect and deal with complications if and when they occur [ 31 ].

Study design

This was a cross-sectional exploratory study using qualitative research methods with purposively selected participants. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. In this context, small group interviews involved a small group of individuals, allowing for in-depth exploration of individual perspectives within a group setting, while focus group discussions were conversations guided by a moderator, emphasizing interactions among 8–10 participants to explore shared perspectives and group dynamics.

The FGDs had an average of 8 individuals while the small group discussions had an average of 4 individuals. For the FGDs demographic dynamics such as gender and age were managed through the selection of participants to ensure diverse representation within the groups. We formed homogeneous groups based on specific demographic criteria, to foster open and comfortable discussions among participants with shared characteristics. In this case we had FGDs specifically for younger women, another for older women, and lastly with the men separately. Conversely, for small groups, we intentionally chose participants representing various demographic profiles to capture a range of perspectives and experiences. The FGDs lasted between 45 and 60 min, the IDIs lasted between 30- 45 min and the KII lasted an average of 45 min.

See the Table  1 below.

The pre-set inclusion criteria included willingness to consent and to participate in the study, and good knowledge or understanding of the areas of inquiry. We employed purposeful participant selection to include diverse demographic characteristics, experiences, and perspectives in relation to the research topic.

Data collection

Data collection took place in November 2022 and in March 2023. Participants were recruited from the antenatal, delivery and post-natal clinics in Lumakanda and Malava sub-County hospitals. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men using guides with questions developed in English and then translated into Swahili.

The interviews covered three broad topics of interest (1) factors that affect women’s autonomy and decision-making power in the household, (2) the process of decision-making at the family level in seeking maternal health care during pregnancy, delivery, and the postpartum period, and (3) how the decision-making process affects women’s ability to access and use maternal health services. Interviews were audio-recorded for participants who consented. During the interviews, detailed descriptive field notes were written covering interactions between the interviewer and respondent, non-verbal communication, environment, and reflections from interview content. All interviews were transcribed verbatim in Swahili and translated to English then cross-checked to ensure appropriate data and its quality before data analysis. Interviews were conducted to the point of theoretical saturation through iterative data analysis of emerging themes which was done alongside data collection. Iterating between data collection and analysis enabled the research team to be mindful of their own biases and actively worked to mitigate them, thus contributing to the robust representation of opinions. A total of 27 interviews including the IDIs, KIIs and FGDs lasting 30-60 min were conducted sequentially.

Data analysis

A thematic analysis approach was adopted. The English transcripts were read several times to develop familiarity with the raw data. Open coding was done to identify women’s expressions highlighting their autonomy; axial coding then followed to relate and label codes with shared concepts, dimension, and properties. Finally selective coding was done to delimit coding to the identified core concepts from the data [ 32 ]. See Table  2 below. E.O independently coded the data in the first phase of analysis. This was then followed by discussions between E.O and J.N, comparing emerging codes and developing a consensus on a final coding framework that was used to code and analyze the data in NVIVO 12.

This section presents the findings from an in-depth exploration of women’s agency and autonomy. Several key themes and sub-themes emerged, providing valuable insights into the complex dynamics surrounding women’s agency and autonomy. These findings contribute to a deeper understanding of the challenges and opportunities women face in asserting their rights, making choices, and navigating their social and cultural environments. The results further reveal the multifaceted nature of women’s agency and autonomy, encompassing individual, immediate relational, and distance relational factors and shed light on the interplay between these factors and uptake and utilization of maternal and child health services.

Individual agency

Independent women with strong self-trust were more likely to exercise their agency with greater adaptability and confidence in decision-making. Such strong inherent trust mediated power within which consequently shaped women’s individual agency and their ability to make decisions regarding maternal care.

“In my life, I’ve always been very independent and doing things on my own. I’ve never really encountered those challenges where I was told that someone else had to speak for me. Most of the time, I just do my own thing.”-ANC2

Conversely, the perception of shame, and insignificance among young pregnant girls diminished their agency in seeking services.

“For some, some are just afraid, especially those of young age. They are scared of coming to the clinic, so they try to hide the pregnancy because it brings them shame.” FGD men

The power within was also influenced by other factors including social support and past experiences. Supportive social networks provided women with the necessary resources, information, and support to develop their power within and exercise agency. Our findings indicate that social networks played a crucial role in shaping women’s individual agency in maternal healthcare decisions as they provided women with information, knowledge, and resources that enhanced their agency. Women sought input from their social networks including, family members, friends, community health volunteers (CHVs), and birth companions. Some elements such as finances, relational trust, and experiences of people were considered before a social network was chosen to aid with the decision-making.

“At times, the husband will help in decision making because it could be a place that is far and needs transport, he will be the one to decide whether I will go to Malava or not. The decision comes from him.”-PNC 1

The contacts drawn from social networks also shared their previous birthing experience with women fostering a sense of agency. Negative birth experiences raised awareness of potential challenges and helped women make more informed decisions while choosing the best options for the next birthing experience. In such instances, while the objective was to look for quality, the previous experiences of others as well as social relationships with health workers constituted the yardstick in making the final choice as the experiences of some participants revealed:

“That time I heard negative views about this place, and I didn’t feel the need to come. I heard that in Lumakanda they are very harsh and I told myself that “let me get used to Turbo”, I never set foot here. But in 2014, I said no, let me try the local facility.”-PNC 3

“Number one, etiquette of these nurses towards these pregnant women. You know you can go somewhere else, and the nurse just shouts at you. It’s like she carries all her stress to the hospital. But here in Lumakanda, I have not faced anything. So, that’s why I decided to come all the way.”-ANC 2

Additionally, health literacy had a great influence on women’s individual agency through the knowledge, attitudes, and beliefs acquired through health education and media exposure. Collectively, we saw how health education, media exposure, and health-seeking behavior significantly impacted women’s individual agency and decision-making for maternal care. With improved knowledge, women were more empowered to actively participate in decision-making processes, assert their preferences, and access appropriate healthcare services. Of note, is how health and financial literacy empowered women by increasing their understanding and enabling them to actively participate in decision-making processes.

“Maybe the media can broadcast that, mothers with children, and pregnant women, need to go to the hospital to get health services. They need to understand that they will benefit from going there. They need to hear it for themselves.”-PNC 3

Additionally, m edia exposure had a substantial impact on shaping women’s perceptions and attitudes toward maternal care. Our findings show that access to accurate and reliable information through various media channels can contribute to informed decision-making and empower women to seek appropriate maternal care. The respondents identified and recognized the value of health literacy in gaining autonomy and control over their health and well-being as corroborated in the quote below.

“Through media, newspapers, radios, councils, through these open places, many mothers have now discovered their rights and they have power now”-CHV.

Immediate relational agency

We found that women’s immediate relationships were also linked to household decision-making and freedom of movement. Our findings demonstrated that when women had their own source of income, it often led to increased empowerment and decision-making power within the household. Conversely, women who did not participate in income generation could hardly participate in decision-making in the house as recounted by this respondent.

“The only thing affecting my ability to make decisions, it’s because I’m not working. I do see those who are working, have the ability to decide, they can do their own things, as they wish. Even if there are obstacles from the husband, she can decide, let me do this. But for someone like me, it’s difficult.”-PNC 3

Health-related decisions, including seeking medical treatment, had financial implications. The costs associated with treatment impacted decision-making, particularly if they were substantial or necessitated long-term financial obligations. In such cases, decisions were made, considering the financial impact and available resources.

“Our clients depend on their husbands and their mothers-in-law as decision-makers. Since they depend on them especially the husbands to give them transport to go to the facility, they (husbands) are the key decision makers on where they seek their service.”-NO-IC

Spousal communication allowed for open dialogue, negotiation, and compromise, leading to decisions that consider the needs and preferences of both partners. Couples who trusted each other navigated power over each other by considering each other and providing a morale boost that facilitated decision-making in the household.

“It’s my husband whom I confide in the most. I feel comfortable talking to him, especially during my pregnancy, when I had a lot of complications like high blood pressure, and even had to undergo an operation. He’s my husband, so I talk to him, and he’s the one who helps me.”-PNC 3

Freedom of movement also influenced women’s immediate rational agency. Household structures were mostly patriarchal, where men held dominant roles and women’s mobility and decision-making power was limited. The traditional role of men as heads of households mandated a restricted life for women as they were expected to be submissive and show respect towards male partners.

“You find in some cultures a woman cannot say anything in front of the husband. The man is the one who speaks. In some areas, you are told “When you get here you follow what the husband, the mother or the father says”. -ANC 1

In contrast, single/separated women had complete freedom of movement and were able to decide alone. This was evidenced by one of the respondents, who shared that.

“When it comes to decision-making, I don’t think anyone can influence me because I make decisions myself. Even if someone discourages me, I know what I’m doing and what I’m looking for.”-ANC 2

Engaging in domestic tasks restricted women’s mobility outside the home. The demands of household chores meant that women could not move freely. Their social functioning was largely restricted to the household, the fields, and tending to children.

“Well, there are hindrances, at times I am alone at home without a house help, and I need to go somewhere. There are cows to take care of and children who may have gone to school waiting for me to make lunch. You see, there are hindrances, and you cannot just leave like that until you plan yourself.”-PNC 3

Mistrust within the household also undermined women’s freedom of movement and decision-making. These restrictions were reinforced by societal expectations and gender norms that prescribe women’s roles as primarily confined to the private sphere. Women’s ability to move about was sometimes constrained due to trust issues between spouses.

“You know, sometimes I come here in the morning and leave at two or three. He thinks it’s not just the hospital, he doesn’t understand, but I only come to the hospital. That’s one of the things he considers that and regulates my time out.”-PNC 3

Distance relational agency

Finally, social-cultural, and health systems factors presented various influences and circumstances that affected women’s ability to exercise agency and make choices in their lives. In this context, religious norms limited women’s access to evidence-based maternal care. Some respondents acknowledged that some religions challenged the idea of seeking healthcare in health facilities.

“In terms of decision-making, the church does not hinder anyone, but our church believes in not taking medication. We believe that if I am sick and you come to pray for me, I will be healed. However, it also says that if you know that your faith is not strong enough, you can go and seek medical treatment. But after you have received treatment, don’t come back to the church until you have finished whatever you need to do. Then, you can call on the elders to come and pray for you before returning to the church.”-CHV

Patriarchal structures including male dominance also limited women’s ability to exercise agency and make decisions independently. Most respondents emphasized men’s cultural role in decision-making regarding seeking MCH care. They acknowledged that increasing the engagement of men would yield considerable health benefits and provide an important avenue for giving men information which would also foster trust between spouses.

“Well, I would really wish to bring him along so he can see for himself how busy it is, from here to there. If he doesn’t see it for himself, he won’t understand.”-PNC 3

However, there were instances where male involvement was recognized as enabler for agency, as evidenced by men accompanying their spouses for clinics.

“You see, for instance, today my husband accompanied me, and he needed to go to work, so he brought me and went to work, and he finished what he was doing, and now he is calling me because we have been waiting here for a long time.”-PNC 1

Additionally, gender norms affected women’s ability to make decisions at the household level. Several women had partial control of their households’ finances but also kept financial secrets from their partners. This could be attributed to the feeling of being disempowered and the belief that financial secrets would give them a sense of autonomy. Interestingly, even after saving this money secretly, some women still needed their spouse’s approval to spend.

“They (women) also fear, even after saving they still can’t use the money without getting approval from the husband because they cannot do anything. It is mandatory, the husband has to know.”-MCH in charge

Women also stressed the need for securing the buy-in of the decision makers through community units, the nyumba kumi initiative, counselors, and healthcare providers.

“If we can find partners like you, we can go to the assistant chief’s council through the community health volunteers (CHVs). We can invite men to attend, and even if not all of them will come, we can create a network by telling a friend who tells another friend. This is like politics, but if we can use this network to spread the importance of maternal healthcare, it will be beneficial.”-CHV.

Health system factors such as facility workload, wait times, staff availability, and distance to health facilities also impacted women’s agency. The healthcare facilities were often overwhelmed with a high patient load, leading to longer waiting times, and delays in receiving care which can reduce women’s agency in seeking timely healthcare and may force them to delay or forgo necessary care. Women’s ability to make decisions about their own health was compromised when they had limited choices or faced barriers to accessing services. It also created a burden on women who had additional responsibilities, such as caregiving or work, as they struggled to find time to visit busy healthcare facilities.

“The health workers here are often overworked and have many patients to attend to. This leads to longer waiting times, which can sometimes make the patients frustrated.”-CHV

“Because of the staff shortage, we have only 2 staff in the ANC area. So, if one goes on leave, the one who is there serves both sides, the ANC and the other clients, the immunization side. So, the long queues and the long waiting time affect them, they don’t like it. I think that demotivates them even just to come to seek the services” -NO IC.

The distance between women’s residences and healthcare facilities also impacted their agency due to challenges related to transportation, time constraints, and financial resources required for travel.

“Most of them I’ve seen prefer the rural facilities, that is health centers or dispensaries instead of coming back to Lumakanda. I think the issue affecting them is transport.”-MS.

“At night, for a car, you’ll spend Ksh. 2,000 and if it’s a motorcycle, you’ll give him Ksh.800 shilling.”-FGD-BC

In some cases, where improved road networks existed, there were reports of women being able to access hospitals easily without difficulties.

“They come to Lumakanda because the road is tarmacked, so, if it’s a pregnant woman, she will not be spun in potholes.”-FGD Men

Our results indicate that individual agency, immediate relational agency, and distance relational agency influence women’s agency and autonomy. In terms of individual agency, factors such as self-stigma, trust in oneself, social networks, and previous birthing experiences emerged as important determinants of women’s decision-making power and control over their lives. Immediate relational agency, on the other hand, highlighted the significance of household decision-making dynamics, including aspects like control of household finances, respect between couples, and spousal communication. These factors played a crucial role in shaping women’s ability to exercise agency within their immediate relationships. Furthermore, distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women’s agency and autonomy. Factors such as facility workload, staff availability, and religious norms were found to significantly influence women’s decision-making power and freedom of movement. Overall, these findings underscore the importance of recognizing and addressing various dimensions of agency and autonomy in order to empower women and promote gender equality.

Our work highlights a myriad of factors that influenced decision-making among women attending ANC, delivery, and PNC clinics during the early days of implementing a service delivery reform aimed at shifting all delivery to hospitals in a rural county in Kenya. Women’s autonomy and agency is still limited despite it being a crucial determinant of the use of maternal healthcare services. In our case, literacy was a pointer when analyzing women’s individual agency and decision-making capacity in engaging with MCH interventions and reforms. Our work revealed how, women with limited health literacy were unaware of their options in regarding participation in decision-making over their own reproductive health. Respondents reported the positive contribution of mass media in enhancing the household decision-making capacity. Similarly, Seidu et al. [ 33 ] demonstrated that women who watched television almost every day had a higher capacity to take household decisions, compared to those who did not watch television at [ 33 ] all. Mass media influences women empowerment, including their ability to take household decisions [ 34 ] by changing some socio-cultural norms such as gender stereotyping [ 35 ] suggesting that interventions to promote shared decision-making may be particularly important for patients with limited health literacy.

When women had individual agency, they reported having informed and better financial choices for themselves, and their families. Thus, individual agency elevated perceived self-efficacy in their decision making. Choices about individual women’s reproductive pathways and decision-making for care seeking therefore depended their perception of self; the self in relation to social environment and reflection on risks associated with the decision to seek care or not [ 36 ]. Social identity influences decision-making practices of individuals emphasizing the importance of deliberately embracing diversity and promoting inclusion future in the design of interventions and reforms with a focus on. This involves acknowledging and valuing different social identities, creating spaces that are safe and accessible for all individuals, and actively involving them in decision-making processes [ 37 ].

Women’s autonomy can also be better understood from a relational perspective since individual autonomy often fails to incorporate social reality. Relational autonomy posits that persons are socially embedded and that their identities are formed within the context of social relationships and shaped by a complex of intersecting social determinants and health system determinants [ 38 ]. We found that in both joint and nuclear families, women who have better spousal communication with their husbands have greater agency. The role of immediate relational agency is therefore mediated through the family context and the quality of relationships the women have which consequently influences their agency. Male heads of households were central in health decisions, and in some instances discussing health issues with their wives before final decisions were made [ 39 , 40 ]. While joint and constructive communication leads to psychological well-being and protect against stressors during pregnancy [ 41 ] the process for decision-making often becomes delayed, consequently mothers’ ability to receive professional health care and other obstetric interventions on time.

Freedom of movement is also an important determinant of immediate relational agency, as the household structure affects women’s freedom of movement, since women residing in joint households are less likely to have decision-making power and need permission more often from other household members to execute some routine household activities [ 42 ]. Women require the permission of a husband or another male to pursue activities outside the home due to trust issues, social norms, and religious norm. This subsequently limited women’s ability to access and use skilled maternal health services including attending antenatal clinics or giving birth at a health facility. However, women who worked outside the home were more mobile, and women who were independent in the social sphere were also confident in their ability to negotiate independent mobility [ 40 ]. Additionally, it has been shown that husbands’ out-migration promotes women’s freedom of movement [ 43 ].

In summary, there is need for deliberate efforts towards empowering women’s autonomy in reproductive matters. Men might also benefit in the empowerment process through enlightenment and through effective implementation of male engagement interventions that leverage men’s power within households and promote women’s autonomy in decision making. Notably, women who receive male engagement education report making joint decisions (such as contraceptive choices, purchases of daily needs, and whether or not to work out of the home) compared to those who do not received such education [ 44 ].

The strength of this study includes the comprehensive exploration of agency across multiple dimensions, providing insights into the influence of factors such as previous birthing experiences, self-esteem, social support, financial control, respectful communication, and health system barriers on women’s agency. Although the challenge of establishing causality between the identified factors and women’s agency pose a challenge, the findings offer compelling descriptive explorations of the often undermined voice of women in shaping maternal and child health interventions policies and practices.

The study findings underscore the limited autonomy of women in Kakamega County, emphasizing the importance of considering women’s decision-making in the successful implementation of the SDR. Moving forward, it is crucial for SDR implementation strategies to recognize and promote women’s autonomy, engaging decision-makers to understand the significance of women’s choices regarding delivery in higher-level facilities. This calls for a concerted effort to enhance women’s autonomy in reproductive healthcare through initiatives such as male involvement, women’s empowerment programs, access to resources, and institutional support. Additionally, MCH programs should prioritize health and financial literacy, freedom of movement, gender equality, and media access to counter cultural and religious barriers to women’s autonomy.

Availability of data and materials

The data that supports the findings of this study are available in the article and its supplementary material.

Abbreviations

Antenatal clinics

Community Health Volunteers

Emergency obstetric and newborn care

Facility Improvement Fund

Focus Group Discussions

International Centre for Research on Women

In-depth interviews

Key Informant Interviews

Newborn Unit

National Health Insurance Fund

Sustainable Development Goal

Service Delivery Redesign

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Acknowledgements

We would like to express our gratitude to the Kakamega County Government for granting us permission to conduct the study and for providing the essential preliminary information that facilitated our research. Furthermore, we would like to convey our sincere appreciation to the study participants for their invaluable cooperation throughout the course of this study.

This study is funded by the Bill and Mellinda Gates Foundation grant number # 263771.5119872. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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JN conceptualized the study, EO conducted the interviews, JN and EO undertook the analysis, EO developed the first draft of the manuscript. KO, KC, DO, JM, and JJ contributed to subsequent drafts and all authors approved this version of the manuscript for publication.

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Olwanda, E., Opondo, K., Oluoch, D. et al. Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study. BMC Women's Health 24 , 181 (2024). https://doi.org/10.1186/s12905-024-02965-9

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Perspective article, meeting the challenges and strategies regarding malaria elimination: qualitative evaluation of perceptions from a local population in colombia.

• 1 Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia
• 2 Maestría en Epidemiología Clínica, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia
• 3 Grupo de Investigación en Salud Pública, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
• 4 Programa de Medicina, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia
• 5 Departamento de Salud Pública y Medicina Comunitaria, Facultad de Ciencias de la Salud, Universidad ICESI, Cali, Colombia
• 6 Programa de Enfermedades Transmitidas por Vectores, Secretaría Departamental de Salud del Cauca, Popayán, Colombia
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“One Health” and “Social Determinants of Health” approaches are crucial for implementation of sustainable strategies for the control and elimination of infectious diseases such as malaria. These approaches highlight the importance of the social component in the design of elimination strategies, as well as the communities’ involvement in the implementation of these measures at local levels. Qualitative analysis approaches for malaria research can be useful for assessing population acceptance of intervention measures and for addressing negative perceptions that can threaten the success of control goals by undermining the community’s trust in interventions. In this paper, we explore some observations and interpretations from the qualitative content analysis of two open-ended questions about malaria, from a survey conducted between September and November 2016 in Guapi, a high risk transmission area in the Colombian Pacific Region. Using the spatial transmission unit concept for the analysis of the conditions and factors involved in malaria transmission under the “One Health” and “Social Determinants of Health” approaches, we reveal that responders’ perceptions reflects both the need and requirement for continuous assistance to solve local problems and also a comprehensive problem-solving effort by the government that includes basic sanitation. From the analyses, we present a graphic model that illustrates how to address the problem of malaria control and elimination from the perspectives of the community’s perceptions in Guapi, highlighting the need for joint efforts of community, academy, and government to achieve the goal of controlling and eliminating malaria in the region.

1 Introduction

Malaria incidence is associated with wide-ranging characteristics and lifestyles that increase transmission risk, including socio-economic conditions, public policies, poverty and working conditions ( Castro, 2017 ). However, the interaction among humans, vectors and parasites in very specific environments give rise to diverse transmission patterns, hindering or challenging control efforts at local and national levels. For example, though that the distribution of malaria cases occurs in hotspots along international borders, the incidence and transmission patterns of Plasmodium vivax and P. falciparum in three border areas of Brazil, Venezuela and Guyana are influenced not only by geographical factors, but also correlate with human migrations caused by the social crisis in Venezuela. Malaria elimination in this context requires both the targeted distribution of resources at local levels and highly coordinated cross-border surveillance efforts among countries with different political systems, languages, and economic resources ( Wangdi et al., 2022 ).

Until recently, control strategies focused almost exclusively on deploying interventions with little or no consideration regarding the perceptions that communities have about those strategies. This paradigm has been changing recently, not only for malaria, but also for the management of other transmissible diseases. Initiatives such as the “One Health” approach, defined by WHO as “ an approach to designing and implementing programs, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes ”, have been crucial for the implementation of sustainable strategies for the control and elimination of malaria and other diseases ( Wangdi et al., 2022 ). In the same way, social determinants of health are also defined by WHO as “ the circumstances in which people are born, grow up, live, work and age, including economic, political, cultural, and health system aspects. These circumstances result from the distribution of money, power, and resources at the global, national, and local levels, which depends on policies adopted ”. Thus, these factors determine population behavior and living conditions and so, influence the outcome of health problems ( Instituto Nacional de Salud, 2021 ).

The Global Technical Strategy for the Elimination of Malaria aimed to reduce malaria incidence and mortality by 40% for the year 2020 through early diagnosis and treatment (artemisinin-based combination therapy), vector control (long-lasting insecticidal nets, indoor residual spraying), investigation and response ( World Health Organization, 2021 ). Within this framework, the Integrated Management Strategy for the Promotion, Prevention and Control of Vector-borne Diseases (EGI-ETV) was implemented in Colombia from 2012 to 2021 as a model for managing the operational response required to achieve the reduction of malaria mortality and morbidity by 80% and 50%, respectively, and to eliminate peri-urban transmission in identified foci, most of them in the Pacific region ( Ministerio de Salud y Protección Social, 2013 ; Ministerio de Salud y Protección social, 2017 ; Organización Panamericana de la Salud et al., 2020 ). However, as in the rest of the country, malaria cases in the Colombian Pacific Region have increased since 2016, registering multiple outbreaks in which P. falciparum infection is the most frequent ( Feged-Rivadeneira et al., 2018 ; Knudson et al., 2020 ).

In Colombia, heterogeneity and focalization are the most common epidemiological characteristics of malaria transmission, but the delimitation of units where control measures can be implemented in a cost-effective way has been challenging, mainly because of the lack of knowledge about factors that locally define malaria burden. Nonetheless, identifying spatial transmission units is key for implementing or improving control programs in ecologically and socially complex endemic areas. Spatial analysis and modelling tools are useful for this purpose, helping to define ecological associations between malaria risk, environment and biological aspects of vectors and parasites, to quantify temporal and spatial diffusion and predict patterns of disease spread.

On the other hand, research about malaria in Colombia has been focused on clinical, biological and epidemiological procedures, with little attention paid to qualitative research. However, qualitative approaches are important because they not only allow population perceptions to be identified in a specific context but also allow successes and setbacks during the control policies to be recognized. Moreover, qualitative research help to understand whether management plans are adequate, opportune and adapted to the target community. In general, qualitative focused investigations about malaria elimination in Colombia have shown similar results regarding structural determiners, effects on individuals and families and ways to understand malaria transmission ( Cardona-Arias et al., 2020 ). Nevertheless, community perceptions about health policies, the systematic deployment of solutions originated from the community core and how to motivate the communities to participate in public health interventions remain poorly understood. Exploring this neglected topic could improve population engagement in malaria control and elimination initiatives ( Cardona-Arias et al., 2020 ).

Through a qualitative analysis approach (content analysis) ( Bengtsson, 2016 ), we describe and interpret findings of a study aimed to analyze the perception of the community towards malaria control and elimination strategies in Guapi, a municipality of the Colombian Pacific region. To perform the content analysis, we used the EGI-ETV as a political framework and the concept of spatial transmission unit (explained in detail in the next section) within the framework of the principles of the “One Health” approach and “Social Determinants of Health”. We chose to use content instead of discursive analysis, because the former is a more flexible and immediate approach to obtain categories and subcategories, and whose results are more suitable for identifying key points in the implementation of public policies for the current malaria scenario in this region. From the community perspective and according to our standpoint, the results from this kind of studies should be considered during the development of health policies and interventions at local or regional levels.

2 Malaria in the Colombian Pacific Region: the Guapi spatial transmission unit

Like all the Pacific Coast of Colombia, Guapi (2°34′11″ N, 77°53′10″ W) is a lowland area, with a maximum altitude of 5 meters above sea level, a tropical rainforest climate according to Köppen classification, with an average temperature of 29 °C, rainfall between 4000 and 6000 mm 3 and relative humidity between 80% and 95%. According to the latest census in Colombia, Guapi had 24,037 inhabitants in 2018 ( Departamento Administrativo Nacional de Estadística DANE, 2018a ; Departamento Administrativo Nacional de Estadística DANE, 2018b ); approximately 45% of the population inhabit rural areas, 97% are from Afro-Colombian origin and the main economic occupations are related to fishing, agriculture, and mining activities ( Knudson-Ospina et al., 2019 ).

Guapi lacks potable water supply, regular garbage collection and separation services; because of that, the Guapi River is the recipient of large amounts of solid waste. Approximately 67.5% of the population had unsatisfied basic needs and the illiteracy rate is around 14.9%. Infant mortality triples the national rate, vaccination coverage is the lowest in the department, and health care is also deficient ( Departamento Administrativo Nacional de Estadística DANE, 2020 ).

Guapi is one of the Pacific Region municipalities considered to be at medium and high-risk of malaria transmission and the frequency of P. falciparum infection is higher than 95%, although, in accordance with the Annual Parasite Index (API), Colombia is classified as a low and unstable malaria transmission zone ( Feged-Rivadeneira et al., 2018 ; Knudson et al., 2020 ; Sistema Nacional de Vigilancia en Salud Pública (SIVIGILA), 2023 ). Malaria in Guapi shows peri-urban, endemic, and epidemic outbreaks as epidemiological patterns which are almost exclusively caused by P. falciparum. Between 2007 and 2021, annual parasite indices for P. falciparum infection fluctuated between 1.8 and 105; four out of the 21 neighborhoods that make up the urban area of Guapi report cases of peri-urban malaria, with Santa Monica being the neighborhood that historically reports the most cases ( Feged-Rivadeneira et al., 2018 ; Knudson et al., 2020 ).

As a region of malaria transmission, Guapi has been target of several strategies and interventions, including the National Malaria Eradication Program in the 20th century and, in recent years, the elimination campaigns focused on urban and peri-urban malaria ( Organización Panamericana de la Salud et al., 2020 ). The success of these attempts has been moderate, partially because of their lack of sustainability as a consequence of program’s financial constraints, socio-political instability (related to human migration caused by illegal culture dynamics and the internal armed conflict), and the resurgence of illegal extraction mining activities. In this context, and considering the national policies for malaria elimination, the optimization of political and administrative resources and recognition and integration of the community role should be acknowledged to achieve the malaria elimination objective.

To understand the dynamics of malaria transmission in Guapi from an epidemiological point of view we have previously defined a spatial malaria transmission unit as the area contributing >= 95% of the malaria cases that are diagnosed at the catchment site i.e. the site where microscopic diagnosis and treatment are provided ( Knudson et al., 2020 ). Using a combination of epidemiological (malaria incidence in human settlements within the spatial unit) and genetic data from parasites circulating in the area (molecular markers for parasite populations, drug resistance and gene targets for Rapid Diagnostic Tests) we were able to characterize the spatial unit in terms of the spatiotemporal heterogeneity of transmission and the connectivity of human populations resulting from human movements and migration ( Knudson et al., 2020 ). This study determined that P. falciparum transmission was heterogeneous in time and space, highly influenced by local human movements and, to a lesser extent, by external migrations ( Knudson et al., 2020 ).

3 Data collection

We conducted a qualitative study using content analysis (inductive and interpretative methodology) ( Bengtsson, 2016 ). The study was carried out between September and November 2016 in Guapi through semi-structured interviews associated with the malaria survey of knowledge, attitudes and practices (KAP) and within the framework of the project “Tools, training and networks aimed at reducing the burden of malaria in the Colombian Pacific Coast” ( Knudson et al., 2020 ). The study is classified as minimal risk and informed consent was obtained from all participants ( WMA - World Medical Association (WMA) and WMA Declaration of Helsinki, 2013 ; Ministerio de Salud y Protección Social, 1993 ) and it was approved by the Faculty of Medicine ethics committee of the Universidad Nacional de Colombia (Evaluation Report 127-14). The KAP survey was applied only in the Santa Monica neighborhood, and it encompassed socio-demographic description, knowledge, attitudes and practices regarding malaria and a section for community participation. The two questions that were open-ended are the focus of this qualitative analysis. The interviews were conducted in participants’ homes and while recording the information, the research group reviewed striking aspects of the responses to deepen the subsequent analysis. All of the houses (229 households in which 1134 people live) were surveyed and one person of legal age (>18 years old) and residing in the neighborhood for at least the previous year, was in charge of answering the questions. Their responses were recorded on physical forms and reviewed; the household was revisited and asked to expand or complete the information if necessary.

Each interview lasted about one hour and was carried out by four female community health workers. Information bias was considered, especially with popular expressions that required further explanation by the participants, who sometimes associated the topic with other social and health problems whether it was related to malaria or not ( Guber, 2004 ). To reduce this bias, the community health workers were four women from the South Pacific region of Colombia, who were between 30-50 year-old, with technical training in nursing, that were instructed by researchers regarding malaria topics and data collection. These women were recognized as health workers in their community, generating an opportunity to promote an empathetic relationship in order to conduct interviews with specific explanations of questions about popular expressions as needed. A pilot test was carried out to ensure the correct use of the data collection tools, and the data recording was supervised by a third person from the research group that did not belong to the community.

4 Qualitative analysis, “One Health” and “Social Determinants of Health” approaches

The two open-ended questions that are the basis of the qualitative component analysis were:

1. Do you believe that malaria cases in Guapi could increase due to (explain)

2. Which strategy would you propose to eliminate malaria in Guapi?

In Figure 1 , we summarized the content analysis strategy from the answers to the open-ended questions. With this approach, an overall (pooled) analysis of the answers was carried out, so we did not explore each question separately. The categories corresponded to the seven components of the Integrated Management Strategy for the Promotion, Prevention and Control of Vector-borne Diseases (EGI-ETV), namely program management, epidemiological intelligence, knowledge management, health promotion, primary prevention of transmission, comprehensive patient care, and contingency management and care ( Ministerio de Salud y Protección social, 2017 ). On the other hand, the content analysis was developed through four stages: decontextualization, recontextualization, categorization, and compilation ( Figure 1 ). Data validation was carried out including researchers that worked with the respondents, others who did not work directly with them and community health workers in order to achieve data saturation through data triangulation and unifying categorization criteria ( Sampieri, 2021 ).

Figure 1 Content analysis: theme, categories, subcategories, and strategies emerging from data analysis in the framework of the “One Health” and “Social Determinants of Health” approaches. For the analysis, the categories corresponded to the seven components of the EGI-ETV. The content analysis was developed in four stages: during the decontextualization stage, the survey responses were transcribed and read by three researchers who independently identified and highlighted the meaning units (descriptors) ( Bengtsson, 2016 ). The same researchers inductively identified emerging subcategories that were subsequently regrouped throughout the analysis according to the objective of the study. Methodological rigor considered the credibility of the work by returning the results to the community to explore how well the descriptors fit into the messages the community wanted to transmit. Each of the meaning units were coded and are included in the results. In the recontextualization stage, the three researchers eliminated the meaning units that did not contribute to the objective of the study. The third step or categorization stage included five researchers (three of the above and two more), who interpreted the information based on the emerging subcategories and their meaning units, and aligned them with the EGI-ETV components (categories). The fourth stage of the quantitative analysis was the compilation where the five researchers described each category, maintaining a neutral and objective perspective in the writing; through a “manifest analysis”, the information from the respondents was used to write the text, considering the objective of the study.

The concepts of “One Health” approach and “Social Determinants of Health” were also used for the analysis. In “One Health”, the role of the environment was taken into account to explain the malaria dynamics from the perception of the participants ( World Health Organization, 2022 ). On the other hand, the structural and intermediate factors of the “Social Determinants of Health” were taken into account to explain the conditions, infrastructure, and lifestyles described by the participants ( Instituto Nacional de Salud, 2021 ) ( Figure 1 ).

5 Community perspectives about malaria control and elimination in Guapi

From the analysis of the answers to the two-opened question regarding perceptions about malaria transmission in Guapi, we were able to define seven subcategories that belong to three of the seven components of the EGI-ETV, as shown in Figure 1 .

The general perception of the inhabitants of the urban area of Guapi, reflects a series of requirements and needs that demand prompt and effective attention. Specifically, participants believe malaria dynamics in their neighborhood are determined by environmental, administrative, socio-cultural, demographic, educational, basic health, and living factors. The participants’ requisitions spanned concerns, associated or not with malaria transmission, about health promotion, community education, collaborative work with academic institutions and the government, solid waste disposal and the absence of potable water and sewage systems, vector control, weather and natural phenomena, individual protective measures, and comprehensive patient care including case search, diagnosis and patient treatment.

In particular, the community identified waste disposal and lack of drinking water supply as the most urgent problems to be solved in Guapi. The inhabitants manifested concerns about solid waste disposal practices such as littering, rubbish accumulation and/or burning, obstruction of drainage systems by dumping residues into rivers and streams, and waste burial to build roads and trails. Besides, the lack of an adequate drinking water supply compels the people to find it from other sources (rain, rivers or artesian wells) and store it in semi-permanent containers or uncovered tanks. According to them, these conditions and the typical climatic and natural phenomena of the region favor the emergence of breeding sites for vectors, not only for malaria, but also for other diseases that require immediate attention. Among the strategies that the community considered important for vector control were vegetation clearing, draining of stagnant water, wells and ponds, elimination of temporary water containers (e.g. plastic bottles), and cleaning and coverage of water tanks. In the same way, people also mentioned the necessity of municipal government support for having an organized and frequent intra- and peridomiciliar insecticide application program and the supply of long-lasting insecticide-impregnated mosquito nets, in spite of some degree of rejection to use them because of the lack of motivation or fear of developing allergic reactions. From their answers, we concluded that even though people from Santa Monica neighborhood did not differentiate clearly which strategies are focused specifically on malaria control, they perceive them as a main axis for preventing malaria transmission at individual level.

6 Community participation: a model for malaria control and elimination in Guapi designed from the community perspectives

In general, the community perceptions align well with three of the seven components of the official policies, as shown in Figure 1 . However, because of the poor Guapi socio-economics infrastructure, people are more concerned about clean water supply and waste disposal than in the specific contribution of these interventions to solve the problem of malaria control and elimination. Based on our analysis, the strategies that emerged from the interpretation of the respondent’s answers for malaria management in Santa Monica, Guapi that are classified into the structural determinants are: 1. Coverage and sustainability of the Vector Transmitted Diseases program (ETV by its Spanish first initials); 2. Social and community networking with government and academics; 3. Healthy domiciliary and community environments. As intermediate determinants, the intervention strategies that are inferred from the community answers are: 4. Human talent education (microscopists and physicians); 5. On-time consultation if symptoms are present; 6. Active case search, notification and long-lasting insecticide-treated nets (LLINs) for miners; 7. Education on solid residues and deposits of water; 8. Use and acceptance of awnings and residual spray; 9. Community education ( Aedes & Anopheles ). It was established that the malaria elimination strategies emerging from the participants’ responses and analyzed in the light of the theoretical approaches of “One Health” and “Social Determinants of Health” are related to the categories corresponding to EGI-ETV components.

After the compilation stage, a graphic model ( Figure 2 ) was developed for describing the strategy to address the problem of malaria control and elimination based on the perception of the community in Santa Monica, Guapi. To establish a specific malaria control and elimination program for the operational spatial transmission unit previously identified, it is necessary to characterize the obstacles to its implementation through the recognition of categories identified, in the first place, by the community that inhabits the region. The obstacles can be of different kinds and include biological components of malaria, functioning of the health system, and social and cultural aspects of the inhabitants of the regions. For example, P. falciparum cases from the Colombian Pacific Region, where this species is more prevalent and, in some places, exceeds 95% prevalence, contribute significantly to the malaria burden in The Americas Region. In terms of the biology of the parasite, P. falciparum infection is eliminable by treatment without relapse risks; nevertheless, this is possible only under the premise of timely access to diagnosis and proper treatment; meaning that the persistence of P. falciparum infection could indirectly reflect the absence of a competent health system unable to ensure adequate treatments. In this scenario, we assume that the malaria control and elimination goal in Guapi is achievable and would contribute to improving the regional and national health situation.

Figure 2 Graphic model for addressing malaria control and elimination in the Guapi spatial transmission unit. The central circles correspond to the role of the environment, a constitutive element of the “One Health” approach, and the small circles on the periphery are considered as strategies for malaria management by respondents; these elements are classified as structural and intermediate determinants of the “Social Determinants of Health” approach, and all of them are influenced by community participation (thick red line).

7 Using the concept of spatial transmission unit for malaria control and elimination in Guapi

The characterization of the spatial transmission unit in Guapi that we achieved in a previous study ( Knudson et al., 2020 ) is a key first step towards converting it into a malaria control unit. Integrating intrinsic or biotic information (parasite, mosquito, and human biological information) and extrinsic or abiotic information (i.e. information regarding control and prevention measures, as well as social, demographic, behavioral, economic, political and environmental information) allow us to evaluate the roadblocks for implementing a malaria elimination program and unequivocally calculate costs of malaria elimination in a clearly delineated area.

The analysis of our current study allows a more precise characterization of the malaria control unit in Guapi, where the following strategies for control and elimination can be suggested: community education on the distinction between vector-borne diseases, specifically those related to Aedes and Anopheles ; management of solid waste and water tanks; the use and acceptance of LLINs and indoor residual spraying; timely medical consultation after recognition of symptoms of malaria; use of protective measures when performing high-risk activities such as mining and fishing as well as conduct active, passive and reactive surveillance for malaria cases. In addition to education, there is a need to promote healthy environments in homes and communities. In parallel, ongoing training and re-training in malaria diagnosis and patient care should be provided to microscopists and healthcare personnel.

Other studies carried out in Colombia using qualitative analysis allow malaria to be approached as a problem from the perspective of the social determinants of health, grouped as structural determinants (the origin of malaria, its relation to life and work conditions, and the importance of home and family) and individual determinants (traditional knowledge about paludism, the importance of knowledge secularization about malaria and the perception of different communities about the risk of infection and death from malaria) ( Cardona-Arias et al., 2019 ; Cardona-Arias et al., 2020 ; Cardona-Arias, 2022 ). Here, our work aimed to use qualitative analysis to understand the perceptions of the residents about: malaria risk areas, their own problems, the solutions proposed by themselves and how those solutions are related to the strategies proposed in the official programs from health institutions.

It is necessary to strengthen the local malaria program, ensuring the coverage and sustainability of activities, using social and community networks, and integrating government entities and academic institutions into the program. On the other hand, a special approach is required in mining areas, where uncontrolled movement of people occurs; the approach should include active surveillance, timely notification, and education on LLINs use. All the above processes should be mediated by community participation through the social groups formed, thus becoming information multipliers. In this context, the transferability of our findings involves the southern subregion of the Colombian Pacific, which includes municipalities with similar ethnographic origins (Afro-Colombian), socioeconomics and environmental characteristics. For populations from other regions, different backgrounds, or as a part of control programs for the management of diseases other than malaria, it could be useful to conduct similar surveys, not only to appraise the penetration and impact of health and government policies on the community, but also to include the communities own proposed solutions on the design and/or improvement of the new strategies, and eventually, to figure it out why those policies are successful or not in a specific locality.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by the Faculty of Medicine ethics committee of the Universidad Nacional de Colombia (Evaluation Report 127-14). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

Author contributions

AKO, VCE, NAI, RSP, LOM and CC contributed to conception and design of the study. AKO and ELSC organized the database. ESC performed the statistical analysis. AKO, ESC, YBZ, MPA and DPR performed qualitative analysis. AKO, ESC, YBZ and OOR wrote the first draft of the manuscript. OOR, MPA, DPR, YAA and APD wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work received financial support from Newton-Caldas Fund Institutional Links G1854. AKO was supported by scholarship award from Colciencias (announcement 617 of 2013).

Acknowledgments

We thank the Guapi and Cuerval communities, Secretaria Municipal de Salud de Guapi and Secretaría Departamental de Salud del Cauca for supporting us, specially Malaria Control Program Office. We especially thank Liliana Mosquera, Albida Luz Orobio, Yenni Rocío Orobio, Mireya Rodriguez y Sandra Perlaza for field support and ensuring linkages with communities.

Conflict of interest

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

Publisher’s note

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

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Keywords: qualitative research, health knowledge, attitudes and practice, community participation, Social Determinants of Health, malaria, One Health, content analysis

Citation: Knudson Ospina A, Simanca Castro EL, Barreto-Zorza YM, Ospina Rodríguez OL, Parada Aguilar MA, Perilla Roa D, Ariza-Araújo Y, Castillo CF, Olaya Másmela LA, Apráez Ippolito G, Piamba Dorado AH, Sánchez Pedraza R and Corredor Espinel V (2024) Meeting the challenges and strategies regarding malaria elimination: qualitative evaluation of perceptions from a local population in Colombia. Front. Malar. 2:1241933. doi: 10.3389/fmala.2024.1241933

Received: 17 June 2023; Accepted: 04 March 2024; Published: 18 March 2024.

Reviewed by:

Copyright © 2024 Knudson Ospina, Simanca Castro, Barreto-Zorza, Ospina Rodríguez, Parada Aguilar, Perilla Roa, Ariza-Araújo, Castillo, Olaya Másmela, Apráez Ippolito, Piamba Dorado, Sánchez Pedraza and Corredor Espinel. 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: Angélica Knudson Ospina, [email protected]

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Choosing a Qualitative Research Approach

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Editor's Note: The online version of this article contains a list of further reading resources and the authors' professional information .

The Challenge

Educators often pose questions about qualitative research. For example, a program director might say: “I collect data from my residents about their learning experiences in a new longitudinal clinical rotation. If I want to know about their learning experiences, should I use qualitative methods? I have been told that there are many approaches from which to choose. Someone suggested that I use grounded theory, but how do I know this is the best approach? Are there others?”

What Is Known

Qualitative research is the systematic inquiry into social phenomena in natural settings. These phenomena can include, but are not limited to, how people experience aspects of their lives, how individuals and/or groups behave, how organizations function, and how interactions shape relationships. In qualitative research, the researcher is the main data collection instrument. The researcher examines why events occur, what happens, and what those events mean to the participants studied. 1 , 2

Qualitative research starts from a fundamentally different set of beliefs—or paradigms—than those that underpin quantitative research. Quantitative research is based on positivist beliefs that there is a singular reality that can be discovered with the appropriate experimental methods. Post-positivist researchers agree with the positivist paradigm, but believe that environmental and individual differences, such as the learning culture or the learners' capacity to learn, influence this reality, and that these differences are important. Constructivist researchers believe that there is no single reality, but that the researcher elicits participants' views of reality. 3 Qualitative research generally draws on post-positivist or constructivist beliefs.

Qualitative scholars develop their work from these beliefs—usually post-positivist or constructivist—using different approaches to conduct their research. In this Rip Out, we describe 3 different qualitative research approaches commonly used in medical education: grounded theory, ethnography, and phenomenology. Each acts as a pivotal frame that shapes the research question(s), the method(s) of data collection, and how data are analyzed. 4 , 5

Choosing a Qualitative Approach

Before engaging in any qualitative study, consider how your views about what is possible to study will affect your approach. Then select an appropriate approach within which to work. Alignment between the belief system underpinning the research approach, the research question, and the research approach itself is a prerequisite for rigorous qualitative research. To enhance the understanding of how different approaches frame qualitative research, we use this introductory challenge as an illustrative example.

The clinic rotation in a program director's training program was recently redesigned as a longitudinal clinical experience. Resident satisfaction with this rotation improved significantly following implementation of the new longitudinal experience. The program director wants to understand how the changes made in the clinic rotation translated into changes in learning experiences for the residents.

Qualitative research can support this program director's efforts. Qualitative research focuses on the events that transpire and on outcomes of those events from the perspectives of those involved. In this case, the program director can use qualitative research to understand the impact of the new clinic rotation on the learning experiences of residents. The next step is to decide which approach to use as a frame for the study.

The table lists the purpose of 3 commonly used approaches to frame qualitative research. For each frame, we provide an example of a research question that could direct the study and delineate what outcomes might be gained by using that particular approach.

Methodology Overview

How You Can Start TODAY

• 1 Examine the foundations of the existing literature: As part of the literature review, make note of what is known about the topic and which approaches have been used in prior studies. A decision should be made to determine the extent to which the new study is exploratory and the extent to which findings will advance what is already known about the topic.
• 2 Find a qualitatively skilled collaborator: If you are interested in doing qualitative research, you should consult with a qualitative expert. Be prepared to talk to the qualitative scholar about what you would like to study and why . Furthermore, be ready to describe the literature to date on the topic (remember, you are asking for this person's expertise regarding qualitative approaches—he or she won't necessarily have content expertise). Qualitative research must be designed and conducted with rigor (rigor will be discussed in Rip Out No. 8 of this series). Input from a qualitative expert will ensure that rigor is employed from the study's inception.
• 3 Consider the approach: With a literature review completed and a qualitatively skilled collaborator secured, it is time to decide which approach would be best suited to answering the research question. Questions to consider when weighing approaches might include the following:
• • Will my findings contribute to the creation of a theoretical model to better understand the area of study? ( grounded theory )
• • Will I need to spend an extended amount of time trying to understand the culture and process of a particular group of learners in their natural context? ( ethnography )
• • Is there a particular phenomenon I want to better understand/describe? ( phenomenology )

What You Can Do LONG TERM

• 1 Develop your qualitative research knowledge and skills : A basic qualitative research textbook is a valuable investment to learn about qualitative research (further reading is provided as online supplemental material). A novice qualitative researcher will also benefit from participating in a massive online open course or a mini-course (often offered by professional organizations or conferences) that provides an introduction to qualitative research. Most of all, collaborating with a qualitative researcher can provide the support necessary to design, execute, and report on the study.
• 2 Undertake a pilot study: After learning about qualitative methodology, the next best way to gain expertise in qualitative research is to try it in a small scale pilot study with the support of a qualitative expert. Such application provides an appreciation for the thought processes that go into designing a study, analyzing the data, and reporting on the findings. Alternatively, if you have the opportunity to work on a study led by a qualitative expert, take it! The experience will provide invaluable opportunities for learning how to engage in qualitative research.

Supplementary Material

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of the Navy, the Department of Defense, or the US government.

References and Resources for Further Reading