reliability for qualitative research

Subscribe to journal Subscribe
Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Rigor or Reliability and Validity in Qualitative Research: Perspectives, Strategies, Reconceptualization, and Recommendations

Cypress, Brigitte S. EdD, RN, CCRN

Brigitte S. Cypress, EdD, RN, CCRN , is an assistant professor of nursing, Lehman College and The Graduate Center, City University of New York.

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Brigitte S. Cypress, EdD, RN, CCRN, Lehman College and The Graduate Center, City University of New York, PO Box 2205, Pocono Summit, PA 18346 ( [email protected] ).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.dccnjournal.com ).

Issues are still raised even now in the 21st century by the persistent concern with achieving rigor in qualitative research. There is also a continuing debate about the analogous terms reliability and validity in naturalistic inquiries as opposed to quantitative investigations. This article presents the concept of rigor in qualitative research using a phenomenological study as an exemplar to further illustrate the process. Elaborating on epistemological and theoretical conceptualizations by Lincoln and Guba, strategies congruent with qualitative perspective for ensuring validity to establish the credibility of the study are described. A synthesis of the historical development of validity criteria evident in the literature during the years is explored. Recommendations are made for use of the term rigor instead of trustworthiness and the reconceptualization and renewed use of the concept of reliability and validity in qualitative research, that strategies for ensuring rigor must be built into the qualitative research process rather than evaluated only after the inquiry, and that qualitative researchers and students alike must be proactive and take responsibility in ensuring the rigor of a research study. The insights garnered here will move novice researchers and doctoral students to a better conceptual grasp of the complexity of reliability and validity and its ramifications for qualitative inquiry.

Conducting a naturalistic inquiry in general is not an easy task. Qualitative studies are more complex in many ways than a traditional investigation. Quantitative research follows a structured, rigid, preset design with the methods all prescribed. In naturalistic inquiries, planning and implementation are simultaneous, and the research design can change or is emergent. Preliminary steps must be accomplished before the design is fully implemented from making initial contact and gaining entry to site, negotiating consent, building and maintaining trust, and identifying participants. The steps of a qualitative inquiry are also repeated multiple times during the process. As the design unfolds, the elements of this design are put into place, and the inquirer has minimal control and should be flexible. There is continuous reassessment and reiteration. Data collection is carried out using multiple techniques, and whatever the source maybe, it is the researcher who is the sole instrument of the study and the primary mode of collecting the information. All the while during these processes, the qualitative inquirer must be concerned with rigor. 1 Appropriate activities must be conducted to ensure that rigor had been attended to in the research process rather than only adhering to set criteria for rigor after the completion of the study. 1-4

Reliability and validity are 2 key aspects of all research. Researchers assert that rigor of qualitative research equates to the concepts reliability and validity and all are necessary components of quality. 5,6 However, the precise definition of quality has created debates among naturalistic inquirers. Other scholars consider different criteria to describe rigor in qualitative research process. 7 The 2 concepts of reliability and validity have been operationalized eloquently in quantitative texts but at the same time were deemed not pertinent to qualitative inquiries in the 1990s. Meticulous attention to the reliability and validity of research studies is particularly vital in qualitative work, where the researcher's subjectivity can so readily cloud the interpretation of the data and where research findings are often questioned or viewed with skepticism by the scientific community (Brink, 1993).

This article will discuss the issue of rigor in relation to qualitative research and further illustrate the process using a phenomenological study as an exemplar based on Lincoln and Guba's 1 (1985) techniques. This approach will clarify and define some of these complex concepts. There are numerous articles about trustworthiness in the literature that are too complex, confusing, and full of jargon. Some of these published articles also discuss rigor vis-à-vis reliability and validity in a very complicated way. Rigor will be first defined followed by how “reliability and validity” should be applied to qualitative research methods during the inquiry (constructive) rather than only post hoc evaluation. Strategies to attain reliability and validity will be described including the criteria and techniques for ensuring its attainment in a study. This discussion will critically focus on the misuse or nonuse of the concept of reliability and validity in qualitative inquiries, reestablish its importance, and relate both to the concept of rigor. Reflecting on my own research experience, recommendations for the renewed use of the concept of reliability and validity in qualitative research will be presented.

RIGOR VERSUS TRUSTWORTHINESS

Rigor of qualitative research continues to be challenged even now in the 21st century—from the very idea that qualitative research alone is open to questions, so with the terms rigor and trustworthiness . It is critical to understand rigor in research. Rigor is simply defined as the quality or state of being very exact, careful, or with strict precision 8 or the quality of being thorough and accurate. 9 The term qualitative rigor itself is an oxymoron, considering that qualitative research is a journey of explanation and discovery that does not lend to stiff boundaries. 10

Rigor and truth are always of concern for qualitative research. 11 Rigor has also been used to express attributes related to the qualitative research process. 12,13 Per Morse et al 4 (2002), without rigor, research is worthless, becomes fiction, and loses its use. The authors further defined rigor as the strength of the research design and the appropriateness of the method to answer the questions. It is expected that qualitative studies be conducted with extreme rigor because of the potential of subjectivity that is inherent in this type of research. This is a more difficult task when dealing with narratives and people than numbers and statistics. 14 Davies and Dodd 13 (2002) refer rigor to the reliability and validity of research and that, inherent to the conception, the concept is a quantitative bias. Several researchers argued that reliability and validity pertain to quantitative research, which is unrelated or not pertinent to qualitative inquiry because it is aligned with the positivist view. 15 It is also suggested that a new way of looking at reliability and validity will ensure rigor in qualitative inquiry. 1,16 From Lincoln and Guba's crucial work in the 1980s, reliability and validity were replaced with the concept “trustworthiness.” Lincoln and Guba 1 (1985) were the first to address rigor in their model of trustworthiness of qualitative research. Trustworthiness is used as the central concept in their framework to appraise the rigor of a qualitative study.

Trustworthiness is described in different ways by researchers. Trustworthiness refers to quality, authenticity, and truthfulness of findings of qualitative research. It relates to the degree of trust, or confidence, readers have in results. 14 Yin 17 (1994) describes trustworthiness as a criterion to judge the quality of a research design. Trustworthiness addressed methods that can ensure one has carried out the research process correctly. 18 Manning 19 (1997) considered trustworthiness as parallel to the empiricist concepts of internal and external validity, reliability, and objectivity. Seale 20 (1999) asserted that trustworthiness of a research study is based on the concepts of reliability and validity. Guba 2 (1981), Guba and Lincoln 3 (1982), and Lincoln and Guba 1 (1985) refer to trustworthiness as something that evolved from 4 major concerns that relate to it in which the set of criteria were based on. Trustworthiness is a goal of the study and, at the same time, something to be judged during the study and after the research is conducted. The 4 major traditional criteria are summarized into 4 questions about truth value, applicability, consistency, and neutrality. From these, they proposed 4 analogous terms within the naturalistic paradigm to replace the rationalistic terms: credibility, transferability, dependability, and confirmability. 1 For each of these 4 naturalistic terms are research activities or steps that the inquirer should be engage in to be able to safeguard or satisfy each of the previously mentioned criteria and thus attain trustworthiness (Supplemental Digital Content 1, https://links.lww.com/DCCN/A18 ). Guba and Lincoln 1 (1985) stated:

The criteria aid inquirers in monitoring themselves and in guiding activities in the field, as a way of determining whether or not various stages in the research are meeting standards for quality and rigor. Finally, the same criteria may be used to render ex-post facto judgments on the products of research, including reports, case studies, or proposed publications.

Standards and checklist were developed in the 1990s based on Lincoln and Guba's 1 (1985) established criteria, which were then discarded in favor of principles. 21 These standards and checklists consisted of long list of strategies used by qualitative researchers, which were thought to cause harm because of the confusion on which strategies were appropriate for certain designs or what type of naturalistic inquiry is being evaluated. Thus, researchers interpreted missing data as faults and flaws. 21 Morse 21 (2012) further claimed that these standards became the qualitative researchers' “worst enemies” and such an approach was not appropriate. Guba and Lincoln 18 (1989) later proposed a set of guidelines for post hoc evaluation of a naturalistic inquiry to ensure trustworthiness based on the framework of naturalism and constructivism and beyond the conventional methodological ideas. The aspects of their criteria have been fundamental to development of standards used to evaluate the quality of qualitative inquiry. 4

THE RIGOR DEBATES: TRUSTWORTHINESS OR RELIABILITY AND VALIDITY?

A research endeavor, whether quantitative or qualitative, is always evaluated for its worth and merits by peers, experts, reviewers, and readers. Does this mean that a study is differentiated between “good” and “bad”? What determines a “good” from a “bad” inquiry? For a quantitative study, this would mean determining the reliability and validity, and for qualitative inquiries, this would mean determining rigor and trustworthiness. According to Golafshani 22 (2003), if the issues of reliability, validity, trustworthiness, and rigor are meant to differentiating a “good” from “bad” research, then testing and increasing the reliability, validity, trustworthiness, and rigor will be important to the research in any paradigm. However, do reliability and validity in quantitative research equate totally to rigor and trustworthiness in qualitative research? There are many ways to assess the “goodness” of a naturalistic inquiry. Guba and Lincoln 18 (1989) asked, “‘What standards ought apply?’… goodness criteria like paradigms are rooted in certain assumptions. Thus, it is not appropriate to judge constructivist evaluations by positivistic criteria or standards or vice versa. To each its proper and appropriate set.”

Reliability and validity are analogues and are determined differently than in quantitative inquiry. 21 The nature and purpose of the quantitative and qualitative traditions are also different that it is erroneous to apply the same criteria of worthiness or merit. 23,24 The qualitative researcher should not focus on quantitatively defined indicators of reliability and validity, but that does not mean that rigorous standards are not appropriate for evaluating findings. 11 Evaluation, like democracy, is a process that, to be at its best, depends on the application of enlightened and informed self-interest. 18 Agar 24 (1986), on the other hand, suggested that terms such as reliability and validity are comparative with the quantitative view and do not fit the details of qualitative research. A different language is needed to fit the qualitative view. From Leininger 25 (1985), Krefting 23 (1991) asserted that addressing reliability and validity in qualitative research is such a different process that quantitative labels should not be used. The incorrect application of the qualitative criteria of rigor to studies is as problematic as the application of inappropriate quantitative criteria. 23 Smith 26 (1989) argued that, for qualitative research, this means that the basis of truth or trustworthiness becomes a social agreement. He emphasizes that what is judged true or trustworthy is what we can agree, conditioned by time and place, and is true or trustworthy. Validity standards in qualitative research are also even more challenging because of the necessity to incorporate rigor and subjectivity, as well as creativity into the scientific process. 27 Furthermore, Leininger 25 (1985) claimed that it is not whether the data are reliable or valid but how the terms reliability and validity are defined. Aside from the debate whether reliability and validity criteria should be used similarly in qualitative inquiries, there is also an issue of not using the concepts at all in naturalistic studies.

Designing a naturalistic inquiry is very different from a traditional quantitative notion of design and that defining a “good” qualitative inquiry is controversial and has gone through many changes. 21 First is the confusion on the use of terminologies “rigor” and “trustworthiness.” Morse 28 (2015) suggested that it is time to return to the terminology of mainstream social science and to use “rigor” rather than “trustworthiness.” Debates also continue about why some qualitative researchers do not use the concept of reliability and validity in their studies referring to Lincoln and Guba's 1 (1985) criteria for trustworthiness, namely, transferability, dependability, confirmability, and credibility. Morse 28 (2015) further suggested replacing these criteria to reliability, validity, and generalizability. The importance and centrality of reliability and validity to qualitative inquiries have in some way been disregarded even in the current times. Researchers from the United Kingdom and Europe continue to do so but not much so in North America. 4 According to Morse 21 (2012), this gives the impression that these concepts are of no concern to qualitative research. Morse 29 (1999) stated, “Is the terminology worth making a fuzz about?”, when Lincoln and Guba 1 (1985) described trustworthiness and reliability and validity as analogs. Morse 29 (1999) further articulated that:

To state that reliability and validity are not pertinent to qualitative inquiry places qualitative research in the realm of being not reliable and not valid. Science is concerned with rigor, and by definition, good rigorous research must be reliable and valid. If qualitative research is unreliable and invalid, then it must not be science. If it is not science, then why should it be funded, published, implemented, or taken seriously?

RELIABILITY AND VALIDITY IN QUALITATIVE RESEARCH

Reliability and validity should be taken into consideration by qualitative inquirers while designing a study, analyzing results, and judging the quality of the study, 30 but for too long, the criteria used for evaluating rigor are applied after a research is completed—a considerably wrong tactic. 4 Morse and colleagues 4 (2002) argued that, for reliability and validity to be actively attained, strategies for ensuring rigor must be built into the qualitative research process per se not to be proclaimed only at the end of the inquiry. The authors suggest that focusing on strategies to establish rigor at the completion of the study (post hoc), rather than during the inquiry, exposes the investigators to the risk of missing and addressing serious threats to the reliability and validity until it is too late to correct them. They further asserted that the interface between reliability and validity is important especially for the direction of the analysis process and the development of the study itself.

Reliability

In the social sciences, the whole notion of reliability in and of itself is problematic. 31 The scientific aspect of reliability assumes that repeated measures of a phenomenon (with the same results) using objective methods establish the truth of the findings. 32-35 Merriam 36 (1995) stated that, “The more times the findings of a study can be replicated, the more stable or reliable the phenomenon is thought to be.” In other words, it is the idea of replicability, 22,34,37 repeatability, 21,22,26,30,31,36,38-40 and stability of results or observation. 25,39,41 The issues are that human behaviors and interactions are never static or the same. Measurements and observations can also be repeatedly wrong. Furthermore, researchers have argued that the concept reliability is misleading and has no relevance in qualitative research related to the notion of “measurement method,” as in quantitative studies. 40,42 It is a fact that quantitative research is supported by the positivist or scientific paradigm that regards the world as made up of observable, measurable facts. Qualitative research, on the other hand, produces findings not arrived at by means of statistical procedures or other means of quantification. On the basis of the constructivist paradigm, it is a naturalistic inquiry that seeks to understand phenomena in context-specific settings in which the researcher does not attempt to manipulate the phenomenon of interest. 23 If reliability is used as a criterion in qualitative research, it would mean that the study is “not good.” A thorough description of the entire research process that allows for intersubjectivity is what indicates good quality when using qualitative methodology. Reliability is based on consistency and care in the application of research practices, which are reflected in the visibility of research practices, analysis, and conclusions, reflected in an open account that remains mindful of the partiality and limits of the research findings. 13 Reliability and similar terms are presented in Supplemental Digital Content 2 (see Supplemental Digital Content 2, https://links.lww.com/DCCN/A19 ).

Validity is broadly defined as the state of being well grounded or justifiable, relevant, meaningful, logical, confirming to accepted principles or the quality of being sound, just, and well founded. 8 The issues surrounding the use and nature of the term validity in qualitative research are controversial and many. It is a highly debated topic both in social and educational research and is still often a subject of debate. 43 The traditional criteria for validity find their roots in a positivist tradition, and to an extent, positivism has been defined by a systematic theory of validity. 22 Validity is rooted from empirical conceptions as universal laws, evidence, objectivity, truth, actuality, deduction, reason, fact, and mathematical data, to name only a few. Validity in research is concerned with the accuracy and truthfulness of scientific findings. 44 A valid study should demonstrate what actually exists and is accurate, and a valid instrument or measure should actually measure what it is supposed to measure. 5,22,29,31,42,45

Novice researchers can become easily perplexed in attempting to understand the notion of validity in qualitative inquiry. 44 There is a multiple array of terms similar to validity in the literature, which the authors equate to same such as authenticity, goodness, adequacy, trustworthiness, verisimilitude, credibility, and plausibility. 1,45-51 Validity is not a single, fixed, or universal concept but rather a contingent construct, inescapably grounded in the processes and intentions of particular research methodologies. 39 Some qualitative researchers have argued that the term validity is not applicable to qualitative research and have related it to terms such as quality, rigor, and trustworthiness. 1,13,22,38,42,52-54 I argue that the concepts of reliability and validity are overarching constructs that can be appropriately used in both quantitative and qualitative methodologies. To validate means to investigate, to question, and to theorize, which are all activities to ensure rigor in a qualitative inquiry. For Leininger 25 (1985), the term validity in a qualitative sense means gaining knowledge and understanding of the nature (ie, the meaning, attributes, and characteristics) of the phenomenon under study. A qualitative method seeks for a certain quality that is typical for a phenomenon or that makes the phenomenon different than others.

Some naturalistic inquirers agree that assuring validity is a process whereby ideals are sought through attention to specified criteria, and appropriate techniques are used to address any threats to validity of a naturalistic inquiry. However, other researchers argue that procedures and techniques are not an assurance of validity and will not necessarily produce sound data or credible conclusions. 38,48,55 Thus, some argued that they should abandon the concept of validity and seek alternative criteria with which to judge their work. Criteria are the standards or rules to be upheld as ideals in qualitative research on which a judgment or decisions may be based, 4,56 whereas the techniques are the methods used to diminish identified validity threats. 56 Criteria, for some researchers, are used to test the quality of the research design, whereas for some, they are the goal of the study. There is also the trend to treat standards, goals, and criteria synonymously. I concur with Morse 29 (1999) that introducing parallel terminology and criteria diminishes qualitative inquiry from mainstream science and scientific legitimacy. The development of alternative criteria compromises the issue of rigor. We must work to have a consensus toward criteria and terminology that are used in mainstream science and how it is attained within the qualitative inquiry during the research process rather than at the end of the study. Despite all these, researchers developed validity criteria and techniques during the years. A synthesis of validity criteria development is summarized in Supplemental Digital Content 3 (see Supplemental Digital Content 3, https://links.lww.com/DCCN/A20 ). The techniques for demonstrating validity are presented in Supplemental Digital Content 4 (see Supplemental Digital Content 4, https://links.lww.com/DCCN/A21 ).

Reliability and Validity as Means in Ensuring the Quality of Findings of a Phenomenological Study in Intensive Care Unit

Reliability and validity are 2 factors that any qualitative researcher should be concerned about while designing a study, analyzing results, and judging its quality. Just as the quantitative investigator must attend to the question of how external and internal validity, reliability, and objectivity will be provided for in the design, so must the naturalistic inquirer arrange for credibility, transferability, dependability, and confirmability. 1 Lincoln and Guba 1 (1985) clearly established these 4 criteria as benchmarks for quality based on the identification of 4 aspects of trustworthiness that are relevant to both quantitative and qualitative studies, which are truth value, applicability, consistency, and neutrality. Guba 2 (1981) stated, “It is to these concerns that the criteria must speak.”

Rigor of a naturalistic inquiry such as phenomenology may be operationalized using the criteria of credibility, transferability, dependability, and confirmability. This phenomenological study aimed to understand and illuminate the meaning of the phenomenon of the lived experiences of patients, their family members, and the nurses during critical illness in the intensive care unit (ICU). From Lincoln and Guba 1 (1985), I first asked the question, “How can I persuade my audience that the research findings of my inquiry are worth paying attention to, and worth taking account of?” My answers to these questions were based on the identified 4 criteria set forth by Lincoln and Guba 1 (1985).

Credibility, the accurate and truthful depiction of a participant's lived experience, was achieved in this study through prolonged engagement and persistent observation to learn the context of the phenomenon in which it is embedded and to minimize distortions that might creep into the data. To achieve this, I spent 6 months with nurses, patients, and their families in the ICU to become oriented to the situation and also to build trust and rapport with the participants. Peer debriefing was conducted through meetings and discussions with an expert qualitative researcher to allow for questions and critique of field journals and research activities. Triangulation was achieved by cross-checking the data and interpretations within and across each category of participants by 2 qualitative researchers. Member checks were accomplished by constantly checking data and interpretations with the participants from which data were solicited.

Transferability was enhanced by using purposive sampling method and providing a thick description and a robust data with a wide possible range of information through the detailed and accurate descriptions of the patients, their family members, and the nurses' lived ICU experiences and by continuously returning to the texts. In this study, recruitment of participants and data collection continued until the data are saturated and complete and replicate. According to Morse et al 4 (2002), interviewing additional participants is for the purpose of increasing the scope, adequacy, and appropriateness of the data. I immersed myself into the phenomenon to know, describe, and understand it fully, comprehensively, and thoroughly. Special care was given to the collection, identification, and analysis of all data pertinent to the study. The audiotaped data were meticulously transcribed by a professional transcriber for future scrutiny. During the analysis phase, every attempt was made to document all aspects of the analysis. Analysis in qualitative research refers to the categorization and ordering of information in such a way as to make sense of the data and to writing a final report that is true and accurate. 36 Every effort was made to coordinate methodological and analytical materials. After I categorized and was able to make sense of the transcribed data, all efforts were exhausted to illuminate themes and descriptors as they emerge.

Lincoln and Guba 1 (1985) use “dependability” in qualitative research, which closely corresponds to the notion of “reliability” in quantitative research. Dependability was achieved by having 2 expert qualitative nursing researchers review the transcribed material to validate the themes and descriptors identified. To be able to validate my findings related to the themes, a doctoral-prepared nursing colleague was asked to review some of the transcribed materials. Any new themes and descriptors illuminated by my colleague were acknowledged and considered. It was then compared with my own thematic analysis from the entire participant's transcribed data. If the theme identified by the colleague did not appear in my own thematic analysis, it was agreed by both analysts not to use the said theme. It was my goal that both analysts agree on the findings related to themes and meanings within the transcribed material.

Confirmability was met by maintaining a reflexive journal during the research process to keep notes and document introspections daily that would be beneficial and pertinent during the study. An audit trail also took place to examine the processes whereby data were collected and analyzed and interpretations were made. The audit trail took the form of documentation (the actual interview notes taken) and a running account of the process (my daily field journal). I maintained self-awareness of my role as the sole instrument of this study. After each interview, I retired in 1 private room to document additional perceptions and recollections from the interviews (Supplemental Digital Content 5, https://links.lww.com/DCCN/A22 ).

Through reflexivity and bracketing, I was always on guard of my own biases, assumptions, beliefs, and presuppositions that I might bring to the study but was also aware that complete reduction is not possible. Van Manen 44 (1990) stated that “if we simply try to forget or ignore what we already know, we may find that the presuppositions persistently creep back into our reflections.” During data collection and analysis, I made my orientation and preunderstanding of critical illness and critical care explicit but held them deliberately at bay and bracketed them. Aside from Lincoln and Guba's 1 (1985) 4 criteria for trustworthiness, a question arises as to the reliability of the researcher as the sole instrument of the study.

Reliability related to the researcher as the sole instrument who conducted the data collection and analysis is a limitation of any phenomenological study. The use of humans as instruments is not a new concept. Lincoln and Guba 1 (1985) articulated that humans uniquely qualify as the instrument of choice for naturalistic inquiry. Some of the giants of conventional inquiry have recognized that humans can provide data very nearly as reliable as that produced by “more” objective means. These are formidable characteristics, but they are meaningless if the human instrument is not also trustworthy. However, no human instrument is expected to be perfect. Humans have flaws, and errors could be committed. When Lincoln and Guba 1 (1985) asserted that qualitative methods come more easily to hand when the instrument is a human being, they mean that the human as instrument is inclined toward methods that are extensions of normal activities. They believe that the human will tend therefore toward interviewing, observing, mining available documents and records, taking account of nonverbal cues, and interpreting inadvertent unobtrusive measures. All of which are complex tasks. In addition, one would not expect an individual to function adequately as human instruments without an extensive background or training and experience. This study has reliability in that I have acquired knowledge and the required training for research at a doctoral level with the professional and expert guidance of a mentor. As Lincoln and Guba 1 (1985) said, “Performance can be improved…when that learning is guided by an experienced mentor, remarkable improvements in human instrumental performance can be achieved.” Whereas reliability in quantitative research depends on instrument construction, in qualitative research, the researcher is the instrument of the study. 31 A reliable research is a credible research. Credibility of a qualitative research depends on the ability and effort of the researcher. 22 We have established that a study can be reliable without being valid, but a study cannot be valid without being reliable.

Establishing validity is a major challenge when a qualitative research project is based on a single, cross-sectional, unstructured interview as the basis for data collection. How do I make judgments about the validity of the data? In qualitative research, the validity of the findings is related to the careful recording and continual verification of the data that the researcher undertakes during the investigative practice. If the validity or trustworthiness can be maximized or tested, then more credible and defensible result may lead to generalizability as the structure for both doing and documenting high-quality qualitative research. Therefore, the quality of a research is related to generalizability of the result and thereby to the testing and increasing of the validity or trustworthiness of the research.

One potential threat to validity that researchers need to consider is researcher bias. Researcher bias is frequently an issue because qualitative research is open and less structured than quantitative research. This is because qualitative research tends to be exploratory. Researcher bias tends to result from selective observation and selective recording of information and from allowing one's personal views and perspectives to affect how data are interpreted and how the research is conducted. Therefore, it is very important that the researchers are aware of their own perceptions and opinions because they may taint their research findings and conclusions. I brought all past experiences and knowledge into the study but learned to set aside my own strongly held perceptions, preconceptions, and opinions. I truly listened to the participants to learn their stories, experiences, and meanings.

The key strategy used to understand researcher bias is called reflexivity. Reflexivity means that the researchers actively engage in critical self-reflection about their potential biases and predispositions that they bring to the qualitative study. Through reflexivity, researchers become more self-aware and monitor and attempt to control their biases. Phenomenological researchers can recognize that their interpretation is correct because the reflective process awakens an inner moral impulse. 4,59 I did my best to be always on guard of my own biases, preconceptions, and assumptions that I might bring to this study. Bracketing was also applied.

Husserl 60 (1931) has made some key conceptual elaborations, which led him to assert that an attempt to hold a previous belief about the phenomena under study in suspension to perceive it more clearly is needed in phenomenological research. This technique is called bracketing. Bracketing is another strategy used to control bias. Husserl 60 (1931) explained further that phenomenological reduction is the process of defining the pure essence of a psychological phenomenon. Phenomenological reduction is a process whereby empirical subjectivity is suspended, so that pure consciousness may be defined in its essential and absolute “being.” This is accomplished by a method of bracketing empirical data away from consideration. Bracketing empirical data away from further investigation leaves pure consciousness, pure phenomena, and pure ego as the residue of phenomenological reduction. Husserl 60 (1931) uses the term epoche (Greek word for “a cessation”) to refer to this suspension of judgment regarding the true nature of reality. Bracketed judgment is an epoche or suspension of inquiry, which places in brackets whatever facts belong to essential “being.”

Bracketing was conducted to separate the assumptions and biases from the essences and therefore achieve an understanding of the phenomenon as experienced by the participants of the study. The collected and analyzed data were presented to the participants, and they were asked whether the narrative is accurate and a true reflection of their experience. My interpretation and descriptions of the narratives were presented to the participants to achieve credibility. They were given the opportunity to review the transcripts and modify it if they wished to do so. As I was the one who served as the sole instrument in obtaining data for this phenomenological study, my goal was that my perceptions would reflect the participant's ICU experiences and that the participants would be able to see their lived experience through the researcher's eyes. Because qualitative research designs are flexible and emergent in nature, there will always be study limitations.

Awareness of the limitations of a research study is crucial for researchers. The purpose of this study was to understand the ICU experiences of patients, their family members, and the nurses during critical illness. One limitation of this phenomenological study as a naturalistic inquiry was the inability of the researcher to fully design and provide specific ideas needed for the study. According to Lincoln and Guba 1 (1985), naturalistic studies are virtually impossible to design in any definitive way before the study is actually undertaken. The authors stated:

Designing a naturalistic study means something very different from the traditional notion of “design”—which as often as not meant the specification of a statistical design with its attendant field conditions and controls. Most of the requirements normally laid down for a design statement cannot be met by naturalists because the naturalistic inquiry is largely emergent.

Within the naturalistic paradigm, designs must be emergent rather than preordinate because (1) meaning is determined by context to such a great extent. For this particular study, the phenomenon and context were the experience of critical illness in the ICU; (2) the existence of multiple realities constrains the development of a design based on only 1 (the investigator's) construction; (3) what will be learned at a site is always dependent on the interaction between the investigator and the context, and the interaction is also not fully predictable; and (4) the nature of mutual shapings cannot be known until they are witnessed. These factors underscore the indeterminacy under which naturalistic inquirer functions. The design must therefore be “played by ear”; it must unfold, cascade, and emerge. It does not follow, however, that, because not all of the elements of the design can be prespecified in a naturalistic inquiry, none of them can. Design in the naturalistic sense means planning for certain broad contingencies without however indicating exactly what will be conducted on relation to each. 1

Reliability and validity are such fundamental concepts that should be continually operationalized to meet the conditions of a qualitative inquiry. Morse et al 4,29 (2002) articulated that “by refusing to acknowledge the centrality of reliability and validity in qualitative methods, qualitative methodologists have inadvertently fostered the default notion that qualitative research must therefore be unreliable and invalid, lacking in rigor, and unscientific.” Sparkes 59 (2001) asserted that Morse et al 4,26 (2002) is right in warning us that turning our backs on such fundamental concepts as validity could cost us dearly. This will in turn affect how we mentor novices, early career researchers, and doctoral students in their qualitative research works.

Reliability is inherently integrated and internally needed to attain validity. 1,26 I concur with the use of the term rigor rather than trustworthiness in naturalistic studies. I have also discussed that I accede that strategies for ensuring rigor must be built into the qualitative research process per se rather than evaluated only after the inquiry is conducted. Threats to reliability and validity cannot be actively addressed by using standards and criteria applied at the end of the study. Ensuring rigor must be upheld by the researcher during the investigation rather than the external judges of the completed study. Whether a study is quantitative or qualitative, rigor is a desired goal that is met through the inclusion of different philosophical perspectives inherent in a qualitative inquiry and the strategies that are specific to each methodological approach including the verification techniques to be observed during the research process. It also involves the researcher's creativity, sensitivity, flexibility, and skill in using the verification strategies that determine the reliability and validity of the evolving study.

Lincoln and Guba's 1 (1985) standards of validity demonstrate the necessity and convenience of overarching principles to all qualitative research, yet there is a need for a reconceptualization of criteria of validity in qualitative research. The development of validity criteria in qualitative research poses theoretical issues, not simply technical problems. 60 Whittemore et al 58 (2001) explored the historical development of validity criteria in qualitative research and synthesized the findings that reflect a contemporary reconceptualization of the debate and dialogue that have ensued in the literature during the years. The authors further presented primary (credibility, authenticity, criticality, and integrity) and secondary (explicitness, vividness, creativity, thoroughness, congruence, and sensitivity) validity criteria to be used in the evaluative process. 56 Before the work of Whittemore and colleagues, 58 Creswell and Miller 48 (2000) asserted that the constructivist lens and paradigm choice should guide validity evaluation and procedures from the perspective of the researcher (disconfirming evidence), the study participants (prolonged engagement in the field), and external reviewers/readers (thick, rich description). Morse et al 4 in 2002 presented 6 major evaluation criteria for validity and asserted that they are congruent and are appropriate within the philosophy of the qualitative tradition. These 6 criteria are credibility, confirmability, meaning in context, recurrent patterning, saturation, and transferability. Synthesis of validity criteria is presented in Supplemental Digital Content 3 (see Supplemental Digital Content 3, https://links.lww.com/DCCN/A20 ).

Common validity techniques in qualitative research refer to design consideration, data generation, analytic procedures, and presentation. 56 First is the design consideration. Developing a self-conscious design, the paradigm assumption, the purposeful choice of small sample of informants relevant to the study, and the use of inductive approach are some techniques to be considered. Purposive sampling enhances the transferability of the results. Interpretivist and constructivist inquiry follows an inductive approach that is flexible and emergent in design with some uncertainty and fluidity within the context of the phenomenon of interest 56,58 and not based on a set of determinate rules. 61 The researcher does not work with a priori theory; rather, these are expected to emerge from the inquiry. Data are analyzed inductively from specific, raw units of information to subsuming categories to define questions that can be followed up. 1 Qualitative studies also follow a naturalistic and constructivist paradigm. Creswell and Miller 48 (2000) suggest that the validity is affected by the researchers' perception of validity in the study and their choice of paradigm assumption. Determining fit of paradigm to focus is an essential aspect of a naturalistic inquiry. 1 Paradigms rest on sets of beliefs called axioms. 1 On the basis of the naturalistic axioms, the researcher should ask questions related to multiplicity or complex constructions of the phenomenon, the degree of investigator-phenomenon interaction and the indeterminacy it will introduce into the study, the degree of context dependence, whether values are likely to be crucial to the outcome, and the constraints that may be placed on the researcher by a variety of significant others. 1

Validity during data generation is evaluated through the researcher's ability to articulate data collection decisions, demonstrate prolonged engagement and persistent observation, provide verbatim transcription, and achieve data saturation. 56 Methods are means to collect evidence to support validity, and this refers to the data obtained by considering a context for a purpose. The human instrument operating in an indeterminate situation falls back on techniques such as interview, observation, unobtrusive measures, document and record analysis, and nonverbal cues. 1 Others remarked that rejecting methods or technical procedures as assurance of truth, thus validity of a qualitative study, lies in the skills and sensitivities of the researchers and how they use themselves as a knower and an inquirer. 57,62 The understanding of the phenomenon is valid if the participants are given the opportunity to speak freely according to their own knowledge structures and perceptions. Validity is therefore achieved when using the method of open-ended, unstructured interviews with strategically chosen participants. 42 We also know that a thorough description of the entire research process enabling unconditional intersubjectivity is what indicates good quality when using a qualitative method. This enhances a clearer and better analysis of data.

Analytical procedures are vital in qualitative research. 56 Not very much can be said about data analysis in advance of a qualitative study. 1 Data analysis is not an inclusive phase that can be marked out as occurring at some singular time during the inquiry. 1 It begins from the very first data collection to facilitate the emergent design and grounding of theory. Validity in a study thus is represented by truthfulness of findings after a careful analysis. 56 Consequently, qualitative researchers seek to illuminate and extrapolate findings to similar situations. 22,63 It is a fact that the interpretations of any given social phenomenon may reflect, in part, the biases and prejudices the interpreters bring to the task and the criteria and logic they follow in completing it. 64 In any case, individuals will draw different conclusions to the debate surrounding validity and will make different judgments as a result. 50 There is a wide array of analytic techniques that the qualitative researcher can choose from based on the contextual factors that will help contribute to the decision as to which technique will optimally reflect specific criteria of validity. 65 Presentation of findings is accomplished by providing an audit trail and evidence that support interpretations, acknowledging the researcher's perspective and providing thick descriptions. Morse et al 4 in 2002 set forth strategies for ensuring validity that include investigator responsiveness and verification through methodological coherence, theoretical sampling and sampling adequacy, an active analytic stance, and saturation. The authors further stated that “these strategies, when used appropriately, force the researcher to correct both the direction of the analysis and the development of the study as necessary, thus ensuring reliability and validity of the completed project (p17). Recently in 2015, Morse 28 presented that the strategies for ensuring validity in a qualitative study are prolonged engagement, persistent observation, thick and rich description, negative case analysis, peer review or debriefing, clarifying researcher's bias, member checking, external audits, and triangulation. These strategies can be upheld with the help of an expert mentor who can in turn guide and affect the reliability and validity of early career researchers and doctoral students' qualitative research works. Techniques for demonstrating validity are summarized in Supplemental Digital Content 4 (see Supplemental Digital Content 4, https://links.lww.com/DCCN/A21 ).

Qualitative researchers and students alike must be proactive and take responsibility in ensuring the rigor of a research study. A lot of times, rigor is at the backseat in some researchers and doctoral students' work related to their novice abilities, lack of proper mentorship, and issues with time and funding. Students should conduct projects that are smaller in scope guided by an expert naturalistic inquirer to come up with the product with depth and, at the same time, gain the grounding experience necessary to become an excellent researcher. Attending to rigor throughout the research process will have important ramifications for qualitative inquiry. 4,26

Qualitative research is not intended to be scary or beyond the grasp of novices and doctoral students. Conducting a naturalistic inquiry is an experience of exploration, discovery, description, and understanding of a phenomenon that transcends one's own research journey. Attending to the rigor of qualitative research is a vital part of the investigative process that offers critique and thus further development of the science.

Cited Here |
Google Scholar

Phenomenology; Qualitative research; Reliability; Rigor; Validity

Supplemental Digital Content

DCCN_2017_04_11_CYPRESS_DCCN-D-16-00060_SDC1.pdf; [PDF] (3 KB)
DCCN_2017_04_11_CYPRESS_DCCN-D-16-00060_SDC2.pdf; [PDF] (4 KB)
DCCN_2017_04_11_CYPRESS_DCCN-D-16-00060_SDC3.pdf; [PDF] (78 KB)
DCCN_2017_04_11_CYPRESS_DCCN-D-16-00060_SDC4.pdf; [PDF] (70 KB)
DCCN_2017_04_11_CYPRESS_DCCN-D-16-00060_SDC5.pdf; [PDF] (4 KB)
+ Favorites
View in Gallery

Readers Of this Article Also Read

Family presence during resuscitation: the education needs of critical care..., increasing access to palliative care services in the intensive care unit, educational interventions to improve support for family presence during..., nursing practices and policies related to family presence during resuscitation.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
My Bibliography
Collections
Citation manager

Save citation to file

Email citation, add to collections.

Create a new collection
Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

Search in PubMed
Search in NLM Catalog
Add to Search

Rigor or Reliability and Validity in Qualitative Research: Perspectives, Strategies, Reconceptualization, and Recommendations

Affiliation.

1 Brigitte S. Cypress, EdD, RN, CCRN, is an assistant professor of nursing, Lehman College and The Graduate Center, City University of New York.
PMID: 28570380
DOI: 10.1097/DCC.0000000000000253

PubMed Disclaimer

Related information

Linkout - more resources, full text sources.

Ovid Technologies, Inc.
Wolters Kluwer

Other Literature Sources

scite Smart Citations

Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Articles and blog posts

Validity and reliability in qualitative research.

What is Validity and Reliability in Qualitative research?

In Quantitative research, reliability refers to consistency of certain measurements, and validity – to whether these measurements “measure what they are supposed to measure”. Things are slightly different, however, in Qualitative research.

Reliability in qualitative studies is mostly a matter of “being thorough, careful and honest in carrying out the research” (Robson, 2002: 176). In qualitative interviews, this issue relates to a number of practical aspects of the process of interviewing, including the wording of interview questions, establishing rapport with the interviewees and considering ‘power relationship’ between the interviewer and the participant (e.g. Breakwell, 2000; Cohen et al., 2007; Silverman, 1993).

What seems more relevant when discussing qualitative studies is their validity , which very often is being addressed with regard to three common threats to validity in qualitative studies, namely researcher bias , reactivity and respondent bias (Lincoln and Guba, 1985).

Researcher bias refers to any kind of negative influence of the researcher’s knowledge, or assumptions, of the study, including the influence of his or her assumptions of the design, analysis or, even, sampling strategy. Reactivity , in turn, refers to a possible influence of the researcher himself/herself on the studied situation and people. Respondent bias refers to a situation where respondents do not provide honest responses for any reason, which may include them perceiving a given topic as a threat, or them being willing to ‘please’ the researcher with responses they believe are desirable.

Robson (2002) suggested a number of strategies aimed at addressing these threats to validity, being prolonged involvement , triangulation , peer debriefing , member checking , negative case analysis and keeping an audit trail .

So, what exactly are these strategies and how can you apply them in your research?

Prolonged involvement refers to the length of time of the researcher’s involvement in the study, including involvement with the environment and the studied participants. It may be granted, for example, by the duration of the study, or by the researcher belonging to the studied community (e.g. a student investigating other students’ experiences). Being a member of this community, or even being a friend to your participants (see my blog post on the ethics of researching friends ), may be a great advantage and a factor that both increases the level of trust between you, the researcher, and the participants and the possible threats of reactivity and respondent bias. It may, however, pose a threat in the form of researcher bias that stems from your, and the participants’, possible assumptions of similarity and presuppositions about some shared experiences (thus, for example, they will not say something in the interview because they will assume that both of you know it anyway – this way, you may miss some valuable data for your study).

Triangulation may refer to triangulation of data through utilising different instruments of data collection, methodological triangulation through employing mixed methods approach and theory triangulation through comparing different theories and perspectives with your own developing “theory” or through drawing from a number of different fields of study.

Peer debriefing and support is really an element of your student experience at the university throughout the process of the study. Various opportunities to present and discuss your research at its different stages, either at internally organised events at your university (e.g. student presentations, workshops, etc.) or at external conferences (which I strongly suggest that you start attending) will provide you with valuable feedback, criticism and suggestions for improvement. These events are invaluable in helping you to asses the study from a more objective, and critical, perspective and to recognise and address its limitations. This input, thus, from other people helps to reduce the researcher bias.

Member checking , or testing the emerging findings with the research participants, in order to increase the validity of the findings, may take various forms in your study. It may involve, for example, regular contact with the participants throughout the period of the data collection and analysis and verifying certain interpretations and themes resulting from the analysis of the data (Curtin and Fossey, 2007). As a way of controlling the influence of your knowledge and assumptions on the emerging interpretations, if you are not clear about something a participant had said, or written, you may send him/her a request to verify either what he/she meant or the interpretation you made based on that. Secondly, it is common to have a follow-up, “validation interview” that is, in itself, a tool for validating your findings and verifying whether they could be applied to individual participants (Buchbinder, 2011), in order to determine outlying, or negative, cases and to re-evaluate your understanding of a given concept (see further below). Finally, member checking, in its most commonly adopted form, may be carried out by sending the interview transcripts to the participants and asking them to read them and provide any necessary comments or corrections (Carlson, 2010).

Negative case analysis is a process of analysing ‘cases’, or sets of data collected from a single participant, that do not match the patterns emerging from the rest of the data. Whenever an emerging explanation of a given phenomenon you are investigating does nto seem applicable to one, or a small number, of the participants, you should try to carry out a new line of analysis aimed at understanding the source of this discrepancy. Although you may be tempted to ignore these “cases” in fear of having to do extra work, it should become your habit to explore them in detail, as the strategy of negative case analysis, especially when combined with member checking, is a valuable way of reducing researcher bias.

Finally, the notion of keeping an audit trail refers to monitoring and keeping a record of all the research-related activities and data, including the raw interview and journal data, the audio-recordings, the researcher’s diary (see this post about recommended software for researcher’s diary ) and the coding book.

If you adopt the above strategies skilfully, you are likely to minimize threats to validity of your study. Don’t forget to look at the resources in the reference list, if you would like to read more on this topic!

Breakwell, G. M. (2000). Interviewing. In Breakwell, G.M., Hammond, S. & Fife-Shaw, C. (eds.) Research Methods in Psychology. 2nd Ed. London: Sage. Buchbinder, E. (2011). Beyond Checking: Experiences of the Validation Interview. Qualitative Social Work, 10 (1), 106-122. Carlson, J.A. (2010). Avoiding Traps in Member Checking. The Qualitative Report, 15 (5), 1102-1113. Cohen, L., Manion, L., & Morrison, K. (2007). Research Methods in Education. 6th Ed. London: Routledge. Curtin, M., & Fossey, E. (2007). Appraising the trustworthiness of qualitative studies: Guidelines for occupational therapists. Australian Occupational Therapy Journal, 54, 88-94. Lincoln, Y. S. & Guba, E. G. (1985). Naturalistic Inquiry. Newbury Park, CA: SAGE. Robson, C. (2002). Real world research: a resource for social scientists and practitioner-researchers. Oxford, UK: Blackwell Publishers.

Silverman, D. (1993) Interpreting Qualitative Data. London: Sage.

There is an argument for using your identity and biases to enrich the research (see my recent blog… researcheridentity.wordpress.com) providing that the researcher seeks to fully comprehend their place in the research and is fully open, honest and clear about that in the write up. I have come to see reliability and validity more as a defence of is the research rigorous, thorough and careful therefore is it morally, ethically and accurately defensible?

Hi Nathan, thank you for your comment. I agree that being explicit about your own status and everything that you bring into the study is important – it’s a very similar issue (although seemingly it’s a different topic) to what I discussed in the blog post about grounded theory where I talked about being explicit about the influence of our previous knowledge on the data. I have also experienced this dilemma of “what to do with” my status as simultaneously a “researcher” an “insider” a “friend” and a “fellow Polish migrant” when conducting my PhD study of Polish migrants’ English Language Identity, and came to similar conclusions as the ones you reach in your article – to acknowledge these “multiple identities” and make the best of them.

I have read your blog article and really liked it – would you mind if I shared it on my Facebook page, and linked to it from my blog section on this page?

Please do share my blog by all means; I’d be delighted. Are you on twitter? I’m @Nathan_AHT_EDD I strongly believe that we cannot escape our past, including our multiple/present habitus and identities when it comes to qualitative educational research. It is therefore, arguably, logical to ethically and sensibly embrace it/them to enrich the data. Identities cannot be taken on and off like a coat, they are, “lived as deeply committed personal projects” (Clegg, 2008: p.336) and so if we embrace them we bring a unique insight into the process and have a genuine investment to make the research meaningful and worthy of notice.

Hi Nathan, I don’t have twitter… I know – somehow I still haven’t had time to get to grips with it. I do have Facebook, feel free to find me there. I also started to follow your blog so that I am notified about your content. I agree with what you said here and in your posts, and I like the topic of your blog. This is definitely something that we should pay more attention to when doing research. It would be interesting to talk some time and exchange opinions, as our research interests seem very closely related. Have a good day !

Reliability and Inter-rater Reliability in Qualitative Research: Norms and Guidelines for CSCW and HCI Practice

New Citation Alert added!

This alert has been successfully added and will be sent to:

You will be notified whenever a record that you have chosen has been cited.

To manage your alert preferences, click on the button below.

New Citation Alert!

Please log in to your account

Information & Contributors

Bibliometrics & citations, view options.

Gierhart A Kurt-Peker Y Ray L Wang L (2024) Cybersecurity Education Across the Middle and High School Curricula Inquiries of Pedagogical Shifts and Critical Mindsets Among Educators 10.4018/979-8-3693-1078-6.ch007 (153-179) Online publication date: 8-Mar-2024 https://doi.org/10.4018/979-8-3693-1078-6.ch007
Chang Y Wang Y Tsai H (2024) The Metaverse in Green Building Concept Learning, Creative Design Performance, and Learning Engagement Sustainability 10.3390/su16146264 16 :14 (6264) Online publication date: 22-Jul-2024 https://doi.org/10.3390/su16146264
Wilson D Saraceni J Roche S Pempek J Habing G Proudfoot K Renaud D (2024) How can better calf care be realized on dairy farms? A qualitative interview study of veterinarians and farmers Journal of Dairy Science 10.3168/jds.2023-23703 107 :3 (1694-1706) Online publication date: Mar-2024 https://doi.org/10.3168/jds.2023-23703
Show More Cited By

Index Terms

Human-centered computing

Human computer interaction (HCI)

HCI design and evaluation methods

HCI theory, concepts and models

Recommendations

Applying inter-rater reliability and agreement in collaborative grounded theory studies in software engineering.

The qualitative research on empirical software engineering that uses Grounded Theory is increasing (GT). The trustworthiness, rigor, and transparency of GT qualitative data analysis can benefit, among others, when ...

Qualitative research on empirical SE that uses Grounded Theory (GT) is increasing.

Testing the reliability of inter-rater reliability

Analyses of learning often rely on coded data. One important aspect of coding is establishing reliability. Previous research has shown that the common approach for establishing coding reliability is seriously flawed in that it produces unacceptably high ...

Inter-rater reliability and validity of peer reviews in an interdisciplinary field

Peer review is an integral part of science. Devised to ensure and enhance the quality of scientific work, it is a crucial step that influences the publication of papers, the provision of grants and, as a consequence, the career of scientists. In order ...

Information

Published in.

cover image Proceedings of the ACM on Human-Computer Interaction

Stockholm University, Sweden

Northwestern University, USA

Association for Computing Machinery

New York, NY, United States

Publication History

Permissions, check for updates, author tags.

content analysis
inter-rater reliability
qualitative methods
Research-article

Funding Sources

Contributors, other metrics, bibliometrics, article metrics.

572 Total Citations View Citations
19,963 Total Downloads
Downloads (Last 12 months) 6,917
Downloads (Last 6 weeks) 649
Staehelin D Dolata M Stöckli L Schwabe G (2024) How Patient-generated Data Enhances Patient-Provider Communication in Chronic Care: A Field Study in Design Science Research (Preprint) JMIR Medical Informatics 10.2196/57406 Online publication date: 16-Feb-2024 https://doi.org/10.2196/57406
Albright L Ko W Buvanesh M Haraldsson H Polubriaginof F Kuperman G Levy M Sterling M Dell N Estrin D (2024) Opportunities and Challenges for Augmented Reality in Family Caregiving: Qualitative Video Elicitation Study JMIR Formative Research 10.2196/56916 8 (e56916) Online publication date: 30-May-2024 https://doi.org/10.2196/56916
Wang Y (2024) Understanding Senior Adults’ Needs, Preferences, and Experiences of Commercial Exergames for Health: Usability Study JMIR Serious Games 10.2196/36154 12 (e36154) Online publication date: 5-Apr-2024 https://doi.org/10.2196/36154
Kočišová L (2024) Options, Problems and Guidelines for Measuring Interrater Agreement - a Descriptive Approach Czech Sociological Review 10.13060/csr.2024.007 Online publication date: 6-Jun-2024 https://doi.org/10.13060/csr.2024.007
Gago C De Leon E Mandal S de la Calle F Garcia M Colella D Dapkins I Schoenthaler A (2024) “Hypertension is such a difficult disease to manage”: federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model Implementation Science Communications 10.1186/s43058-024-00587-8 5 :1 Online publication date: 2-May-2024 https://doi.org/10.1186/s43058-024-00587-8
Karas Z Bansal A Zhang Y Li T McMillan C Huang Y (2024) A Tale of Two Comprehensions? Analyzing Student Programmer Attention during Code Summarization ACM Transactions on Software Engineering and Methodology 10.1145/3664808 Online publication date: 15-May-2024 https://dl.acm.org/doi/10.1145/3664808
Kingsley S Silberman M Wang C Lambeth R Zhi J Eslami M Li B Bigham J (2024) ‘Your Duties Are To Sweep A Floor Remotely’: Low Information Quality in Job Advertisements is a Barrier to Low-Income Job-Seekers’ Successful Use of Digital Platforms Proceedings of the 3rd Annual Meeting of the Symposium on Human-Computer Interaction for Work 10.1145/3663384.3663403 (1-20) Online publication date: 25-Jun-2024 https://dl.acm.org/doi/10.1145/3663384.3663403

View options

View or Download as a PDF file.

View online with eReader .

Login options

Check if you have access through your login credentials or your institution to get full access on this article.

Full Access

Share this publication link.

Copying failed.

Share on social media

Affiliations, export citations.

Please download or close your previous search result export first before starting a new bulk export. Preview is not available. By clicking download, a status dialog will open to start the export process. The process may take a few minutes but once it finishes a file will be downloadable from your browser. You may continue to browse the DL while the export process is in progress. Download
Download citation
Copy citation

We are preparing your search results for download ...

We will inform you here when the file is ready.

Your file of search results citations is now ready.

Your search export query has expired. Please try again.

Validity and Reliability in Qualitative Research

Post prepared and written by Joe Tise, PhD, Senior Education Researcher

In this series we have discovered the many ways in which evidence of validity can be produced and ways in which reliable data can be produced. To be sure, the bulk of this series was focused on quantitative research, but any mixed-methods or qualitative researcher will tell you that quantitative research only tells us one piece of the puzzle.

Qualitative research is needed to answer questions not suited for quantitative research, and validity and reliability need to be considered in qualitative research too. Qualitative research includes numerous methodological approaches, such as individual and focus group interviews, naturalistic observations, artifact analysis, and even open-ended survey questions. Unlike quantitative research–which utilizes forms, surveys, tests, institutional data, etc.–in qualitative research, the researcher often is the data collection mechanism and the analysis mechanism.

Researchers usually don’t run a statistical analysis on qualitative data; instead, a researcher typically analyzes the qualitative data, extracts meaning from it, and answers a research question from that meaning. Though this is similar to quantitative research, some of the analysis methods can be viewed as more subjective.

So, how can we know that results obtained from a qualitative analysis reflect some truth, and not the researcher’s personal biases, experiences, or lenses?

Reliability and validity are equally important to consider in qualitative research. Ways to enhance validity in qualitative research include:

Use multiple analysts
Create/maintain audit trails
Conduct member checks
Include positionality statements
Solicit peer review of analytical approach
Triangulate findings via multiple data sources
Search for and discuss negative cases (i.e., those which refute a theme)

Building reliability can include one or more of the following:

Clearly define your codes and criteria for applying them
Use detailed transcriptions which include things like pauses, crosstalk, and non-word verbal expressions
Train coders on a common set of data
Ensure coders are consistent with each other before coding the reset of the data
Periodically reassess interrater agreement/reliability
Use high-quality recording devices

The most well-known measure of qualitative reliability in education research is inter-rater reliability and consensus coding. I want to make a distinction between two common measures of inter-rater reliability: percent agreement and Cohen’s Kappa.

Percent agreement refers to the percentage of coding instances in which two raters assign the same code to a common “piece” of data. Because this is a simple percentage, it’s more intuitive to understand. But it also does not account for chance–in any deductive coding framework (i.e., when all possible codes are already defined), there is a random chance that two coders will apply the same code without actually “seeing” the same thing in the data.

By contrast, Cohen’s Kappa is designed to parse out the influence of chance agreement, and for this reason Cohen’s Kappa will always be smaller than the percent agreement for a given dataset. Many qualitative data analysis software packages (e.g., NVivo) will calculate both percent agreement and Cohen’s Kappa.

In consensus coding, multiple raters code the same data, discuss the codes that may apply, and decide together how to code the data. With consensus coding, the need for inter-rater agreement/reliability metrics is circumvented, because by definition, you will always have 100% agreement/reliability. The major downside of consensus coding is, of course, the time and effort needed to engage it. With large sets of qualitative data, consensus coding may not be feasible.

For a deeper dive into these topics, there are many excellent textbooks that explore the nuances of qualitative validity and reliability. Below, you’ll find a selection of recommended resources, as well as others that provide detailed insights into strengthening qualitative research methods.

Corbin, J., & Strauss, A. (2015). Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory (4th ed.). Sage Publications. Creswell, J. W., & Báez, J. C. (2021). 30 Essential Skills for the Qualitative Researcher (2nd ed.). Sage Publications. Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry and research design: Choosing among five approaches . Sage Publications. Saldaña, J. (2013). An introduction to codes and coding. In The coding manual for qualitative researchers (pp. 1–40). Sage Publications.

Comments are closed

Privacy Overview

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

Knowledge Base

Methodology

Reliability vs. Validity in Research | Difference, Types and Examples

Published on July 3, 2019 by Fiona Middleton . Revised on June 22, 2023.

Reliability and validity are concepts used to evaluate the quality of research. They indicate how well a method , technique. or test measures something. Reliability is about the consistency of a measure, and validity is about the accuracy of a measure.opt

It’s important to consider reliability and validity when you are creating your research design , planning your methods, and writing up your results, especially in quantitative research . Failing to do so can lead to several types of research bias and seriously affect your work.

Reliability vs validity
	Reliability	Validity
What does it tell you?	The extent to which the results can be reproduced when the research is repeated under the same conditions.	The extent to which the results really measure what they are supposed to measure.
How is it assessed?	By checking the consistency of results across time, across different observers, and across parts of the test itself.	By checking how well the results correspond to established theories and other measures of the same concept.
How do they relate?	A reliable measurement is not always valid: the results might be , but they’re not necessarily correct.	A valid measurement is generally reliable: if a test produces accurate results, they should be reproducible.

Understanding reliability vs validity, how are reliability and validity assessed, how to ensure validity and reliability in your research, where to write about reliability and validity in a thesis, other interesting articles.

Reliability and validity are closely related, but they mean different things. A measurement can be reliable without being valid. However, if a measurement is valid, it is usually also reliable.

What is reliability?

Reliability refers to how consistently a method measures something. If the same result can be consistently achieved by using the same methods under the same circumstances, the measurement is considered reliable.

What is validity?

Validity refers to how accurately a method measures what it is intended to measure. If research has high validity, that means it produces results that correspond to real properties, characteristics, and variations in the physical or social world.

High reliability is one indicator that a measurement is valid. If a method is not reliable, it probably isn’t valid.

If the thermometer shows different temperatures each time, even though you have carefully controlled conditions to ensure the sample’s temperature stays the same, the thermometer is probably malfunctioning, and therefore its measurements are not valid.

However, reliability on its own is not enough to ensure validity. Even if a test is reliable, it may not accurately reflect the real situation.

Validity is harder to assess than reliability, but it is even more important. To obtain useful results, the methods you use to collect data must be valid: the research must be measuring what it claims to measure. This ensures that your discussion of the data and the conclusions you draw are also valid.

Receive feedback on language, structure, and formatting

Professional editors proofread and edit your paper by focusing on:

Academic style
Vague sentences
Style consistency

See an example

Reliability can be estimated by comparing different versions of the same measurement. Validity is harder to assess, but it can be estimated by comparing the results to other relevant data or theory. Methods of estimating reliability and validity are usually split up into different types.

Types of reliability

Different types of reliability can be estimated through various statistical methods.


Type of reliability	What does it assess?	Example
	The consistency of a measure : do you get the same results when you repeat the measurement?	A group of participants complete a designed to measure personality traits. If they repeat the questionnaire days, weeks or months apart and give the same answers, this indicates high test-retest reliability.
	The consistency of a measure : do you get the same results when different people conduct the same measurement?	Based on an assessment criteria checklist, five examiners submit substantially different results for the same student project. This indicates that the assessment checklist has low inter-rater reliability (for example, because the criteria are too subjective).
	The consistency of : do you get the same results from different parts of a test that are designed to measure the same thing?	You design a questionnaire to measure self-esteem. If you randomly split the results into two halves, there should be a between the two sets of results. If the two results are very different, this indicates low internal consistency.

Types of validity

The validity of a measurement can be estimated based on three main types of evidence. Each type can be evaluated through expert judgement or statistical methods.


Type of validity	What does it assess?	Example
	The adherence of a measure to of the concept being measured.	A self-esteem questionnaire could be assessed by measuring other traits known or assumed to be related to the concept of self-esteem (such as social skills and ). Strong correlation between the scores for self-esteem and associated traits would indicate high construct validity.
	The extent to which the measurement of the concept being measured.	A test that aims to measure a class of students’ level of Spanish contains reading, writing and speaking components, but no listening component. Experts agree that listening comprehension is an essential aspect of language ability, so the test lacks content validity for measuring the overall level of ability in Spanish.
	The extent to which the result of a measure corresponds to of the same concept.	A is conducted to measure the political opinions of voters in a region. If the results accurately predict the later outcome of an election in that region, this indicates that the survey has high criterion validity.

To assess the validity of a cause-and-effect relationship, you also need to consider internal validity (the design of the experiment ) and external validity (the generalizability of the results).

The reliability and validity of your results depends on creating a strong research design , choosing appropriate methods and samples, and conducting the research carefully and consistently.

Ensuring validity

If you use scores or ratings to measure variations in something (such as psychological traits, levels of ability or physical properties), it’s important that your results reflect the real variations as accurately as possible. Validity should be considered in the very earliest stages of your research, when you decide how you will collect your data.

Choose appropriate methods of measurement

Ensure that your method and measurement technique are high quality and targeted to measure exactly what you want to know. They should be thoroughly researched and based on existing knowledge.

For example, to collect data on a personality trait, you could use a standardized questionnaire that is considered reliable and valid. If you develop your own questionnaire, it should be based on established theory or findings of previous studies, and the questions should be carefully and precisely worded.

Use appropriate sampling methods to select your subjects

To produce valid and generalizable results, clearly define the population you are researching (e.g., people from a specific age range, geographical location, or profession). Ensure that you have enough participants and that they are representative of the population. Failing to do so can lead to sampling bias and selection bias .

Ensuring reliability

Reliability should be considered throughout the data collection process. When you use a tool or technique to collect data, it’s important that the results are precise, stable, and reproducible .

Apply your methods consistently

Plan your method carefully to make sure you carry out the same steps in the same way for each measurement. This is especially important if multiple researchers are involved.

For example, if you are conducting interviews or observations , clearly define how specific behaviors or responses will be counted, and make sure questions are phrased the same way each time. Failing to do so can lead to errors such as omitted variable bias or information bias .

Standardize the conditions of your research

When you collect your data, keep the circumstances as consistent as possible to reduce the influence of external factors that might create variation in the results.

For example, in an experimental setup, make sure all participants are given the same information and tested under the same conditions, preferably in a properly randomized setting. Failing to do so can lead to a placebo effect , Hawthorne effect , or other demand characteristics . If participants can guess the aims or objectives of a study, they may attempt to act in more socially desirable ways.

It’s appropriate to discuss reliability and validity in various sections of your thesis or dissertation or research paper . Showing that you have taken them into account in planning your research and interpreting the results makes your work more credible and trustworthy.

Reliability and validity in a thesis
Section	Discuss
	What have other researchers done to devise and improve methods that are reliable and valid?
	How did you plan your research to ensure reliability and validity of the measures used? This includes the chosen sample set and size, sample preparation, external conditions and measuring techniques.
	If you calculate reliability and validity, state these values alongside your main results.
	This is the moment to talk about how reliable and valid your results actually were. Were they consistent, and did they reflect true values? If not, why not?
	If reliability and validity were a big problem for your findings, it might be helpful to mention this here.

Here's why students love Scribbr's proofreading services

Discover proofreading & editing

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.

Normal distribution
Degrees of freedom
Null hypothesis
Discourse analysis
Control groups
Mixed methods research
Non-probability sampling
Quantitative research
Ecological validity

Research bias

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

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

Middleton, F. (2023, June 22). Reliability vs. Validity in Research | Difference, Types and Examples. Scribbr. Retrieved August 1, 2024, from https://www.scribbr.com/methodology/reliability-vs-validity/

Is this article helpful?

Fiona Middleton

Other students also liked, what is quantitative research | definition, uses & methods, data collection | definition, methods & examples, get unlimited documents corrected.

✔ Free APA citation check included ✔ Unlimited document corrections ✔ Specialized in correcting academic texts

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

Advanced Search
Journal List
Neurol Res Pract

How to use and assess qualitative research methods

Loraine busetto.

1 Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

Wolfgang Wick

2 Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany

Christoph Gumbinger

Associated data.

Not applicable.

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 – 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 – 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.

An external file that holds a picture, illustration, etc.
Object name is 42466_2020_59_Fig1_HTML.jpg

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 .

An external file that holds a picture, illustration, etc.
Object name is 42466_2020_59_Fig2_HTML.jpg

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 ].

An external file that holds a picture, illustration, etc.
Object name is 42466_2020_59_Fig3_HTML.jpg

From data collection to data analysis

Attributions for icons: see Fig. Fig.2, 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 – 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 .

An external file that holds a picture, illustration, etc.
Object name is 42466_2020_59_Fig4_HTML.jpg

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 – 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 – 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 Table1. 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.

Take-away-points


• Assessing complex multi-component interventions or systems (of change) • What works for whom when, how and why? • Focussing on intervention improvement	• Document study • Observations (participant or non-participant) • Interviews (especially semi-structured) • Focus groups	• Transcription of audio-recordings and field notes into transcripts and protocols • Coding of protocols • Using qualitative data management software

• Combinations of quantitative and/or qualitative methods, e.g.: • : quali and quanti in parallel • : quanti followed by quali • : quali followed by quanti	• Checklists • Reflexivity • Sampling strategies • Piloting • Co-coding • Member checking • Stakeholder involvement	• Protocol adherence • Sample size • Randomization • Interrater reliability, variability and other “objectivity checks” • Not being quantitative research

Acknowledgements

Abbreviations.

EVT	Endovascular treatment
RCT	Randomised Controlled Trial
SOP	Standard Operating Procedure
SRQR	Standards for Reporting Qualitative Research

Authors’ contributions

LB drafted the manuscript; WW and CG revised the manuscript; all authors approved the final versions.

no external funding.

Availability of data and materials

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Search Menu
Sign in through your institution
Advance articles
Editor's Choice
Author Guidelines
Submission Site
Open Access
About The British Journal of Social Work
About the British Association of Social Workers
Editorial Board
Advertising and Corporate Services
Journals Career Network
Self-Archiving Policy
Dispatch Dates
Journals on Oxford Academic
Books on Oxford Academic

Article Contents

Introduction, materials and methods, study strengths and limitations, supplementary material, author contributions, post-disaster social connectedness in parent–child dyads: a qualitative investigation of changes in coping and social capital of rural australian families following bushfires.

Article contents
Figures & tables
Supplementary Data

Lisa Stribley, Govind Krishnamoorthy, Vicki Dallinger, Jennifer Ma, Thomas Nielson, India Bryce, Bronwyn Rees, Alyssa Morse, Marg Rogers, Lorelle Burton, Post-Disaster Social Connectedness in Parent–Child Dyads: A Qualitative Investigation of Changes in Coping and Social Capital of Rural Australian Families Following Bushfires, The British Journal of Social Work , 2024;, bcae123, https://doi.org/10.1093/bjsw/bcae123

Permissions Icon Permissions

The increasing frequency of natural disasters, such as bushfires, pose significant challenges for countries like Australia. This research investigates the changes in social connectedness following a bushfire disaster in 2019 in the rural community of Cudlee Creek, South Australia, Australia. Research has repeatedly highlighted the importance of social connectedness, social capital and secure attachment relationships in mitigating post-disaster mental health concerns. This study utilised semi-structured interviews with eight parent–child dyads twenty months post-disaster to understand changes in parent–child relationships, the quality of extended family ties and the role of the broader community in recovery and coping. Reflexive thematic analysis revealed three themes: (i) differences in children and parents in preferred forms of social support; (ii) a thinning of previously available support and (iii) altered patterns of communication in the parent–child relationships. The findings highlight the complex interactions of multi-systemic and intersectional disadvantages on social isolation and loss of social capital following disasters. The results also highlight the influence of stoic beliefs on patterns of miscommunication in parent–child dyads in rural contexts. Implications for the implementation of community-wide post-disaster supports, sociometric approaches to mental health screening and assessment, and targeted interventions for rural families.

Bushfires (or wildfires) pose an immediate threat of death and injury and cause extensive destruction of homes and workplaces. In addition, bushfires are a source of stress and trauma for individuals, particularly children and their families, with the potential of long-lasting repercussions on their mental health and well-being ( Krishnamoorthy et al. , 2020a , b ). Such were the challenges faced by residents of the rural Australian town of Cudlee Creek. The town faced a catastrophic bushfire in December 2019, resulting in substantial property damage, loss of livelihoods and wildlife destruction ( Local Recovery Team, 2020 ). The fire threatened townships, destroying vineyards and orchards, and killing wildlife and stock. The fire burnt 23,253 hectares, destroyed ninety-eight homes and damaged fifty-six homes, and either destroyed or extensively damaged 542 outbuildings ( Local Recovery Team, 2020 ).

Meta-analytic research has found that the pooled prevalence of psychological distress in the Australian general population (fifteen or more years of age) at two to three years post-bushfire is 14% ( Zhang et al. , 2022 ). Research has found an increased prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) in affected populations ( North, 2016 ). The psychosocial factors that contribute to coping and post-disaster recovery are complex and multifaceted, often entwining elements such as the severity of the disaster, social and cultural context, individual attributes and pre-existing social supports and psychological resources ( Tausczik et al. , 2012 ).

Among these factors, social connectedness, defined as the sense of belonging and the social support provided by family, friends and the broader community, has been identified as a vital protective factor in mitigating the adverse effects of natural disasters ( Cacioppo and Patrick, 2008 ). Disaster experiences are often conflictingly, characterised by an initial outpouring and mobilisation of received social support and aid followed by a profound loss of perceived social support and community ( Kaniasty, 2020 ). Understanding the influence of natural disasters on social relationships requires further investigation into the interplay of intrapersonal, interpersonal and community-based factors that contribute to the protection and promotion of long-term mental health post-disaster.

The importance of social connectedness for families in a post-disaster context can be understood through social capital theory (SCT). SCT refers to the resources individuals and communities can access through their social networks. Relationships in SCT are categorised into bonding, linking and bridging social capital ( Aldrich, 2012 ). Bonding social capital refers to the strong ties between individuals who share similar characteristics, such as family members or close friends. Linking social capital refers to the connections between individuals who are not necessarily similar, such as relationships between employers and employees. Bridging social capital refers to the relationships between individuals from different social groups, such as people from different ethnic or socioeconomic backgrounds ( Aldrich, 2012 ). Social capital plays a crucial role in disaster risk management, including providing food, initiating debris removal, providing childcare, financial aid and immediate psychological support. Natural disasters have the potential to decrease social capital, as individual members, families and communities’ networks get disconnected or weakened ( Choo and Yoon, 2022 ).

For children, arguably the most important source of support in post-disaster contexts may lie in their relationships with their parents and caregivers. Attachment theory, introduced by Bowlby (1969) , posits that individuals have an inherent need to form strong emotional bonds with caregivers, which serve as a foundation for psychological development and social relationships. Secure attachments are formed when caregivers are consistently responsive and available, fostering an environment of safety and reliability. Secure attachments are shown to buffer against the psychological impacts of disasters by promoting emotional regulation, and the ability to seek and utilise support effectively ( Sroufe et al. , 2005 ). Insecure attachments, on the other hand, arise from inconsistent or unresponsive caregiving, leading to feelings of uncertainty and worthlessness ( Bowlby, 1969 ). Insecure attachments can exacerbate vulnerability to stress and trauma, highlighting the importance of nurturing secure relationships for disaster recovery ( O’Connor and Elklit, 2008 ).

Research indicates that there may be variations in the perceptions of social support within family units, between children and their parents or caregivers in a post-disaster context ( Wisner, 2016 ). Parents and guardians often prioritise their role as caregivers, while children emphasise the importance of peer relationships and emotional support from friends ( Rothi and Leavey, 2006 ). These contrasting perceptions are often influenced by shifts in the parent–child relationship in the wake of natural disasters, where parents may experience increased stress, emotional distress and compromised ability to address their children’s additional needs for emotional support and reassurance ( Cobham and McDermott, 2014 ). While it has been established that social connectedness has positive effects on the physical ( Drukker et al. , 2005 ) and mental wellbeing of adults and children more broadly, there is a need to discern how changes in the parent–child relationship following natural disasters may affect familial coping mechanisms and the development of social connectedness and resilience in children. Research highlights the complex interplay between children’s perceptions of threat, family support systems and community cohesion in mitigating the impact of disasters on family functioning. These studies collectively advocate for a child-centred approach and the need to further understand children’s subjective experiences in affected families ( Peek et al. , 2010 ).

Furthermore, there have been calls for more comprehensive approaches to disaster support that address the needs of children and parents in ways tailored to the specific contexts of disaster-affected communities ( Van Beek and Patulny, 2022 ). For instance, living in a remote or rural location is a significant risk factor for social isolation and loneliness ( L’Heurex et al. , 2020 ). Rural communities face unique challenges in accessing support services due to geographic isolation, limited access to transportation and a lack of resources and infrastructure ( Kapucu et al. , 2013 ). Understanding the dynamics of social connectedness in rural families post-disaster will support the development of tailored interventions and social services that respond appropriately to the specific social connectedness, resilience and wellbeing needs of children and their families.

Summary and research context

The potential, long-term negative impact of natural disasters on children’s mental health is well documented ( Masten and Narayan, 2012 ). However, research on post-disaster resilience and recovery in children is limited, primarily due to the complex interplay between family relationships, peer interaction, school environments, community support and developmental processes. Studies have predominantly employed quantitative methodologies, focusing on the clinical implications associated with natural disasters and PTSD ( Le Roux and Cobham, 2021 ). Few studies have explored the critical dyad of parent–child relationships in these contexts, which may confer a unique source of social connectedness or conflict in managing mental health and resilience outcomes following disaster experiences ( Norris et al. , 2002 ).

Qualitative methods are ideally placed to investigate the relational dynamics in parent–child dyads as they can provide a rich, textured understanding of participants’ lived experiences, meanings, interpretations and subjective experiences. Australia is a bushfire-prone country, and bushfire risk (and its management) regularly form part of the national crisis response ( Australian Broadcasting Corporation, 2020 ). Cudlee Creek, an area with mixed horticultural properties, hobby farms and rural lifestyle blocks. The town has a population of 425 residents in 2021 ( ABS, 2022 )—with over 300 residents moving out of the area after the bushfire. The participants of the study were caregiver–child dyads that continued to live in the area following the bushfires.

Research aims

The study aimed to (i) map the similarities and differences in social connectedness and coping between children and parents impacted by the bushfires; and (ii) compare the relative influence of social connectedness on coping and mental health post-disaster for children and parents.

Study design

The University of Southern Queensland Human Research Ethics Committee (Ethics approval number: H21REA030) granted the study ethical approval. To explore the influence of social connectedness on post-bushfire recovery, potential participants needed to meet the following eligibility criteria: (i) they were between five and seventeen years old at the time of the fires and, (ii) they were affected by the bushfires through property damage or (iii) their family property was within 500 m of the fire impact zone.

Participants were recruited through five local schools’ communication platforms in the fire zone, word-of-mouth referrals, and a parent Facebook group. The South Australian Department for Education and five school principals provided permission to source participants for the study. To minimise burdens on the schools, permission for the recruitment and interviewing of participants was obtained for three months (i.e. one school term). Detailed informed consent was obtained from each child and their parent before participation and interview recording. Participants were informed of local mental health services and supports. Eight parent–child dyads participated, with one family providing two sibling participants. All the parents interviewed identified as women and were the biological mothers of the children in the dyads. Eight child participants (three girls and five boys) were interviewed. The average age of the children was 10.4 years (range = nine to twelve years).

All the dyads had experienced: fire damage to the fencing in their family homes due to the fires; children evacuated during the fires, and at least one family member remained in the fire zone after children were evacuated to put out spot fires and protect the family home. One dyad experienced the loss of their family home due to the bushfire, and four dyads had other extended family members also impacted by the bushfires. The data collection took place approximately twenty to twenty-three months post-event, allowing time for participants to reflect on the longer-term impacts of the bushfire. Despite the relatively small number of dyads, the data collected provided rich, in-depth data on the experiences of the families who remained in the community post-bushfire. The interviews yielded detailed accounts of participants’ experiences, allowing for meaningful analysis to address the study aims.

An interview guide consisting of open and close-ended questions directed the interviews ( Supplementary Appendix ). All the interviews were transcribed manually by the first author (L.S.) into Microsoft Word. A parent or a nominated adult was present for the child interviews to provide support if required. None of the children opted to have their parents assist them in the interviews and opted to not have them in the room during the data collection process. Arts-based interview questions were utilised to engage the children in a developmentally appropriate manner (e.g. can draw a picture for me of yourself before the bushfire?). Interview questions focused on the child’s mental health and functioning following the bushfires and social connectedness. Similarly, parent interviews focused on perceptions of their child and family’s mental state and coping before and after the bushfires and changes in social connectedness for the family. The average duration of the child interviews was seventeen minutes (range = 13–30 min), and of the parent interviews was thirteen minutes (range = 20–44 min).

Data analysis

The data were analysed using thematic and content analysis, applying the COREQ checklist ( Tong et al. , 2007 ) and employing a mix of deductive and inductive analysis ( Braun and Clarke, 2021 ). Pre-defined codes were developed based on key concepts from social capital theory (e.g. bonding, bridging and linking social capital; Aldrich, 2012 ) and attachment theory (e.g. secure and insecure attachment patterns; Bowlby, 2008 ). The inductive analysis allowed for identification of unexpected patterns in the data. Findings from the cycles of analysis were combined by comparing the strength of supporting evidence between the two coders (L.S. and G.K.). Final themes reflect a combination of theoretical concepts and researchers’ interpretations of emergent patterns.

Three themes were identified from the data ( Table 1 ). All themes are supported by quotes from child and parent interviews to demonstrate the influence of social connectedness in the recovery of children and parents following a bushfire natural disaster. Identifying information has been redacted from the quotes to minimise the risk of members of the small rural community being identifiable. Parent and child quotes corresponding to each dyad are presented together in each section.

Themes corresponding to intra-dyad and inter-dyad comparisons.

Themes .	Theme description .
Differences in available and preferred supports
Thinning of social support networks.
Altered patterns of parent–child communication

Themes .	Theme description .
Differences in available and preferred supports
Thinning of social support networks.
Altered patterns of parent–child communication

Differences in available and preferred supports

We’re quite social, so have other families come or you know, we’ll, you know, socialise with other people. Quite sporty, involved with quite a few different sporting clubs (Child from Dyad 3) We had a lot of support, a lot of support from friends. People we have known for a long time…it definitely made a difference (Parent from Dyad 3).

We didn’t know many people, so it was hard to find help when the bushfires happened (Child from Dyad 4) My neighbours aren’t particularly connected with us… We moved here from the city for a less stressful and complicated life.less expenses and stress. The bushfires changed all that. I was away from my friends and family…and everything after [the bushfires] we needed seemed to be in the city…it’s been harder for us since (Parent from Dyad 4)

The quotes highlight the impact of social isolation, intersectional disadvantage and cumulative burdens experienced by members of rural communities’ post-disaster. The excerpt also illustrates how marginalised families often resort to engaging with urban centres to access the required infrastructure and supports required post-disaster.

We talked to Mum and my brothers (Child from Dyad 8). she’s pretty good at talking, so she will let you know how she’s feeling and if she’s upset or whatever (Parent from Dyad 8).

I kind of just talked to my friends online. And then seeing them at school…that was good to hang out (Child from Dyad 6). It was the fact that he was online on his headset actually talking to his friends. It helped a lot, gave a lot of distraction too (Parent from Dyad 6).

… Fire Support were our immediate source of support in our area, quite literally on the ground, and I’m forever grateful to those amazing people who just turned up and asked what we needed and seemed to just make it happen (Parent from Dyad 3).

Going away to …Beach for a short holiday allowed us to leave behind the stress of the disaster, focusing instead on each other. (Parent from Dyad 4) It was a nice break from the bushfire. (Child from Dyad 4)

Thinning of social support networks

The cumulative loss reverberated through these networks, leading to a discernible ‘thinning’ of available support. Within rural communities affected by bushfires, it was observed that the immediate recovery efforts substantially decreased the availability of pragmatic support from family and friends. The focus on securing disaster recovery grants and other government supports and services interfered with time previously allocated to spending time with loved ones. The process of accessing post-disaster support also emerged as a complex concern.

‘It was very stressful, and it went on for most of the year….I’m the director of my Mum and Dad farm so I, I was getting grants for them. I didn’t have time for much else to be honest’ (Parent from Dyad 1). ‘Sometimes at school…when it’s fun or whatever. I feel bad…I think I should be helping my parents at home with things’ (Child from Dyad 1).

I was lucky that I could send my child off to my sister’s house and so she [daughter] was sort of out of the picture. I know lots of other people who couldn’t do that. I just had too much to do and I didn’t want to worry about her [daughter]. I know she needed me but I had so much to get on top of (Parent from Dyad 5). [At my aunt’s home] They always talk about it….every time we went up to the rental they talked about [loss from the bushfires] and then it just, I had to go out the room sometimes (Child from Dyad 5)

they’re like, oh, you’re fine .because your property didn’t burn down like your house didn’t burn down, your shed didn’t burn down, you didn’t lose any livestock (Child from Dyad 2) I think the biggest problem was that they just didn’t have, like, they hadn’t experienced it themselves, they were quite distant from it, and it was just hard for them to understand (Parent from Dyad 2)

…. people don’t complain about this sort of thing. You just deal with it, you know. Everyone just gets on with it, and you’ll deal with it …you fix it and you’ll sort it and you’ll move on. People are proud and don’t ask for help (Parent from Dyad 6). …I always feel like it wasn’t so bad for us. Like we know so many families… need more help than us…but they are ok. So you don’t want to carry on [complain] too much (Child from Dyad 6)

.effects of the bushfire, go on for so long…everyone …is still dealing with it a year later, like whether it be the stress, the financial stress the, we still don’t have a home stress we’re still rebuilding back. My parents’ fences only just got built…. There is no time to stop and think about everything we lost or could have lost.. Honestly thought Dad was gonna die [in the bushfires]. I really did. He still has a really weak heart. A lot of heart problems. But he didn’t die…but there’s no time for that. Everyone is busy trying to get their life back, so you carry on (Parent from Dyad 4)

Altered patterns of parent–child communication

its been like two years…we are a bit tuned in to the weather…checking about for the rain, like we had after the fires…I’m also more tuned in to how they are going, like the mental impact of looking at black [burnt trees and landscape] all the time…I guess its just trying to protect my family from all of it’ (Parent from Dyad 3) ‘We had to go to grandma’s [birthday] in [another Australian state], and I could tell everybody was nervous about leaving…mum was starting to get stressed, so I was trying to help. I can tell now when its starting to get like that…’ (Child from Dyad 3)

I was pretty chill with the fires…. I found it more entertaining and fun than it being a big disaster, which it very much was. (Child from Dyad 5) all this time that he’s been saying I wasn’t really affected by it, umm, truthfully, he didn’t react in any big way…. But after that, he stopped watching David Attenborough, and he’s always been really environmentally concerned…. He still hasn’t been back to the park. Won’t go there. (Parent from Dyad 5).

He won’t open up to me about these things… It’s his way of coping is to keep the atmosphere really calm… I think he needs everyone around him calm. And if he tells me he thinks …maybe I won’t be calm and I will get stressed… it’s hard. I know the more I ask and push, the more he will shut down’ (Parent from Dyad 1) ‘Felt sad for…. couple months. Then I had, like, anxiety over sleeping in my own room for months, like ages. Yes. That. I don’t know why I was just like that. And I didn’t want to talk about it because I didn’t know why…it was annoying when they were asking me about it because they were make me feel like a problem …like I’m a wuss and weak… I didn’t want to make it a thing for everyone to be worried about’ (Child from Dyad 1)

As illustrated in the quotes, dyads described a cycle of approach and withdrawal in their parent–child relationships. Parents spoke of difficulties understanding their children’s emotional needs, leading to increased vigilance for signs of distress. Children, primarily boys from four of the dyads, perceived this increased vigilance as intrusive, causing them to withdraw further and mask their emotional needs. This cycle seemed to lead to feelings of helplessness in parents and conflict in parent–child dyads.

I think we, we talk better. As in we talked before, but I think….a relationship that’s more even (Child from Dyad 5) I certainly feel like our relationship between the three of us is a little more, umm, as friends more, less like ‘I’m the adult decision maker, and you’re just the kids (Parent from Dyad 5)

We just felt so grateful. That probably is a keyword as well. Grateful that we you know that [husband] was safe after fighting the fires on Kangaroo Island. It’s the small things, but you realise how fragile life is.your kids, the house, our farm… you know we are so grateful for all that stuff (Parent from Dyad 2) Lots of things have changed.like Christmas and Easter…but we still got the TV, still got [gifts]. Still have my family. (Child from Dyad 2)

Climate change predictions highlight the increased risk of substantial storm, flood and drought events ( Cleugh et al. , 2011 ) and increased severity and frequency of catastrophic bushfires (Australian Academy of Science, 2015). This study aimed to investigate changes in social connectedness in parent–child dyads following a bushfire event. The findings of this study are consistent with the social capital theory ( Aldrich, 2012 ) and with the extant literature on the relationship between social connectedness in adults and positive mental health outcomes (Bryant et al. , 2017). The ‘recovery advantage’ to those with stronger pre-bushfire social connections was evident in the narratives of this study. Overall, our findings align with previous research on family functioning post-disaster. For example, Pujadas et al. (2013) found similar patterns of family communication in their study of nineteen families after the 2011 Slave Lake wildfires. They found families focused on emotional support, community involvement and positive reframing to cope with the disaster’s aftermath and foster resilience (Pujadas et al. , 2013).

Several participants described challenges related to social isolation, socioeconomic difficulties or being new to the community. While not systematically assessed across all participants, these factors appeared to influence post-disaster experiences for several families in the study. The disadvantage experienced by those who were more socially isolated seemed to interact with other domains of inequality and marginalisation, such as socioeconomic difficulties. Further research is needed to more comprehensively examine how various forms of marginalisation may impact social connectedness and disaster recovery in rural communities (e.g. Fraser and Blake, 2020 ) and innovative methods to promote the social capital of these families is warranted.

The findings provide preliminary support for the notion that parents from both socially isolated and connected dyads may prefer more bridging social capital in the form of relationships across the community. They highlighted the benefits of community events in making links with other community members while also providing them with a respite from post-disaster recovery stressors. Reports of limited bridging capital amongst the families in this study may reflect the paucity of access to local community-based organisations in rural regions of Australia ( AIHW, 2022 ).

The study’s findings of children’s preferences for contact with friends and peers in the school setting highlight the importance of considering developmental differences in post-disaster support. Schools constitute a significant community structure for children and relate to a broad range of child-specific services and referral agencies. They embody structure, safety and social connections, which are vital for positive post-disaster outcomes and resilience ( Ayre and Krishnamoorthy, 2020 ; McDonald-Harker et al. , 2021 ). Schools are well placed to facilitate engagement with social resources and trauma-informed support ( Mutch, 2015 ; Schimke et al. , 2022 ) and provide access to multi-disciplinary care post-disaster ( Curtin et al. , 2020 ; Krishnamoorthy and Ayre, 2021 ). Children, families and staff in school communities can offer input into screening and assessment processes and assist in providing information to families ( Bellamy et al. , 2022 ; Bowyer et al. , 2023 ). Allowing integrated services within schools improves access to services for overburdened parents.

Changes in the parent–child relationships post-disaster appear to be characterised by a cycle of hyper-attunement and masking/withholding for fears of being burdensome. Research on such patterns of hyper-attunement in parents could be understood as a mechanism by which parents seek to limit their distress and that of their child and to keep their child mentally safe and healthy ( Williamson et al. , 2017 ). Studies have also linked this hypervigilance to parental beliefs about their children being ‘permanently damaged’, leading to a heightened sense of future danger, preoccupation with child’s vulnerability and ruminations about traumatic stress reactions in their children ( Hiller et al. , 2018 ). While it is important to note that no assessments of parent–child attachment were undertaken in this this study, previous research highlights that parents exhibiting insecure attachment styles may face challenges in their reflective functioning (RF) capabilities ( Fonagy et al. , 2002 ; Krishnamoorthy et al. , 2020a , b ).

RF relates to the ability of adults to think about their personal and their child’s mental states, as well as the influence of these states on their parent–child relationship ( Fonagy et al. , 2002 ). It is noteworthy to mention that a specific dimension of RF termed ‘hyper-mentalisation’ is characterised by an over-attribution (or misattribution) of mental states, occasionally incommensurate with the observable cues in the child’s behaviour ( Sharp et al. , 2011 ). Specifically, misalignment in ascribing accurate emotional states in children may inadvertently perpetuate destabilising interactions—such as the approach-withdrawal patterns identified in the findings. Although scant literature addresses hyper-mentalisation post-bushfires and no assessments of RF or mentalisation were conducted in the study, further research is warranted to explore the relationship between these constructs in a post-disaster context.

The difficulties in accurately mentalising children’s needs may be related to the limited communication between some dyads of emotional reactions and needs. This was linked to the endorsement of a stoic coping style, concerns about burdensomeness and pride in self-reliance during post-disaster recovery. Previous research has highlighted the role of stoicism and self-reliance as significant factors influencing help-seeking in men in post-disaster contexts (e.g. Whittaker, 2019 ). In this study, there appears to be evidence to suggest the presence of such attitudes in the interviews of caregivers. While the research suggests the prevalence of such attitudes in regional and rural communities in Australia ( Whitaker, 2019 ), more targeted research in the Cuddlee Creek community may need to be conducted to confirm such beliefs and copings styles.

While this study did not include assessments of post-traumatic stress within the dyads, a large body of literature confirms the substantial negative influence of parent post-traumatic stress symptoms on children’s coping ( Afzal et al. , 2023 ; Miko et al. , 2023 ). Such findings have prompted scholars to recommend a focus on reducing parents’ post-traumatic stress symptoms & distress and bolster their coping to enable them to be more emotionally available and appropriately attuned to the needs of their children. A family-focused screening approach for mental health may allow the detection of psychological concerns in both children and their parents—particularly in cases where anxious parents are seeking support for their children’s mental health. In the context of the present research, the access to social capital, and sense of social connectedness of the families may have been mitigated by parent mental health concerns ( Afzal et al. , 2023 ). Further investigations of these issues in the context of post-disaster rural and regional areas are warranted.

Given the growing prevalence of mental health concerns in children and adolescents ( Lu et al. , 2022 ), the findings of this study hold important implications for social work practice in a post-disaster context to mitigate child mental health concerns and promote family coping. Guidance on preventative practice—including positive parenting practices that encourage supportive and developmentally appropriate communication and limits on children’s exposure to disaster-related information ( Phoenix Australia Centre for Post-traumatic Health, 2013 ; Dallinger et al. , 2022 ). Social workers are well placed to personalise such guidance by incorporating the influence of multi-systemic factors on families in rural areas—such as the challenges related to the bushfires including financial strain and increased familial conflict ( Taylor and Goodman, 2015 ). Social work responses to supporting parents and children may need to also consider those with clinical levels of post-traumatic stress and other mental health concerns. Research has shown that universal screening of children in schools in post-disaster areas can inform a stepped-care approach to providing varying levels of mental health support for children and their families ( McDermott and Cobham, 2014 ). The implementation of such stepped-care practices will likely require a systematic approach to understanding the specific and idiosyncratic needs of rural centres—including key assets and resources that can be mobilised in post-disaster contexts ( McDermott, 2014 ).

The qualitative nature of this study both enhances its richness and introduces limitations. By prioritising children’s autonomy and personal experiences within the context of natural disasters, the research provides nuanced insights into the parent–child dyadic post-disaster social connectedness after an Australian bushfire. This approach, however, relies on self-reported accounts, potentially missing the objective assessment of actual behaviours and receipt of support. While the study captures the essence of children’s experiences, it acknowledges limitations in the depth of their qualitative responses. In addition, given the timing of the interviews (twenty to twenty-three months after the bushfire), and the traumatic nature of the events, it is possible that recollection abilities of parents and children may have been impacted. This may constrain the comprehensive understanding of their emotional and social dynamics post-disaster. Moreover, the study’s focus exclusively on bushfire events restricts the generalisability of findings to other types of natural disasters, each entailing distinct challenges and support mechanisms. Another dimension lies in the diverse interpretations of social connection, evident in the differentiation between parents and children. This variability in perspectives challenges the alignment of findings with established theoretical models. The study thus underscores the complexity of post-disaster social connectedness and highlights potential discrepancies between lived experience and theoretical constructs.

This study investigated the effect of dyadic social connectedness on the recovery of children and parents in the aftermath of bushfires in a rural community in Australia. The results revealed the complex multi-systemic influences on the impact of the bushfires on the social capital of families and the attachment relationship between children and their parents. Among the identified differences, parents often tended to seek community-level support, while children found solace in family and friends. These differences were consistent with prior research and hold important implications for influence on community-wide recovery-oriented events and school-based supports for rural families that are isolated or have less available social support. Patterns of insecure attachment and communication—characterised by the cycle of limited emotional communication, fears of being burdensome and hypervigilance for the mental state of others—is a novel finding. Given the prevalence of stoic and self-reliance attitudes among rural communities, this finding holds important implications for the design of screening and intervention programmes aimed at promoting post-disaster mental health and well-being in families. With evidence of increasing frequencies of natural disasters like bushfires, the present research highlights the importance of adopting sociometric planning, assessment and monitoring approaches to disaster resilience and recovery and the need to continually honour and understand the lived experiences of children and their families impacted by natural disasters.

Supplementary material is available at British Journal of Social Work Journal online.

Data collection and analysis were performed by L.B. and G.K. The first draft of the manuscript was written by V.D., G.K. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Conflict of interest statement : The authors have no other competing interests to declare that are relevant to the content of this article.

No funds, grants or other support was received.

Afzal M. , Pang D. , Luo J. , Zhao S. ( 2023 ) ‘ The impact of parental post-traumatic stress on children’s mental health outcomes: A systematic review and meta-analysis ’, Journal of Affective Disorders , 320 , pp. 211 – 23 .

Google Scholar

Aldrich D. P. ( 2012 ) Building Resilience: Social Capital in Post-Disaster Recovery , Chicago , University of Chicago Press .

Google Preview

Australian Broadcasting Corporation . ( 2020 ) ‘Calls to Lifeline up 10 Per Cent in Bushfire Crisis’, available online at: https://www.abc.net.au/triplej/programs/hack/calls-to-lifeline-up-10-per-cent-in-bushfire-crisis/11877844 (accessed December 18, 2022).

Australian Bureau of Statistics . ( 2022 ) Cudlee Creek (Suburb and Locality) , Canberra, Australia , Australian Census 2021 QuickStats . https://www.abs.gov.au (accessed December 2022).

Australian Institute of Health and Welfare . ( 2022 ) ‘Rural and Remote Health’, AIHW, available online at: https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health (accessed December 20, 2022).

Ayre K. , Krishnamoorthy G. ( 2020 ) Trauma-Informed Behaviour Support: A Practical Guide to Developing Resilient Learners , Queensland, Australia , University of Southern Queensland . https://usq.pressbooks.pub/traumainformedpractice/accessed December 2022.

Bellamy T. , Krishnamoorthy G. , Ayre K. , Berger E. , Machin T. , Rees B. E. ( 2022 ) ‘ Trauma-informed school programming: A partnership approach to culturally responsive behaviour support ’, Sustainability , 14 ( 7 ), pp. 3997 .

Bowlby J. ( 1969 ) Attachment and Loss: Vol. 1. Attachment , New York, NY , Basic Books .

Bowlby J. ( 2008 ) A Secure Base: Parent-Child Attachment and Healthy Human Development , New York, NY , Basic Books .

Bowyer M. , Fein E. C. , Krishnamoorthy G. ( 2023 ) ‘ Teacher mental health literacy and child development in Australian primary schools: A program evaluation ’, Education Sciences , 13 ( 4 ), pp. 329 .

Braun V. , Clarke V. ( 2021 ) ‘ One size fits all? What counts as quality practice in (reflexive) thematic analysis ’, Qualitative Research in Psychology , 18 ( 3 ), pp. 328 – 52 .

Bryant R. A. , Waters E. , Gibbs L. , Gallagher H. C. , Pattison P. , Lusher D. , MacDougall C. , Harms L. , Block K. , Snowdon E. , Sinnott V. , Ireton G. , Richardson J. , Forbes D. ( 2014 ) ‘ Psychological outcomes following the Victorian Black Saturday bushfires ’, The Australian and New Zealand Journal of Psychiatry , 48 ( 7 ), pp. 634 – 43 .

Cacioppo J. T. , Patrick W. ( 2008 ) Loneliness: Human Nature and the Need for Social Connection , New York, NY , WW Norton & Company .

Cobham V. E. , McDermott B. ( 2014 ) ‘ Perceived parenting change and child post-traumatic stress following a natural disaster ’, Journal of Child and Adolescent Psychopharmacology , 24 ( 1 ), pp. 18 – 23 .

Choo M. , Yoon D. K. ( 2022 ) ‘ Examining the effects of the local communities’ social capital on disaster response capacity in Seoul, South Korea’ International Journal of Disaster Risk Reduction , 75 , 102973 .

Cleugh H. , Grimmond S. ( 2011 ). ‘Urban climates and global climate change’ The Future of the World’s Climate (Second Edition), pp. 47 – 76 .

Curtin M. , Anderson G. A. , Maslin-Prothero S. E. , Shepperd D. ( 2020 ) ‘ Recovery in the aftermath of trauma: Longitudinal comparisons of burn survivors and their supporters ’, Burns , 46 ( 3 ), pp. 566 – 73 .

Dallinger V. C. , Krishnamoorthy G. , Burton L. J. , du Plessis C. , Pillai-Sasidharan A. , Ayres A. ( 2022 ) ‘ Internet-based interventions to support recovery in youth: A systematic review ’, Digital Health , 8 , p. 20552076221129094 .

Drukker M. , Buka S. L. , Kaplan C. , McKenzie K. , Van Os J. ( 2005 ) ‘ Social capital and young adolescents’ perceived health in different sociocultural settings’ , Social Science & Medicine , 61 ( 1 ), pp. 185 – 98 .

Fonagy P. , Gergely G. , Jurist E. L. , Target M. ( 2002 ) Affect Regulation, Mentalisation, and the Development of the Self , New York, NY , Other Press .

Fraser C. , Blake D. ( 2020 ) Valuing Voices: Sex Workers’ Experiences Following the Canterbury Earthquakes , Wellington, NZ , Disaster Research Science Report .

Hiller R. M. , Meiser‐Stedman R. , Lobo S. , Creswell C. , Fearon P. , Ehlers A. , Murray L. , Halligan S. L. ( 2018 ) ‘ A longitudinal investigation of the role of parental responses in predicting children’s post‐traumatic distress ’, Journal of Child Psychology and Psychiatry, and Allied disciplines , 59 /( 7 ), pp. 781 – 9 .

Kaniasty K. ( 2020 ) ‘ Social support, interpersonal, and community dynamics following disasters caused by natural hazards ’, Current Opinion in Psychology , 32 , pp. 105 – 9 .

Kapucu N. , Hawkins C. V. , Rivera F. I. ( 2013 ) ‘ Disaster preparedness and resilience for rural communities ’, Risk, Hazards & Crisis in Public Policy , 4 ( 4 ), pp. 215 – 33 .

Krishnamoorthy G. , Ayre K. , Rees B. ( 2020a ) ‘ Helping children who have been affected by bushfires ’, Reflections , 1 , 3 – 6 .

Krishnamoorthy G. , Hessing P. , Middeldorp C. , Branjerdporn M. ( 2020b ) ‘ Effects of the “circle of security” group parenting program (COS-P) with foster carers: An observational study ’, Children and Youth Services Review , 115 , p. 105082 .

Krishnamoorthy G. , Ayre K. ( 2021 ) ‘ Sustaining interdisciplinary work in trauma-informed education ’, The Australian Educational Researcher , 49 ( 3 ), pp. 529 – 46 .

Le Roux I. H. , Cobham V. E. ( 2021 ) ‘ Psychological interventions for children experiencing PTSD after exposure to a natural disaster: a scoping review ’, Clinical Child and Family Psychology Review , 25 ( 2 ), pp. 249 – 82 .

L’Heureux J. , Gillespie D. J. ( 2020 ). Community preparedness: Disaster nursing . In D. Gillespie (Ed.), The many roles of the registered nurse (pp. 179–184). Cambridge Scholars Publishing.

Local Recovery Team . ( 2020 ) Cudlee Creek Bushfire: Community Recovery Plan , Adelaide, Australia , Local Government Association of South Australia .

Lu Z. Q. , de Geus H. , Roest S. , Payne L. , Krishnamoorthy G. , Littlewood R. , Hoyland M. , Stathis S. , Bor W. , Middeldorp C. M. ( 2022 ) ‘ Characteristics and treatment outcomes of children and adolescents accessing treatment in Child and Youth Mental Health Services ’, Early Intervention in Psychiatry , 16 ( 12 ), pp. 1297 – 308 .

McDermott B. ( 2014 ) ‘ Disasters, children and families: Have we arrived at a comprehensive model of emotional health care ’, Australian Journal of Emergency Management , 29 ( 1 ), pp. 10 – 1 .

McDermott B. M. , Cobham V. E. ( 2014 ) ‘ A stepped-care model of post-disaster child and adolescent mental health service provision ’, European Journal of Psychotraumatology , 5 ( 1 ), pp. 24294 .

McDonald-Harker C. , Drolet J. L. , Sehgal A. , Brown M. R. , Silverstone P. H. , Brett-MacLean P. , Agyapong V. I. ( 2021 ) ‘ Social-ecological factors associated with higher levels of resilience in children and youth after disaster: the importance of caregiver and peer support ’, Frontiers in Public Health , 9 , 682634 .

Masten A. S. , Narayan A. J. ( 2012 ) ‘ Child development in the context of disaster, war, and terrorism: Pathways of risk and resilience ’, Annual Review of Psychology , 63 , 227 – 57 .

Miko A. L. , Berger E. , Krishnamoorthy G. ( 2023 ) ‘ Exploring self-care practices in foster carers: A qualitative study ’, Journal of Public Child Welfare , 17 /( 2 ), pp. 333 – 55 .

Mutch C. ( 2015 ) ‘ Schools and disaster recovery: The unique and vital role that teachers and education professionals play in ensuring the mental health of students following natural disasters ’, Journal of Psychology & Psychotherapy , 5 ( 2 ), pp. 1 – 6 .

North C. S. ( 2016 ) ‘ Current research and recent breakthroughs on the mental health effects of disasters ’, Current Psychiatry Reports , 18 ( 10 ), pp. 1 – 8 .

Norris F. H. , Friedman M. J. , Watson P. J. , Byrne C. M. , Diaz E. , Kaniasty K. ( 2002 ) ‘ 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981–2001 ’, Psychiatry , 65 ( 3 ), pp. 207 – 39 .

O’Connor M. , Elklit A. ( 2008 ) ‘ Attachment styles, traumatic events, and PTSD: A cross-sectional investigation of adult attachment and trauma ’, Attachment & Human Development , 10 ( 1 ), pp. 59 – 71 .

Peek L. , Stough L. M. ( 2010 ) ‘ Children with disabilities in the context of disaster: A social vulnerability perspective’ Child Development , 81 ( 4 ), pp. 1260 – 70 .

Phoenix Australia Centre for Post-traumatic Health . ( 2013 ) ‘Australian Guidelines for the Treatment of Acute Stress Disorder and Post-traumatic Stress Disorder’, available online at: https://www.phoenixaustralia.org/wp-content/uploads/2015/03/Phoenix-ASD-PTSD-Guidelines.pdf (accessed December 2022).

Pujadas Botey A. , Kulig J. C. ( 2014 ) ‘ Family functioning following wildfires: Recovering from the 2011 Slave Lake fires’ Journal of Child and Family Studies , 23 , pp. 1471 – 83 .

Rothì D. M. , Leavey G. ( 2006 ) ‘ Mental health help-seeking and young people: A review ’, Pastoral Care in Education , 24 ( 3 ), pp. 4 – 13 .

Schimke D. , Krishnamoorthy G. , Ayre K. , Berger E. , Rees B. ( 2022 ) ‘ Multi-tiered culturally responsive behaviour support: A qualitative study of trauma-informed education in an Australian primary school ’, Frontiers in Education , 7 , p. 866266 .

Sharp C. , Pane H. , Ha C. , Venta A. , Patel A. B. , Sturek J. , Fonagy P. ( 2011 ) ‘ Theory of mind and emotion regulation difficulties in adolescents with borderline traits ’, Journal of the American Academy of Child and Adolescent Psychiatry , 50 ( 6 ), pp. 563 – 73.e1 .

Sroufe L. A. , Egeland B. , Carlson E. A. , Collins W. A. ( 2005 ) The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood , New York, NY , Guilford Press .

Tausczik Y. , Faasse K. , Pennebaker J. W. , Petrie K. J. ( 2012 ) ‘ Public anxiety and information seeking following the H1N1 outbreak: Blogs, newspaper articles, and Wikipedia visits ’, Health Communication , 27 ( 2 ), pp. 179 – 85 .

Taylor D. , Goodman H. ( 2015 ) Place-Based and Community-Led: Specific Disaster Preparedness and Generalisable Community Resilience , Melbourne, Australia , CatholicCare Bushfire Community Recovery Service .

Tong A. , Sainsbury P. , Craig J. ( 2007 ) ‘ Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups ’, International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care , 19 ( 6 ), pp. 349 – 57 .

Van Beek M. , Patulny R. ( 2022 ) ‘ The threat is in all of us’: Perceptions of loneliness and divided communities in urban and rural areas during COVID‐19 ’, Journal of Community Psychology , 50 ( 3 ), pp. 1531 – 48 .

Whittaker J. ( 2019 ) ‘ Ten Years after the black Saturday fires, what have we learnt? ’ Australian Journal of Emergency Management , 34 ( 2 ), pp. 32 – 7 .

Williamson V. , Creswell C. , Fearon P. , Hiller R. M. , Walker J. , Halligan S. L. ( 2017 ) ‘ The role of parenting behaviors in childhood posttraumatic stress disorder: A meta-analytic review ’, Clinical Psychology Review , 53 , pp. 1 – 13 .

Wisner B. ( 2016 ) ‘ Panic’ and perception of risk in hazards research ’, The Geographical Journal , 182 ( 2 ), pp. 123 – 9 .

Zhang Z. , Li N. , Wang M. , Liu K. , Huang C. , Zhuang L. , Liu F. ( 2022 ) ‘ Economic ripple effects of individual disasters and disaster clusters’ International Journal of Disaster Risk Science , 13 ( 6 ), pp. 948 – 61 .

Supplementary data

Email alerts, citing articles via.

Recommend to your Library

Affiliations

Online ISSN 1468-263X
Print ISSN 0045-3102
Copyright © 2024 British Association of Social Workers
About Oxford Academic
Publish journals with us
University press partners
What we publish
New features
Open access
Institutional account management
Rights and permissions
Get help with access
Accessibility
Advertising
Media enquiries
Oxford University Press
Oxford Languages
University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

Copyright © 2024 Oxford University Press
Cookie settings
Cookie policy
Privacy policy
Legal notice

This Feature Is Available To Subscribers Only

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Open access
Published: 01 August 2024

Understanding women’s and men’s perspectives on cervical cancer screening in Uganda: a qualitative study

Kathryn Bouskill 1 ,
Glenn J. Wagner 1 ,
Mahlet Gizaw 1 ,
Joseph KB Matovu 2 , 3 ,
Margrethe Juncker 4 ,
Eve Namisango 5 ,
Sylvia Nakami 4 ,
Jolly Beyeza-Kashesya 6 , 7 ,
Emmanuel Luyirika 5 &
Rhoda K. Wanyenze 2 , 8

BMC Cancer volume 24 , Article number: 933 ( 2024 ) Cite this article

Metrics details

Cervical cancer remains a significant but preventable threat to women’s health throughout much of the developing world, including Uganda. Cervical cancer screening and timely treatment of pre-cancerous lesions is a cost-effective means of mitigating cervical cancer morbidity and mortality. However, only 5% of women in Uganda have ever been screened. Barriers to screening, such as social stigma and access to safe conditions, have been previously identified, but insights into the role of male spouses in encouraging or discouraging screening have been limited. To our knowledge, no studies have compared barriers and facilitators among women who had or had not yet been screened and male partners of screened and unscreened women.

To resolve this gap, we conducted 7 focus groups– 3 among women who had been screened, 3 among those who had not been screened, and 1 among men whose female partners had or had not been screened. We performed qualitative thematic analysis on the focus group data.

We identified several important factors impacting screening and the decision to screen among women, ranging from stigma, availability of screening, false beliefs around the procedure and side effects, and the role of spousal support in screening promotion. Male spousal perspectives for screening ranged from full support to hesitancy around male-performed exams and possible prolonged periods without intercourse.

This exploratory work demonstrates the importance of dialogue both among women and their male partners in enhancing screening uptake. Efforts to address screening uptake are necessary given that it is an important means of mitigating the burden of cervical cancer. Interventions along these lines need to take these barriers and facilitators into account in order to drive up demand for screening.

Peer Review reports

Cervical cancer (CC) is a significant public health issue in Uganda, where the age-standardised incidence rate of 54.8 and age-standardised mortality rate of 40.5 per 100,000 are some of the highest in the world [ 1 , 2 , 3 , 4 ]. Cervical cancer accounts for around a quarter of all cancer deaths among Ugandan women [ 1 ] with 80% presenting with advanced disease (i.e., stage III or higher) [ 5 ].

Treatment for advanced CC in Uganda (outside of palliative care) remains limited to radiotherapeutic, chemotherapeutic, surgical provided through the Uganda Cancer Institute (UCI) in Kampala [ 5 ]. Due to the scarcity and high costs to accessing care, especially for those outside of the capital, [ 6 ] and prevention of advanced CC through screening is paramount.

Unfortunately, the lifetime screening rate for CC in Uganda is estimated to be as low as 5%, and the prevalence of human papilloma virus (HPV), which causes CC, is around 34% [ 5 , 7 ]. Guideline recommendations call for CC screening every 3 years, but no formalised national effort has been mobilised [ 8 ].

In Uganda, CC screening is conducted with a visual inspection of the cervix with acetic acid (VIA) or pap smear [ 9 ]. Rapid HPV testing is emerging in Uganda, but is limited [ 10 ]. A systematic review of barriers to CC screening in Sub-Saharan Africa identified a range of significant barriers: fear of screening and embarrassment, fear of a positive screen, lack of privacy during screening, social stigma, lack of access and prohibitively high costs, negative experiences with health care personnel and at health care facilities, and a lack of spousal support [ 11 ]. Similar findings were found in a systematic review of barriers and facilitators to screening in Uganda [ 6 ]. The procedure is inexpensive if it is not free where it is available, but access outside the capital Kampala is limited, and the vast majority of the Ugandan population is in rural areas. Removal of pre-cancerous lesions is performed through thermal therapy, and at no or low cost, but is also not widely available outside of Kampala.

Qualitative explorations of women’s experiences with CC screening in Uganda have revealed additional barriers to screening, including lack of awareness of CC, misconceptions such as CC being attributed to contraceptive materials and witchcraft, fear of unsafe conditions from unsterilised screening instruments, and confusion over the purpose of asymptomatic screening [ 12 , 13 , 14 ]. These barriers, such as lack of awareness, cost of screening, distance to be screened, embarrassment, and lack of spousal support, were echoed in a systematic review of barriers to CC screening in low- and middle-income countries [ 15 ]. Another recent systematic review of drivers of CC screening in East Africa confirmed the aforementioned factors, as well as interpersonal stigma at the community level [ 16 ].

There has been recent exploration of the importance role of spousal support in the use of CC screening in Sub-Saharan Africa, and particularly in Uganda. Rawat et al.’s study in rural Uganda of men’s knowledge, beliefs, and perspectives called attention to the cultural importance of men’s power in household decision-making, including whether or not women are permitted to attend cervical cancer screening, highlighting the critical importance of involving men in the implementation and education of community-based cervical cancer screening programs [ 17 ]. An earlier qualitative study found concerns from Ugandan women that their spouse might think they were unfaithful if they engage in CC screening [ 18 ]. Studies have pointed to the positive impact that spousal support can have on intent to screen, [ 19 , 20 ] while lack of emotional and financial support from a spouse and fear that a spouse would leave a woman if she were found to be at risk for CC are barriers to screening [ 12 , 21 ]. Another study found that women would be willing to engage in screening irrespective of their spouse’s view [ 22 ]. These preliminary findings of the role of spousal influence over screening warrant the need to continue highlighting the importance of improving men’s support for CC screening and women’s empowerment into interventions and programs to increase CC screening uptake, [ 11 ] as well as push to engage local community women leaders to promote screening [ 6 ].

As part of the development of a peer advocacy intervention to promote CC screening, [ 23 , 24 ] we conducted a series of focus group discussions with Ugandan women who had or had not screened for CC, and with men whose wives had or had not been screened. This work contributes an understanding of women’s experiences of being screened and their readiness to serve as advocates for other women to be screened, the ways in which men’s perspectives on screening can come to bear on whether or not women are screened, and the persistence of awareness of and access to screening as critical drivers of screening uptake.

Study design

This paper presents findings from the qualitative research conducted in the initial phase of a larger study that conducted a pilot randomised-controlled trial of a peer-led, group intervention aimed at training women who had screened for CC to conduct advocacy for CC screening among women in their social networks [ 23 , 24 ]. This first phase consisted of a series of seven focus group discussions– three with women who had been screened (and in some cases, treated for cervical cancer risk) for CC, three with women who had never been screened for CC, and one with men whose spouses had either screened or not for CC. The study protocol was approved by the [redacted], and [redacted].

Sample and location

Participant recruitment and focus group discussions took place at Buyinja Health Centre in Namayingo, a rural community in the Busogo region of Uganda. CC screening and thermal therapy are available at Buyinja Health Centre, as well as another nearby health centre in the district (Banda Health Centre), and from Rays of Hope Hospice Jinja (RHHJ), which conducts periodic mobile CC screening and thermal therapy “day camps.” Women who need biopsies are sent to Jinja (approximately 90 km from Namayingo), and if cancerous lesions are present, they are referred to the Uganda Cancer Institute, the tertiary public cancer care centre located in Kampala.

Recruitment

To assess the range of sentiment towards CC screening, we sought to recruit women between ages 18–34 and over 35 who had been screened, women between ages 18–34 and over 35 who had not been screened, and men aged 18 + whose partners had and had not been screened. RHHJ maintains a registry of women who they have screened for CC, which was used to identify women who had screened within the past year. An RHHJ community health worker used the registry to purposively sample from a random list of women who had screened negative and screened positive (and received treatment if pre-cancerous lesions were present); these women were informed of the study and then, if interested in participating, were linked to the study coordinator for consent procedures. The women who had not been screened and men whose partners had and had not been screened and treated were also identified by RHHJ community health workers and contacted via phone. Written informed consent was given by all participants. We recruited a convenience sample of 50 women roughly equivalently split across those who had or had not been screened, and stratified into younger (18–34 years) and older age groups (35 + years). Men were recruited through staff and their network through local community health centers. This led to an additional 8 men, 4 of whose wives had and 4 whose wives had not been screened, participated in the male focus group discussion. All participants received 25,000 Ush (~$8 USD) for their participation.

Data collection instrument and procedures

The women’s focus group discussion guide asked whether women discuss CC and CC screening, and if so, what is discussed and with whom. Specifically, any questions, fears, and concerns with screening were discussed, as well as factors that motivate discussions of CC screening. The men’s focus group discussion guide asked about perspectives on their wives’ health, their knowledge of screening and whether they know anyone who had been screened, perspectives on women’s need to abstain from sexual intercourse following treatment for cervical lesions, and opinions about the proposed intervention. Both focus group discussion guides were translated from English into Lusoga or Lusamia (depending on the tribal composition in the area where the focus group discussions were conducted) and reviewed by the study team for accuracy. The women’s focus groups were facilitated by skilled Ugandan women moderators, while a skilled Ugandan male moderator led the men’s focus group. The group discussions, each of which were over two hours, were conducted in Lusamia or Lusoga, audio-recorded, translated into English, transcribed and then uploaded into the qualitative data analysis software, Dedoose [ 25 ].

Qualitative data analysis

The team created a codebook that mapped onto the respective focus group discussion guides and represented various domains of interest (e.g., whether and how people discuss CC screening; misconceptions of CC and CC screening; sources of stigma). We began by double-coding two transcripts, and then calculated interrater reliability across the all transcripts with a pooled Cohen’s Kappa coefficient for each of the codes. Coding procedures were discussed and revised until the pooled Cohen’s Kappa coefficient was > 0.80, which indicates near-perfect agreement among a coding team [ 26 ]. Any discrepancies were resolved through discussion. We followed standard approaches to identify key themes, or the range of responses under each code, by noting specific words, phrases, and ideas [ 27 ]. We identified additional themes through repetition and, metaphors used, and through existing literature of sources of CC-related perceptions [ 28 ].

Overall impressions of cervical cancer screening

The seven focus groups– three with women who had been screened for CC ( n = 35), three with women who had not yet been screened ( n = 15), and one focus group with 8 men (4 of whom had wives who had screened and 4 whose wives had not)– revealed a general awareness of CC and relative openness to sharing one’s status of having been screened (and in some cases treated for CC-related lesions).

No clear differences were observed across the groups of younger and older women, and misconceptions and perceived stigma were present among those who had and had not been screened. Women who had not been screened were open to screening, but cited barriers such as lack of availability, lack of awareness of when screening is taking place, prohibitive cost, mistrust from their partner and adverse impacts on their relationships, and fear of pain, discomfort, and stigma from screening. Some were unaware of CC and that it can be prevented when detected early. Several misconceptions of CC screening and CC more generally were also reported by women who had been screened. Some men were motivated to support screening and treatment to relieve their partners of symptoms and avoid treatment-related costs and abstinence, while others expressed concern over having women be screened by other men.

Most women who had been screened spoke about CC screening and treatment with friends, church parishioners, sisters, mothers, co-wives– but they reported often neglecting to follow up with their peers after initial discussions of screening. Nearly everyone who had screened emphasized its importance and noted that it may be uncomfortable, but not painful. Others described how local nurses promote screening, even “mobilising us even during funeral services and burials.” Despite this relative openness, participants also shared misconceptions and barriers to getting screened. It is also important to note that some unscreened women complained of severe symptoms that are often indicative of later-stage CC, such as back and pelvic pain and vaginal discharge. For example, one older unscreened woman noted, “I have prickly pain inside my private parts. I no longer have sex with my husband. I cannot bear the pain” (unscreened 35 + woman). Only women who had been screened and treated for pre-cancerous lesions discussed ways to prevent CC, and all spoke favourably about their experience of reducing their CC risk.

Women’s impressions of cervical cancer screening and treatment

Promoting screening and preventing infection.

All women spoke of peers who have questions about the screening procedure, and screened women reported that they would use their experience to inform unscreened women about what to expect. A screened woman explained,

I asked my friend if she has ever heard about anything concerning CC screening, and I explained to her that she will be asked to go into a private room, they will ask her name, then she will be told to remove her undergarments and then sit in a position that requires her to open her legs. A machine will be fixed into her private parts and if it dictates that she has CC risk, medicine will be inserted in her there, and then but if she does not have CC the machine will be removed. I even told her that her uterus will not be removed like many people assume (screened 18–34 woman).

This quote highlights an additional misconception and concern among women that the uterus will be removed during screening, which will be described in more detail below.

Women who had been screened for CC spoke of the need for women to visit a health facility and be screened if they are experiencing symptoms. One screened woman explained,

As women, we tend to meet and complain a lot about our health…Go to the hospital and screen so that they tell you what exactly is affecting your health. You may have or be developing CC. Don’t complain while sitting at home talking to people who won’t help you. You still have a lot of responsibility and roles to play in your homes. You have children to up bring, home to look after, and gardens to tend, but above all you need life, and the only way is by going to the hospital (screened 35 + woman).

Screened women cautioned others about the need for continuous periodic screening and other preventative measures, such as using condoms before one is married, “I do tell my friends that every time there is an opportunity to screen for CC they should do it because our men keep having sex with multiple partners, so we can never be sure that we are safe. You may think that the CC is cured completely and yet the man re-infect you. Men should also go for circumcision and keep clean” (screened 18–34 woman).

Another added, “I will give an example of us women who are not yet married, a man would want to have unprotected sex with us which may lead to CC. I think it is good practice to use a condom especially for us who are not married to reduce the risk of contracting CC.” (screened 18–34 woman).

Misconceptions about cervical cancer screening

Misconceptions related to CC were reported by both screened and unscreened women. As noted, one of the primary misconceptions is that screening involves removal of the uterus. Women who had undergone screening dispelled this myth, as exemplified in this quote from a screened woman, “Yes, when people talk about screening, they say that they pull out the uterus and put it on the table to have it checked, and it makes them change their mind about screening” (screened 18–34 woman). However, this false belief was echoed by several unscreened women, some who believed the uterus could be reinserted upside down, leaving a woman barren.

Another screened woman described having to dispel a rumor that screening involves “roasting the uterus,” assuring her friends that the procedure is “not so painful, but you have to ensure the whole process if you want to know and be treated” (screened 18–34 woman). Still, several unscreened women had similar sentiments: “They say those machines they use to examine the cervix are pushed inside deeply and so intense is the pain. This has scared off so many of us. But, I feel I need to put away the fear and come today to see or get the experience myself simply because much as they scare us, many are testing and getting their life back. Yet we are left behind dying slowly but surely” (unscreened 35 + woman).

Other women who had been screened said nurses had told them that genital hygiene or having sexual intercourse during one’s menstrual period can lead to CC. Another woman noted, “The nurses advised us not to use our long nails to wash inside our private parts because it may also cause CC,” or that “dirt in the knickers causes CC” (screened 18–34 woman). In addition, one woman who had been screened also noted, “I overheard people say that syphilis is also symptom of CC” (screened 18–34 woman).

The concern that contraceptives cause CC was also shared by women who had been screened for CC. However, it is possible that women were conflating the risk of CC with having multiple sexual partners. One woman who had not yet been screened spoke of telling her husband they could no longer use condoms because they would cause CC. Another screened woman noted, “I would tell my friend that in case she uses family planning she will get CC, and also if she has sex with more than three men, she is most likely going to get CC” (screened 18–34 woman). An unscreened woman (35+) said, “I have never seen anybody die from being screened. I also dismissed that story. I need to be screened.”

Another important misconception was that screening and treatment can stretch out a woman’s genitals and make her “undesirable” to her partner. One screened woman said, “We get so many and funny questions. One asked me whether that screening machine doesn’t enlarge or stretch one’s private parts and become too wide for her husband to enjoy her tightness during sex” (screened 35 + woman), to which another answered:

I tell them that it’s not even the size of the head of the baby, and not even bigger than the normal penis which goes there every other day, so you tell her the reality and the truth about that. One asked me how the lesions are burned and if there is pain. I told them all you feel is the rod being pushed in but the rest is not felt. There is nothing like a burning sensation. It’s a small rod which is inserted but no pain at all. Their fears are around that; they are scared that once they burn the lesions, they will instead widen and spread into the uterus…They believe once a cancer is burned they think it never heals. But I tell them my story. I am a living testimony. I was treated with that procedure and I am now normal (screened 35 + woman).

In addition to these misconceptions, women who had not been screened described additional structural barriers to getting screened, which are described below.

Additional barriers to getting screened

Cost of screening.

Although VIA screening is supposedly free of cost, women also cited screening-related costs. It may be a misconception that women believe there are costs to being screening, but transportation, loss of work time, and treatment can bring about costs for women and their families. One unscreened woman said, “What I usually tell them wherever I am, wherever I get these various pains is how I feel and the pains I go through but what is causing these pains is because I never got screened, not even treated to know what I am suffering from. I tell them that this all due to poverty. How I wish I could afford I would go, get screened and know what is causing all this and get treated” (unscreened 35 + woman).

Social stigma did not seem to play a major role in the challenges that women expressed regarding CC screening and treatment; nonetheless, some women did report experiences with social stigma and discrimination. Both the male and female participants in their respective focus groups expressed an openness in speaking about CC, but some women who had been screened and treated for pre-cancerous lesions reported getting laughed at and having people “point fingers” at them for living with cancer risk and also experiencing internalized stigma for their diagnosis. Another unscreened woman was concerned about gossip in her community if the screening revealed she had pre-cancerous lesions, “I do fear somehow because I may trust some person and confide in her, yet this person is going to betray my trust and go on telling the whole community about my status. Before long everybody will have known” (unscreened 18–34 woman). Another woman who had been screened described the process of getting undressed and being examined as “shameful,” but still advocated that others be screened to stop pre-cancerous lesions before they become symptomatic.

Furthermore, some were mocked when talking about health risks when they are not health care workers themselves. As one woman recounted, “Sometimes when we talk to people about going for screening, they say, ‘Are you a health worker?’ As in, why would I have the audacity to come and start teaching them about CC” (screened 18–34 woman). Hence, women described the importance of credibility when discussing CC screening.

Fear of adverse impacts on intimate relationships

As noted above, others feared telling their husbands that they would have to abstain from sexual intercourse for several weeks following treatment, adding, “I fear to disclose at times because the health workers tell you not to have sexual intercourse for six weeks, some men cannot accept you to deny them sex to wait” (screened 18–34 woman). Another woman who had not been screened stated, “Honestly, I fear to be screened by a man I would prefer a fellow woman to screen me…It looks shaming especially to a man who is not my husband. I do not wish to be seen by a man” (unscreened 35 + woman).

Other women were able to overcome their husbands’ resistance. One screened woman spoke about this challenge:

I tell my friends that even when you feel much better you should not have sex for a period of one month and one week or until complete your medication. I give an example where my husband wanted to have sex with me when I was receiving treatment, and he said, “Do you want me to go have it with a goat?” and I comforted him and told him that its better we follow the orders given to us by the nurses and better to take free medication rather than you having to spend a lot of money on me when the CC reappears. My husband insisted that maybe I have got another man with whom I am having sex, but I gave him the phone number of the nurses for him to be able to witness for himself that it is the nurses who gave me those instructions (screened 18–34 woman).

Women who had been screened and treated spoke unanimously about returning to good health and normal sexual relations after being treated, which could allay concerns on the part of their husbands. One woman added, “I talk about the trouble I went through [before being treated]. I had stopped having sex with my husband completely. I had so much pain– backaches and lower abdominal pain. The moment I would have sex, I would yell and ask him why he is not ending this painful game, but now all that is no more. I tell them I got healed of all the sign and symptoms. I am normal now” (screened 18–34 woman).

Screened women also described initiating conversations with wives of men whom they had identified as risky: “I started initiating the conversation with my sister-in-law as I realized that her husband is a womanizer and is HIV positive, and women living with HIV are at a high risk of getting CC” (screened 18–34 woman). Another added, “I intend to talk to my husband because he is the kind of man who sleeps around with every woman he admires” (screened 18–34 woman).

Motivation to be screened

Women who had not yet been screened mentioned becoming motivated to be screened after they were educated by others about the procedure and the benefits of CC screening during the process of participating in a focus group. Women who were symptomatic learned that CC can be “cured” if treated early, even though they had not yet been screened. One younger woman said,

What gives me the courage to talk about cervical cancer is once I am screened and treated, I will become a living testimony…Even if I am negative, I will become a champion who will speak from a point of a person who understands the disease due to the education I will have got. I need to empower my friends with my experience and the need to tell them of the progress I have made in whatever way. If not, I will preach the gospel of healing. The possibility to heal gives me the courage to talk (unscreened 18–34 woman).

This was particularly poignant for women who were experiencing severe symptoms, with one older woman who had not yet been screened recounting, “I talk mainly about the possibility of getting treatment because what I know is that once I am treated, I will be able to live my full life again. I no longer work. I have lots of pain now all over my private parts. What I need is treatment. So, I will keep inquiring about when the doctors will be back and I will go for screening” (unscreened 35 + woman). This led women to be more open to spreading the message that screening and early treatment can prevent cancer, although there were still misconceptions regarding pre-cancerous lesions. As one woman noted, “The belief I had that cancer is not curable are now gone because of joining the meeting today. Such feelings are now gone. I know the truth so I want to be an ambassador who will tell people that” (unscreened 18–34 woman).

Overview of men’s perspectives

The male focus group was comprised of men whose wives had been screened and those whose wives had not. Acceptance of screening, support for their wives, and misconceptions differed within the group. Several men lamented that it was “ignorance” among men and women that was causing women to die of CC and championed the need to educate those in Namayingo about CC screening and treatment. However, others expressed misgivings with having their wives be screened by men and not being able to have intercourse for a short period of time if pre-cancerous lesions are removed.

Women’s symptoms as motivation to encourage screening

All men who had witnessed a positive screen and treatment were in favor of screening initiatives. One man noted, “I just feel good– what can I say? My partner got healed. There is a benefit to mobilising other women to get screened, treated, and healed.” A few men were able to describe the process of screening and treatment, including temporary abstinence from sexual intercourse, in detail. One man assured the other men that it was because of the screening and the treatment that his wife received that, “she is now fine and got healed.” Another described the challenges of having his wife experience pain during sexual intercourse, adding, “when she is screened early and treated, she’ll get healed. I witnessed this when my own wife got healed. That is [the] reason why I want her to be screened again to avoid problems which might make me not eat good sauce [have sex].” These testimonies led other men to react in saying, “My wife has not been screened yet, but after what I am hearing here, I have to take her to be screened,” before adding that access to health care services is limited across the board. Another, whose wife was unable to have sex because of pain and was treated, pleaded for more “machines that test for cervical cancer because we are going to bury someone who died of CC.”

Financial concerns as motivation to encourage screening

One man described how he sent his wife back to her parents’ home and accused her of being a drain on his finances following her diagnosis. Then, after facing condemnation from his wife’s parents, he took her back and she started treatment and is now “very fine.” The man had then started to “advocate for better CC screening and treatment at our health center.” Men also spoke of the respect for their wives as “mothers of the nation,” and how “if a woman acquires CC, it means we men also get a shock.” Another added that he knew of the shock and the difficulty of having to allocate two months of wages to his wife’s treatment.

One man described having his second wife also get screened, and the relief he felt when she was not found to have any lesions because he was “financially handicapped” from treating his first wife. Other men echoed the financial hardship of treating advanced CC. One man described his sister-in-law’s experience, adding, “She consumed all our money in the struggle to cure her cancer, but now she is looking very strong and healed.”

Men’s mistrust over the screening procedure and screening-related abstinence

Some men described having mistrust in their partner and frustration over not being able to have sexual intercourse if pre-cancerous lesions are found and removed following screening. Following a diagnosis, one man said,

It brought serious problems and misunderstanding between me and her. I told my wife that if it is like this then you better go back to your parents’ home because I can’t stay with a person without doing “the work I do” (having sexual intercourse). She explained her issues to me privately. I said, “you are lying me. Why haven’t you been telling me?” She replied, “I have been waiting to tell you, but I was afraid.” I said I would take her to the doctor to prove whether she is telling me the truth.

Others carried the misconception and mistrust of men performing screening and treatment on their wives, reporting rumors of a doctor who has a “bad habit of having sex with his patients.” Another added,

A male health worker enters the room with my wife and they close the door. Even if the health workers didn’t have any thoughts of an affair, I as a man am still in fear…You can’t know whether the health worker is having sex with your wife. Health workers are human beings– they are not bishops! Therefore, only female health workers should work on fellow women in the cancer department.

Others refuted this worry, adding that they do not have sex with female nurses when they are alone with them being treated, so men should be able to screen the cervix, and that male doctors would not want to contract the virus, adding, “a health worker is just medical personnel regardless of the gender.”

Men also had several questions regarding CC and reproductive health more broadly, including whether “CC” [HPV] could be transmitted to a male partner, whether circumcision impacts transmission, how cancer spreads, why men cannot be screened, how CC impacts pregnancy, and whether there are male doctors who perform screenings but do not have wives (and may try to have sexual intercourse with their wives).

Men also conveyed several misconceptions with respect to CC risk. Like some of the female participants, one man talked about a previous belief that witchcraft causes CC. Another mentioned that he had learned that family planning can cause CC. Others spoke about how pain during childbirth or giving birth to a stillborn child can cause CC. Another cautioned that screening and treatment can cause the removal of the uterus.

The themes from these focus groups revealed support for social influences to encourage women to get screened (and treated) for CC risk, but also important insights into how misconceptions, stigma, and fears impede uptake of screening and treatment. Women who had not been screened described concerns over undressing in front of medical personnel and of negative impacts on their marriages, gossip within their social networks if they screen positive, and fear of becoming infertile (e.g., through the misconception that the uterus is removed during screening) through screening and treatment. Overcoming these issues is critical to increasing Uganda’s very low screening rates.

Despite these barriers, a predominant and encouraging theme among women who had been screened for CC was the desire and need to share their screening experience and to encourage peers to also get screened. Such sentiments were often conveyed passionately, particularly among women who had received treatment (either for pre-cancerous or cancerous lesions) and had their health restored. This highlights how women who have been screened can act as change agents for promoting CC screening, which was corroborated by a recent effective pilot peer-based intervention in Uganda [ 24 ]. The potential impact and power of social influence for dissemination of knowledge about CC by women with experience of CC screening was demonstrated even in the focus group discussions. Women who have never been screened spoke of having newfound revelations about the ability of CC risk to be cured through screening and treatment, and how this now motivated them to get screened. Having credibility from medical personnel who can attest to the importance and the fact that often fellow women perform the exams is important in increasing the motivation to be screened.

The women and men who participated in these focus groups revealed certain misconceptions, sources of stigma, and other challenges related to CC screening and subsequent treatment that are important to consider in both care delivery and in interventions to mitigate CC through increased uptake of screening (and treatment when needed). Informing women of the ability of screening and treatment to resolve physical symptoms, particularly if identified early, may help alleviate stigma and fear and thereby promote CC screening. In addition, Mwaka et al.’s 2018 research highlighted Northern Ugandan women’s worries over the removal of the uterus during cervical cancer treatment and the subsequent stigma from infertility. This furthermore underscores the need to inform women of the efficacy of early detection and treatment to avoid drastic measures like removal of the uterus [ 29 ].

A critical misconception expressed by some participants was that only symptomatic women should be screened for CC. If women wait for physical symptoms to be screened, the greater the likelihood that they will develop advanced signs of disease before these signs are detected and that treatment will be too costly to obtain. Indeed, the vast majority of Uganda women have advanced stage CC at first onset into care [ 30 ]. However, because treatment for CC is prohibitively expensive and difficult to access, increasing screening and concurrent treatment for pre-cancerous lesions is the most effective way to reduce the CC burden in Uganda.

Another misconception expressed by some participants was potential harm to the uterus. Given the fact that Uganda is a pronatalist nation where polygamy is common, being able to have children is paramount, and dispelling myths over infertility is critical. Women who had been screened spoke emphatically about how sharing their experience and knowledge can go a long way to dispelling such myths.

Including men’s perspectives was an important contribution that demonstrated the ways in which men can influence screening for CC. Several of the men spoke of the need for fellow men to support their women getting screened, and to even encourage other women in the community to get screened, in addition to fellow men to support their wives in getting screened. Hence, just as women can serve as agents of change, so too can men with regard to promoting women’s health. Women were exalted by some as “mothers of the nation” – to emphasize the importance of promoting the health and wellbeing of women in their community. However, the discussion also brought to light certain misconceptions and concerns, such as mistrust of male practitioners. This may be addressed by increasing the number of female practitioners who can deliver CC screening and treatment, or by inviting men to attend screening with their wives. Collectively, these findings and those described in Rawat et al.’s (2023) qualitative study of Ugandan men’s perspectives of CC screening underscore the critical importance of planning CC screening interventions that account for gender, power, and structural access to screening and women’s health more broadly [ 17 ].

This exploratory study is limited in terms of its external validity; i.e., it is unclear if the viewpoints presented here would hold across other regions of Uganda and East Africa more broadly. Given that CC remains a significant public health issue in Uganda, it is important to continue to gather context-rich qualitative data to identify ways to enact CC control. There is also a possibility that focus group participants already had more positive perceptions of CC screening and treatment given that they had already received care in health centers. There is also the possibility of social desirability bias whereby responses in the group may have been influenced by the presence of peers. Lastly, the current study does not directly take on the issue of availability and accessibility of screening, although this work shows that it can act as a significant barrier for women seeking to be screened. Despite these limitations, this study calls attention to the importance of understanding women’s interpersonal dynamics to influence CC screening, the role of men in women’s preventative health, and persistent barriers of access to and knowledge of screening and CC more broadly.

Sentiment towards CC screening was largely positive, from both the female and male participants, demonstrating the need to augment access to screening and treatment performed by female health practitioners. Women who had been screened expressed a desire and willingness to openly share their experiences with other women, and to engage in advocacy for CC screening. The potential power of such advocacy was demonstrated in the focus groups themselves, as women who had never been screened expressed improved knowledge and motivation for screening because of their participation. However, stigma and misconceptions related to CC screening and treatment were present, which likely contributes to the low rates of screening. Interventions to control CC through timely screening and treatment will need to actively address these fears and misconceptions. Women sharing their personal experiences with screening and treatment may effectively address the need for dissemination of accurate CC-related information and stigma reduction. Furthermore, men can and should play an important role in CC screening interventions, both in terms of education and awareness, but also in dispelling misconceptions and stigma around male medical personnel. As is the case with women who have been screened, men whose wives have been screened should also be considered as important change agents for influencing other men to encourage their wives to get screened. Given that treatment for CC remains prohibitively expensive and difficult to access, improving screening rates is paramount for curbing the excessive burden of CC in Uganda and much of the developing world.

Data availability

The data collected include data that could potentially identify individuals participating in the study and could thus erode privacy of the participating individuals. We are, thus, unable to share the raw data, but will be willing to share the codebook and the focus group protocol if a reasonable request is made. Contact Glenn Wagner at [email protected] for enquiries.

Abbreviations

Cervical Cancer

Human Papilloma Virus

Ugandan Shillings

United States Dollar

Rays of Hope Hospice Jinja

African Cancer Registry Network [Internet]. 2018 [cited 2023 Dec 10]. Uganda - Kampala Cancer Registry. http://afcrn.org/membership/membership-list/81-kampala-uganda .

Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M et al. Cancer today. 2018. Global Cancer Observatory: Cancer today. https://gco.iarc.fr/today/ .

International Agency of Cancer Registries [Internet]. 2018. Kampala Cancer Registry.

Wabinga H, Parkin D, Nambooze S. Kampala Cancer Registry report for the period 2007–2009. Kampala, Uganda: Kampala Cancer Registry; 2012.

Google Scholar

Nakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecologic Oncol Rep. 2017;20:37–40.

Article Google Scholar

Black E, Hyslop F, Richmond R. Barriers and facilitators to uptake of cervical cancer screening among women in Uganda: a systematic review. BMC Women’s Health. 2019;19(1):108.

Article PubMed PubMed Central Google Scholar

Ndejjo R, Mukama T, Musabyimana A, Musoke D. Uptake of Cervical Cancer Screening and Associated Factors among Women in Rural Uganda: A Cross Sectional Study. Tornesello ML, editor. PLoS ONE. 2016;11(2):e0149696.

World Health Organization. WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions [Internet]. Geneva: World Health Organization. 2019 [cited 2023 Dec 10]. 108 p. https://iris.who.int/handle/10665/329299 .

Auma J, Ndawula A, Ackers-Johnson J, Horder C, Seekles M, Kaul V, et al. Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda. Front Public Health. 2023;11:1105559.

Sultanov M, Van Der Schans J, Koot JAR, De Zeeuw J, Nakisige C, Greuter MJW, et al. EE685 screen-and-treat Cervical Cancer Screening Strategy using high-risk HPV testing: early evaluation for Uganda. Value Health. 2023;26(12):S186.

Lim JNW, Ojo AA. Barriers to utilisation of cervical cancer screening in Sub Sahara Africa: a systematic review. Eur J Cancer Care. 2017;26(1):e12444.

Ndejjo R, Mukama T, Kiguli J, Musoke D. Knowledge, facilitators and barriers to cervical cancer screening among women in Uganda: a qualitative study. BMJ Open. 2017;7(6):e016282.

Natuhwera G, Ellis P, Acuda SW. Women’s lived experiences of advanced cervical cancer: a descriptive qualitative study. Int J Palliat Nurs. 2021;27(9):450–62.

Article PubMed Google Scholar

Hasahya OT, Berggren V, Sematimba D, Nabirye RC, Kumakech E. Beliefs, perceptions and health-seeking behaviours in relation to cervical cancer: a qualitative study among women in Uganda following completion of an HPV vaccination campaign. Global Health Action. 2016;9(1):29336.

Srinath A, Van Merode F, Rao SV, Pavlova M. Barriers to cervical cancer and breast cancer screening uptake in low- and middle-income countries: a systematic review. Health Policy Plann. 2023;38(4):509–27.

Atnafu DD, Khatri R, Assefa Y. Drivers of cervical cancer prevention and management in sub-saharan Africa: a qualitative synthesis of mixed studies. Health Res Policy Sys. 2024;22(1):21.

Rawat A, Mithani N, Sanders C, Namugosa R, Payne B, Mitchell-Foster S, et al. We shall tell them with love, inform them what we have Learnt and then allow them to go - men’s perspectives of self-collected cervical Cancer Screening in Rural Uganda: a qualitative Inquiry. J Canc Educ. 2023;38(2):618–24.

Mutyaba T, Faxelid E, Mirembe F, Weiderpass E. Influences on uptake of reproductive health services in Nsangi community of Uganda and their implications for cervical cancer screening. Reprod Health. 2007;4(1):4.

Twinomujuni C, Nuwaha F, Babirye JN. Understanding the Low Level of Cervical Cancer Screening in Masaka Uganda Using the ASE Model: A Community-Based Survey. Favato G, editor. PLoS ONE. 2015;10(6):e0128498.

Paul P, Winkler JL, Bartolini RM, Penny ME, Huong TT, Nga LT, et al. Screen-and-treat Approach to Cervical Cancer Prevention using Visual Inspection with Acetic Acid and Cryotherapy: experiences, perceptions, and Beliefs from Demonstration projects in Peru, Uganda, and Vietnam. Oncologist. 2013;18(S2):6–12.

Mwaka AD, Wabinga HR, Mayanja-Kizza H. Mind the gaps: a qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for cervical cancer help-seeking in post conflict northern Uganda. BMC Fam Pract. 2013;14(1):193.

Teng FF, Mitchell SM, Sekikubo M, Biryabarema C, Byamugisha JK, Steinberg M, et al. Understanding the role of embarrassment in gynaecological screening: a qualitative study from the ASPIRE cervical cancer screening project in Uganda. BMJ Open. 2014;4(4):e004783.

Wanyenze RK, Matovu JKB, Bouskill K, Juncker M, Namisango E, Nakami S, et al. Social network-based group intervention to promote uptake of cervical cancer screening in Uganda: study protocol for a pilot randomized controlled trial. Pilot Feasibility Stud. 2022;8(1):247.

Wagner GJ, Matovu JKB, Juncker M, Namisango E, Bouskill K, Nakami S, et al. Effects of a peer advocacy intervention on cervical cancer screening among social network members: results of a randomized controlled trial in Uganda. J Behav Med. 2023;46(6):930–9.

Dedoose. Los Angeles CA, SocioCultural Research Consultants LLC. 2016. (Web application for managing, analyzing, and presenting qualitative and mixed method research data).

Burla L, Knierim B, Barth J, Liewald K, Duetz M, Abel T. From text to codings: Intercoder Reliability Assessment in qualitative content analysis. Nurs Res. 2008;57(2):113–7.

Butler-Kisber L, Qualitative Inquiry. Thematic, Narrative and Arts-Informed Perspectives [Internet]. 1 Oliver’s Yard, 55 City Road London EC1Y 1SP: SAGE Publications, Inc.; 2010 [cited 2023 Dec 10]. https://methods.sagepub.com/book/qualitative-inquiry-thematic-narrative-and-arts-informed-perspectives .

Ryan GW, Bernard HR. Techniques to identify themes. Field Methods. 2003;15(1):85–109.

Mwaka AD, Okello ES, Wabinga H. Perceptions and beliefs of lay people from northern Uganda regarding surgery for diagnosis and treatment of cervical cancer. Psycho-oncology. 2018;27(8):1965–70.

Mwaka AD, Garimoi CO, Were EM, Roland M, Wabinga H, Lyratzopoulos G. Social, demographic and healthcare factors associated with stage at diagnosis of cervical cancer: cross-sectional study in a tertiary hospital in Northern Uganda. BMJ Open. 2016;6(1):e007690.

Download references

Acknowledgements

We would like to acknowledge the contribution of our study coordinators, Grace Namisi and Ishita Ghai, who were responsible for participation recruitment and all data collection and data management. We thank the women and men who agreed to participate in the study.

This research is funded by a grant from the Fogarty International Center, National Institutes of Health (R21TW011728; PI: Wanyenze).

Author information

Authors and affiliations.

RAND Corporation, 1776 Main Street, Santa Monica, CA, 90411, USA

Kathryn Bouskill, Glenn J. Wagner & Mahlet Gizaw

School of Public Health, Makerere University, Kampala, Uganda

Joseph KB Matovu & Rhoda K. Wanyenze

Faculty of Health Sciences, Busitema University, Mbale, Uganda

Joseph KB Matovu

Rays of Hope Hospice Jinja, Jinja, Uganda

Margrethe Juncker & Sylvia Nakami

African Palliative Care Association, Kampala, Uganda

Eve Namisango & Emmanuel Luyirika

Mulago Specialized Women and Neonatal Hospital, Kampala, Uganda

Jolly Beyeza-Kashesya

School of Medicine, Makerere University, Kampala, Uganda

Frederick S. Pardee RAND Graduate School, RAND Corporation, Santa Monica, CA, USA

Rhoda K. Wanyenze

You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study design and data collection. Material preparation and data analysis were performed by KB and MG. The first draft of the manuscript was written by KB and GW, and all authors contributed significantly to editing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kathryn Bouskill .

Ethics declarations

Ethics approval and consent to participate.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Written informed consent was obtained from all individual participants included in the study. The study protocol was approved by the Makerere University School of Public Health Research and Ethics Committee, and Uganda National Council for Science and Technology. The approval number is: SPH-2021-103.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Bouskill, K., Wagner, G.J., Gizaw, M. et al. Understanding women’s and men’s perspectives on cervical cancer screening in Uganda: a qualitative study. BMC Cancer 24 , 933 (2024). https://doi.org/10.1186/s12885-024-12671-2

Download citation

Received : 26 December 2023

Accepted : 22 July 2024

Published : 01 August 2024

DOI : https://doi.org/10.1186/s12885-024-12671-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Cervical cancer screening
Facilitators
Social beliefs
Spousal support

ISSN: 1471-2407

Submission enquiries: [email protected]
General enquiries: [email protected]

Log in using your username and password

Search More Search for this keyword Advanced search
Latest content
Current issue
BMJ Journals

Alex I P Craston 1 ,
Harriet Scott-Murfitt 1 ,
Mariam T Omar 1 ,
Ruw Abeyratne 2 ,
Kate Kirk 3 ,
Nicola Mackintosh 3 ,
http://orcid.org/0000-0001-9334-5144 Damian Roland 2 , 3 ,
http://orcid.org/0000-0002-2570-7112 James David van Oppen 3 , 4
1 Medical School , University of Leicester , Leicester , UK
2 Emergency & Specialist Medicine , University Hospitals of Leicester NHS Trust , Leicester , UK
3 Department of Population Health Sciences , University of Leicester , Leicester , UK
4 Centre for Urgent and Emergency Care Research (CURE) , The University of Sheffield , Sheffield , UK
Correspondence to Dr James David van Oppen; james.vanoppen{at}doctors.org.uk

Background Emergency department (ED) crowding causes increased mortality. Professionals working in crowded departments feel unable to provide high-quality care and are predisposed to burnout. Awareness of the impact on patients, however, is limited to metrics and surveys rather than understanding perspectives. This project investigated patients’ experiences and identified mitigating interventions.

Methods A qualitative service evaluation was undertaken in a large UK ED. Adults were recruited during periods of high occupancy or delayed transfers. Semi-structured interviews explored experience during these attendances. Participants shared potential mitigating interventions. Analysis was based on the interpretative phenomenological approach. Verbatim transcripts were read, checked for accuracy, re-read and discussed during interviewer debriefing. Reflections about positionality informed the interpretative process.

Results Seven patients and three accompanying partners participated. They were aged 24–87 with characteristics representing the catchment population. Participants’ experiences were characterised by ‘loss of autonomy’, ‘unmet expectations’ and ‘vulnerability’. Potential mitigating interventions centred around information provision and better identification of existing ED facilities for personal needs.

Conclusion Participants attending a crowded ED experienced uncertainty, helplessness and discomfort. Recommendations included process and environmental orientation.

emergency care systems

Data availability statement

No data are available.

https://doi.org/10.1136/emermed-2023-213751

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Handling editor Liza Keating

X @damian_roland, @J_vanOppen

AIPC, HS-M and MTO contributed equally.

Contributors JDvO conceptualised the project. AIPC, HS-M, MTO and JDvO collected and analysed the data and wrote the first draft. RA, KK, NM and DR gave academic supervision and reviewed the first draft. All authors revised the draft manuscripts. JDvO accepts full responsibility as guarantor for the work and conduct of the study.

Funding This project was not specifically funded. JDvO was funded by the National Institute for Health and Care Research (NIHR): Doctoral Research Fellowship 300901 and Clinical Lectureship.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting, or dissemination of this service evaluation.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Read the full text or download the PDF:

IMAGES

How to establish the validity and reliability of qualitative research?
Types of reliability in qualitative research
Understanding reliability and validity in qualitative research
Validity and Reliability in Qualitative Research
Reliability in qualitative research pdf
Validity and Reliability in Qualitative Research

VIDEO

BSN
QUANTITATIVE METHODOLOGY (Part 2 of 3):
Validity and Reliability in Research
Objectivity, Validity and Reliability in Qualitative Research
MSO-002 Research Methodologies and Methods
Research Methodology: Philosophically Explained!

COMMENTS

Validity, reliability, and generalizability in qualitative research
In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative ...
Issues of validity and reliability in qualitative research
Although the tests and measures used to establish the validity and reliability of quantitative research cannot be applied to qualitative research, there are ongoing debates about whether terms such as validity, reliability and generalisability are appropriate to evaluate qualitative research.2-4 In the broadest context these terms are applicable, with validity referring to the integrity and ...
Rigor or Reliability and Validity in Qualitative Research
nts the concept of rigor in qualitative research using a phenomenological study as an exemplar to further illustrate the process. Elaborating on epistemological and theoretical conceptualizations by Lincoln and Guba, strategies congruent with qualitative perspective for ensuring validity to establish the credibility of the study are described. A synthesis of the historical development of ...
Verification Strategies for Establishing Reliability and Validity in
The rejection of reliability and validity in qualitative inquiry in the 1980s has resulted in an interesting shift for "ensuring rigor" from the investigator's actions during the course of the research, to the reader or consumer of qualitative inquiry.
Contextualizing reliability and validity in qualitative research
Issues of trustworthiness in qualitative leisure research, often demonstrated through particular techniques of reliability and/or validity, is often either nonexistent, unsubstantial, or unexplaine...
What Is Qualitative Research? An Overview and Guidelines
This guide explains the focus, rigor, and relevance of qualitative research, highlighting its role in dissecting complex social phenomena and providing in-depth, human-centered insights. The guide ...
A Review of the Quality Indicators of Rigor in Qualitative Research
Generating and refining a qualitative research question requires thorough, systematic, and iterative review of the literature, and the use of those results to establish a clear context and foundation for the question and study design.
(PDF) Validity and Reliability in Qualitative Research
In qualitative research, the validity of the findings is critical. Arslan (2022) and Hayashi et al. (2019) underscore the need for a processual approach to validity, with Arslan providing a ...
Inter-Rater Reliability Methods in Qualitative Case Study Research
Central to all research is the goal of finding plausible and credible outcome explanations using the concepts of reliability and validity to attain rigor as "without rigor, research is worthless, becomes fiction, and loses its utility" (Morse et al. 2002:14).The validity of theory or findings (assuring that what is measured accurately reflects what is intended) and reliability (assuring ...
Reliability and Validity in Qualitative Research
Kirk and Miller define what is -- and what is not -- qualitative research. They suggest that the use of numbers in the process of recording and analyzing observations is less important than that the research should involve sustained interaction with the people being studied, in their own language and on their own turf.
How is reliability and validity realized in qualitative research?
Reliability in qualitative research refers to the stability of responses to multiple coders of data sets. It can be enhanced by detailed field notes by using recording devices and by transcribing the digital files. However, validity in qualitative research might have different terms than in quantitative research. Lincoln and Guba (1985) used "trustworthiness" of ...
PDF Issues of validity and reliability in qualitative research
Issues of validity and reliability in qualitative research Helen Noble,1 Joanna Smith2 Evaluating the quality of research is essential if ﬁndings are to be utilised in practice and incorporated into care
The pillars of trustworthiness in qualitative research
Dear Editor, The global community of medical and nursing researchers has increasingly embraced qualitative research approaches. This surge is seen in their autonomous utilization or incorporation as essential elements within mixed-method research attempts [1].The growing trend is driven by the recognized additional benefits that qualitative approaches provide to the investigation process [2], [3].
Understanding Reliability and Validity in Qualitative Research
The Qualitative Report Volume 8 Number 4 Article 6 12-1-2003 Understanding Reliability and Validity in Qualitative Research Nahid Golafshani
Rigor or Reliability and Validity in Qualitative Research: Perspectives
Issues are still raised even now in the 21st century by the persistent concern with achieving rigor in qualitative research. There is also a continuing debate about the analogous terms reliability and validity in naturalistic inquiries as opposed to quantitative investigations. This article presents …
Validity and Reliability in Qualitative research
What is Validity and Reliability in Qualitative research? In Quantitative research, reliability refers to consistency of certain measurements, and validity - to whether these measurements "measure what they are supposed to measure". Things are slightly different, however, in Qualitative research.. Reliability in qualitative studies is mostly a matter of "being thorough, careful and ...
Reliability and Inter-rater Reliability in Qualitative Research:
What does reliability mean for building a grounded theory? What about when writing an auto-ethnography? When is it appropriate to use measures like inter-rater reliability (IRR)? Reliability is a familiar concept in traditional scientific practice, but ...
Series: Practical guidance to qualitative research. Part 4
Introduction. This article is the fourth and last in a series of four articles aiming to provide practical guidance for qualitative research. In an introductory paper, we have described the objective, nature and outline of the series [].Part 2 of the series focused on context, research questions and design of qualitative research [], whereas Part 3 concerned sampling, data collection and ...
Understanding Reliability and Validity in Qualitative Research
The use of reliability and validity are common in quantitative research and now it is reconsidered in the qualitative research paradigm. Since reliability and validity are rooted in positivist ...
Validity and Reliability in Qualitative Research
Qualitative research is needed to answer questions not suited for quantitative research, validity and reliability need to be considered too.
Validity in Qualitative Evaluation: Linking Purposes, Paradigms, and
However, the increased importance given to qualitative information in the evidence-based paradigm in health care and social policy requires a more precise conceptualization of validity criteria that goes beyond just academic reflection. After all, one can argue that policy verdicts that are based on qualitative information must be legitimized by valid research, just as quantitative effect ...
Reliability vs. Validity in Research
Types of reliability; Type of reliability What does it assess? Example; Test-retest reliability: The consistency of a measure across time: do you get the same results when you repeat the measurement?: A group of participants complete a questionnaire designed to measure personality traits. If they repeat the questionnaire days, weeks or months apart and give the same answers, this indicates ...
PDF Validity and Reliability within Qualitative Research in the Caring Sciences
International Journal of Caring Sciences September-December 2021 Volume 14| Issue 3| Page 2041 www.internationaljournalofcaringsciences.org
Comprehensive Criteria for Reporting Qualitative Research (CCQR
Globally, the demand for qualitative research has risen, driven by the health sector's need for in-depth investigation of complex issues behind any phenomenon that may be inadequately comprehended and that other research methods cannot explore, uncover, or describe. The authors aimed to improve the accessibility and comprehensiveness of reporting guidelines for qualitative research.
What is trustworthiness in qualitative research and how can you improve
Credibility: The confidence in the truth of the findings.It parallels internal validity in quantitative research. Transferability: The extent to which the findings can be applied in other contexts ...
How to use and assess qualitative research methods
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.
Post-Disaster Social Connectedness in Parent-Child Dyads: A Qualitative
Lisa Stribley, Govind Krishnamoorthy, Vicki Dallinger, Jennifer Ma, Thomas Nielson, India Bryce, Bronwyn Rees, Alyssa Morse, Marg Rogers, Lorelle Burton, Post-Disaster Social Connectedness in Parent-Child Dyads: A Qualitative Investigation of Changes in Coping and Social Capital of Rural Australian Families Following Bushfires, The British Journal of Social Work, 2024;, bcae123, https://doi ...
Frontiers
Instruments Demographic, crime, and institutional behavior interview. This interview was designed for this research study and consists of collecting information about sociodemographic data, type of offenses (drug possession and/or consumption and gender violence crimes) and their penalties, and sanctions within the prison according to the Prison Regulations (Royal Decree 1201/1981, May 8 ...
Understanding women's and men's perspectives on cervical cancer
Study design. This paper presents findings from the qualitative research conducted in the initial phase of a larger study that conducted a pilot randomised-controlled trial of a peer-led, group intervention aimed at training women who had screened for CC to conduct advocacy for CC screening among women in their social networks [23, 24].This first phase consisted of a series of seven focus ...
Being a patient in a crowded emergency department: a qualitative
Background Emergency department (ED) crowding causes increased mortality. Professionals working in crowded departments feel unable to provide high-quality care and are predisposed to burnout. Awareness of the impact on patients, however, is limited to metrics and surveys rather than understanding perspectives. This project investigated patients' experiences and identified mitigating ...

Secondary Logo

Rigor or Reliability and Validity in Qualitative Research: Perspectives, Strategies, Reconceptualization, and Recommendations

RIGOR VERSUS TRUSTWORTHINESS

THE RIGOR DEBATES: TRUSTWORTHINESS OR RELIABILITY AND VALIDITY?

RELIABILITY AND VALIDITY IN QUALITATIVE RESEARCH

Reliability

Reliability and Validity as Means in Ensuring the Quality of Findings of a Phenomenological Study in Intensive Care Unit

Supplemental Digital Content

Readers Of this Article Also Read

Save citation to file

Add to My Bibliography

Rigor or Reliability and Validity in Qualitative Research: Perspectives, Strategies, Reconceptualization, and Recommendations

Similar articles

Related information

Other Literature Sources

Articles and blog posts

What is Validity and Reliability in Qualitative research?

So, what exactly are these strategies and how can you apply them in your research?

Reliability and Inter-rater Reliability in Qualitative Research: Norms and Guidelines for CSCW and HCI Practice

New Citation Alert added!

New Citation Alert!

Information & Contributors

Index Terms

Recommendations

Testing the reliability of inter-rater reliability

Inter-rater reliability and validity of peer reviews in an interdisciplinary field

Information

Publication History

Funding Sources

View options

Login options

Full Access

Share on social media

Validity and Reliability in Qualitative Research

Privacy Overview

Have a language expert improve your writing

Reliability vs. Validity in Research | Difference, Types and Examples

Table of contents

What is reliability?

What is validity?

Receive feedback on language, structure, and formatting

Types of reliability

Types of validity

Ensuring validity

Ensuring reliability

Here's why students love Scribbr's proofreading services

Cite this Scribbr article

Is this article helpful?

Fiona Middleton

How to use and assess qualitative research methods

Wolfgang Wick

Christoph Gumbinger

What is qualitative research?

Why conduct qualitative research?

How to conduct qualitative research?

Data collection

Document study

Observations

Semi-structured interviews

Focus groups

Choosing the “right” method

Data analysis

How to report qualitative research?

How to combine qualitative with quantitative research?

How to assess qualitative research?

Reflexivity

Sampling and saturation

Member checking

Stakeholder involvement

How not to assess qualitative research

Protocol adherence

Sample size

Randomisation

Interrater reliability, variability and other “objectivity checks”

Not being quantitative research

Acknowledgements

Authors’ contributions

Availability of data and materials

Article Contents

Summary and research context