peer reviewed articles qualitative research

Qualitative Study

Affiliations.

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

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

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

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

Examples of Qualitative Research Approaches

Ethnography

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

Grounded Theory

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

Phenomenology

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

Narrative Research

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

Research Paradigm

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

Positivist vs Postpositivist

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

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

Constructivist

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

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

Data Sampling

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

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

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

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

Extreme case sampling- targeted selection of rare cases.

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

Data Collection and Analysis

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

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

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

Dissemination

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

Examples of Application

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

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

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

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

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

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

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

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

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

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

Copyright © 2024, StatPearls Publishing LLC.

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

Publication types

• Study Guide

What is Qualitative in Research

• Review Essay
• Open access
• Published: 28 October 2021
• Volume 44 , pages 599–608, ( 2021 )

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• Patrik Aspers 1 &
• Ugo Corte 2  

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In this text we respond and elaborate on the four comments addressing our original article. In that piece we define qualitative research as an “iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied.” In light of the comments, we identify three positions in relation to our contribution: (1) to not define qualitative research; (2) to work with one definition for each study or approach of “qualitative research” which is predominantly left implicit; (3) to systematically define qualitative research. This article elaborates on these positions and argues that a definition is a point of departure for researchers, including those reflecting on, or researching, the fields of qualitative and quantitative research. The proposed definition can be used both as a standard of evaluation as well as a catalyst for discussions on how to evaluate and innovate different styles of work.

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What is Qualitative in Qualitative Research

What is “qualitative” in qualitative research why the answer does not matter but the question is important, unsettling definitions of qualitative research.

Avoid common mistakes on your manuscript.

The editors of Qualitative Sociology have given us the opportunity not only to receive comments by a group of particularly qualified scholars who engage with our text in a constructive fashion, but also to reply, and thereby to clarify our position. We have read the four essays that comment on our article What is qualitative in qualitative research (Aspers and Corte 2019 ) with great interest. Japonica Brown-Saracino, Paul Lichterman, Jennifer Reich, and Mario Luis Small agree that what we do is new. We are grateful for the engagement that the four commenters show with our text.

Our article is based on a standard approach: we pose a question drawing on our personal experiences and knowledge of the field, make systematic selections from existing literature, identify, collect and analyze data, read key texts closely, make interpretations, move between theory and evidence to connect them, and ultimately present a definition: “ qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied” (Aspers and Corte 2019 , 139) . We acknowledge that there are different qualitative characteristics of research, meaning that we do not merely operate with a binary code of qualitative versus non-qualitative research. Our definition is an attempt to make a new distinction that clarifies what is qualitative in qualitative research and which is useful to the scientific community. Consequently, our work is in line with the definition that we have proposed.

Given the interest that our contribution has already generated, it is reasonable to argue that the new distinction we put forth is also significant . As researchers we make claims about significance, but it is always the audience—other scientists—who decide whether the contribution is significant or not. Iteration means that one goes back and forth between theory and evidence, and improved understanding refers to the epistemic gains of a study. To achieve this improved understanding by pursuing qualitative research, it is necessary that one gets close to the empirical material. When these four components are combined, we speak of qualitative research.

The four commentators welcome our text, which does not imply that they agree with all of the arguments we advance. In what follows, we single out some of the most important critiques we received and provide a reply aiming to push the conversation about qualitative research forward.

Why a Definition?

We appreciate that all critics have engaged closely with our definition. One main point of convergence between them is that one should not try to define qualitative research. Small ( Forthcoming ) asks rhetorically: “Is producing a single definition a good idea?” He justifies his concern by pointing out that the term is used to describe both different practices (different kinds of studies) and three elements (types of data; data collection, and analysis). Similarly, both Brown-Saracino ( Forthcoming ) and Lichterman, ( Forthcoming ) argue that not only there is no single entity called qualitative research—a view that we share, but instead, that definitions change over time. For Small, producing a single definition for a field as diverse as sociology, or the social sciences for that matter, is restrictive, a point which is also, albeit differently, shared by Brown-Saracino. Brown-Saracino asserts that our endeavor “might calcify boundaries, stifle innovation, and prevent recognition of areas of common ground across areas that many of us have long assumed to be disparate.” Hence, one should not define what is qualitative, because definitions may harm development. Both Small and Brown-Saracino say that we are drawing boundaries between qualitative and quantitative approaches and overstate differences between them. Yet, part of our intent was the opposite: to build bridges between different approaches by arguing that the ‘qualitative’ feature of research pertains both quantitative and qualitative methodologies, which may use and even combine different methods.

In light of these comments we need to elaborate our argument. Moreover, it is important not to maintain hard lines that may lead to scientific tribalism. Nonetheless, the critique of our—or any other definition of qualitative research—typically implies that there is something “there,” but that we have not captured it correctly with our definition. Thus, the critique that we should not define qualitative research comes with an implicit contradiction. If all agree that there is something called “qualitative research,” even if it is only something that is not quantitative, this still presumes that there is something called “qualitative.” Had we done research on any other topic it would probably have been requested by reviewers to define what we are talking about. The same criteria should apply also when we turn the researcher’s gaze on to our own practice.

Moreover, it is doubtful that our commentators would claim that qualitative research can be “anything,” as the more Dadaistic interpretation by Paul Feyerabend ( 1976 ) would have it. But without referring to the realist view of Karl Popper ( 1963 , 232–3) and his ideas of verisimilitude (i.e., that we get close to the truth) we have tried to spell out what we see as an account of the phenomenology of “qualitative.” We identify three positions in relation to the issue of definition of qualitative research:

We should not define qualitative research.

We can work with one definition for each study or approach of “qualitative research,” which is predominantly left implicit.

We can try to systematically define qualitative research.

Obviously, we have embraced and practiced position 3 in reaction to the current state of the field which is largely dominated by position 2--namely that what is qualitative research is open to a large variety of “definitions.” The critical points of our commentators explicitly or implicitly argue in favor of position 1, or perhaps position 2. Our claim that a definition can help researchers sort good from less good research has triggered criticism. Below, we elaborate on this issue.

We maintain that a definition is a valid starting point useful for junior scholars to learn more about what is qualitative and what is quantitative, and for more advanced researchers it may feature as a point of departure to make improvements, for instance, in clarifying their epistemological positions and goals. But we could have done a better job in clarifying our position. Nonetheless, we contend that change and improvement at this late stage of development in social sciences is partially related to and dependent upon pushing against or building upon clear benchmarks, such as the definition that we have formulated. We acknowledge that “definitions might evolve or diversify over time,” as Brown-Saracino suggests. Still, surely social scientists can keep two things in mind at the same time: an existing definition may be useful, but new research may change it. This becomes evident if one applies our definition to the definition itself: our definition is not immune to work that leads to new qualitative distinctions! Having said this, we are happy to see that all four comments profit from getting in close contact with the definition. This means that our definition and the article offer the reader an opportunity to think with (Fine and Corte 2022 ) or, as Small writes, “forces the reader to think.” We believe that both in principle and in practice, we all agree that clarity and definitions are scientific virtues.

What can a Definition Enable?

While we agree with several points in Small’s essay, we disagree on others. Our underlying assumption is that we can build on existing knowledge, albeit not in the way positivism envisioned it. It follows that work which is primarily descriptive, evocative, political, or generally aimed at social change may entail new knowledge, but it does not fit well within the frame within which we operate in this piece. The existence of different kinds of work, each of which relies on different standards of evaluation—which are often unclear and consequential, especially to graduate students and junior scholars (see Corte and Irwin 2017 )—brings us to another point highlighted by both Small and Lichterman: can the definition be used to differentiate good from lesser good kinds of work?

Small argues that while our article promises to develop a standard of evaluation, it fails to do so. We agree: our definition does not specify the exact criteria of what is good and what is poor research. Our definition demarcates qualitative research from non-qualitative by spelling out the qualitative elements of research, which advances a criterion of evaluation. In addition, there is definitely research that meets the characteristics of being qualitative, but that is uninteresting, irrelevant, or essentially useless (see Alvesson et al. 2017 on “gap spotting,” for instance). What is good or not good research  is to be decided in an ongoing scientific discussion led by those who actively contribute to the development of a field. A definition, nonetheless, can serve as a point of reference to evaluate scholarly work, and it can also serve as a guideline to demarcate what is qualitative from what it is not.

A Good Definition?

Even if one accepts that there should be a definition of qualitative research, and thinks that such a definition could be useful, it does not follow that one must accept our definition. Small identifies what he sees a paradox in our text, namely that we both speak of qualitative research in general and of qualitative elements in different research activities. The term qualitative, as we note and as Small specifies, is used to describe different things: from small n studies to studies of organizations, states, or other units conceptualized as case studies and analyzed quantitatively as well as qualitatively. We are grateful for this observation, which is correct. We failed to properly address this issue in the original text.

As we discuss in the article, the elements used in our definitions (distinctions, process, closeness, and improved understanding) are present in all kinds of research, even quantitative. Perhaps the title of our article should have been: “What is Qualitative in Research?” Our position is that only when all the elements of the definition are applied can one speak of qualitative research. Hence, the first order constructs (i.e., the constructs the actors in the field have made) (Aspers 2009 ) of, for example, “qualitative observations,” may indeed refer to observations that make qualitative distinction in the Aristotelian sense on which we rely. Still, if these qualitative observations are commensurated with a ratio-scale (i.e., get reduced to numbers) this research can no longer be called “qualitative.” It is for this reason that we say that, to refer to first order constructs, “quantitative” research processes entail “qualitative” elements. This research is, as it were, partially qualitative, but it is not, taken together, qualitative research. Brown-Saracino raises a similar point in relation to her own and others works that combine “qualitative” and “quantitative” research. We do not think that one is inherently better, yet we agree with the general idea that qualitative research is particularly useful in identifying research questions and formulating theories (distinctions) that, at a later point should, when possible, be tested quantitatively on larger samples (cf. Small 2005 ). It is our hope that, with our clarification above, it will be easier for researchers to understand what one is and what one is not doing. We also hope that our study will stimulate further dialogue and collaboration between researchers who primarily work within different traditions.

Small wonders if a researcher who tries to replicate a “qualitative” study (according to our definition) is doing qualitative research. The person is certainly doing research, and some elements are likely conducted in a qualitative fashion according to our definition, for example if the method of in-depth fieldwork is employed. But regardless of the method used, and regardless of whether the person finds new things, if the result is binary coded as either confirming or disconfirming existing research, qualitative research is not being conducted because no new distinction is offered. Imagine the same study being replicated for the 20 th time. Surely the researcher must use the same “qualitative” methods (to use the first order construct). It may even excite a large academic audience, but it would not count as qualitative research according to our definition. Our definition requires both that the research process has made use of all its elements, but it also requires the acceptance by the audience. Having said this, in practice, it is more likely that such a study would also report new distinctions that are acknowledged by an audience. If such a study is reviewed and published, these are additional indicators that the new distinctions are considered significant, at least to some extent: how much research space it opens up, and how much it helps other researchers continue the discussion by formulating their own questions and making their own claims (Collins 1998 , 31), whether by agreeing with it by applying it, by refining it (Snow et al. 2003 ), or by disagreeing and identifying new ways forward. There are two key characteristics that make a contribution relevant: newness and usefulness (Csikszentmihalyi 1996 ), both of which are related to the established state of knowledge within a field. Relatedly, Small asks: “Is newness enough? What does a new distinction that does not improve understanding look like?” There are also other indicators that demarcate whether a contribution is significant and to what extent. Some of these indicators include the number of citations a piece of work generates, the reputation of the journal or press where the work is published, and how widely the contribution is used—for instance, across specializations within the same discipline, or across different fields (i.e., different ways of valuation and evaluation) (Aspers and Beckert 2011 ) of scientific output. In principle, if a contribution ends up being used in an area where it would have unlikely been used, then one may further argue for its significance.

As it is implicit in our work when we talk about distinctions, we refer to theory building, albeit appreciating different conceptualizations and uses of the term theory (Abend 2008 ) and ways to achieve it (e.g., Zerubavel 2020 ). Brown-Saracino writes that our project may hold “the unintended consequence of limiting exploratory research designs and methodological innovations.” While we cannot predict the impact of our research, we are certainly in favor of experimentation and different styles of work. In line with David Snow, Calvin Morrill and Leon Anderson ( 2003 , 184), we argue that many qualitative researchers start their projects being underprepared in theory and theory development, oftentimes with the goal of describing, and leaving alone the black box of theory, or postponing it to later phases of the project. Our definition, along with the work by those authors and others on theory development, can be one way to heighten the chances researchers can make distinctions and develop theory.

Lichterman argues that we are not giving enough weight to interpretation and that we should relate more strongly to the larger project of the Geistenwissenschaften . We agree that interpretation is a key element in qualitative research, and we draw on Hans-Georg Gadamer ( 1988 ) who refined the idea of the hermeneutic circle.

Another critique, raised by Reich ( Forthcoming ), is that positionality is a key element of qualitative research. That in working towards a definition, we have “overlooked much of the methodological writings and contributions of women, scholars of color, and queer scholars” that could have enriched our definition, especially regarding “getting closer to the phenomenon studied.” Surely, the way we have searched for and included references means that we have ‘excluded’ the vast majority of research and researchers who do qualitative work. However, we have not included texts by some authors in our sample based on any specific characteristics or according to any specific position. This critique is valid only if Reich shows more explicitly what this inclusion would add to our definition.

Though we agree with much of what Reich says, for example about the role of bodies and reflexivity in ethnographic work, the idea of positionality as a normative notion is problematic. At least since Gadamer wrote in the early 1960s (1988), it is clear that there are no interpretations ‘from nowhere.’ Who one is cannot be bracketed in an interpretation of what has occurred. The scientific value of this more identity- and positionality-oriented research that accounts also of the positionality of the interpreter, is essentially already well acknowledged. Reflection is not just something that qualitative researcher do; it is a general aspect of research. Ethnographic researchers may need certain skills to get close and understand the phenomenon they study, yet they also need to maintain distance. As Fine and Hallett write: “The ethnographic stranger is uniquely positioned to be a broker in connecting the field with the academy, bringing the site into theory and, perhaps, permitting the academy to consider joint action with previously distant actors” (Fine and Hallett 2014 , 195). Moreover, Brown-Saracino illustrates well what it means to get close, and we too see that ethnography, in various forms and ways, is useful as other qualitative activities. Though ethnographic research cannot be quantitative, qualitative work is broader than solely ethnographic research. Furthermore, reflexivity is not something that one has to do when doing qualitative research, but something one does as a researcher.

Reich’s second point is more important. The claim is that if the standpoint-oriented argument is completely accepted, it will most likely violate what we see as the essence of research. We warned in our article that qualitative research may be treated as less scientific than quantitative within academia, but also in the general public, if too many in academia claim to be doing “qualitative research” while they are in fact telling stories, engaging in activism, or writing like journalists. Such approaches are extra problematic if only some people with certain characteristics are viewed as the only legitimate producers of certain types of knowledge. If these tendencies are fueled, it is not merely the definition of “qualitative” that is at stake, but what the great majority see as research in general. Science cannot reach “The Truth,” but if one gives up the idea communal and universal nature of scientific knowledge production and even a pragmatic notion of truth, much of its value and rationale of science as an independent sphere in society is lost (Merton 1973 ; Weber 1985 ). Ralf Dahrendorf framed this form of publicness by writing that: “Science is always a concert, a contrapuntal chorus of the many who are engaged in it. Insofar as truth exists at all, it exists not as a possession of the individual scholar, but as the net result of scientific interchange” (1968, 242–3). The issue of knowledge is a serious matter, but it is also another debate which relates to social sciences being low consensus fields (Collins 1994 ; Fuchs 1992 ; Parker and Corte 2017 , 276) in which the proliferation of journals and lack of agreement about common definitions, research methods, and interpretations of data contributes to knowledge fragmentation. To abandon the idea of community may also cause confusion, and piecemeal contributions while affording academics a means to communicate with a restricted in-group who speak their own small language and share their views among others of the same tribe, but without neither the risk nor possibility of gaining general public recognition. In contrast, we see knowledge as something public, that, ideal-typically, “can be seen and heard by everybody” (Arendt 1988 , 50), reflecting a pragmatic consensual approach to knowledge, but with this argument we are way beyond the theme of our article.

Our concern with qualitative research was triggered by the external critique of what is qualitative research and current debates in social science. Our definition, which deliberately tries to avoid making the use of a specific method or technique the essence of qualitative, can be used as a point of reference. In all the replies by Brown-Saracino, Lichterman, Reich, and Small, several examples of practices that are in line with our definition are given. Thus, the definition can be used to understand the practice of research, but it would also allow researchers to deliberately deviate from it and develop it. We are happy to see that all commentators have used our definition to move further, and in this pragmatic way the definition has already proved its value.

New research should be devoted to delineating standards and measures of evaluation for different kinds of work such as the those we have identified above: theoretical, descriptive, evocative, political, or aimed at social change (see Brady and Collier 2004; Ragin et al. 2004 ; Van Maanen 2011 ). And those standards could respectively be based upon scientific or stylistic advancement and social and societal impact. Footnote 1 Different work should be evaluated in relation to their respective canons, goals, and audiences, and there is certainly much to gain from learning from other perspectives. Relatedly, being fully aware of the research logics of both qualitative and quantitative traditions (Small 2005 ) is also an advantage for improving both of them and to spur further collaboration. Bringing further clarity on these points will ultimately improve different traditions, foster creativity potentially leading to innovative projects, and be useful both to younger researchers and established scholars.

The last two terms refer to whether the impacts are more micro as related to agency, or macro, as related to structural changes. An example of the latter kind is Matthew Desmond’s Eviction (2016) having substantial societal impact on public policy discussions, raising and researching a broader range of housing issues in the US. A case of the former is Arlie Hochchild’s studies on emotional labor of women in the workplace (1983) and her more recent book on the alienation of white, working-class Americans (2016).

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Acknowledgements

The authors are grateful for comments by Gary Alan Fine, Jukka Gronow, and John Parker.

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Aspers, P., Corte, U. What is Qualitative in Research. Qual Sociol 44 , 599–608 (2021). https://doi.org/10.1007/s11133-021-09497-w

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

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The COVID-19 pandemic has highlighted and exacerbated the difficult juggling act women in the U.S. have to do between parenting their children and working outside the home. The pandemic has also led to a decline in maternal mental health, particularly among mothers with young children, mothers of color, and those with previous mental health issues. The authors noted these experiences in their own lives as mothers with children and observed them in the lives of the women around them. These observations informed the design of this narrative inquiry study, in which we used semi-structured interviews to explore mothers’ shifting ideas and experiences of mothering, work, and family life during a global pandemic. We used creative analytic practice (CAP) to compose reflexive researcher conversations around the interview data that enabled us to highlight nuances in the data, show more transparently our meaning-making, make visible our researcher subjectivities, show uncertainties about aspects of data interpretation, and create a more accessible data representation.

Keywords: Mothering, COVID-19 pandemic, U.S. women, Narrative inquiry, Creative analytic practice.

The COVID-19 pandemic put France’s healthcare system under extreme tension and led to significant levels of stress among healthcare professionals in general and nurses in particular. Research has shown how these elements affected nurses’ physical and psychological health and manifested as insomnia, anxiety, and depressive syndromes. The present qualitative study aimed to explore the lived experiences of France’s nurses as a function of their level of exposure to the virus and whether they worked in the hospital sector or practiced privately in the community during the pandemic’s first wave. It also sought to describe the resources nurses used to maintain their overall health. We administered 19 qualitative interviews to 19 nurses in the autumn of 2021. The present study revealed that nurses were subjected to significant stress during the pandemic. Our data analysis enabled us to draw out three principal themes: 1) Being on the edge in stormy period ; 2) Personal impact on several levels and 3) Floating together and learning. There were no significant differences between the groups that were subjected to different levels of exposure to COVID-19. All the groups were affected by the pandemic that struck a healthcare system that was already systematically fragile. Nurses were severely tested by the COVID-19 pandemic, but their consciousness of the importance of their role grew, despite questioning what meaning there was to their profession, perhaps even to their lives . The trauma still felt fresh 18 months later, during the interviews, and this cannot be ignored in future healthcare policymaking .

Keywords: COVID-19, nurses, salutogenesis, stressors, health resources.

Annual mammography screening is recommended by the US Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) to reduce mortality through early detection of breast cancer. In rural Appalachia, rates of later-stage breast cancer incidence and mortality are higher than national averages. We explored the ways that providers and staff at breast cancer screening facilities employed novel approaches to overcome patient- and facility-level barriers to access to breast cancer screening in the Appalachian region. We conducted 23 semi-structured interviews with 28 clinical providers and staff of breast health facilities in Appalachia. Themes reflect how limiting features of breast screening facilities influenced access to care; the way patient-level barriers presented challenges to access to breast screening; and that external and regulatory forces presented obstacles to access to care. In addition, the unique geographical and geographical attributes of the Appalachian region shaped access and adherence to mammography screening recommendations. Thematic findings highlight that facilities implemented patient-centered strategies to overcome access-related barriers. Results may inform the ways breast cancer screening facilities address suboptimal access to breast health screening. They may also inform future resource allocations to enable facilities to reach breast cancer screening performance goals.

Keywords: rural health, breast cancer, preventive health care, women’s health.

Paternal parenting affects child development; hence, the father’s absence has a deleterious effect on the male child. The literature on parenting shows limited focus on how parenting impacts children by gender. This qualitative hermeneutic phenomenological study investigated the key question, “How does a father’s absence during childhood influence a man’s subsequent parenting of his son(s)?” An integrated theoretical framework was used to guide the study: Parenting Style Theory, Social-Cognitive Theory, and Bioecological Systems Theory. Nine Trinidadian males aged 20 to 35 years who were parenting sons were recruited to participate using snowball sampling. Data on men’s adverse childhood experiences were gathered using semi-structured interviews. Content and thematic analyses were done using DELVE software. Key findings include the influence of stereotypical cultural constructs, the church’s critical role in addressing childhood trauma, the transmission of father absence across generations, and the relationship between neurodevelopment and adverse childhood experiences. Implications of these findings will benefit child and adolescent advocacy, inform policymaking, aid professional intervention in mental health and education, and strengthen familial systems and ecclesiastical contexts. Future research should explore the lived experiences of men who crave emotional connection with their sons yet struggle with the stereotypical cultural perception of manhood.

Keywords: father absence, brain development, childhood trauma, intergenerational, the transmission of behavior.

The purpose of this qualitative transcendental phenomenological study was to understand the essence of the shared lived experiences of undergraduate college students with anxiety disorders at two universities in the Southeastern United States. Ellis’s cognitive theory, rational emotive behavior therapy, guided the study which took place at a mid-sized, public nonsectarian university and a small, private liberal arts college. The central research question elicited rich data regarding the shared lived experiences of the study participants. The four research sub-questions address participants’ perceptions regarding the impact of their disorders on their lifestyles and academic performance. A purposeful criterion sample was used to select the participants who completed a questionnaire, open-ended individual interviews, a single focus group interview, and participant journals. Phenomenological reduction was used to create a composite integration of meaning and the essence of the lived experience of the participants. Data results identified five themes: (a) social fears, (b) stressor issues, (c) generational issues, (d) academic performance barriers, and (e) institutional education and accommodation preferences.

Keywords: Alexithymia, anxiety, disorder, qualitative, stressors

School shootings are traumatic events that can lead to anxiety, depression, and post-traumatic stress disorder among students who experience these events. It is important to find effective strategies to help students cope with their return to school, as well as their anxiety and stress levels while on campus. There exists a gap in the literature on the effects of therapy dogs on students who have witnessed a school shooting. This current study used a retrospective mixed-methods survey that was sent to recent graduates of Marjory Stoneman Douglas High School (located in Parkland, Florida) who witnessed the February 2018 shooting. Data were collected to assess how the therapy dogs affected students' willingness to return to school and their stress/anxiety levels while on campus. Identified themes indicated that the therapy dogs helped with anxiety levels, stress levels, and overall moods of Marjory Stoneman Douglas High School students. These findings provide important implications for community leaders and school administrators who want to promote healing and well-being in a community that has experienced violence.

Keywords: Therapy dog, school shooting, community violence.

Identifying the relation between the processes of programming and foreign language writing may lead to new directions for programming language and natural language focused instructional design. The present qualitative case study supported by quantitative data investigated foreign language writing experiences of computer engineering students taking an object-oriented programming course. Forty-five sophomores learning programming and academic English simultaneously in a foundation university in Ankara, Turkey, were selected purposefully for the case study. There were two data sources (students’ opinions and documents) and three data collection tools (a semi-structured interview, a short diary, and a composition. In terms of the findings of the research, four themes were obtained; however, only the use of metacognitive strategies will be explained in detail due to the length of the study. Participants stated that they feel the positive effects of programming experience on the use of self-evaluation strategy and that there are similarities and differences between the processes of programming and foreign language writing. Participants’ views on the effect of programming on foreign language writing did not differ according to their writing and programming performance scores. Participants stated that programming experience may have an effect on the use of metacognitive language learning strategies in the writing process. Upon analyzing participants’ comments, it is understood that programming experience does not hinder the use of metacognitive strategies but has a role in supporting and reinforcing their use. It is suggested that multiple case studies be done for similar views on the effects of programming and that each finding be proven by quantitative studies.

Keywords: programming, foreign language writing, metacognitive strategies.

The significance of participatory decision-making in educational institutions is widely acknowledged as essential in school management and administration. This study aimed to determine how involved teachers are in making decisions in their schools and what role they think they play in shaping different parts of school policies and procedures. It also looked at their perspectives on how decisions made by others are carried out in schools. Semi-structured interviews with 10 secondary school teachers focused on teachers' role in decision-making related to their routine school tasks, strategic decision-making, participatory role in making school decisions, and their willingness to participate in decision-making. This study showed that teachers' low participation is attributed to their shared desire to be involved in school management and administration-related decisions. Teachers expressed that participatory school-based decision-making can promote collaboration and collectivism among the school staff, and it plays a significant role in shaping their work satisfaction and motivation. By gaining insights into teachers' perspectives, this study aims to contribute to the broader understanding of participatory school decision-making in the Rwandan secondary education system and communicate potential improvements for fostering a more collaborative and inclusive educational environment.

Keywords: teachers’ perceptions, qualitative research, decision-making, secondary schools.

One of the major inefficiencies in qualitative research is the accuracy and timeliness of transcribing audio files into analyzable text. However, researchers may now have the ability to leverage artificial intelligence to increase research efficiency through Chat GPT. As a result, this study performs feasibility and accuracy testing of Chat GPT versus human transcription to compare accuracy and timeliness. Results suggest that by using specific commands, Chat GPT can clean interview transcriptions in seconds with a <1% word error rate and near 0% syntactic error rate. Implications for research and ethics are addressed.

Keywords: Chat GPT, artificial intelligence, qualitative research, educational research, transcription

Alcohol misuse on college campuses has been shown to be the cause of physical, socio-emotional, and academic harms. Alcohol is also an issue at Gallaudet University but there is a gap in the literature describing this phenomenon. Using the social ecological model, this qualitative case study explored student perceptions and experiences with alcohol use through interviews with 24 deaf and hard of hearing college students at Gallaudet University. The main themes included: something to do, isolation, coping, communication, “playing catch up with life,” belonging, peer pressure, and university dynamics. The results of this study supported the research on alcohol use in the college environment, showing these themes to also be true at Gallaudet University. As a result, researchers recommend for Gallaudet University and other institutions use the education and interventions shown to be effective in the College Alcohol Intervention Matrix with deaf and hard of hearing students. Researchers also identified themes that were divergent from general college students and specific to the experience of being deaf and hard of hearing. This study highlighted the interpersonal level impact and importance of communication with alcohol and related harms. Researchers recommend further research on the spectrum of communication isolation on alcohol use, related harms, and the social-ecological impact of these experiences. In addition, researchers recommend programming and services to specifically address the issues that occur as a result of isolation, coping challenges, desire to belong, susceptibility to peer pressure, and wanting to catch up on life. It is hoped that the insights gained from this study will be used to inform interventions for deaf and hard of hearing college students, to reduce alcohol misuse, and thus to impact positive change.

Keywords: Deaf, hard of hearing, alcohol, college, university, isolation.

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Introduction, when to use qualitative research, how to judge qualitative research, conclusions, authors' roles, conflict of interest.

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Qualitative research methods: when to use them and how to judge them

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K. Hammarberg, M. Kirkman, S. de Lacey, Qualitative research methods: when to use them and how to judge them, Human Reproduction , Volume 31, Issue 3, March 2016, Pages 498–501, https://doi.org/10.1093/humrep/dev334

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In March 2015, an impressive set of guidelines for best practice on how to incorporate psychosocial care in routine infertility care was published by the ESHRE Psychology and Counselling Guideline Development Group ( ESHRE Psychology and Counselling Guideline Development Group, 2015 ). The authors report that the guidelines are based on a comprehensive review of the literature and we congratulate them on their meticulous compilation of evidence into a clinically useful document. However, when we read the methodology section, we were baffled and disappointed to find that evidence from research using qualitative methods was not included in the formulation of the guidelines. Despite stating that ‘qualitative research has significant value to assess the lived experience of infertility and fertility treatment’, the group excluded this body of evidence because qualitative research is ‘not generally hypothesis-driven and not objective/neutral, as the researcher puts him/herself in the position of the participant to understand how the world is from the person's perspective’.

Qualitative and quantitative research methods are often juxtaposed as representing two different world views. In quantitative circles, qualitative research is commonly viewed with suspicion and considered lightweight because it involves small samples which may not be representative of the broader population, it is seen as not objective, and the results are assessed as biased by the researchers' own experiences or opinions. In qualitative circles, quantitative research can be dismissed as over-simplifying individual experience in the cause of generalisation, failing to acknowledge researcher biases and expectations in research design, and requiring guesswork to understand the human meaning of aggregate data.

As social scientists who investigate psychosocial aspects of human reproduction, we use qualitative and quantitative methods, separately or together, depending on the research question. The crucial part is to know when to use what method.

The peer-review process is a pillar of scientific publishing. One of the important roles of reviewers is to assess the scientific rigour of the studies from which authors draw their conclusions. If rigour is lacking, the paper should not be published. As with research using quantitative methods, research using qualitative methods is home to the good, the bad and the ugly. It is essential that reviewers know the difference. Rejection letters are hard to take but more often than not they are based on legitimate critique. However, from time to time it is obvious that the reviewer has little grasp of what constitutes rigour or quality in qualitative research. The first author (K.H.) recently submitted a paper that reported findings from a qualitative study about fertility-related knowledge and information-seeking behaviour among people of reproductive age. In the rejection letter one of the reviewers (not from Human Reproduction ) lamented, ‘Even for a qualitative study, I would expect that some form of confidence interval and paired t-tables analysis, etc. be used to analyse the significance of results'. This comment reveals the reviewer's inappropriate application to qualitative research of criteria relevant only to quantitative research.

In this commentary, we give illustrative examples of questions most appropriately answered using qualitative methods and provide general advice about how to appraise the scientific rigour of qualitative studies. We hope this will help the journal's reviewers and readers appreciate the legitimate place of qualitative research and ensure we do not throw the baby out with the bath water by excluding or rejecting papers simply because they report the results of qualitative studies.

In psychosocial research, ‘quantitative’ research methods are appropriate when ‘factual’ data are required to answer the research question; when general or probability information is sought on opinions, attitudes, views, beliefs or preferences; when variables can be isolated and defined; when variables can be linked to form hypotheses before data collection; and when the question or problem is known, clear and unambiguous. Quantitative methods can reveal, for example, what percentage of the population supports assisted conception, their distribution by age, marital status, residential area and so on, as well as changes from one survey to the next ( Kovacs et al. , 2012 ); the number of donors and donor siblings located by parents of donor-conceived children ( Freeman et al. , 2009 ); and the relationship between the attitude of donor-conceived people to learning of their donor insemination conception and their family ‘type’ (one or two parents, lesbian or heterosexual parents; Beeson et al. , 2011 ).

In contrast, ‘qualitative’ methods are used to answer questions about experience, meaning and perspective, most often from the standpoint of the participant. These data are usually not amenable to counting or measuring. Qualitative research techniques include ‘small-group discussions’ for investigating beliefs, attitudes and concepts of normative behaviour; ‘semi-structured interviews’, to seek views on a focused topic or, with key informants, for background information or an institutional perspective; ‘in-depth interviews’ to understand a condition, experience, or event from a personal perspective; and ‘analysis of texts and documents’, such as government reports, media articles, websites or diaries, to learn about distributed or private knowledge.

Qualitative methods have been used to reveal, for example, potential problems in implementing a proposed trial of elective single embryo transfer, where small-group discussions enabled staff to explain their own resistance, leading to an amended approach ( Porter and Bhattacharya, 2005 ). Small-group discussions among assisted reproductive technology (ART) counsellors were used to investigate how the welfare principle is interpreted and practised by health professionals who must apply it in ART ( de Lacey et al. , 2015 ). When legislative change meant that gamete donors could seek identifying details of people conceived from their gametes, parents needed advice on how best to tell their children. Small-group discussions were convened to ask adolescents (not known to be donor-conceived) to reflect on how they would prefer to be told ( Kirkman et al. , 2007 ).

When a population cannot be identified, such as anonymous sperm donors from the 1980s, a qualitative approach with wide publicity can reach people who do not usually volunteer for research and reveal (for example) their attitudes to proposed legislation to remove anonymity with retrospective effect ( Hammarberg et al. , 2014 ). When researchers invite people to talk about their reflections on experience, they can sometimes learn more than they set out to discover. In describing their responses to proposed legislative change, participants also talked about people conceived as a result of their donations, demonstrating various constructions and expectations of relationships ( Kirkman et al. , 2014 ).

Interviews with parents in lesbian-parented families generated insight into the diverse meanings of the sperm donor in the creation and life of the family ( Wyverkens et al. , 2014 ). Oral and written interviews also revealed the embarrassment and ambivalence surrounding sperm donors evident in participants in donor-assisted conception ( Kirkman, 2004 ). The way in which parents conceptualise unused embryos and why they discard rather than donate was explored and understood via in-depth interviews, showing how and why the meaning of those embryos changed with parenthood ( de Lacey, 2005 ). In-depth interviews were also used to establish the intricate understanding by embryo donors and recipients of the meaning of embryo donation and the families built as a result ( Goedeke et al. , 2015 ).

It is possible to combine quantitative and qualitative methods, although great care should be taken to ensure that the theory behind each method is compatible and that the methods are being used for appropriate reasons. The two methods can be used sequentially (first a quantitative then a qualitative study or vice versa), where the first approach is used to facilitate the design of the second; they can be used in parallel as different approaches to the same question; or a dominant method may be enriched with a small component of an alternative method (such as qualitative interviews ‘nested’ in a large survey). It is important to note that free text in surveys represents qualitative data but does not constitute qualitative research. Qualitative and quantitative methods may be used together for corroboration (hoping for similar outcomes from both methods), elaboration (using qualitative data to explain or interpret quantitative data, or to demonstrate how the quantitative findings apply in particular cases), complementarity (where the qualitative and quantitative results differ but generate complementary insights) or contradiction (where qualitative and quantitative data lead to different conclusions). Each has its advantages and challenges ( Brannen, 2005 ).

Qualitative research is gaining increased momentum in the clinical setting and carries different criteria for evaluating its rigour or quality. Quantitative studies generally involve the systematic collection of data about a phenomenon, using standardized measures and statistical analysis. In contrast, qualitative studies involve the systematic collection, organization, description and interpretation of textual, verbal or visual data. The particular approach taken determines to a certain extent the criteria used for judging the quality of the report. However, research using qualitative methods can be evaluated ( Dixon-Woods et al. , 2006 ; Young et al. , 2014 ) and there are some generic guidelines for assessing qualitative research ( Kitto et al. , 2008 ).

Although the terms ‘reliability’ and ‘validity’ are contentious among qualitative researchers ( Lincoln and Guba, 1985 ) with some preferring ‘verification’, research integrity and robustness are as important in qualitative studies as they are in other forms of research. It is widely accepted that qualitative research should be ethical, important, intelligibly described, and use appropriate and rigorous methods ( Cohen and Crabtree, 2008 ). In research investigating data that can be counted or measured, replicability is essential. When other kinds of data are gathered in order to answer questions of personal or social meaning, we need to be able to capture real-life experiences, which cannot be identical from one person to the next. Furthermore, meaning is culturally determined and subject to evolutionary change. The way of explaining a phenomenon—such as what it means to use donated gametes—will vary, for example, according to the cultural significance of ‘blood’ or genes, interpretations of marital infidelity and religious constructs of sexual relationships and families. Culture may apply to a country, a community, or other actual or virtual group, and a person may be engaged at various levels of culture. In identifying meaning for members of a particular group, consistency may indeed be found from one research project to another. However, individuals within a cultural group may present different experiences and perceptions or transgress cultural expectations. That does not make them ‘wrong’ or invalidate the research. Rather, it offers insight into diversity and adds a piece to the puzzle to which other researchers also contribute.

In qualitative research the objective stance is obsolete, the researcher is the instrument, and ‘subjects’ become ‘participants’ who may contribute to data interpretation and analysis ( Denzin and Lincoln, 1998 ). Qualitative researchers defend the integrity of their work by different means: trustworthiness, credibility, applicability and consistency are the evaluative criteria ( Leininger, 1994 ).

Trustworthiness

A report of a qualitative study should contain the same robust procedural description as any other study. The purpose of the research, how it was conducted, procedural decisions, and details of data generation and management should be transparent and explicit. A reviewer should be able to follow the progression of events and decisions and understand their logic because there is adequate description, explanation and justification of the methodology and methods ( Kitto et al. , 2008 )

Credibility

Credibility is the criterion for evaluating the truth value or internal validity of qualitative research. A qualitative study is credible when its results, presented with adequate descriptions of context, are recognizable to people who share the experience and those who care for or treat them. As the instrument in qualitative research, the researcher defends its credibility through practices such as reflexivity (reflection on the influence of the researcher on the research), triangulation (where appropriate, answering the research question in several ways, such as through interviews, observation and documentary analysis) and substantial description of the interpretation process; verbatim quotations from the data are supplied to illustrate and support their interpretations ( Sandelowski, 1986 ). Where excerpts of data and interpretations are incongruent, the credibility of the study is in doubt.

Applicability

Applicability, or transferability of the research findings, is the criterion for evaluating external validity. A study is considered to meet the criterion of applicability when its findings can fit into contexts outside the study situation and when clinicians and researchers view the findings as meaningful and applicable in their own experiences.

Larger sample sizes do not produce greater applicability. Depth may be sacrificed to breadth or there may be too much data for adequate analysis. Sample sizes in qualitative research are typically small. The term ‘saturation’ is often used in reference to decisions about sample size in research using qualitative methods. Emerging from grounded theory, where filling theoretical categories is considered essential to the robustness of the developing theory, data saturation has been expanded to describe a situation where data tend towards repetition or where data cease to offer new directions and raise new questions ( Charmaz, 2005 ). However, the legitimacy of saturation as a generic marker of sampling adequacy has been questioned ( O'Reilly and Parker, 2013 ). Caution must be exercised to ensure that a commitment to saturation does not assume an ‘essence’ of an experience in which limited diversity is anticipated; each account is likely to be subtly different and each ‘sample’ will contribute to knowledge without telling the whole story. Increasingly, it is expected that researchers will report the kind of saturation they have applied and their criteria for recognising its achievement; an assessor will need to judge whether the choice is appropriate and consistent with the theoretical context within which the research has been conducted.

Sampling strategies are usually purposive, convenient, theoretical or snowballed. Maximum variation sampling may be used to seek representation of diverse perspectives on the topic. Homogeneous sampling may be used to recruit a group of participants with specified criteria. The threat of bias is irrelevant; participants are recruited and selected specifically because they can illuminate the phenomenon being studied. Rather than being predetermined by statistical power analysis, qualitative study samples are dependent on the nature of the data, the availability of participants and where those data take the investigator. Multiple data collections may also take place to obtain maximum insight into sensitive topics. For instance, the question of how decisions are made for embryo disposition may involve sampling within the patient group as well as from scientists, clinicians, counsellors and clinic administrators.

Consistency

Consistency, or dependability of the results, is the criterion for assessing reliability. This does not mean that the same result would necessarily be found in other contexts but that, given the same data, other researchers would find similar patterns. Researchers often seek maximum variation in the experience of a phenomenon, not only to illuminate it but also to discourage fulfilment of limited researcher expectations (for example, negative cases or instances that do not fit the emerging interpretation or theory should be actively sought and explored). Qualitative researchers sometimes describe the processes by which verification of the theoretical findings by another team member takes place ( Morse and Richards, 2002 ).

Research that uses qualitative methods is not, as it seems sometimes to be represented, the easy option, nor is it a collation of anecdotes. It usually involves a complex theoretical or philosophical framework. Rigorous analysis is conducted without the aid of straightforward mathematical rules. Researchers must demonstrate the validity of their analysis and conclusions, resulting in longer papers and occasional frustration with the word limits of appropriate journals. Nevertheless, we need the different kinds of evidence that is generated by qualitative methods. The experience of health, illness and medical intervention cannot always be counted and measured; researchers need to understand what they mean to individuals and groups. Knowledge gained from qualitative research methods can inform clinical practice, indicate how to support people living with chronic conditions and contribute to community education and awareness about people who are (for example) experiencing infertility or using assisted conception.

Each author drafted a section of the manuscript and the manuscript as a whole was reviewed and revised by all authors in consultation.

No external funding was either sought or obtained for this study.

The authors have no conflicts of interest to declare.

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• Open access
• Published: 06 May 2024

“We know what we should be eating, but we don’t always do that.” How and why people eat the way they do: a qualitative study with rural australians

• Nina Van Dyke   ORCID: orcid.org/0000-0002-8872-3451 1 ,
• Michael Murphy   ORCID: orcid.org/0000-0003-0434-4567 2 &
• Eric J. Drinkwater   ORCID: orcid.org/0000-0002-9594-9360 3  

BMC Public Health volume  24 , Article number:  1240 ( 2024 ) Cite this article

295 Accesses

Metrics details

There is evidence that most people are aware of the importance of healthy eating and have a broad understanding regarding types of food that enhance or detract from health. However, greater health literacy does not always result in healthier eating. Andreasen’s Social Marketing Model and Community-Based Social Marketing both posit that, in order to change health behaviours, it is crucial to understand reasons for current behaviours and perceived barriers and benefits to improved behaviours. Limited research has been conducted, however, that explores these issues with general populations. This study aimed to help address this gap in the evidence using a qualitative methodology.

Three group discussions were conducted with a total of 23 participants: (1) young women aged 18–24 with no children; (2) women aged 35–45 with primary school aged children; and (3) men aged 35–50 living with a partner and with pre- or primary school aged children. The discussions took place in a regional centre of Victoria, Australia. Transcriptions were thematically analysed using an inductive descriptive approach and with reference to a recent integrated framework of food choice that identified five key interrelated determinants: food– internal factors; food– external factors; personal-state factors; cognitive factors; and sociocultural factors.

We found that food choice was complex, with all five determinants evident from the discussions. However, the “Social environment” sub-category of “Food-external factors”, which included family, work, and social structures, and expectations (or perceived expectations) of family members, colleagues, friends, and others, was particularly prominent. Knowledge that one should practice healthy eating, which falls under the “Cognitive factor” category, while seen as an aspiration by most participants, was often viewed as unrealistic, trumped by the need and/or desire for convenience, a combination of Food-external factor: Social environment and Personal-state factor: Psychological components.

Conclusions

We found that decisions regarding what, when, and how much to eat are seen as heavily influenced by factors outside the control of the individual. It appears, therefore, that a key to improving people’s eating behaviours is to make it easy to eat more healthfully, or at least not much harder than eating poorly.

Peer Review reports

A plethora of recommendations exist regarding how people should eat to maintain better health [e.g., 1 , 2 , 3 ]. Moreover, there is evidence that most people have a reasonable awareness of connections between healthier foods and better health, and a broad understanding regarding types of food that enhance or detract from health [ 4 , 5 , 6 ]. However, greater health literacy does not always result in healthier eating [ 7 – 8 ].

Evidence suggests that public health and health-promotion interventions with a theoretical basis are more effective than those lacking such a foundation [ 9 , 10 , 11 ]. Andreasen’s Social Marketing Model [ 12 ] posits that a primary focus for behaviour change is on learning what people want and need rather than trying to persuade them to adopt particular behaviours or goals. Community-based social marketing sets out six steps necessary for enacting societal behavioural change; step two is to understand perceived barriers and benefits to develop interventions [ 13 ].

Limited research has been conducted, however, that explores how people in the general population eat and their perceptions regarding why they eat the way they do [ 14 – 15 ]. Although several recent papers have examined barriers to and enablers of healthier eating [e.g., 16 ], relatively few are from the perspective of the consumers themselves [e.g., 17 – 18 ] or are narrowly focused on particular types of healthy consumption [e.g., 19 ].

Healthy eating: knowing vs. doing

Food-based dietary guidelines are available for more than 90 countries globally. Although there is some variation across guidelines regarding particular foods, there is broad agreement to consume a variety of foods; consume some foods in higher proportion than others; consume fruits, vegetables, and legumes; and to limit sugar, fat, and salt [ 20 , 21 , 22 ].

There is mixed evidence regarding whether most people broadly understand what constitutes a healthy diet and believe they should try to eat healthily. A systematic review of the psychological literature on healthy diet, for example, found that the public has a “remarkably accurate” understanding of healthy nutrition and that this understanding reflects key dietary guidelines [ 23 ]. Focus groups with participants segmented by age and gender found that most participants were aware of the type of foods that contributed to a healthy diet and the importance of achieving a healthy balance within a diet [ 24 ]. Other studies, however, have found evidence of confusion and misperceptions amongst the general public. A cross-sectional survey of 1,097 adults aged 18–64 in Victoria, Australia and 135 professional dietitians, for example, found large discrepancies in which of various food items were considered healthy. Amongst women and those living in higher socio-economic areas, however, views were similar [ 25 ]. An earlier survey of Swiss consumers found that between 3% and 38% incorrectly answered procedural nutrition knowledge items. Again, this overall finding differed by sub-groups [ 26 ].

However, this knowledge does not necessarily result in healthy eating [ 27 ]. A systematic review of the relationship between nutrition knowledge and dietary intake found that the majority of studies reported significant, positive associations, but the relationship was weak ( r  < 0.5 ) and mostly involved slightly higher intake of fruits and vegetables. The authors also noted that study quality ranged widely and that most participants were female and with a tertiary education, with limited representation of individuals from lower socio-economic status background [ 28 ]. A qualitative study with adults in New Zealand reported “the impossible rightness of healthy eating”, meaning that the people in their study knew they should be eating healthfully, but simultaneously felt that this was very difficult or impossible to do [ 29 ]. A Canadian study argued that the concept of "food literacy" needed to extend beyond nutritional recommendations and cooking lessons to fostering connections between food, people, health, and the environment to bridge this gap between knowing and doing [ 30 ].

Theoretical frameworks

Andreasen’s Social Marketing Model [ 12 ] presents behaviour change as the dependent variable, influenced by four classes of independent variables: (1) the attractiveness of behavioural alternatives, (2) community pressures, (3) the cooperation of critical supporting agencies, and (4) marketing efforts. Of specific relevance to this study, Andreasen [ 12 ] posits that a primary focus for behaviour change is on learning what people want and need rather than trying to persuade them to adopt particular behaviours or goals.

Also relevant is Community-Based Social Marketing. Community-Based Social Marketing is based on six steps. Step one is to identify the target behaviour– in this case, unhealthy eating. Step two is to understand perceived barriers and benefits to develop interventions [ 13 ]. It is this second step that we focus on in this study.

• Food choice

Decisions regarding what food to eat, when, and in what quantity are “frequent, multifaceted, situational, dynamic, and complex” [ 31 ]. A recent review and analysis of existing models of food choice integrates key elements into a single framework (Fig.  1 ) [ 32 ]. In this framework, key determinants of general food choice were identified and categorised, including Food– internal factor (sensory and perceptual features), Food– external factor (information, social environment, physical environment), Personal– state factor (biological features and physiological needs, psychological components, habits and experiences), Cognitive factor (knowledge and skills, attitude, liking and preference, anticipated consequences, and personal identity), and Sociocultural factors (culture, economic variables, political elements). According to this framework, any attempt to shift choice must consider these interrelated factors.

Conceptual model of food choice. The lines in the figure indicate the interactions between different factors [ 32 ]

Literature on perceived barriers and enablers of healthy eating

Most of the recent evidence on perceived barriers to and enablers of healthy eating focuses on particular sub-populations, such as young people with obesity, shift workers, or people with Type 2 diabetes [ 33 , 34 , 35 , 36 , 37 ], and/or a particular type of diet, such as the Mediterranean Diet [ 38 – 39 ].

Studies examining more general populations tend to focus on younger people. A scoping review of barriers to and enablers of healthy eating for young adults in Western countries, for example, identified the following barriers: male apathy towards diet; unhealthy diet of friends and family; expected consumption of unhealthy foods in certain situations; relative low cost of unhealthy foods; lack of time to plan, shop, prepare, and cook healthy foods; lack of facilities to prepare, cook and store healthy foods; widespread presence of unhealthy foods; lack of knowledge and skills to plan, shop, prepare, and cook healthy foods; and lack of motivation to eat healthily (including risk-taking behaviour). Key enablers included: female interest in a healthy diet; healthy diet of friends and family; support/encouragement of friends and family to eat healthily; desire for improved health; desire for weight management; desire for improved self-esteem; desire for attractiveness to potential partners and others; possessing autonomous motivation to eat healthily and existence and use of self-regulatory skills [ 40 ]. A qualitative study of college students aged 18–24 at one university in Hawaii, U.S., of perceived barriers to and enablers of healthy eating found the largest barriers to be nutrition knowledge deficit, peer pressure, unsupportive institutional environment, and cost. The largest enablers were nutrition knowledge, parental influence, an institutional environment with consistent healthy offerings, and social media. It was noted that several of these factors served as barriers for some participants and enablers for others, such as nutrition knowledge, parental influence, and institutional environment [ 41 ]. Another qualitative study with college students at a U.S. college found that common barriers to healthy eating were time constraints, unhealthy snacking, convenience high-calorie food, stress, high prices of healthy food, and easy access to junk food. Conversely, enablers to healthy behaviour were improved food knowledge and education, meal planning, involvement in food preparation, and being physically active. Parental food behaviour and friends’ social pressure were considered to have both positive and negative influences on individual eating habits [ 42 ]. Much of this food choice literature identified the importance of social factors and social norms [ 43 – 44 ].

Limited research exists that explores why people in a general population eat the way they do and what, from their perspective, are the barriers and enablers to doing so. From a public health perspective, such evidence is crucial for developing population-level interventions or advocating for policy change. This study aimed to help address this gap in the evidence by using a qualitative methodology to explore the eating patterns and process by which eating decisions were made amongst a general population of non-metropolitan adults in Australia. A non-metropolitan sample was chosen for several reasons. First, Australians living in rural and remote areas experience higher rates of diet-related disease when compared to urban residents, including cardiovascular disease, type 2 diabetes, high blood pressure, chronic kidney disease, and obesity [ 45 – 46 ]. Second, access to healthy food is more challenging in rural and remote Australia due to further distances from urban centres and higher prices [ 47 – 48 ]. Third, Australians living in rural and remote areas experience greater socio-economic disadvantage than those living in urban areas [ 49 ], which makes healthy food relatively more unaffordable. Finally, most qualitative research in Australia tends to be conducted with people in metropolitan areas, with less known about people living in non-metropolitan locations.

This study is part of a larger, mixed-methods study examining eating behaviours. Data collection took place in 2010. A detailed discussion of the methodology employed for the qualitative component has been published previously in a paper examining what people think of intuitive eating [ 50 ]. Other papers published from this study include a quantitative investigation of the associations between intuitive eating and indicators of physical and mental health [ 51 ], a review of the literature on the relationship between intuitive eating and health indicators [ 52 ], and an experimental study testing whether the accuracy of self-reported height and weight in surveys could be improved by changes to the question wording [ 53 ].

Study design and participants

Three group discussions were conducted with a total of 23 participants: (1) young women aged 18–24 with no children; (2) women aged 35–45 with primary school aged children; and (3) men aged 35–50 living with a partner and with pre- or primary school aged children. These three group demographics were selected to target significant age and life-stages in which shifts in eating behaviours may occur [ 54 ]. The groups were conducted in Bendigo, a regional centre of Victoria, Australia, with participants recruited from Bendigo city and outlying areas.

Recruitment was conducted by a professional recruitment agency. Participants were paid AUD70. Participants were chosen such that at least two in each group had previously been on a weight loss diet and at least two had never been on a weight loss diet; at least three in each group were “over my most healthy weight”.

All focus groups were conducted in a hotel conference room facility in Bendigo and were recorded for the purposes of analysis. The groups began with a general discussion about food choices and approaches to eating, including discussion of the factors that influenced food choices. Topics included influences on eating decisions– what, when, how much; eating patterns– when, why, what; feelings around eating; enjoyment of food/eating; and the role that healthy eating played in their decisions around food.

Data analysis

With the permission of participants, all research sessions were recorded and transcribed. Transcriptions were thematically analysed using an inductive descriptive approach [ 55 – 56 ].

This study received ethics approval from the Charles Sturt University Human Research Ethics Committee (2010/144).

The conversations about what people ate in terms of choice of food and the amount consumed were contextualised within an appreciation of participants’ living and working situations. While it was beyond the scope of this study to provide a documentation of the diets of participants, some information was provided about specific food preferences. However, the main interest was on the factors that affected their food choices.

Across the groups, there was a general and consistent belief that what one ate was affected by a range of factors, and that as a consequence, none of these participants felt that they were entirely in control of their own diets. While some of these factors were personal, others were felt to be determined by family, work and other social structures.

Participants were clear that the term, “diet”, while most obviously associated with weight loss, can be used to refer to general eating patterns or specific kinds of approaches to eating. Hence, the term, “diet” will be used in this paper to refer to the usual or regular food and patterns of eating. When the topic is related to a specific kind of diet that is being pursued for a particular purpose, this is referred to as the specific kind of diet, and when the specific purpose is related to weight loss, we have referred to this as a “weight loss diet”.

As an inductive approach was used in the analysis, we did not endeavour to match identified themes to the factors presented in the Chen and Antonelli [ 32 ] model. Instead, we discuss how our findings align with this model in the Discussion section. Seven main themes were identified, most with several sub-themes. Main themes included taste and health considerations, family factors, work and workplaces, social factors, planning and preparation, meal patterns, and perceptions of own eating.

Taste and health considerations

Across the groups, participants commonly talked about foods that they liked or did not like and suggested that food tastes and preferences were a primary determinant of their diets. In each group, there was some discussion of eating according to what one feels like at the time. However, it was apparent that this approach tended to mean that people’s eating varied widely in terms of eating healthily or otherwise. While they might experience times when they simply felt like foods that they considered to be healthy, it was apparent that these cravings were not the norm, and that some were almost surprised at the idea of desiring salads or vegetables.

Some days you feel like eating cold meat and salad for tea, or some days you’ll just eat a whole loaf of garlic bread. (Women, 18–24)

Some noted that food preferences seem to go in phases.

I’ve just gone off those. (Women, 18–24)

Participants also commonly talked about health as a factor that would influence their diet, but that they tended to wax and wane in terms of their degree of commitment to maintaining a healthy diet. Even those who reported being quite focussed on health as a motivator felt that it was quite hard to consistently maintain a healthy diet, and that there would be times when they did not feel like making the effort. Underlying these thoughts was a belief that eating healthily was hard work, and certainly harder than eating for convenience.

Mine varies between wanting to be super detox, organic; as natural as possible to, um, I’m totally energy depleted, give me some carbs. So I will, like, live a contradictory diet by having regular meals that are semi-regular, so really, really good, and then just crash and you know you get into work and you come home and you haven’t had time for a proper lunch or you didn’t, you know, take the time to prepare it and they come home after school and… well, it annoys me because I want to be consistent basically, and I want to be role model for my kids as well. (Women, 35–45) Oh, I have had…I’ll have the healthy breakfast for you know a week or two and then I think, “Oh, I’m sick of that, I’ll just go for toast. You get a bit tired of being strong and healthy. (Women, 35–45)

Some mentioned specific health concerns, including particular diseases or even injuries that affected their capacity to prepare meals.

Oh, our eating habits are very erratic at the moment because I’m not cooking because of an injury, and my husband has to cook so if he’s late home from work, usually the kids have made something for themselves, like a chicken burger or a slice of bread, or a can of spaghetti or something like that. (Women, 35–45)

Within these discussions, it was apparent that participants’ knowledge about nutrition and health varied considerably, and that their level of knowledge did tend to affect food choices. Some participants talked about the idea of balance, and of making choices to ensure a balance of food over the day or week. For some, balance was also about compensating for other aspects of life and health, such as smoking or drinking or physical activity. Some of the men, in particular, talked about doing more activity to compensate for having eaten too much or consumed too much alcohol.

For me, like if I’ve eaten too much, one night I know I’ve got this exercise the next day, so I have to go to the gym or get up in the morning and do some physical activity. (Men, 35–50) Yeah to me I was the same, I used to smoke and I still drink every now and then you know, I’ll try to keep fit and I know if I eat too much, I’ve got to try and do some exercises to balance it out. (Men, 35–50) I do heaps of exercise because I love eating… I run so that I can eat. (Men, 35–50)

Family factors

Time and convenience.

Throughout the discussions, it was apparent that food choices were substantially affected by factors associated with time and convenience. Participants talked about having busy schedules (e.g., family, work, school, sports), and that these activities had an impact on both the choice and timing of food.

Convenience, especially in terms of the time available for food preparation, was a major factor in food choices. In this context, participants referred to take-away foods, frozen or pre-prepared foods, and meals that were quick to prepare as offering considerable advantage in terms of fitting in with their lifestyles. As noted later, these factors interacted with the time of the week, so that weekdays tended to be more hectic with less time available for food preparation, while weekends commonly afforded greater choice.

Household members

Across the groups, participants reported that the choice of food that they consumed at any particular time was not always entirely up to them. Rather, what they ate at any particular meal was commonly affected by where they were eating, who else they were eating with, and other people’s food preferences. This was especially an issue for people who lived with others, most obviously those who were parents and were catering for children and spouses, but also for those who lived in shared households. In this context, the household makeup was a primary determinant of food choices and approaches to eating. This included the mix of males and females in the household as well as the age of children.

That’s me: quick and easy. And I love the chance when I can actually get a recipe, get all the, um, ingredients and make it properly, but that doesn’t happen very often. It’s just usually what’s there and what’s quick. And what everyone will eat. (Women, 35–45) Oh, yes, that’s a big one for me of having four children and a couple of fussy buggers. You do tend to stick to the things that they will eat… spaghetti bol[ognese], four times a week. (Women, 35–45) You have to cater for different tastes in the household. (Women, 35–45) There’s nothing more heartbreaking… when you do go to a lot of effort and they won’t even try it. (Women, 35–45)

In this context, catering for teenage boys was raised as a specific issue. Parents of teenage boys reported that they were often primarily driven by a need to provide filling food, and this tended to mean a reliance on carbohydrate-based meals, such as rice or pasta. Some amongst the group of men also talked about the main motivator for food choices being about filling themselves up. They would choose foods that provided bulk so that they could feel full. Certainly amongst the men, and in the context of parents talking about their sons, there was a substantial focus on the need for food to be bulky and filling.

I usually choose my food for size, value for money and something that the boys will eat. Bigger is better. (Men, 35–50) Size, you know, steak, parma, my son will eat, you know, most things, money comes into it again, but bigger is better. (Men, 35–50) I’d rather go big than fancy. (Men, 35–50) For me I’ve always just, I eat until I’m completely full, if you are breathing and food isn’t coming into your mouth, because you’ve so full, then you are not full enough, so keep eating, that’s the kind of, my whole family is the same, none of them are overweight or fat. (Men, 35–50) Every second meal is probably pasta or rice [to fill up the kids]. (Women, 35–45)

Throughout these discussions, it was apparent that some of the women who were involved in preparing family meals tended to ignore their own preferences for the sake of catering for partners and children. They believed that it was not worth preparing a different meal for themselves, and so tended to eat whatever they were preparing for others. Several of the women commented that this meant that they did not eat as healthily as they would like to. When prompted, those in the group of mothers commented that they only really enjoyed some of their meals.

Whatever’s in the fridge or cupboard. If there’s salad I’ll have salad, but if we’ve got leftovers I’ll have that… whatever I can grab. (Women, 35–45) [I enjoy] half to three-quarters [of my meals] and the rest are a bit of a chore. (Women, 35–45) We’re just eating because you got to eat to keep going, but tea time is more of an enjoyable meal. And the snacks in between are usually enjoyable. (Women, 35–45) Well, it made me realise that probably maybe it’s more complicated in bringing up children, that I really ignored my own health for quite a long time. (Women, 35–45)

Interestingly, however, some of these same participants commented that when they did have the opportunity to choose meals that were not dependent on the preferences of others, such as when they were at home on their own during the day, they commonly chose foods that were convenient, and reported that they could not be bothered preparing for themselves. They reported that they would find something that they considered simple and easy to make (e.g., leftovers; toast; cheese and biscuits).

Yeah, there are days like that, I just grab one of those [Up & Go drinks]. Um, because I’m part-time sometimes I’ll be home at lunch time and I’ll say to myself in the morning, “Oh, I’ll eat when I go home. I’ll have a good meal when I go home", but what happens is that I stay on at school longer and I’ll come home at 2:00, 2:30/3:00 and then it’s like, “I’ll wait till the kids are home, we’ll just have afternoon…or I’ll come home carb crave, you know, deprived and just…just grab some, like Cruskets or Saladas or some rubbish, a bit of cheese". (Women, 35–45) I think if I didn’t have to cook for the kids I would eat differently but, then having said that, as we’ve been talking I thought you know I don’t make the effort at lunch time, I just go by routine, whatever, and…if I’m not enjoying it I’ll just eat it because it’s there rather than spend the time to make something I really like, like vegetables or a salad. A lot of basic things. (Women, 35–45)

Those who lived with children talked about the age of their children affecting both the kind of food they ate and when they ate. In particular, those with younger children tended to report that they tried to arrange meals around reasonably set timelines. They reasoned that this structure fit in best with other patterns of their children’s day-to-day activities, especially school, sports, and sleep. It was apparent that such set structures were less important for those with older children or without children.

Price and budgets

The cost of food was commonly mentioned as a determinant of food choices. This was especially the case for those with teenage boys, given the need to provide large amounts of food. Several of the family participants talked about buying food in bulk when it was cheap and commented that this would then govern their food choices for a period of time.

I buy cereal in boxes of twenty or thirty, so if Nutrigrain is on Special for $4 a box, I buy twenty or thirty… Vita Brits I went and brought, it was $2 a box or something for Vita Brits the other day, and $2 a box for Weet Bix somewhere else, so I actually had a whole car filled with two trolleys full of Vita Brits, Weet Bix, and I haven’t brought Nutrigrain in a while, we are down to about our last three boxes, we had about forty boxes in there the other day. (Men, 35–50) We’re looking at economy; we’ve all got children. You know, we’ve got to budget. (Women, 35–45)

Work and workplaces

Outside of the home, some noted that their lunch time food choices when they were at work depended on where they were, what was available, and who else they were eating with or purchasing for. Some commented that they were not always able to take lunch with them to work, and that this, combined with where they were working, determined what they could eat at lunch time. Some commented that they worked in areas with only limited choice and some reported that they would be on the road for work and what they ate depended on which town they were visiting at lunch time. In both of these situations, participants noted that it was especially difficult to make food choices that they believed were healthy, simply because the healthy options were not readily available. Some noted that at their workplaces, a group of workers would take it in turns to decide where they would go for lunch, and therefore the individual’s choice was dependent on what that one place had available that day.

Participants also commented that their workplace, type of work, and working hours determined when they could eat. Some experienced set working hours and had little flexibility to decide when they ate, with references being made to shift work, school hours, or retail businesses with defined customer service hours. Working hours were also regarded as one of the factors that determined whether breakfast was eaten and what was eaten at the time. Some participants talked about not feeling like eating as soon as they got up, preferring to wait until sometime later to have breakfast. However, some of these people also noted that the nature of their work meant that they were unable to eat at the time that they would prefer (e.g., teachers), and therefore that they would have to have something first thing in the morning so they could last through until lunch time.

Social factors

Location of eating.

Participants consistently pointed out that eating food that they had not prepared affected their choice of foods, from the perspective of both availability and desire. For example, when eating out, participants reported that they tended to have something they wouldn’t eat at home. They were more likely to have foods they considered to be treats. Some also commented that they would choose foods at these times that were restricted at home because others in the household did not like them. A specific example was food that was provided for free, which was typically at some kind of function. Free food meant different motivations for choice. Partly this was related to not being able to be as fussy as they would be if they were providing their own food or making their own choices. Partly it was related to going for the unusual, commonly more decadent, choice. In both of the above situations (eating out and free food), some participants talked about the idea of feeling like they had to eat all that they were served so as to not waste the opportunity or their money.

Most of the time if I’ve overeaten is when we go to the buffets, where it’s all you can eat sort of thing… so I try to avoid those sort of places, because I will overeat and I feel guilty and then I’ll go out for a walk before I go to bed and then I’ll punish myself the next day. (Men, 35–50)

Other factors related to location were discussed previously under the heading, ‘Work and workplaces’.

Social and physical activities

Participants talked about a range of activities that affected both choice and timing of food. A common factor was that of physical activity, and especially in the context of organised team sports. It was noted that these activities, especially if they were during the week, often overlapped with normal eating times, and therefore that meals would need to be rearranged around the activity. With respect to sports, participants also reported that they needed to consider the impact of their meal on their ability to take part in the sport, noting that they might not have sufficient energy to play a sport if they had not eaten, but that they could not eat too soon before being active. This commonly meant that meals on these evenings were either very early or very late, neither of which was regarded as ideal, but something that participants had no control over. It was also noted that physical activity could affect the type of food chosen, specifically that they would need to eat either to provide or replenish energy.

Some of those who were parents also noted that the sports activities of their children affected their own diet, in terms of both timing of meals and choice of food. Because families were reluctant to prepare more than one meal, the whole family had to fit around everyone else’s activities.

Well we have our set days where, like Wednesday nights we have to have Mackie cheese [macaroni cheese] and nuggets, because that’s what the boys want after their swimming lesson, and sometimes I have to go to the supermarket because I haven’t got any left in the fridge, so… pasta is a bit of a staple. (Men, 35–50) Wednesday is late because I’ve got touch football, so I don’t eat dinner before going to play, I don’t want to go on a full stomach, so lunch is always bigger on a Wednesday than any other day… I hate it because one of the touch footie games isn’t till seven thirty, I hate it, because normally eating at six, there is no way I can have tea beforehand, because I’m just going to run around and get sick, so you don’t get home till… eight thirty, quarter to nine, nine if they are running late, and… yeah, pretty much [McDonald’s] or homemade pizza… because you know they only take about eight minutes in the oven.(Women, 18–24) Well whether the boys are going to be home or we know they are going to be home or one of the daughters is playing sport or I’m playing sport, it varies. (Men, 35–50)

Participants talked about a range of other social activities, such as various groups and clubs, which affected when and what they ate. While these activities might not have had the same physiological impact on food preferences and choices as sports activities, they did similarly affect when meals were eaten, which in turn affected what was eaten. For example, some mentioned after work activities, which meant that they would not get a chance to eat until late, and by then the quickest and most convenient thing to do was to buy take-away food on the way home or eat pre-prepared frozen meals when they got home.

My partner plays pool on a Monday and Wednesday night, so we always have tea a lot earlier then and cook the simple things that don’t take as long, so he can have dinner before he goes rather than buying pub meals which cost more money.(Women, 18–24)

Planning and preparation

Throughout the research, it was apparent that different people had different approaches to planning and preparing meals. The approaches tended to depend on factors such as where they lived, how they shopped, and who and how many people they were shopping for. For example, some mentioned that they lived out of town and therefore that they tended to shop less frequently but buy more at a time. Some of those who reported having large families also mentioned that they would shop in bulk. Several of these participants talked about their food shopping being driven by pre-planned meals.

Yeah and as you drift through the town you stop at the supermarket and pick up the required… it’s a half hour drive in and out, so it creates that sense of planning. (Men, 35–50) For our family… my wife actually sits down each fortnight, because we get paid fortnightly, she works full time, I’m studying full time, and working part time, five kids, the budget is not extensive, so she actually sits down each fortnight and works out what we are going to eat for the fortnight, and then goes and gets all the set ingredients for those meals, and so there’s nothing above and beyond that, now and then there might be a treat thrown in or whatever, all the stuff for the school lunches and that sort of thing. So it’s basically dependent, the amount we eat is dependent on that. She works out ok we need so much to make a meal for seven people. (Men, 35–50)

Participants’ approach to planning was also driven by factors such as their work schedules. They reported that these factors meant that they had different amounts of time available on different days of the week, and therefore that the planning and food preparation process varied according to what was possible on each day.

Oh, well, my aspiration is that I eat more healthily and more natural foods but that’s quite often sabotaged by my planning. My husband probably does want to do that as well but, um, I find it’s often, “Oh, my goodness, I’ve got half an hour to make something and there’s nothing for them, there’s nothing in the fridge, so what are we going to have. So, occasionally it’s fish and chips instead or, um, yeah, just quickly putting something together which isn’t really what I’d want to do but if I’ve done more planning in advance then…(Women, 35–45)

It was also apparent that some participants simply preferred to have a set structure to their diet, and this meant set meals and set shopping patterns.

I guess going back to the getting groceries, I tend to map my weeks out from the Sunday, buy everything for the weekend and that’s it, but I stick to the same recipe every day, so usually lunch is a wrap with ham and a certain amount of grams of tomato and cucumber… it’s just easier to stick to.(Women, 18–24) I pretty much eat at the same time every day…. 9.30 breakfast, twelve lunch, six o’clock dinner. (Women, 18–24)

By contrast, others tended to be a bit more ad hoc in terms of planning, and therefore shopping. These participants reported that they would decide what to eat each day and might quickly visit the supermarket on the way home. It was apparent during these discussions that this approach was more likely in situations in which men were more involved in day-to-day food choices.

And depending on the timing of the day, what’s happened during the day and that sort of thing, what we feel like, necessarily on the day, will be dependent on… well [my wife] either sorts it out in the morning, or puts the slow cooker on or something like that… [depending on] you know who’s going where, that day, because she’s working, at the moment, she’s teaching up at the uni so she’s there till five o’clock most nights of the week… I’ve got subjects or classes, until four or five, I’ve got one on a Monday that finishes at seven, in the evening. (Men, 35–50)

Finally, participants varied in their attitudes regarding whether they liked to have food in the freezer that could be ready to thaw and prepare, or whether they preferred to buy and eat fresh food.

Meal patterns

Timing of meals.

As noted above, participants across these groups reported that their patterns of eating, in particular the time at which they ate, were commonly governed by factors that they felt were external and therefore that they had no control over. Some mentioned that they would eat in the morning because they needed something to get through the start of the day. Even if they did not feel hungry at this time, they were aware that they would feel hungry before there was another chance to eat. From this perspective, for some people and some meals, food was about fuel. They would stock up to prevent themselves running low later on, even if they did not really feel like eating at the time. As noted above, participants in each of the groups talked about the routines and structures of their day-to-day existence determining when they could eat, and that this affected what they would eat. To some extent, they did not feel that this was an ideal approach but felt that they had limited capacity to do otherwise. Hence, in some situations, timing of eating was based on the desire to prevent later hunger, rather than as a response to current hunger.

I think, I mostly eat because, well I’m hungry and you have to, rather than oh my god that’s fantastic, and I’d love to cook it and eat it and enjoy it, I think it’s just more of a…. (Men, 35–50) You’ve got to eat, it’s fuel. (Men, 35–50) Yeah, like breakfast I wouldn’t normally eat, well I don’t enjoy breakfast, but I eat because I know, come nine o’clock, ten o’clock I’m going to be hungry I’m going to be lethargic, so I’ll force Wheeties in or some toast or… I do enjoy food but I don’t deliberately go out because I enjoy the taste or the texture or whatever, it’s more, well you have to eat. (Men, 35–50) If I know I’m travelling and I have to skip lunch or something, I’ll probably have a bigger, breakfast than normal, but if I know I’m going to have access to lunch, then no problem, I’ll just have something to keep me, just to get me there, rather than, cook up the big pancakes and the bacon and eggs, you’ve got to taste nice, I’ll be just a couple of bits of toast just to keep the hunger away. (Men, 35–50)

Standard and variable meals

Participants were prompted to talk about which meals were standard and which were more variable. For most participants, breakfast, lunch, and dinner were each affected by different factors, as were weekday and weekend meals.

Weekday vs. Weekend

Across the groups, weekdays tended to involve more structure, and therefore the weekday meals also tended to involve more structure. This appeared to be most obviously true for those with younger (primary school age) children but was also the case for those with older children and those who did not have or live with children. In other words, the typical weekday involved a degree of externally imposed structure (e.g., working hours: travel times: sporting activities), and for those who lived with others, this was further impacted by the need to coordinate times. For some, food choices tended to be group choices rather than individual choices, especially during the week. By contrast, weekends tended to involve more flexibility of schedules, and as a consequence, more time could be spent in food preparation and decisions about meals were less time and convenience based.

I cook…during the week is when I have…we have set meals and then weekends when I don’t cook… [during the week] we have a meal together every night…at the moment they’re all young so no-one’s out doing things. Yeah, I’m cooking a meal every night, but on the weekend it’s more relaxed, it’s like, “get your own". (Women, 35–45)

Breakfast, lunch, and dinner

While there were some exceptions across these groups, breakfast tended to be a more standard and regular meal. To a large degree, this was because time was a major issue, as breakfast needed to be consumed at a set time and in a brief period of time, typically while the family was getting ready for the day’s activities. Interestingly, some participants suggested that they did not experience the same need for variety when it came to breakfast as they did with other meals, commenting that they were happy to have the same thing day after day. As noted above, weekend breakfasts were commonly quite different from weekday breakfasts, being more about choice, enjoyment, and variety than time and convenience. Weekend breakfasts also tended to be more of a family event than simply eating something before the day’s activities.

However, some participants in each of the groups reported that they did not always eat breakfast, typically feeling that it was too early to eat. Amongst this group, some reported having breakfast some days and not others. These people reported they would wake up and decide whether they felt hungry, and if so, what they felt like eating.

It was also common for some to talk about breakfast being a time when they were more in touch with what they felt like eating, or whether they felt like eating at all, although the breakfast choices tended to be quite narrow (e.g., toast: cereal: fruit). Similarly, some reported that they had two or more standard breakfasts, and that they would choose on the day what they “feel like".

I just wake up and whatever I feel like… like if I wake up hungry, then I’ll go and have some, if I feel like cereal, then I’ll have cereal… and if I do sport in the morning, then I usually have toast… I just feel like toast after a run. (Women, 18–24) It can range from cereal or toast in the morning, my wife makes her own sourdough, so we have that in the morning, which is really good… depends on the mood, because what happens, if the kids wake up, it’s cereal, and I’ll do three bowls at the same time, one, two, three… If everyone is still sleeping, I’ll make my toast and wrap it up and eat it on the way to work so… it just depends on how you feel. (Men, 35–50)

As discussed earlier, lunches tended to vary according to where people were and what they were doing. Convenience was also a key driver for lunch time choices. For those not working during the day, lunches were commonly leftovers from the night before or simple snacks. The mothers talked about not really putting aside time or food for lunch, and often skipping it or simply not getting around to it. If they were not at home, lunch would depend on where they were and what they were doing. For those who were working, there was also the issue of choice being affected by the group, as was previously documented.

Dinner was generally regarded as the most important meal of the day and was afforded more effort and planning. All of the factors discussed previously as influencing food choices tended to be applied to dinners. Most obviously, weekday dinners tended to follow somewhat more of a routine, while there was greater variation and potentially a broader choice on the weekends.

Perceptions of own eating

Participants were asked to comment on how they felt about their diets and their approach to eating. The typical response was to say that it was mostly okay but could be improved. There was a tendency for participants to comment that they ate too much of some foods that they perceived as not good foods, and/or not enough of other foods that they perceived as good foods. Interestingly though, participants commonly responded to these questions with a range of justifications for the shortcomings that they perceived in their diets. For example, some would claim that it was okay that they ate so much high fat foods because they did a lot of exercise; others would report that it was okay because they had a “good metabolism".

Yeah I’m pretty happy with mine [diet], I think I drink too much Coke, I’m really addicted to Coke, but apart from that I’m pretty happy with it. I really love my vegetables, so we eat a lot of vegies… maybe I do justify it, but I really do think that I eat alright. (Women, 18–24) I’m so lucky I’ve got a really good metabolism, and also people will be like, I’ve got a block of chocolate down to fifteen minutes, because if I’ve got a five-hour shift, I only get a few minutes, and they are like but that’s so bad for you, yeah but it’s like calcium… and then if I’m at uni and I want to be healthy, I’ll have like steamed dim sims instead of fried dim sims… so I can justify it all in my head, and I know that it’s not right.(Women, 18–24)

Amongst the younger women in particular, some felt that as long as they were happy with their weight, their diet was all right.

Yeah that’s right, I’ll go for a run, and I do exercise, I don’t put on weight, I don’t, but I do exercise, but I think I do justify my bad eating because I don’t put on weight. (Women, 18–24)

Participants were prompted to discuss whether they ever ate too much, and if so, in what circumstances. Generally, participants felt that they were aware when they were eating too much, but as with comments about their diets in general, they tended to have reasons for doing so that made it acceptable in the circumstances. Commonly, participants reported that when they went out for a meal they would clean their plates even if they were full. They reported that serving sizes tended to be large and that they did not want to leave food if they had paid for it. A specific example of this was the ‘All you can eat’ deals. In the context of these discussions, there was some awareness of the idea of stopping before you feel full, but it was apparent that the actual practice of this idea was less than the knowledge. In essence, participants experienced far more benefits to eating till they were full than disadvantages.

A [chicken parmigiana] and a steak and it’s huge, I’ll, because it’s there, I’ll just keep going until it’s finished… half way through I’ve probably had enough, I’ll be thinking I’m not hungry anymore, but I’ll just keep going. (Men, 35–50). And because you’ve paid for it. (Men, 35–50).

Overall, these findings support Sobal and Bisogni’s [ 31 ] contention that food choice is multifaceted, situational, dynamic, and complexx. However, some components of their model received more affirmation than others. A key overarching theme from the findings was the strong and pervasive impact of external forces, or at least the perception of these forces, on what and when food is eaten. Although taste and preferences for particular foods, as well as health considerations, were mentioned, often as competing considerations [ 57 ], most of the discussion was about the impact of outside forces on food choice. These included family, work, and social structures, and the expectations (or perceived expectations) of family members, colleagues, friends, and others. According to Chen and Antonelli’s [ 32 ] food choice framework, these largely fall into the category, Food-external factors and, in particular, the Social environment sub-category.

The knowledge that one should be practicing healthy eating, which falls under the Framework’s Cognitive factor category, while seen as an aspiration by most participants, was often viewed as unrealistic, trumped by the need and/or desire for convenience, which might be considered a combination of Food-external factor: Social environment and Personal-state factor: Psychological components, in the Framework. Mete et al. [ 58 ], in a qualitative study with adults aged 25–58, also concluded that healthy food choices were important but not a daily priority, and that healthy eating information was known but viewed as difficult to apply to everyday life. Other research has noted the importance of convenience in food choice [ 59 – 60 ]. Jabs et al. [ 61 ], for example, in a study with low-wage employed mothers, found that most expressed feelings of time scarcity and that, while they prioritised feeding their children, they also wanted to complete meals quickly to move on to other tasks. Bava et al. [ 62 ] found that, while the working women in their study said they would ideally choose healthier food, the reality of their lives demanded convenience in food provision to minimise time and cognitive effort.

Other categories and sub-categories of Chen and Antonelli’s [ 32 ] framework, while less discussed by participants, were mentioned. Dearth of food choices when travelling for work, for example, might be categorised under Food-external factor: Physical environment. Personal-state factor: Habits and experiences was demonstrated by discussions around eating the same breakfast every day [ 63 ]. Personal-state factor: Physiological needs came up in discussions around needing to eat even if one didn’t feel like it in order to not go hungry later in the day, or with men's and boys' needs to eat bulky food to fill up. Desires or cravings for less healthy foods (Food-internal factor) were also perceived as working against the ideal of healthy eating.

Although our study did not seek to explore gender or life stage differences in food choice, several tendencies were observed, which future research may want to further explore. In particular, the women with children discussed food choice largely in terms of what others in the family– i.e., their partner and children– liked and which fit in with their schedules. The men, on the other hand, all of whom had children, more often spoke of eating to fill themselves up, or ‘food as fuel.’ Newcome et al. [ 64 ], in a study with partnered men, concluded that men in families displayed unease at expressing enjoyment in food (‘Men downplayed their hedonic consumption’), and instead spoke about food as being largely functional as fuel for their bodies. If these gender and life stage differences prove to be robust, this may suggest quite different public health messaging targeted to women with children, men with children, and those without partners or children. Much of the literature on food choice focuses on women, who continue to be more involved with family food decisions than do their male partners [ 65 ], and thus more is known about women’s food choices.

The findings from this study suggest that public health efforts aimed at educating and encouraging individuals to eat more healthfully are, on their own, insufficient to significantly improve healthy eating at a population level. These public health efforts need to be delivered in conjunction with legislation that removes structural barriers to promote healthy eating.

The vast majority of our participants knew they should be eating more healthfully but felt largely unable to do so. Instead, some of these identified structural barriers must be addressed. In particular, improvements to the food environment are needed, particularly in rural areas where distances are greater [ 66 ]. Greater provision of quickly preparable, accessible, and reasonably priced food, for example, would assist with some of the time barriers. More workplaces could consider providing free and accessible fruit or other healthy snacks for their employees [ 67 ]. Children’s sporting facilities could ensure that healthy foods are available [ 68 ].

As with any study, this one has several limitations. First, the focus groups were conducted in 2010; since then, various changes have occurred in the food environment that are potentially relevant to food choice and the findings from this study. These include the rapid proliferation of online food delivery services. There is evidence, for example, that such services increase the geographic access to foods prepared away from home and that these foods tend not to meet healthy eating recommendations [ 69 ]. There has also been a significant increase in the production and promotion of convenience and ultra-processed foods over this time [ 70 ]. In addition, the marketing of fast food, beverage, and snack brands has expanded via social media [ 71 ], with evidence that digital food marketing and social media can influence food choices, preferences, and consumption [ 72 ]. Therefore, our findings should be interpreted within this context. Future studies are needed to determine the extent to which the various barriers and enablers to healthy eating identified in this study continue to hold.

Second, the findings of this study are based on only three groups of people with a total of 23 participants, all of whom live in or near a rural region in Victoria, Australia. However, one would assume that many of the discussions around personal, family, and workplace factors would translate beyond this specific group of people, and particularly to other people living in Western countries in non-metropolitan areas. A third limitation of this study is that neither actual dietary intake data nor measures of nutritional knowledge was collected from participants, which would have allowed comparison of what participants discussed against more objective data. However, the focus of this study was on understanding how people think about their eating behaviours and perceptions of motivations and barriers to eating more healthily, rather than on whether their self-reports are factually correct. Moreover, we know that food diary data is often inaccurate [ 73 – 74 ]. Fourth, a single researcher conducted the focus groups and analysed the data. However, with thematic analysis, coding quality is not dependent on multiple coders [ 75 ]. The results were discussed with the other co-authors and the first author also read the transcripts. All three authors agreed with the findings.

Despite a plethora of information regarding how people should eat, surprisingly little research explores how and why people eat the way they do– particularly in a general population. Based on findings from focus groups with a range of participants from a rural region of Victoria, Australia, we found that, although decisions regarding when, what, and how much to eat are determined in part by taste preferences and health considerations, they are heavily influenced by a host of other factors. Moreover, many of these factors exist outside the control of the individual, including other household members’ preferences, family activities, and workplace and time constraints, as well as convenience and price. It appears, therefore, that education alone will not solve the problem of unhealthy eating. People want to eat healthier, or at least know they should eat healthier, but it’s all just too hard. It would seem, then, that a key to improving people’s eating behaviours is to make it easy to eat more healthfully, or at least not much harder than eating poorly.

Data availability

De-identified transcripts will be considered by the corresponding author upon request.Due to the nature of the data (i.e.,dSAZX a small number of focus group participants from a single geographic area), it is very difficult to anonymize the data. In addition, the participants did not provide explicit consent for the transcripts to be shared publicly.

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Acknowledgements

We would like to thank the Social Research Centre for conducting the focus groups at cost. We would also like to acknowledge the focus group participants, who generously shared information and insights about themselves and their families.

This study was funded in part by a Research Development Fund from Charles Sturt University. In addition, The Social Research Centre provided an in lieu contribution of four hours per week of author Van Dyke’s time to work on this project.

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NV conceived the project and wrote the main manuscript text other than the Results section. MM conducted the analysis of data and wrote the Results section. All authors reviewed the manuscript.

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Van Dyke, N., Murphy, M. & Drinkwater, E.J. “We know what we should be eating, but we don’t always do that.” How and why people eat the way they do: a qualitative study with rural australians. BMC Public Health 24 , 1240 (2024). https://doi.org/10.1186/s12889-024-18432-x

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Exploring factors affecting the unsafe behavior of health care workers’ in using respiratory masks during COVID-19 pandemic in Iran: a qualitative study

• Azadeh Tahernejad 1 ,
• Sanaz Sohrabizadeh   ORCID: orcid.org/0000-0002-9170-178X 1 &
• Somayeh Tahernejad 2  

BMC Health Services Research volume  24 , Article number:  608 ( 2024 ) Cite this article

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The use of respiratory masks has been one of the most important measures to prevent the spread of COVID-19 among health care workers during the COVID-19 pandemic. Therefore, correct and safe use of breathing masks is vital. The purpose of this study was to exploring factors affecting the unsafe behavior of health care workers’ in using respiratory masks during the COVID-19 pandemic in Iran.

This study was carried out using the conventional qualitative content analysis. Participants were the number of 26 health care workers selected by purposive sampling method. Data collection was conducted through in-depth semi-structured interviews. Data analysis was done using the content analysis approach of Graneheim and Lundman. This study aligns with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist and was conducted between December 2021 and April 2022.

The factors affecting the unsafe behavior of health care workers while using respiratory masks were divided into 3 main categories and 8 sub-categories. Categories included discomfort and pain (four sub-categories of headache and dizziness, skin discomfort, respiratory discomfort, feeling hot and thirsty), negative effect on performance (four sub-categories of effect on physical function, effect on cognitive function, system function vision, and hearing), and a negative effect on the mental state (two subcategories of anxiety and depression).

The findings can help identify and analyze possible scenarios to reduce unsafe behaviors at the time of using breathing masks. The necessary therapeutic and preventive interventions regarding the complications of using masks, as well as planning to train personnel for the correct use of masks with minimal health effects are suggested.

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The COVID-19 pandemic has brought unprecedented challenges to healthcare systems worldwide, requiring Health Care Workers (HCWs) to adopt strict infection control measures to protect themselves [ 1 ]. Among these measures, the proper use of respiratory masks plays a crucial role in preventing the transmission of the virus [ 2 ]. Iran was among the initial countries impacted by COVID-19. In Iran, as in many other countries, HCWs have been at the forefront of the battle against COVID-19, facing various challenges in utilizing respiratory masks effectively [ 3 ]. Over 7.6 million Iranians have been infected by the SARS-CoV-2 virus, with more than 146,480 reported deaths as of August 2023 [ 4 ]. Amid the COVID-19 pandemic, Iran’s healthcare system experienced significant impacts as well [ 5 ].

Despite the passage of several years since the onset of the COVID-19 pandemic, new variant of the virus continues to emerge worldwide. It is crucial to be prepared for future pandemics and similar biological disasters.

Due to the SARS-CoV-2 virus transmission via respiratory droplets, the use of masks and personal protective equipment is essential [ 6 ]. The World Health Organization recommended the use of medical masks, such as surgical masks, for HCWs during the COVID-19 pandemic [ 7 ]. These masks are designed to provide a barrier to respiratory droplets and help reduce the transmission of the virus [ 8 ].

Few studies have been devoted to negative aspects of using respiratory masks in human being. The physiological and adverse effects of using PPE have been investigated in a systematic review study [ 9 ]. In another review study, of skin problems related to the use of respiratory masks were studied [ 10 ]. Also, in some studies, a significant relationship has been found between the time of using masks and the severity of the adverse effects of using masks [ 11 ]. In all the above studies, questionnaires have been used to check the prevalence of these adverse effects among HCWs.

Incorrect use of masks is considered as the unsafe behaviors of HCWs. In some studies, unsafe behaviors are defined as disobeying an accepted safe method while working with the capability of causing an accident [ 12 ]. Since the reasons for unsafe behavior are complex and multifaceted, their prevention requires a clear understanding of important and influential factors. In various studies about the prevalence of unsafe behaviors in work environments, several factors such as individual characteristics, psychological aspects, safety conditions, perceived risk, and stress have been introduced as effective factors in demonstrating the unsafe behaviors [ 12 , 13 , 14 ]. However, the findings are still unable to provide a deep understanding of the underlying causes and motivations contributing to unsafe behaviors.

In the present study, unsafe behaviors while using respiratory masks is defined as the behaviors that are seen by some HCWs, which reduce the effectiveness of respiratory masks due to improper placement on the face or hand contact with the mask [ 15 ]. Some researchers in their studies indicated that other unknown factors are also effective in the unsafe behaviors [ 14 ]. However, the findings are still unable to provide a deep understanding of the underlying causes and motivations contributing to unsafe behaviors. Qualitative studies are needed to answer these questions and determine its causes. Hence, the present study is aimed to explore the factors affecting the unsafe behavior of HCWs while using respiratory masks during the COVID-19 pandemic through a qualitative study.

Study design

This study was carried out using conventional qualitative content analysis (item 9 in COREQ checklist). The interviews explored HCWs’ experiences regarding factors affecting the unsafe behavior in using respiratory masks during covid-19 pandemic in Iran. This research adheres to the guidelines outlined in the Consolidated Criteria for Reporting Qualitative Research (COREQ).

This study was conducted in government and non-government hospitals in Tehran, Mashhad and Rafsanjan that admitted patients with COVID-19 disease. The authors’ place of work and access to participants were important causes of choosing the settings. Moreover, these hospitals experienced a large amount of patients seeking healthcare during the Covid-19 pandemic. This study was performed between December 2021 and April 2022.

Participants

In this study, interviews were performed with healthcare workers (HCWs) including nurses, physicians and hospital workers who had direct contact with patients that used masks for more than 4 h in each work shift. Also, participants frequently utilized surgical masks. Among them, few employed filter masks or a combination of both types. The inclusion criteria were people with experience of using respiratory masks for more than one year and the ability to express their experiences and point of views. The sole exclusion criterion of the current study was a lack of interest in further participation. The participants were selected using purposive sampling method (item 10 in COREQ checklist) in which the researcher selected the most informed people who could explain their experiences regarding the research topic [ 16 ]. The number of participants was determined based on the data saturation principle in which no new concepts were obtained. Data saturation was achieved after 24 interviews, and to ensure saturation, two more interviews were also performed. Finally, the total number of participants was 26 people (items 12–13 in COREQ checklist).

Data gathering

Data collection was performed through in-depth face to face (item 11 in COREQ checklist) semi-structured interviews. The first author, who received training in qualitative research methods, conducted all the interviews (items 1–5 in COREQ checklist). The participants were presented with information about the research topic, objectives, and the researchers’ identities. The researcher thoroughly described the study procedure to those who consented to participate, and written informed consent was obtained from all participants (items 6–8 in COREQ checklist). The data was gathered in the workplace of the participants. Additionally, demographic data of the participants was documented (items 14–16 in COREQ checklist). At first, 5 unstructured interviews were done to extract the primary concept, and then, 21 semi-structured interviews were conducted using the interview guide. The interviews were done in a quiet and comfortable place. The interviews started with simple and general topics and were gradually directed to specific questions based on the answers. Some of the questions were: Based on your experience, what factors are effective in not using your mask safely?

New concepts were extracted from each interview, and this process continued until data saturation was reached. After obtaining permission from the participants to record the interviews, the implementation of the interviews was done immediately after the completion of each interview to increase the accuracy of the obtained data. The duration of the interviews was between 15 and 40 min (30 min on average). Field notes were made during or after the interview and transcripts were returned to participants for the comments and corrections (items 17–23 in COREQ checklist).

Data analysis

Data analysis was done using the five-step content analysis approach of Graneheim and Lundman [ 17 ]. Immediately after conducting each interview, the recorded file of the interview was transcribed in Word software. The interview text was read several times and based on the research question, all the content related to the participants’ experiences were extracted in the form of meaning units. In addition, notes were written in the margins of the text and then, the abstracted meaning units were designated as the code. Subsequently, the compiled codes were categorized into subcategories according to similarities. This process was repeated for all transcribed interviews until the main categories were established. The whole data analysis process was carried out by the researchers. Direct quotes from the interviews included in the results section to elucidate the codes, categories, and themes. (items 24–32 in COREQ checklist).

Trustworthiness

The strategies of transferability, dependability, credibility outlined by Lincoln and Guba were employed to achieve data trustworthiness [ 18 ]. Credibility and dependability were established through data triangulation approach, which involved interviews and field notes. Furthermore, peer check and member check were applied for ensuring credibility. To obtain member check, the transcribed interviews and codes were shared with some participants to receive their feedbacks. In the case of peer check, the research team and independent experts were verified the extracted codes and sub-categories. Data transferability and Confirmability were met through the detailed explanation of the research stages and process.

Women were 50% of all participants and the highest frequency of education was bachelor’s degree ( n  = 17). Furthermore, the highest amount of work experience was 22 years (Table  1 ).

In the present study, 689 initial codes were identified in the initial writing, and after removing duplicate codes and cleaning, the number of final codes included 132 codes. After reviewing and analyzing the data, the factors affecting the unsafe behavior of HCWs while using respiratory masks were divided into 3 main categories and 8 sub-categories (Table  2 ). Categories included discomfort and pain (four sub-categories of headache and dizziness, skin discomfort, respiratory discomfort, feeling hot and thirsty), negative effect on performance (four sub-categories of effect on physical function, effect on cognitive function, system function vision and hearing), and a negative effect on the mental state (two subcategories of anxiety and depression).

Pain and discomfort

Some of the participants reported that the reason for improper and unsafe use of the mask is feeling pain and discomfort, and the reasons include the four subcategories of headache and dizziness, skin discomfort, respiratory discomfort, discomfort caused by heat and thirst.

Skin disorders

The side effects of the mask on the skin are of the important factors in this category. Thus, some participants, due effects of the mask to their skin, limited the use of the mask or did not use it correctly. Among the skin problems experienced by the participants were acne and skin sensitivities, which in some cases required drug treatments. The subcategory of skin sensitivities such as itching and burning was mentioned by more than 70% of the samples as the most important cause of discomfort.

“…I can’t help touching my mask. After half an hour when I put on the new mask, my face, especially my nose, starts to itch badly and I often have to blow my nose from under the mask or over the mask with my fingers, palm or the back of my hand…” (P1)

Respiratory disorders

Most of the participants in the study noted to problems such as difficulty in breathing, heart palpitations, carbon dioxide and unpleasant smell inside the mask as the most important respiratory problems. Therefore, it can be one of the important reasons for removing the mask and unsafe behavior in using the mask.

“… at any opportunity, I remove my mask to take a breath…” (P15)

Feeling hot and thirsty

Temperature discomfort, especially in long-term use and when people had to use two masks, was mentioned as an annoying factor.

“… the heat inside the mask bothers me a lot, I sweat and the mask gets wet… no matter how much water I drink, I still feel thirsty…” (P6)

Unfitness of mask with the individual’s face

Another important point extracted from the interviews was the importance of when to use the mask. In this way, as the time of using the mask increased, the person’s feeling of discomfort due to the mismatch between the belt and the mask increased, because the feeling of pressure and pain on the nose, behind the ears, and the face usually occurs several hours after wearing the mask. Several participants reported experiencing discomfort and headaches after wearing the mask. Although These headaches were often short-term and didn’t have long-term complications according to the participants’ reports, they could affect the work performance of HCWs and their behavior in the correct use of respiratory masks.

“…. After a while, the mask puts pressure on my nose and parts of my head and face. Sometimes I touch and move it unintentionally…” (P3) “… if I don’t move the mask on my face, I get a headache because the mask strap puts pressure on my head and nose…” (P21)

Effects on performance

The participants reported that wearing a mask for a long time is one of their important problems in performing their duties, and one of the main categories extracted from this study is the effects on performance, which includes the physical, cognitive, vision and hearing performance.

Effects on physical performance

The effect on the physical performance of HCWs had less effect on their unsafe behavior in using masks than other cases. But when masks were used for a long time and people were more physically tired, sometimes people removed the mask to increase their ability to perform physical work.

“…when I wear a mask, it becomes difficult for me to walk and do physical work, as if I am short of breath…” (P17)

Effects on cognitive function

It was the most frequent subcategory. Because when people feel uncomfortable, their attention decreases and part of the working memory is involved in feeling uncomfortable. Of course, it should be noted that many of the participants in the present study reported the decrease in alertness to be an effective factor in reducing their cognitive performance.

“…When I take off the mask, I can focus better on my work. Especially when I wear it in longer times, I get tired. Many times, I move the mask to finish my job faster…” (P8)

Based on the participants’ point of views, data perception (understanding information through the visual and auditory systems) decreases while using the mask. However, the negative effect of mask on the visual performance affects the unsafe behavior of the HCWs in the incorrect use of the mask and moving it on the face more than other cases. Most of the people who used glasses reported the steam condensation under the glasses as an important cause of discomfort and interference of the mask with their work duties.

“…Using glasses with a mask is really annoying. I have eye pain and burning, and there is always a fog in front of my eyes…” (P2)

Effects on mental status

Among the other main categories extracted in this study is the effects on mental status, which includes the subcategories of depression and anxiety. The negative effect of the mask on the mental state unconsciously affects the person’s behavior in using the respiratory mask.

Some of the participants in this study reported feeling anxious while wearing the mask for various reasons. Therefore, they refuse to wear masks, although they have no justification for doing so. In many cases, the participants in this study expressed that during higher psychological stress, they suffer more from wearing masks and tend to wear them improperly.

“… Sometimes I distractedly take off my mask so that the other person hears my voice better. However, there are many patients, So I am afraid of getting infected. Sometimes I have to speak loudly and this makes me furious … I worry about making a mistake or misunderstanding the conversation, and …” (P4)

One of the most important factors mentioned as a cause of depression was harder communication with colleagues and patients while wearing a mask. This occurs by increasing the physical and mental workload and placing people in social isolation. In this situation, HCWs sometimes consciously take off their masks, so that they can communicate with each other more conveniently.

“…When I wear a mask, I get tired when talking to others. I prefer not to talk to my colleague. Sometimes I don’t pay attention, I take the mask down so they can understand me …” (P5)

To the best of our knowledge, this research is one of the first qualitative studies to extract the experiences of HCWs for explaining the factors affecting the unsafe behavior of HCWs in using respiratory masks during the COVID-19 pandemic in Iran. Although many reasons can cause the unsafe behavior of HCWs in the correct use of respiratory masks in the hospital, according to the present results, three main categories include discomfort and pain, effects on performance, effects on mental status. Skin and respiratory discomforts and the negative effect of the mask on cognitive functions are among the most important factors affecting the unsafe behavior of HCWs in the field of correct use of respiratory masks.

Based on the present study, the participants experienced discomfort and pain while using the mask, and this was one of the important factors of unsafe use of respiratory masks. Discomfort while wearing masks has been confirmed in several studies [ 19 ]. Additionally, in a similar study, researchers found that wearing face masks during the COVID-19 era heightens the discomfort experienced by HCWs [ 20 ]. Some studies have delved into these discomforts in greater detail. For example, the prevalence of skin disorders among HCWs using PPE during the COVID-19 pandemic was reported to be significant [ 21 ]. Some researchers also reported significant prevalence of respiratory disorders and headaches when using PPE [ 22 ]. The findings of a study suggested that a novel form of headache has emerged among HCWs when using a mask during the COVID-19 pandemic. Both exacerbation of existing headaches and the onset of new headaches have been observed to rise with mask usage, irrespective of the use duration [ 23 ]. In some studies, a significant percentage of people reported feeling thirsty and dehydrated after long-term use of respiratory masks [ 24 ]. Several studies reported disturbing rates of perspiration from prolonged use of respiratory masks [ 25 , 26 , 27 ]. A similar study reported that prolonged exposure to masks and protective gear, especially among HCWs, can lead to various issues such as acne, skin irritation, cognitive impairment, and headaches [ 28 ]. According to the results of the present study, discomfort often causes HCWs to move the mask and disturb the correct fitness of the mask on their face.

The results of the present study indicated that respiratory masks have the ability to hinder the work performance of their users. Various studies have confirmed the adverse effect of respiratory masks on HCWs performance. A similar research indicated that respiratory masks reduce physical performance [ 29 ]. Several studies have highlighted the issue of mask users’ ability to see and read being hindered by fogging of glasses [ 22 , 27 , 30 ]. The feel of weakness to perform cognitive tasks has also been reported in various studies [ 31 , 32 ]. An increase in physical fatigue has been mentioned in some studies as an adverse effect of respiratory masks [ 27 , 31 ]. A research showed the effect of respiratory mask on hearing and visual performance [ 33 ]. Another study reported that high-protection respiratory masks reduced physiological and psychological ability, especially if the workers perform physical work [ 34 ].

The third category is related to the negative impact on the psychological state of HCWs. Some studies noted the use of some PPE, including respiratory masks, as one of the possible reasons for the increase of mental health problems among HCWs [ 35 , 36 ]. Before the prevalence of the COVID-19 virus, the hypothesis of the negative effect of respiratory masks on the mental state of people was investigated and confirmed by some studies [ 37 ]. Furthermore, one study reported that wearing respiratory masks leads to an increase in anxiety [ 38 ].

The non-ergonomic nature of respiratory masks (the lack of suitability of masks for people for long-term use) can affect the effectiveness of respiratory masks by encouraging people to perform unsafe behaviors in using respiratory masks [ 39 ]. An important point was that the attitude and knowledge of health care works regarding the use of respiratory masks were not identified as the cause of unsafe behavior of HCWs. However, this factor has been reported in some previous studies as a reason for people not using PPE properly [ 40 ]. The COVID-19 pandemic situation and the extensive information collected about this pandemic may improve the level of awareness and the attitude of the HCWs.

The escalation in infection rates among HCWs, despite receiving training and utilizing personal protective equipment, served as a catalyst for this research endeavor. So far, there has been a deficiency in the context-specific research that could offer a more profound understanding of this issue. Therefore, the outcomes of this qualitative study may prove beneficial in enhancing the design and execution of respiratory protection programs for HCWs in infectious hospital departments or during similar pandemics.

Implications for nursing practice

It is expected that the findings of this study can provide a better understanding of the factors influencing the unsafe behavior of HCWs while using masks. Furthermore, it can be used as a preliminary study to evaluate the effectiveness of safety and infection control programs in hospitals in the COVID-19 pandemic and similar disasters in the future.

Discomfort and pain, effects on performance, and effects on mental status are important factors for unsafe behavior of HCWs’ in using respiratory masks. Our results could contribute to the identification and analysis of possible scenarios to reduce unsafe behaviors in the use of respiratory masks. Accordingly, it is recommended to provide the necessary therapeutic and preventive interventions regarding the complications of using masks. Planning to reduce the side effects of masks and training personnel on the correct use of masks with minimal health effects are recommended as well.

Limitations

The physical and cognitive workload of HCWs which increased during the COVID-19 pandemic [ 41 ], had possible impacts on the work ability of the staff [ 42 ]. Therefore, their explanation about the negative effects of wearing masks may be affected by their specific working conditions.

Data availability

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

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All authors have read and approved the manuscript. AT, SS, ST are responsible for the overall conceptualization and oversight of the study, including study design, data interpretation, and manuscript write-up. AT is responsible for the first draft. All authors reviewed and provided feedback on the manuscript prior to submission.

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Tahernejad, A., Sohrabizadeh, S. & Tahernejad, S. Exploring factors affecting the unsafe behavior of health care workers’ in using respiratory masks during COVID-19 pandemic in Iran: a qualitative study. BMC Health Serv Res 24 , 608 (2024). https://doi.org/10.1186/s12913-024-11000-4

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Knowledge, perception, attitude, and practice of complementary and alternative medicine by health care workers in Garki hospital Abuja, Nigeria

• Enole Jennifer Onche 1 ,
• Mojisola Morenike Oluwasanu 1 &
• Yetunde Olufisayo John-Akinola 1  

BMC Complementary Medicine and Therapies volume  24 , Article number:  177 ( 2024 ) Cite this article

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Healthcare workers are currently making efforts to offer services that cater to the holistic care needs of their patients. Previous studies have shown that some healthcare workers encounter challenges when advising patients about Complementary and Alternative Medicine (CAM), even though its use is widespread. Many health care workers may not have received formal education or training in CAM and consequently are unable to address their patients’ questions about it. This study explored the knowledge, perception, attitude and practice of CAM by healthcare workers in Garki Hospital, Abuja, Nigeria.

This was an institution-based cross-sectional study, design and a convergent parallel, mixed methods design was used for data collection. Five (5) healthcare workers were purposively selected as participants for the key informant interviews, while two hundred and fifty (250) selected using a simple random sampling method completed the questionnaire. The data collection instruments used were a key informant interview guide and a 35-item self-administered questionnaire. Knowledge was assessed with a 4-item scale with a maximum score of 8. Perceptions and attitudes were assessed using Likert scales with a maximum score of 45 and 20, respectively. Practice was assessed with a 6-item scale with a maximum score of 18. Qualitative data was analysed using framework analysis. Quantitative data was analysed using descriptive and inferential statistics. Data acquired from both methods were integrated to form the findings.

The average age of respondents for the quantitative study was 34.0  ±  7.8 years, and they were predominantly females (61.2%) with one to ten years of work experience (68.8%). The mean knowledge, perception and attitude scores were 1.94 ± 1.39, 13.08 ± 2.34 and 32.68 ± 6.28, respectively. Multiple linear regression result showed that knowledge (t = 2.025, p  = 0.044) and attitude (t = 5.961, p  = 0.000) had statistically significant effects on the practice of CAM. Qualitative data revealed that the majority of the participants perceive CAM favourably, provided it is properly introduced into mainstream medicine with evidence of safety and research to prove its efficacy.

The study has shown the gaps in knowledge and the practices of CAM by conventional medical practitioners. This has implications for their ability to counsel and refer patients who may require CAM therapies. Policy, research and programmatic initiatives that seek to enhance their knowledge of CAM, and improve collaboration with CAM practitioners are recommended.

Peer Review reports

Complementary and Alternative Medicine (CAM) is “a system of complex medical and health care practices and products that are not generally considered part of conventional medicine” and has been used since antiquity [ 1 ]. As centuries passed, the practice receded with more emphasis on the practice of conventional medicine [ 2 ]. Recently, CAM has gained increasing attention and interest from healthcare workers and the general public [ 3 ]. The use of CAM persists in local communities, especially in low-income countries [ 1 ]. Tertiary institutions in some high-income countries have taken steps to integrate CAM curricula into their medical education system [ 2 , 4 ]. The decision to recommend CAM therapy to a patient is related to the healthcare worker’s knowledge and training [ 5 ].

The healthcare system in Nigeria will benefit from increased communication between conventional medicine practitioners and CAM practitioners as both play complementary roles in healthcare delivery, especially given community members’ favourable views on the accessibility and affordability of CAM [ 6 , 7 , 8 ]. Legally, the Medical and Dental Practice Act states that CAM practitioners are not authorised to practice medicine and are liable to be punished [ 9 ]. However, special provisions (that allow for the supervised, regulated practice of CAM) are made for them under the National Primary Health Care Development Agency (NPHCDA) Act, whose agency was set up to promote CAM’s relevance in the advancement of primary health care [ 9 ]. The recorded efforts at integrating CAM into the health care system are selected training of CAM practitioners and public health campaigns with the purpose of training CAM practitioners to adopt good agricultural practices and sound medical practices [ 9 ]. These were conducted by the Federal Ministry of Health and international development partners such as the World Health Organisation [ 10 ].

Few studies have been conducted on CAM among conventional healthcare workers in Nigeria; all these were quantitative studies [ 6 , 7 ]. This study explored the knowledge, perception, attitude and practice of CAM by health care workers in Garki Hospital Abuja, Nigeria.

The findings can contribute to the fulfilment of the Sustainable Development Goal (SDG 3) of Good Health and Well-being by creating an enabling environment for patients seeking care for health problems by offering them the choice of using conventional medicine and/ or CAM.

Study design

This was an institution-based, cross-sectional study and a convergent parallel, mixed methods design was used for data collection. The quantitative approach was a cross-sectional study while the qualitative was key informant interviews. Both the quantitative and qualitative data were equally important and occurred concurrently.This approach was adopted to support the collection of complimentary data and enrich the interpretation of the results. The qualitative and quantitative data were analysed separately, and the results were integrated to generate conclusions.

Data collection comprised key informant interviews and a descriptive cross-sectional survey among conventional healthcare workers in Garki Hospital, Abuja, Nigeria. The study assessed healthcare workers’ knowledge, perception, attitude and practice of CAM. The study also identified factors [ 11 , 12 ] that may influence the healthcare workers’ perception of CAM and its integration into the healthcare system [ 13 ].

Description of the study area

Garki is an urban area located in Abuja, in the Federal Capital Territory of Nigeria, and the main languages spoken are English and Hausa. However, people from many different ethnicities populate the area. The residents engage in various economic activities ranging from banking, health care, civil service, public service, business and telecommunications. The study was limited only to the healthcare workers in Garki Hospital Abuja. Garki Hospital Abuja is a tertiary hospital located in Garki Local Government Area (LGA) of the Federal Capital Territory Abuja Municipal Area Council.

The number of health workers in this institution was 500 as of the time of this study. These consist of 137 doctors (including consultants, senior registrars, registrars and medical officers), 156 nurses, 21 pharmacists, 20 medical lab scientists, six physiotherapists and others including 82 patient care attendants, five preventive medicine counsellors, 10 radiographers, nine medical lab technicians, three optometrists, two embryologists, two psychologists, 10 renal technicians, one dietician and five mortuary attendants.

Study population

The study population comprised medical doctors (physicians and surgeons), nurses, pharmacists, medical lab scientists, physiotherapists and other healthcare workers working in Garki Hospital Abuja, Nigeria. The inclusion criteria were at least one year of experience post-qualification, complete registration with the appropriate professional bodies and employment as permanent staff. Key informant interviews were also conducted with heads of units of medicine, surgery, nursing, medical laboratory science and pharmacy.

Sample size determination

The sample size was calculated using the standard formula (derived from Cochran’s formula and Slovin’s formula) [ 14 ].

n = the required sample size.

z = 1.96 (95%) standard normal deviation at the required confidence interval.

p = proportion of health care providers with a favourable attitude toward CAM.

e = margin of error set at 0.05.

p  = 60.0% (proportion of physicians with a favourable attitude toward CAM in Lagos University Teaching Hospital) 7 .

N = known population of health care workers in Garki Hospital that is 500.

A non-response rate of 10% of the minimum sample size was calculated to address possible cases of loss or incomplete completion of the questionnaire.

n a = n x 1/1 – r.

where: n a is the adjusted sample size, n is the initial sample size calculated using standard formula, r is the expected non-response rate (expressed as a decimal).

n a = 213 × 1/1–0.1.

= 213 × 1/0.9.

= 213 × 1.11.

Therefore, the minimum sample size estimate for the study is 237, which was increased to 250.

Sampling procedure

The healthcare workers were stratified into the different cadres of healthcare. The sample population was selected using a simple random method. The proportionate allocation method was applied in sample selection; the proportion of healthcare workers selected from each subgroup was determined by their number relative to the entire population. The ratio used in the proportionate allocation of health workers into the study is shown in additional file 1 .

Five healthcare workers who participated in the key informant interviews were selected through a purposive method. The decision to include them was based on their position as heads of key service delivery units and their level of experience.

Study instruments

A ten-item key informant interview guide (Additional file 2 ) was developed from previous studies [ 2 , 15 , 16 , 17 , 18 , 19 ] and used to gather information on the knowledge, perception, attitude, practice, challenges, and facilitators to incorporating CAM and the recommendations for the same. The interviewer -administered interviews were conducted to illustrate the perspectives and opinions of experienced authority figures on their perception and attitudes towards CAM.

Quantitative data was collected using a 35-item self-administered questionnaire (Additional file 3 ) developed from a literature review [ 2 , 5 , 7 , 17 , 18 , 19 ]. This instrument included sections covering the socio-demographic characteristics, knowledge of CAM therapies [ 2 , 5 , 7 ], attitude and perception towards CAM therapies [ 17 , 18 , 19 ], and practice [ 2 , 19 ].

Training of research assistants, pretesting of tools and data collection

Before data collection, the researcher had a two-day orientation with two members of staff of Garki Hospital who had degrees in the social sciences, and they were engaged as research assistants in the study. The orientation focused on the study’s objectives, interview techniques, procedures for data collection and ethical issues. Soon after, the quantitative and qualitative research tools were pre-tested in a nearby hospital with similar characteristics to the study area and revised as appropriate before the conduct of the actual study.

Data collection was conducted between 12th September 2020 and 12th November 2020. For the quantitative data, 250 respondents completed the self-administered questionnaire while interviews were held with five key informants by the researcher.

Analysis of quantitative and qualitative data

Responses in each questionnaire were coded using a coding guide developed by the research team. This coding guide includes scores for variables to be analysed. The variable, knowledge, was assessed using four questions, and the maximum score for knowledge was 8. For each question, If the respondent answered “Yes” with valid examples, a score of 2 was given; “Yes” without correct examples was assigned a score of 1 and responses that were either “No” or “Don’t know” were given a score of 0. Perception was assessed using four questions on a Likert scale, and the score ranged from 0 to 20. Attitude was also assessed using nine (9) questions on a Likert scale and the score ranged between 0 and 45. The knowledge, attitude and practice were reported using the mean and standard deviation. Practice was assessed using a 6-item scale, and the questions included ever use of CAM by the health worker and counselling and referral of patients for CAM services. The highest and lowest scores were 0 and 18, respectively.

Analysis of quantitative data was done using SPSS version 26. Continuous variables were summarised using mean and standard deviation. Categorical variables such as age, knowledge, perception and practice were grouped into categories derived from the coding and scoring guides. Independent t-test, one-way analysis of variance, pearson correlation and multiple linear regression analysis were used to determine associations and test statistical significance at p  < 0.05.

For the qualitative data, the audio recordings were transcribed verbatim into Microsoft Word document and analysed using framework analysis to identify common themes supported by normative quotes [ 20 ].

This involved a 5-step process: familiarisation with the data, development of a thematic framework, indexing, charting, mapping and interpretation [ 20 ]. During the familiarisation process, members of the research team, read the transcripts to get acquainted with the data; after that, there was a discussion of the data. A thematic coding framework was developed based on the discussion during this phase. After that, portions of the transcripts were indexed by identifying the themes and codes where they belong. These were charted by arranging the information in a table according to the themes with the aid of Microsoft Word. Finally, the mapping and interpretation were done by arranging and discussing the charted information on perception, attitude and factors influencing the utilszation of CAM. At this point, the researchers were interested in deducing explanations and patterns across the data.

There was integration and synthesis of the qualitative and quantitative data sets [ 21 ]. This helped deepen understanding of CAM among conventional healthcare practitioners providing a more detailed qualitative description. Themes from the quantitative and qualitative data sets were compared to identify areas of differences or commonalities. The data from both sources were integrated during final data interpretation using the weaving approach, which entails a narrative description and presentation of both the qualitative and quantitative findings by themes [ 21 ].

Participants’ profile (key informant interviews)

For the interviews, the participants’ ages ranged from 38 to 53 years. The results further showed that 60% of the participants were male. 40% were either Idoma or Igbo, and the remaining 20% were Hausa. All participants were Christian and had between two to thirteen years of experience in a supervisory role. The selected individuals include a consultant physician, a consultant surgeon, a senior nurse, a senior pharmacist and a preventive medicine counsellor working under the jurisdiction of the Institute of Human Virology, Nigeria (IHVN).

Socio-demographic characteristics of respondents

The results showed that the mean age was 34.0  ±  7.8 years and the highest age group proportion (81.2%) was for those aged 20 to 39 years. The results showed that the majority (61.2%) of the respondents were female. Most of the respondents were either medical doctors 41.6% or nurses 29.6%. The data showed that the majority of the respondents, 68.8% had between one to ten years of work experience. The results are shown in Table  1 .

Knowledge of CAM

The results in Table  2 show the respondents’ knowledge of CAM. The mean knowledge score for the study population is 1.94 ± 1.39 with a range of 0 to 6 from a total possible score of 8 points.

Most (59.6%) had read materials on CAM. Respondents were then asked if they knew the names of alternative/traditional medicines used by practitioners and to list at least three. The majority (65.2%) answered “No” or “Don’t Know”, about one quarter (24.4%) answered “Yes,” and the remaining (10.4%) were able to list correct examples of the medicines that were asked. A high percentage (70.4%) were aware of the risks associated with CAM use.

According to the qualitative findings, most of the participants were unaware of changes within the health system, including government policies favouring the use of CAM or training sessions to instill the knowledge of CAM though they acknowledge a few efforts by governmental and non-governmental organizations to promote integration of CAM as illustrated in these quotes:

“ There have been efforts but everything has to go through a process. It has been delayed. However, there are NGOs and other private bodies that are readily advocating for CAM to be used in the professional health system. But it has not yet been approved. ” Key informant.

“In the past, there probably were efforts to bring CAM into the mainstream (conventional medicine) but has not seen the light of day due to the problem of effecting policies in Nigeria.” – Key informant.

Perception of complementary and alternative

The results in Table  3 show the respondents’ perceptions of CAM. The mean perception score of the respondents is 13.08 ± 2.34 with a range of 4 to 19, out of a total possible score of 20.0. Less than half, 47.2%, of the respondents, disagree with the statement that healthcare systems should rely on conventional medicine alone. Less than two-thirds (56.2%) of the respondents either agree or strongly agree with the statement that healthcare systems should provide conventional medicine and CAM at the patients’ discretion. A similar percentage (55.2%) agreed or strongly agreed with the statement that healthcare systems should provide conventional medicine and CAM at the healthcare providers’ discretion. The majority of the respondents (73.2%) agree or strongly agree that healthcare systems should provide conventional medicine and evidence-based CAM as integrative medicine.

According to the qualitative findings, the majority of the participants thought that CAM can be appropriately introduced into mainstream medicine provided there is evidence and a lot of research channelled along that path to make sure it is beneficial for patients as shown in this quote: “If [CAM is] properly introduced into mainstream medicine and there is evidence and a lot of research channelled along that path to make sure CAM is beneficial for patients, I am totally for it.” – Key informant .

In addition, there were concerns expressed by most of the participants that some CAM practitioners may not understand the biological or pharmacological basis for the efficacy of their products and the National Agency for Food and Drug Administration and Control (NAFDAC) may not approve the use of some CAM products due to this issue as illustrated in this quote:

“Hardly will NAFDAC give CAM practitioners license to practice. Some practitioners cannot defend [do not know the pharmacological basis for the efficacy of their products] what they are giving out. It (CAM practice) will only be done well if it is done the right way.” – Key informant.

Attitude towards complementary and alternative

Table  4 shows the respondents’ attitude toward CAM. The mean attitudinal score of the respondents is 32.68 ± 6.28 with a range of 9 to 45, out of a total possible score of 45 points. Almost half (48%) of the respondents strongly agree or agree with the statement that practising with knowledge of CAM and Conventional Medicine is superior to practising with only the knowledge of conventional medicine. The majority (95%) of the respondents agree or strongly agree that research on the efficacy and safety of CAM should be performed. Most, (76.8%) of the respondents agree or strongly agree that medical practitioners should be more educated in the use of CAM.

According to the qualitative findings, some of the potential adverse effects of CAM, which all the participants expressed, include concerns that it will affect conventional medicine practice leading to interferences when a patient decides to explore and use both CAM and conventional medicine causing harm to the patient as illustrated in this quote:

“There will be interferences because a patient will decide to explore and try both CAM and conventional medicine. This may be harmful to the patient. In terms of our unit (HIV unit managed by the Institute of Human Virology of Nigeria), we try to make our patients understand the repercussions of doing both (CAM and conventional medicine).” – Key informant.

Another concern expressed by some participants was potential resistance by healthcare providers to accept and provide care using CAM since they were not trained on it. This could hinder acceptability by the health workers, as shown in this quote:

“We still have a long way to go because the training in conventional medicine has made us believe that if it is not conventional, it shouldn’t be accepted.” – Key informant.

The positive effects expressed by all the participants include that CAM would be cheaper than conventional medicine, and in a low-income country like Nigeria, it would help people access care at a cost they can afford. Also, it would lead to greater patient acceptability because most of their clients are raised within the traditional Nigerian setting, and a lot still believe in it. In addition, compliance will be enhanced; patient load and satisfaction will increase, as illustrated in these quotes:

“It will make health care delivery much more affordable, and the health of many Nigerians will be taken care of, meaning cheaper and less resource intensive.” – Key informant.

“ It would lead to greater patients’ acceptability because most of our clients are raised within the traditional Nigerian setting, and a lot still believe in it.” – Key informant.

Practice of CAM

The mean practice score of the respondents is 9.1 ± 2.6 with a range of 4 to 18, out of a total possible score of 20 points. It was shown that 82.4% of the respondents had a poor score on CAM utilisation and outcomes (practice) while 17.6% had a good score on the same. The result presented in Table  5 shows that the majority of the respondents (70.0%) had not used or recommended CAM. In comparison, 26.0% of the respondents and 48% were likely to refer their patients to a CAM practitioner if available at the institution. Only 10.4% of the respondents had ever referred their patients to a CAM practitioner while 83.2% had not done so. The majority of the respondents (69.6%) had discussed the possible benefits of CAM therapy with 0–25% of their patients, while 33.2% of the respondents had discussed the possible harmful outcomes of the same with 0–25% of their patients. Almost half (49.6%) of the respondents said that their patients are the ones to initiate discussion of the benefits and risks of CAM therapy. In contrast, the following proportions said it was either themselves (21.2%) or a third party (23.2%).

Potential barriers and facilitators to the incorporation of CAM into the Hospital practice

A barrier expressed by some of the participants to the incorporation of CAM into Hospital practice includes health care workers not readily aligning with CAM because the institution they work in has not made provisions for it as reflected in these quotes:

“People [Health workers] will not want to accept it at first because they do not understand it. Garki Hospital has an already established conventional medical practice.” – Key Informant.

“ Garki Hospital is located in an urban area. The management will not look too kindly on anything that will decrease patient patronage. Practitioners themselves will not readily align with considering CAM.” – Key informant.

A potential facilitator identified by one of the participants was the availability of financial resources which must be channeled to the conduct of research to prove that these therapies are beneficial and not as harmful.

Another facilitator identified was education. Specifically, a two-pronged approach was emphasised that includes patient education and practitioner education to improve the acceptability of CAM as stated in the quotes below:

“We need to develop a two-pronged approach consisting of patient education and practitioner ………which will improve acceptability of CAM.” –Key informant.

“Mainstream conventional medicine took several years to be accepted so factors such as education, education, education! It is important to educate people on the positive side (of CAM).” – Key informant.

Association between the socio-demographic characteristics of respondents and their perception of CAM

Table  6 shows there is no relationship between the respondent’s gender, years of experience, ethnicity, profession and their perception towards CAM. The exception is religion ( P  < 0.05).

Association between the socio-demographic characteristics of respondents and their practice of CAM

There is no relationship between the respondent’s age, gender, ethnicity, years of experience and their practice of CAM. The exceptions are religion and profession (P  ≤  0.05). The result of this finding is shown in Table  7 .

Hypothesis 1

There is no significant relationship between the healthcare provider’s knowledge of CAM and their likelihood of incorporating it into their practice.

The results of the findings are shown in Table  8 . The table shows that there is a positive correlation between the respondents’ knowledge of complementary and alternative medicine and the likelihood of incorporating it into their practice ( r=.206 ,  p  = .001). Therefore, the null hypothesis is rejected.

Hypothesis 2

There is no association between the healthcare provider’s attitude toward CAM and their likelihood of incorporating it into their practice.

There is a positive correlation between the attitude of the respondents towards CAM and their likelihood of incorporating it into their practice ( r=.428,   p  = .000). The result of this finding is shown in Table  8 . This means that the attitude of the respondents towards complementary and alternative medicine has a significant influence on their likelihood of incorporating it into their practice. Therefore, the null hypothesis is rejected.

Hypothesis 3

There is no significant relationship between the healthcare provider’s perception of CAM and their likelihood of incorporating it into their practice.

The results of the findings are shown in Table  8 . The table shows that there is a positive correlation between the respondents’ perception of complementary and alternative medicine and the likelihood of incorporating it into their practice ( r=.215,   p  = .001). Therefore, the null hypothesis is rejected.

The results showed that the multiple linear regression model was statistically significant (F = 20.067, P  = 0.000, adjusted R2 = 0.187); knowledge (t = 2.025, p  = 0.044) and attitude (t = 5.961, p  = 0.000) had statistically significant effects on the practice of CAM as shown in Table  9 .

Findings from this study revealed that the healthcare workers had poor knowledge about CAM and this had implications on practice. This aligns with finding in the North West [ 6 ] and South West [ 7 ] regions of Nigeria which showed that the knowledge of CAM is low and related to the healthcare providers’ years of experience. Most had read CAM materials but the majority did not know the products. In addition, the majority were unaware of therapies listed/approved by the National Agency for Food and Drug Administration and Control and only a tenth knew the name of CAM used by practitioners. Several studies among conventional healthcare practitioners in different regions of the world have documented poor knowledge about CAM [ 5 , 22 , 23 , 24 ]. This finding can be attributed to the fact that many of the respondents may not have been taught CAM during their training nor had they come across such knowledge in the years since graduation. The poor knowledge of CAM has grave implications for the competencies of healthcare workers to counsel, address concerns and provide proper guidance to the increasing number of patients who may be contemplating using CAM therapies or integrative medicine [ 5 ]. This is essential because patients form their health beliefs largely on the advice of the health care provider [ 5 ]. This finding underscores the need for further education for this cadre of health workers, particularly medical doctors, and this can be implemented through the introduction of CAM courses in medical education institutions [ 25 , 26 ] or through in-service training [ 27 ].

Conversely, the majority of the respondents had a positive perception and attitude towards CAM. Studies in the North West and South West regions of Nigeria have also documented a positive attitude towards CAM among physicians [ 6 , 7 ]. Respondents in this study expressed that conventional medical practitioners should be more educated on the use of CAM including its possible inclusion in the undergraduate curriculum of their previous course of study. This finding is similar to what was obtained in studies by Hilal et al., and Yurtseven et al. [ 5 , 28 ].

Majority of the respondents expressed their reluctance to refer their patients to a CAM practitioner due to concerns about the safety and efficacy of the drug. This is similar to findings of a study conducted among physicians in Lagos, Nigeria which revealed that despite a good knowledge of the commonly used herbal preparations, skepticism remained about the value of CAM. Most indicated that they would discourage patients from taking these therapies [ 7 ]. Reasons for this were insufficient research conducted on CAM therapies with a lack of data on efficacy and safety of the same. Similar findings were reported in Sokoto [ 8 ] where the respondents showed a high degree of concern about the safety of CAM.

The majority of respondents in this study had never used nor referred patients to CAM practitioners, nor had they discussed the benefits of using CAM therapies. These echo the findings from a study conducted in Sokoto, Nigeria, among healthcare workers [ 6 ]. This is an expected finding because most healthcare workers have not been trained on CAM and must follow the ethics of their profession and rely on evidence-based research [ 13 ] to guide their practice. From this study, some factors affecting the perception of CAM are the respondent’s religion and profession. This is similar to the findings of a study conducted among healthcare workers in Trinidad and Tobago [ 17 ].

Potential barriers and challenges to the acceptance of CAM were highlighted. Most respondents believe that healthcare workers are more likely not to accept CAM because they are under the authority and follow the etiquette of sound medical practice in the institution [ 10 ]. Another barrier is that patients using the hospital are well-educated; some will not even consider its use. Others cited a lack of standardisation of CAM practice as a reason why it would be difficult to incorporate it into their hospital practice [ 11 ]. All these potential barriers and challenges must be considered, especially for patients who may desire to utilise CAM services [ 12 ].

The implications of these findings are that there is need for effective integration of CAM into practice that will lead to overcoming communication challenges with patients, addressing potential safety issues and skepticism about CAM efficacy. Addressing these implications requires ongoing education and training to improve healthcare workers’ understanding and approach to CAM, enabling them to provide more comprehensive and patient-centered care.

Limitations

There are two main limitations to this study. The first is that nurses and healthcare assistants make up the majority of healthcare workers in Garki Hospital and the proportional allocation in the initial sampling reflected this. However, the response rate for these cadres was very low prompting the researchers to administer more questionnaires to the medical doctors to achieve the sample size. The second is that this study was carried out among healthcare workers in one tertiary hospital in Abuja the capital city of Nigeria.

Further studies could consider including healthcare workers in different hospitals to cut across the primary, secondary and tertiary healthcare facilities in Nigeria. This will ensure the results can be generalised.

This study investigated healthcare workers’ knowledge, perception, attitude and practice towards CAM. The findings have shown the gaps in knowledge and the poor utilisation or referral for CAM services by conventional medical practitioners. Other potential barriers and challenges which may hinder the acceptance of CAM were highlighted. Therefore, the relevant government agencies and professional associations should implement policy, research and programmatic initiatives that enhance CAM and improve collaboration with CAM practitioners.

Data availability

All qualitative and quantitative data generated during and/or analysed during the current study are currently not publicly available but are available from the corresponding author on request. This can only be used for non-commercial purposes which ensures that participants’ confidentiality is protected.

Abbreviations

Complementary and Alternative Medicine

Federal Ministry of Health

Head of Department

Institute of Human Virology, Nigeria

Local Government Area

National Agency for Food and Drug Administration and Control

National Association of Nigeria Traditional Medicine Practitioners

National Primary Health Care Development Agency

Nigerian Institute of Pharmaceutical Research and Development

Statistical Package for the Social Sciences

Traditional Complementary and Alternative Medicine

World Health Organisation

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Acknowledgements

The authors express gratitude to all the respondents and participants who participated in the study. The authors also acknowledge the support and contributions of all the academic staff in the Department of Health Promotion and Education including Professors O. Oladepo, A.J. Ajuwon, Oyedunni S. Arulogun and the late Dr. F. O. Oshiname. Doctors O.E. Oyewole, M Titiloye, I.O. Dipeolu, Adeyimika T. Desmennu and Mr. John Imaledo. The following individuals are appreciated for their immense support throughout the conduct of this study; Mrs. O.J. Onche, Abraham I. Onche, Mr. Adole Onche, Dr. F. Ogedegbe, Dr. D Igbinovia and the late Dr. G. Etudoh.

The research was funded in full by the authors.

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EJO conceptualised the study and conducted the interviews. EJO analysed the qualitative and quantitative data under supervision and wrote the draft manuscript. MMO provided leadership for the conduct of the study, supervised the design of the protocol and tools, quantitative and qualitative data collection and analysis. MMO and YOJ also critically reviewed the manuscript and performed extensive edits. All authors read and approved the final manuscript.

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The research ethics application for conducting this study was reviewed and approved by the Health Research Ethics Committee of the Federal Capital Territory Administrations board in Abuja, Nigeria. The reference number is FHREC/2020/01/03/04-02-20 and the research was conducted following the guidelines and regulations of the National Health Research Committee, Nigeria. All participants provided written informed consent to participate in the study.

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Onche, E.J., Oluwasanu, M.M. & John-Akinola, Y.O. Knowledge, perception, attitude, and practice of complementary and alternative medicine by health care workers in Garki hospital Abuja, Nigeria. BMC Complement Med Ther 24 , 177 (2024). https://doi.org/10.1186/s12906-024-04429-x

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Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

• Alexandra Norton 1 &
• Hannah Tappis 2  

Reproductive Health volume  21 , Article number:  64 ( 2024 ) Cite this article

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Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Plain English summary

Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

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Over the past few decades, the field of public health implementation research (IR) has grown as a means by which the real-world conditions affecting health improvement efforts can be better understood. Peters et al. put forward the following broad definition of IR for health: “IR is the scientific inquiry into questions concerning implementation – the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions)” [ 1 ].

As IR emphasizes real-world circumstances, the context within which a health intervention is delivered is a core consideration. However, much IR implemented to date has focused on higher-resource settings, with many proposed frameworks developed with particular utility for a higher-income setting [ 2 ]. In recognition of IR’s potential to increase evidence across a range of settings, there have been numerous reviews of the use of IR in lower-resource settings as well as calls for broader use [ 3 , 4 ]. There have also been more focused efforts to modify various approaches and frameworks to strengthen the relevance of IR to low- and middle-income country settings (LMICs), such as the work by Means et al. to adapt a specific IR framework for increased utility in LMICs [ 2 ].

Within LMIC settings, the centrality of context to a health intervention’s impact is of particular relevance in humanitarian settings, which present a set of distinct implementation challenges [ 5 ]. Humanitarian responses to crisis situations operate with limited resources, under potential security concerns, and often under pressure to relieve acute suffering and need [ 6 ]. Given these factors, successful implementation of a particular health intervention may require different qualities than those that optimize intervention impact under more stable circumstances [ 7 ]. Despite increasing recognition of the need for expanded evidence of health interventions in humanitarian settings, the evidence base remains limited [ 8 ]. Furthermore, despite its potential utility, there is not standardized guidance on IR in humanitarian settings, nor are there widely endorsed recommendations for the frameworks best suited to analyze implementation in these settings.

Sexual and reproductive health (SRH) is a core aspect of the health sector response in humanitarian settings [ 9 ]. Yet, progress in addressing SRH needs has lagged far behind other services because of challenges related to culture and ideology, financing constraints, lack of data and competing priorities [ 10 ]. The Minimum Initial Service Package (MISP) for SRH in Crisis Situations is the international standard for the minimum set of SRH services that should be implemented in all crisis situations [ 11 ]. However, as in other areas of health, there is need for expanded evidence for planning and implementation of SRH interventions in humanitarian settings. Recent systematic reviews of SRH in humanitarian settings have focused on the effectiveness of interventions and service delivery strategies, as well as factors affecting utilization, but have not detailed whether IR frameworks were used [ 12 , 13 , 14 , 15 ]. There have also been recent reviews examining IR frameworks used in various settings and research areas, but none have explicitly focused on humanitarian settings [ 2 , 16 ].

Given the need for an expanded evidence base for SRH interventions in humanitarian settings and the potential for IR to be used to expand the available evidence, a scoping review was undertaken. This scoping review sought to identify IR approaches that have been used in the last ten years to evaluate SRH interventions in humanitarian settings.

This review also sought to shed light on whether there is a need for a common framework to guide research design, analysis, and reporting for SRH interventions in humanitarian settings and if so, if there are any established frameworks already in use that would be fit-for-purpose or could be tailored to meet this need.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews was utilized to guide the elements of this review [ 17 ]. The review protocol was retrospectively registered with the Open Science Framework ( https://osf.io/b5qtz ).

Search strategy

A two-fold search strategy was undertaken for this review, which covered the last 10 years (2013–2022). First, recent systematic reviews pertaining to research or evaluation of SRH interventions in humanitarian settings were identified through keyword searches on PubMed and Google Scholar. Four relevant systematic reviews were identified [ 12 , 13 , 14 , 15 ] Table 1 .

Second, a literature search mirroring these reviews was conducted to identify relevant papers published since the completion of searches for the most recent review (April 2017). Additional file 1 includes the search terms that were used in the literature search [see Additional file 1 ].

The literature search was conducted for papers published from April 2017 to December 2022 in the databases that were searched in one or more of the systematic reviews: PubMed, Embase, PsycInfo, CINAHL and Global Health. Searches were completed in January 2023 Table 2 .

Two reviewers screened each identified study for alignment with inclusion criteria. Studies in the four systematic reviews identified were considered potentially eligible if published during the last 10 years. These papers then underwent full-text review to confirm satisfaction of all inclusion criteria, as inclusion criteria were similar but not fully aligned across the four reviews.

Literature search results were exported into a citation manager (Covidence), duplicates were removed, and a step-wise screening process for inclusion was applied. First, all papers underwent title and abstract screening. The remaining papers after abstract screening then underwent full-text review to confirm satisfaction of all inclusion criteria. Title and abstract screening as well as full-text review was conducted independently by both authors; disagreements after full-text review were resolved by consensus.

Data extraction and synthesis

The following content areas were summarized in Microsoft Excel for each paper that met inclusion criteria: publication details including author, year, country, setting [rural, urban, camp, settlement], population [refugees, internally displaced persons, general crisis-affected], crisis type [armed conflict, natural disaster], crisis stage [acute, chronic], study design, research methods, SRH intervention, and intervention target population [specific beneficiaries of the intervention within the broader population]; the use of an IR framework; details regarding the IR framework, how it was used, and any rationale given for the framework used; factors cited as impacting SRH interventions, either positively or negatively; and other key findings deemed relevant to this review.

As the focus of this review was on the approach taken for SRH intervention research and evaluation, the quality of the studies themselves was not assessed.

Twenty papers underwent full-text review due to their inclusion in one or more of the four systematic reviews and meeting publication date inclusion criteria. The literature search identified 7,016 unique papers. After full-text screening, 69 met all inclusion criteria and were included in the review. Figure  1 illustrates the search strategy and screening process.

Flow chart of paper identification

Papers published in each of the 10 years of the review timeframe (2013–2022) were included. 29% of the papers originated from the first five years of the time frame considered for this review, with the remaining 71% papers coming from the second half. Characteristics of included publications, including geographic location, type of humanitarian crisis, and type of SRH intervention, are presented in Table  3 .

A wide range of study designs and methods were used across the papers, with both qualitative and quantitative studies well represented. Twenty-six papers were quantitative evaluations [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], 17 were qualitative [ 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ], and 26 used mixed methods [ 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ]. Within the quantitative evaluations, 15 were observational, while five were quasi-experimental, five were randomized controlled trials, and one was an economic evaluation. Study designs as classified by the authors of this review are summarized in Table  4 .

Six papers (9%) explicitly cited use of an IR framework. Three of these papers utilized the Consolidated Framework for Implementation Research (CFIR) [ 51 , 65 , 70 ]. The CFIR is a commonly used determinant framework that—in its originally proposed form in 2009—is comprised of five domains, each of which has constructs to further categorize factors that impact implementation. The CFIR domains were identified as core content areas influencing the effectiveness of implementation, and the constructs within each domain are intended to provide a range of options for researchers to select from to “guide diagnostic assessments of implementation context, evaluate implementation progress, and help explain findings.” [ 87 ] To allow for consistent terminology throughout this review, the original 2009 CFIR domains and constructs are used.

Guan et al. conducted a mixed methods study to assess the feasibility and effectiveness of a neonatal hepatitis B immunization program in a conflict-affected rural region of Myanmar. Guan et al. report mapping data onto the CFIR as a secondary analysis step. They describe that “CFIR was used as a comprehensive meta-theoretical framework to examine the implementation of the Hepatitis B Virus vaccination program,” and implementation themes from multiple study data sources (interviews, observations, examination of monitoring materials) were mapped onto CFIR constructs. They report their results in two phases – Pre-implementation training and community education, and Implementation – with both anchored in themes that they had mapped onto CFIR domains and constructs. All but six constructs were included in their analysis, with a majority summarized in a table and key themes explored further in the narrative text. They specify that most concerns were identified within the Outer Setting and Process domains, while elements identified within the Inner Setting domain provided strength to the intervention and helped mitigate against barriers [ 70 ].

Sarker et al. conducted a qualitative study to assess provision of maternal, newborn and child health services to Rohingya refugees residing in camps in Cox’s Bazar, Bangladesh. They cite using CFIR as a guide for thematic analysis, applying it after a process of inductive and deductive coding to index these codes into the CFIR domains. They utilized three of the five CFIR domains (Outer Setting, Inner Setting, and Process), stating that the remaining two domains (Intervention Characteristics and Characteristics of Individuals) were not relevant to their analysis. They then proposed two additional CFIR domains, Context and Security, for use in humanitarian contexts. In contrast to Guan et al., CFIR constructs are not used nor mentioned by Sarker et al., with content under each domain instead synthesized as challenges and potential solutions. Regarding the CFIR, Sarker et al. write, “The CFIR guided us for interpretative coding and creating the challenges and possible solutions into groups for further clarification of the issues related to program delivery in a humanitarian crisis setting.” [ 51 ]

Sami et al. conducted a mixed methods case study to assess the implementation of a package of neonatal interventions at health facilities within refugee and internally displaced persons camps in South Sudan. They reference use of the CFIR earlier in the study than Sarker et al., basing their guides for semi-structured focus group discussions on the CFIR framework. They similarly reference a general use of the CFIR framework as they conducted thematic analysis. Constructs are referenced once, but they do not specify whether their application of the CFIR framework included use of domains, constructs, or both. This may be in part because they then applied an additional framework, the World Health Organization (WHO) Health System Framework, to present their findings. They describe a nested approach to their use of these frameworks: “Exploring these [CFIR] constructs within the WHO Health Systems Framework can identify specific entry points to improve the implementation of newborn interventions at critical health system building blocks.” [ 65 ]

Three papers cite use of different IR frameworks. Bolan et al. utilized the Theoretical Domains Framework in their mixed methods feasibility study and pilot cluster randomized trial evaluating pilot use of the Safe Delivery App by maternal and newborn health workers providing basic emergency obstetric and newborn care in facilities in the conflict-affected Maniema province of the Democratic Republic of the Congo (DRC). They used the Theroetical Domains Framework in designing interview questions, and further used it as the coding framework for their analysis. Similar to the CFIR, the Theoretical Domains Framework is a determinant framework that consists of domains, each of which then includes constructs. Bolan et al. utilized the Theoretical Domains Framework at the construct level in interview question development and at the domain level in their analysis, mapping interview responses to eight of the 14 domains [ 83 ]. Berg et al. report using an “exploratory design guided by the principles of an evaluation framework” developed by the Medical Research Council to analyze the implementation process, mechanisms of impact, and outcomes of a three-pillar training intervention to improve maternal and neonatal healthcare in the conflict-affected South Kivu province of the DRC [ 67 , 88 ]. Select components of this evaluation framework were used to guide deductive analysis of focus group discussions and in-depth interviews [ 67 ]. In their study of health workers’ knowledge and attitudes toward newborn health interventions in South Sudan, before and after training and supply provision, Sami et al. report use of the Conceptual Framework of the Role of Attitudes in Evidence-Based Practice Implementation in their analysis process. The framework was used to group codes following initial inductive coding analysis of in-depth interviews [ 72 ].

Three other papers cite use of specific frameworks in their intervention evaluation [ 19 , 44 , 76 ]. As a characteristic of IR is the use of an explicit framework to guide the research, the use of the frameworks in these three papers meets the intention of IR and serves the purpose that an IR framework would have in strengthening the analytical rigor. Castle et al. cite use of their program’s theory of change as a framework for a mixed methods evaluation of the provision of family planning services and more specifically uptake of long-acting reversible contraception use in the DRC. They describe use of the theory of change to “enhance effectiveness of [long-acting reversible contraception] access and uptake.” [ 76 ] Thommesen et al. cite use of the AAAQ (Availability, Accessibility, Acceptability and Quality) framework in their qualitative study assessing midwifery services provided to pregnant women in Afghanistan. This framework is focused on the “underlying elements needed for attainment of optimum standard of health care,” but the authors used it in this paper to evaluate facilitators and barriers to women accessing midwifery services [ 44 ]. Jarrett et al. cite use of the Centers for Disease Control and Prevention’s (CDC) Guidelines for Evaluating Public Health Surveillance Systems to explore the characteristics of a population mobility, mortality and birth surveillance system in South Kivu, DRC. Use of these CDC guidelines is cited as one of four study objectives, and commentary is included in the Results section pertaining to each criteria within these guidelines, although more detail regarding use of these guidelines or the authors’ experience with their use in the study is not provided [ 19 ].

Overall, 22 of the 69 papers either explicitly or implicitly identified IR as relevant to their work. Nineteen papers include a focus on feasibility (seven of which did not otherwise identify the importance of exploring questions concerning implementation), touching on a common outcome of interest in implementation research [ 89 ].

While a majority of papers did not explicitly or implicitly use an IR framework to evaluate their SRH intervention of focus, most identified factors that facilitated implementation when they were present or served as a barrier when absent. Sixty cite factors that served as facilitators and 49 cite factors that served as barriers, with just three not citing either. Fifty-nine distinct factors were identified across the papers.

Three of the six studies that explicitly used an IR framework used the CFIR, and the CFIR is the only IR framework that was used by multiple studies. As previously mentioned, Means et al. put forth an adaptation of the CFIR to increase its relevance in LMIC settings, proposing a sixth domain (Characteristics of Systems) and 11 additional constructs [ 2 ]. Using the expanded domains and constructs as proposed by Means et al., the 59 factors cited by papers in this review were thematically grouped into the six domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process. Within each domain, alignment with CFIR constructs was assessed for, and alignment was found with 29 constructs: eight of Means et al.’s 11 constructs, and 21 of the 39 standard CFIR constructs. Three factors did not align with any construct (all fitting within the Outer Setting domain), and 14 aligned with a construct label but not the associated definition. Table 5 synthesizes the mapping of factors affecting SRH intervention implementation to CFIR domains and constructs, with the construct appearing in italics if it is considered to align with that factor by label but not by definition.

Table 6 lists the CFIR constructs that were not found to have alignment with any factor cited by the papers in this review.

This scoping review sought to assess how IR frameworks have been used to bolster the evidence base for SRH interventions in humanitarian settings, and it revealed that IR frameworks, or an explicit IR approach, are rarely used. All four of the systematic reviews identified with a focus on SRH in humanitarian settings articulate the need for more research examining the effectiveness of SRH interventions in humanitarian settings, with two specifically citing a need for implementation research/science [ 12 , 13 ]. The distribution of papers across the timeframe included in this review does suggest that more research on SRH interventions for crisis-affected populations is taking place, as a majority of relevant papers were published in the second half of the review period. The papers included a wide range of methodologies, which reflect the differing research questions and contexts being evaluated. However, it also invites the question of whether there should be more standardization of outcomes measured or frameworks used to guide analysis and to facilitate increased comparison, synthesis and application across settings.

Three of the six papers that used an IR framework utilized the CFIR. Guan et al. used the CFIR at both a domain and construct level, Sarker et al. used the CFIR at the domain level, and Sami et al. did not specify which CFIR elements were used in informing the focus group discussion guide [ 51 , 65 , 70 ]. It is challenging to draw strong conclusions about the applicability of CFIR in humanitarian settings based on the minimal use of CFIR and IR frameworks within the papers reviewed, although Guan et al. provides a helpful model for how analysis can be structured around CFIR domains and constructs. It is worth considering that the minimal use of IR frameworks, and more specifically CFIR constructs, could be in part because that level of prescriptive categorization does not allow for enough fluidity in humanitarian settings. It also raises questions about the appropriate degree of standardization to pursue for research done in these settings.

The mapping of factors affecting SRH intervention implementation provides an example of how a modified CFIR framework could be used for IR in humanitarian contexts. This mapping exercise found factors that mapped to all five of the original CFIR domains as well as the sixth domain proposed by Means et al. All factors fit well within the definition for the selected domain, indicating an appropriate degree of fit between these existing domains and the factors identified as impacting SRH interventions in humanitarian settings. On a construct level, however, the findings were more variable, with one-quarter of factors not fully aligning with any construct. Furthermore, over 40% of the CFIR constructs (including the additional constructs from Means et al.) were not found to align with any factors cited by the papers in this review, also demonstrating some disconnect between the parameters posed by the CFIR constructs and the factors cited as relevant in a humanitarian context.

It is worth noting that while the CFIR as proposed in 2009 was used in this assessment, as well as in the included papers which used the CFIR, an update was published in 2022. Following a review of CFIR use since its publication, the authors provide updates to construct names and definitions to “make the framework more applicable across a range of innovations and settings.” New constructs and subconstructs were also added, for a total of 48 constructs and 19 subconstructs across the five domains [ 90 ]. A CFIR Outcomes Addendum was also published in 2022, based on recommendations for the CFIR to add outcomes and intended to be used as a complement to the CFIR determinants framework [ 91 ]. These expansions to the CFIR framework may improve applicability of the CFIR in humanitarian settings. Several constructs added to the Outer Setting domain could be of particular utility – critical incidents, local attitudes, and local conditions, each of which could help account for unique challenges faced in contexts of crisis. Sub-constructs added within the Inner Setting domain that seek to clarify structural characteristics and available resources would also be of high utility based on mapping of the factors identified in this review to the original CFIR constructs. As outcomes were not formally included in the CFIR until the 2022 addendum, a separate assessment of implementation outcomes was not undertaken in this review. However, analysis of the factors cited by papers in this review as affecting implementation was derived from the full text of the papers and thus captures content relevant to implementation determinants that is contained within the outcomes.

Given the demonstrated need for additional flexibility within an IR framework for humanitarian contexts, while not a focus of this review, it is worth considering whether a different framework could provide a better fit than the CFIR. Other frameworks have differing points of emphasis that would create different opportunities for flexibility but that do not seem to resolve the challenges experienced in applying the CFIR to a humanitarian context. As one example, the EPIS (Exploration, Preparation, Implementation, Sustainment) Framework considers the impact of inner and outer context on each of four implementation phases; while the constructs within this framework are broader than the CFIR, an emphasis on the intervention characteristics is missing, a domain where stronger alignment within the CFIR is also needed [ 92 ]. Alternatively, the PRISM (Practical, Robust Implementation and Sustainability Model) framework is a determinant and evaluation framework that adds consideration of context factors to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes framework. It has a stronger emphasis on intervention aspects, with sub-domains to account for both organization and patient perspectives within the intervention. While PRISM does include aspects of context, external environment considerations are less robust and intentionally less comprehensive in scope, which would not provide the degree of alignment possible between the Characteristics of Systems and Outer Setting CFIR domains for the considerations unique to humanitarian environments [ 93 ].

Reflecting on their experience with the CFIR, Sarker et al. indicate that it can be a “great asset” in both evaluating current work and developing future interventions. They also encourage future research of humanitarian health interventions to utilize the CFIR [ 51 ]. The other papers that used the CFIR do not specifically reflect on their experience utilizing it, referring more generally to having felt that it was a useful tool [ 65 , 70 ]. On their use of an evaluation framework, Berg et al. reflected that it lent useful structure and helped to identify aspects affecting implementation that otherwise would have gone un-noticed [ 67 ]. The remaining studies that utilized an IR framework did not specifically comment on their experience with its use [ 72 , 83 ]. While a formal IR framework was not engaged by other studies, a number cite a desire for IR to contribute further detail to their findings [ 21 , 37 ].

In their recommendations for strengthening the evidence base for humanitarian health interventions, Ager et al. speak to the need for “methodologic innovation” to develop methodologies with particular applicability in humanitarian settings [ 7 ]. As IR is not yet routinized for SRH interventions, this could be opportune timing for the use of a standardized IR framework to gauge its utility. Using an IR framework to assess factors influencing implementation of the MISP in initial stages of a humanitarian response, and interventions to support more comprehensive SRH service delivery in protracted crises, could lend further rigor and standardization to SRH evaluations, as well as inform strategies to improve MISP implementation over time. Based on categorizing factors identified by these papers as relevant for intervention evaluation, there does seem to be utility to a modified CFIR approach. Given the paucity of formal IR framework use within SRH literature, it would be worth conducting similar scoping exercises to assess for explicit use of IR frameworks within the evidence base for other health service delivery areas in humanitarian settings. In the interim, the recommended approach from this review for future IR on humanitarian health interventions would be a modified CFIR approach with domain-level standardization and flexibility for constructs that may standardize over time with more use. This would enable use of a common analytical framework and vocabulary at the domain level for stakeholders to describe interventions and the factors influencing the effectiveness of implementation, with constructs available to use and customize as most appropriate for specific contexts and interventions.

This review had a number of limitations. As this was a scoping review and a two-part search strategy was used, the papers summarized here may not be comprehensive of those written pertaining to SRH interventions over the past 10 years. Papers from 2013 to 2017 that would have met this scoping review’s inclusion criteria may have been omitted due to being excluded from the systematic reviews. The review was limited to papers available in English. Furthermore, this review did not assess the quality of the papers included or seek to assess the methodology used beyond examination of the use of an IR framework. It does, however, serve as a first step in assessing the extent to which calls for implementation research have been addressed, and identify entry points for strengthening the science and practice of SRH research in humanitarian settings.

With one in 23 people worldwide in need of humanitarian assistance, and financing required for response plans at an all-time high, the need for evidence to guide resource allocation and programming for SRH in humanitarian settings is as important as ever [ 94 ]. Recent research agenda setting initiatives and strategies to advance health in humanitarian settings call for increased investment in implementation research—with priorities ranging from research on effective strategies for expanding access to a full range of contraceptive options to integrating mental health and psychosocial support into SRH programming to capturing accurate and actionable data on maternal and perinatal mortality in a wide range of acute and protracted emergency contexts [ 95 , 96 ]. To truly advance guidance in these areas, implementation research will need to be conducted across diverse humanitarian settings, with clear and consistent documentation of both intervention characteristics and outcomes, as well as contextual and programmatic factors affecting implementation.

Conclusions

Implementation research has potential to increase impact of health interventions particularly in crisis-affected settings where flexibility, adaptability and context-responsive approaches are highlighted as cornerstones of effective programming. There remains significant opportunity for standardization of research in the humanitarian space, with one such opportunity occurring through increased utilization of IR frameworks such as a modified CFIR approach. Investing in more robust sexual and reproductive health research in humanitarian contexts can enrich insights available to guide programming and increase transferability of learning across settings.

Availability of data and materials

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

Abbreviations

Availability, Accessibility, Acceptability and Quality

Centers for Disease Control and Prevention

Consolidated Framework for Implementation Research

Democratic Republic of the Congo

Exploration, Preparation, Implementation, Sustainment

• Implementation research

Low and middle income country

Minimum Initial Service Package

Practical, Robust Implementation and Sustainability Model

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Reach, Effectiveness, Adoption, Implementation, Maintenance

• Sexual and reproductive health

World Health Organization

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• NATURE INDEX
• 01 May 2024

Plagiarism in peer-review reports could be the ‘tip of the iceberg’

• Jackson Ryan 0

Jackson Ryan is a freelance science journalist in Sydney, Australia.

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Time pressures and a lack of confidence could be prompting reviewers to plagiarize text in their reports. Credit: Thomas Reimer/Zoonar via Alamy

Mikołaj Piniewski is a researcher to whom PhD students and collaborators turn when they need to revise or refine a manuscript. The hydrologist, at the Warsaw University of Life Sciences, has a keen eye for problems in text — a skill that came in handy last year when he encountered some suspicious writing in peer-review reports of his own paper.

Last May, when Piniewski was reading the peer-review feedback that he and his co-authors had received for a manuscript they’d submitted to an environmental-science journal, alarm bells started ringing in his head. Comments by two of the three reviewers were vague and lacked substance, so Piniewski decided to run a Google search, looking at specific phrases and quotes the reviewers had used.

To his surprise, he found the comments were identical to those that were already available on the Internet, in multiple open-access review reports from publishers such as MDPI and PLOS. “I was speechless,” says Piniewski. The revelation caused him to go back to another manuscript that he had submitted a few months earlier, and dig out the peer-review reports he received for that. He found more plagiarized text. After e-mailing several collaborators, he assembled a team to dig deeper.

Meet this super-spotter of duplicated images in science papers

The team published the results of its investigation in Scientometrics in February 1 , examining dozens of cases of apparent plagiarism in peer-review reports, identifying the use of identical phrases across reports prepared for 19 journals. The team discovered exact quotes duplicated across 50 publications, saying that the findings are just “the tip of the iceberg” when it comes to misconduct in the peer-review system.

Dorothy Bishop, a former neuroscientist at the University of Oxford, UK, who has turned her attention to investigating research misconduct, was “favourably impressed” by the team’s analysis. “I felt the way they approached it was quite useful and might be a guide for other people trying to pin this stuff down,” she says.

Peer review under review

Piniewski and his colleagues conducted three analyses. First, they uploaded five peer-review reports from the two manuscripts that his laboratory had submitted to a rudimentary online plagiarism-detection tool . The reports had 44–100% similarity to previously published online content. Links were provided to the sources in which duplications were found.

The researchers drilled down further. They broke one of the suspicious peer-review reports down to fragments of one to three sentences each and searched for them on Google. In seconds, the search engine returned a number of hits: the exact phrases appeared in 22 open peer-review reports, published between 2021 and 2023.

The final analysis provided the most worrying results. They took a single quote — 43 words long and featuring multiple language errors, including incorrect capitalization — and pasted it into Google. The search revealed that the quote, or variants of it, had been used in 50 peer-review reports.

Predominantly, these reports were from journals published by MDPI, PLOS and Elsevier, and the team found that the amount of duplication increased year-on-year between 2021 and 2023. Whether this is because of an increase in the number of open-access peer-review reports during this time or an indication of a growing problem is unclear — but Piniewski thinks that it could be a little bit of both.

Why would a peer reviewer use plagiarized text in their report? The team says that some might be attempting to save time , whereas others could be motivated by a lack of confidence in their writing ability, for example, if they aren’t fluent in English.

The team notes that there are instances that might not represent misconduct. “A tolerable rephrasing of your own words from a different review? I think that’s fine,” says Piniewski. “But I imagine that most of these cases we found are actually something else.”

The source of the problem

Duplication and manipulation of peer-review reports is not a new phenomenon. “I think it’s now increasingly recognized that the manipulation of the peer-review process, which was recognized around 2010, was probably an indication of paper mills operating at that point,” says Jennifer Byrne, director of biobanking at New South Wales Health in Sydney, Australia, who also studies research integrity in scientific literature.

Paper mills — organizations that churn out fake research papers and sell authorships to turn a profit — have been known to tamper with reviews to push manuscripts through to publication, says Byrne.

The fight against fake-paper factories that churn out sham science

However, when Bishop looked at Piniewski’s case, she could not find any overt evidence of paper-mill activity. Rather, she suspects that journal editors might be involved in cases of peer-review-report duplication and suggests studying the track records of those who’ve allowed inadequate or plagiarized reports to proliferate.

Piniewski’s team is also concerned about the rise of duplications as generative artificial intelligence (AI) becomes easier to access . Although his team didn’t look for signs of AI use, its ability to quickly ingest and rephrase large swathes of text is seen as an emerging issue.

A preprint posted in March 2 showed evidence of researchers using AI chatbots to assist with peer review, identifying specific adjectives that could be hallmarks of AI-written text in peer-review reports .

Bishop isn’t as concerned as Piniewski about AI-generated reports, saying that it’s easy to distinguish between AI-generated text and legitimate reviewer commentary. “The beautiful thing about peer review,” she says, is that it is “one thing you couldn’t do a credible job with AI”.

Preventing plagiarism

Publishers seem to be taking action. Bethany Baker, a media-relations manager at PLOS, who is based in Cambridge, UK, told Nature Index that the PLOS Publication Ethics team “is investigating the concerns raised in the Scientometrics article about potential plagiarism in peer reviews”.

How big is science’s fake-paper problem?

An Elsevier representative told Nature Index that the publisher “can confirm that this matter has been brought to our attention and we are conducting an investigation”.

In a statement, the MDPI Research Integrity and Publication Ethics Team said that it has been made aware of potential misconduct by reviewers in its journals and is “actively addressing and investigating this issue”. It did not confirm whether this was related to the Scientometrics article.

One proposed solution to the problem is ensuring that all submitted reviews are checked using plagiarism-detection software. In 2022, exploratory work by Adam Day, a data scientist at Sage Publications, based in Thousand Oaks, California, identified duplicated text in peer-review reports that might be suggestive of paper-mill activity. Day offered a similar solution of using anti-plagiarism software , such as Turnitin.

Piniewski expects the problem to get worse in the coming years, but he hasn’t received any unusual peer-review reports since those that originally sparked his research. Still, he says that he’s now even more vigilant. “If something unusual occurs, I will spot it.”

doi: https://doi.org/10.1038/d41586-024-01312-0

Piniewski, M., Jarić, I., Koutsoyiannis, D. & Kundzewicz, Z. W. Scientometrics https://doi.org/10.1007/s11192-024-04960-1 (2024).

Article   Google Scholar  

Liang, W. et al. Preprint at arXiv https://doi.org/10.48550/arXiv.2403.07183 (2024).

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Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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Qualitative study.

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• Introduction

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. [1] 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’. [2] 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. [2] One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. [3] 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. [4] 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. [2] 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. [2] 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.” [5] 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. [3] [2] 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”. [5] 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. [2] 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. [2] 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”. [2]

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. [4] 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. [2] 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. [4] 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. [4] 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. [4] 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”. [6] 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.” [4]

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. [2] 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: [7]

• 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. [8] [9] [10]

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. [11] 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. [12] The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research. [13]

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. [14] [15]

Qualitative research functions as a standalone research design or in combination with quantitative research to enhance our understanding of the world. Qualitative research uses techniques including structured and unstructured interviews, focus groups, and participant observation to not only help generate hypotheses which can be more rigorously tested with quantitative research but also to help researchers delve deeper into the quantitative research numbers, understand what they mean, and understand what the implications are.  Qualitative research provides researchers with a way to understand what is going on, especially when things are not easily categorized. [16]

• Issues of Concern

As discussed in the sections above, quantitative and qualitative work differ in many different ways, including the criteria for evaluating them. There are four well-established criteria for evaluating quantitative data: internal validity, external validity, reliability, and objectivity. The correlating concepts in qualitative research are credibility, transferability, dependability, and confirmability. [4] [11] The corresponding quantitative and qualitative concepts can be seen below, with the quantitative concept is on the left, and the qualitative concept is on the right:

• Internal validity--- Credibility
• External validity---Transferability
• Reliability---Dependability
• Objectivity---Confirmability

In conducting qualitative research, ensuring these concepts are satisfied and well thought out can mitigate potential issues from arising. For example, just as a researcher will ensure that their quantitative study is internally valid so should qualitative researchers ensure that their work has credibility.  

Indicators such as triangulation and peer examination can help evaluate the credibility of qualitative work.

• Triangulation: Triangulation involves using multiple methods of data collection to increase the likelihood of getting a reliable and accurate result. In our above magic example, the result would be more reliable by also interviewing the magician, back-stage hand, and the person who "vanished." In qualitative research, triangulation can include using telephone surveys, in-person surveys, focus groups, and interviews as well as surveying an adequate cross-section of the target demographic.
• Peer examination: Results can be reviewed by a peer to ensure the data is consistent with the findings.

‘Thick’ or ‘rich’ description can be used to evaluate the transferability of qualitative research whereas using an indicator such as an audit trail might help with evaluating the dependability and confirmability.

• Thick or rich description is a detailed and thorough description of details, the setting, and quotes from participants in the research. [5] Thick descriptions will include a detailed explanation of how the study was carried out. Thick descriptions are detailed enough to allow readers to draw conclusions and interpret the data themselves, which can help with transferability and replicability.
• Audit trail: An audit trail provides a documented set of steps of how the participants were selected and the data was collected. The original records of information should also be kept (e.g., surveys, notes, recordings).

One issue of concern that qualitative researchers should take into consideration is observation bias. Here are a few examples:

• Hawthorne effect: The Hawthorne effect is the change in participant behavior when they know they are being observed. If a researcher was wanting to identify factors that contribute to employee theft and tells the employees they are going to watch them to see what factors affect employee theft, one would suspect employee behavior would change when they know they are being watched.
• Observer-expectancy effect: Some participants change their behavior or responses to satisfy the researcher's desired effect. This happens in an unconscious manner for the participant so it is important to eliminate or limit transmitting the researcher's views.
• Artificial scenario effect: Some qualitative research occurs in artificial scenarios and/or with preset goals. In such situations, the information may not be accurate because of the artificial nature of the scenario. The preset goals may limit the qualitative information obtained.
• Clinical Significance

Qualitative research by itself or combined with quantitative research helps healthcare providers understand patients and the impact and challenges of the care they deliver. Qualitative research provides an opportunity to generate and refine hypotheses and delve deeper into the data generated by quantitative research. Qualitative research does not exist as an island apart from quantitative research, but as an integral part of research methods to be used for the understanding of the world around us. [17]

• Enhancing Healthcare Team Outcomes

Qualitative research is important for all members of the health care team as all are affected by qualitative research. Qualitative research may help develop a theory or a model for health research that can be further explored by quantitative research.  Much of the qualitative research data acquisition is completed by numerous team members including social works, scientists, nurses, etc.  Within each area of the medical field, there is copious ongoing qualitative research including physician-patient interactions, nursing-patient interactions, patient-environment interactions, health care team function, patient information delivery, etc. 

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Disclosure: Janelle Brannan declares no relevant financial relationships with ineligible companies.

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