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What is survey research.
15 min read Find out everything you need to know about survey research, from what it is and how it works to the different methods and tools you can use to ensure you’re successful.
Survey research is the process of collecting data from a predefined group (e.g. customers or potential customers) with the ultimate goal of uncovering insights about your products, services, or brand overall .
As a quantitative data collection method, survey research can provide you with a goldmine of information that can inform crucial business and product decisions. But survey research needs careful planning and execution to get the results you want.
So if you’re thinking about using surveys to carry out research, read on.
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Calling these methods ‘survey research’ slightly underplays the complexity of this type of information gathering. From the expertise required to carry out each activity to the analysis of the data and its eventual application, a considerable amount of effort is required.
As for how you can carry out your research, there are several options to choose from — face-to-face interviews, telephone surveys, focus groups (though more interviews than surveys), online surveys, and panel surveys.
Typically, the survey method you choose will largely be guided by who you want to survey, the size of your sample , your budget, and the type of information you’re hoping to gather.
Here are a few of the most-used survey types:
Before technology made it possible to conduct research using online surveys, telephone, and mail were the most popular methods for survey research. However face-to-face interviews were considered the gold standard — the only reason they weren’t as popular was due to their highly prohibitive costs.
When it came to face-to-face interviews, organisations would use highly trained researchers who knew when to probe or follow up on vague or problematic answers. They also knew when to offer assistance to respondents when they seemed to be struggling. The result was that these interviewers could get sample members to participate and engage in surveys in the most effective way possible, leading to higher response rates and better quality data.
While phone surveys have been popular in the past, particularly for measuring general consumer behaviour or beliefs, response rates have been declining since the 1990s .
Phone surveys are usually conducted using a random dialling system and software that a researcher can use to record responses.
This method is beneficial when you want to survey a large population but don’t have the resources to conduct face-to-face research surveys or run focus groups, or want to ask multiple-choice and open-ended questions .
The downsides are they can: take a long time to complete depending on the response rate, and you may have to do a lot of cold-calling to get the information you need.
You also run the risk of respondents not being completely honest . Instead, they’ll answer your survey questions quickly just to get off the phone.
Focus groups are a separate qualitative methodology rather than surveys — even though they’re often bunched together. They’re normally used for survey pretesting and designing , but they’re also a great way to generate opinions and data from a diverse range of people.
Focus groups involve putting a cohort of demographically or socially diverse people in a room with a moderator and engaging them in a discussion on a particular topic, such as your product, brand, or service.
They remain a highly popular method for market research , but they’re expensive and require a lot of administration to conduct and analyse the data properly.
You also run the risk of more dominant members of the group taking over the discussion and swaying the opinions of other people — potentially providing you with unreliable data.
Online surveys have become one of the most popular survey methods due to being cost-effective, enabling researchers to accurately survey a large population quickly.
Online surveys can essentially be used by anyone for any research purpose – we’ve all seen the increasing popularity of polls on social media (although these are not scientific).
Using an online survey allows you to ask a series of different question types and collect data instantly that’s easy to analyse with the right software.
There are also several methods for running and distributing online surveys that allow you to get your questionnaire in front of a large population at a fraction of the cost of face-to-face interviews or focus groups.
This is particularly true when it comes to mobile surveys as most people with a smartphone can access them online.
However, you have to be aware of the potential dangers of using online surveys, particularly when it comes to the survey respondents. The biggest risk is because online surveys require access to a computer or mobile device to complete, they could exclude elderly members of the population who don’t have access to the technology — or don’t know how to use it.
It could also exclude those from poorer socio-economic backgrounds who can’t afford a computer or consistent internet access. This could mean the data collected is more biased towards a certain group and can lead to less accurate data when you’re looking for a representative population sample.
When it comes to surveys, every voice matters.
A panel survey involves recruiting respondents who have specifically signed up to answer questionnaires and who are put on a list by a research company. This could be a workforce of a small company or a major subset of a national population. Usually, these groups are carefully selected so that they represent a sample of your target population — giving you balance across criteria such as age, gender, background, and so on.
Panel surveys give you access to the respondents you need and are usually provided by the research company in question. As a result, it’s much easier to get access to the right audiences as you just need to tell the research company your criteria. They’ll then determine the right panels to use to answer your questionnaire.
However, there are downsides. The main one being that if the research company offers its panels incentives, e.g. discounts, coupons, money — respondents may answer a lot of questionnaires just for the benefits.
This might mean they rush through your survey without providing considered and truthful answers. As a consequence, this can damage the credibility of your data and potentially ruin your analyses.
Depending on the research method you use, there are lots of benefits to conducting survey research for data collection. Here, we cover a few:
Most research surveys are easy to set up, administer and analyse. As long as the planning and survey design is thorough and you target the right audience , the data collection is usually straightforward regardless of which survey type you use.
Survey research can be relatively cheap depending on the type of survey you use.
Generally, qualitative research methods that require access to people in person or over the phone are more expensive and require more administration.
Online surveys or mobile surveys are often more cost-effective for market research and can give you access to the global population for a fraction of the cost.
Again, depending on the type of survey, you can obtain survey results from an entire population at a relatively low price. You can also administer a large variety of survey types to fit the project you’re running.
Using survey software, you can use advanced statistical analysis techniques to gain insights into your responses immediately.
Analysis can be conducted using a variety of parameters to determine the validity and reliability of your survey data at scale.
While most people view surveys as a quantitative research method, they can just as easily be adapted to gain qualitative information by simply including open-ended questions or conducting interviews face to face.
While surveys are a great way to obtain data, that data on its own is useless unless it can be analysed and developed into actionable insights.
The easiest, and most effective way to measure survey results, is to use a dedicated research tool that puts all of your survey results into one place.
When it comes to survey measurement, there are four measurement types to be aware of that will determine how you treat your different survey results:
With a nominal scale , you can only keep track of how many respondents chose each option from a question, and which response generated the most selections.
An example of this would be simply asking a responder to choose a product or brand from a list.
You could find out which brand was chosen the most but have no insight as to why.
Ordinal scales are used to judge an order of preference. They do provide some level of quantitative value because you’re asking responders to choose a preference of one option over another.
Ratio scales can be used to judge the order and difference between responses. For example, asking respondents how much they spend on their weekly shopping on average.
In an interval scale, values are lined up in order with a meaningful difference between the two values — for example, measuring temperature or measuring a credit score between one value and another.
Conducting a survey and collecting data is relatively straightforward, but it does require some careful planning and design to ensure it results in reliable data.
What do you want to learn from the survey? How is the data going to help you? Having a hypothesis or series of assumptions about survey responses will allow you to create the right questions to test them.
Once you’ve got your hypotheses or assumptions, write out the questions you need answering to test your theories or beliefs. Be wary about framing questions that could lead respondents or inadvertently create biased responses .
Your survey should include a variety of question types and should aim to obtain quantitative data with some qualitative responses from open-ended questions. Using a mix of questions (simple Yes/ No, multiple-choice, rank in order, etc) not only increases the reliability of your data but also reduces survey fatigue and respondents simply answering questions quickly without thinking.
Before sending your questionnaire out, you should test it (e.g. have a random internal group do the survey) and carry out A/B tests to ensure you’ll gain accurate responses.
Depending on your objectives, you might want to target the general population with your survey or a specific segment of the population. Once you’ve narrowed down who you want to target, it’s time to send out the survey.
After you’ve deployed the survey, keep an eye on the response rate to ensure you’re getting the number you expected. If your response rate is low, you might need to send the survey out to a second group to obtain a large enough sample — or do some troubleshooting to work out why your response rates are so low. This could be down to your questions, delivery method, selected sample, or otherwise.
Once you’ve got your results back, it’s time for the fun part.
Break down your survey responses using the parameters you’ve set in your objectives and analyse the data to compare to your original assumptions. At this stage, a research tool or software can make the analysis a lot easier — and that’s somewhere Qualtrics can help.
Gaining feedback from customers and leads is critical for any business, data gathered from surveys can prove invaluable for understanding your products and your market position, and with survey software from Qualtrics , it couldn’t be easier.
Used by more than 13,000 brands and supporting more than 1 billion surveys a year, Qualtrics empowers everyone in your organisation to gather insights and take action. No coding required — and your data is housed in one system.
Get feedback from more than 125 sources on a single platform and view and measure your data in one place to create actionable insights and gain a deeper understanding of your target customers.
Automatically run complex text and statistical analysis to uncover exactly what your survey data is telling you, so you can react in real-time and make smarter decisions.
We can help you with survey management, too. From designing your survey and finding your target respondents to getting your survey in the field and reporting back on the results, we can help you every step of the way.
And for expert market researchers and survey designers, Qualtrics features custom programming to give you total flexibility over question types, survey design, embedded data, and other variables.
No matter what type of survey you want to run, what target audience you want to reach, or what assumptions you want to test or answers you want to uncover, we’ll help you design, deploy and analyse your survey with our team of experts.
Start your survey research today with Qualtrics
Thematic analysis 11 min read, post event survey questions 10 min read, choosing the best survey tools 16 min read, survey app 11 min read, close-ended questions 7 min read, survey vs questionnaire 12 min read, likert scales 14 min read, request demo.
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Victor Yocco, PhD, has over a decade of experience as a UX researcher and research director. He is currently affiliated with Allelo Design and is taking on … More about Victor ↬
Weekly tips on front-end & UX . Trusted by 200,000+ folks.
Communication is in everything we do. We communicate with users through our research, our design, and, ultimately, the products and services we offer. UX practitioners and those working on digital product teams benefit from understanding principles of communication and their application to our craft. Treating our UX processes as a mode of communication between users and the digital environment can help unveil in-depth, actionable insights.
In this article, I’ll focus on UX research. Communication is a core component of UX research , as it serves to bridge the gap between research insights, design strategy, and business outcomes. UX researchers, designers, and those working with UX researchers can apply key aspects of communication theory to help gather valuable insights, enhance user experiences, and create more successful products.
Communications as an academic field encompasses various models and principles that highlight the dynamics of communication between individuals and groups. Communication theory examines the transfer of information from one person or group to another. It explores how messages are transmitted, encoded, and decoded, acknowledges the potential for interference (or ‘noise’), and accounts for feedback mechanisms in enhancing the communication process.
In this article, I will focus on the Transactional Model of Communication . There are many other models and theories in the academic literature on communication. I have included references at the end of the article for those interested in learning more.
The Transactional Model of Communication (Figure 1) is a two-way process that emphasizes the simultaneous sending and receiving of messages and feedback . Importantly, it recognizes that communication is shaped by context and is an ongoing, evolving process. I’ll use this model and understanding when applying principles from the model to UX research. You’ll find that much of what is covered in the Transactional Model would also fall under general best practices for UX research, suggesting even if we aren’t communications experts, much of what we should be doing is supported by research in this field.
Let’s take a deeper dive into the six key factors and their applications within the realm of UX research:
We can become complacent or feel rushed to create our research protocols. I think this is natural in the pace of many workplaces and our need to deliver results quickly. You can apply the lens of the Transactional Model of Communication to your research preparation without adding much time. Applying the Transactional Model of Communication to your preparation should:
You can address the specific elements of the Transactional Model through the following steps while preparing for research:
In UX research, the sender can often be the UX researcher conducting the study, while the receiver is usually the research participant. Understanding this dynamic can help researchers craft questions or tasks more empathetically and efficiently. You should try to collect some information on your participant in advance to prepare yourself for building a rapport.
For example, if you are conducting contextual inquiry with the field technicians of an HVAC company, you’ll want to dress appropriately to reflect your understanding of the context in which your participants (receivers) will be conducting their work. Showing up dressed in formal attire might be off-putting and create a negative dynamic between sender and receiver.
The message in UX research typically is the questions asked or tasks assigned during the study. Careful consideration of tenor, terminology, and clarity can aid data accuracy and participant engagement. Whether you are interviewing or creating a survey, you need to double-check that your audience will understand your questions and provide meaningful answers. You can pilot-test your protocol or questionnaire with a few representative individuals to identify areas that might cause confusion.
Using the HVAC example again, you might find that field technicians use certain terminology in a different way than you expect, such as asking them about what “tools” they use to complete their tasks yields you an answer that doesn’t reflect digital tools you’d find on a computer or smartphone, but physical tools like a pipe and wrench.
The channel selection depends on the method of research. For instance, face-to-face methods might use physical verbal communication, while remote methods might rely on emails, video calls, or instant messaging. The choice of the medium should consider factors like tech accessibility, ease of communication, reliability, and participant familiarity with the channel. For example, you introduce an additional challenge (noise) if you ask someone who has never used an iPhone to test an app on an iPhone.
Noise in UX research comes in many forms, from unclear questions inducing participant confusion to technical issues in remote interviews that cause interruptions. The key is to foresee potential issues and have preemptive solutions ready.
You should be prepared for how you might collect and act on participant feedback during the research. Encouraging regular feedback from the user during UX research ensures their understanding and that they feel heard. This could range from asking them to ‘think aloud’ as they perform tasks or encouraging them to email queries or concerns after the session. You should document any noise that might impact your findings and account for that in your analysis and reporting.
You can track what you do to align your processes with the Transactional Model prior to and during research using a spreadsheet. I’ll provide an example of a spreadsheet I’ve used in the later case study section of this article. You should create your spreadsheet during the process of preparing for research, as some of what you do to prepare should align with the factors of the model.
You can use these tips for preparation regardless of the specific research method you are undertaking. Let’s now look closer at a few common methods and get specific on how you can align your actions with the Transactional Model.
UX research relies on interaction with users. We can easily incorporate aspects of the Transactional Model of Communication into our most common methods. Utilizing the Transactional Model in conducting interviews, surveys, and usability testing can help provide structure to your process and increase the quality of insights gathered.
Interviews are a common method used in qualitative UX research. They provide the perfect method for applying principles from the Transactional Model. In line with the Transactional Model, the researcher (sender) sends questions (messages) in-person or over the phone/computer medium (channel) to the participant (receiver), who provides answers (feedback) while contending with potential distraction or misunderstanding (noise). Reflecting on communication as transactional can help remind us we need to respect the dynamic between ourselves and the person we are interviewing. Rather than approaching an interview as a unidirectional interrogation, researchers need to view it as a conversation.
Applying the Transactional Model to conducting interviews means we should account for a number of facts to allow for high-quality communication. Note how the following overlap with what we typically call best practices.
To truly harness a two-way flow of communication, open-ended questions, rather than close-ended ones, are crucial. For instance, rather than asking, “Do you use our mobile application?” ask, “Can you describe your use of our mobile app?”. This encourages the participant to share more expansive and descriptive insights, furthering the dialogue.
As the success of an interview relies on the participant’s responses, active listening is a crucial skill for UX researchers. The researcher should encourage participants to express their thoughts and feelings freely. Reflective listening techniques , such as paraphrasing or summarizing what the participant has shared, can reinforce to the interviewee that their contributions are being acknowledged and valued. It also provides an opportunity to clarify potential noise or misunderstandings that may arise.
Building on the simultaneous send-receive nature of the Transactional Model, researchers must remain responsive during interviews. Providing non-verbal cues (like nodding) and verbal affirmations (“I see,” “Interesting”) lets participants know their message is being received and understood, making them feel comfortable and more willing to share.
We should always attempt to account for noise in advance, as well as during our interview sessions. Noise, in the form of misinterpretations or distractions, can disrupt effective communication. Researchers can proactively reduce noise by conducting a dry run in advance of the scheduled interviews . This helps you become more fluent at going through the interview and also helps identify areas that might need improvement or be misunderstood by participants. You also reduce noise by creating a conducive interview environment, minimizing potential distractions, and asking clarifying questions during the interview whenever necessary.
For example, if a participant uses a term the researcher doesn’t understand, the researcher should politely ask for clarification rather than guessing its meaning and potentially misinterpreting the data.
Additional forms of noise can include participant confusion or distraction. You should let participants know to ask if they are unclear on anything you say or do. It’s a good idea to always ask participants to put their smartphones on mute. You should only provide information critical to the process when introducing the interview or tasks. For example, you don’t need to give a full background of the history of the product you are researching if that isn’t required for the participant to complete the interview. However, you should let them know the purpose of the research, gain their consent to participate, and inform them of how long you expect the session to last.
Researchers should build strategic thinking into their interviews to support the Transaction Model. Starting the interview with less intrusive questions can help establish rapport and make the participant more comfortable, while more challenging or sensitive questions can be left for later when the interviewee feels more at ease.
A well-planned interview encourages a fluid dialogue and exchange of ideas. This is another area where conducting a dry run can help to ensure high-quality research. You and your dry-run participants should recognize areas where questions aren’t flowing in the best order or don’t make sense in the context of the interview, allowing you to correct the flow in advance.
While much of what the Transactional Model informs for interviews already aligns with common best practices, the model would suggest we need to have a deeper consideration of factors that we can sometimes give less consideration when we become overly comfortable with interviewing or are unaware of the implications of forgetting to address the factors of context considerations, power dynamics, and post-interview actions.
You need to account for both the context of the participant, e.g., their background, demographic, and psychographic information, as well as the context of the interview itself. You should make subtle yet meaningful modifications depending on the channel you are conducting an interview.
For example, you should utilize video and be aware of your facial and physical responses if you are conducting an interview using an online platform, whereas if it’s a phone interview, you will need to rely on verbal affirmations that you are listening and following along, while also being mindful not to interrupt the participant while they are speaking.
Researchers need to be aware of how your role, background, and identity might influence the power dynamics of the interview. You can attempt to address power dynamics by sharing research goals transparently and addressing any potential concerns about bias a participant shares.
We are responsible for creating a safe and inclusive space for our interviews. You do this through the use of inclusive language, listening actively without judgment, and being flexible to accommodate different ways of knowing and expressing experiences. You should also empower participants as collaborators whenever possible . You can offer opportunities for participants to share feedback on the interview process and analysis. Doing this validates participants’ experiences and knowledge and ensures their voices are heard and valued.
You have a number of options for actions that can close the loop of your interviews with participants in line with the “feedback” the model suggests is a critical part of communication. Some tactics you can consider following your interview include:
You also need to do something with the feedback you receive. Researchers and product teams should make time for reflexivity and critical self-awareness.
As practitioners in a human-focused field, we are expected to continuously examine how our assumptions and biases might influence our interviews and findings. “
We shouldn’t practice our craft in a silo. Instead, seeking feedback from colleagues and mentors to maintain ethical research practices should be a standard practice for interviews and all UX research methods.
By considering interviews as an ongoing transaction and exchange of ideas rather than a unidirectional Q&A, UX researchers can create a more communicative and engaging environment. You can see how models of communication have informed best practices for interviews. With a better knowledge of the Transactional Model, you can go deeper and check your work against the framework of the model.
The Transactional Model of Communication reminds us to acknowledge the feedback loop even in seemingly one-way communication methods like surveys. Instead of merely sending out questions and collecting responses, we need to provide space for respondents to voice their thoughts and opinions freely. When we make participants feel heard, engagement with our surveys should increase, dropouts should decrease, and response quality should improve.
Like other methods, surveys involve the researcher(s) creating the instructions and questionnaire (sender), the survey, including any instructions, disclaimers, and consent forms (the message), how the survey is administered, e.g., online, in person, or pen and paper (the channel), the participant (receiver), potential misunderstandings or distractions (noise), and responses (feedback).
Understanding the Transactional Model will help researchers design more effective surveys. Researchers are encouraged to be aware of both their role as the sender and to anticipate the participant’s perspective as the receiver. Begin surveys with clear instructions, explaining why you’re conducting the survey and how long it’s estimated to take. This establishes a more communicative relationship with respondents right from the start. Test these instructions with multiple people prior to launching the survey.
The questions should be crafted to encourage feedback and not just a simple yes or no. You should consider asking scaled questions or items that have been statistically validated to measure certain attributes of users.
For example, if you were looking deeper at a mobile banking application, rather than asking, “Did you find our product easy to use?” you would want to break that out into multiple aspects of the experience and ask about each with a separate question such as “On a scale of 1–7, with 1 being extremely difficult and 7 being extremely easy, how would you rate your experience transferring money from one account to another?” .
Reducing ‘noise,’ or misunderstandings, is crucial for increasing the reliability of responses. Your first line of defense in reducing noise is to make sure you are sampling from the appropriate population you want to conduct the research with. You need to use a screener that will filter out non-viable participants prior to including them in the survey. You do this when you correctly identify the characteristics of the population you want to sample from and then exclude those falling outside of those parameters.
Additionally, you should focus on prioritizing finding participants through random sampling from the population of potential participants versus using a convenience sample, as this helps to ensure you are collecting reliable data.
When looking at the survey itself, there are a number of recommendations to reduce noise. You should ensure questions are easily understandable, avoid technical jargon, and sequence questions logically. A question bank should be reviewed and tested before being finalized for distribution.
For example, question statements like “Do you use and like this feature?” can confuse respondents because they are actually two separate questions: do you use the feature, and do you like the feature? You should separate out questions like this into more than one question.
You should use visual aids that are relevant whenever possible to enhance the clarity of the questions. For example, if you are asking questions about an application’s “Dashboard” screen, you might want to provide a screenshot of that page so survey takers have a clear understanding of what you are referencing. You should also avoid the use of jargon if you are surveying a non-technical population and explain any terminology that might be unclear to participants taking the survey.
The Transactional Model suggests active participation in communication is necessary for effective communication . Participants can become distracted or take a survey without intending to provide thoughtful answers. You should consider adding a question somewhere in the middle of the survey to check that participants are paying attention and responding appropriately, particularly for longer surveys.
This is often done using a simple math problem such as “What is the answer to 1+1?” Anyone not responding with the answer of “2” might not be adequately paying attention to the responses they are providing and you’d want to look closer at their responses, eliminating them from your analysis if deemed appropriate.
While descriptive feedback questions are one way of promoting dialogue, you can also include areas where respondents can express any additional thoughts or questions they have outside of the set question list. This is especially useful in online surveys, where researchers can’t immediately address participant’s questions or clarify doubts.
You should be mindful that too many open-ended questions can cause fatigue , so you should limit the number of open-ended questions. I recommend two to three open-ended questions depending on the length of your overall survey.
After collecting and analyzing the data, you can send follow-up communications to the respondents. Let them know the changes made based on their feedback, thank them for their participation, or even share a summary of the survey results. This fulfills the Transactional Model’s feedback loop and communicates to the respondent that their input was received, valued, and acted upon.
You can also meet this suggestion by providing an email address for participants to follow up if they desire more information post-survey. You are allowing them to complete the loop themselves if they desire.
Applying the transactional model to surveys can breathe new life into the way surveys are conducted in UX research. It encourages active participation from respondents, making the process more interactive and engaging while enhancing the quality of the data collected. You can experiment with applying some or all of the steps listed above. You will likely find you are already doing much of what’s mentioned, however being explicit can allow you to make sure you are thoughtfully applying these principles from the field communication.
Usability testing is another clear example of a research method highlighting components of the Transactional Model. In the context of usability testing, the Transactional Model of Communication’s application opens a pathway for a richer understanding of the user experience by positioning both the user and the researcher as sender and receiver of communication simultaneously.
Here are some ways a researcher can use elements of the Transactional Model during usability testing:
When a researcher assigns tasks to a user during usability testing, they act as the sender in the communication process. To ensure the user accurately receives the message, these tasks need to be clear and well-articulated. For example, a task like “Register a new account on the app” sends a clear message to the user about what they need to do.
You don’t need to tell them how to do the task, as usually, that’s what we are trying to determine from our testing, but if you are not clear on what you want them to do, your message will not resonate in the way it is intended. This is another area where a dry run in advance of the testing is an optimal solution for making sure tasks are worded clearly.
As the participant interacts with the application, concept, or design, the researcher, as the receiver, picks up on verbal and nonverbal cues. For instance, if a user is clicking around aimlessly or murmuring in confusion, the researcher can take these as feedback about certain elements of the design that are unclear or hard to use. You can also ask the user to explain why they are giving these cues you note as a way to provide them with feedback on their communication.
The transactional nature of the model recognizes the importance of real-time interaction. For example, if during testing, the user is unsure of what a task means or how to proceed, the researcher can provide clarification without offering solutions or influencing the user’s action. This interaction follows the communication flow prescribed by the transactional model. We lose the ability to do this during unmoderated testing; however, many design elements are forms of communication that can serve to direct users or clarify the purpose of an experience (to be covered more in article two).
In usability testing, noise could mean unclear tasks, users’ preconceived notions, or even issues like slow software response. Acknowledging noise can help researchers plan and conduct tests better. Again, carrying out a pilot test can help identify any noise in the main test scenarios, allowing for necessary tweaks before actual testing. Other forms of noise can be less obvious but equally intrusive. For example, if you are conducting a test using a Macbook laptop and your participant is used to a PC, there is noise you need to account for, given their unfamiliarity with the laptop you’ve provided.
The fidelity of the design artifact being tested might introduce another form of noise. I’ve always advocated testing at any level of fidelity, but you should note that if you are using “Lorem Ipsum” or black and white designs, this potentially adds noise.
One of my favorite examples of this was a time when I was testing a financial services application, and the designers had put different balances on the screen; however, the total for all balances had not been added up to the correct total. Virtually every person tested noted this discrepancy, although it had nothing to do with the tasks at hand. I had to acknowledge we’d introduced noise to the testing. As at least one participant noted, they wouldn’t trust a tool that wasn’t able to total balances correctly.
Under the Transactional Model’s guidance, feedback isn’t just final thoughts after testing; it should be facilitated at each step of the process. Encouraging ‘think aloud’ protocols , where the user verbalizes their thoughts, reactions, and feelings during testing, ensures a constant flow of useful feedback.
You are receiving feedback throughout the process of usability testing, and the model provides guidance on how you should use that feedback to create a shared meaning with the participants. You will ultimately summarize this meaning in your report. You’ll later end up uncovering if this shared meaning was correctly interpreted when you design or redesign the product based on your findings.
We’ve now covered how to apply the Transactional Model of Communication to three common UX Research methods. All research with humans involves communication. You can break down other UX methods using the Model’s factors to make sure you engage in high-quality research.
The Transactional Model of Communication doesn’t only apply to the data collection phase (interviews, surveys, or usability testing) of UX research. Its principles can provide valuable insights during the data analysis process.
The Transactional Model instructs us to view any communication as an interactive, multi-layered dialogue — a concept that is particularly useful when unpacking user responses. Consider the ‘message’ components: In the context of data analysis, the messages are the users’ responses. As researchers, thinking critically about how respondents may have internally processed the survey questions, interview discussion, or usability tasks can yield richer insights into user motivations.
Just as the Transactional Model emphasizes the simultaneous interchange of communication, UX researchers should consider the user’s context while interpreting data. Decoding the meaning behind a user’s words or actions involves understanding their background, experiences, and the situation when they provide responses.
In the Transactional Model, noise presents a potential barrier to effective communication. Similarly, researchers must be aware of snowballing themes or frequently highlighted issues during analysis. Noise, in this context, could involve patterns of confusion, misunderstandings, or consistently highlighted problems by users. You need to account for this, e.g., the example I provided where participants constantly referred to the incorrect math on static wireframes.
Remember that as a UX researcher, your interpretation of user responses will be influenced by your understandings, biases, or preconceptions, just as the responses were influenced by the user’s perceptions. By acknowledging this, researchers can strive to neutralize any subjective influence and ensure the analysis remains centered on the user’s perspective. You can ask other researchers to double-check your work to attempt to account for bias.
For example, if you come up with a clear theme that users need better guidance in the application you are testing, another researcher from outside of the project should come to a similar conclusion if they view the data; if not, you should have a conversation with them to determine what different perspectives you are each bringing to the data analysis.
Understanding your audience is crucial for delivering a persuasive UX research presentation. Tailoring your communication to resonate with the specific concerns and interests of your stakeholders can significantly enhance the impact of your findings. Here are some more details:
Respecting this Transactional Model’s feedback loop, remember to revisit user insights after implementing design changes. This ensures you stay user-focused, continuously validating or adjusting your interpretations based on users’ evolving feedback. You can do this in a number of ways. You can reconnect with users to show them updated designs and ask questions to see if the issues you attempted to resolve were resolved.
Another way to address this without having to reconnect with the users is to create a spreadsheet or other document to track all the recommendations that were made and reconcile the changes with what is then updated in the design. You should be able to map the changes users requested to updates or additions to the product roadmap for future updates. This acknowledges that users were heard and that an attempt to address their pain points will be documented.
Crucially, the Transactional Model teaches us that communication is rarely simple or one-dimensional. It encourages UX researchers to take a more nuanced, context-aware approach to data analysis, resulting in deeper user understanding and more accurate, user-validated results.
By maintaining an ongoing feedback loop with users and continually refining interpretations, researchers can ensure that their work remains grounded in real user experiences and needs. “
You might find it useful to track how you align your research planning and execution to the framework of the Transactional Model. I’ve created a spreadsheet to outline key factors of the model and used this for some of my work. Demonstrated below is an example derived from a study conducted for a banking client that included interviews and usability testing. I completed this spreadsheet during the process of planning and conducting interviews. Anonymized data from our study has been furnished to show an example of how you might populate a similar spreadsheet with your information.
You can customize the spreadsheet structure to fit your specific research topic and interview approach. By documenting your application of the transactional model, you can gain valuable insights into the dynamic nature of communication and improve your interview skills for future research.
Stage | Columns | Description | Example |
---|---|---|---|
Pre-Interview Planning | Topic/Question (Aligned with research goals) | Identify the research question and design questions that encourage open-ended responses and co-construction of meaning. | Testing mobile banking app’s bill payment feature. How do you set up a new payee? How would you make a payment? What are your overall impressions? |
Participant Context | Note relevant demographic and personal information to tailor questions and avoid biased assumptions. | 35-year-old working professional, frequent user of the online banking and mobile application but unfamiliar with using the app for bill pay. | |
Engagement Strategies | Outline planned strategies for active listening, open-ended questions, clarification prompts, and building rapport. | Open-ended follow-up questions (“Can you elaborate on XYZ? Or Please explain more to me what you mean by XYZ.”), active listening cues, positive reinforcement (“Thank you for sharing those details”). | |
Shared Understanding | List potential challenges to understanding participant’s perspectives and strategies for ensuring shared meaning. | Initially, the participant expressed some confusion about the financial jargon I used. I clarified and provided simpler [non-jargon] explanations, ensuring we were on the same page. | |
During Interview | Verbal Cues | Track participant’s language choices, including metaphors, pauses, and emotional expressions. | Participant used a hesitant tone when describing negative experiences with the bill payment feature. When questioned, they stated it was “likely their fault” for not understanding the flow [it isn’t their fault]. |
Nonverbal Cues | Note participant’s nonverbal communication like body language, facial expressions, and eye contact. | Frowning and crossed arms when discussing specific pain points. | |
Researcher Reflexivity | Record moments where your own biases or assumptions might influence the interview and potential mitigation strategies. | Recognized my own familiarity with the app might bias my interpretation of users’ understanding [e.g., going slower than I would have when entering information]. Asked clarifying questions to avoid imposing my assumptions. | |
Power Dynamics | Identify instances where power differentials emerge and actions taken to address them. | Participant expressed trust in the research but admitted feeling hesitant to criticize the app directly. I emphasized anonymity and encouraged open feedback. | |
Unplanned Questions | List unplanned questions prompted by the participant’s responses that deepen understanding. | What alternative [non-bank app] methods for paying bills that you use? (Prompted by participant’s frustration with app bill pay). | |
Post-Interview Reflection | Meaning Co-construction | Analyze how both parties contributed to building shared meaning and insights. | Through dialogue, we collaboratively identified specific design flaws in the bill payment interface and explored additional pain points and areas that worked well. |
Openness and Flexibility | Evaluate how well you adapted to unexpected responses and maintained an open conversation. | Adapted questioning based on participant’s emotional cues and adjusted language to minimize technical jargon when that issue was raised. | |
Participant Feedback | Record any feedback received from participants regarding the interview process and areas for improvement. | Thank you for the opportunity to be in the study. I’m glad my comments might help improve the app for others. I’d be happy to participate in future studies. | |
Ethical Considerations | Reflect on whether the interview aligned with principles of transparency, reciprocity, and acknowledging power dynamics. | Maintained anonymity throughout the interview and ensured informed consent was obtained. Data will be stored and secured as outlined in the research protocol. | |
Key Themes/Quotes | Use this column to identify emerging themes or save quotes you might refer to later when creating the report. | Frustration with a confusing interface, lack of intuitive navigation, and desire for more customization options. | |
Analysis Notes | Use as many lines as needed to add notes for consideration during analysis. | Add notes here. |
You can use the suggested columns from this table as you see fit, adding or subtracting as needed, particularly if you use a method other than interviews. I usually add the following additional Columns for logistical purposes:
By incorporating aspects of communication theory into UX research, UX researchers and those who work with UX researchers can enhance the effectiveness of their communication strategies, gather more accurate insights, and create better user experiences. Communication theory provides a framework for understanding the dynamics of communication, and its application to UX research enables researchers to tailor their approaches to specific audiences, employ effective interviewing techniques, design surveys and questionnaires, establish seamless communication channels during usability testing, and interpret data more effectively.
As the field of UX research continues to evolve, integrating communication theory into research practices will become increasingly essential for bridging the gap between users and design teams, ultimately leading to more successful products that resonate with target audiences.
As a UX professional, it is important to continually explore and integrate new theories and methodologies to enhance your practice . By leveraging communication theory principles, you can better understand user needs, improve the user experience, and drive successful outcomes for digital products and services.
Integrating communication theory into UX research is an ongoing journey of learning and implementing best practices. Embracing this approach empowers researchers to effectively communicate their findings to stakeholders and foster collaborative decision-making, ultimately driving positive user experiences and successful design outcomes.
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BMC Health Services Research volume 24 , Article number: 738 ( 2024 ) Cite this article
Metrics details
The mental health of medical students is a national and international problem increasing in both demand and acuity. Medical students face barriers to accessing mental health support that is clinically effective, timely and appropriate for their needs. This mixed methods study aimed to explore experiences of these barriers and the challenges to health service delivery aligned to the Candidacy Framework.
One hundred three medical students studying at The University of Sheffield completed an online survey comprising the CCAPS-34 and follow-up questions about service access and use. Semi-structured interviews with a nested sample of 20 medical students and 10 healthcare professionals explored barriers to service access and provision. A stakeholder panel of medical students and professionals met quarterly to co-produce research materials, interpret research data and identify touchpoints by pinpointing specific areas and moments of interaction between a medical student as a service user and a mental health service.
Medical students who experienced barriers to help-seeking and accessing support scored significantly higher for psychological symptoms on the CCAPS-34. Uncertainty and fear of fitness to practice processes were important barriers present across all seven stages of candidacy. The fragmented structure of local services, along with individual factors such as perceived stigma and confidentiality concerns, limited the progression of medical students through the Candidacy Framework (a framework for understanding the different stages of a person’s journey to healthcare).
This study outlines important areas of consideration for mental health service provision and policy development to improve access to and the quality of care for medical students.
Peer Review reports
The mental health of medical students is a national and international problem [ 1 ], requiring urgent attention [ 2 ]. Mental health problems can emerge as early as the first year with symptoms of depression, anxiety, burnout and suicidal ideation [ 3 , 4 ]. A meta-analysis of 183 studies across 43 countries showed that the prevalence of depression among medical students was 27%, with 11% of those students reporting suicidal ideation and more than 80% feeling under-supported [ 1 ]. Episodes of poor mental health are associated with adverse outcomes such as alcohol and substance abuse, self-harm and dropping out of medical school [ 3 , 5 ].
Medical students face particular sets of barriers to help-seeking and accessing mental health support; less than a quarter of those with clinical levels of depression report using counselling services [ 6 ]. Barriers include stigma, perceiving a mental health problem as a weakness and beliefs about “fitness to practice” (FTP) proceedings, with presumed implications for career progression [ 7 ] and the possibility of expulsion [ 8 ]. Jadzinski et al. [ 9 ] reported a lack of understanding of what FTP expectations are for medical students and inconsistencies with Higher Education Institution (HEI) processes in managing FTP concerns. Internationally, the barriers to help-seeking, which affect medical students disproportionately, are complex and multi-faceted [ 10 , 11 ].
HEIs have seen a growing demand for services to meet the mental health needs of medical students [ 12 , 13 , 14 ]. University support services are required to provide brief in-house support to students, including counselling or mental health centres, disability support, and wellbeing services. Longer-term or specialist support for acute mental health problems are provided by external services. The Student Services Partnership Evaluation and Quality Standards (SPEQS), developed by Sheffield and University College London, included a toolkit addressing some of the challenges to cross-sector working from a professional perspective [ 15 ]. SPEQS provides a generic groundwork that must now be tailored to understanding how professionals can better meet the specific mental health needs of medical students and the associated challenges.
Access barriers, difficulty navigating pathways and overstretched health services mean that medical students who feel able to seek help can fall between the gaps [ 16 ]. Medical students may delay approaching services until their needs are severe or impact their studies [ 17 ], and may turn to more acute care settings to access professional support [ 18 ]. Understanding the experiences of medical students who have ‘fallen through the cracks’ and the challenges to treatment access are essential to improving the quality of services [ 19 ]. The aim of this study was to examine how barriers to accessing and navigating mental health services arise and intersect with challenges to service provision in the unique context of medical student mental health.
We adopted the Candidacy Framework developed by Mary Dixon-Woods and colleagues [ 20 ]. Candidacy represents the idea that an individual’s access to and successful use of health services is an iterative process influenced by individual, professional, organisational, structural and resource factors. It has been used to understand healthcare experiences of vulnerable groups, including persons with MS [ 21 ] and young onset dementia [ 22 ], but has not been applied to medical students who experience mental health problems. Our study explored help-seeking behaviours, access barriers and the challenges to health service delivery aligned to the Candidacy Framework.
This study used a mixed methods sequential design, consisting of two distinct work packages: (1) quantitative survey to describe patterns of help seeking and unmet mental health needs and (2) nested semi-structured interviews to understand more nuanced aspects of accessing and delivering support. We adhered to the Good Reporting of A Mixed Methods Study (GRAMMS) guidelines (Additional Material 1) [ 19 , 20 ].
Improved systems of support can only be achieved in partnership with their intended users, participating on equal terms as stakeholders [ 23 ]. Based on the reported benefits of service user involvement in mental health service development and delivery [ 24 ], a stakeholder panel of nine medical students and five professionals met quarterly to co-produce research materials, interpret research data and identify touchpoints by pinpointing specific moments and areas of interaction between a medical student as a service user and a mental health service. These touchpoints are critical for understanding the user experience and are often targets for improving satisfaction and effectiveness. Professionals were selected for involvement in the stakeholder panel based on their organisation and role. Staff from the University of Sheffield’s Medical School ( n = 2), NHS professionals working in community mental health settings (including low-intensity and acute care provision) ( n = 2), and a researcher specialising in the field of student mental health ( n = 1) were approached by e-mail. Medical students with lived experience were self-selected following an advertisement that was circulated by e-mail to all medical students at The University of Sheffield’s Medical School. The stakeholder panel therefore involved a diversity of voices to ensure meaningful input throughout that was based on both professional and lived experiences.
Work Package 1 involved a cross-sectional online survey of medical students studying at School of Medicine and Population Health, The University of Sheffield. The survey included the Counselling Centre Assessment of Psychological Symptoms (CCAPS-34) [ 25 ], a 34-item instrument with seven distinct sub-scales related to psychological symptoms and distress in university students. Items are rated on a five-point Likert scale (0 = not at all like me, 4 = extremely like me) with higher scores indicating higher severity. The survey employed multiple choice questions on participant demographics, help-seeking behaviours and service use (Additional Material 2). The survey was conducted using the Qualtrics Research Suite (Qualtrics, Provo, UT), with a one-week response window from 04/11/2022 to 11/11/2022.
An email invitation was sent to all eligible medical students aged 18 or over and studying MBChB Medicine (A100) degree or MBChB Graduate Entry Medicine (A101) at The University of Sheffield. The email included a webpage link to the Participant Information Sheet and online survey. Informed consent was completed online prior to data collection. The survey link was advertised on the student intranet news feed.
To ensure confidentiality, names were not collected except where medical students consented to contact for the interviews. Data was stored on a secure file server accessible only to the research team. Descriptive statistics and one-way ANOVAs were produced using the software R version 4.2.1 to explore differences in symptom profiles between demographics, help-seeking behaviours and service use. CCAPS-34 subscales could not be calculated where participants responded with the same value for each question in the subscale. At least 33% of questions must be answered in the subscale to calculate a valid subscale score. The overall CCPAS-34 scores and subscale scores are calculated by the mean of the available items, assuming the missing data rules hold. Details on the scoring and handling of missing data for the CCPAS-34 can be found in Additional Material 3.
Medical students responding to the survey were invited to register interest in semi-structured interviews (Work Package 2). The survey therefore provided a nested cohort from which a purposive sample of medical students were approached by email. Sampling was based on those with the highest CCAPS-34 scores, or a disclosure of previous or current use of mental health services. Medical students who disclosed mental health concerns but decided not to seek help based on their responses to the multiple-choice questions on help-seeking behaviours and service use were also approached. The stakeholder panel informed sampling based on maximum variation for demographic characteristics. Professionals were contacted for interview by email based on their organisation and role. 20 medical students and ten professionals were invited to take part by e-mail that provided a Participant Information Sheet and contact details for the research team This was considered adequate for data saturation [ 26 ] using established frameworks [ 27 ] and demonstrates integration of mixed methods at the design stage.
Interviews took place using a secure internet application with an audio consent procedure. Topic guides were co-designed with the stakeholder panel (Additional Materials 4 and 5). Potential items for the topic guide were informed by theories of (non-) help-seeking in young adults [ 28 ], covering known barriers to help-seeking and risk factors. Stakeholders selected, modified and added items for inclusion in the topic guide based on their lived experiences, values and priorities. Final drafts of the topic guides were reviewed and approved by the stakeholder panel. Encrypted digital recordings were transcribed verbatim. Two researchers analysed the transcripts and all free-text survey responses within NVivo Version 12 (QSR International), using the five stages of National Centre for Social Care ‘Framework’ analysis approach: familiarisation; identifying themes; indexing; charting; interpretation and mapping [ 29 ]. This process involved using codes as a system for marking ‘parts of the text that are of special interest’ and themes as converting ‘codes into core concepts that represent the most important aspects of the results’ [ 30 ] based on the Candidacy Framework (Table 1 ).
This project received favourable opinion from ScHARR Research Ethics Committee (049592).
Survey demographics.
We received 103 survey responses (103/1500, 6.9% response rate). Table 2 shows a breakdown of participant demographic categories and responses to the follow-up questions. The majority of medical students were female (66.0%), white (69.9%) and studying in their home/birth country (93.2%). Most respondents were in their first year of study (14.6%) with fewer respondents in their fifth (10.7%) and sixth years (7.8%).
Of the 103 respondents, 102 completed all CCAPS items; the remaining participant completed less than 50% so were excluded in the analysis. The mean (SD) overall score for the 102 participants was 1.28 (0.62). Medical students obtained the highest score on Social Anxiety (mean = 1.96, SD = 0.94) and the lowest score on Frustration/Anger (mean = 0.76, SD = 0.68). The following subscales could not be scored because those participants responded with the same value for each question in that subscale, so their score could not be calculated: Academic Distress (8/103), Alcohol (39/103), Depression (12/103), Eating Concerns (49/103), Frustration (36/103), Generalised Anxiety (6/103) and Social Anxiety (6/103).
The results of the statistical analyses are found in Additional Material 6. No significant findings were found between overall CCAPS-34 scores and participant demographics or the subscale scores and demographics ( p > 0.05). Significant responses were found between overall CCAPS-34 scores and the follow-up questions, indicating those who responded ‘yes’ to those questions scored significantly higher for psychological symptoms ( p < 0.05).
Significant responses were found between the following CCAPS-34 subscale scores and follow-up questions: Academic Distress, Depression, Frustration, Generalised Anxiety and Social Anxiety (where three out of the four questions were significant). Floor and ceiling effects for each subscale were calculated with the unadjusted mean differences (Additional Material 7).
Of the 103 respondents, 64 (62%) medical students consented to be contacted for interview. Interviews were conducted with 20 medical students and 10 professionals (see Table 3 for participant characteristics). As well as generic issues with access to mental healthcare for all University students, medical students face particular barriers at each stage of the Candidacy Framework (Fig. 1 ). Uncertainty and fear of FTP processes were mapped to all stages of candidacy as an important barrier to help-seeking and accessing support. The stigma of appearing “weak” in medical school culture; the challenges of clinical placements; and confidentiality concerns when working clinically were also highlighted as key individual-level barriers. Healthcare professionals offered insights into the fragmented structure of local services, in particular the gap in support provision between primary and secondary care.
The Candidacy Framework aligned with key barriers and facilitators in the medical student pathway
FTP concerns were mapped as a barrier across all Candidacy stages. Medical students who were unable to progress beyond Stage 1 reported being in denial about having a mental health problem in fear of FTP ramifications: ‘As soon as you access support you’re admitting you have a problem, so if you don’t access the support it’s just like, the denial can keep going’ (S14). Some medical students rejected referrals and offers of treatment (Stage 6): ‘I was really worried it was going to have an effect on whether or not people thought I was able to study, so I didn’t access it’ (S01).
Professionals described how FTP concerns limited data sharing opportunities where medical students chose to opt out of their information being shared with the University. In reality however, FTP proceedings were experienced as exceptional cases where symptoms were complex, acute and presented significant risks to patient safety. Crucially, professionals emphasised that concerns arise when care is not sought or accepted: ‘We do our best to say to students you’re not going to get into trouble for having a health problem. […]. You will get into trouble for letting it get worse and not dealing with it, because you’ve got a responsibility to be safe and practice’ (P03).
Medical students spend a considerable amount of time in this first stage of the Candidacy Framework where they determine whether their mental health concern warrants professional support. One reason for failing to identify themselves as suitable candidates was the prioritisation of studies over mental health and wellbeing. The stigma associated with mental illness amongst peers meant that seeking help is perceived as weakness or professional risk.
‘For people who work in the medical field or want to, then I think [the stigma] can be higher because they think it shouldn’t happen to them and they shouldn’t need support’ (P06).
Once medical students identified themselves as a candidate, they determined where and how to receive appropriate care. Participants described:
A lack of knowledge of services available for their mental health concern
Practical barriers related to studying medicine, for example inconvenient appointment times. Often participants described that they ‘just simply don’t have the time’ (S16).
‘That’s definitely one of the reasons why I wouldn’t access help. [...] It’s really hard to arrange appointments if you don’t know who or what you’re going to be doing’ (S18).
Professionals reflected that whilst there are a range of services accessible to medical students, they often lack awareness of what support is available. The challenge for professionals is to help medical students navigate that system by signposting to the appropriate service, arranging access via referrals or providing information on how to access a service.
‘I think being able to work out which box you fit into and how to access that is more of a challenge than there not being support around.’ (P02).
Most medical students reported that services were chosen based on ease of access or permeability. For those with common or ‘mild’ mental health symptoms, the University services and NHS Sheffield Talking Therapies were accessed often and easily. Medical students with acute or complex mental health problems defaulted to services that were most permeable – i.e., those with the fewest criteria to gain entry, such as the emergency department. Mental health services that would be appropriate for their level of acuity were considered inaccessible due to long waiting lists and complex referral processes.
‘There’s a lot available for mild mental health, but for the more complex or unwell states of mental health it’s more difficult. […] It’s difficult when you fall somewhere between mild mental health and severe mental health’ (S02).
Professionals recognised the gap between care offered at a primary and secondary care level. This important challenge to service provision arose when medical students required longer-term or specialist services which have high thresholds for acceptance. Professionals reflected however, that this barrier is experienced beyond the medical student context and is recognised nationally in the UK.
‘There’s a big gap between what’s available at the primary and secondary care level. So people with acute mental health problems where a short-term approach is not going to be helpful for, it’s hard to access psychotherapy for those people’ (P10).
Medical students expressed feeling uncomfortable attending appointments to discuss their mental health concerns to practitioners and described concerns that they might be known to them in an academic context.
‘When I go to the GP, anything that I’m saying, I’m potentially saying to a future colleague that I’m potentially working with so how are they going to view me?’ (S07).
Medical students then faced the task of convincing healthcare providers of their candidacy for care. Many participants reported feeling invalidated or dismissed due to preconceptions held on medical students’ risk.
Healthcare provider adjudications were influenced by perceptions that there is nothing suitable to offer students and were therefore considered unfit candidates for care. In these cases, medical students reported being discharged without support or being signposted to an alternative service with lower thresholds for acceptance.
‘They went along the lines of you’re a medical student, you’re functioning, you don’t need input from us. So they discharged me, and they discharged me without any support’ (S01).
Professionals described their frustrations however, when support cannot be offered based on a medical students’ presentation and the level of acuity required for acceptance. What was perceived as dismissive by medical students may reflect limited support options at a secondary care level.
‘So often you want to give people something or you can identify something that could really help them but they don’t meet the criteria to access that. So that’s a big barrier’ (P01).
Medical students rejected offers of care due to:
Practical barriers, such as long working hours on placement.
Inappropriate or limited support offered that did not fit their needs.
Support not offered within an acceptable time frame.
‘During that time I was on placement and I was like, they’d already wriggled around my placement, I really I can’t do that again. So I declined that’ (S06).
Some medical students accepted care offers from private services to overcome these barriers. This is particularly unacceptable when considering the widening participation strategies to include medical students who are less likely to have affluent socioeconomic backgrounds and experience increased financial burden whilst studying in the UK. Professionals made efforts to overcome barriers by adapting to individual needs, for example by offering study leave so that treatment offers could be facilitated.
Participants described overarching influences, including:
Poor coordination, continuity or transference of care, especially for those who received care prior to university.
Low capacity due to high caseloads and demand for local services.
Limited room space; inappropriate waiting environments.
‘I think due to waiting time, if you are at the point where you’re trying to access services and they’re just not there, it deters you from it.’ (S17).
Medical students who experienced higher levels of psychological symptoms were significantly more likely to report help-seeking concerns. This study presents key barriers to accessing mental health support at each stage of the Candidacy Framework. Uncertainty and fear of FTP processes were important barriers present across all stages. The fragmented structure of local services, along with individual factors such as stigma and confidentiality concerns, further limited the progression of medical students through the candidacy stages.
Previous studies and policy frameworks have identified similar barriers to seeking and accessing mental health care for medical students [ 6 , 7 , 8 , 26 , 27 ], focusing primarily on individual barriers such as stigma or FTP concerns. Importantly, our findings reinforce that medical students are reluctant to disclose a mental health problem due to the feared consequences of regulatory FTP proceedings that would lead to dismissal and expulsion. The Candidacy Framework allowed us to go further by understanding how individual and service-level barriers arise and intersect with professional challenges to service provision. Applying the Framework to guide the qualitative analysis also uncovered new and unique challenges across the ‘service-user’ journey. For example, medical students with acute and complex mental health problems may fall through the gaps between primary and secondary healthcare. While there are similar studies in this field, previous findings are based on small focus groups of medical students which do not consider the perspectives of professionals working across healthcare and educational settings. To our knowledge, our study is the first to provide mixed methods findings that represent a diversity of voices and provide deeper insights into the fragmented structure of services, with care providers working across different healthcare organisations and HEIs, which are driven by different priorities. Taken together, these barriers significantly impact on candidacy and mean that medical students may feel unable to seek or access support that is clinically effective, timely and appropriate for their needs.
A strength of this work was that the study protocol and research materials were co-produced by a stakeholder panel of professionals and medical students with lived experience. Data was discussed by the panel to ensure views were robust, accurate and representative of values and needs. This study therefore provides an example of how working in partnership with people with lived experience and professional stakeholders can meaningfully inform our understanding of mental health service delivery and development. Another strength was the triangulation of multiple data sources to understand barriers to service access and delivery. The initial survey data uncovered how mental health symptoms may relate to help-seeking behaviours and service use. After this data was analysed, we determined how these barriers aligned with the Candidacy Framework and professionals’ experiences of service provision.
Surveying and interviewing medical students at one time point does not however, allow for an exploration of the complete student journey across a medicine degree. Potential limitations are the cross-sectional survey design, where a longitudinal approach may have allowed for a more robust view of how help-seeking may change during the academic year. We also acknowledge that the online survey was administered at the tail-end of the COVID-19 Pandemic, which may have accounted for increased psychological symptoms, such as anxiety [ 31 ]. Another limitation is the sole focus on a single UK medical school. Our low response rate may indicate a potential response bias, with medical students who have previously experienced mental health issues being more likely to participate in the survey than those who have not. We aimed for maximal variation by interviewing professionals from a range of settings and selecting medical students with different mental health profiles who had accessed a range of services. However, our findings are limited to a small sample size and reflect local context and policies – particularly in terms of how healthcare systems are configured and their operating conditions.
Asserting candidacy takes work from the service user, healthcare and University professionals and other stakeholders [ 32 ]. Our findings can help to identify groups of medical students who are at risk of ‘falling through the cracks’ in the system, which is an essential condition to prioritising resource allocation and providing accessible care. In line with guidance from MQ Mental Health Research [ 33 ], policy-makers should aim to improve the accessibility of mental health services by providing integrated high-quality care and prioritising strategies to reduce stigma. For medical schools in particular, stigma reduction strategies should provide clear FTP guidance that supports informed decision-making, personalised planning and seeking timely and appropriate support for mental health symptoms. Universities and healthcare services should further aim to address the gap between primary and secondary services by providing care that is more integrated and coordinated – particularly for medical students with complex and acute mental health problems who, based on our findings, are possibly more at risk of falling between this gap in service provision. The Sheffield Primary and Community Mental Health Transformation Programme [ 34 ] provides a local model of care aiming to inform a new way of delivering adult mental health services and break down barriers between primary and secondary care. More generally, we recommend partnership working between HEIs, healthcare services and medical students to inform service development and delivery.
Future studies should explore the experiences of specific case groups of medical students, particularly those with different types and acuity of mental health symptoms to determine how these factors influence candidacy. The MIND collaboration ( https://doi.org/10.17605/OSF.IO/48WE2 ) is co-producing a process map of existing service pathways to identify gaps along the student journey and is co-designing a toolkit to address some of the touchpoints and barriers identified in this research.
Our findings indicate that fear of FTP processes, along with the fragmented structure of local services and individual factors such as perceived stigma, limit the progression of medical students through the Candidacy Framework. By understanding these barriers and gaps in service provision, Universities and healthcare services can be developed to better to meet medical students’ mental health needs based on their presenting problem and stage of candidacy.
The statistical analysis plan and outputs are included as additional files. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Counselling Centre Assessment of Psychological Symptoms
Fitness to practice
Higher Education Institution
National Health Service
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The authors would like to thank the stakeholder panel of professionals and people with lived experience for their contributions: Dr Helen Crimlisk, Dr Fran Oldale, Dr Emma Broglia, Dr Dominic Strezynski, Adiy Ibrahim, Amran O Jimale, Changmin Doh, Eleanor Morris, Manjeevan Singh, Mohamed Morgan, Oscar Han, Sanjana Mehrotra and Srinath Ravi.
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ES, JY, MSB, CB and DH conceived and designed the study. ES, NE, JY, CB and DH designed interview guides. ES and NE collected data and conducted the analysis and interpretation. ES, CB and DH conceptualised the theoretical framework. NE prepared the figures. LD conducted the statistical analyses. ES wrote the article and all authors critically revised the paper. All authors read and approved the final manuscript.
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Sheldon, E., Ezaydi, N., Desoysa, L. et al. Barriers to help-seeking, accessing and providing mental health support for medical students: a mixed methods study using the candidacy framework. BMC Health Serv Res 24 , 738 (2024). https://doi.org/10.1186/s12913-024-11204-8
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We’ve all seen the words “complementary,” “alternative,” and “integrative,” but what do they really mean?
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According to a 2012 national survey, many Americans—more than 30 percent of adults and about 12 percent of children—use health care approaches that are not typically part of conventional medical care or that may have origins outside of usual Western practice. When describing these approaches, people often use “alternative” and “complementary” interchangeably, but the two terms refer to different concepts:
Most people who use non-mainstream approaches also use conventional health care.
In addition to the terms complementary and alternative, you may also hear the term “functional medicine.” This term sometimes refers to a concept similar to integrative health (described below), but it may also refer to an approach that more closely resembles naturopathy (a medical system that has evolved from a combination of traditional practices and health care approaches popular in Europe during the 19th century).
Integrative health brings conventional and complementary approaches together in a coordinated way. Integrative health also emphasizes multimodal interventions, which are two or more interventions such as conventional health care approaches (like medication, physical rehabilitation, psychotherapy), and complementary health approaches (like acupuncture, yoga, and probiotics) in various combinations, with an emphasis on treating the whole person rather than, for example, one organ system. Integrative health aims for well-coordinated care among different providers and institutions by bringing conventional and complementary approaches together to care for the whole person.
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According to the 2012 National Health Interview Survey (NHIS), which included a comprehensive survey on the use of complementary health approaches by Americans, 17.7 percent of American adults had used a dietary supplement other than vitamins and minerals in the past year. These products were the most popular complementary health approach in the survey. (See chart.) The most commonly used nonvitamin, nonmineral dietary supplement was fish oil.
Researchers have done large, rigorous studies on a few dietary supplements, but the results often showed that the products didn’t work for the conditions studied. Research on others is in progress. While there are indications that some may be helpful, more needs to be learned about the effects of these products in the human body, and about their safety and potential interactions with medicines and other natural products.
Complementary physical and/or psychological approaches include tai chi , yoga , acupuncture , massage therapy , spinal manipulation , art therapy, music therapy, dance, mindfulness-based stress reduction, and many others. These approaches are often administered or taught by a trained practitioner or teacher. The 2012 NHIS showed that yoga, chiropractic and osteopathic manipulation , and meditation are among the most popular complementary health approaches used by adults. According to the 2017 NHIS , the popularity of yoga has grown dramatically in recent years, from 9.5 percent of U.S. adults practicing yoga in 2012 to 14.3 percent in 2017. The 2017 NHIS also showed that the use of meditation increased more than threefold from 4.1 percent in 2012 to 14.2 percent in 2017.
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The primary objective of this research was to use qualitative methods to assess the knowledge, attitudes, and confidence of caregivers in their ability to provide oral hygiene assistance to residents. The secondary objective was to assess the knowledge and attitude of administrators on the provision of oral hygiene assistance for residents, and their confidence in caregivers’ ability to provide oral hygiene assistance to nursing home residents in San Antonio, Texas.
A semi-structured interview guide was used to conduct face-to-face interviews with seven caregivers and twelve administrative staff from ten nursing homes in San Antonio, Texas. Employees in nursing homes who are caring for residents are referred to as caregivers and those whom they care for are referred to as nursing home residents. One survey instrument was developed for the caregiver’s knowledge, attitude, and confidence toward providing oral health care, and another to assess the administrator’s knowledge, attitude, and confidence in caregivers providing oral care for nursing home residents. The interviews were recorded, transcribed, and coded for thematic content.
The findings revealed that caregivers and administrators had adequate knowledge of the connection between oral and systemic health. The administrators were confident that caregivers were adequately trained to provide oral hygiene care for residents. Caregivers had a positive attitude toward the importance of good oral health. They regularly assessed the residents’ oral health, but due to time constraints, staffing shortages, and other competing tasks providing oral health care to the residents was challenging. Most caregivers were confident in their skills in providing oral care for the residents since 85.6% agreed. On the contrary, almost half of the administrators were confident that caregivers have the necessary skills to provide oral care for residents, while 41.7% were unsure.
The study gave a broader insight into the provision of oral care in nursing home residents from the perspectives of caregivers and administrative staff. Administrators must provide caregivers with adequate training and time so they can provide adequate oral health care for the residents.
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Since 2012, the older adult population aged 65 and older in the United States has experienced a rising trajectory and by the year 2050, this population was projected to be around 83.6 million, almost double the estimated 2012 population of 43.1 million [ 1 ]. As recent as 2011, about 4.1% of adults over the age of 65 years live in nursing homes, and about 15% of residents 85 years and older residing in nursing homes across the United States [ 2 ]. The city of San Antonio in Texas has a population of 243,000 inhabitants above the age of 60 years, and that population was expected to double by the year 2040 [ 3 ]. Older adults in nursing homes were more susceptible to poor oral health due to negligence, which led to unnecessary delays in responding to oral health issues, eventually affecting general health [ 4 , 5 , 6 ].
Poor oral hygiene, periodontal disease, and disease-causing bacteria in the oral cavity were associated with systemic diseases such as pneumonia, cardiovascular disease, and diabetes [ 6 ]. Pneumonia accounts for 13–48% of nursing home-related infections and had a 55% mortality rate among older adults residing in nursing homes. The aspiration of bacteria secretions from the oropharyngeal space into the lower respiratory tract was the primary pathway for bacterial pneumonia infections, particularly in patients with periodontal disease [ 2 ]. Nursing home residents with chronic diseases, degenerative nerve diseases that cause dysphagia, and those who use nasogastric or percutaneous enterogastric tubes were at a higher risk of bacteria-induced pneumonia [ 7 ]. The application of effective tooth brushing techniques, regular cleaning of dentures, and routine treatment by dentists and hygienists can decrease the rate of aspiration pneumonia in nursing home residents [ 6 ].
Most nursing home residents had poor manual dexterity and were heavily dependent on the knowledge and skills of caregivers (registered nurse (RN), licensed vocational nurse (LVN), certified nursing assistants (CNA), and medical aides) to care for their oral health. For this reason, it was essential for caregivers and administrators (social workers, Nursing home administrators, directors and assistant directors of nursing (DON) to have adequate knowledge of oral health care so they can successfully care for these residents [ 8 ]. Caregivers who were knowledgeable about caring for older adults were inclined to improve the patient’s health status, which can satisfy the expectations of the patient and their families [ 9 ]. Additionally, caregivers who had adequate knowledge, positive attitude, and skills to care for older adults in nursing homes had fewer problems in meeting the job’s daily demands and responded empathetically to the daily oral care of residents [ 10 ].
The negative attitudes of some caregivers towards oral care had affected the quality of care they provide for older adults, which can eventually lead to unfavorable oral health outcomes [ 11 ]. A cross-sectional study conducted by Lui et al. (2017) found that highly educated caregivers exhibited significant knowledge of oral health and a positive attitude toward oral hygiene care for patients [ 12 ]. Goh et al. (2016) investigated the perspectives and attitudes of caregivers toward oral care and found that caregivers had positive attitudes toward providing oral care, but about 50% lacked the confidence to provide oral care for the residents [ 13 ].
The confidence of caregivers in the delivery of oral healthcare can affect the caregiver’s ability to perform clinical tasks, quality of care, and patient’s oral health outcomes, and potentially further impact their relationships with patients and the healthcare team [ 14 ].
Studies had been performed to assess caregivers’ knowledge, attitudes, and practices regarding the oral hygiene assistance of nursing home residents internationally [ 12 , 15 , 16 ]. However, there were no reported studies regarding the assessment of the knowledge, attitudes, and confidence of caregivers in the provision of oral hygiene assistance to nursing home residents in the United States. This study aims to address the gaps in the literature regarding the beliefs and behaviors of caregivers and administrative staff in the provision of oral hygiene assistance for nursing home residents in San Antonio, Texas, and provide a new perspective for future studies. The primary objective of this research was to use qualitative methods to assess the knowledge, attitudes, and confidence of caregivers in their ability to provide oral hygiene assistance to residents. The secondary objective was to assess the knowledge and attitude of administrators in the provision of oral hygiene assistance for residents, and their confidence in caregivers’ ability to provide oral hygiene assistance to nursing home residents in San Antonio, Texas.
This research was deemed exempt (protocol number: 20210714NRR) by the Institutional Review Board (IRB) at the University of Texas Health Science Center in San Antonio. Twenty nursing homes in San Antonio that were affiliated with the University of Texas Health San Antonio School of Dentistry were randomly selected and invited to participate in the study. Out of twenty nursing homes invited to participate in the study, only 10 agreed to allow their staff to participate in the study. Nursing homes in San Antonio vary in size with 20–30 caregivers and 3–5 administrators per site. The study population included caregivers and administrators working at nursing homes or long-term care facilities in San Antonio, Texas. Registered nurses (RNs) licensed vocational nurses (LVNs), certified nursing assistants (CNAs), and medical aides are referred to as caregivers while social workers, nursing home administrators, directors, and assistant directors of nursing were referred to as administrators. Out of 250 caregivers and 40 administrators from 10 nursing homes who were eligible for the study, we were only able to recruit 7 caregivers and 12 administrators using a non-probability convenience sampling method. This study was conducted during the COVID-19 pandemic, so it was difficult to get more than 19 volunteers to participate in the study.
All caregivers and administrators who had worked at the nursing homes for at least three months, were 18 years and older, communicated in the English language, and voluntarily consented to participate in the study were eligible to participate. The participants who did not meet the inclusion criteria were excluded from the study. Also, participants provided informed consent by signing a consent form when they arrived at the interview location and before engaging in the interview. The participants were not offered any incentives for their involvement in the study.
A semi-structured interview guide developed from previous oral healthcare-related studies [ 17 , 18 , 19 , 20 ] that examined the knowledge, attitudes, practices, and confidence of various populations regarding oral healthcare was used to conduct face-to-face interviews with caregivers and administrators at nursing homes in San Antonio. Two different survey instruments were used for interviewing the caregivers and administrators. The first part of the interviews collected demographic data for the participants, such as age, gender, experience, and education. The following sections included questions to assess the knowledge of caregivers and administrators regarding oral health and their attitudes regarding the provision of oral care for nursing home residents. The final sections focus on assessing the caregiver’s confidence and administrators’ confidence in caregivers providing daily oral care for residents.
Each interview was conducted in a private space to maintain the confidentiality of the participant and lasted for 20–30 min. The interviewer obtained written informed consent before the interview, and the interviewer asked all the questions including the demographic questions. The interviews were conducted between October 2021 and January 2022 by a member of the research team and digitally recorded on an encrypted laptop, with only the research team having access to it. Data collected from study participants were stored in a safe and locked storage space at the University. The identity and confidentiality of the participants and collected data were protected throughout the study procedures.
Interviews were digitally recorded, transcribed, and hand-coded to form themes by one team member, and a qualitative data management software technology MAXQDA was used to code and generate themes by another team member using calibration among coders. The themes were compared between the two coders and a third member of the team broke the tie if the coders disagreed on t theme. The confidence-based questions were categorized on a 5-point Likert scale as it allows for a lower margin of error and provided a deeper insight. The themes gleaned from key-informant interviews were explored among team members which were followed by a discussion for quality assurance purposes.
The demographic data of caregivers ( N = 7) and administrative staff ( N = 12) from 10 nursing homes across San Antonio is shown in Table 1 .
Most of the study participants were female (79%), more than half of the caregivers had a high school education, and (43%) had an associate degree. All the administrators had an associate degree or higher and the participants’ mean work experience was 13.8 years.
Both the hand-coded and the MAXQDA software data analysis of the Interview data on the knowledge questions resulted in the themes, the connection between oral and systemic health, and training in oral health and oral healthcare. Interview data on attitudes resulted in the themes, the importance of good oral health, caregivers’ time constraints, and assessment of residents’ oral health.
Theme 1: The connection between oral and systemic health : Most caregivers and staff understood the connection between oral and systemic health. They were aware that most nursing home residents had two or more morbidities some of which may lead to mortality if not treated accordingly. Their understanding of the connection between systemic and oral diseases such as diabetes, cardiovascular disease, and the side effects of certain medications on oral health has incentivized caregivers to care for the resident’s oral health to prevent the systemic spread of disease.
“At their age, if they (resident) get a tooth infection, that can travel through their bloodstream…and the resident needs to understand that. ” Caregiver.
“If you have poor oral hygiene, it can lead to infections in your system. You can get pneumonia; I think you can get it from poor oral health. It’s like a big problem: the chain of events that can lead to other things.” Administrator.
“The mouth is the gateway to your heart and the condition of your mouth will tell a lot of things about your health in general. If you are not getting good oral care, you are going to get more health issues as you progress in life, especially if you are elderly. “Administrator.
“If a resident has an infection from a tooth, it can travel throughout their body and may cause death…. I know in the past, we had problems with a patient because of tooth infection, which led to other issues with their health.” Administrator.
Theme 2: Training in oral health : Caregivers and administrators mentioned that they need more training to improve their oral health knowledge and learn new techniques to work with residents on ventilators and those with dementia who sometimes refuse or resist care. They also indicated that receiving continuing education (CE) on oral care will raise their level of awareness, increase their confidence in the delivery of oral care and hygiene, and improve health outcomes. One administrator also stressed the need to improve the curriculum of the certified nursing assistant (CNA) programs so they can get more hours of oral health education.
“More training will help a lot because sometimes we try different ways to do it, but it does not work out, so we need more information, and more training because dental care is very important.” Caregiver.
“I have been an instructor for the CNA program, and I know the training is good. If it comes from a dentist, it will probably be better regarding what the resident needs. But it is not something we can offer at this time. The training is there, but it is probably not as accepted as it should be, which needs improvement.” Administrator.
“There would be some new people coming in and may need more training on brushing teeth and doing denture care; some may be different from others. I am all up for new training and learning new things.” Caregiver.
“We need more training on the provision of oral care for residents, we need more individuals who are confident enough to train caregivers to provide oral hygiene assistance for residents. Oral care is an expertise so we need more education on that.” Administrator.
In response to the attitude-based questions, the themes that emerged were the importance of good oral health, caregivers’ time constraints, and residents’ oral health assessment.
Theme 3: The importance of good oral health : Almost all participants stressed the importance of good oral health and its impact on the residents’ overall health and well-being. They acknowledged that good oral health enables residents to consume their food adequately and absorb critical micronutrients, which were essential for the growth and function of their immune cells. Administrators believed that residents with compromised immune systems were more susceptible to chronic diseases that can be fatal. Good oral health can prevent aspiration pneumonia and other chronic diseases prevalent in nursing homes.
“Good oral health contributes to the health of the body. If you have good oral health, you tend to eat more, better, and more adequately. You will also be more likely to take your medication and be more outgoing because you feel comfortable about how you look.” Caregiver. “Residents with good oral health may have better health outcomes and be in a good mood. Good oral health makes them a whole different person, they can eat better, and their health is better.” Administrator. “In this nursing home, good oral health was essential because many patients were under ventilator and gastrostomy. Good oral health will decrease their risk of aspiration pneumonia, which was a horrible thing sometimes, we have here.” Administrator. “I think good oral health is important, especially for those who cannot do oral care because their disease process does not allow them to remember how to do it. It was also important for the caregivers to do it daily, and the family needs to see that oral care was performed and they are not going to visit their loved one and see food in their teeth… or a bad odor coming from their mouth.” Administrator.
Theme 4: Caregiver’s time constraints :. Prior to the coronavirus pandemic, some nursing homes had a proportion of 14 residents per caregiver. This situation worsened during the pandemic because nursing homes were competing with hospitals to employ caregivers. Almost all the caregivers and administrators stated that the shortage of caregivers, staff taking time off from work, absenteeism, and other competing tasks limited the time caregivers must provide oral care for the residents.
“Sometimes we have no time to care for the oral health of the residents. We have like 60 patients and 2 or 3 people to care for them, so we have no time.” Caregiver. “I don’t think they had enough time. I had always thought you had 30 patients in a hallway, and you only had two CNAs. They usually split it, and most of them require two persons’ help, limiting their time with all the chores they must do to take care of the patients.” Administrator. “I don’t think they are allowed enough time. If you have call-ins and you cannot get somebody to come in, then they are working short… they must be on that routine base, and they had to make sure they cover the shift and provide care for all the residents.” Administrator. “Making sure that caregivers had enough time to do their work is a challenge. Time management is everything but it also depends on what going on with your patients, what is going on in the hall, and how you are staffed, it depends on lots of things coming into play.” Administrator. “Our ratio of patient to caregiver is probably 1:12 and if they experience call-ins or no show then the ratio will increase from there so it is really hard to provide good oral hygiene if you are rushing from one patient to the next. Also, some of our resident’s caseloads just grow if there was a shortage of staffing and we don’t feel we had enough time as each day fluctuates. “Administrator.
Theme 5: Assessment of residents’ oral health : The state of Texas regulatory services for nursing homes requires that nursing home residents participate in an annual health screening to assess their oral health status so that nursing home administrators can plan and facilitate the provision of oral care for residents. Initial oral health assessment of newly admitted residents was also required for all nursing homes, served as a baseline, and was essential for planning and treating chronic oral diseases. Additionally, the regular assessment of the resident’s oral cavity helped caregivers determine the type of diet (soft or regular) that was suitable for the resident and subsequently enabled the nutritionist to plan the resident’s diet accordingly.
“As part of the initial assessment process, we examined the resident’s oral cavity to determine if they had total or partial dentures so we can plan for their oral care.” Caregiver. “We do initial oral health assessment for the residents upon arrival to our facility…. the nurses check their oral mucosa, gums, teeth, check for oral sores, thrush, and a partial denture or edentulous so we can carefully plan for the resident’s oral care and food type.” Administrator. “They had to assess the oral health of residents and if there were any oral issues they (caregivers) must report to the doctor, social worker, or director of nursing so they can attend to their needs.” Administrator. “We had to assess the resident’s oral cavity for missing teeth, chipped teeth, full or partial dentures… upon admission and document it. If we fail to identify any existing oral problems upon admission and something happens later then it will be our responsibility to care for that. So, it is important that we do an initial and regular assessment of the resident’s oral health.” Administrator.
Confidence of caregivers relates to their confidence in the provision of oral care for residents. Administrators’ confidence in the provision of oral care relates to their confidence in their caregiver’s provision of oral health care.
The responses to the confidence-based questions for seven caregivers were based on a 5-point Likert scale (Table 2 ).
In response to questions on caregivers’ skills and denture care for residents, most caregivers agreed that they were confident in their skills to provide oral care (85.6%) and denture care (71.3%) for the residents, respectively. When asked about their confidence in providing oral care to resistive residents and discussing the harmful effects of tobacco use with the residents, most caregivers agreed that they were confident in working with combative residents (85.6%) and discussing tobacco use (57%) respectively.
The responses to the confidence-based questions for twelve administrators were also based on a 5-point Likert scale (Table 3 ).
The administrators were asked about caregivers’ confidence in providing adequate care for the residents and whether their diet contained essential nutrients for optimal oral health. Most of the administrators were confident that caregivers provided adequate care for the residents (66.7%) and that the resident’s diet contained all the nutrients to maintain optimal oral health (75%). In response to the question on caregivers’ skills to provide oral care, half of the administrators (50%were confident that their caregivers had adequate skills to provide oral care for residents, while 41.7% were unsure. Regarding training, administrators were confident that caregivers were adequately trained since 50% agreed with the statement.
To the best of our knowledge, this is the first study conducted in the United States that assessed the knowledge, attitudes, and confidence of caregivers and administrators in the provision of oral care for nursing home residents. Our findings showed that caregivers and administrators have adequate knowledge about the connection between oral and systemic health which is broadly consistent with previous studies [ 21 , 22 ]. A 2009 study to evaluate the importance of oral health in nursing homes revealed that older adults were more susceptible to chronic systemic diseases that can affect their overall health, and periodontal disease has been linked to systemic conditions through inflammatory processes [ 21 ]. In our study, caregivers and administrators were knowledgeable about the connection between oral and systemic health and that infection in the oral cavity can metastasize to other body organs through the bloodstream. They also understood that poor oral hygiene can lead to aspiration pneumonia prevalent among nursing home residents.
Another theme that emerged from the study was the need for more training for caregivers in providing oral care for the residents, which was consistent with previous studies [ 23 , 24 , 25 ]. Although caregivers and administrators were knowledgeable about oral health, a vast majority of caregivers requested continuing education (CE) to improve their knowledge and enhance their skills in providing oral healthcare for hostile and resistant patients. Additionally, almost half of the administrators felt that caregivers were adequately trainedto provide oral care for residents. Administrators who were responsible for planning and implementing CE programs for caregivers stated that they could not offer such programs due to staffing shortages, lack of time, and logistical challenges involved in implementing such programs. As a result, they are highly dependent on the oral care knowledge the Certified Nursing Assistants (CNAs) acquired from their CNA training programs which may be insufficient.
Caregivers’ time constraints emerged as a significant barrier to providing care for residents, consistent with other studies (23–24,). In this study, nearly all the administrators agreed that the caregivers lack sufficient time to provide oral care for the residents due to competing tasks, and staffing shortages leading to 1 caregiver caring for 8–10 residents at a time. Additionally, it was time-consuming to provide care for residents with dementia and combative residents. In a systematic review of studies on the knowledge, attitudes, and beliefs acting as barriers and facilitators for the provision of oral care, the authors found that it takes plenty of time to provide oral care to combative patients [ 26 ]. On the contrary, in a 2011 cross-sectional study performed in Sweden, the authors found that the nursing staff believed they had sufficient time to perform oral care practices [ 27 ].
Both caregivers and administrators understood the importance of good oral health which was consistent with previous studies [ 20 , 28 ]. Coleman (2002) found that effective oral care practice was about recognizing the importance and ensuring that daily oral hygiene care was given similar priority as bathing residents, combing their hair, administering medication, and other care practices [ 28 ]. In this study, caregivers believed that oral care was essential for nursing home residents, especially those on ventilators and gastrostomy. Residents with gastrostomy cannot be fed through the oral cavity resulting in neglect of oral care. Maeda and Akagi (2014) found that patients with limited oral intake or tube feeders need meticulous oral care to reduce poor clinical outcomes related to aspiration pneumonia [ 29 ].
Most participants revealed they must perform an initial assessment of the resident’s oral health before admission to their facility and whenever they complain of toothache. Some participants also explained that they sometimes could not adequately assess the resident’s teeth and periodontal structures due to a lack of cooperation by the residents. In a study performed in 2009, the authors stated that oral care was i not always adequately evaluated during assessments of the general health of residents due to lack of patient cooperation, time, restricted mouth opening, unpleasant nature of the task, lack of training, and knowledge [ 21 ].
Our study indicated that most of the caregivers agreed that they were confident in their skills in providing oral and denture care for the residents. However, administrators were confident in the caregiver’s ability and skills to provide oral and denture care for the residents. This is consistent with a 2014 study that reported that more caregivers felt confident in assisting residents with brushing their teeth than with flossing [ 30 ]. However, a cross-sectional study found that half of the caregivers lack confidence in providing oral care because of fear of harming the patient [ 13 ]. In our study, caregivers mentioned their challenges with providing oral care for residents on ventilators, but their experience had given them the confidence to provide adequate care.
One of the strengths of this study is that the interviews were conducted by a dentist who had no prior encounter with the participants, making it possible for participants to respond to the questions openly thereby reducing the potential for bias. Another strength of the study was that using qualitative methods provided insights into the attitudes of the respondents and why they agreed or disagreed with some of the questions and comments. Despite several strengths of this study, there were some limitations.
The study used a convenience sampling method to recruit participants, which may have led to selection bias. Most of the participants in the study were those who wanted to see positive change in the provision of oral care for residents, which may have accounted for response and social desirability bias. Participants may not have felt comfortable talking about their lack of confidence and abilities to a dentist for fear of being judged by an oral health expert, especially a dentist. They may have felt pressured to give good answers to look competent in the eyes of a dentist. Another limitation is that caregivers who volunteered to participate in the study may have been those who felt confident with their knowledge and skills, thus overestimating the caregiver’s knowledge and skills compared to the general caregiver population. Participant recruitment was a major challenge due to staffing shortages and COVID-19 restrictions in nursing homes. On several occasions, scheduled interviews with participants were canceled due to COVID-19 outbreaks and other emergencies which inadvertently prolonged the time for data collection. Although we assumed the sample is representative of nursing homes throughout Texas, the findings of this study may not be generalized to all nursing home residents in the United States due to possible differences in the regulation of oral care in nursing homes across states. Lastly, the question of whether caregivers had adequate time to perform oral hygiene care was not included in the survey instrument thereby limiting caregivers’ responses to the lack of adequate time to perform their daily tasks.
The study gave a broader insight into the provision of oral care in nursing homes from the perspectives of caregivers and administrative staff. Administrators must provide adequate training and time to caregivers so they can provide adequate oral health care for the residents. Future research must be undertaken to investigate the role of nursing home administrators in the provision of oral care for residents.
Implementation of a national policy for the provision of oral care for residents in long-term care settings, standardization of procedures coupled with an effective auditing system for compliance is indicated. In addition, nursing home authorities should be able to recruit and retain more caregivers through collaborative efforts with nursing training schools within the community to eliminate the problem of staffing shortages. We suggested that the oral care component of the curriculum of the CNA programs should be upgraded and enhanced in addition to being instructed by dental professionals. Lastly, nursing homes should consider appointing a dental champion who can coordinate continuing education and provision of oral hygiene and care for residents, especially those without dental insurance.
The data that supports the findings of this study are available from the corresponding author upon reasonable request.
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We would like to acknowledge the participating nursing homes and staff who contributed their time and effort to this work. We also appreciate the support from co-resident Girish Shelke.
This program is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling USD 3.25 million with 0% financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the US Government.
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Surgeon General Dr. Vivek Murthy Urges Action to Ensure Social Media Environments are Healthy and Safe, as Previously-Advised National Youth Mental Health Crisis Continues
Today, United States Surgeon General Dr. Vivek Murthy released a new Surgeon General’s Advisory on Social Media and Youth Mental Health . While social media may offer some benefits, there are ample indicators that social media can also pose a risk of harm to the mental health and well-being of children and adolescents. Social media use by young people is nearly universal, with up to 95% of young people ages 13-17 reporting using a social media platform and more than a third saying they use social media “almost constantly.”
With adolescence and childhood representing a critical stage in brain development that can make young people more vulnerable to harms from social media, the Surgeon General is issuing a call for urgent action by policymakers, technology companies, researchers, families, and young people alike to gain a better understanding of the full impact of social media use, maximize the benefits and minimize the harms of social media platforms, and create safer, healthier online environments to protect children. The Surgeon General’s Advisory is a part of the Department of Health and Human Services’ (HHS) ongoing efforts to support President Joe Biden’s whole-of-government strategy to transform mental health care for all Americans.
“The most common question parents ask me is, ‘is social media safe for my kids’. The answer is that we don't have enough evidence to say it's safe, and in fact, there is growing evidence that social media use is associated with harm to young people’s mental health,” said U.S. Surgeon General Dr. Vivek Murthy . “Children are exposed to harmful content on social media, ranging from violent and sexual content, to bullying and harassment. And for too many children, social media use is compromising their sleep and valuable in-person time with family and friends. We are in the middle of a national youth mental health crisis, and I am concerned that social media is an important driver of that crisis – one that we must urgently address.”
Usage of social media can become harmful depending on the amount of time children spend on the platforms, the type of content they consume or are otherwise exposed to, and the degree to which it disrupts activities that are essential for health like sleep and physical activity. Importantly, different children are affected by social media in different ways, including based on cultural, historical, and socio-economic factors. Among the benefits, adolescents report that social media helps them feel more accepted (58%), like they have people who can support them through tough times (67%), like they have a place to show their creative side (71%), and more connected to what’s going on in their friends’ lives (80%).
However, social media use can be excessive and problematic for some children. Recent research shows that adolescents who spend more than three hours per day on social media face double the risk of experiencing poor mental health outcomes, such as symptoms of depression and anxiety; yet one 2021 survey of teenagers found that, on average, they spend 3.5 hours a day on social media. Social media may also perpetuate body dissatisfaction, disordered eating behaviors, social comparison, and low self-esteem, especially among adolescent girls. One-third or more of girls aged 11-15 say they feel “addicted” to certain social media platforms and over half of teenagers report that it would be hard to give up social media. When asked about the impact of social media on their body image, 46% of adolescents aged 13-17 said social media makes them feel worse, 40% said it makes them feel neither better nor worse, and only 14% said it makes them feel better. Additionally, 64% of adolescents are “often” or “sometimes” exposed to hate-based content through social media. Studies have also shown a relationship between social media use and poor sleep quality, reduced sleep duration, sleep difficulties, and depression among youth.
While more research is needed to determine the full impact social media use has on nearly every teenager across the country, children and adolescents don’t have the luxury of waiting years until we know the full extent of social media’s effects. The Surgeon General’s Advisory offers recommendations stakeholders can take to help ensure children and their families have the information and tools necessary to make social media safer for children:
In concert with the Surgeon General’s Advisory, leaders at six of the nation’s medical organizations have expressed their concern on social media’s effects on youth mental health:
“Social media can be a powerful tool for connection, but it can also lead to increased feelings of depression and anxiety – particularly among adolescents. Family physicians are often the first stop for parents and families concerned about the physical and emotional health of young people in their lives, and we confront the mental health crisis among youth every day. The American Academy of Family Physicians commends the Surgeon General for identifying this risk for America's youth and joins our colleagues across the health care community in equipping young people and their families with the resources necessary to live healthy, balanced lives.” – Tochi Iroku-Malize, M.D., MPH, MBA, FAAFP, President, American Academy of Family Physicians
“Today’s children and teens do not know a world without digital technology, but the digital world wasn’t built with children’s healthy mental development in mind. We need an approach to help children both on and offline that meets each child where they are while also working to make the digital spaces they inhabit safer and healthier. The Surgeon General’s Advisory calls for just that approach. The American Academy of Pediatrics looks forward to working with the Surgeon General and other federal leaders on Youth Mental Health and Social Media on this important work.” – Sandy Chung, M.D., FAAP, President, American Academy of Pediatrics
“With near universal social media use by America’s young people, these apps and sites introduce profound risk and mental health harms in ways we are only now beginning to fully understand. As physicians, we see firsthand the impact of social media, particularly during adolescence – a critical period of brain development. As we grapple with the growing, but still insufficient, research and evidence in this area, we applaud the Surgeon General for issuing this important Advisory to highlight this issue and enumerate concrete steps stakeholders can take to address concerns and protect the mental health and wellbeing of children and adolescents.We continue to believe in the positive benefits of social media, but we also urge safeguards and additional study of the positive and negative biological, psychological, and social effects of social media.”— Jack Resneck Jr., M.D., President, American Medical Association
“The first principle of health care is to do no harm – that’s the same standard we need to start holding social media platforms to. As the Surgeon General has pointed out throughout his tenure, we all have a role to play in addressing the youth mental health crisis that we now face as a nation. We have the responsibility to ensure social media keeps young people safe. And as this Surgeon General’s Advisory makes clear, we as physicians and healers have a responsibility to be part of the effort to do so.” – Saul Levin, M.D., M.P.A., CEO and Medical Director, American Psychiatric Association
“The American Psychological Association applauds the Surgeon General's Advisory on Social Media and Youth Mental Health, affirming the use of psychological science to reach clear-eyed recommendations that will help keep our youth safe online. Psychological research shows that young people mature at different rates, with some more vulnerable than others to the content and features on many social media platforms. We support the advisory's recommendations and pledge to work with the Surgeon General's Office to help build the healthy digital environment that our kids need and deserve.” – Arthur Evans, Jr., Ph.D., Chief Executive Officer and Executive Vice President, American Psychological Association.
“Social media use by young people is pervasive. It can help them, and all of us, live more connected lives – if, and only if, the appropriate oversight, regulation and guardrails are applied. Now is the moment for policymakers, companies and experts to come together and ensure social media is set up safety-first, to help young users grow and thrive. The Surgeon General’s Advisory about the effects of social media on youth mental health issued today lays out a roadmap for us to do so, and it’s critical that we undertake this collective effort with care and urgency to help today’s youth.” – Susan L. Polan, Ph.D., Associate Executive Director, Public Affairs and Advocacy, American Public Health Association
The National Parent Teacher Association shared the following:
“Every parent’s top priority for their child is for them to be happy, healthy and safe. We have heard from families who say they need and want information about using social media and devices. This Advisory from the Surgeon General confirms that family engagement on this topic is vital and continues to be one of the core solutions to keeping children safe online and supporting their mental health and well-being.” – Anna King, President of the National Parent Teacher Association .
In December 2021, Dr. Murthy issued a Surgeon General’s Advisory on Protecting Youth Mental Health calling attention to our national crisis of youth mental health and well-being. Earlier this month, he released a Surgeon General’s Advisory on Our Epidemic of Loneliness and Isolation , where he outlined the profound health consequences of social disconnection and laid out six pillars to increase connection across the country, one of which being the need to reform our digital environments. The new Surgeon General’s Advisory on Social Media and Youth Mental Health is a continuation of his work to enhance the mental health and well-being of young people across the country.
The full Surgeon General’s Advisory can be read here . For more information about the Office of the Surgeon General, visit www.surgeongeneral.gov/priorities .
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COMMENTS
An interview is a qualitative research method that relies on asking questions in order to collect data. Interviews involve two or more people, one of whom is the interviewer asking the questions. ... It occurs in all types of interviews and surveys, but is most common in semi-structured interviews, unstructured interviews, ...
Learning from Strangers: The Art and Method of Qualitative Interview Studies. New York: Simon and Schuster. A classic and well-regarded textbook on interviewing. Because Weiss has extensive experience conducting surveys, he contrasts the qualitative interview with the survey questionnaire well; particularly useful for those trained in the latter.
Interview and survey are both commonly used research methods. They are used to gather data, opinions, and insights from participants. However, the two methods are distinct in their approach and execution. An interview is a method of research where a researcher asks questions to a participant in person, over the phone, or online.
Survey and interview methods form the basis of a vast amount of the literature in clinical psychology. After all, the easiest way to infer and measure a psychological state is often to ask the person to report it directly. ... Book: The Cambridge Handbook of Research Methods in Clinical Psychology; Online publication: 23 March 2020; Chapter DOI ...
If your answers are positive to these questions, then survey design rather than the interviews might be a better option for you. For those who would like to gather more diverse information on their topic of choice, an interview is the method to use. What are the different types of Interviews? There are three main kinds of research interviews. 1.
Develop an interview guide. Introduce yourself and explain the aim of the interview. Devise your questions so interviewees can help answer your research question. Have a sequence to your questions / topics by grouping them in themes. Make sure you can easily move back and forth between questions / topics. Make sure your questions are clear and ...
An interview is a qualitative research method that relies on asking questions in order to collect data. Interviews involve two or more people, one of whom is the interviewer asking the questions. ... more nuanced and unfiltered feedback than individual interviews and are easier to organise than experiments or large surveys. However, their small ...
Interviews are more resource-intensive but can provide great depth to your research. Meanwhile, surveys are quick and easy to get off the ground and to analyse—especially with SurveyMonkey's survey templates and suite of tools—and bring an excellent breadth to your findings. Create a successful survey in 10 easy steps.
Survey research means collecting information about a group of people by asking them questions and analyzing the results. To conduct an effective survey, follow these six steps: Determine who will participate in the survey. Decide the type of survey (mail, online, or in-person) Design the survey questions and layout.
Survey research means collecting information about a group of people by asking them questions and analysing the results. To conduct an effective survey, follow these six steps: Determine who will participate in the survey. Decide the type of survey (mail, online, or in-person) Design the survey questions and layout. Distribute the survey.
6. Qualitative Research and Interviews. So we've described doing a survey and collecting quantitative data. But not all questions can best be answered by a survey. A survey is great for understanding what people think (for example), but not why they think what they do. If your research is intending to understand the underlying motivations or ...
QuestionPro is a flexible online survey platform that can help researchers do different kinds of interviews, like structured, semi-structured, unstructured, phone interview, group interview, etc. It gives researchers a flexible platform that can be changed to fit their needs and the needs of their research project.
Chapter 5 takes a close look at survey research as a process of interviewing. We often think of sur-veys in the narrower context of self-completed questionnaires or telephone surveys. However, surveys in research are actually a broader category that refers to structured questioning. It includes both the questionnaires and the structured interviews.
An interview is a survey research method where the researcher facilitates some sort of conversation with the research participant to gather useful information about the research subject. This conversation can happen physically as a face-to-face interview or virtually as a telephone interview or via video and audio-conferencing platforms.
182 DOING RESEARCH Learning how to design and use structured interviews, questionnaires and observation instruments is an important skill for research-ers. Such survey instruments can be used in many types of research, from case study, to cross-sectional survey, to experiment. A study of this sort can involve anything from a short
Survey research is defined as "the collection of information from a sample of individuals through their responses to questions" ( Check & Schutt, 2012, p. 160 ). This type of research allows for a variety of methods to recruit participants, collect data, and utilize various methods of instrumentation. Survey research can use quantitative ...
Qualitative research method-interviewing and observation. Buckley and Chiang define research methodology as "a strategy or architectural design by which the researcher maps out an approach to problem-finding or problem-solving.". [ 1] According to Crotty, research methodology is a comprehensive strategy 'that silhouettes our choice and ...
Survey Research. Definition: Survey Research is a quantitative research method that involves collecting standardized data from a sample of individuals or groups through the use of structured questionnaires or interviews. The data collected is then analyzed statistically to identify patterns and relationships between variables, and to draw conclusions about the population being studied.
Mixing interview and questionnaire methods: Practical problems in aligning data. Lois R. Harris, The University of Auckland Gavin T. L. Brown, The Hong Kong Institute of Education. Structured questionnaires and semi-structured interviews are often used in mixed method studies to generate confirmatory results despite differences in methods of ...
Social Science Research - Principles, Methods, and Practices (Bhattacherjee) 9: Survey Research 9.3: Interview Survey ... focus groups are usually used for exploratory research rather than descriptive or explanatory research. A third type of interview survey is telephone interviews. In this technique, interviewers contact potential respondents ...
The primary mission of PSR is to provide survey research resources to enhance the quality of teaching and research at Harvard. Internet, Phone, Mail, ... while helping them understand how to design and implement specific research methods. "Learning to Interview in the Social Sciences" Qualitative Inquiry, 9(4) 2003, 643-668 by Roulston, K ...
Pre-test the survey - Test the questions. Conduct the survey - Ask the questions. Analyze the data collected - Produce the report. The key step in designing a survey is setting the goals. The ...
Interviewing is a very effective method of data collection. It is a systematic and objective conversation between an investigator and respondent for collecting relevant data for a specific research study. Along with conversation, learning about the gestures, facial expressions and environmental conditions of a respondent are also very important.
Survey research is the process of collecting data from a predefined group (e.g. customers or potential customers) with the ultimate goal of uncovering insights about your products, services, or brand overall. As a quantitative data collection method, survey research can provide you with a goldmine of information that can inform crucial business and product decisions.
Utilizing the Transactional Model in conducting interviews, surveys, and usability testing can help provide structure to your process and increase the quality of insights gathered. Interviews. Interviews are a common method used in qualitative UX research. They provide the perfect method for applying principles from the Transactional Model.
This study used a mixed methods sequential design, consisting of two distinct work packages: (1) quantitative survey to describe patterns of help seeking and unmet mental health needs and (2) nested semi-structured interviews to understand more nuanced aspects of accessing and delivering support.
The mission of NCCIH is to determine, through rigorous scientific investigation, the fundamental science, usefulness, and safety of complementary and integrative health approaches and their roles in improving health and health care. NCCIH's vision is that scientific evidence informs decision making by the public, by health care professionals ...
The primary objective of this research was to use qualitative methods to assess the knowledge, attitudes, and confidence of caregivers in their ability to provide oral hygiene assistance to residents. ... Two different survey instruments were used for interviewing the caregivers and administrators. The first part of the interviews collected ...
Psychological research shows that young people mature at different rates, with some more vulnerable than others to the content and features on many social media platforms. We support the advisory's recommendations and pledge to work with the Surgeon General's Office to help build the healthy digital environment that our kids need and deserve."