research study on qualitative

Qualitative Study

Affiliations.

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

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

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

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

Examples of Qualitative Research Approaches

Ethnography

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

Grounded Theory

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

Phenomenology

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

Narrative Research

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

Research Paradigm

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

Positivist vs Postpositivist

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

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

Constructivist

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

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

Data Sampling

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

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

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

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

Extreme case sampling- targeted selection of rare cases.

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

Data Collection and Analysis

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

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

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

Dissemination

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

Examples of Application

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

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

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

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

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

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

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

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

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

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

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

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• Study Guide

• Open access
• Published: 27 May 2020

How to use and assess qualitative research methods

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

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

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

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Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z

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Qualitative Research : Definition

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Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

Qualitative research is a type of research methodology that focuses on exploring and understanding people’s beliefs, attitudes, behaviors, and experiences through the collection and analysis of non-numerical data. It seeks to answer research questions through the examination of subjective data, such as interviews, focus groups, observations, and textual analysis.

Qualitative research aims to uncover the meaning and significance of social phenomena, and it typically involves a more flexible and iterative approach to data collection and analysis compared to quantitative research. Qualitative research is often used in fields such as sociology, anthropology, psychology, and education.

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

This method involves conducting an interview with a single participant to gain a detailed understanding of their experiences, attitudes, and beliefs. One-to-one interviews can be conducted in-person, over the phone, or through video conferencing. The interviewer typically uses open-ended questions to encourage the participant to share their thoughts and feelings. One-to-one interviews are useful for gaining detailed insights into individual experiences.

Focus Groups

This method involves bringing together a group of people to discuss a specific topic in a structured setting. The focus group is led by a moderator who guides the discussion and encourages participants to share their thoughts and opinions. Focus groups are useful for generating ideas and insights, exploring social norms and attitudes, and understanding group dynamics.

Ethnographic Studies

This method involves immersing oneself in a culture or community to gain a deep understanding of its norms, beliefs, and practices. Ethnographic studies typically involve long-term fieldwork and observation, as well as interviews and document analysis. Ethnographic studies are useful for understanding the cultural context of social phenomena and for gaining a holistic understanding of complex social processes.

Text Analysis

This method involves analyzing written or spoken language to identify patterns and themes. Text analysis can be quantitative or qualitative. Qualitative text analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Text analysis is useful for understanding media messages, public discourse, and cultural trends.

This method involves an in-depth examination of a single person, group, or event to gain an understanding of complex phenomena. Case studies typically involve a combination of data collection methods, such as interviews, observations, and document analysis, to provide a comprehensive understanding of the case. Case studies are useful for exploring unique or rare cases, and for generating hypotheses for further research.

Process of Observation

This method involves systematically observing and recording behaviors and interactions in natural settings. The observer may take notes, use audio or video recordings, or use other methods to document what they see. Process of observation is useful for understanding social interactions, cultural practices, and the context in which behaviors occur.

Record Keeping

This method involves keeping detailed records of observations, interviews, and other data collected during the research process. Record keeping is essential for ensuring the accuracy and reliability of the data, and for providing a basis for analysis and interpretation.

This method involves collecting data from a large sample of participants through a structured questionnaire. Surveys can be conducted in person, over the phone, through mail, or online. Surveys are useful for collecting data on attitudes, beliefs, and behaviors, and for identifying patterns and trends in a population.

Qualitative data analysis is a process of turning unstructured data into meaningful insights. It involves extracting and organizing information from sources like interviews, focus groups, and surveys. The goal is to understand people’s attitudes, behaviors, and motivations

Qualitative Research Analysis Methods

Qualitative Research analysis methods involve a systematic approach to interpreting and making sense of the data collected in qualitative research. Here are some common qualitative data analysis methods:

Thematic Analysis

This method involves identifying patterns or themes in the data that are relevant to the research question. The researcher reviews the data, identifies keywords or phrases, and groups them into categories or themes. Thematic analysis is useful for identifying patterns across multiple data sources and for generating new insights into the research topic.

Content Analysis

This method involves analyzing the content of written or spoken language to identify key themes or concepts. Content analysis can be quantitative or qualitative. Qualitative content analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Content analysis is useful for identifying patterns in media messages, public discourse, and cultural trends.

Discourse Analysis

This method involves analyzing language to understand how it constructs meaning and shapes social interactions. Discourse analysis can involve a variety of methods, such as conversation analysis, critical discourse analysis, and narrative analysis. Discourse analysis is useful for understanding how language shapes social interactions, cultural norms, and power relationships.

Grounded Theory Analysis

This method involves developing a theory or explanation based on the data collected. Grounded theory analysis starts with the data and uses an iterative process of coding and analysis to identify patterns and themes in the data. The theory or explanation that emerges is grounded in the data, rather than preconceived hypotheses. Grounded theory analysis is useful for understanding complex social phenomena and for generating new theoretical insights.

Narrative Analysis

This method involves analyzing the stories or narratives that participants share to gain insights into their experiences, attitudes, and beliefs. Narrative analysis can involve a variety of methods, such as structural analysis, thematic analysis, and discourse analysis. Narrative analysis is useful for understanding how individuals construct their identities, make sense of their experiences, and communicate their values and beliefs.

Phenomenological Analysis

This method involves analyzing how individuals make sense of their experiences and the meanings they attach to them. Phenomenological analysis typically involves in-depth interviews with participants to explore their experiences in detail. Phenomenological analysis is useful for understanding subjective experiences and for developing a rich understanding of human consciousness.

Comparative Analysis

This method involves comparing and contrasting data across different cases or groups to identify similarities and differences. Comparative analysis can be used to identify patterns or themes that are common across multiple cases, as well as to identify unique or distinctive features of individual cases. Comparative analysis is useful for understanding how social phenomena vary across different contexts and groups.

Applications of Qualitative Research

Qualitative research has many applications across different fields and industries. Here are some examples of how qualitative research is used:

• Market Research: Qualitative research is often used in market research to understand consumer attitudes, behaviors, and preferences. Researchers conduct focus groups and one-on-one interviews with consumers to gather insights into their experiences and perceptions of products and services.
• Health Care: Qualitative research is used in health care to explore patient experiences and perspectives on health and illness. Researchers conduct in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education: Qualitative research is used in education to understand student experiences and to develop effective teaching strategies. Researchers conduct classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work : Qualitative research is used in social work to explore social problems and to develop interventions to address them. Researchers conduct in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : Qualitative research is used in anthropology to understand different cultures and societies. Researchers conduct ethnographic studies and observe and interview members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : Qualitative research is used in psychology to understand human behavior and mental processes. Researchers conduct in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy : Qualitative research is used in public policy to explore public attitudes and to inform policy decisions. Researchers conduct focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

• Identify your research question: Qualitative research starts with a research question or set of questions that you want to explore. This question should be focused and specific, but also broad enough to allow for exploration and discovery.
• Select your research design: There are different types of qualitative research designs, including ethnography, case study, grounded theory, and phenomenology. You should select a design that aligns with your research question and that will allow you to gather the data you need to answer your research question.
• Recruit participants: Once you have your research question and design, you need to recruit participants. The number of participants you need will depend on your research design and the scope of your research. You can recruit participants through advertisements, social media, or through personal networks.
• Collect data: There are different methods for collecting qualitative data, including interviews, focus groups, observation, and document analysis. You should select the method or methods that align with your research design and that will allow you to gather the data you need to answer your research question.
• Analyze data: Once you have collected your data, you need to analyze it. This involves reviewing your data, identifying patterns and themes, and developing codes to organize your data. You can use different software programs to help you analyze your data, or you can do it manually.
• Interpret data: Once you have analyzed your data, you need to interpret it. This involves making sense of the patterns and themes you have identified, and developing insights and conclusions that answer your research question. You should be guided by your research question and use your data to support your conclusions.
• Communicate results: Once you have interpreted your data, you need to communicate your results. This can be done through academic papers, presentations, or reports. You should be clear and concise in your communication, and use examples and quotes from your data to support your findings.

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

• Customer Feedback: A company may conduct qualitative research to understand the feedback and experiences of its customers. This may involve conducting focus groups or one-on-one interviews with customers to gather insights into their attitudes, behaviors, and preferences.
• Healthcare : A healthcare provider may conduct qualitative research to explore patient experiences and perspectives on health and illness. This may involve conducting in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education : An educational institution may conduct qualitative research to understand student experiences and to develop effective teaching strategies. This may involve conducting classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work: A social worker may conduct qualitative research to explore social problems and to develop interventions to address them. This may involve conducting in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : An anthropologist may conduct qualitative research to understand different cultures and societies. This may involve conducting ethnographic studies and observing and interviewing members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : A psychologist may conduct qualitative research to understand human behavior and mental processes. This may involve conducting in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy: A government agency or non-profit organization may conduct qualitative research to explore public attitudes and to inform policy decisions. This may involve conducting focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

Purpose of Qualitative Research

The purpose of qualitative research is to explore and understand the subjective experiences, behaviors, and perspectives of individuals or groups in a particular context. Unlike quantitative research, which focuses on numerical data and statistical analysis, qualitative research aims to provide in-depth, descriptive information that can help researchers develop insights and theories about complex social phenomena.

Qualitative research can serve multiple purposes, including:

• Exploring new or emerging phenomena : Qualitative research can be useful for exploring new or emerging phenomena, such as new technologies or social trends. This type of research can help researchers develop a deeper understanding of these phenomena and identify potential areas for further study.
• Understanding complex social phenomena : Qualitative research can be useful for exploring complex social phenomena, such as cultural beliefs, social norms, or political processes. This type of research can help researchers develop a more nuanced understanding of these phenomena and identify factors that may influence them.
• Generating new theories or hypotheses: Qualitative research can be useful for generating new theories or hypotheses about social phenomena. By gathering rich, detailed data about individuals’ experiences and perspectives, researchers can develop insights that may challenge existing theories or lead to new lines of inquiry.
• Providing context for quantitative data: Qualitative research can be useful for providing context for quantitative data. By gathering qualitative data alongside quantitative data, researchers can develop a more complete understanding of complex social phenomena and identify potential explanations for quantitative findings.

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

• Exploring a new area: If little is known about a particular topic, qualitative research can help to identify key issues, generate hypotheses, and develop new theories.
• Understanding complex phenomena: Qualitative research can be used to investigate complex social, cultural, or organizational phenomena that are difficult to measure quantitatively.
• Investigating subjective experiences: Qualitative research is particularly useful for investigating the subjective experiences of individuals or groups, such as their attitudes, beliefs, values, or emotions.
• Conducting formative research: Qualitative research can be used in the early stages of a research project to develop research questions, identify potential research participants, and refine research methods.
• Evaluating interventions or programs: Qualitative research can be used to evaluate the effectiveness of interventions or programs by collecting data on participants’ experiences, attitudes, and behaviors.

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

• Focus on subjective experience: Qualitative research is concerned with understanding the subjective experiences, beliefs, and perspectives of individuals or groups in a particular context. Researchers aim to explore the meanings that people attach to their experiences and to understand the social and cultural factors that shape these meanings.
• Use of open-ended questions: Qualitative research relies on open-ended questions that allow participants to provide detailed, in-depth responses. Researchers seek to elicit rich, descriptive data that can provide insights into participants’ experiences and perspectives.
• Sampling-based on purpose and diversity: Qualitative research often involves purposive sampling, in which participants are selected based on specific criteria related to the research question. Researchers may also seek to include participants with diverse experiences and perspectives to capture a range of viewpoints.
• Data collection through multiple methods: Qualitative research typically involves the use of multiple data collection methods, such as in-depth interviews, focus groups, and observation. This allows researchers to gather rich, detailed data from multiple sources, which can provide a more complete picture of participants’ experiences and perspectives.
• Inductive data analysis: Qualitative research relies on inductive data analysis, in which researchers develop theories and insights based on the data rather than testing pre-existing hypotheses. Researchers use coding and thematic analysis to identify patterns and themes in the data and to develop theories and explanations based on these patterns.
• Emphasis on researcher reflexivity: Qualitative research recognizes the importance of the researcher’s role in shaping the research process and outcomes. Researchers are encouraged to reflect on their own biases and assumptions and to be transparent about their role in the research process.

Advantages of Qualitative Research

Qualitative research offers several advantages over other research methods, including:

• Depth and detail: Qualitative research allows researchers to gather rich, detailed data that provides a deeper understanding of complex social phenomena. Through in-depth interviews, focus groups, and observation, researchers can gather detailed information about participants’ experiences and perspectives that may be missed by other research methods.
• Flexibility : Qualitative research is a flexible approach that allows researchers to adapt their methods to the research question and context. Researchers can adjust their research methods in real-time to gather more information or explore unexpected findings.
• Contextual understanding: Qualitative research is well-suited to exploring the social and cultural context in which individuals or groups are situated. Researchers can gather information about cultural norms, social structures, and historical events that may influence participants’ experiences and perspectives.
• Participant perspective : Qualitative research prioritizes the perspective of participants, allowing researchers to explore subjective experiences and understand the meanings that participants attach to their experiences.
• Theory development: Qualitative research can contribute to the development of new theories and insights about complex social phenomena. By gathering rich, detailed data and using inductive data analysis, researchers can develop new theories and explanations that may challenge existing understandings.
• Validity : Qualitative research can offer high validity by using multiple data collection methods, purposive and diverse sampling, and researcher reflexivity. This can help ensure that findings are credible and trustworthy.

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

• Subjectivity : Qualitative research relies on the subjective interpretation of researchers, which can introduce bias into the research process. The researcher’s perspective, beliefs, and experiences can influence the way data is collected, analyzed, and interpreted.
• Limited generalizability: Qualitative research typically involves small, purposive samples that may not be representative of larger populations. This limits the generalizability of findings to other contexts or populations.
• Time-consuming: Qualitative research can be a time-consuming process, requiring significant resources for data collection, analysis, and interpretation.
• Resource-intensive: Qualitative research may require more resources than other research methods, including specialized training for researchers, specialized software for data analysis, and transcription services.
• Limited reliability: Qualitative research may be less reliable than quantitative research, as it relies on the subjective interpretation of researchers. This can make it difficult to replicate findings or compare results across different studies.
• Ethics and confidentiality: Qualitative research involves collecting sensitive information from participants, which raises ethical concerns about confidentiality and informed consent. Researchers must take care to protect the privacy and confidentiality of participants and obtain informed consent.

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Qualitative Research Using R: A Systematic Approach pp 1–19 Cite as

Qualitative Research: An Overview

• Yanto Chandra 3 &
• Liang Shang 4  
• First Online: 24 April 2019

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Qualitative research is one of the most commonly used types of research and methodology in the social sciences. Unfortunately, qualitative research is commonly misunderstood. In this chapter, we describe and explain the misconceptions surrounding qualitative research enterprise, why researchers need to care about when using qualitative research, the characteristics of qualitative research, and review the paradigms in qualitative research.

• Qualitative research
• Gioia approach
• Yin-Eisenhardt approach
• Langley approach
• Interpretivism

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Qualitative research is defined as the practice used to study things –– individuals and organizations and their reasons, opinions, and motivations, beliefs in their natural settings. It involves an observer (a researcher) who is located in the field , who transforms the world into a series of representations such as fieldnotes, interviews, conversations, photographs, recordings and memos (Denzin and Lincoln 2011 ). Many researchers employ qualitative research for exploratory purpose while others use it for ‘quasi’ theory testing approach. Qualitative research is a broad umbrella of research methodologies that encompasses grounded theory (Glaser and Strauss 2017 ; Strauss and Corbin 1990 ), case study (Flyvbjerg 2006 ; Yin 2003 ), phenomenology (Sanders 1982 ), discourse analysis (Fairclough 2003 ; Wodak and Meyer 2009 ), ethnography (Geertz 1973 ; Garfinkel 1967 ), and netnography (Kozinets 2002 ), among others. Qualitative research is often synonymous with ‘case study research’ because ‘case study’ primarily uses (but not always) qualitative data.

The quality standards or evaluation criteria of qualitative research comprises: (1) credibility (that a researcher can provide confidence in his/her findings), (2) transferability (that results are more plausible when transported to a highly similar contexts), (3) dependability (that errors have been minimized, proper documentation is provided), and (4) confirmability (that conclusions are internally consistent and supported by data) (see Lincoln and Guba 1985 ).

We classify research into a continuum of theory building — >   theory elaboration — >   theory testing . Theory building is also known as theory exploration. Theory elaboration refers to the use of qualitative data and a method to seek “confirmation” of the relationships among variables or processes or mechanisms of a social reality (Bartunek and Rynes 2015 ).

In the context of qualitative research, theory/ies usually refer(s) to conceptual model(s) or framework(s) that explain the relationships among a set of variables or processes that explain a social phenomenon. Theory or theories could also refer to general ideas or frameworks (e.g., institutional theory, emancipation theory, or identity theory) that are reviewed as background knowledge prior to the commencement of a qualitative research project.

For example, a qualitative research can ask the following question: “How can institutional change succeed in social contexts that are dominated by organized crime?” (Vaccaro and Palazzo 2015 ).

We have witnessed numerous cases in which committed positivist methodologists were asked to review qualitative papers, and they used a survey approach to assess the quality of an interpretivist work. This reviewers’ fallacy is dangerous and hampers the progress of a field of research. Editors must be cognizant of such fallacy and avoid it.

A social enterprises (SE) is an organization that combines social welfare and commercial logics (Doherty et al. 2014 ), or that uses business principles to address social problems (Mair and Marti 2006 ); thus, qualitative research that reports that ‘social impact’ is important for SEs is too descriptive and, arguably, tautological. It is not uncommon to see authors submitting purely descriptive papers to scholarly journals.

Some qualitative researchers have conducted qualitative work using primarily a checklist (ticking the boxes) to show the presence or absence of variables, as if it were a survey-based study. This is utterly inappropriate for a qualitative work. A qualitative work needs to show the richness and depth of qualitative findings. Nevertheless, it is acceptable to use such checklists as supplementary data if a study involves too many informants or variables of interest, or the data is too complex due to its longitudinal nature (e.g., a study that involves 15 cases observed and involving 59 interviews with 33 informants within a 7-year fieldwork used an excel sheet to tabulate the number of events that occurred as supplementary data to the main analysis; see Chandra 2017a , b ).

As mentioned earlier, there are different types of qualitative research. Thus, a qualitative researcher will customize the data collection process to fit the type of research being conducted. For example, for researchers using ethnography, the primary data will be in the form of photos and/or videos and interviews; for those using netnography, the primary data will be internet-based textual data. Interview data is perhaps the most common type of data used across all types of qualitative research designs and is often synonymous with qualitative research.

The purpose of qualitative research is to provide an explanation , not merely a description and certainly not a prediction (which is the realm of quantitative research). However, description is needed to illustrate qualitative data collected, and usually researchers describe their qualitative data by inserting a number of important “informant quotes” in the body of a qualitative research report.

We advise qualitative researchers to adhere to one approach to avoid any epistemological and ontological mismatch that may arise among different camps in qualitative research. For instance, mixing a positivist with a constructivist approach in qualitative research frequently leads to unnecessary criticism and even rejection from journal editors and reviewers; it shows a lack of methodological competence or awareness of one’s epistemological position.

Analytical generalization is not generalization to some defined population that has been sampled, but to a “theory” of the phenomenon being studied, a theory that may have much wider applicability than the particular case studied (Yin 2003 ).

There are different types of contributions. Typically, a researcher is expected to clearly articulate the theoretical contributions for a qualitative work submitted to a scholarly journal. Other types of contributions are practical (or managerial ), common for business/management journals, and policy , common for policy related journals.

There is ongoing debate on whether a template for qualitative research is desirable or necessary, with one camp of scholars (the pluralistic critical realists) that advocates a pluralistic approaches to qualitative research (“qualitative research should not follow a particular template or be prescriptive in its process”) and the other camps are advocating for some form of consensus via the use of particular approaches (e.g., the Eisenhardt or Gioia Approach, etc.). However, as shown in Table 1.1 , even the pluralistic critical realism in itself is a template and advocates an alternative form of consensus through the use of diverse and pluralistic approaches in doing qualitative research.

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The word qualitative implies an emphasis on the qualities of entities and on processes and meanings that are not experimentally examined or measured [if measured at all] in terms of quantity, amount, intensity, or frequency. Qualitative researchers stress the socially constructed nature of reality, the intimate relationship between the researcher and what is studied, and the situational constraints that shape inquiry. Such researchers emphasize the value-laden nature of inquiry. They seek answers to questions that stress how social experience is created and given meaning. In contrast, quantitative studies emphasize the measurement and analysis of causal relationships between variables, not processes. Qualitative forms of inquiry are considered by many social and behavioral scientists to be as much a perspective on how to approach investigating a research problem as it is a method.

Denzin, Norman. K. and Yvonna S. Lincoln. “Introduction: The Discipline and Practice of Qualitative Research.” In The Sage Handbook of Qualitative Research . Norman. K. Denzin and Yvonna S. Lincoln, eds. 3 rd edition. (Thousand Oaks, CA: Sage, 2005), p. 10.

Characteristics of Qualitative Research

Below are the three key elements that define a qualitative research study and the applied forms each take in the investigation of a research problem.

• Naturalistic -- refers to studying real-world situations as they unfold naturally; non-manipulative and non-controlling; the researcher is open to whatever emerges [i.e., there is a lack of predetermined constraints on findings].
• Emergent -- acceptance of adapting inquiry as understanding deepens and/or situations change; the researcher avoids rigid designs that eliminate responding to opportunities to pursue new paths of discovery as they emerge.
• Purposeful -- cases for study [e.g., people, organizations, communities, cultures, events, critical incidences] are selected because they are “information rich” and illuminative. That is, they offer useful manifestations of the phenomenon of interest; sampling is aimed at insight about the phenomenon, not empirical generalization derived from a sample and applied to a population.

The Collection of Data

• Data -- observations yield a detailed, "thick description" [in-depth understanding]; interviews capture direct quotations about people’s personal perspectives and lived experiences; often derived from carefully conducted case studies and review of material culture.
• Personal experience and engagement -- researcher has direct contact with and gets close to the people, situation, and phenomenon under investigation; the researcher’s personal experiences and insights are an important part of the inquiry and critical to understanding the phenomenon.
• Empathic neutrality -- an empathic stance in working with study respondents seeks vicarious understanding without judgment [neutrality] by showing openness, sensitivity, respect, awareness, and responsiveness; in observation, it means being fully present [mindfulness].
• Dynamic systems -- there is attention to process; assumes change is ongoing, whether the focus is on an individual, an organization, a community, or an entire culture, therefore, the researcher is mindful of and attentive to system and situational dynamics.

The Analysis

• Unique case orientation -- assumes that each case is special and unique; the first level of analysis is being true to, respecting, and capturing the details of the individual cases being studied; cross-case analysis follows from and depends upon the quality of individual case studies.
• Inductive analysis -- immersion in the details and specifics of the data to discover important patterns, themes, and inter-relationships; begins by exploring, then confirming findings, guided by analytical principles rather than rules.
• Holistic perspective -- the whole phenomenon under study is understood as a complex system that is more than the sum of its parts; the focus is on complex interdependencies and system dynamics that cannot be reduced in any meaningful way to linear, cause and effect relationships and/or a few discrete variables.
• Context sensitive -- places findings in a social, historical, and temporal context; researcher is careful about [even dubious of] the possibility or meaningfulness of generalizations across time and space; emphasizes careful comparative case study analysis and extrapolating patterns for possible transferability and adaptation in new settings.
• Voice, perspective, and reflexivity -- the qualitative methodologist owns and is reflective about her or his own voice and perspective; a credible voice conveys authenticity and trustworthiness; complete objectivity being impossible and pure subjectivity undermining credibility, the researcher's focus reflects a balance between understanding and depicting the world authentically in all its complexity and of being self-analytical, politically aware, and reflexive in consciousness.

Berg, Bruce Lawrence. Qualitative Research Methods for the Social Sciences . 8th edition. Boston, MA: Allyn and Bacon, 2012; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 2nd ed. Thousand Oaks, CA: Sage Publications, 1995; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Basic Research Design for Qualitative Studies

Unlike positivist or experimental research that utilizes a linear and one-directional sequence of design steps, there is considerable variation in how a qualitative research study is organized. In general, qualitative researchers attempt to describe and interpret human behavior based primarily on the words of selected individuals [a.k.a., “informants” or “respondents”] and/or through the interpretation of their material culture or occupied space. There is a reflexive process underpinning every stage of a qualitative study to ensure that researcher biases, presuppositions, and interpretations are clearly evident, thus ensuring that the reader is better able to interpret the overall validity of the research. According to Maxwell (2009), there are five, not necessarily ordered or sequential, components in qualitative research designs. How they are presented depends upon the research philosophy and theoretical framework of the study, the methods chosen, and the general assumptions underpinning the study. Goals Describe the central research problem being addressed but avoid describing any anticipated outcomes. Questions to ask yourself are: Why is your study worth doing? What issues do you want to clarify, and what practices and policies do you want it to influence? Why do you want to conduct this study, and why should the reader care about the results? Conceptual Framework Questions to ask yourself are: What do you think is going on with the issues, settings, or people you plan to study? What theories, beliefs, and prior research findings will guide or inform your research, and what literature, preliminary studies, and personal experiences will you draw upon for understanding the people or issues you are studying? Note to not only report the results of other studies in your review of the literature, but note the methods used as well. If appropriate, describe why earlier studies using quantitative methods were inadequate in addressing the research problem. Research Questions Usually there is a research problem that frames your qualitative study and that influences your decision about what methods to use, but qualitative designs generally lack an accompanying hypothesis or set of assumptions because the findings are emergent and unpredictable. In this context, more specific research questions are generally the result of an interactive design process rather than the starting point for that process. Questions to ask yourself are: What do you specifically want to learn or understand by conducting this study? What do you not know about the things you are studying that you want to learn? What questions will your research attempt to answer, and how are these questions related to one another? Methods Structured approaches to applying a method or methods to your study help to ensure that there is comparability of data across sources and researchers and, thus, they can be useful in answering questions that deal with differences between phenomena and the explanation for these differences [variance questions]. An unstructured approach allows the researcher to focus on the particular phenomena studied. This facilitates an understanding of the processes that led to specific outcomes, trading generalizability and comparability for internal validity and contextual and evaluative understanding. Questions to ask yourself are: What will you actually do in conducting this study? What approaches and techniques will you use to collect and analyze your data, and how do these constitute an integrated strategy? Validity In contrast to quantitative studies where the goal is to design, in advance, “controls” such as formal comparisons, sampling strategies, or statistical manipulations to address anticipated and unanticipated threats to validity, qualitative researchers must attempt to rule out most threats to validity after the research has begun by relying on evidence collected during the research process itself in order to effectively argue that any alternative explanations for a phenomenon are implausible. Questions to ask yourself are: How might your results and conclusions be wrong? What are the plausible alternative interpretations and validity threats to these, and how will you deal with these? How can the data that you have, or that you could potentially collect, support or challenge your ideas about what’s going on? Why should we believe your results? Conclusion Although Maxwell does not mention a conclusion as one of the components of a qualitative research design, you should formally conclude your study. Briefly reiterate the goals of your study and the ways in which your research addressed them. Discuss the benefits of your study and how stakeholders can use your results. Also, note the limitations of your study and, if appropriate, place them in the context of areas in need of further research.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Heath, A. W. The Proposal in Qualitative Research. The Qualitative Report 3 (March 1997); Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 3rd edition. Thousand Oaks, CA: Sage, 1999; Maxwell, Joseph A. "Designing a Qualitative Study." In The SAGE Handbook of Applied Social Research Methods . Leonard Bickman and Debra J. Rog, eds. 2nd ed. (Thousand Oaks, CA: Sage, 2009), p. 214-253; Qualitative Research Methods. Writing@CSU. Colorado State University; Yin, Robert K. Qualitative Research from Start to Finish . 2nd edition. New York: Guilford, 2015.

Strengths of Using Qualitative Methods

The advantage of using qualitative methods is that they generate rich, detailed data that leave the participants' perspectives intact and provide multiple contexts for understanding the phenomenon under study. In this way, qualitative research can be used to vividly demonstrate phenomena or to conduct cross-case comparisons and analysis of individuals or groups.

Among the specific strengths of using qualitative methods to study social science research problems is the ability to:

• Obtain a more realistic view of the lived world that cannot be understood or experienced in numerical data and statistical analysis;
• Provide the researcher with the perspective of the participants of the study through immersion in a culture or situation and as a result of direct interaction with them;
• Allow the researcher to describe existing phenomena and current situations;
• Develop flexible ways to perform data collection, subsequent analysis, and interpretation of collected information;
• Yield results that can be helpful in pioneering new ways of understanding;
• Respond to changes that occur while conducting the study ]e.g., extended fieldwork or observation] and offer the flexibility to shift the focus of the research as a result;
• Provide a holistic view of the phenomena under investigation;
• Respond to local situations, conditions, and needs of participants;
• Interact with the research subjects in their own language and on their own terms; and,
• Create a descriptive capability based on primary and unstructured data.

Anderson, Claire. “Presenting and Evaluating Qualitative Research.” American Journal of Pharmaceutical Education 74 (2010): 1-7; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Limitations of Using Qualitative Methods

It is very much true that most of the limitations you find in using qualitative research techniques also reflect their inherent strengths . For example, small sample sizes help you investigate research problems in a comprehensive and in-depth manner. However, small sample sizes undermine opportunities to draw useful generalizations from, or to make broad policy recommendations based upon, the findings. Additionally, as the primary instrument of investigation, qualitative researchers are often embedded in the cultures and experiences of others. However, cultural embeddedness increases the opportunity for bias generated from conscious or unconscious assumptions about the study setting to enter into how data is gathered, interpreted, and reported.

Some specific limitations associated with using qualitative methods to study research problems in the social sciences include the following:

• Drifting away from the original objectives of the study in response to the changing nature of the context under which the research is conducted;
• Arriving at different conclusions based on the same information depending on the personal characteristics of the researcher;
• Replication of a study is very difficult;
• Research using human subjects increases the chance of ethical dilemmas that undermine the overall validity of the study;
• An inability to investigate causality between different research phenomena;
• Difficulty in explaining differences in the quality and quantity of information obtained from different respondents and arriving at different, non-consistent conclusions;
• Data gathering and analysis is often time consuming and/or expensive;
• Requires a high level of experience from the researcher to obtain the targeted information from the respondent;
• May lack consistency and reliability because the researcher can employ different probing techniques and the respondent can choose to tell some particular stories and ignore others; and,
• Generation of a significant amount of data that cannot be randomized into manageable parts for analysis.

Research Tip

Human Subject Research and Institutional Review Board Approval

Almost every socio-behavioral study requires you to submit your proposed research plan to an Institutional Review Board. The role of the Board is to evaluate your research proposal and determine whether it will be conducted ethically and under the regulations, institutional polices, and Code of Ethics set forth by the university. The purpose of the review is to protect the rights and welfare of individuals participating in your study. The review is intended to ensure equitable selection of respondents, that you have met the requirements for obtaining informed consent , that there is clear assessment and minimization of risks to participants and to the university [read: no lawsuits!], and that privacy and confidentiality are maintained throughout the research process and beyond. Go to the USC IRB website for detailed information and templates of forms you need to submit before you can proceed. If you are  unsure whether your study is subject to IRB review, consult with your professor or academic advisor.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Labaree, Robert V. "Working Successfully with Your Institutional Review Board: Practical Advice for Academic Librarians." College and Research Libraries News 71 (April 2010): 190-193.

Another Research Tip

Finding Examples of How to Apply Different Types of Research Methods

SAGE publications is a major publisher of studies about how to design and conduct research in the social and behavioral sciences. Their SAGE Research Methods Online and Cases database includes contents from books, articles, encyclopedias, handbooks, and videos covering social science research design and methods including the complete Little Green Book Series of Quantitative Applications in the Social Sciences and the Little Blue Book Series of Qualitative Research techniques. The database also includes case studies outlining the research methods used in real research projects. This is an excellent source for finding definitions of key terms and descriptions of research design and practice, techniques of data gathering, analysis, and reporting, and information about theories of research [e.g., grounded theory]. The database covers both qualitative and quantitative research methods as well as mixed methods approaches to conducting research.

SAGE Research Methods Online and Cases

NOTE :  For a list of online communities, research centers, indispensable learning resources, and personal websites of leading qualitative researchers, GO HERE .

For a list of scholarly journals devoted to the study and application of qualitative research methods, GO HERE .

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Research methods--quantitative, qualitative, and more: overview.

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About Research Methods

This guide provides an overview of research methods, how to choose and use them, and supports and resources at UC Berkeley. 

As Patten and Newhart note in the book Understanding Research Methods , "Research methods are the building blocks of the scientific enterprise. They are the "how" for building systematic knowledge. The accumulation of knowledge through research is by its nature a collective endeavor. Each well-designed study provides evidence that may support, amend, refute, or deepen the understanding of existing knowledge...Decisions are important throughout the practice of research and are designed to help researchers collect evidence that includes the full spectrum of the phenomenon under study, to maintain logical rules, and to mitigate or account for possible sources of bias. In many ways, learning research methods is learning how to see and make these decisions."

The choice of methods varies by discipline, by the kind of phenomenon being studied and the data being used to study it, by the technology available, and more.  This guide is an introduction, but if you don't see what you need here, always contact your subject librarian, and/or take a look to see if there's a library research guide that will answer your question. 

Suggestions for changes and additions to this guide are welcome! 

START HERE: SAGE Research Methods

Without question, the most comprehensive resource available from the library is SAGE Research Methods.  HERE IS THE ONLINE GUIDE  to this one-stop shopping collection, and some helpful links are below:

• SAGE Research Methods
• Little Green Books  (Quantitative Methods)
• Little Blue Books  (Qualitative Methods)
• Dictionaries and Encyclopedias  
• Case studies of real research projects
• Sample datasets for hands-on practice
• Streaming video--see methods come to life
• Methodspace- -a community for researchers
• SAGE Research Methods Course Mapping

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Library Data Services Program and Digital Scholarship Services

The LDSP offers a variety of services and tools !  From this link, check out pages for each of the following topics:  discovering data, managing data, collecting data, GIS data, text data mining, publishing data, digital scholarship, open science, and the Research Data Management Program.

Be sure also to check out the visual guide to where to seek assistance on campus with any research question you may have!

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Other Data Services at Berkeley

D-Lab Supports Berkeley faculty, staff, and graduate students with research in data intensive social science, including a wide range of training and workshop offerings Dryad Dryad is a simple self-service tool for researchers to use in publishing their datasets. It provides tools for the effective publication of and access to research data. Geospatial Innovation Facility (GIF) Provides leadership and training across a broad array of integrated mapping technologies on campu Research Data Management A UC Berkeley guide and consulting service for research data management issues

General Research Methods Resources

Here are some general resources for assistance:

• Assistance from ICPSR (must create an account to access): Getting Help with Data , and Resources for Students
• Wiley Stats Ref for background information on statistics topics
• Survey Documentation and Analysis (SDA) .  Program for easy web-based analysis of survey data.

Consultants

• D-Lab/Data Science Discovery Consultants Request help with your research project from peer consultants.
• Research data (RDM) consulting Meet with RDM consultants before designing the data security, storage, and sharing aspects of your qualitative project.
• Statistics Department Consulting Services A service in which advanced graduate students, under faculty supervision, are available to consult during specified hours in the Fall and Spring semesters.

Related Resourcex

• IRB / CPHS Qualitative research projects with human subjects often require that you go through an ethics review.
• OURS (Office of Undergraduate Research and Scholarships) OURS supports undergraduates who want to embark on research projects and assistantships. In particular, check out their "Getting Started in Research" workshops
• Sponsored Projects Sponsored projects works with researchers applying for major external grants.
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• Qualitative vs. Quantitative Research | Differences, Examples & Methods

Qualitative vs. Quantitative Research | Differences, Examples & Methods

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

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

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

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

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

Table of contents

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

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

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

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

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

Quantitative data collection methods

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

Qualitative data collection methods

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

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

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

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

Quantitative research approach

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

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

Qualitative research approach

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

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

Mixed methods approach

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

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

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

Analyzing quantitative data

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

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

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

Analyzing qualitative data

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

Some common approaches to analyzing qualitative data include:

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

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

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

Research bias

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

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

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

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

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

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

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

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

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

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

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

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Qualitative vs Quantitative Research Methods & Data Analysis

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On This Page:

What is the difference between quantitative and qualitative?

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

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

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

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

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

What Is Qualitative Research?

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

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

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

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

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

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

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

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

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

Qualitative Methods

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

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

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

Here are some examples of qualitative data:

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

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

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

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

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

Qualitative Data Analysis

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

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

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

Key Features

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

Limitations of Qualitative Research

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

Advantages of Qualitative Research

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

What Is Quantitative Research?

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

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

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

Quantitative Methods

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

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

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

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

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

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

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

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

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

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

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

Quantitative Data Analysis

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

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

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

Limitations of Quantitative Research

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

Advantages of Quantitative Research

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

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

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

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

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

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

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

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

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

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

Further Information

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

• Open access
• Published: 27 March 2024

Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon

• Reem Hoteit   ORCID: orcid.org/0000-0001-8139-9321 1 ,
• Aya Hassoun 2 ,
• Elie Bou Sanayeh 3 ,
• Marie Christelle Saade 3 ,
• Gladys Honein-AbouHaidar 4 &
• Elie A. Akl   ORCID: orcid.org/0000-0002-3444-8618 3 , 5  

Health Research Policy and Systems volume  22 , Article number:  38 ( 2024 ) Cite this article

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The coronavirus disease 2019 (COVID-19) pandemic has strained healthcare systems globally, particularly in terms of access to medicines. Lebanon has been greatly affected by the pandemic, having faced concomitant financial and economic crises. The objective of the study was to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines.

For this qualitative study, we conducted 28 semi-structured interviews. We used purposive sampling to recruit participants with a diverse range of perspectives. The data collection phase spanned from August to November 2021 and was conducted virtually. After transcribing and translating the interviews, we employed thematic analysis to identify recurring themes and patterns.

In total, 28 individuals participated in this study. Participants highlighted challenges owing to the COVID-19 pandemic and economic crisis. Accessing COVID-19 medicines posed major hurdles for physicians and patients, given limited availability, global shortages, local circumstances, community hoarding and stockpiling by pharmacies. Providers based treatment decisions on research, local and international practice guidelines, experiences and expert feedback. Patients sought information from social media, community members and physicians, as well as through word of mouth. Accessing medicines involved navigating the healthcare system, the black market, charities, personal networks and political parties and sourcing from abroad. The medicines were either free, subsidized or at inflated costs.

Conclusions

This study highlights the diversity and complexity of factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon. Future research should explore strategies for ensuring medicine access during crises, drawing insights from comparative studies across different countries.

Peer Review reports

Introduction

The emergence of the coronavirus disease 2019 (COVID-19) instigated a global health crisis, presenting formidable challenges to healthcare systems and economies across the world [ 1 , 2 ]. Since its first appearance in December 2019 in China, severe acute respiratory coronavirus 2 (SARS-CoV-2) has infected around 700 million individuals, resulting in a staggering death toll exceeding 6.9 million by November 2023 [ 3 , 4 ]. Owing to COVID-19-related lockdowns and the heightened demand for essential medications, drug shortages have become a significant global problem [ 5 , 6 ].

Prior to the pandemic, healthcare systems in low- and middle-income countries (LMICs) suffered from limited financial resources, healthcare workforce shortages and unavailability of medications [ 7 , 8 , 9 ]. The pandemic further strained these already fragile health systems [ 2 ]. For example, the strong demand for medications to treat COVID-19 patients, including analgesics, sedatives, antibiotics, hydroxychloroquine and remdesivir, considerably affected medication accessibility and inadvertently encouraged black market activity [ 10 , 11 , 12 , 13 ]. Escalating medication prices rendered these crucial medications unaffordable for many patients, particularly in LMICs [ 13 , 14 , 15 ].

The economic and financial crises in Lebanon, coupled with the Beirut Port’s destruction, severely impacted the entire healthcare sector, affecting hospitals, healthcare providers and the pharmaceutical and medical supply industry [ 16 ]. The COVID-19 pandemic worsened this situation, posing two major challenges: the selection of appropriate therapies and ensuring access to these treatments [ 17 , 18 ]. This shortage of prescription drugs in Lebanon peaked during the COVID-19 pandemic [ 19 ].

Factors influencing decisions regarding COVID-19 treatment can be complicated and multidimensional. They encompass an individual patient’s medical history, comorbidities and risk factors, as well as the availability and efficacy of various therapeutic options [ 20 ]. Therapeutic management in the early stages of the pandemic was challenging owing to uncertainty and continuously evolving evidence [ 21 ]. Clinicians attempted to manage COVID-19 using a variety of treatments that targeted numerous possible mechanisms, such as antiviral, anti-inflammatory and immunomodulatory drugs [ 22 ]. There was also misinformation in various media outlets about the benefits of some medications for either preventing or treating COVID-19 [ 23 ]. This resulted in an increase in risky self-medication with several over-the-counter medications [ 2 , 24 ].

The objective of the study is to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines.

Study design

This study adopted a descriptive qualitative research design using semi-structured individual interviews (refer to Appendix 1 for the interview guide). The qualitative approach utilized is rooted in naturalistic inquiry and offers a wide array of theoretical or philosophical orientations, sampling techniques and data-gathering strategies [ 25 ].

Participants

We recruited participants from different regions in Lebanon. Eligible participants belonged to one of the following groups:

physicians and nurses directly involved in caring for patients diagnosed with COVID-19

hospital and community pharmacists involved in dispensing medications for patients diagnosed with COVID-19

patients previously diagnosed with COVID-19

family members or caregivers of patients previously diagnosed with COVID-19.

We excluded patients who were psychologically unable to participate or provide coherent and clear descriptions of their experiences.

Sampling and recruitment

We used purposeful sampling by approaching individuals belonging to the groups of interest. We also used snowballing sampling by asking participants to refer us to other eligible individuals. Additionally, physicians and pharmacists assisted in the recruitment of potential former patients and caregivers. The Institutional Review Board (IRB) at the American University of Beirut (AUB) approved the study. All participants provided oral consent prior to participation. The interviewers took all precautions to guarantee participants’ anonymity and confidentiality. Participants were informed that their participation was entirely voluntary and that they could opt-out at any time.

Data collection

Following an explanation of the study’s objectives, we interviewed participants virtually in either English or Arabic, depending on their preferences. We audio-recorded interviews following participants’ consent. We conducted a total of 28 interviews, and we ceased to collect data when thematic saturation was reached, that is, no new themes emerged from the data analysis [ 26 ].

Two team members (AH and EBS) conducted the interviews between August and November of 2021. The individuals received thorough training on conducting interviews, focusing on techniques to remain neutral and nonjudgemental and to sustain the interviewees’ engagement in the subject matter. To enhance the quality of data collection, we held regular debriefing meetings following the initial interviews. These meetings provided an opportunity for reflection on the data collection process and identification of areas of improvement.

Data analysis

The interviewers transcribed the audio-recorded interviews, and translated them into English when applicable. Another team member (RH) verified transcript accuracy by checking them against the audio recordings. We employed Quirkos, a qualitative analysis software, for coding and organizing the data. We applied Braun and Clarke’s six-step thematic analysis approach [ 27 ]. In phase 1, GHA and RH read a few transcripts independently to familiarize themselves with the information and established a preliminary framework for data coding. In phase 2, they independently annotated the transcripts line by line. They assigned labels to each idea (coding), leaving room for new codes as they emerged. In phase 3, GHA, EAA and RH reviewed the coded transcripts and identified emerging themes, along with quotes that illustrated each theme. In phase 4, GHA, EAA and RH reviewed and refined the list of emerging themes, and created a thematic map. In phase 5, they outlined the final thematic framework. Finally, in phase 6, we developed a complete narrative of the findings and selected interviewee quotes for each theme and sub-theme.

Increasing rigour

All interviewers received training in interviewing skills, maintaining consistency and rigour [ 28 ]. We also made sure that interviewers had no prior relationship with participants, fostering objectivity and minimizing bias [ 28 ]. We interviewed participants in their preferred language as a way to ensure their understanding of the questions and their ability to easily express their thoughts [ 28 , 29 ]. To ensure transferability, we employed triangulation by compiling viewpoints of various population groups [ 29 ]. We halted data collection upon reaching saturation [ 30 ], ensuring comprehensive data coverage and depth. We verified transcript accuracy by checking them against the audio recordings [ 31 ]. Three members of our research team (GHA, EAA and RH) actively participated in the analysis and the generation of codes, themes and subthemes. In reporting this study, we adhered to the highest standards by following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [ 32 ].

Demographics

We recruited 28 participants: 3 community pharmacists, 4 hospital pharmacists, 8 physicians, 1 nurse, 3 patients and 9 caregivers. The interviews lasted about 40 min on average.

Emerging themes

The following themes emerged in relation to the experiences of participants with regards to treatment decisions and accessibility to COVID-19 medicines: country crises, access challenges, cost challenges, drivers for providers’ decision-making, drivers for patients and caregivers’ decision-making and accessing medicines (Fig.  1 ).

Factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon

When the majority of participants expressed the same opinions, we used the term “most participants”; otherwise, we used the terms “many” or “few” as appropriate. When citing quotes from participants, we used the following acronyms: physicians (Phys), nurses (Nurse), community pharmacists (C-Pharm), hospital pharmacists (H-Pharm), patients (Pt) and caregivers (Cg).

Country crises

Most participants discussed current events in the country, including the COVID-19 pandemic, the economic crisis and the financial crisis. “Because of the current situation in Lebanon, we’re seeing things we never thought we would” (H-Pharm 02). “COVID-19 came around in March 2020, and Lebanon had already started its economic crisis” (H-Pharm 04).

Participants noted their experiences with the financial crisis and the closure of banks. “I woke up in the morning at 6:45 am, wore my clothes and went down to the bank but found it closed […], I went down to [..], same thing, it closed as I was on my way so I said, ‘where should I get them the money now?; they asked for money for the tests” (Cg 08).

One caregiver also mentioned that the economic crisis had forced them to work multiple jobs. “I work two jobs but now if you work in Lebanon the salaries are not enough” (Cg 08).

In addition to this, participants complained about how the country’s financial situation impacted access to medicines. “The purchasing power of the patients had already decreased. And like all countries when it comes to medication and the healthcare system, which was already collapsing in Lebanon, it’s common that in the end, the patient has to self-fund their treatment. And patients in low economical standing will have no access to treatment” (H-Pharm 04).

Access challenges

The crisis impacted the supply of COVID-19 medications. First, there were drug shortages directly related to the COVID-19 medicines, similar to the global crisis “… we saw that everyone is facing this, worldwide… Then we went into shortages, we didn’t have anymore because the consumption had increased” (H-Pharm 02). “Even the Colchicine, we heard about it, and we went around and looked for it and it was very hard for us to find it easily” (Cg 02).

“For example, remdesivir they used for my mother-in-law we got six injections, and the first day we tried to get it we called the pharmacies they told us they don’t have it. In the hospital, there was no remdesivir because it was getting brought based on an order from the company and it needed a prescription from the doctor to obtain” (Cg 01).

Second, the challenging circumstances in Lebanon had an additional impact on the accessibility of medicines. “The effect of the medications is unrelated to COVID-19. I mean, the availability of the medications. Now, even after COVID-19 has decreased, we have shortages in medications that are unrelated to COVID-19, it has to do with the economic situation. So, it’s not COVID-19 that made the crisis in medications, not at all” (Phys 08). “It was hard to provide medications because of the terrible situation of Lebanon” (Nurse 01).

Many pharmacists discussed community hoarding. “People were running to the pharmacies to secure one of these medications even if they did not need it at the time, just for the sake of keeping it at home just in case, which led to a huge shortage of supply” (C-Pharm 02).

However, patients were concerned about pharmacies stockpiling medications. “Exactly, because of the economic crisis selling the drug was not beneficial for the pharmacies so they started keeping it for emergency cases and selling it at the black market rate. After all the demand was very high” (Cg 07).

Few physicians mentioned lack of availability of medicines specifically in the hospitals, particularly for the new medications. “They had to get the medications outside of the hospital…the shortage was due to the fact that basically, this is a new medication, and it hasn’t been brought to Lebanon yet.” (Phys 08).

A few pharmacists stated that they always had a backup plan. “To be honest we never had really bad shortages, we never fully ran out, we always had a plan B. When there was no more dexamethasone for IV, we prepared other corticoids, even if it wasn’t mentioned in any studies or guidelines. We used to prepare them and keep them as backups in case they were ever needed” (H-Pharm 04).

Cost challenges

Both providers and patients noted unaffordable costs as another factor affecting access to medications, considering the devaluation of the currency. “The single pill got to about 50 USD, it was very expensive. So, it was really expensive for most people. Its actual price was 5000 Lira” [H-Pharm 04; note that at the time 5000 Lira was worth less than 5 US dollars (USD)]. “Even tablets like vitamins are available but they are very expensive, not everyone can afford them” (Cg 04).

Patients complained about price manipulation. “The prices were definitely manipulated because when I would buy a medication I would find more than one price tag… The lozenges for her throat used to cost 19 000 Lira and now it costs 45 000 Lira. They put more than one label on the box of medication, there are about three price tags on it” (Cg 06).

Additionally, it was mentioned that the pricing of medications was changed to the US currency. “Yes, most of the time they were fresh dollar” (Phys 08).

Drivers of decision-making for providers

During the COVID-19 pandemic, several factors influenced decisions by providers, patients and caregivers about which medicines to use or not use.

Owing to the rapid development of evidence, providers were compelled to rely on research to prescribe certain medications. “There was a committee that used to review the data available and to review all the evidence at the time and make the decisions.” (Phys 04). “… the COVID-19 protocol changed every couple of days. Every once in a while, a new study would appear, a new update, and it would change again” (H-Pharm 01).

Providers also relied on clinical practice guidelines developed either locally or internationally, for example, by the WHO. “The medications we were prescribing were based on WHO” (Phys 03). Although they relied on those guidelines, some providers expressed hesitations about them. “Yes, we were following the guidelines of treatment of COVID-19, we would tell this is the medication that needs to be taken because this is what the guidelines say. We are not sure of the guidelines, but this is what is needed now” (Phys 09).

Additionally, the providers’ prior experience or trial and error played a role in the decision-making process. “At first, personally, I did not have much experience with this disease but later on and after I acquired some experience, I was finally able to give my own opinion on the matter” (C-Pharm 01).

Reliance on local peers with different specialities played a significant role in decision-making. “Because we had several specialities – cardiovascular, internal medicine, and others – everyone did their research and every week we would meet and explain to each other… Everyone gave their inputs and propositions, in their own specialities, about which drugs might be good, and which drugs were used in which cases” (H-Pharm 04).

International expertise was also sought during the pandemic. “We also had video conferences with hospitals and ICUs in France and the United States, because we had physicians that went and studied in those countries and still had contacts, we did one video conference with France, and one with the US to ask about their protocols. And there were discussions about what’s best. And when Actemra was first being used by the ones we talked to somewhere in Houston, we weren’t using it yet in our hospital. After the video conference, they found that their patients are showing good results, so it was added to our protocol..” (H-Pharm 04).

It is of note that the country’s situation and drug availability influenced the decision-making process. As expressed by many doctors: “We were following the new guidelines, taking into consideration the situation of the country and the availability of the drugs and imaging” (Phys 02).

Drivers of decision-making for patients and caregivers

Patients and caregivers relied on social media to decide on drug purchases. “Yes. Honestly, they saw me crying and I had posted on Instagram that if anyone please could help with their experience because there were no studies at that time” (Cg 03). “At first people used to wait for what the media says and then come running to the pharmacies to buy these medications, it happened first with vitamin C then 2 weeks later with vitamin D then it was the zinc 25 mg and then zinc 50 mg turns” (C-Pharm 01). “Even the colchicine, we heard about it on social media, and we went around and looked for it and it was very hard for us to find easily” (Cg 02).

Patients and caregivers were also influenced by people in their communities, some of whom had experience with COVID-19. “Other people around us who also had corona, everyone that got corona would say take this and do this” (Pt 02). “My dad caught it in the beginning, so I started asking people to see what we could do. One of my friends told me that there was a person who took this medicine, and they told me to try it, so I decided to do that” (Cg 03).

Patients reported different attitudes about consulting with their doctors. “We heard about remdesivir and asked the doctor, he told us he can’t advise us to take it or not, if we would like to try it based on other patients and not on medical research then go ahead” (Cg 07). Some made decisions on their own on the basis of word of mouth. “My friend called me and told to me not listen to the doctors and to take zithromax. I bought it and took one pill” (Pt 08).

Accessing medicines

We have identified two subthemes under the theme of “accessing medicines”: information about how to get the medicines and the sources of medicines.

Information about how to get the medicines

Typically, patients obtained information about how to get the medicines from healthcare providers, including nurses, physicians and pharmacists. “Yes sure!… [local charities] used to give those medications (remdesivir, Actemra, etc.) for free. And there were some other providers. We used to indicate the providers to the families of the patients” (Nurse 01).

Patients also inquired about the source of medicines from recovered COVID-19 patients: “From other people around us who also had corona” (Pt 02).

Sources of medicines

Patients and their caregivers obtained the medicines either through the healthcare system or from outside the healthcare systems, including the black market, nongovernmental organizations (NGOs), personal networks, political parties and outside of the country.

• Healthcare system

When patients were admitted, few reported that COVID-19 medicines were available in the hospital. “They were all found in the hospital” (Cg 05). However, for several patients, their family members had to seek medicines from community pharmacies. “We got them from the pharmacy” (Cg 01).

Medicines were obtained at no cost thanks to a subsidy by the Lebanese government. “So, it was for free if it was from the Ministry” (Cg 02). However, some other medicines were purchased on an unsubsidized basis and at high cost. “A few pills were for 1 300 000 Lebanese Lira in the pharmacy” (Cg 02).

• Black market

Owing to the limited supply and urgent need for COVID-19 medications, the black market flourished. “There were two more weeks, and the Ministry was supposed to secure it, but we needed it urgently, so they gave us the number of someone who sells it in the black market and he got it for us” (Pt 03).

The black market was viewed as a double-edged sword because it allowed access but at an inflated cost. “They gave us five remdesivir and one Actemra for US$ 1200” (Cg 07). “The remdesivir is like. So, he made us pay US$ 700 for one,.. So, US$ 4200 for six pills” (Pt 03).

Because of the country’s financial crisis, inflated black market prices presented a major challenge for patients. “… it was a challenge for us to financially secure the medicine. And of course, him asking for US$ 4200 cash was not something easy for someone to get and pay, but if it is the only solution of course we would do it” (Pt 03).

Charities supported patients in accessing their medicines either for free or through financial support. “Suppose I were to get COVID-19 now, my name would go down at the municipality and they get you vitamin C and vitamin D – a charity organization, not from the government” (Cg 08). “I paid 1 million and the rest was on the charity organization” (Cg 08); “For ivermectin there were a lot of organizations trying to supply it, it’s a very cheap drug… that costs US$ 4. There were also a lot of organizations trying to supply remdesivir, ‘Hariri’ (a local charity) was trying to help with it since hospitals did not have it, people were going to her villa to get it, it costs I think about US$ 4000” (Phys 02).

Personal network

Caregivers of patients with COVID-19 used their personal networks, including family and friends: “Also, from a person who knows a pharmacist he’s friends with, they got them for us” (Cg 02). “We had to get the baricitinib from someone we know, who got it for us from the Ministry” (Cg 02).

Political parties

Political parties also supplied medicines to their supporters. “There were parties that were obtaining them, like [name of political parties]. Those were for free as a donation from [name of political party]” (Pt 02).

From outside of the country

Typically, family or friends helped by purchasing medicines while travelling. “At the time, an Iraqi who is friends with my relative got it and he paid US$ 400” (Pt 08).

Out-of-country purchases were driven by either lack of local supply or inflated costs. “The ivermectin was still not in Lebanon, so we got it elsewhere, from a woman who lives in Africa, she got it for us and sent it. And we started with cortisone, this is from day 1” (Cg 02). “My cousin sent it from Sweden, she sent zinc and vitamin C because vitamin C here now costs 60 000 Lira, before it cost 14 000 Lira and now it costs 60 000” (Cg 06).

This study aimed to to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, physicians, nurses and pharmacists, with regards to their treatment decisions and accessibility to COVID-19 medicines.

The participants highlighted the country’s difficulties, especially the severe impact of COVID-19 pandemic and the economic crisis. Access to COVID-19 medicines and their costs were major challenges according to the three groups interviewed. Limited access related to global shortage of medicines, the local challenging circumstances, community hoarding (according to pharmacists) and stockpiling by pharmacies (according to patients). For providers, the decision-making process for COVID-19 treatments was shaped by research evidence, local and international practice guidelines, previous experiences and feedback from both local and international experts. Patients and their caregivers relied on social media, community members, physicians and word of mouth. Information on how to get the medicines was obtained from either healthcare providers or patients who recovered from COVID-19. Accessing medicines involved navigating through the healthcare system (hospitals and pharmacies), as well as outside that system, including the black market, charities, personal networks, political parties and outside of the country. Across these different sources, the medicines were either free, subsidized or at inflated costs.

Comparison to similar studies

A major finding in our study was the accessibility of patients and healthcare providers to needed medicines. This is corroborated by other studies conducted in Lebanon [ 33 , 34 ] and low-and middle-income countries [ 35 ]. The global impact of lockdowns on medicine manufacturing, supply and distribution contributed to shortages during the high-demand period of the COVID-19 pandemic [ 36 , 37 ]. Furthermore, Lebanon has faced severe economic and financial crises starting in 2019, which severely hindered the capacity to import vital healthcare equipment and medicines [ 38 , 39 ]. Indeed, the World Bank characterized the crisis as “among the world’s worst since the 1850s” [ 40 ]. The lack of government reimbursement further hindered hospitals in procuring necessary medications and medical supplies [ 41 ]. Consequently, individuals affected by COVID-19 in Lebanon resorted to unregulated sources, including the black market, often resulting in inflated prices and the risk of expired or counterfeit drugs [ 13 , 14 , 15 , 42 ].

Moreover, in line with our findings, other studies found that healthcare providers followed both international and national guidelines when deciding on potential treatments for COVID-19 patients [ 43 , 44 ]. However, in the absence of effective medications, discussion on various social media platforms encouraged self-medication and the use of herbal medicines [ 45 , 46 ]. In addition, a recent study conducted in Jordan assessing the usage of medications and natural products amidst the second wave of COVID-19 revealed that individuals primarily sought guidance from family and friends, with social media platforms serving as significant sources of advice concerning the use of these medications [ 47 ]. The same study showed that pharmacists notably played a significant role in guiding individuals on choosing these treatments compared with other healthcare providers [ 47 ].This highlights the impact of social media on treatment choices and emphasizes the need for disseminating accurate and evidence-based information.

Strengths and limitations

To our knowledge, this is the first study in Lebanon to comprehensively explore the interplay between country crises and medication accessibility during the COVID-19 pandemic, offering valuable insights into the unique challenges faced by the country. We explored in-depth the lived experiences of our participants, ensuring the representation of the perspectives of healthcare providers, patients and caregivers. Also, we used a rigorous qualitative methodology (please refer to the “Increasing rigour” section).

There are several limitations to consider. Firstly, the study focuses primarily on Lebanon, which may limit the findings’ generalizability to other countries with distinct settings and healthcare systems. Moreover, there is a possibility of recall bias among participants, as their recollections of events and experiences concerning medication accessibility during the crisis might be influenced by subjective interpretations or memory lapses. Additionally, the sampling technique employed might introduce selection bias, as participants were recruited through purposive sampling. Furthermore, it is important to note that this study is based on a specific snapshot in time during the COVID-19 pandemic. Consequently, its findings may not fully encapsulate the dynamic and evolving nature of the crisis or account for potential shifts in medication accessibility and decision-making processes over time.

This study sheds light on the wide range of factors influencing treatment decisions during the COVID-19 pandemic in Lebanon. It also unveils how patients and their families had to access medications either through the formal healthcare systems or through black markets and other channels. Plans are needed to address medicine availability, affordability and equitable distribution during similar future crises. There is an urgent need for collaborative efforts involving stakeholders, policy-makers and key systems such as Meditrack and AMAN within the Ministry of Public Health [ 48 , 49 ]. These initiatives are intended to establish resilient and sustainable drug supply chains and to ensure timely and equitable access to medications for all individuals, particularly in times of crisis. Furthermore, improving collaboration among healthcare providers, expediting medication access and creating patient support programs can alleviate the difficulties that people seeking treatment confront. For example, streamlining communication between hospitals, pharmacies and primary care doctors could speed up the prescription and dispensing processes.

Future research should focus on effective strategies to ensure medicine access during crises. Comparative research across different countries can provide valuable insights into successful tactics that can be tailored across different countries.

What is already known on this topic

global healthcare systems have been strained owing to the COVID-19 pandemic, leading to challenges in medicine access; and

Lebanon’s healthcare system has been significantly impacted by the pandemic and financial crises, affecting the availability of medicines.

What this study adds

it uncovers key factors influencing both healthcare providers and patients in their treatment decisions, providing a comprehensive perspective; and

it describes varied sources for medicines, including informal networks and the black market.

How this study might affect research, practice or policy

the findings emphasize the necessity for strategies that ensure continuous medicine access, particularly during times of crises and economic instability.

Availability of data and materials

The datasets analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

American University of Beirut

Consolidated Criteria for Reporting Qualitative Research

Coronavirus disease 2019

Community pharmacists

Hospital pharmacists

Institutional review board

Low- and middle-income countries

Lebanese Ministry of Public Health

Nongovernmental organizations

Severe acute respiratory syndrome coronavirus 2

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Aya Hassoun

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Elie Bou Sanayeh, Marie Christelle Saade & Elie A. Akl

Rafic Hariri School of Nursing, American University of Beirut, Beirut, Lebanon

Gladys Honein-AbouHaidar

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Hoteit, R., Hassoun, A., Bou Sanayeh, E. et al. Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon. Health Res Policy Sys 22 , 38 (2024). https://doi.org/10.1186/s12961-024-01131-9

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• Volume 41, Issue 4
• Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study
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• http://orcid.org/0000-0003-3067-9416 Jo Daniels 1 , 2 ,
• http://orcid.org/0000-0002-8013-3297 Emilia Robinson 1 ,
• http://orcid.org/0000-0001-5686-5132 Elizabeth Jenkinson 3 ,
• http://orcid.org/0000-0002-2064-4618 Edward Carlton 4 , 5
• 1 Department of Psychology , University of Bath , Bath , UK
• 2 Psychology , North Bristol NHS Trust , Westbury on Trym , Bristol , UK
• 3 Department of Health and Social Sciences , University of the West of England , Bristol , UK
• 4 Emergency Department, Southmead Hospital , North Bristol NHS Trust , Westbury on Trym , UK
• 5 Bristol Medical School , University of Bristol , Bristol , UK
• Correspondence to Dr Jo Daniels, Department of Psychology, University of Bath, Bath, UK; j.daniels{at}bath.ac.uk

Background Staff retention in Emergency Medicine (EM) is at crisis level and could be attributed in some part to adverse working conditions. This study aimed to better understand current concerns relating to working conditions and working practices in Emergency Departments (EDs).

Methods A qualitative approach was taken, using focus groups with ED staff (doctors, nurses, advanced care practitioners) of all grades, seniority and professional backgrounds from across the UK. Snowball recruitment was undertaken using social media and Royal College of Emergency Medicine communication channels. Focus group interviews were conducted online and organised by profession. A semi-structured topic guide was used to explore difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Data were analysed using a directive content analysis to identify common themes.

Results Of the 116 clinical staff who completed the eligibility and consent forms, 46 met criteria and consented, of those, 33 participants took part. Participants were predominantly white British (85%), females (73%) and doctors (61%). Four key themes were generated: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data pertaining to barriers and opportunities for change were identified as sub-themes. In particular, strong leadership emerged as a key driver of change across all aspects of working practices.

Conclusion This study identified four key themes related to workplace concerns and their associated barriers and opportunities for change. Culture, working environment and need for support echoed current narratives across healthcare settings. Leadership emerged more prominently than in prior studies as both a barrier and opportunity for well-being and retention in the EM workplace. Further work is needed to develop leadership skills early on in clinical training, ensure protected time to deliver the role, ongoing opportunities to refine leadership skills and a clear pathway to address higher levels of management.

• qualitative research
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Data availability statement

Data are available upon reasonable request. Requests go to the corresponding author - Jo Daniels ([email protected], University of Bath, UK). De-identified participant data can be made available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/emermed-2023-213189

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Retention of staff in emergency medicine is at crisis level and has been a high priority area for over a decade.

Multiple guidelines have been published to outline improvements that need to be made to retain staff; however, little improvement has been seen on the ground in EDs.

Key factors such as staff burnout and poor working conditions are known to influence intention to leave; however, it is unclear why change has not taken place despite knowledge of these problems and existing guidelines seeking to address these issues.

WHAT THIS STUDY ADDS

This qualitative study assessed perceived barriers that may be inhibiting the implementation to working conditions and working practices in EDs.

Leadership is identified as an important driver of change in working practices and can play an important role in workplace well-being and retention.

Key recommendations for avenues of improvement are made, identifying key actions at government, professional, organisational and personal level.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

This study identifies leadership as a key opportunity for change and as a result makes specific recommendations for policy and practice regarding leadership in emergency medicine.

Introduction

Emergency Medicine (EM) is facing a global staffing crisis. 1 Record numbers of staff continue to leave the UK NHS with EM the most affected specialty. 2 EM reports the highest work intensity of all medical specialties, 3 with ‘intensity’ recognised as one of the leading factors in job dissatisfaction, attrition and career burnout. 3–5 These factors are amplified in an already stretched workforce. 2 Psychological well-being of the EM workforce is compromised, with working conditions recognised as playing a key role. 6 7 Staff attrition has a systemic impact: lower staff ratios lead to higher workloads, reduced quality of care, 8 higher levels of medical errors 9 and poorer staff well-being, 10 all factors associated with staff absence and intention to leave. 11 The landscape of EM has also changed; increased prevalence of high patient acuity, multimorbidity and an ageing population all bear considerable impact.

Key sector stakeholder initiatives and policy recommendations relating to retention and well-being 12–14 are largely generic and forfeit relevance to the specialty due to the lack of specificity to the clinical context within which these guidelines need to be implemented. Retention improvement programmes suggest approaches should be tailored per organisation, 12 however, this assumes that the challenges faced by staff across specialities and disciplines are homogeneous. In a specialty which reports the highest pressured environment, highest attrition and rates of burnout, 15 considerations of workplace context and specificity of policy recommendations are likely to be crucial. Interventions or initiatives must take account of the unique demands of the EM working environment, and how feasible it is to implement recommendations.

The James Lind Alliance (JLA) priority setting partnership in EM 16 identified initiatives to improve staff retention as research priorities in 2017 and again in the 2022 JLA refresh, 17 signalling the need for further research in this area due to a deepening workforce crisis. Current guidelines and initiatives target working conditions which are known to be associated with retention; however, these initiatives have been poorly implemented or enforced, with few formal evaluations of such interventions. 5 Moreover, current research is limited to the perspectives of specific professional groups and most are survey-based studies. 18

In order to better address current working conditions, with a view to improving retention, this research was aimed at determining practical barriers and opportunities for change in the ED working environment as perceived by professional staff working in this environment. This will tooffer insight into the shared experiences, constraints and priorities of those working within the ED.

Enhanced understanding of these issues can provide a firm basis from which to shape, inform and underpin future policies and workplace initiatives, ensuring that practical barriers and opportunities for change are embedded in a way that optimises relevance and feasibility of implementation in the ED working environment.

Study aims and objectives

This study sought to engage three core professional groups (doctors, nurses, advanced care practitioners; ACPs) who work within an EM context to better understand (a) primary concerns relating to working conditions; (b) perceived barriers to implementing change and (c) perceived opportunities and targets for change. Findings will be used to underpin key recommendations that are tailored to the needs of an over-burdened and under-resourced ED.

This qualitative study forms part of a larger collaborative project between the University of Bath and the Royal College of Emergency Medicine (RCEM), funded by a UKRI Policy Fund. The full recommendations relating to the four core themes are available on the RCEM website (Psychologically Informed Practice and Policy (PIPP) | RCEM).

Methodology

This study uses a qualitative approach involving online focus groups in order to gain a rich and detailed understanding of participant perspectives and views, unrestricted by closed question responses. Focus groups offer the opportunity to gain an understanding of shared experiences and narratives, using a dynamic approach to the subject matter, allowing further probing for clarification and participant interaction for deeper insights. The COVID Clinicians Cohort (CoCCo) study 19 was used to organise data into key categories; this model mirrors Maslow’s Hierarchy of Needs 20 from a workplace perspective.

Participants

To be eligible for participation, ED staff must have been currently employed in a UK NHS ED as either a doctor, nurse or ACP.

ACPs are a recently developed workforce of accredited clinicians who have received advanced training to expand the scope of their usual role (eg, paramedic, nurse), permitting them to take on additional clinical responsibility in the ED.

These three groups are core affiliates of the RCEM and represent the majority of the workforce in the ED. The ED setting was used as the focus (rather than all acute care settings) as this represents the core and central setting for EM.

Recruitment and procedure

Online adverts and qualtrics survey links were distributed through social media (ie, Twitter) and RCEM communication channels using snowball recruitment methods. Profession-specific focus group interviews were conducted online using MS teams by two study researchers (JD, ER) using a semi-structured topic guide (see online supplemental materials ). The guide was shaped by the scope of study aims and the current evidence base and explored difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Focus groups were 60–90 min in duration and were recorded using encrypted audio recorders, transcribed and stored securely. Participants were given debrief information sheets following the focus group. Transcripts were not returned to participants and no repeat focus groups were carried out.

Supplemental material

Directive content analysis was applied to the data. 21 This analysis strategy was used to identify common themes from participant responses, using deductive codes by identifying key concepts from existing theory 19 and prior research. Two researchers (ER, JD) read through each transcript, highlighting passages that could be categorised in the pre-determined codes. Any passages that could not be categorised within the initial coding theme were given new codes. Further coding was then conducted and this iteration was reviewed and updated. After coding was completed, initial notes from the focus groups were revisited to ensure all reflective notes were incorporated where relevant. Final themes were refined through an iterative process between JD, ER and EJ (qualitative analysis expert), with all stages of analysis reaching consensus agreement with regard to the content and labelling of codes and themes.

Patient and public involvement

As this study focused on staff experiences in an EM workplace, a Clinical Advisory Group (CAG) was used in place of patient or public involvement. The CAG comprised of five clinicians working in the ED who advised on the scope and priorities of the study. This included two medical consultants, one charge nurse, one trainee and one specialty grade doctor. Of those, three were males and two were females. All CAG members were offered renumeration for their time.

Of the 117 total responses to the study advert, 16 respondents were eligible but not available to attend focus groups and 55 either did not consent or were not eligible based on their role and/or department. From the remaining 46 respondents, 13 of these could not attend or cancelled, leaving a final sample of N=33 (28% of total responses). Due to higher response rates from doctors, these focus groups were further grouped by grade; nurses and ACPs were grouped by profession only and were organised base on availability. There were 11 groups in total (see table 1 ). Participants were mostly female, and from a white British background. Ages were spread fairly evenly across the categories, except ages 35–44 which included substantially fewer participants.

• View inline

Participant and focus group characteristics

Following analysis of the qualitative data, four key themes were generated. These were termed: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data within these themes that were identified as ‘barriers’ or ‘opportunities’ for change were extracted ( table 2 ). Illustrative participant quotes are identified by researcher codes, which reflect the profession and a recoded group number, to preserve anonymity.

Primary concerns, barriers and opportunities for change

Culture of blame and negativity

When asked about the most difficult aspects of their working conditions, participants commonly reported a culture of blame and negativity in the ED. The work culture not only felt unsupportive and ‘toxic’ but had a marked effect on well-being. Participants described a culture which was quick to blame rather than support:

You worry about making a mistake, and if you did make a mistake who would have your back. (ACP, G7) You very rarely get anyone saying that was a good job. (SAS doctor, G8)

This was particularly felt top-down, where those in management position were perceived to take an unsympathetic view of extended waiting times and unmet targets, despite the tangible constraints of operating at overcapacity and ‘exit block’, problems that participants perceived to be out of their control. Participants in all groups indicated that the negative culture instils anxiety over how they might be perceived by peers, but particularly by senior colleagues:

That’s a classic example… she’s a senior member of the team, really knows her job…. She was quite critical really, in a very negative way about how you managed that patient. (Nurse, G11)

Some participants reported senior colleagues having unrealistic expectations of the more junior staff, with little consideration of the increased pressures that have arisen in recent years:

It’s ridiculous to compare the needs, even for our senior colleagues who were registrars five years ago, the reality of running the department overnight is not the same as it was then. (SAS doctor, G1)

Existing structures and working practices of the NHS were described as ‘archaic’ and ‘old fashioned’, leading staff to feel blamed if they could not cope with the pressures and disempowered to seek support due to the expectation that they should be ‘unbreakable’ (Trainee, G9). Participants also voiced that they were unclear on lines of accountability, who to approach for what problem. This barrier to escalating their concerns was further compounded by the belief that both clinical leadership and higher management were generally overburdened and unreceptive to discussions on workplace concerns.

Increasing pressure and longer waiting times were described as driving antisocial behaviour from patients, exposing staff to risks to physical and psychological well-being:

So the long wait causes verbal or physical violence and aggression, which has a massive impact on staff well-being. (Nurse, G11)

Participants highlighted the desire to be supported to learn from difficult experiences and develop in light of them, suggesting that a simple checking in on how individual staff members are progressing would be well received and beneficial to well-being:

We have intermittent debriefs… but it’s not every time. It doesn’t necessarily need to be every time, but it’s not as frequent as it should be. Even if it is just ask are you okay? (Trainee, G5)

Interprofessional respect and development of a more empathic culture of shared responsibility were flagged as key opportunities for change that would support better team cohesion:

We need to change how we speak and respect each group, and we need to try and understand each other’s point of view, and if we could get better ways of working, but just talking to each other about what are my problems, what are your problems, why is this stressing you, what’s stressing us, how can we work together to do that. (ACP, G2)

Findings suggest that EM professionals are confronted with outdated perceptions of clinical demand from within teams and systems, with unrealistic expectations which compound a blame and shame culture when expectations are not met. Operating within this chronically under-resourced system was framed as compromising workforce well-being and risking burnout, yet participants indicated that simple interventions such as check-ins, clearer lines of accountability and a more civil and respectful culture would offer key opportunities for growth and sustainability even in the face of a staffing crisis.

Untenable work environments

The complex work environment within the ED was described as being of significant concern, compromising care and leaving staff feeling undervalued due to basic needs being unmet. Participants frequently reported poor quality or inadequate facilities, such as provision of toilets, lockers and changing rooms, hot food only available within limited hours, poorly functioning IT systems and rest spaces being in a different building.

So you’re just basically sharing (toilets) with the patients. In the urgent care centre there’s two toilets for the whole of the department in there, often one of those is broken…and not enough lockers for every member of staff. (ACP, G2) Stuff like working computers, a consistently working POD system… those little things I think make a bigger impact on your life than how many people come in through the front door. (Trainee, G5)

A lack of physical space for administrative tasks was highlighted by many clinical staff, being described as ‘woefully inadequate’ (ACP, G2). Wards were described as ‘unfit for purpose ’ (Nurse, G11), which was attributed, in part, to higher management lacking understanding of the needs and practices of the ED. One example highlighted the long-term impact of ED workspace changes that were not fit for purpose:

…it was clear that no clinical staff had been involved. Doors were in the wrong space, no sinks in the right place, not enough storage, poor flow, poor layout (ACP, G2)

Existing rest spaces or staff rooms were reported to be taken over to provide more clinical room, limiting the space for staff to change, rest and decompress.

The nurses were getting changed in a corridor, now they seem to have a cubicle they can get changed in. But the facilities for the same trust are really very different. (Nurse, G10)

This was perceived to be particularly important due to working in the high-pressure environments of a crowded ED, where staff voiced concerns regarding the sustainability of working with a high workload safely without private spaces.

EDs were perceived to be more busy, for reasons associated with shifts in societal expectations and perceptions of the scope and role of ED:

Go back ten years ago in the emergency department and people would try their best at home, would take painkillers, will see how it goes, not wanting to trouble A&E, but seems like now it seems like A&E is the open door for everybody just to come in with everything. (ACP, G7)

Participants used emotionally laden language when describing the intensity of the workload itself, with parallels drawn between being at war and working on the NHS frontline, where staff worked under similar levels of intensity but longer term and without rest.

…when people are deployed (in the forces) they are deployed for 6 months…because that 6 months is intense, it’s intense on your body, it’s intense on your mind, it’s intense on your family, it’s intense on everything about you, and that’s while you were deployed for 6 months, and then there’s some recovery time coming back. (Consultant, G4)

Comparisons were also made to the sinking of ‘the Titanic’:

There is the jollying everybody along, being the redcoat on the shift, cheering everybody up, saying everything is going to be okay, but feeling like you’re just rearranging the deckchairs on the Titanic (Nurse, G10)

The impact of a consistently high workload was described as being compacted by a lack of agency and autonomy over working patterns, which was perceived to be related to non-clinical staff making decisions about shifts without understanding the inherent pressures:

The people who control our rotas are… her job is a rota co-ordinator, she works in an office, she is administrative, and the person who signs that off is the manager for the department, again non-clinical, and getting leave is a nightmare, it’s awful. (Trainee doctor, G5)

Consultants identified that there were limited options to reduce workload when approaching retirement, and they did not necessarily feel well-equipped to continue operating under high pressure and for long hours. Those in training posts reported insufficient time to meet requirements or study due to workload, influencing both career progression and confidence in the role.

You are getting no progression because you’re not getting your training, and I know that personally in the last year I made my decision that I will not continue to work clinically, I will step back in the next few years because there’s… why would I stay doing something that there’s no reward for? (Nurse, G11)

Participants agreed that there was both a need and an opportunity for the ED to be a ‘nicer place to work’ (ACP, G2). Specific suggestions included a full staffing quota, ensuring staff are adequately rested to return to work and the opportunity for peer support:

My top three things would be coming on with a full staffing quote so you know there’s no gaps in the rota, so you’re all there. Everyone is well rested and ready for the shift, just being able to talk to each other on the shop floor and being quite open with each other on how everyone is feeling. (ACP, G7)

Many of the suggested changes directed at making working conditions in the ED more sustainable related to basic needs such as being able to take breaks, access healthy food and functioning IT when needed:

…having those opportunities to go off and have a five minutes when you need to, to be able to continue your shift. (ACP, G7) It would be really nice to be able to have some healthy nice food in the department. (Nurse, G11) As more and more of our job goes electronic, electronic notes, electronic prescribing, actually having IT systems that are fit for purpose, everyone has access to (Trainee doctor, G9)

Self-rostering was frequently mentioned as a positive experience for participants and a useful avenue to help participants to deliver better care and improve well-being:

One day off between a set of shifts is not enough to decompress and be re-energised to start back on your next set of shifts. So I think the rota, we have moved to a more self-rostering method now, and I think that’s helping with staff well-being, especially in our team. (A7)

Overall, working in existing ED environments was described as ‘untenable’ and ‘unsustainable’ in terms of both the working environment and the lack of agency and autonomy over high-intensity workloads. Many of the problems and solutions relate to provision of resources to meet basic needs, many of which are subject to professional and NHS regulations; however, due to pressures this is not being implemented.

Compromised leadership

Clinical leads in the ED were perceived to hold responsibility for setting the tone for culture and behaviour in the ED, leading by example:

And you lead by example as well, so if your consultant in charge is not taking a break you feel like you can’t ask to take a break. It’s the same with the nurses, if the nurse in charge is not taking a break then a lot of the junior nurses won’t come and ask for a break because again you’re guided by the leadership aren’t you? (A7)

The clinical lead in the ED is a key conduit for change, from a cultural and environmental perspective especially. However, participants expressed frustration about feeling that their voices were not heard or valued outside of the department, in part due to clinical leads being reluctant to escalate their concerns due to the discrepancies between clinical priorities within the ED and the priorities expressed by trust level executive management:

You’ve got the clinical side, and we are to one degree or another worried about the patients, and then you have got the management side and they are worried about figures, times or money, and those two things don’t really mesh together (ACP, G2)

Yet, within the EDs, leadership was described as being poorly supported in terms of protected time to train and deliver the role fully. Consultants voiced reluctance to take on a leadership role due to lack of ‘visible leaders’ to provide inspiration or exemplar: ‘There is no one for us to look up to, to lead us’ (Consultant, G4), ‘We need compassionate leadership’ (SAS doctor, G1).

A lack of definition or clear understanding of what the clinical role entailed was reported to make it difficult for clinical leads to be effective in their role:

People tell you that you’re there to lead, and you’re like I know but what does that mean? And then you don’t know if you’ve got to go to all these meetings, which ones you really need to go to, which ones can I not go to, also for me I do the job on my own. (Clinical lead, G6)

Participants emphasised they need a ‘clear definition of what the college would see the role to be, and how much time they would expect it to take of your job ’ (Clinical lead, G6). Any possibility for growth was hampered by a lack of training or support from colleagues to help with even the practicalities of the role (such as recruitment and personnel management):

I have literally started last week on a leadership course that’s been for other clinical leads in the organisation. But I feel a bit could have done with this maybe earlier. But that’s more about your leadership qualities and conflict resolution, it’s all that side of it as opposed to the actual practicalities of the job. (Clinical Lead, G6)

When considering possible solutions to these difficulties, participants suggested that an accessible time to do the job and an online repository may offer an opportunity to share resources, learn from one another and foster development:

I think sharing all the stuff we shared on the WhatsApp, trying to share stuff, so how to write a business case, what you need to do. (Clinical lead, G6) I should be doing work at a time I am getting paid, so you need to give me that time. (Trainee doctor, G9)

Mentorship was also deemed to be important for successful delivery of the role:

I think personally as leads and stuff we should all have some kind of mentoring type…Supervision, that’s the thing, we don’t get any. (Nurses, G10)

Participants described having difficulties feeding into emerging issues to address unmet need, blocked from communication with leaders by ‘layers of bureaucratic sediment’. This was compounded by the career trajectory of NHS management, where often those in post would swiftly move on for promotion.

Overall, clinical leadership within the ED was described as compromised, unsupported and, ultimately, a key barrier or missed opportunity for change in culture and working practices in the ED. However, there were clear indications of opportunities for growth and change, including a need for compassionate leadership, shared resources, time to do the job and mentorship.

Striving for support

This final theme encompasses the concerns raised by participants regarding well-being and staff support, specifically the barriers to accessing well-being support and their preferences in relation to what changes are likely to improve their well-being. Common barriers included having to attend support or well-being services during time off, with the scheduling of support geared to a ‘nine to five’ non-clinical workforce (ACP, G2). Mental health stigma in the ED was also cited as a key barrier.

I think for me it still feels like a bit of a stigma about saying I am struggling what should I do next. (Nurses, G11) There’s nowhere that I can express how I am feeling or even understand how I am feeling. (Consultant, G4)

This was reinforced by well-being not being viewed as a priority, with team check-ins or formal appraisals described as having ‘nothing in there about wellbeing’ (Clinical lead, G6), despite suggestions that simple well-being check-ins would suffice.

Participants suggested that support should not be purely accessed after the fact but something that should be prioritised and routinely available to staff to safeguard mental health:

… psychological support…it shouldn’t be something that we access when there is a problem, it should be something where we go well every month on a Friday at this time I go and talk to someone about what I have seen. (Trainee, G9)

Participants’ lack of understanding about which services were being offered was raised by many, with participants often able to list services available, or where the staff support centre was based, but not how or when one might access them. This offers a key opportunity for collaboration between staff support services and the ED to develop clearer pathways or a clear role for a departmental well-being lead.

Peer support was consistently highlighted as a highly valued resource that should be considered part of supportive culture ‘gives you somebody else to share the load with, and not be that single voice’ (Trainee doctor, G9). However, limited physical space and time to engage in peer activities were cited as barriers:

Well yeah it would be lovely to sit down and chat with my peers, apart from the fact that 1) we’re constantly busy, 2) we don’t have anywhere where we can sit and have a confidential gas. (SAS doctor, G8)

Overall, accounts suggested that existing support was largely unfit for purpose, and where it was easy to access (such as peer support) and available, it was often incompatible with ED working practices and within a culture where seeking support was often stigmatised.

Some participants expressed that having a psychologist embedded within the department was highly valued as a resource, particularly the different levels of support dependent on need:

…(during the pandemic) we setup weekly drop-in sessions with the psychologist… and it was really great for a lot of people to be able to drop-in, and then that led on to having one to one for people who felt they needed that, and also within ED we had a psychologist come round to our supervision when we needed them. (ACP, G7)

Participants reflected that psychological input introduced in response to the impact of the COVID-19 pandemic was highly valued. While many were open to discussion about their mental health and well-being, for many, stigma still permeates the ED culture and is further compounded by poor understanding and communication of available resources. Appointment of well-being leads, more value placed on well-being (including informal peer support) and routine access to psychology are suggested as opportunities to make strides towards improved well-being.

This study identified four key themes describing the difficulties in the ED work place. Working culture, physical working environment, pathways to care and leadership represent the core workplace concerns within our sample. These issues were perceived to play an instrumental role in their ability to sustain good working practices, well-being and, importantly, their intention to leave. Participants identified key barriers and opportunities within their work contexts which resonate with existing research and policy and can be used to shape the future policy and research development. 22 , 2 5 These findings act as a basis for the development of specialty-specific targets for change that are aligned with the views and voices of those working in this working environment and also take account the barriers and opportunities faced in the fast-paced unique environment of the ED. For a full set of EM-specific recommendations to underpin change across all of these four areas, see the Psychologically Informed Practice and Policy (PIPP) recommendations ( https://rcem.ac.uk/workforce/psychologically-informed-practice-and-policy-pipp/ )

Several of our findings have been noted in previous studies, particularly the role of culture, environment and access to support. 22 Most of the research examining factors associated with working conditions and retention in EM are profession specific 3 6 18 19 and are not readily generalisable to other professional groups in the ED. However, our study included doctors, nurses and ACPs from which emerged common cross-cutting themes affecting all of these professions working in the ED, themes which are consistent with the broader literature 9 10 but specific to the EM working environment.

As reflected in the work by Darbyshire et al , 5 the nature of the problems described were systemic; the workplace challenges were interrelated and appeared reciprocal in influence, arguably maintaining one another. The cyclical nature itself proves a key barrier to change, which raises the question: which is the primary target to effect most change? Leadership has a pivotal influence across these themes and is unequivocally vital to workforce transformation; however, this is an area that has been largely neglected in EM, with very little research seeking to develop or evaluate leadership interventions in this environment. Indeed, there is an assumption that leadership naturally develops over time and is fully formed on appointment to the role. 23 However, leadership within the ED is particularly complex and demanding due to the range of competencies required (clinical, managerial and administrative) 23 and the high-pressured environment within which this role needs to be delivered. This warrants tailored training and support to fully succeed. In settings where the nature of the work is unpredictable and at times clinically critical, leadership is pivotal to patient outcomes and team functioning, 23 24 which are particularly crucial in the ED setting. Leadership has the potential to be a powerful driver in workforce transformation, cultural change 25 and team functioning within these highly skilled, professionally interdependent teams. 26 To fully harness the capacity of leaders as agents of change, those in leadership positions must be sufficiently skilled, 27 feel supported to act on important issues 27 and have time to do the job. Yet, participants in this study reported poor role definition, lack of training and absence of protected time to deliver the role. This was compounded by blurred lines of accountability that led to impotence to effect change.

Implications

The development of leadership in EM should now be a primary focus. There are clear steps that can be taken to begin to mobilise and maximise the pivotal influence of leadership in effecting change, across government, professional, organisational and individual levels.

On a public policy level, there has been a rapid growth of government level publications and resources to recognise the role of leadership as a conduit to better patient and team health. 28 However, recommended leadership training is often generic and never mandated. This is surprising given the clear links with patient safety and team functioning. 23 24 Leadership training in healthcare should be mandated by government bodies, not least due to links with patient safety. 29

Significant work has been undertaken by RCEM to integrate and embed mandatory leadership training into the training curriculum for EM trainees, without which they cannot progress. While this demonstrates forward thinking and some future-proofing for the medical profession, it cannot cease at this point, it must be supported with continuing professional development post-training. The relevant professional bodies provide access to good quality leadership training such as the RCEM EM Leaders Programme and the RCN Leadership Programme, however, this is largely online without protected time to access or support development. More work is needed to ensure leadership training is visible, supported as part of a workplan, and a priority area championed by all relevant professional bodies.

Further work is needed to ensure that leadership competencies are introduced at an early stage of training 23 so the necessary skills are embedded and cultivated on the pathway towards and within leadership roles, rather than ad hoc when necessity dictates. This falls to both training and professional bodies to work together to ensure that theory-driven leadership is a core part of the teaching curriculum, with mentorship and practical resources (such as role definition, a personal development plan, human resource support) to complement and facilitate the necessary continuing professional development throughout a clinical career. Responsibility then moves to the employing local NHS trusts to support the development of those individuals within leadership positions. It is at this level that ED clinical leads and their teams can harness their influence; local NHS trust policies are driven by guidance from government and professional bodies, however, they have the power to shape local policy and mandate change in view of the needs of a service. We summarise key recommendations to underpin change at a local NHS level in Box 1 .

Key leadership recommendations for local NHS trust level commissioning

Those in leadership positions should be supported to attend leadership training as part of their workplan, within their workplace hours. This would include top-up training and training assignments.

Support to engage with a leadership mentorship or coaching programme as part of their workplan, with a view to continuing professional leadership development and creating safe spaces to problem-solve, reflect and seek support.

Access to the consultation service within the local NHS staff support services.

Appointment of a designated ‘Wellbeing Lead’ with protected time and support to deliver the role.

Clear description of roles and responsibilities, to include protected time dedicated to undertaking additional responsibilities associated with a leadership role and a professional development plan that is reviewed annually.

Support to engage with the EM clinical lead network in order to access resources to support the delivery of the role and access peer support when necessary.

Clear lines of accountability at an NHS organisational level with identified pathways to escalate concerns.

EM, emergency medicine.

Appointment of well-being leads within the ED, as outlined in the RCEM PIPP recommendations 30 and other key documents, 22 is also a key step towards workplace transformation through leadership; however, it is imperative this role is also supported with protected time and development. A well-being lead with a clearly defined remit and role would play a pivotal gatekeeper role in encouraging attitudes towards well-being in the ED by delivering ‘warm handovers’ and well-being initiatives, such as informal check-ins, staff team activities (ie, safety huddles), and well-being surveys.

On an individual level, those in leadership positions are more likely to succeed by harnessing the influence and opportunity that accompanies the role, identifying and taking inventory of challenges and barriers, clarifying lines of accountability to drive forward change and advocating for the needs of their team. Two mechanisms by which leadership bears the greatest influence include leading and prioritising a continuous cycle of quality improvement (eg, autonomy over work patterns, access to rest spaces, patient flow, taking steps to address the diversity gap) and role modelling of positive professional behaviours. 26 The latter includes compassionate and inclusive attributes but also speaks to the necessity to meet basic needs: taking breaks, adhering to annual leave, destigmatising views on mental health and openness to learning and change. Those in leadership roles should be encouraged to engage with the leadership networks, broadened to encompass a platform or virtual environment (ie, repository) to share and access resources and be granted access to leadership consultation with the well-being team as and when necessary. Those in leadership positions should also be provided with clear referral processes and internal professional standards to help address any incivility, including bullying, harassment and issues of inclusion. This would help promote a culture of care and interprofessional valuing and respect, improving team cohesion.

Finally, it is imperative that lines of accountability are clear for those in a leadership position. While many NHS trusts differ in their management structures, each trust will have communication pathways to divisional and executive management leadership teams. In order to drive the full potential of leaders to action change through these mechanisms, it is fundamental that pathways from ‘shop floor’ to the chief executive are clear and opinions and concerns of ED leadership are welcomed.

Flow through the ED, staff ratios, pay and pension structures are of course prime targets for change and where the current high-profile focus lies. However, leadership is a key conduit to change and those with mandatory powers must now move to recognise this in order to unlock the full potential of this role.

Limitations and future directions

There are inherent limitations in the small size of some of the participant groups, and as such the views and opinions expressed cannot be considered transferable across their respective professions. While many prospective participants did not proceed to focus group meetings due to last minute requests to cover shifts, the participant pool was comfortably within the bounds of what is acceptable for a qualitative study.

Findings should be interpreted in light of the sample consisting mainly of white women, therefore the views of males and minority groups may not be fully represented. Doctors made up a higher proportion of the final sample; this may be a consequence of using RCEM communication channels as a primary recruitment method, which has more members registered as doctors than nurses. As not all professions working in ED were included (eg, physiotherapy, psychology) it is possible that additional themes or differences might have been missed.

The geographical spread reflects a broad reach; however, there was a preponderance towards the South West, where the research was conducted. While none of the interviewees were known to the research team, those in the South West may have been more exposed to recruitment drives through mutual connections.

The development and testing of leadership training and packages should be a priority for professional bodies and at organisational level. This should take account of the overlapping and competing competencies required of ED leadership, including managerial, administrative and clinical components and the high-pressured context within which these skills are required.

This study identified key themes in understanding workplace concerns in the ED, and their associated barriers and opportunities for change. Leadership in EM should now be a primary focus, with further investment and support to target the development of leadership skills early on in training and provide protected time to refine these leadership skills and qualities across the working lifetime. This will serve to harness the pivotal influence of leadership in EM, which, if properly supported, holds the potential to act as a conduit for change across all areas of focus.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by University of Bath Psychology Research Ethics Committee (22-039). The Health Research Authority toolkit confirmed further approval was not required. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The study authors would like to extend thanks to all who contributed to this project including participants and the clinical advisory group. The authors would also like to acknowledge and thank RCEM President (AB) and policy advisor (SMcI) who advised on the policy priorities of RCEM and wellbeing clinical leads (Dr Jo Poitier, Consultant Clinical Psychologist at Alder Hey Children's NHS Foundation Trust; Dr Olivia Donnelly, Consultant Clinical Psychologist at North Bristol NHS Trust) who were consulted on their respective areas of expertise. They also thank Rita De Nicola for help in preparing the manuscript.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

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Handling editor Caroline Leech

Twitter @drjodaniels

Contributors The original concept for the paper was developed by JD and shaped in consultation with EC and the RCEM President AB. JD was the primary contributor, guarantor and lead for the content and refinement of the paper. EJ gave expert methodological advice and contributed to the reporting and refinement of results. ER and JD performed the analysis, both contributing to the reporting of the results. ER prepared the manuscript for publication. EC gave expert advice on all aspects of the study from an Emergency Medicine standpoint and also contributed to the write-up of the paper. All authors contributed to the final version of the paper and approved for publication.

Funding This research has been carried out through funding from the UK Research and Innovation Policy (UKRI) Support Fund. The funder did not provide a grant number for this project, it is part of block 'UKRI Policy Support' funding from UKRI directly to Universities who distribute within their institutions. The funders had no role in considering the study design or in the collection, analysis or interpretation of data; the writing of the report or the decision to submit the article for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

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.

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Unit Notes Unit 4 Notes Qualitative Research Methods

This paper is in the following e-collection/theme issue:

Published on 27.3.2024 in Vol 26 (2024)

Assessment of the Barriers and Enablers of the Use of mHealth Systems in Sub-Saharan Africa According to the Perceptions of Patients, Physicians, and Health Care Executives in Ethiopia: Qualitative Study

Authors of this article:

Original Paper

• Genet Tadese Aboye 1, 2 , BSc, MSc, PGD   ; 
• Gizeaddis Lamesgin Simegn 2 , BSc, MSc, PhD   ; 
• Jean-Marie Aerts 1 , BSc, MSc, PhD  

1 M3-BIORES (Measure, Model & Manage Bioreponses), Division of Animal and Human Health Engineering, Department of Biosystems, KU Leuven, Leuven, Belgium

2 School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia

Corresponding Author:

Genet Tadese Aboye, BSc, MSc, PGD

M3-BIORES (Measure, Model & Manage Bioreponses)

Division of Animal and Human Health Engineering, Department of Biosystems

kasteelpark Arenberg 30

Leuven, 3001

Phone: 32 489304866

Email: [email protected]

Background: Digital technologies are increasingly being used to deliver health care services and promote public health. Mobile wireless technologies or mobile health (mHealth) technologies are particularly relevant owing to their ease of use, broad reach, and wide acceptance. Unlike developed countries, Sub-Saharan Africa experiences more challenges and obstacles when it comes to deploying, using, and expanding mHealth systems. In addition to barriers, there are enabling factors that could be exploited for the design, implementation, and scaling up of mHealth systems. Sub-Saharan Africa may require tailored solutions that address the specific challenges facing the region.

Objective: The overall aim of this study was to identify the barriers and enablers for using mHealth systems in Sub-Saharan Africa from the perspectives of patients, physicians, and health care executives.

Methods: Multi-level and multi-actor in-depth semistructured interviews were employed to qualitatively explore the barriers and enablers of the use of mHealth systems. Data were collected from patients, physicians, and health care executives. The interviews were audio recorded, transcribed verbatim, translated, and coded. Thematic analysis methodology was adopted, and NVivo software was used for the data analysis.

Results: Through this rigorous study, a total of 137 determinants were identified. Of these determinants, 68 were identified as barriers and 69 were identified as enablers. Perceived barriers in patients included lack of awareness about mHealth systems and language barriers. Perceived enablers in patients included need for automated tools for health monitoring and an increasing literacy level of the society. According to physicians, barriers included lack of available digital health systems in the local context and concern about patients’ mHealth capabilities, while enablers included the perceived usefulness in reducing workload and improving health care service quality, as well as the availability of mobile devices and the internet. As perceived by health care executives, barriers included competing priorities alongside digitalization in the health sector and lack of interoperability and complete digitalization of implemented digital health systems, while enablers included the perceived usefulness of digitalization for the survival of the highly overloaded health care system and the abundance of educated manpower specializing in technology.

Conclusions: mHealth systems in Sub-Saharan Africa are hindered and facilitated by various factors. Common barriers and enablers were identified by patients, physicians, and health care executives. To promote uptake, all relevant stakeholders must actively mitigate the barriers. This study identified a promising outlook for mHealth in Sub-Saharan Africa, despite the present barriers. Opportunities exist for successful integration into health care systems, and a user-centered design is crucial for maximum uptake.

Introduction

eHealth, or the secure and cost-effective application of information and communication technology (ICT) to support health and health-related sectors, includes, but is not limited to, the use of mobile wireless technologies for public health or mobile health (mHealth) [ 1 , 2 ]. Digital technologies are increasingly being used to deliver health care services and promote public health. mHealth technologies are particularly relevant due to their ease of use, broad reach, and wide acceptance [ 3 ]. Global health service delivery could change as a result of the use of mHealth to support the accomplishment of health objectives. This transformation is being fueled by a potent confluence of different elements. These include the quick development of mobile technologies and apps, the rise of new chances for incorporating mHealth into already existing eHealth services, and the ongoing expansion of mobile cellular network coverage [ 4 , 5 ].

In the literature, it has been shown that mHealth systems in the form of SMS text messages, apps, and telemedicine projects are being used efficiently in the developed world. mHealth solutions are advancing rapidly in these regions [ 6 - 8 ]. The reason for this is the fact that there are a number of enabling factors that facilitate or encourage the use and implementation of such systems. Today, a wide variety of barriers and enablers are present in the developing world that influence the use and implementation of mHealth systems [ 9 - 11 ].

The prevalence and exploitation of mHealth technologies are steadily rising, presenting a significant opportunity for their incorporation into clinical services as a means to enhance the provision of high-quality medical care. Recent data on mobile phone usage in Sub-Saharan Africa revealed that 51% of residents possess a mobile device [ 12 ]. The latest statistics on mobile service subscriptions suggest an ongoing upward trajectory, with expectations of further increases. As of the end of 2020, 495 million individuals, equivalent to 46% of the population in Sub-Saharan Africa, held active mobile service subscriptions. Projections anticipate that this figure will rise, with an estimated 50% of the population (equivalent to 619 million individuals) anticipated to subscribe to mobile services by the end of 2025. Presently, there are 303 million internet users in Sub-Saharan Africa, constituting 28% of the population, and this number is projected to increase to 474 million by 2025 [ 12 , 13 ]. These data underscore the widespread penetration of mobile technology in the region and lay a solid foundation for exploring the potential advantages and challenges associated with its integration into health care services.

Even though the mass penetration of mobile phones is a fact and a very substantial condition to adopt mHealth systems in such countries, there are a number of factors that need to be considered when designing and developing mHealth systems in developing countries. Most mHealth systems initiated in such countries remain in the proof of concept or pilot testing stage. The large implementation of such systems is not widely documented [ 14 , 15 ].

mHealth approaches are widely embraced, and the health care system heavily relies on them in developed regions. From patient management systems to individual patient-centered mobile apps, these initiatives have been operational for a considerable period, in contrast to their counterparts in developing nations. A minor portion of Sub-Saharan African countries, less than half of the total [ 16 , 17 ], are currently endeavoring to incorporate mHealth platforms into their health care systems. This underscores the requirement for additional development of mHealth technology in the region. Ethiopia is currently focusing on strengthening its health care system and aligning it with the Sustainable Development Goals [ 18 ]. With a largely rural population, the nation encounters difficulties in accessing essential services like health care among others. A potential path for improvement lies in the digitalization of health care services, offering the opportunity to enhance efficiency, accessibility, and overall health care outcomes [ 19 ].

The implementation of digital health systems may encounter various challenges, and these challenges are generally context-specific. There is no universal solution that can address these challenges in all circumstances. Given the variation in challenges and the absence of a one-size-fits-all solution, success factors center on designing an mHealth platform that is specific to the context and the target population. This involves identifying these determining factors and incorporating sensitive design considerations to address unique needs [ 13 ]. Various studies have been performed for understanding technology adaption factors using various frameworks such as the Technology Acceptance Model (TAM) and the Unified Theory of Acceptance and Use of Technology (UTAUT) [ 20 - 22 ]. The research conducted by Liu et al [ 21 ] using the UTAUT indicated that users’ intentions to adopt mHealth systems are positively influenced by factors such as effort expectancy, performance expectancy, subjective norm, and perceived ubiquitousness. Notably, privacy concerns exhibited a significantly negative impact only on perceived ubiquity, with no significant effects observed on effort expectancy, performance expectancy, subjective norm, and intention to adopt [ 21 ]. The study by Yang et al [ 20 ] examined consumers’ intentions and behaviors related to the use of digital applications based on the UTAUT and provided valuable guidance for broadening the use of mHealth apps among consumers.

A systematic research study by Jacob et al [ 23 ] comprehending the sociotechnical factors influencing patients’ acceptance of mHealth tools proposed adopting a patient-centric strategy by ensuring that the tools seamlessly integrate into the overall patient journey and treatment plan. This involves giving priority to inclusive design and ensuring thorough patient education and support. Different frameworks have been used to evaluate the implementation of mHealth approaches, but they fall short of addressing all aspects comprehensively. In response, researchers have put forth a consolidated framework to address this limitation by incorporating various factors such as organizational and policy factors, social and personal factors, and technical and material factors [ 24 ].

The digital divide, characterized by unequal access to digital technology, is another factor that may be worsened or improved through the adoption of mHealth [ 25 - 27 ]. Despite evidence showing increased access to mobile devices, there is insufficient implementation of mHealth in Sub-Saharan Africa. Accelerating the integration of digitalization into the heavily burdened health care system could help address the challenges associated with inadequate health care and contribute to narrowing the digital divide in the region. Sub-Saharan Africa presents a unique challenge when it comes to the implementation and scaling up of mHealth systems. In contrast to developed countries, the region faces significant barriers that hinder the adoption and effective use of these systems. However, despite the numerous obstacles facing mHealth adoption in Sub-Saharan Africa, there are also opportunities and enabling factors. Consequently, the design and implementation of mHealth interventions in Sub-Saharan Africa must be tailored to address these specific challenges. Ethiopia, a representative country of Sub-Saharan Africa, is considered as one of these nations with limited implementation and consumption of mHealth systems. Thus, there is a pressing need for a comprehensive study of the barriers and enablers for mHealth adoption in Sub-Saharan Africa in order to help guide the development of tailored mHealth interventions that are suited to the local context and can effectively address the unique challenges facing the region. For this, it is vital to investigate the determinants that could affect the use of mHealth approaches. mHealth strategies are tailored to diverse end users, with certain approaches adapted for organizational use, while others target health care professionals or patients, and sometimes both. The factors influencing each of these populations may exhibit overlaps, yet they are varied and complex, necessitating a comprehensive and separate investigation for each category.

The overall aim of this study was to identify the barriers and enablers from the perspectives of patients, physicians, and health care executives for using mHealth systems in Sub-Saharan Africa and to provide recommendations on mHealth system design and policy-making. The study’s anticipated outcome is a description of the elements that encourage or inhibit the use of mHealth approaches, along with suggestions for resolving these barriers and exploring the enablers. This study can be used as a primary step in undertaking a user-centered design study of mHealth platforms in the Sub-Saharan African context.

Study Design

A multi-level and multi-actor in-depth semistructured interview was employed in order to identify the barriers and enablers of the use of mHealth systems.

Study Area and Sampling

The sample areas for this study included 1 city administration and 2 regions in Ethiopia, namely, Addis Ababa city administration, Oromia region, and Harari region. The study locations were selected based on the Human Development Index (HDI), which serves as a composite measure of a region’s average achievements in 3 fundamental aspects of human development, namely, health, knowledge, and standard of living [ 28 ]. Participants were recruited through nonprobability sampling, with a specific emphasis on purposive sampling techniques. For recruiting individuals, the snowball sampling technique [ 29 ] was used by means of colleagues, organizational contacts, and initial participants.

Participants

Data were collected from patients, physicians, and health care executives. For the health care executive group, individuals eligible for participation included decision-making persons and managers of health offices, hospitals, or similar organizations. For the physician group, individuals eligible for participation included health care professionals working at chronic disease outpatient departments (OPDs), who possessed the ability to communicate in Amharic. Lastly, for the patient group, individuals eligible for participation included chronic disease patients aged between 17 and 50 years who could communicate effectively in Amharic. These criteria were carefully defined to ensure that the selection of participants aligned with the specific characteristics and roles of each group within the study.

The participants in the health care executive group had a variety of positions, including office and hospital directors, coordinators, and ICT heads in federal offices, health bureaus, and hospitals. Additionally, in-depth interviews were conducted with physicians working at chronic disease OPDs. Furthermore, patients who visited the selected health facilities for chronic disease follow-ups were involved in the study.

Data Collection and Analysis

Semistructured interviews [ 30 , 31 ] were selected for this study as they provide the required balance between flexibility and structure for our research. This approach offers the necessary room to explore a subject while maintaining sufficient structure to accomplish the objectives of the study. The interview guides for patients, physicians, and executives are presented in Multimedia Appendix 1 , Multimedia Appendix 2 , and Multimedia Appendix 3 , respectively. The interview guides were structured based on the consolidated framework of the factors impacting clinicians’ adaptation of mHealth [ 24 ]. All interviews were conducted in-person with the participants. Prior to conducting the interviews, participants received an information letter explaining the overall goal of the PhD research and this specific study. An oral explanation was also provided where necessary. Informed consent was obtained from each participant in written form, and their participation was voluntary. When confidentiality and privacy could be assured, interviews with patients were conducted in the waiting area of the hospital. Interviews with physicians and executives were conducted at their offices. No monetary compensation was provided to any of the participants. All of the interviews were carried out by a female researcher (author GTA), who is a biomedical engineer and a PhD student with a focus on the design and development of mHealth systems for Sub-Saharan Africa. The researcher has experience and training in various research methodologies, including qualitative study. The interviews were conducted in Amharic and were audio recorded. The audio recordings from the interviews were first transcribed verbatim and then translated to English. No automatic tool was used for transcription. Google Translate was used for translation, and the information was checked manually for correctness. The thematic analysis methodology described by Braun et al [ 32 ] was employed for this study. The author GTA coded the interview transcripts and revised them with the 2 researchers JMA and GLS. NVivo software (QSR International) was used during the data analysis to code and categorize the data and to create a thematic framework. To report the study, we used the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist [ 33 ], which has been provided in Multimedia Appendix 4 .

Ethical Considerations

Ethical clearance was obtained from the KU Leuven Social and Societal Ethics Committee (SMEC) (G-2022-5491-R3(MIN)) and from the Jimma University Institute of Health Institutional Review Board (IRB) (JUIH/IRB/311/23).

A total of 48 interviewees participated in the one-to-one interviews. In the patient group, 17 patients (10 men and 7 women) were interviewed. Eight additional patients were approached, but they declined to be interviewed as they were in a hurry, were not willing to be interviewed, or were already frustrated with the system. The mean patient age was 33.9 years, and the mean interview duration was 6.25 minutes.

In the physician group, 19 physicians (12 men and 7 women) were interviewed. Six additional physicians were approached, but they declined to be interviewed as they had hectic schedules. The physicians included in the study were general practitioners who worked in chronic disease OPDs and had an average of 5 years of experience. In this group of individuals, the mean interview duration was 15.7 minutes.

In the health care executive group, 12 health care executives (10 men and 2 women) were interviewed. Owing to a scheduling conflict, 1 additional executive declined to be interviewed. In this group, the mean interview duration was 19.34 minutes. The executives had a variety of positions, including directors in the country’s health minister’s office, directors in city health administrative offices at the zonal and regional levels, hospital chief clinical officers, and ICT heads at hospitals. Owing to the limited number of key respondents in the health care executive group, the number of participants in our study was restricted. Nonetheless, we ensured that the interview process was comprehensive enough to address all crucial aspects, and we included all key informants while also exploring any new viewpoints that emerged.

The total sample size was established based on data saturation, which occurs when new data no longer provide additional perspectives or insights after a certain point. In this study, data saturation was reached following 48 interviews (17 patients, 19 physicians, and 12 health care executives), indicating that an adequate sample size had been achieved. Table 1 provides an overview of the interview characteristics.

a N/A: not applicable.

b ICT: information and communication technology.

A total of 137 determinants for using mHealth systems in Sub-Saharan Africa were identified from the perspectives of patients, physicians, and health care executives. Of the 137 determinants, 68 were barriers and 69 were enablers. Themes were derived from the data. Further categorization of these aspects in the study resulted in the identification of 3 major categories: organizational and policy, social and personal, and technical and material. These categories were based on the consolidated framework of the factors impacting clinicians’ adaptation of mHealth [ 24 ], which takes into account the numerous factors influencing adoption of mHealth systems. The organizational and policy factors pertain to health care organizations’ internal workings, workflow, policies, regulations, patient-related factors, and user engagement. The technical and material factors pertain to system design, system usefulness, IT capabilities, compatibility, data management, user experiences, monetary factors, and ease of use. The social and personal factors include personal characteristics, social and cultural factors, and moderating factors.

Perspectives of Patients

Among patients, after a detailed examination of the data, we identified 10 unique factors that could impede progress, which were referred to as barriers, and 8 unique factors that could facilitate progress, which were referred to as enablers. Figure 1 provides a comprehensive list of these barriers and enablers. Patients were assigned a code based on the study area as follows: those from Addis Ababa were coded “AP,” those from Harari were coded “HP,” and those from Jimma were coded “JP.”

Among the 10 barriers hindering the adoption of mHealth systems, 6 were under the technical and material category. These challenges included system design, system usefulness, IT capabilities, compatibility, data management, user experiences, monetary factors, and ease of use. The remaining 4 barriers were under the social and personal category, which included personal characteristics, social and cultural factors, and moderating factors.

The majority of patients reported that they have never used mHealth systems. However, most of them reported that they would use mHealth systems if they had awareness and if they could access these systems in an affordable way.

More than half of the participants had no awareness about mHealth systems and how they could benefit them. However, upon a detailed explanation about mHealth systems and their importance, they reported that they recognize the usefulness of such tools. They reported that they would use these systems if they could get trustable systems and if recommended by their doctors.

Regarding the barriers associated with using mHealth approaches, the most frequently cited theme was a lack of awareness about mHealth systems.

I don't have the information about such things either. Apart from seeing the texts that come to me, I never installed the application and tried nothing. [AP4]

To be honest... I have never heard or seen health practitioners recommending this to me. I have no idea about such systems. [AP6]

I don't know much about that, but I think it is useful for monitoring my diet and sugar levels. [HP3]

The knowledge gap… For example, when I see my friends using such things, I don't know the source of it. And I learn from them, but for example, when I am talking about this idea with my friends with whom I have the same interest like me they ask me from where I get it from. [JP2]

I don't have the information about this. [JP6]

Patients also perceived the fact that mHealth systems are not readily available as a barrier to not using them. They reported that they browse Google or YouTube when they need to obtain information related to health.

I will download some stuff on YouTube. Video… I see…. I am downloading some video. [JP4]

The only thing I've used so far is Walk Exercise. It is by just browsing. [AP2]

The affordability of smart mobile phones, the requirement for a paid subscription, and the high cost of smart systems were identified as economic factors that can impede the adoption of mHealth systems. These factors are believed to create obstacles for individuals who may not have access to the necessary technology or cannot afford the associated costs.

Because this information is from the internet. It is not possible to access the internet if it is not purchased. Again, you can find that if you go to a place with internet. Even if I have a cell phone, it costs money. [HP1]

But the affordability... I can't afford that mobile so I won't use it. [HP1]

But with the systems, the smart ones are a little expensive, so the cost of the sensors is a barrier. [AP6]

A lack of trustworthy mHealth systems is a significant obstacle to their adoption. Patients feared that the information and services provided by these systems may not be based on reliable evidence. This concern arose from the potential harm caused by inaccurate information or ineffective treatments.

I want it to be something secure. First is the issue of medication. Medical information is not something you can just throw away. Therefore, they have a question of credibility. [AP4]

The reason I don't use it is because most of them are not desirable. Because I hear things that are not trustworthy; I won't take advantage of it. [AP5]

The application must be supported by evidence. [JP4]

Inconvenient features (presentation) of mHealth systems were also perceived as an obstacle to the use of these systems.

I think that a lot of data frustrates people. When you read more data, it is like an education. It needs your time. It needs your opinion. Anyone who is not in the health field may not have an interest in such things. [JP2]

The presentation is a biggest barrier... even if it is translated... there are some words that are cultural and from our community language... there is, isn't it... I think there is a small barrier. Medical terms... because it's a bit difficult to how interpret them. [AP6]

Digital illiteracy, which refers to the lack of ability to effectively use digital technologies, such as computers, smartphones, and the internet, is a recognized barrier to the adoption of mHealth technologies. This challenge is believed to limit the ability to take advantage of the benefits provided by mHealth tools.

Lack of skill in using mobile phones. Configuring systems specially in IOS it is also same for android is difficult. Like Entering Personal Details. And because the app won't start without you doing it. [AP6]

I don't know how to use this kind of thing. I don’t have the knowledge of how to use such systems. So, I never used it. [HP4]

Among the 8 enablers facilitating the adoption of mHealth systems, 5 were under the technical and material category and the remaining 3 were under the social and personal category.

Patients with chronic diseases had a need for easy and automated tools for health monitoring.

It's a matter of health. To control my blood sugar level, there are mandatory things that I have to do. So if there are things installed on my phone to help me with this, it helps. [AP2]

I am suffering from hemorrhoids. Some say wash with cold water; Some say to wash with warm water; not to be confused it will be good if there is a tool to use in my phone. [AP3]

One of the things that inspired me to use it was to find out how many calories I burned in a day; It reminds me how much I should move, if I don't move, I will be exposed to other related diseases. It means it has health benefit for myself. [AP6]

It will be very good. I may not always in need to go to the hospital. I am able to adjust myself from that information; Use the medicine on time. Adjusting the food system; doing activities; There are also recommendations. I have arrived to that conclusion. And it's good. And it's important to have. [HP1]

I think it would be helpful to have more of information, especially to monitor my health. [HP4]

I think it makes things easier for us. If I use it, it will be beneficial. The usefulness is very high. [JP1]

Patients recognized the availability of the internet as one of the facilitating factors of the use of mHealth systems as it could help them access such platforms.

At home, I have Wi-Fi, so it's easy. [AP2]

Now there is telephone, there is Internet, there is Wi-Fi, now there is internet even in a pool house, there is even in a tea house. [JP2]

There is a big difference between where there is internet and where there is no internet. Internet is a way to get many new technologies. We have it now more than ever. [JP4]

Another enabler was the perceived usefulness of mHealth as a convenient tool to access health information.

…. And it helps you to be proactive about your health. It means it prevents you from going to the hospital after something happens. [AP6]

Perspectives of Physicians

Among physicians, we identified a total of 54 factors that were perceived to influence the adoption of mHealth systems. Of the 54 factors, 27 were identified as barriers that hinder the use of mHealth systems and 27 were identified as enablers that facilitate their adoption. The study further classified these factors into 3 main categories, namely, organizational and policy, social and personal, and technical and material. Physicians were assigned a code based on the study area as follows: those from Addis Ababa were coded “AD,” those from Harari were coded “HD,” and those from Jimma were coded “JD.”

Specifically, among the 27 identified barriers, 7 were under the organizational and policy category, 11 were under the social and personal category, and 9 were under the technical and material category. Figure 2 displays the obstacles to the use of mHealth systems from the viewpoint of physicians.

Physicians identified the lack of established mHealth systems as the primary reason for not using them. They acknowledged that their lack of exposure to these systems has prevented them from gaining experience in their use.

Actually, there is no such system or application based health care at the organization where I work. [HD3]

For example, a patient comes to us and we ask about the patient's problem, then we ask and investigate to do a case diagnosis, and at the end we write an investigation paper to investigate and send it to the patient. And we give them hard paper. And we have not prepared them in a computerized way. There is none. [HD6]

The main thing is that this type of system does not exist here. [JD2]

According to physicians, certain types of mHealth systems have been implemented in some organizations they work for. However, these systems are often interrupted and lack continuity. Physicians considered the discontinuity of established mHealth systems as one of the key barriers to the effective use of mHealth tools.

Around two years ago, this program was being popularized, but nobody in the middle was using it. It is not waited until we become experts. It was interrupted in the middle. [JD5]

Sometimes, due to the data and various factors, the system encounters some errors. So we will go back to the manual paperwork at that time. Therefore, when we report using a digital system, if there is an interruption, we often go back to paperwork. [HD7]

Another barrier preventing the use of mHealth systems was the required extra time amidst an overloaded work schedule, especially for recommending such systems to patients.

And again, just because there is high patient load here; I don't have that kind of time. It does not allow to say use this or not. As one patient leaves, another enters. There is a load, and it doesn't allow us to have much contact with the patient. We are going to send by diagnosing and treating with what we already have. [AD1]

A further barrier to the adoption of mHealth systems was the lack of physicians’ awareness about mHealth systems for patients. Some physicians reported that they are not well-informed about these systems, and even for their own personal health and wellness, they rely on browsing the internet rather than using stand-alone health systems. This lack of knowledge and personal use can limit their ability to confidently recommend and implement mHealth tools in their practice, which in turn can hinder patient adoption and engagement. To overcome this barrier, there is a need for greater education and training programs for physicians on the benefits and effective use of mHealth systems, as well as efforts to increase physician engagement with these tools to help build their confidence and understanding.

Now, for example, I don't know anything personally, but for example, I don't know an app for diet. Honestly, now, in terms of exercise, I use YouTube downloads even for myself. [AD2]

Some physicians claimed that they have never given these systems any consideration.

From my point of view, there were no situations where we would recommend using this to my patients. Maybe, I have never thought about it. [JD4]

I don't have the knowledge. I mean, I didn't know there was anything like that about mHealth that you just told me about. To tell you the truth, I only found out about Mobile Health Solution today. [AD5]

Another barrier was physicians’ concerns about patients’ mHealth capability. They acknowledged being worried that their patients do not have the necessary skills or access to technology to make the most of mHealth tools.

But as I said, it's not that the applications have problems; As I told you before, I don't think anyone will use it. It just doesn't feel like that to me. [AD1]

Most of them are illiterate. It is uneducated and I don't think they will use this app. [AD5]

As I mentioned earlier, the problem is that the demographics of the patients are too old to use such systems. They may have a little trouble. [AD6]

What I would consider being the biggest obstacle... Most of the chronic follow-ups have a low level of education. So they may find it very difficult to use applications. [AD7]

I think they are less literate and less qualified. Because the majority cannot read a book. So I think that will be like a gap. [JD2]

Physicians mentioned a further obstacle in the adoption of mHealth systems, namely, lack of trustworthy systems, which raises concerns about the potential risks of recommending them to patients.

People with chronic conditions are very bitter, so they search for something to escape. Sometimes there is information that takes you to stop taking medicine. So, this is the side effect of modern digital. It's not even called a limitation. [JD4]

Another barrier was the lack of readily available mHealth systems in the local context.

But it is not prepared at the app level in our country. It is better if we use this application prepared like this. We tell patients that they will find it on Google because it is not set up like that. [AD7]

The first and most important thing that we can't do is we see it from our country's perspective, if we see it like Ethiopia, there are no rich digital applications for that. Not being able to provide us with that information is the number one factor. [HD7]

Most of the time, because those data are based on foreign populations, those findings have nothing to do with the population of our country. [HD1]

Security and data confidentiality concerns were also perceived as barriers to the use of mHealth systems.

I usually log in with my Google account. I have already accepted my Google account. And I have doubts. I am not sure. As I don't have details about the system. I don't know much about server security. Some app says you can accept or not about personal issue when you open an app. It may be exposed. I'm not sure about the data security and confidentiality. [HD4]

Another barrier was the inconvenient features of some mHealth systems. Most mHealth systems that physicians can use do not have an offline option, and many of these systems work online.

The biggest problem is that they are all online. They don't have offline. And you absolutely need data. [HD4]

A lack of reliable internet and electricity was an additional obstacle.

After all, if there is no internet, we cannot get this information. The main obstacle is the internet. Most mHealth applications are internet-based, so information cannot be accessed when the internet is down. [HD7]

Among the 27 enablers that facilitate the adoption of mHealth systems, 14 were under the organizational policy category. These factors pertain to health care organizations’ internal workings, workflow, policies, regulations, patient-related factors, and user engagement. Moreover, 4 enablers were under the personal and social category involving personal characteristics, cultural factors, and moderating factors. Furthermore, 16 enablers were under the technical and material category encompassing mHealth system design, IT capability, compatibility, user experience, data-related factors, ease of use, and monetary aspects. Physicians’ perspectives on factors that facilitate the use of mHealth systems are depicted in Figure 3 .

Physicians perceived usefulness in promoting easy information storage, access, and retrieval as one of the enablers of the use of mHealth systems. Despite limited exposure to these systems, physicians believed that they represent a convenient way to manage patient data, with the advantages of avoiding loss of information and enabling reliable information retrieval.

On the positive side, there is no such thing as loss of information such as manual cards and paper, papers can be torn and lost. Patients can also be abused. But if we use mHealth systems such as EMR, it will not disappear because we will simply be here and send all the investigations. Whether the data is from this year or before, I can check many things about the patient. It makes it easier for me because I have everything I need there. [AD1]

You will not lose the file, it is well recorded. What did they have before? Or what medication were they taking? Even if the patients don't know what medicine they are taking, how much dose they are prescribed, how many times a day they are taking, so I can get a record from this. [AD2]

Therefore, getting reliable information and then delivering that information to the concerned patient is of great importance. Using mHealth in general allows us to get better information and updated information. [HD7]

You will find information in applications in a very easy and understandable manner. There are books in hard copy. Sometimes when you read those hard copies, you don't understand them, when you go with those applications, they are very encouraging because they are easy to understand. [HD3]

Knowledge is not a big deal as it used to be. Knowledge is cheap. Knowledge is what you can find anywhere by Googling. It is a matter of reading and not reading. But everything is up in the air. And it's not like you used to go to the library to look for a book and get a book. Everything is on your phone. You can open and use it even during operation. Whenever you want. It's very easy. [HD4]

Another enabler was the perceived usefulness in reducing workload and improving health care quality. According to physicians, using mHealth systems has the potential to lessen the strain of health care personnel while also raising the standard of care.

The first reason for not providing quality service is the workload and if something reduces that load, if there are supportive things like this, I think the quality will improve. [AD1]

The timing itself. If you have a current patient, what time did she take her medicine? Did she take it or not? She will be evaluated strictly on time. She takes her medicine on time. A professional can't lie if he skips it knowingly or unknowingly. He cannot say that he gave it to her. When you record what you just did, it will record the time. [AD4]

You can treat your patient in an international standard way. [HD4]

Physicians mentioned that mHealth systems allow for better access to health information for patients. Some believed that providing patients with access to various health-related information at their fingertips will empower them.

Using mHealth in general allows to get better information and updated information. Especially when it comes to health. It helps to live a healthy life by getting new information every day. [HD7]

If the patients have it on their hands, I think it will be a daily experience for them too. It will be easily accessible and it will save our time for the patients as well. [HD2]

Our patients, who have been treated, do not come back with any complications. Because they can get health information and monitor theirs case. Because they may be able to get every detail on the system. [HD6]

Another enabler was the need for a chronic disease management support tool. Physicians recognized the potential benefits of digital automated tools for patients having chronic diseases, as consultations and visits to their office alone may not suffice. To promote healthy lifestyle changes and provide necessary support, it is imperative to equip patients with user-friendly tools that can be integrated into their daily routine.

First, when there is a patient like this... there are chronic ones, for example, diabetic, hypertensive, heart failure. Because they need not only medication but also life modification, they may not achieve what we have told them in one day. But everything how to modify their lifestyle detail is there, so when they get access, they can easily remember what we told them and continue their life. Beyond medication, by the way, also cares about their lifestyle. [HD6]

Availability of phones and the internet was also perceived as a facilitator. According to physicians, availability of phones and the internet has tremendously facilitated the adoption of mHealth systems in a variety of ways. First, regardless of location or the time of day, users may readily access health information and services via their mobile phones. Second, health professionals can use digital tools to gather, preserve, and share patient data, which can improve the quality and efficiency of health care services. The increasing use of mobile phones and the internet in Sub-Saharan Africa has created an opportunity to use these platforms to deliver health information and services to individuals who may have limited access to traditional health care services.

This is because there is internet access and broadband, so everyone works connected to the network. Without that, this simple system wouldn't exist. [AD1]

Now, for medical and other purposes, because of this technology, because of the advent of smartphones, the spread of Wi-Fi, the advent of the Internet, I think that it has made everything easier even the medical education. [HD4]

Having a mobile phone and the internet makes things easier. [HD5]

Physicians who have experienced mHealth systems recognized that these systems are easy to understand and operate. They declared that for users who are familiar with technology, these systems are easy to use.

So you need to know how to access the systems. They are mostly easy. There is nothing difficult unless you are someone who is not familiar with technology to use it. You can search. You can log in and access what you want. I don't have anyone who says it's a challenge. [AD6]

Perspectives of Health Care Executives

Among health care executives, we identified 65 factors that were perceived to influence the adoption of mHealth systems. Of these 65 factors, 31 were classified as barriers and the remaining 34 were classified as enablers. Further categorization of these aspects in the study resulted in the identification of 3 major categories: organizational and policy, social and personal, and technical and material. Health care executives were assigned a code based on the study area as follows: those from Addis Ababa were coded “AA,” those from Harari were coded “HA,” and those from Jimma were coded “JA.”

Among the 31 barriers, 14 were under the organizational and policy category involving elements like the internal working environment of health care organizations, workflow-related challenges, policies and regulations, patient-related factors, and user engagement issues. Moreover, 6 barriers were under the social and personal category involving aspects like social and cultural norms, personal traits, and moderating factors. Furthermore, 11 barriers were under the technical and material category involving difficulties with usefulness, IT capability, compatibility, data-related factors, user experiences, financial factors, and ease of use of mHealth systems. Health care executives’ viewpoints on obstacles to the use of mHealth systems are presented in Figure 4 .

From the perspectives of executives, one of the challenges of implementing mHealth systems in Sub-Saharan Africa is the availability of competing priorities alongside digitalization in the health sector. There are competing demands for resources and attention, such as investing in health care infrastructure, improving health care workforce capacity, and addressing immediate health needs.

We are facing multiple health challenges, including infectious diseases as well as non-communicable diseases like diabetes and hypertension. Additionally, the health sector faces critical issues such as inadequate infrastructure, a shortage of skilled healthcare workers, and limited financial resources. Because there are competing priority areas in the sector that require money. From all of them, it is assigned to this sector and these are taken as a challenge not to work completely with hands. [AA5]

High initial investment required for mHealth technologies was also perceived as a barrier by executives. The cost of implementing mHealth systems includes not only the purchase of hardware and software, but also the cost of training health care workers, adapting existing health care workflows, and establishing new data management and privacy protocols.

As a problem in supply, mHealth technology is expensive. Not being able to avail of all of them is an issue. [HA3]

These start-ups require financing. Although the return is high, the initial investment is also high. mHealth activities require so much investment. [JA2]

Another barrier was that some donor-initiated mHealth systems previously implemented in health care facilities lack government takeover plans after contract expiry. These mHealth systems involving donor support do not have clear take over and exit strategies for ensuring sustainability of the projects.

A project has a lifecycle. It comes up with a project by donors and be started that way.. It won't be owned when it is done. It will not be owned by the government. [AA34]

Skill gap in basic computer literacy was also perceived as a barrier. These skill gaps can be partly attributed to limited exposure or access to digital devices such as computers.

Computer access is limited. The smaller the access, the less likely it is to use mHealth activities. So there is an obvious skill gap. So does the professional. [JA2]

Another barrier was inefficient use of technology.

Efficiently manipulating those technologies if we had them; Proper use of data; One of the challenges is not using technologies properly. We should use them properly and take the appropriate value from them. [AA5]

The absence of individual patient–focused mHealth system implementation was perceived as another barrier to the adoption and implementation of mHealth systems in health care.

While some health care facilities have implemented mHealth initiatives, these initiatives are more focused on the institution rather than the individual patient.

The one that we are using on ART is not to be used by the individual patients. It is an application more with professionals on the periphery than with patients. [JA2]

A further barrier was that implemented mHealth systems lack interoperability and full digitalization. Although attempts to implement mHealth are sparse in health care facilities, lessons can be borrowed from implementation challenges in other areas, such as electronic medical records (EMRs). Some facilities have deployed EMR systems. EMR systems are not fully digitized, with most of them involving a combination of manual and digital systems. Some health care executives also reported that due to mismatch or lack of integration between some medical devices, they are unable to deploy fully digital systems.

There is a lot of fragmented stuff. [AA34]

It is half and half... It is only for reporting, but to make our work more active, it is very good if the facility is fully digital and the delivery points pass through the system through the network. [HA1]

Interoperability is not yet implemented. The two systems are not interoperable. The interoperability is being tested for the country. [JA1]

We have implemented about 80% of the Laboratory Information System (LIS) in our hospital. [JA2]

Another barrier was the difficulty of staff to quickly and easily adapt to mHealth systems.

First of all, sometimes when new things come, there are problems of getting used to that digital thing quickly and not keeping up with it. [JA1]

Another barrier was the lack of awareness among staff members. Going fully digital requires a great deal of work to create awareness, as mHealth technologies are relatively new in the region and many health care workers may not be familiar with them.

As a challenge, we still need a lot of attention for technology in general by the government. We are still in the early stages of our own user experience. [AA2]

There is an opportunity created by technology. However, creating awareness of the work at all levels, from the leadership to health institutions or to the community should be done. Therefore, one of the biggest tasks is to make the awareness. From top to bottom, the importance needs to be well inculcated. This is the lack of awareness of the decision makers from the community level to the top level. [AA5]

The above issue is further exacerbated by the fact that the barrier is related with staff’s reluctance to transition from traditional to digital systems. This lack of awareness and knowledge can lead to resistance or hesitancy in adopting mHealth systems, even if they have the potential to improve patient outcomes and operational efficiency. Health care staff may be unsure of how to use mHealth tools and systems, or they may not understand the benefits of using them.

People who are used to paper work often don't want to be told that we are going to do digital work. [JA2]

The biggest thing I have seen is that there is a problem of commitment. It means that it is very challenging for a person to leave what he used to and come to something new. [JA3]

Among the 34 factors that facilitate the adoption of mHealth systems, 14 were under the organizational and policy category. These factors pertain to health care organizations’ internal workings, workflow, policies, regulations, patient-related factors, and user engagement. Moreover, 4 enablers were under the personal and social category involving personal characteristics, cultural factors, and moderating factors. Additionally, 16 enablers were under the technical and material category encompassing mHealth system design, IT capability, compatibility, user experiences, data-related factors, ease of use, and monetary aspects. Health care executives’ viewpoints on enablers of the use of mHealth systems are presented in Figure 5 .

From the perspectives of executives, the health ministry’s plan to digitalize the health care system is one of the main facilitators or enablers of the use of mHealth systems.

There is a direction according to the government. To use such technologies in most cases; It is for online use. The ministry itself has a strategic plan. To digitalize the healthcare system. It is a priority. [AA1]

The executives emphasized that the plan is not just a matter of execution but also of giving priority and actively pursuing it.

And now technology is making a big contribution to the health sector. And the ministry understands what a great advantage we have; Departments in the Ministry of Health are working with great initiative using mobile technology. [AA5]

Another factor that enables the implementation of mHealth systems is the existence of governance frameworks. Such frameworks were nonexistent a few years ago. However, now, in order to regulate and promote the adoption of mHealth systems, the health ministry has developed a framework that is currently being deployed. Furthermore, a dedicated directorate office has been established to oversee and manage the adoption and implementation of mHealth systems.

Therefore, it is mandatory to create favorable conditions. Facilitating conditions on the ground such as governance frameworks are required. We are working on it. Standards guidelines are required. In addition to this, data standards have also been developed. Now, for example, there are disease codes. A standardized health data access policy has been developed. All these guides the mobile health and govern mHealth as a whole. [AA5]

Now, for example, during the time of Covid, There were mandatory situations to initiate telehealth teleconsultation, but if you ask how it works, there was nothing. But now, there is this direction at the level of the Ministry of Health. They have a directorate office. [JA2]

Another enabler is the recognition that digitalization is crucial for the survival of the heavily burdened health care system in Sub-Saharan Africa. Hospital executives strongly believed that the failure to digitalize the entire health care system within the facility will ultimately lead to its downfall.

But now, considering the complexity of the treatment and the number of patients we see, the staff is now demanding digital solutions. It is understood that we cannot survive if we do not digitize. We have to digitize the entire operation of the hospital. As I said before, it is a matter of survival. It is a hospital where three thousand four thousand people come and go every day. We have 250,000 to 300,000 outpatients per year. We treat about 20000 people. About 170,000 to 180,000 people will come for emergency. We perform surgery on 15000 people. So this process it is huge process. If this process is not digitized, we cannot provide a smooth service. Because it is causing problems for the patient. As a hospital, we have an assessment that it is increasing the number of deaths. [JA2]

According to the executives, another enabler is efforts made toward maximizing the necessary infrastructure provision required for the implementation of mHealth systems. Executives at all levels within the organization realized the importance of providing the required infrastructure, such as ICT and hardware or software resources, to support the deployment of mHealth systems.

In terms of infrastructure... the main thing for digitalization is the internet. They have been given internet access in all nine districts. In terms of computers, they have computers. All adequate internet access to the DHIS health information system, capable computers, and PCs are available at all health centers in the district. [HA2]

For example, they can be computers. Servers. It is not directly from the office but it is fulfilled by different partners as they work together with us. [HA3]

Along with training, tablets are distributed along with resources such as tablets in areas where they are needed. [JA1]

We have invested a lot in infrastructure. Especially our hospital as a health institute has a large ICT infrastructure. We deployed computers. We are working on servers and databases. We trained people and experts for that purpose... It is itself strategically supported and supported by infrastructure. [JA2]

Another enabler is the growing societal familiarity with digital technologies, including social media and financial systems. As more individuals become comfortable with using digital technologies in their daily lives, they may also be more open to using mHealth systems.

At the same time, the opportunity is also very profitable because the number of users of social media is increasing from time to time. [HA3]

Mobile is now used by many people for money transfer. A lot of things... even if a mHealth system doesn't expand, in the finances... a lot... you sit at home and pay. You can withdraw without an ATM machine. It's simple, a person in finance has experience elsewhere. Mobile is now used by many people for money transfers. It is one exposure to general digital systems. [JA2]

The abundance of educated manpower specialized in technology was also perceived as an enabling factor for the adoption of mHealth systems in Sub-Saharan Africa. With a growing pool of technology professionals in the region, there is a greater capacity to develop and implement mHealth solutions that are tailored to the specific needs of the region. This includes the development of innovative technologies, such as mHealth systems and telemedicine platforms, which can improve access to health care services and support patient care. In addition, the presence of a skilled technology workforce can support the deployment, maintenance, and troubleshooting of mHealth systems, which can improve the overall reliability and sustainability of these systems.

… there are many educated young people who can do a lot of creative work; Universities have expanded significantly. [AA2]

… Because educational institutions at the national level can easily produce graduates who can easily design and develop these emerging technology applications. [AA5]

We also have an ICT director with us. We have teams working on software development. So, as a university, as a health institute, as a medical center, we are doing this work. Second, we are building human capacity. Many students are studying. Despite the quality, I think we have that capacity human power. [JA2]

Executives perceived that mHealth solutions are capable of reaching remote and underserved areas where traditional health care services are not readily available, which is a significant enabler for the adoption of mHealth systems in Sub-Saharan Africa. Furthermore, mHealth solutions were thought to aid in overcoming the scarcity of health care personnel by providing remote consultation, training, and education to health care workers, as well as assisting in the delivery of health care services in places with limited resources.

In terms of accessibility, the technology is generally accessible to all communities. The community of our country is located in a very remote place and access to health facilities is very limited. Therefore, mobile technology can be used to make these sections of society that are accessible at different distances easily accessible. Secondly, as mentioned, we have a shortage of health professionals. It is very important to make the service available remotely even if our experts are very limited. From this perspective, it is very important for a society like Ethiopia where there is a shortage of health professionals and the most accessible health facilities are few. [AA5]

Executives perceived mHealth solutions as useful tools for enhancing health care service quality, which is a significant enabler for the adoption of mHealth systems in the region. Health care providers can improve the quality and efficiency of health care services by embracing mHealth technologies, such as electronic health records, clinical decision support systems, and telemedicine platforms. Real-time data collection, monitoring, and analysis enabled by mHealth technologies can also influence evidence-based decision-making and assist health care providers in providing fast and accurate diagnoses and treatment plans.

For example, the patient can take advice without coming to the facility. Alerts can go be sent to him. You will find a lot of information. It means that they will not be abused by looking for their doctors. And it generally makes things easier. [AA1]

It's easy. It's very simple. It makes it easier. It will be easy for everything in time and for the number of people. So it is very good if we use and serve. It is from two sides. Client side and provider side. It also reduces other errors. Another thing is that it reduces time. So it's very good. [HA1]

It will help us gain efficiency. As mentioned earlier, efficiency gains for the health care system are linked to access, mortality, and quality. [JA2]

Another enabler perceived by executives is the availability of mobile phones and the internet. The increasing availability of mobile phones and the internet in Sub-Saharan Africa has created an opportunity to use these platforms to deliver health information and services to individuals who may have limited access to traditional health care services.

The fact that the majority of the society is using mobile technology gives the ministry a great opportunity to implement the system. Second, mobile accessibility is expanding. In Ethiopia, it is said that quite a large number of people have mobile phones in their hands. Therefore, the service can be accessed without coming to the health facility. [AA5]

For example, if you visit the OPD in a hospital, you will find very few people without a smartphone. If you want to buy a laptop and buy a tablet, It is easy. It is available. [JA2]

The overlapping barriers and enablers among the various stakeholders are summarized in Tables 2 and 3 , respectively.

a mHealth: mobile health.

Principal Findings

The barriers and enablers of the implementation of mHealth solutions in Sub-Saharan Africa were identified and explored in detail in this study. All interviewees (patients, physicians, and health care executives) recognized the potential benefits of mHealth. Several overlapping barriers and enablers were identified among the 3 participant groups.

Lack of awareness about mHealth solutions was highlighted as a common barrier to implementing mHealth systems by patients and physicians. They claimed that it was preventing them from experiencing and using mHealth services. They emphasized the importance of raising awareness among stakeholders. Developers and advocates of mHealth solutions must give outreach and education efforts top priority in order to overcome these issues and increase public knowledge of the potential advantages of these solutions. This might entail collaborations with health care institutions, neighborhood-based outreach initiatives, and population-specific marketing plans. Additionally, in order for health care professionals to use mHealth solutions efficiently and explain the advantages to their patients, they need to receive proper training and support. Finally, overcoming cultural barriers will call for sensitivity to the distinctive cultural perspectives and beliefs of various populations, as well as the customization of outreach and education initiatives [ 11 , 34 ].

Another overlapping challenge noted by patients and physicians is digital illiteracy, which refers to a lack of competency or expertise in using digital technologies, such as computers, the internet, and other digital devices or tools. The good news is that an improving literacy level in the society was also viewed as a facilitator by patients and clinicians. According to physicians, the younger generation’s strong digital literacy level is a tremendous opportunity to leverage and apply mHealth systems. The perspective of executives that supports this view is their observation that society is becoming increasingly accustomed to digital technologies, including social media and financial applications. A study involving cancer survivors reported that low digital literacy may hinder information acquisition and technology-enabled cancer care. The study recommended that digital interventions should be adaptable to varying levels of digital health literacy. Policymakers in health care should acknowledge digital disparities and create targeted initiatives to narrow the digital divide while also meeting the pressing demand for the digitization of health care services [ 25 ]. Using digital health information resources and engaging in digital interactions with health care providers offer significant advantages, holding the potential to enhance the efficiency, quality, and accessibility of health care systems, all while empowering patients [ 26 , 35 ].

Another hindrance mentioned is the lack of incorporation of local languages and contextual factors, such as demography, culture, and population, in mHealth systems. Physicians reported that while they are willing to use mHealth systems developed in foreign languages, they prefer those available in the local language. In contrast, all patients interviewed expressed a preference for mHealth systems that incorporate one or more local languages. Studies have also reported the positive impact of user-centric design and local contextualization of mHealth approaches for improved uptake [ 36 , 37 ].

The challenge in engaging patients for accessing diverse patient populations for education or engagement remains an issue. The study by Martin [ 38 ] described barriers for patient engagement, including literacy, access to hard-wired technologies, and understanding of an increasingly complex network of medical care. Developers of mHealth systems need to concentrate more on patient-centered design, involve users in the development process, and work to deliver a customized user experience in order to overcome these difficulties. This can make mHealth systems more usable, effective, and accessible for patients, which will ultimately improve patient outcomes. Additionally, by educating patients on the use of mHealth systems, offering support for their use, and highlighting the advantages of these systems for patient care, health care organizations and providers can encourage patients to use them.

Aside from not being aware of mHealth systems, those who have been exposed to the technology are concerned about the availability of trustworthy systems. Because health is a sensitive issue, patients mentioned that if doctors recommend it during their follow-up, they could use it. However, the majority of doctors said that they had never recommended such systems to their patients. This is due to 2 major reasons. First, physicians have little expertise with mHealth systems, which limits their capacity to use them. Second, because of a lack of understanding of patient-focused mHealth systems, physicians are often unaware of mHealth systems that they could recommend to their patients. According to recent research conducted in developed countries, the findings indicate that health care professionals do not endorse the use of mHealth systems to their patients [ 39 ]. Nonetheless, the aforementioned study revealed that while health care professionals do not recommend mHealth systems to their patients, they do inform them about the existence of these systems should they express a desire to use them. In contrast to the notion that health care professionals solely remind their patients about the availability of mHealth systems, the findings of this study suggest that physicians harbor a degree of skepticism regarding the ability of their patients, particularly those who are elderly or possess limited education, to effectively use such technologies. Consequently, these physicians generally do not recommend mHealth systems to individuals having chronic diseases. The other reason, as perceived by physicians, is that they could not find trustworthy health care systems to prescribe to patients confidently. The lack of adequate regulation and control is one of the key reasons for the unreliability of mHealth systems. Numerous systems make efficacy claims without any supporting data from the scientific community [ 21 , 40 ]. This may cause consumers to rely on incorrect or partial information, which could be harmful to their health.

Even though security issues were mentioned as common barriers by all the stakeholders in the study, some respondents also expressed different beliefs regarding data confidentiality and security. Some of the participants in both patient and physician groups were not worried about security. Some believed that the system they are using has security features, and some mentioned that they are not worried at all whether the system is secured. However, some patients mentioned that they are not sure whether data confidentiality will be maintained during the use of such systems and said that they are skeptical about it. They recommended better security features while designing such systems. The potential for data privacy violations is another problem. Some systems collect users’ private health information but fail to adequately safeguard it from unauthorized access by outside parties. Users may experience serious repercussions as a result, such as discrimination and identity theft. It is crucial to set precise standards and guidelines for mHealth systems in order to address these problems. Researchers have also suggested ways to underpin a radical rethinking of information privacy, confidentiality, security, and integrity to unlock the potential of mHealth and ensure verified access to often sensitive data [ 41 ]. Given the rapid pace of technological development, the protection of personal health information stored in mHealth solutions is an important consideration. In order to protect people’s privacy, it is essential to ensure the confidentiality of such data. This is especially important in light of laws like the Global Data Protection Regulation (GDPR) [ 42 , 43 ].

All patients, physicians, and health care executives perceived the widespread availability of the internet, mobile phones, and digital devices as creating a favorable opportunity to integrate mHealth systems. Though the Sub-Saharan African region is way behind other regions in employing mHealth activities, there is now a high level of commitment and a strong strategic plan to benefit from this opportunity. Furthermore, there is a high need for an individualized patient-focused mHealth system for managing chronic conditions such as diabetes and hypertension. A study conducted by Doyle et al [ 27 ] concluded that implementing mobile phone–based interventions is viable; however, there is a risk of exacerbating inequities, particularly if these interventions necessitate internet access. Internet-based mHealth approaches should carefully assess potential risks for participants and include skill-building sessions on secure internet and phone usage.

The Sub-Saharan African region’s population is growing at an alarming rate, and the region is facing the double burden of communicable and noncommunicable diseases. As a result of these, access to high-quality health care systems may be jeopardized. To make problems worse, social distancing necessitated by the COVID-19 outbreak made face-to-face consulting and care-taking difficult in many cases. According to health care executives, integrating digitalization in health care systems is becoming increasingly important for the health care sector, which is under high pressure. Sub-Saharan Africa faces numerous health care challenges, including limited access to health care services, inadequate health care infrastructure, and a shortage of health care professionals. The COVID-19 pandemic has also highlighted the need for mHealth solutions that can help provide care remotely [ 44 ].

Digitalization can help address these challenges by improving access to health care services, enabling remote consultation and telemedicine, and improving the accuracy and completeness of patient records. This can help reduce the burden on health care facilities and make it easier for patients to access care, especially in remote or underserved areas. Physicians believed that employing a mHealth system can help to reduce workload and also help to achieve quality health care services. Other scholarly works have also affirmed that digital technologies contribute to improved efficiency and the streamlining of health care services. The potential of mHealth to provide health information to patients and the accessibility of patient data through EHRs make the situation easier for health care practitioners, reducing administrative tasks and enhancing care coordination [ 10 , 45 , 46 ].

According to patients, a lack of easily available mHealth systems is also a hindrance. This viewpoint was also shared by both physicians and executives. Physicians reported some experience in using mHealth systems such as reference guidelines, gestational age calculators, etc. These mHealth systems, however, lack local context. Furthermore, physicians reported that they were unable to find standalone systems in the form of apps that would allow them easy access to vital information to update their knowledge and fill knowledge gaps. Despite the fact that the integration of mHealth in health care facilities is not widespread, it is possible to draw on the experiences and obstacles encountered during the implementation of other technologies, such as EMR systems. EMR systems deployed in some health facilities have a lot of challenges for use to the full extent possible. However, owing to discontinuity and nonmaturity of the systems, they are not fully functional and some of them have stopped working. This is also perceived as another hindering factor. Despite efforts to launch mHealth systems, health care executives indicated that most launched mHealth systems so far are for health care personnel. Governments, health care organizations, and technology firms must collaborate to develop infrastructure, raise money, lower regulatory barriers, and encourage user adoption of mHealth systems in order to address these issues. By doing this, we can guarantee that mHealth systems are made more accessible to individuals around the world and contribute to improving access to health care services. A body of literature indicated that health care providers face challenges in improving digital health applications, and collaborating with stakeholders for value creation remains a significant obstacle. Despite these challenges, involving stakeholders and addressing their needs could promote the sustainable development of digital health services [ 47 ].

According to reports from executive stakeholders, many attempts were made to implement mHealth systems in various health care facilities, but most of them were unsuccessful due to a range of issues such as inadequate government ownership, insufficient budget for recurring operational costs, lack of training, insufficient infrastructure, and lack of interoperability. A recent systematic review of systematic reviews indicated that infrastructure, lack of equipment, and technology gaps together accounted for barriers to the use of mHealth systems in developing countries [ 48 ]. Despite these challenges, there were several valuable lessons, such as the need for allocating a sufficient operational budget, proper takeover of projects, and engaging well-matured systems through learning from failed projects. As a result, there is now a renewed focus on digitalization in health care, and mHealth solutions are viewed as valuable tools for addressing complex health care challenges from multiple angles.

A multitude of analogous studies have examined the obstacles hindering the adoption of mHealth systems within health care facilities. Many studies reported lack of knowledge of mHealth systems, infrastructure, lack of equipment, and technology gaps as barriers, and identified the ubiquity of smartphones and apps as a facilitator, especially for the younger generation [ 39 , 48 ]. Absence of a national policy on mHealth, poor internet connectivity, and shortage of electricity were also highlighted as important inhibiting factors for mHealth adoption in low and middle income countries [ 49 ]. The perceived usefulness of mHealth approaches among patients has been reported [ 50 ]. Some of the enablers identified in this study were introduced by previous studies, such as perceived usefulness in improving health service quality and perceived ease of use [ 51 ].

One of the common barriers as perceived by all the stakeholders is security concerns. The results of this study are consistent with the findings of other studies reporting that mHealth app users have security and privacy concerns. The study reported that lack of security features in mHealth apps was a barrier for adoption [ 52 , 53 ].

In the literature, knowledge and limited literacy were presented as barriers for mHealth adoption. However, in this study, an increasing literacy level of the society was identified as one of the enablers. This same factor was reported as a barrier in another similar study [ 53 ]. Consistent with the results in this study, a prior study reported that limited digital literacy and the unreliability of health information from mHealth platforms are barriers for mHealth use [ 25 ].

Developing mHealth solutions that are suited to the local environment, raising awareness, offering adequate training, assigning adequate funding, incorporating various security features, and putting in place and implementing simple governance principles are a few ways to tackle the challenges.

This study is the first of its kind to provide a comprehensive exploration of the barriers and enablers of the use of mHealth systems in Sub-Saharan Africa, with a focus on the multi-level and multi-actor perspectives of patients, physicians, and health care executives. The barriers identified in this study highlight the challenges and limitations that must be overcome in order to successfully implement mHealth systems in Sub-Saharan Africa. Understanding these barriers can help inform the design and implementation of mHealth solutions that are tailored to the specific needs and context of the region. Addressing these challenges necessitates increased investment in mHealth infrastructure, health care worker training programs, and financial sustainability methods for mHealth initiatives. If these barriers are effectively addressed, it may become possible to overcome the challenges associated with implementing mHealth systems in the region, thereby unlocking the full potential of mHealth to enhance health care outcomes for patients, health care providers, and policy makers. The identified enablers will be further investigated and considered in the design of future mHealth platforms for studies in Sub-Saharan Africa.

Limitations of the Study

This study is subject to certain limitations, notably the relatively modest sample size, which may restrict the extent to which the findings can be extrapolated to the broader population. Nonetheless, efforts were made to address this concern by selectively recruiting participants from diverse age cohorts and employment backgrounds. Other limitations include a small patient population (the disease may have influenced the patients’ perceptions). Future investigations could benefit from expanding the sample size to enhance the representativeness of the outcomes. Another potential limitation of this study is the absence of triangulation of results. However, steps were taken to mitigate this shortcoming by collecting sufficient data to comprehensively comprehend the phenomenon, thereby enhancing the validity and reliability of the findings.

The use of mHealth systems in Sub-Saharan Africa has been hindered by a range of factors and has also been facilitated by various enabling factors. Patients, physicians, and health care executives identified common barriers and enablers to the uptake of mHealth systems. The identified barriers must be actively mitigated through the involvement of all relevant stakeholders. Despite the existing barriers, the findings of this study provide a promising outlook for the implementation of mHealth systems in Sub-Saharan Africa. The study highlights the numerous opportunities that exist for the successful integration of mHealth systems into the region’s health care systems. To ensure maximum uptake, it is crucial to adopt a user-centered design approach in mHealth system design and development.

The results of this study have important implications for both mHealth system design and policy-making. The identified barriers and enablers can serve as a guide for the design of mHealth systems that are tailored to meet the needs and preferences of patients, physicians, and health care executives. Additionally, the study findings can inform policy makers on the necessary steps to be taken to facilitate the successful integration of mHealth systems into health care systems in Sub-Saharan Africa.

In conclusion, some of the barriers and enablers of the uptake of mHealth systems in Sub-Saharan Africa are interconnected and require the active involvement of all stakeholders to be addressed. The study provides valuable insights that can inform mHealth system design and policy-making, with the aim of facilitating the successful integration of mHealth systems into health care systems in Sub-Saharan Africa.

Acknowledgments

We extend our gratitude to the Network for Advancement of Sustainable Capacity in Education and Research in Ethiopia (NASCERE). We would also like to thank Eyerusalem Tadese for assisting in interview transcription.

Conflicts of Interest

None declared.

Interview guide for patients.

Interview guide for physicians.

Interview guide for health care executives.

COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist.

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Abbreviations

Edited by A Mavragani; submitted 28.06.23; peer-reviewed by L Guo, H Pilabré; comments to author 11.10.23; revised version received 01.11.23; accepted 13.02.24; published 27.03.24.

©Genet Tadese Aboye, Gizeaddis Lamesgin Simegn, Jean-Marie Aerts. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 27.03.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

ORIGINAL RESEARCH article

Adapting to climate change-induced flooding: insights from women traders in the riverine areas of nigeria -a qualitative study provisionally accepted.

• 1 University of Johannesburg, South Africa

The final, formatted version of the article will be published soon.

In the riverine areas of Bayelsa State, Nigeria, the intersection of climate change and flooding poses an escalating threat to the livelihoods and well-being of women traders. This qualitative study investigates the experiences and adaptive strategies employed by women traders in response to climate change-induced flooding. Employing an exploratory research design with purposive sampling, 46 women traders participated in the study, involving 23 indepth interviews and three focus group discussions. Thematic analysis was applied to scrutinize the collected data. The study unravels the impacts of climate change-induced flooding on economic, social, and gender dynamics, revealing economic disparities, gender inequality, livelihood disruptions, inadequate infrastructure, and limited access to information among women traders. Vulnerabilities emanated from disruptions in supply chains, damage to goods, and constrained market access, with agricultural traders being notably affected. Flood events exacerbated gender inequalities, amplifying caregiving responsibilities and limiting decisionmaking power for women traders. Resilience surfaced through diversified income sources, community solidarity, collective narratives, and local adaptive strategies, including indigenous knowledge and innovations. Policymakers and stakeholders should prioritize resilient infrastructure investments, such as flood-resistant marketplaces and storage facilities, to safeguard women traders' businesses during flooding events and enhance the overall economic resilience of the community.

Keywords: Climate Change, flooding, experiences, adaptations, Women traders

Received: 13 Feb 2024; Accepted: 26 Mar 2024.

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

* Correspondence: Dr. Turnwait O. Michael, University of Johannesburg, Johannesburg, South Africa

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Qualitative research

Vibha pathak.

Department of Clinical Research, Bharti Hospital and BRIDE, Karnal, Haryana, India

Bijayini Jena

1 Department of Nutrition, Bharti Hospital and BRIDE, Karnal, Haryana, India

Sanjay Kalra

2 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India

Scientific research is based upon finding a solution to a particular problem one can identify. There are various methods of formulating a research design for the study. Two broad approaches of data collection and interpretation in research are qualitative and quantitative research. The elementary method of conducting research was quantitative, but recently, qualitative method of research has also gained momentum among researchers.

Qualitative research focuses in understanding a research query as a humanistic or idealistic approach. Though quantitative approach is a more reliable method as it is based upon numeric and methods that can be made objectively and propagated by other researchers. Qualitative method is used to understand people's beliefs, experiences, attitudes, behavior, and interactions. It generates non-numerical data. The integration of qualitative research into intervention studies is a research strategy that is gaining increased attention across disciplines. Although once viewed as philosophically incongruent with experimental research, qualitative research is now recognized for its ability to add a new dimension to interventional studies that cannot be obtained through measurement of variables alone.[ 1 ] Qualitative research was initially used in psychological studies when researchers found it tedious to evaluate human behavior in numeric. Since then, qualitative research is used in other research fields as well. In clinical research, qualitative approach can help view the data more extensively. It strengthens clinical trials by enhancing user involvement in it.

Three broad categories of qualitative research of interest exists in clinical research: Observational studies, interview studies and documentary/textual analysis of various written records.[ 2 ] Qualitative research gives voice to the participants in the study.[ 1 ] It permits the participants to share their experiences of the effects of the drug of interest. This can open our eyes to new aspects of the study and help modify the design of the clinical trial. Qualitative study enhances the involvement of everyone related to the study. The researcher works on the social parameters in addition to the quantitative measures in the study. The subjects also have an empowering experience in the study. They have an active role in the study and can voice their individual benefits and harms of the study. In addition, with qualitative methods, the relationship between the researcher and the participant is often less formal than in quantitative research.

Qualitative research can have a major contribution in health research. In clinical trials, qualitative research can have a great impact on data collection, its analysis and the interpretation of results. Qualitative studies should be well-designed and the aims, procedures of the study should be meticulously adjudicated. Study should have pre-determined methods to nullify research bias. When combined with quantitative measures, qualitative study can give a better understanding of health related issues. The perspectives in clinical research should highlight advances in qualitative research as well, to optimize quality and utility of this method of research.