the research questions for this study were

Get science-backed answers as you write with Paperpal's Research feature

How to Write a Research Question: Types and Examples 

The first step in any research project is framing the research question. It can be considered the core of any systematic investigation as the research outcomes are tied to asking the right questions. Thus, this primary interrogation point sets the pace for your research as it helps collect relevant and insightful information that ultimately influences your work.   

Typically, the research question guides the stages of inquiry, analysis, and reporting. Depending on the use of quantifiable or quantitative data, research questions are broadly categorized into quantitative or qualitative research questions. Both types of research questions can be used independently or together, considering the overall focus and objectives of your research.  

What is a research question?

A research question is a clear, focused, concise, and arguable question on which your research and writing are centered. 1 It states various aspects of the study, including the population and variables to be studied and the problem the study addresses. These questions also set the boundaries of the study, ensuring cohesion. 

Designing the research question is a dynamic process where the researcher can change or refine the research question as they review related literature and develop a framework for the study. Depending on the scale of your research, the study can include single or multiple research questions. 

A good research question has the following features: 

• It is relevant to the chosen field of study. 
• The question posed is arguable and open for debate, requiring synthesizing and analysis of ideas. 
• It is focused and concisely framed. 
• A feasible solution is possible within the given practical constraint and timeframe. 

A poorly formulated research question poses several risks. 1   

• Researchers can adopt an erroneous design. 
• It can create confusion and hinder the thought process, including developing a clear protocol.  
• It can jeopardize publication efforts.  
• It causes difficulty in determining the relevance of the study findings.  
• It causes difficulty in whether the study fulfils the inclusion criteria for systematic review and meta-analysis. This creates challenges in determining whether additional studies or data collection is needed to answer the question.  
• Readers may fail to understand the objective of the study. This reduces the likelihood of the study being cited by others. 

Now that you know “What is a research question?”, let’s look at the different types of research questions. 

Types of research questions

Depending on the type of research to be done, research questions can be classified broadly into quantitative, qualitative, or mixed-methods studies. Knowing the type of research helps determine the best type of research question that reflects the direction and epistemological underpinnings of your research. 

The structure and wording of quantitative 2 and qualitative research 3 questions differ significantly. The quantitative study looks at causal relationships, whereas the qualitative study aims at exploring a phenomenon. 

• Quantitative research questions:  
• Seeks to investigate social, familial, or educational experiences or processes in a particular context and/or location.  
• Answers ‘how,’ ‘what,’ or ‘why’ questions. 
• Investigates connections, relations, or comparisons between independent and dependent variables. 

Quantitative research questions can be further categorized into descriptive, comparative, and relationship, as explained in the Table below. 

• Qualitative research questions  

Qualitative research questions are adaptable, non-directional, and more flexible. It concerns broad areas of research or more specific areas of study to discover, explain, or explore a phenomenon. These are further classified as follows: 

• Mixed-methods studies  

Mixed-methods studies use both quantitative and qualitative research questions to answer your research question. Mixed methods provide a complete picture than standalone quantitative or qualitative research, as it integrates the benefits of both methods. Mixed methods research is often used in multidisciplinary settings and complex situational or societal research, especially in the behavioral, health, and social science fields. 

What makes a good research question

A good research question should be clear and focused to guide your research. It should synthesize multiple sources to present your unique argument, and should ideally be something that you are interested in. But avoid questions that can be answered in a few factual statements. The following are the main attributes of a good research question. 

• Specific: The research question should not be a fishing expedition performed in the hopes that some new information will be found that will benefit the researcher. The central research question should work with your research problem to keep your work focused. If using multiple questions, they should all tie back to the central aim. 
• Measurable: The research question must be answerable using quantitative and/or qualitative data or from scholarly sources to develop your research question. If such data is impossible to access, it is better to rethink your question. 
• Attainable: Ensure you have enough time and resources to do all research required to answer your question. If it seems you will not be able to gain access to the data you need, consider narrowing down your question to be more specific. 
• You have the expertise 
• You have the equipment and resources 
• Realistic: Developing your research question should be based on initial reading about your topic. It should focus on addressing a problem or gap in the existing knowledge in your field or discipline. 
• Based on some sort of rational physics 
• Can be done in a reasonable time frame 
• Timely: The research question should contribute to an existing and current debate in your field or in society at large. It should produce knowledge that future researchers or practitioners can later build on. 
• Novel 
• Based on current technologies. 
• Important to answer current problems or concerns. 
• Lead to new directions. 
• Important: Your question should have some aspect of originality. Incremental research is as important as exploring disruptive technologies. For example, you can focus on a specific location or explore a new angle. 
• Meaningful whether the answer is “Yes” or “No.” Closed-ended, yes/no questions are too simple to work as good research questions. Such questions do not provide enough scope for robust investigation and discussion. A good research question requires original data, synthesis of multiple sources, and original interpretation and argumentation before providing an answer. 

Steps for developing a good research question

The importance of research questions cannot be understated. When drafting a research question, use the following frameworks to guide the components of your question to ease the process. 4  

• Determine the requirements: Before constructing a good research question, set your research requirements. What is the purpose? Is it descriptive, comparative, or explorative research? Determining the research aim will help you choose the most appropriate topic and word your question appropriately. 
• Select a broad research topic: Identify a broader subject area of interest that requires investigation. Techniques such as brainstorming or concept mapping can help identify relevant connections and themes within a broad research topic. For example, how to learn and help students learn. 
• Perform preliminary investigation: Preliminary research is needed to obtain up-to-date and relevant knowledge on your topic. It also helps identify issues currently being discussed from which information gaps can be identified. 
• Narrow your focus: Narrow the scope and focus of your research to a specific niche. This involves focusing on gaps in existing knowledge or recent literature or extending or complementing the findings of existing literature. Another approach involves constructing strong research questions that challenge your views or knowledge of the area of study (Example: Is learning consistent with the existing learning theory and research). 
• Identify the research problem: Once the research question has been framed, one should evaluate it. This is to realize the importance of the research questions and if there is a need for more revising (Example: How do your beliefs on learning theory and research impact your instructional practices). 

How to write a research question

Those struggling to understand how to write a research question, these simple steps can help you simplify the process of writing a research question. 

Sample Research Questions

The following are some bad and good research question examples 

• Example 1 
• Example 2 

References:  

• Thabane, L., Thomas, T., Ye, C., & Paul, J. (2009). Posing the research question: not so simple.  Canadian Journal of Anesthesia/Journal canadien d’anesthésie ,  56 (1), 71-79. 
• Rutberg, S., & Bouikidis, C. D. (2018). Focusing on the fundamentals: A simplistic differentiation between qualitative and quantitative research.  Nephrology Nursing Journal ,  45 (2), 209-213. 
• Kyngäs, H. (2020). Qualitative research and content analysis.  The application of content analysis in nursing science research , 3-11. 
• Mattick, K., Johnston, J., & de la Croix, A. (2018). How to… write a good research question.  The clinical teacher ,  15 (2), 104-108. 
• Fandino, W. (2019). Formulating a good research question: Pearls and pitfalls.  Indian Journal of Anaesthesia ,  63 (8), 611. 
• Richardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. (1995). The well-built clinical question: a key to evidence-based decisions.  ACP journal club ,  123 (3), A12-A13 

Paperpal is a comprehensive AI writing toolkit that helps students and researchers achieve 2x the writing in half the time. It leverages 21+ years of STM experience and insights from millions of research articles to provide in-depth academic writing, language editing, and submission readiness support to help you write better, faster.  

Get accurate academic translations, rewriting support, grammar checks, vocabulary suggestions, and generative AI assistance that delivers human precision at machine speed. Try for free or upgrade to Paperpal Prime starting at US$19 a month to access premium features, including consistency, plagiarism, and 30+ submission readiness checks to help you succeed.  

Experience the future of academic writing – Sign up to Paperpal and start writing for free!  

Related Reads:

• Scientific Writing Style Guides Explained
• Ethical Research Practices For Research with Human Subjects
• 8 Most Effective Ways to Increase Motivation for Thesis Writing 
• 6 Tips for Post-Doc Researchers to Take Their Career to the Next Level

Transitive and Intransitive Verbs in the World of Research

Language and grammar rules for academic writing, you may also like, how to write the first draft of a..., mla works cited page: format, template & examples, academic editing: how to self-edit academic text with..., measuring academic success: definition & strategies for excellence, phd qualifying exam: tips for success , quillbot review: features, pricing, and free alternatives, what is an academic paper types and elements , 9 steps to publish a research paper, what are the different types of research papers, how to make translating academic papers less challenging.

• Affiliate Program

• UNITED STATES
• 台灣 (TAIWAN)
• TÜRKIYE (TURKEY)
• Academic Editing Services
• - Research Paper
• - Journal Manuscript
• - Dissertation
• - College & University Assignments
• Admissions Editing Services
• - Application Essay
• - Personal Statement
• - Recommendation Letter
• - Cover Letter
• - CV/Resume
• Business Editing Services
• - Business Documents
• - Report & Brochure
• - Website & Blog
• Writer Editing Services
• - Script & Screenplay
• Our Editors
• Client Reviews
• Editing & Proofreading Prices
• Wordvice Points
• Partner Discount
• Plagiarism Checker
• APA Citation Generator
• MLA Citation Generator
• Chicago Citation Generator
• Vancouver Citation Generator
• - APA Style
• - MLA Style
• - Chicago Style
• - Vancouver Style
• Writing & Editing Guide
• Academic Resources
• Admissions Resources

How to Write a Good Research Question (w/ Examples)

What is a Research Question?

A research question is the main question that your study sought or is seeking to answer. A clear research question guides your research paper or thesis and states exactly what you want to find out, giving your work a focus and objective. Learning  how to write a hypothesis or research question is the start to composing any thesis, dissertation, or research paper. It is also one of the most important sections of a research proposal . 

A good research question not only clarifies the writing in your study; it provides your readers with a clear focus and facilitates their understanding of your research topic, as well as outlining your study’s objectives. Before drafting the paper and receiving research paper editing (and usually before performing your study), you should write a concise statement of what this study intends to accomplish or reveal.

Research Question Writing Tips

Listed below are the important characteristics of a good research question:

A good research question should:

• Be clear and provide specific information so readers can easily understand the purpose.
• Be focused in its scope and narrow enough to be addressed in the space allowed by your paper
• Be relevant and concise and express your main ideas in as few words as possible, like a hypothesis.
• Be precise and complex enough that it does not simply answer a closed “yes or no” question, but requires an analysis of arguments and literature prior to its being considered acceptable. 
• Be arguable or testable so that answers to the research question are open to scrutiny and specific questions and counterarguments.

Some of these characteristics might be difficult to understand in the form of a list. Let’s go into more detail about what a research question must do and look at some examples of research questions.

The research question should be specific and focused 

Research questions that are too broad are not suitable to be addressed in a single study. One reason for this can be if there are many factors or variables to consider. In addition, a sample data set that is too large or an experimental timeline that is too long may suggest that the research question is not focused enough.

A specific research question means that the collective data and observations come together to either confirm or deny the chosen hypothesis in a clear manner. If a research question is too vague, then the data might end up creating an alternate research problem or hypothesis that you haven’t addressed in your Introduction section .

The research question should be based on the literature 

An effective research question should be answerable and verifiable based on prior research because an effective scientific study must be placed in the context of a wider academic consensus. This means that conspiracy or fringe theories are not good research paper topics.

Instead, a good research question must extend, examine, and verify the context of your research field. It should fit naturally within the literature and be searchable by other research authors.

References to the literature can be in different citation styles and must be properly formatted according to the guidelines set forth by the publishing journal, university, or academic institution. This includes in-text citations as well as the Reference section . 

The research question should be realistic in time, scope, and budget

There are two main constraints to the research process: timeframe and budget.

A proper research question will include study or experimental procedures that can be executed within a feasible time frame, typically by a graduate doctoral or master’s student or lab technician. Research that requires future technology, expensive resources, or follow-up procedures is problematic.

A researcher’s budget is also a major constraint to performing timely research. Research at many large universities or institutions is publicly funded and is thus accountable to funding restrictions. 

The research question should be in-depth

Research papers, dissertations and theses , and academic journal articles are usually dozens if not hundreds of pages in length.

A good research question or thesis statement must be sufficiently complex to warrant such a length, as it must stand up to the scrutiny of peer review and be reproducible by other scientists and researchers.

Research Question Types

Qualitative and quantitative research are the two major types of research, and it is essential to develop research questions for each type of study. 

Quantitative Research Questions

Quantitative research questions are specific. A typical research question involves the population to be studied, dependent and independent variables, and the research design.

In addition, quantitative research questions connect the research question and the research design. In addition, it is not possible to answer these questions definitively with a “yes” or “no” response. For example, scientific fields such as biology, physics, and chemistry often deal with “states,” in which different quantities, amounts, or velocities drastically alter the relevance of the research.

As a consequence, quantitative research questions do not contain qualitative, categorical, or ordinal qualifiers such as “is,” “are,” “does,” or “does not.”

Categories of quantitative research questions

Qualitative research questions.

In quantitative research, research questions have the potential to relate to broad research areas as well as more specific areas of study. Qualitative research questions are less directional, more flexible, and adaptable compared with their quantitative counterparts. Thus, studies based on these questions tend to focus on “discovering,” “explaining,” “elucidating,” and “exploring.”

Categories of qualitative research questions

Quantitative and qualitative research question examples.

Good and Bad Research Question Examples

Below are some good (and not-so-good) examples of research questions that researchers can use to guide them in crafting their own research questions.

Research Question Example 1

The first research question is too vague in both its independent and dependent variables. There is no specific information on what “exposure” means. Does this refer to comments, likes, engagement, or just how much time is spent on the social media platform?

Second, there is no useful information on what exactly “affected” means. Does the subject’s behavior change in some measurable way? Or does this term refer to another factor such as the user’s emotions?

Research Question Example 2

In this research question, the first example is too simple and not sufficiently complex, making it difficult to assess whether the study answered the question. The author could really only answer this question with a simple “yes” or “no.” Further, the presence of data would not help answer this question more deeply, which is a sure sign of a poorly constructed research topic.

The second research question is specific, complex, and empirically verifiable. One can measure program effectiveness based on metrics such as attendance or grades. Further, “bullying” is made into an empirical, quantitative measurement in the form of recorded disciplinary actions.

Steps for Writing a Research Question

Good research questions are relevant, focused, and meaningful. It can be difficult to come up with a good research question, but there are a few steps you can follow to make it a bit easier.

1. Start with an interesting and relevant topic

Choose a research topic that is interesting but also relevant and aligned with your own country’s culture or your university’s capabilities. Popular academic topics include healthcare and medical-related research. However, if you are attending an engineering school or humanities program, you should obviously choose a research question that pertains to your specific study and major.

Below is an embedded graph of the most popular research fields of study based on publication output according to region. As you can see, healthcare and the basic sciences receive the most funding and earn the highest number of publications. 

2. Do preliminary research  

You can begin doing preliminary research once you have chosen a research topic. Two objectives should be accomplished during this first phase of research. First, you should undertake a preliminary review of related literature to discover issues that scholars and peers are currently discussing. With this method, you show that you are informed about the latest developments in the field.

Secondly, identify knowledge gaps or limitations in your topic by conducting a preliminary literature review . It is possible to later use these gaps to focus your research question after a certain amount of fine-tuning.

3. Narrow your research to determine specific research questions

You can focus on a more specific area of study once you have a good handle on the topic you want to explore. Focusing on recent literature or knowledge gaps is one good option. 

By identifying study limitations in the literature and overlooked areas of study, an author can carve out a good research question. The same is true for choosing research questions that extend or complement existing literature.

4. Evaluate your research question

Make sure you evaluate the research question by asking the following questions:

Is my research question clear?

The resulting data and observations that your study produces should be clear. For quantitative studies, data must be empirical and measurable. For qualitative, the observations should be clearly delineable across categories.

Is my research question focused and specific?

A strong research question should be specific enough that your methodology or testing procedure produces an objective result, not one left to subjective interpretation. Open-ended research questions or those relating to general topics can create ambiguous connections between the results and the aims of the study. 

Is my research question sufficiently complex?

The result of your research should be consequential and substantial (and fall sufficiently within the context of your field) to warrant an academic study. Simply reinforcing or supporting a scientific consensus is superfluous and will likely not be well received by most journal editors.  

Editing Your Research Question

Your research question should be fully formulated well before you begin drafting your research paper. However, you can receive English paper editing and proofreading services at any point in the drafting process. Language editors with expertise in your academic field can assist you with the content and language in your Introduction section or other manuscript sections. And if you need further assistance or information regarding paper compositions, in the meantime, check out our academic resources , which provide dozens of articles and videos on a variety of academic writing and publication topics.

Research Aims, Objectives & Questions

The “Golden Thread” Explained Simply (+ Examples)

By: David Phair (PhD) and Alexandra Shaeffer (PhD) | June 2022

The research aims , objectives and research questions (collectively called the “golden thread”) are arguably the most important thing you need to get right when you’re crafting a research proposal , dissertation or thesis . We receive questions almost every day about this “holy trinity” of research and there’s certainly a lot of confusion out there, so we’ve crafted this post to help you navigate your way through the fog.

Overview: The Golden Thread

• What is the golden thread
• What are research aims ( examples )
• What are research objectives ( examples )
• What are research questions ( examples )
• The importance of alignment in the golden thread

What is the “golden thread”?  

The golden thread simply refers to the collective research aims , research objectives , and research questions for any given project (i.e., a dissertation, thesis, or research paper ). These three elements are bundled together because it’s extremely important that they align with each other, and that the entire research project aligns with them.

Importantly, the golden thread needs to weave its way through the entirety of any research project , from start to end. In other words, it needs to be very clearly defined right at the beginning of the project (the topic ideation and proposal stage) and it needs to inform almost every decision throughout the rest of the project. For example, your research design and methodology will be heavily influenced by the golden thread (we’ll explain this in more detail later), as well as your literature review.

The research aims, objectives and research questions (the golden thread) define the focus and scope ( the delimitations ) of your research project. In other words, they help ringfence your dissertation or thesis to a relatively narrow domain, so that you can “go deep” and really dig into a specific problem or opportunity. They also help keep you on track , as they act as a litmus test for relevance. In other words, if you’re ever unsure whether to include something in your document, simply ask yourself the question, “does this contribute toward my research aims, objectives or questions?”. If it doesn’t, chances are you can drop it.

Alright, enough of the fluffy, conceptual stuff. Let’s get down to business and look at what exactly the research aims, objectives and questions are and outline a few examples to bring these concepts to life.

Research Aims: What are they?

Simply put, the research aim(s) is a statement that reflects the broad overarching goal (s) of the research project. Research aims are fairly high-level (low resolution) as they outline the general direction of the research and what it’s trying to achieve .

Research Aims: Examples  

True to the name, research aims usually start with the wording “this research aims to…”, “this research seeks to…”, and so on. For example:

“This research aims to explore employee experiences of digital transformation in retail HR.”   “This study sets out to assess the interaction between student support and self-care on well-being in engineering graduate students”  

As you can see, these research aims provide a high-level description of what the study is about and what it seeks to achieve. They’re not hyper-specific or action-oriented, but they’re clear about what the study’s focus is and what is being investigated.

Need a helping hand?

Research Objectives: What are they?

The research objectives take the research aims and make them more practical and actionable . In other words, the research objectives showcase the steps that the researcher will take to achieve the research aims.

The research objectives need to be far more specific (higher resolution) and actionable than the research aims. In fact, it’s always a good idea to craft your research objectives using the “SMART” criteria. In other words, they should be specific, measurable, achievable, relevant and time-bound”.

Research Objectives: Examples  

Let’s look at two examples of research objectives. We’ll stick with the topic and research aims we mentioned previously.  

For the digital transformation topic:

To observe the retail HR employees throughout the digital transformation. To assess employee perceptions of digital transformation in retail HR. To identify the barriers and facilitators of digital transformation in retail HR.

And for the student wellness topic:

To determine whether student self-care predicts the well-being score of engineering graduate students. To determine whether student support predicts the well-being score of engineering students. To assess the interaction between student self-care and student support when predicting well-being in engineering graduate students.

  As you can see, these research objectives clearly align with the previously mentioned research aims and effectively translate the low-resolution aims into (comparatively) higher-resolution objectives and action points . They give the research project a clear focus and present something that resembles a research-based “to-do” list.

Research Questions: What are they?

Finally, we arrive at the all-important research questions. The research questions are, as the name suggests, the key questions that your study will seek to answer . Simply put, they are the core purpose of your dissertation, thesis, or research project. You’ll present them at the beginning of your document (either in the introduction chapter or literature review chapter) and you’ll answer them at the end of your document (typically in the discussion and conclusion chapters).  

The research questions will be the driving force throughout the research process. For example, in the literature review chapter, you’ll assess the relevance of any given resource based on whether it helps you move towards answering your research questions. Similarly, your methodology and research design will be heavily influenced by the nature of your research questions. For instance, research questions that are exploratory in nature will usually make use of a qualitative approach, whereas questions that relate to measurement or relationship testing will make use of a quantitative approach.  

Let’s look at some examples of research questions to make this more tangible.

Research Questions: Examples  

Again, we’ll stick with the research aims and research objectives we mentioned previously.  

For the digital transformation topic (which would be qualitative in nature):

How do employees perceive digital transformation in retail HR? What are the barriers and facilitators of digital transformation in retail HR?  

And for the student wellness topic (which would be quantitative in nature):

Does student self-care predict the well-being scores of engineering graduate students? Does student support predict the well-being scores of engineering students? Do student self-care and student support interact when predicting well-being in engineering graduate students?  

You’ll probably notice that there’s quite a formulaic approach to this. In other words, the research questions are basically the research objectives “converted” into question format. While that is true most of the time, it’s not always the case. For example, the first research objective for the digital transformation topic was more or less a step on the path toward the other objectives, and as such, it didn’t warrant its own research question.  

So, don’t rush your research questions and sloppily reword your objectives as questions. Carefully think about what exactly you’re trying to achieve (i.e. your research aim) and the objectives you’ve set out, then craft a set of well-aligned research questions . Also, keep in mind that this can be a somewhat iterative process , where you go back and tweak research objectives and aims to ensure tight alignment throughout the golden thread.

The importance of strong alignment 

Alignment is the keyword here and we have to stress its importance . Simply put, you need to make sure that there is a very tight alignment between all three pieces of the golden thread. If your research aims and research questions don’t align, for example, your project will be pulling in different directions and will lack focus . This is a common problem students face and can cause many headaches (and tears), so be warned.

Take the time to carefully craft your research aims, objectives and research questions before you run off down the research path. Ideally, get your research supervisor/advisor to review and comment on your golden thread before you invest significant time into your project, and certainly before you start collecting data .  

Recap: The golden thread

In this post, we unpacked the golden thread of research, consisting of the research aims , research objectives and research questions . You can jump back to any section using the links below.

As always, feel free to leave a comment below – we always love to hear from you. Also, if you’re interested in 1-on-1 support, take a look at our private coaching service here.

Psst... there’s more!

This post was based on one of our popular Research Bootcamps . If you're working on a research project, you'll definitely want to check this out ...

You Might Also Like:

39 Comments

Thank you very much for your great effort put. As an Undergraduate taking Demographic Research & Methodology, I’ve been trying so hard to understand clearly what is a Research Question, Research Aim and the Objectives in a research and the relationship between them etc. But as for now I’m thankful that you’ve solved my problem.

Well appreciated. This has helped me greatly in doing my dissertation.

An so delighted with this wonderful information thank you a lot.

so impressive i have benefited a lot looking forward to learn more on research.

I am very happy to have carefully gone through this well researched article.

Infact,I used to be phobia about anything research, because of my poor understanding of the concepts.

Now,I get to know that my research question is the same as my research objective(s) rephrased in question format.

I please I would need a follow up on the subject,as I intends to join the team of researchers. Thanks once again.

Thanks so much. This was really helpful.

I know you pepole have tried to break things into more understandable and easy format. And God bless you. Keep it up

i found this document so useful towards my study in research methods. thanks so much.

This is my 2nd read topic in your course and I should commend the simplified explanations of each part. I’m beginning to understand and absorb the use of each part of a dissertation/thesis. I’ll keep on reading your free course and might be able to avail the training course! Kudos!

Thank you! Better put that my lecture and helped to easily understand the basics which I feel often get brushed over when beginning dissertation work.

This is quite helpful. I like how the Golden thread has been explained and the needed alignment.

This is quite helpful. I really appreciate!

The article made it simple for researcher students to differentiate between three concepts.

Very innovative and educational in approach to conducting research.

I am very impressed with all these terminology, as I am a fresh student for post graduate, I am highly guided and I promised to continue making consultation when the need arise. Thanks a lot.

A very helpful piece. thanks, I really appreciate it .

Very well explained, and it might be helpful to many people like me.

Wish i had found this (and other) resource(s) at the beginning of my PhD journey… not in my writing up year… 😩 Anyways… just a quick question as i’m having some issues ordering my “golden thread”…. does it matter in what order you mention them? i.e., is it always first aims, then objectives, and finally the questions? or can you first mention the research questions and then the aims and objectives?

Thank you for a very simple explanation that builds upon the concepts in a very logical manner. Just prior to this, I read the research hypothesis article, which was equally very good. This met my primary objective.

My secondary objective was to understand the difference between research questions and research hypothesis, and in which context to use which one. However, I am still not clear on this. Can you kindly please guide?

In research, a research question is a clear and specific inquiry that the researcher wants to answer, while a research hypothesis is a tentative statement or prediction about the relationship between variables or the expected outcome of the study. Research questions are broader and guide the overall study, while hypotheses are specific and testable statements used in quantitative research. Research questions identify the problem, while hypotheses provide a focus for testing in the study.

Exactly what I need in this research journey, I look forward to more of your coaching videos.

This helped a lot. Thanks so much for the effort put into explaining it.

What data source in writing dissertation/Thesis requires?

What is data source covers when writing dessertation/thesis

This is quite useful thanks

I’m excited and thankful. I got so much value which will help me progress in my thesis.

where are the locations of the reserch statement, research objective and research question in a reserach paper? Can you write an ouline that defines their places in the researh paper?

Very helpful and important tips on Aims, Objectives and Questions.

Thank you so much for making research aim, research objectives and research question so clear. This will be helpful to me as i continue with my thesis.

Thanks much for this content. I learned a lot. And I am inspired to learn more. I am still struggling with my preparation for dissertation outline/proposal. But I consistently follow contents and tutorials and the new FB of GRAD Coach. Hope to really become confident in writing my dissertation and successfully defend it.

As a researcher and lecturer, I find splitting research goals into research aims, objectives, and questions is unnecessarily bureaucratic and confusing for students. For most biomedical research projects, including ‘real research’, 1-3 research questions will suffice (numbers may differ by discipline).

Awesome! Very important resources and presented in an informative way to easily understand the golden thread. Indeed, thank you so much.

Well explained

The blog article on research aims, objectives, and questions by Grad Coach is a clear and insightful guide that aligns with my experiences in academic research. The article effectively breaks down the often complex concepts of research aims and objectives, providing a straightforward and accessible explanation. Drawing from my own research endeavors, I appreciate the practical tips offered, such as the need for specificity and clarity when formulating research questions. The article serves as a valuable resource for students and researchers, offering a concise roadmap for crafting well-defined research goals and objectives. Whether you’re a novice or an experienced researcher, this article provides practical insights that contribute to the foundational aspects of a successful research endeavor.

A great thanks for you. it is really amazing explanation. I grasp a lot and one step up to research knowledge.

I really found these tips helpful. Thank you very much Grad Coach.

I found this article helpful. Thanks for sharing this.

thank you so much, the explanation and examples are really helpful

Submit a Comment Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

• Print Friendly

• Privacy Policy

Home » Research Questions – Types, Examples and Writing Guide

Research Questions – Types, Examples and Writing Guide

Table of Contents

Research Questions

Definition:

Research questions are the specific questions that guide a research study or inquiry. These questions help to define the scope of the research and provide a clear focus for the study. Research questions are usually developed at the beginning of a research project and are designed to address a particular research problem or objective.

Types of Research Questions

Types of Research Questions are as follows:

Descriptive Research Questions

These aim to describe a particular phenomenon, group, or situation. For example:

• What are the characteristics of the target population?
• What is the prevalence of a particular disease in a specific region?

Exploratory Research Questions

These aim to explore a new area of research or generate new ideas or hypotheses. For example:

• What are the potential causes of a particular phenomenon?
• What are the possible outcomes of a specific intervention?

Explanatory Research Questions

These aim to understand the relationship between two or more variables or to explain why a particular phenomenon occurs. For example:

• What is the effect of a specific drug on the symptoms of a particular disease?
• What are the factors that contribute to employee turnover in a particular industry?

Predictive Research Questions

These aim to predict a future outcome or trend based on existing data or trends. For example :

• What will be the future demand for a particular product or service?
• What will be the future prevalence of a particular disease?

Evaluative Research Questions

These aim to evaluate the effectiveness of a particular intervention or program. For example:

• What is the impact of a specific educational program on student learning outcomes?
• What is the effectiveness of a particular policy or program in achieving its intended goals?

How to Choose Research Questions

Choosing research questions is an essential part of the research process and involves careful consideration of the research problem, objectives, and design. Here are some steps to consider when choosing research questions:

• Identify the research problem: Start by identifying the problem or issue that you want to study. This could be a gap in the literature, a social or economic issue, or a practical problem that needs to be addressed.
• Conduct a literature review: Conducting a literature review can help you identify existing research in your area of interest and can help you formulate research questions that address gaps or limitations in the existing literature.
• Define the research objectives : Clearly define the objectives of your research. What do you want to achieve with your study? What specific questions do you want to answer?
• Consider the research design : Consider the research design that you plan to use. This will help you determine the appropriate types of research questions to ask. For example, if you plan to use a qualitative approach, you may want to focus on exploratory or descriptive research questions.
• Ensure that the research questions are clear and answerable: Your research questions should be clear and specific, and should be answerable with the data that you plan to collect. Avoid asking questions that are too broad or vague.
• Get feedback : Get feedback from your supervisor, colleagues, or peers to ensure that your research questions are relevant, feasible, and meaningful.

How to Write Research Questions

Guide for Writing Research Questions:

• Start with a clear statement of the research problem: Begin by stating the problem or issue that your research aims to address. This will help you to formulate focused research questions.
• Use clear language : Write your research questions in clear and concise language that is easy to understand. Avoid using jargon or technical terms that may be unfamiliar to your readers.
• Be specific: Your research questions should be specific and focused. Avoid broad questions that are difficult to answer. For example, instead of asking “What is the impact of climate change on the environment?” ask “What are the effects of rising sea levels on coastal ecosystems?”
• Use appropriate question types: Choose the appropriate question types based on the research design and objectives. For example, if you are conducting a qualitative study, you may want to use open-ended questions that allow participants to provide detailed responses.
• Consider the feasibility of your questions : Ensure that your research questions are feasible and can be answered with the resources available. Consider the data sources and methods of data collection when writing your questions.
• Seek feedback: Get feedback from your supervisor, colleagues, or peers to ensure that your research questions are relevant, appropriate, and meaningful.

Examples of Research Questions

Some Examples of Research Questions with Research Titles:

Research Title: The Impact of Social Media on Mental Health

• Research Question : What is the relationship between social media use and mental health, and how does this impact individuals’ well-being?

Research Title: Factors Influencing Academic Success in High School

• Research Question: What are the primary factors that influence academic success in high school, and how do they contribute to student achievement?

Research Title: The Effects of Exercise on Physical and Mental Health

• Research Question: What is the relationship between exercise and physical and mental health, and how can exercise be used as a tool to improve overall well-being?

Research Title: Understanding the Factors that Influence Consumer Purchasing Decisions

• Research Question : What are the key factors that influence consumer purchasing decisions, and how do these factors vary across different demographics and products?

Research Title: The Impact of Technology on Communication

• Research Question : How has technology impacted communication patterns, and what are the effects of these changes on interpersonal relationships and society as a whole?

Research Title: Investigating the Relationship between Parenting Styles and Child Development

• Research Question: What is the relationship between different parenting styles and child development outcomes, and how do these outcomes vary across different ages and developmental stages?

Research Title: The Effectiveness of Cognitive-Behavioral Therapy in Treating Anxiety Disorders

• Research Question: How effective is cognitive-behavioral therapy in treating anxiety disorders, and what factors contribute to its success or failure in different patients?

Research Title: The Impact of Climate Change on Biodiversity

• Research Question : How is climate change affecting global biodiversity, and what can be done to mitigate the negative effects on natural ecosystems?

Research Title: Exploring the Relationship between Cultural Diversity and Workplace Productivity

• Research Question : How does cultural diversity impact workplace productivity, and what strategies can be employed to maximize the benefits of a diverse workforce?

Research Title: The Role of Artificial Intelligence in Healthcare

• Research Question: How can artificial intelligence be leveraged to improve healthcare outcomes, and what are the potential risks and ethical concerns associated with its use?

Applications of Research Questions

Here are some of the key applications of research questions:

• Defining the scope of the study : Research questions help researchers to narrow down the scope of their study and identify the specific issues they want to investigate.
• Developing hypotheses: Research questions often lead to the development of hypotheses, which are testable predictions about the relationship between variables. Hypotheses provide a clear and focused direction for the study.
• Designing the study : Research questions guide the design of the study, including the selection of participants, the collection of data, and the analysis of results.
• Collecting data : Research questions inform the selection of appropriate methods for collecting data, such as surveys, interviews, or experiments.
• Analyzing data : Research questions guide the analysis of data, including the selection of appropriate statistical tests and the interpretation of results.
• Communicating results : Research questions help researchers to communicate the results of their study in a clear and concise manner. The research questions provide a framework for discussing the findings and drawing conclusions.

Characteristics of Research Questions

Characteristics of Research Questions are as follows:

• Clear and Specific : A good research question should be clear and specific. It should clearly state what the research is trying to investigate and what kind of data is required.
• Relevant : The research question should be relevant to the study and should address a current issue or problem in the field of research.
• Testable : The research question should be testable through empirical evidence. It should be possible to collect data to answer the research question.
• Concise : The research question should be concise and focused. It should not be too broad or too narrow.
• Feasible : The research question should be feasible to answer within the constraints of the research design, time frame, and available resources.
• Original : The research question should be original and should contribute to the existing knowledge in the field of research.
• Significant : The research question should have significance and importance to the field of research. It should have the potential to provide new insights and knowledge to the field.
• Ethical : The research question should be ethical and should not cause harm to any individuals or groups involved in the study.

Purpose of Research Questions

Research questions are the foundation of any research study as they guide the research process and provide a clear direction to the researcher. The purpose of research questions is to identify the scope and boundaries of the study, and to establish the goals and objectives of the research.

The main purpose of research questions is to help the researcher to focus on the specific area or problem that needs to be investigated. They enable the researcher to develop a research design, select the appropriate methods and tools for data collection and analysis, and to organize the results in a meaningful way.

Research questions also help to establish the relevance and significance of the study. They define the research problem, and determine the research methodology that will be used to address the problem. Research questions also help to determine the type of data that will be collected, and how it will be analyzed and interpreted.

Finally, research questions provide a framework for evaluating the results of the research. They help to establish the validity and reliability of the data, and provide a basis for drawing conclusions and making recommendations based on the findings of the study.

Advantages of Research Questions

There are several advantages of research questions in the research process, including:

• Focus : Research questions help to focus the research by providing a clear direction for the study. They define the specific area of investigation and provide a framework for the research design.
• Clarity : Research questions help to clarify the purpose and objectives of the study, which can make it easier for the researcher to communicate the research aims to others.
• Relevance : Research questions help to ensure that the study is relevant and meaningful. By asking relevant and important questions, the researcher can ensure that the study will contribute to the existing body of knowledge and address important issues.
• Consistency : Research questions help to ensure consistency in the research process by providing a framework for the development of the research design, data collection, and analysis.
• Measurability : Research questions help to ensure that the study is measurable by defining the specific variables and outcomes that will be measured.
• Replication : Research questions help to ensure that the study can be replicated by providing a clear and detailed description of the research aims, methods, and outcomes. This makes it easier for other researchers to replicate the study and verify the results.

Limitations of Research Questions

Limitations of Research Questions are as follows:

• Subjectivity : Research questions are often subjective and can be influenced by personal biases and perspectives of the researcher. This can lead to a limited understanding of the research problem and may affect the validity and reliability of the study.
• Inadequate scope : Research questions that are too narrow in scope may limit the breadth of the study, while questions that are too broad may make it difficult to focus on specific research objectives.
• Unanswerable questions : Some research questions may not be answerable due to the lack of available data or limitations in research methods. In such cases, the research question may need to be rephrased or modified to make it more answerable.
• Lack of clarity : Research questions that are poorly worded or ambiguous can lead to confusion and misinterpretation. This can result in incomplete or inaccurate data, which may compromise the validity of the study.
• Difficulty in measuring variables : Some research questions may involve variables that are difficult to measure or quantify, making it challenging to draw meaningful conclusions from the data.
• Lack of generalizability: Research questions that are too specific or limited in scope may not be generalizable to other contexts or populations. This can limit the applicability of the study’s findings and restrict its broader implications.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

You may also like

Problem Statement – Writing Guide, Examples and...

Research Approach – Types Methods and Examples

Research Findings – Types Examples and Writing...

Institutional Review Board – Application Sample...

Tables in Research Paper – Types, Creating Guide...

Assignment – Types, Examples and Writing Guide

• USU Library

Systematic Reviews: 1. Developing Your Research Question

• Getting Started & Timelines
• 1. Developing Your Research Question
• 2. Select Databases
• 3. Select Grey Literature Sources
• 4. Write a Search Strategy
• 5. Registering Your Protocol
• 6. Citation Management
• 7. Article Screening
• 8. Risk of Bias Assessment
• 9. Data Extraction

Developing Your Research Question

Developing your research question is one of the most important steps in the evidence synthesis process. At this stage in the process, you and your team have identified a knowledge gap in your field and are aiming to answer a specific question:

• If X is prescribed, then Y will happen to patients?

OR assess an intervention:

• How does X affect Y?

OR synthesize the existing evidence

• What is the nature of X? 

Whatever your aim, formulating a clear, well-defined research question of appropriate scope is key to a successful evidence synthesis. The research question will be the foundation of your synthesis and from it your research team will identify 2-5 possible search concepts. These search concepts will later be used in step 5 to build your search strategy.

Formulating a research question takes time and your team may go through different versions until settling on the right research question. To help formulate your research question, some research question frameworks are listed below. Think of these frameworks as you would for a house or building. A framework is there to provide support and to be a scaffold for the rest of the structure. In the same way, a research question framework can also help structure your evidence synthesis question. 

PICO for Quantitative Studies

• P       Population/Problem
• I        Intervention/Exposure
• C       Comparison
• O       Outcome

Is gabapentin (intervention), compared to placebo (comparison), effective in decreasing pain symptoms (outcome) in middle aged male amputees suffering phantom limb pain (population)?

PICO for Qualitative Studies

• I         Phenomenon of Interest
• Co    Context

Example: What are the experiences (phenomenon of interest) of caregivers providing home based care to patients with Alzheimer's disease (population) in Australia (context)?

• S     Setting
• P   Perspective (for whom)
• I    Intervention/Exposure
• C   Comparison
• E   Evaluation

What are the benefits (evaluation) of a doula (intervention) for low income mothers (perspective) in the developed world (setting) compared to no support (comparison)?

• S     Sample
• PI   Phenomenon of Interest
• D    Design
• E     Evaluation
• R    Study Type

What are the experiences (evaluation) of women (sample) undergoing IVF treatment (phenomenon of interest) as assessed?

Design:  questionnaire or survey or interview

Study Type: qualitative or mixed method

Inclusion & Exclusion Criteria

Inclusion and exclusion criteria are developed after a research question is finalized but before a search is carried out. They determine the limits for the evidence synthesis and are typically reported in the methods section of the publication. For unfamiliar or unclear concepts, a definition may be necessary to adequately describe the criterion for readers.

Inclusion/Exclusion Criteria

• << Previous: Getting Started & Timelines
• Next: 2. Select Databases >>
• Last Updated: Sep 11, 2023 11:04 AM
• URL: https://libguides.usu.edu/systematic_reviews

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

• USC Libraries
• Research Guides

Organizing Your Social Sciences Research Paper

• 8. The Discussion
• Purpose of Guide
• Design Flaws to Avoid
• Independent and Dependent Variables
• Glossary of Research Terms
• Reading Research Effectively
• Narrowing a Topic Idea
• Broadening a Topic Idea
• Extending the Timeliness of a Topic Idea
• Academic Writing Style
• Applying Critical Thinking
• Choosing a Title
• Making an Outline
• Paragraph Development
• Research Process Video Series
• Executive Summary
• The C.A.R.S. Model
• Background Information
• The Research Problem/Question
• Theoretical Framework
• Citation Tracking
• Content Alert Services
• Evaluating Sources
• Primary Sources
• Secondary Sources
• Tiertiary Sources
• Scholarly vs. Popular Publications
• Qualitative Methods
• Quantitative Methods
• Insiderness
• Using Non-Textual Elements
• Limitations of the Study
• Common Grammar Mistakes
• Writing Concisely
• Avoiding Plagiarism
• Footnotes or Endnotes?
• Further Readings
• Generative AI and Writing
• USC Libraries Tutorials and Other Guides
• Bibliography

The purpose of the discussion section is to interpret and describe the significance of your findings in relation to what was already known about the research problem being investigated and to explain any new understanding or insights that emerged as a result of your research. The discussion will always connect to the introduction by way of the research questions or hypotheses you posed and the literature you reviewed, but the discussion does not simply repeat or rearrange the first parts of your paper; the discussion clearly explains how your study advanced the reader's understanding of the research problem from where you left them at the end of your review of prior research.

Annesley, Thomas M. “The Discussion Section: Your Closing Argument.” Clinical Chemistry 56 (November 2010): 1671-1674; Peacock, Matthew. “Communicative Moves in the Discussion Section of Research Articles.” System 30 (December 2002): 479-497.

Importance of a Good Discussion

The discussion section is often considered the most important part of your research paper because it:

• Most effectively demonstrates your ability as a researcher to think critically about an issue, to develop creative solutions to problems based upon a logical synthesis of the findings, and to formulate a deeper, more profound understanding of the research problem under investigation;
• Presents the underlying meaning of your research, notes possible implications in other areas of study, and explores possible improvements that can be made in order to further develop the concerns of your research;
• Highlights the importance of your study and how it can contribute to understanding the research problem within the field of study;
• Presents how the findings from your study revealed and helped fill gaps in the literature that had not been previously exposed or adequately described; and,
• Engages the reader in thinking critically about issues based on an evidence-based interpretation of findings; it is not governed strictly by objective reporting of information.

Annesley Thomas M. “The Discussion Section: Your Closing Argument.” Clinical Chemistry 56 (November 2010): 1671-1674; Bitchener, John and Helen Basturkmen. “Perceptions of the Difficulties of Postgraduate L2 Thesis Students Writing the Discussion Section.” Journal of English for Academic Purposes 5 (January 2006): 4-18; Kretchmer, Paul. Fourteen Steps to Writing an Effective Discussion Section. San Francisco Edit, 2003-2008.

Structure and Writing Style

I.  General Rules

These are the general rules you should adopt when composing your discussion of the results :

• Do not be verbose or repetitive; be concise and make your points clearly
• Avoid the use of jargon or undefined technical language
• Follow a logical stream of thought; in general, interpret and discuss the significance of your findings in the same sequence you described them in your results section [a notable exception is to begin by highlighting an unexpected result or a finding that can grab the reader's attention]
• Use the present verb tense, especially for established facts; however, refer to specific works or prior studies in the past tense
• If needed, use subheadings to help organize your discussion or to categorize your interpretations into themes

II.  The Content

The content of the discussion section of your paper most often includes :

• Explanation of results : Comment on whether or not the results were expected for each set of findings; go into greater depth to explain findings that were unexpected or especially profound. If appropriate, note any unusual or unanticipated patterns or trends that emerged from your results and explain their meaning in relation to the research problem.
• References to previous research : Either compare your results with the findings from other studies or use the studies to support a claim. This can include re-visiting key sources already cited in your literature review section, or, save them to cite later in the discussion section if they are more important to compare with your results instead of being a part of the general literature review of prior research used to provide context and background information. Note that you can make this decision to highlight specific studies after you have begun writing the discussion section.
• Deduction : A claim for how the results can be applied more generally. For example, describing lessons learned, proposing recommendations that can help improve a situation, or highlighting best practices.
• Hypothesis : A more general claim or possible conclusion arising from the results [which may be proved or disproved in subsequent research]. This can be framed as new research questions that emerged as a consequence of your analysis.

III.  Organization and Structure

Keep the following sequential points in mind as you organize and write the discussion section of your paper:

• Think of your discussion as an inverted pyramid. Organize the discussion from the general to the specific, linking your findings to the literature, then to theory, then to practice [if appropriate].
• Use the same key terms, narrative style, and verb tense [present] that you used when describing the research problem in your introduction.
• Begin by briefly re-stating the research problem you were investigating and answer all of the research questions underpinning the problem that you posed in the introduction.
• Describe the patterns, principles, and relationships shown by each major findings and place them in proper perspective. The sequence of this information is important; first state the answer, then the relevant results, then cite the work of others. If appropriate, refer the reader to a figure or table to help enhance the interpretation of the data [either within the text or as an appendix].
• Regardless of where it's mentioned, a good discussion section includes analysis of any unexpected findings. This part of the discussion should begin with a description of the unanticipated finding, followed by a brief interpretation as to why you believe it appeared and, if necessary, its possible significance in relation to the overall study. If more than one unexpected finding emerged during the study, describe each of them in the order they appeared as you gathered or analyzed the data. As noted, the exception to discussing findings in the same order you described them in the results section would be to begin by highlighting the implications of a particularly unexpected or significant finding that emerged from the study, followed by a discussion of the remaining findings.
• Before concluding the discussion, identify potential limitations and weaknesses if you do not plan to do so in the conclusion of the paper. Comment on their relative importance in relation to your overall interpretation of the results and, if necessary, note how they may affect the validity of your findings. Avoid using an apologetic tone; however, be honest and self-critical [e.g., in retrospect, had you included a particular question in a survey instrument, additional data could have been revealed].
• The discussion section should end with a concise summary of the principal implications of the findings regardless of their significance. Give a brief explanation about why you believe the findings and conclusions of your study are important and how they support broader knowledge or understanding of the research problem. This can be followed by any recommendations for further research. However, do not offer recommendations which could have been easily addressed within the study. This would demonstrate to the reader that you have inadequately examined and interpreted the data.

IV.  Overall Objectives

The objectives of your discussion section should include the following: I.  Reiterate the Research Problem/State the Major Findings

Briefly reiterate the research problem or problems you are investigating and the methods you used to investigate them, then move quickly to describe the major findings of the study. You should write a direct, declarative, and succinct proclamation of the study results, usually in one paragraph.

II.  Explain the Meaning of the Findings and Why They are Important

No one has thought as long and hard about your study as you have. Systematically explain the underlying meaning of your findings and state why you believe they are significant. After reading the discussion section, you want the reader to think critically about the results and why they are important. You don’t want to force the reader to go through the paper multiple times to figure out what it all means. If applicable, begin this part of the section by repeating what you consider to be your most significant or unanticipated finding first, then systematically review each finding. Otherwise, follow the general order you reported the findings presented in the results section.

III.  Relate the Findings to Similar Studies

No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your results to those found in other studies, particularly if questions raised from prior studies served as the motivation for your research. This is important because comparing and contrasting the findings of other studies helps to support the overall importance of your results and it highlights how and in what ways your study differs from other research about the topic. Note that any significant or unanticipated finding is often because there was no prior research to indicate the finding could occur. If there is prior research to indicate this, you need to explain why it was significant or unanticipated. IV.  Consider Alternative Explanations of the Findings

It is important to remember that the purpose of research in the social sciences is to discover and not to prove . When writing the discussion section, you should carefully consider all possible explanations for the study results, rather than just those that fit your hypothesis or prior assumptions and biases. This is especially important when describing the discovery of significant or unanticipated findings.

V.  Acknowledge the Study’s Limitations

It is far better for you to identify and acknowledge your study’s limitations than to have them pointed out by your professor! Note any unanswered questions or issues your study could not address and describe the generalizability of your results to other situations. If a limitation is applicable to the method chosen to gather information, then describe in detail the problems you encountered and why. VI.  Make Suggestions for Further Research

You may choose to conclude the discussion section by making suggestions for further research [as opposed to offering suggestions in the conclusion of your paper]. Although your study can offer important insights about the research problem, this is where you can address other questions related to the problem that remain unanswered or highlight hidden issues that were revealed as a result of conducting your research. You should frame your suggestions by linking the need for further research to the limitations of your study [e.g., in future studies, the survey instrument should include more questions that ask..."] or linking to critical issues revealed from the data that were not considered initially in your research.

NOTE: Besides the literature review section, the preponderance of references to sources is usually found in the discussion section . A few historical references may be helpful for perspective, but most of the references should be relatively recent and included to aid in the interpretation of your results, to support the significance of a finding, and/or to place a finding within a particular context. If a study that you cited does not support your findings, don't ignore it--clearly explain why your research findings differ from theirs.

V.  Problems to Avoid

• Do not waste time restating your results . Should you need to remind the reader of a finding to be discussed, use "bridge sentences" that relate the result to the interpretation. An example would be: “In the case of determining available housing to single women with children in rural areas of Texas, the findings suggest that access to good schools is important...," then move on to further explaining this finding and its implications.
• As noted, recommendations for further research can be included in either the discussion or conclusion of your paper, but do not repeat your recommendations in the both sections. Think about the overall narrative flow of your paper to determine where best to locate this information. However, if your findings raise a lot of new questions or issues, consider including suggestions for further research in the discussion section.
• Do not introduce new results in the discussion section. Be wary of mistaking the reiteration of a specific finding for an interpretation because it may confuse the reader. The description of findings [results section] and the interpretation of their significance [discussion section] should be distinct parts of your paper. If you choose to combine the results section and the discussion section into a single narrative, you must be clear in how you report the information discovered and your own interpretation of each finding. This approach is not recommended if you lack experience writing college-level research papers.
• Use of the first person pronoun is generally acceptable. Using first person singular pronouns can help emphasize a point or illustrate a contrasting finding. However, keep in mind that too much use of the first person can actually distract the reader from the main points [i.e., I know you're telling me this--just tell me!].

Analyzing vs. Summarizing. Department of English Writing Guide. George Mason University; Discussion. The Structure, Format, Content, and Style of a Journal-Style Scientific Paper. Department of Biology. Bates College; Hess, Dean R. "How to Write an Effective Discussion." Respiratory Care 49 (October 2004); Kretchmer, Paul. Fourteen Steps to Writing to Writing an Effective Discussion Section. San Francisco Edit, 2003-2008; The Lab Report. University College Writing Centre. University of Toronto; Sauaia, A. et al. "The Anatomy of an Article: The Discussion Section: "How Does the Article I Read Today Change What I Will Recommend to my Patients Tomorrow?” The Journal of Trauma and Acute Care Surgery 74 (June 2013): 1599-1602; Research Limitations & Future Research . Lund Research Ltd., 2012; Summary: Using it Wisely. The Writing Center. University of North Carolina; Schafer, Mickey S. Writing the Discussion. Writing in Psychology course syllabus. University of Florida; Yellin, Linda L. A Sociology Writer's Guide . Boston, MA: Allyn and Bacon, 2009.

Writing Tip

Don’t Over-Interpret the Results!

Interpretation is a subjective exercise. As such, you should always approach the selection and interpretation of your findings introspectively and to think critically about the possibility of judgmental biases unintentionally entering into discussions about the significance of your work. With this in mind, be careful that you do not read more into the findings than can be supported by the evidence you have gathered. Remember that the data are the data: nothing more, nothing less.

MacCoun, Robert J. "Biases in the Interpretation and Use of Research Results." Annual Review of Psychology 49 (February 1998): 259-287; Ward, Paulet al, editors. The Oxford Handbook of Expertise . Oxford, UK: Oxford University Press, 2018.

Another Writing Tip

Don't Write Two Results Sections!

One of the most common mistakes that you can make when discussing the results of your study is to present a superficial interpretation of the findings that more or less re-states the results section of your paper. Obviously, you must refer to your results when discussing them, but focus on the interpretation of those results and their significance in relation to the research problem, not the data itself.

Azar, Beth. "Discussing Your Findings."  American Psychological Association gradPSYCH Magazine (January 2006).

Yet Another Writing Tip

Avoid Unwarranted Speculation!

The discussion section should remain focused on the findings of your study. For example, if the purpose of your research was to measure the impact of foreign aid on increasing access to education among disadvantaged children in Bangladesh, it would not be appropriate to speculate about how your findings might apply to populations in other countries without drawing from existing studies to support your claim or if analysis of other countries was not a part of your original research design. If you feel compelled to speculate, do so in the form of describing possible implications or explaining possible impacts. Be certain that you clearly identify your comments as speculation or as a suggestion for where further research is needed. Sometimes your professor will encourage you to expand your discussion of the results in this way, while others don’t care what your opinion is beyond your effort to interpret the data in relation to the research problem.

• << Previous: Using Non-Textual Elements
• Next: Limitations of the Study >>
• Last Updated: May 30, 2024 9:38 AM
• URL: https://libguides.usc.edu/writingguide

Research Writing and Analysis

• NVivo Group and Study Sessions
• SPSS This link opens in a new window
• Statistical Analysis Group sessions
• Using Qualtrics
• Dissertation and Data Analysis Group Sessions
• Defense Schedule - Commons Calendar This link opens in a new window
• Research Process Flow Chart
• Research Alignment Chapter 1 This link opens in a new window
• Step 1: Seek Out Evidence
• Step 2: Explain
• Step 3: The Big Picture
• Step 4: Own It
• Step 5: Illustrate
• Annotated Bibliography
• Literature Review This link opens in a new window
• Systematic Reviews & Meta-Analyses
• How to Synthesize and Analyze
• Synthesis and Analysis Practice
• Synthesis and Analysis Group Sessions
• Problem Statement
• Purpose Statement
• Conceptual Framework
• Theoretical Framework
• Locating Theoretical and Conceptual Frameworks This link opens in a new window
• Quantitative Research Questions

Qualitative Research Questions

• Trustworthiness of Qualitative Data
• Analysis and Coding Example- Qualitative Data
• Thematic Data Analysis in Qualitative Design
• Dissertation to Journal Article This link opens in a new window
• International Journal of Online Graduate Education (IJOGE) This link opens in a new window
• Journal of Research in Innovative Teaching & Learning (JRIT&L) This link opens in a new window

What’s in a Qualitative Research Question?

Qualitative research questions are driven by the need for the study. Ideally, research questions are formulated as a result of the problem and purpose, which leads to the identification of the methodology. When a qualitative methodology is chosen, research questions should be exploratory and focused on the actual phenomenon under study.

From the Dissertation Center, Chapter 1: Research Question Overview , there are several considerations when forming a qualitative research question. Qualitative research questions should

Below is an example of a qualitative phenomenological design. Note the use of the term “lived experience” in the central research question. This aligns with phenomenological design.

RQ1: “ What are the lived experiences of followers of mid-level managers in the financial services sector regarding their well-being on the job?”

If the researcher wants to focus on aspects of the theory used to support the study or dive deeper into aspects of the central RQ, sub-questions might be used. The following sub-questions could be formulated to seek further insight:

RQ1a.   “How do followers perceive the quality and adequacy of the leader-follower exchanges between themselves and their novice leaders?”

RQ1b.  “Under what conditions do leader-member exchanges affect a follower’s own level of well-being?”

Qualitative research questions also display the desire to explore or describe phenomena. Qualitative research seeks the lived experience, the personal experiences, the understandings, the meanings, and the stories associated with the concepts present in our studies.

We want to ensure our research questions are answerable and that we are not making assumptions about our sample. View the questions below:

How do healthcare providers perceive income inequality when providing care to poor patients?

In Example A, we see that there is no specificity of location or geographic areas. This could lead to findings that are varied, and the researcher may not find a clear pattern. Additionally, the question implies the focus is on “income inequality” when the actual focus is on the provision of care. The term “poor patients” can also be offensive, and most providers will not want to seem insensitive and may perceive income inequality as a challenge (of course!).

How do primary care nurses in outreach clinics describe providing quality care to residents of low-income urban neighborhoods?

In Example B, we see that there is greater specificity in the type of care provider. There is also a shift in language so that the focus is on how the individuals describe what they think about, experience, and navigate providing quality care.

Other Qualitative Research Question Examples

Vague : What are the strategies used by healthcare personnel to assist injured patients?

Try this : What is the experience of emergency room personnel in treating patients with a self-inflicted household injury?

The first question is general and vague. While in the same topic area, the second question is more precise and gives the reader a specific target population and a focus on the phenomenon they would have experienced. This question could be in line with a phenomenological study as we are seeking their experience or a case study as the ER personnel are a bounded entity.

Unclear : How do students experience progressing to college?

Try this : How do first-generation community members describe the aspects of their culture that promote aspiration to postsecondary education?

The first question does not have a focus on what progress is or what students are the focus. The second question provides a specific target population and provides the description to be provided by the participants. This question could be in line with a descriptive study.

• << Previous: Quantitative Research Questions
• Next: Trustworthiness of Qualitative Data >>
• Last Updated: May 29, 2024 8:05 AM
• URL: https://resources.nu.edu/researchtools

Understanding the Stigma Experience of Men Living with HIV in Sub-Saharan Africa: A Qualitative Meta-synthesis

• Substantive Review
• Published: 22 May 2024

Cite this article

• Sarah E. Janek   ORCID: orcid.org/0009-0002-1213-2791 1 ,
• Sandy Hatoum   ORCID: orcid.org/0009-0002-3618-9733 2 ,
• Leila Ledbetter   ORCID: orcid.org/0000-0002-5206-8002 3 &
• Michael V. Relf   ORCID: orcid.org/0000-0002-4951-8869 1 , 2  

51 Accesses

Explore all metrics

Men living with HIV (MLWH) in sub-Saharan Africa experience poor health outcomes and increased AIDS-related deaths due to stigma influencing testing and treatment uptake and adherence. PRISMA 2020 was used to report a meta-synthesis of the stigma experiences of MLWH in SSA. With the help of an expert librarian, a search of six databases was formulated and performed to examine the available qualitative and mixed method studies with qualitative results relevant to the research question. Studies focused on adult men living with HIV, with five studies specifically examining the HIV experience of men who have sex with men. Study themes were synthesized to describe MLWH’s perceived, internalized, anticipated, enacted, and intersectional stigma experiences. Most studies included masculinity as a key theme that affected both testing and treatment adherence upon diagnosis. Future research is needed to better understand subpopulations, such as men who have sex with men living with HIV, and what interventions may be beneficial to mitigate the disparities among MLWH in SSA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Similar content being viewed by others

“It is not an acceptable disease”: A qualitative study of HIV-related stigma and discrimination and impacts on health and wellbeing for people from ethnically diverse backgrounds in Australia

Overcoming hiv stigma a qualitative analysis of hiv cure research and stigma among men who have sex with men living with hiv, understanding hiv-related stigma among women in the southern united states: a literature review.

Kaiser Family Foundation. The global HIV/AIDS epidemic. KFF. 2022. https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/ . Accessed 13 Nov 2022.

UNAIDS. Fact sheet—latest global and regional statistics on the status of the AIDS epidemic. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2022. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf . Accessed 23 Oct 2022.

West CA, Chang GC, Currie DW, Bray R, Kinchen S, Behel S, McCullough-Sanden R, Low A, Bissek A, Shang JD, Ndongmo CB, Dokubo EK, Balachandra S, Lobognon LR, Dube L, Nuwagaba-Biribonwoha H, Li M, Pasipamire M, Getaneh Y, Lulseged S, Eshetu F, Kingwara L, Zielinski-Gutierrez E, Tlhomola M, Ramphalla P, Kalua T, Auld AF, Williams DB, Remera E, Rwibasira GN, Mugisha V, Malamba SS, Mushi J, Jalloh MF, Mgomella GS, Kirungi WL, Biraro S, Awor AC, Barradas DT, Mugurungi O, Rogers JH, Bronson M, Bodika SM, Ajiboye A, Gaffga N, Moore C, Patel HK, Voetsch AC. Unawareness of HIV infection among men aged 15–59 years in 13 sub-Saharan African countries: findings from the population-based HIV impact assessments, 2015–2019. JAIDS. 2021;87:S97.

PubMed   Google Scholar  

UNAIDS. Executive summary—in danger: UNAIDS global AIDS update 2022 [Internet]. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2022. https://www.unaids.org/sites/default/files/media_asset/2022-global-aids-update-summary_en.pdf . Accessed 23 Oct 2022.

UNAIDS. Addressing a blind spot in the response to HIV—reaching out to men and boys. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2017. https://www.unaids.org/sites/default/files/media_asset/blind_spot_en.pdf . Accessed 23 Oct 2022.

Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health. 2013;103:813–21. https://doi.org/10.2105/AJPH.2012.301069 .

Article   PubMed   PubMed Central   Google Scholar  

Relf MV, Holzemer WL, Holt L, Nyblade L, Caiola CE. A review of the state of the science of HIV and stigma: context, conceptualization, measurement, interventions, gaps, and future priorities. J Assoc Nurses AIDS Care. 2021;32:392–407. https://doi.org/10.1097/JNC.0000000000000237 .

Herek GM. AIDS and stigma. Am Behav Sci. 1999;42:1106–16. https://doi.org/10.1177/00027649921954787 .

Article   Google Scholar  

Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17:1785–95. https://doi.org/10.1007/s10461-013-0437-9 .

Derlega VJ, Winstead BA, Greene K, Serovich J, Elwood WN. Perceived HIV-related stigma and HIV disclosure to relationship partners after finding out about the seropositive diagnosis. J Health Psychol. 2002;7:415–32. https://doi.org/10.1177/1359105302007004330 .

Article   PubMed   Google Scholar  

Arinaitwe I, Amutuhaire H, Atwongyeire D, Tusingwire E, Kawungezi PC, Rukundo GZ, Ashaba S. Social support, food insecurity, and HIV stigma among men living with HIV in rural southwestern Uganda: a cross-sectional analysis. HIV AIDS (Auckl). 2021;13:657–66. https://doi.org/10.2147/HIV.S316174 .

Mburu G, Ram M, Siu G, Bitira D, Skovdal M, Holland P. Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes. BMC Public Health. 2014;14:1061. https://doi.org/10.1186/1471-2458-14-1061 .

Sileo KM, Fielding-Miller R, Dworkin SL, Fleming PJ. A scoping review on the role of masculine norms in men’s engagement in the HIV care continuum in sub-Saharan Africa. AIDS Care. 2019;31:1435–46. https://doi.org/10.1080/09540121.2019.1595509 .

Abara WE, Garba I. HIV epidemic and human rights among men who have sex with men in sub-Saharan Africa: implications for HIV prevention, care, and surveillance. Glob Public Health. 2017;12:469–82. https://doi.org/10.1080/17441692.2015.1094107 .

Joshi K, Lessler J, Olawore O, Loevinsohn G, Bushey S, Tobian AAR, Grabowski MK. Declining HIV incidence in sub-Saharan Africa: a systematic review and meta-analysis of empiric data. J Int AIDS Soc. 2021. https://doi.org/10.1002/jia2.25818 .

Nyato D, Kuringe E, Drake M, Casalini C, Nnko S, Shao A, Komba A, Baral SD, Wambura M, Changalucha J. Participants’ accrual and delivery of HIV prevention interventions among men who have sex with men in sub-Saharan Africa: a systematic review. BMC Public Health. 2018. https://doi.org/10.1186/s12889-018-5303-2 .

Hamilton A, Thompson N, Choko AT, Hlongwa M, Jolly P, Korte JE, Conserve DF. HIV self-testing uptake and intervention strategies among men in sub-Saharan Africa: a systematic review. Front Public Health. 2021. https://doi.org/10.3389/fpubh.2021.594298 .

Hlongwa M, Hlongwana K, Makhunga S, Choko AT, Dzinamarira T, Conserve D, Tsai AC. Linkage to HIV care following HIV self-testing among men: systematic review of quantitative and qualitative studies from six countries in sub-Saharan Africa. AIDS Behav. 2022. https://doi.org/10.1007/s10461-022-03800-8 .

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021. https://doi.org/10.1136/bmj.n71 .

Turan B, Hatcher AM, Weiser SD, Johnson MO, Rice WS, Turan JM. Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. Am J Public Health. 2017;107:863–9. https://doi.org/10.2105/AJPH.2017.303744 .

McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6. https://doi.org/10.1016/j.jclinepi.2016.01.021 .

UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2014. https://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf . Accessed 10 June 2023.

UNAIDS. AIDS by the numbers: AIDS is not over, but it can be. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2016. https://www.unaids.org/sites/default/files/media_asset/AIDS-by-the-numbers-2016_en.pdf . Accessed 10 June 2023.

Covidence systematic review software. Veritas Health Innovation. 2022. https://www.covidence.org/ . Accessed 8 Mar 2022.

Kmet LM, Lee RC, Cook LS. HTA initiative #13: standard quality assessment criteria for evaluating primary research papers from a variety of fields. Alberta Heritage Foundation for Medical Research. 2004. https://www.ihe.ca/download/standard_quality_assessment_criteria_for_evaluating_primary_research_papers_from_a_variety_of_fields.pdf . Accessed 24 Oct 2022.

Sandelowski M, Barroso J. Handbook for synthesizing qualitative research. New York: Springer Publishing Company; 2007.

Google Scholar  

Belay YA, Yitayal M, Atnafu A, Taye FA. Patient experiences and preferences for antiretroviral therapy service provision: implications for differentiated service delivery in Northwest Ethiopia. AIDS Res Ther. 2022;19:1–16. https://doi.org/10.1186/s12981-022-00452-5 .

Hlongwa M, Jama NA, Mehlomakulu V, Pass D, Basera W, Nicol E. Barriers and facilitating factors to HIV treatment among men in a high-HIV-burdened district in KwaZulu-Natal, South Africa: a qualitative study. Am J Mens Health. 2022. https://doi.org/10.1177/15579883221120987 .

Lofgren SM, Tsui S, Atuyambe L, Ankunda L, Komuhendo R, Wamala N, Sadiq A, Kirumira P, Srishyla D, Flynn A, Pastick KA, Meya DB, Nakasujja N, Porta C. Barriers to HIV care in Uganda and implications for universal test-and-treat: a qualitative study. AIDS Care. 2022;34:597–605. https://doi.org/10.1080/09540121.2021.1946000 .

Mandawa MB, Mahiti GR. Factors contributing to loss to follow-up from HIV care among men living with HIV/AIDS in Kibaha District, Tanzania. HIV AIDS (Auckl). 2022;14:503–16. https://doi.org/10.2147/hiv.S381204 .

Mange T, Henderson N, Lukelelo N. ‘After 25 years of democracy we are still stigmatised and discriminated against’ healthcare experiences of HIV-positive older black gay men in a township in South Africa. J Pract Teach Learn. 2022;9:87–100. https://doi.org/10.1921/jpts.v19i1-2.1674 .

Mathenjwa M, Khidir H, Milford C, Mosery N, Rambally Greener L, Pratt MC, O’Neil K, Harrison A, Bangsberg DR, Safren SA, Smit JA, Psaros C, Matthews LT. Acceptability of an intervention to promote viral suppression and serostatus disclosure for men living with HIV in South Africa: qualitative findings. AIDS Behav. 2022;26:1–12. https://doi.org/10.1007/s10461-021-03278-w .

Muwanguzi PA, Nelson LE, Ngabirano TD, Kiwanuka N, Osingada CP, Sewankambo NK. Linkage to care and treatment among men with reactive HIV self-tests after workplace-based testing in Uganda: a qualitative study. Front Public Health. 2022. https://doi.org/10.3389/fpubh.2022.650719 .

Nabikande S, Namutundu J, Nangendo J, Okello T, Agwang W, Tusabe J, Kabwama SN, Katahoire AR. Men’s late presentation for HIV care in Eastern Uganda: the role of masculinity norms. PLoS ONE. 2022. https://doi.org/10.1371/journal.pone.0277534 .

Ndione AG, Procureur F, Senne JN, Cornaglia F, Gueye K, Ndour CT, Lépine A. Sexuality-based stigma and access to care: intersecting perspectives between health care providers and men who have sex with men in HIV care centres in Senegal. Health Policy Plan. 2022;37:587–96. https://doi.org/10.1093/heapol/czac010 .

Rich C, Mavhu W, France NF, Munatsi V, Byrne E, Willis N, Nolan A. Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: a qualitative study. PLoS ONE. 2022. https://doi.org/10.1371/journal.pone.0268498 .

Hendrickson ZM, Naugle DA, Tibbels N, Dosso A, Van Lith LM, Mallalieu EC, Kamara D, Dailly-Ajavon P, Cisse A, Ahanda KS, Thaddeus S, Babalola S, Hoffman CJ. “You take medications, you live normally”: the role of antiretroviral therapy in mitigating men’s perceived threats of HIV in Côte d’Ivoire. AIDS Behav. 2019;23:2600–9. https://doi.org/10.1007/s10461-019-02614-5 .

Naugle DA, Tibbels NJ, Hendrickson ZM, Dosso A, Van Lith LM, Mallalieu EC, Kouadio AM, Kra W, Kamara D, Dailly-Ajavon P, Cissé A, Seifert-Ahanda K, Thaddeus S, Babalola S, Hoffman CJ. Bringing fear into focus: the intersections of HIV and masculine gender norms in Côte d’Ivoire. PLoS ONE. 2019. https://doi.org/10.1371/journal.pone.0223414 .

Tibbels NJ, Hendrickson ZM, Naugle DA, Dosso A, Van Lith LM, Mallalieu EC, Kouadio AM, Kra W, Kamara D, Dailly-Ajavon P, Cisse A, Seifert-Ahanda K, Thaddeus S, Babalola S, Hoffmann CJ. Men’s perceptions of HIV care engagement at the facility- and provider-levels: experiences in Cote d’Ivoire. PLoS ONE. 2019. https://doi.org/10.1371/journal.pone.0211385 .

Balogun A, Bissell P, Saddiq M. Negotiating access to the Nigerian healthcare system: the experiences of HIV-positive men who have sex with men. Cult Health Sex. 2020;22:233–46. https://doi.org/10.1080/13691058.2019.1582802 .

Mukumbang FC. Leaving no man behind: how differentiated service delivery models increase men’s engagement in HIV care. Int J Health Policy Manag. 2021;10:129–40. https://doi.org/10.34172/ijhpm.2020.32 .

Ogunbajo A, Kershaw T, Kushwaha S, Boakye F, Wallace-Atiapah N-D, Nelson LE. Barriers, motivators, and facilitators to engagement in HIV care among HIV-infected Ghanaian men who have sex with men (MSM). AIDS Behav. 2018;22:829–39. https://doi.org/10.1007/s10461-017-1806-6 .

Okal J, Lango D, Matheka J, Obare F, Ngunu-Gituathi C, Mugambi M, Avina S. “It is always better for a man to know his HIV status”—a qualitative study exploring the context, barriers and facilitators of HIV testing among men in Nairobi, Kenya. PLoS ONE. 2020. https://doi.org/10.1371/journal.pone.0231645 .

Okoror TA, Falade CO, Walker EM, Olorunlana A, Anaele A. Social context surrounding HIV diagnosis and construction of masculinity: a qualitative study of stigma experiences of heterosexual HIV positive men in southwest Nigeria. BMC Public Health. 2016;16:507. https://doi.org/10.1186/s12889-016-3165-z .

Sileo KM, Reed E, Kizito W, Wagman JA, Stockman JK, Wanyenze RK, Chemusto H, Musoke W, Mukasa B, Kiene SM. Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda. Cult Health Sex. 2019;21:774–88. https://doi.org/10.1080/13691058.2018.1516299 .

Zissette S, Watt MH, Prose NS, Mntambo N, Moshabela M. “If you don’t take a stand for your life, who will help you?”: men’s engagement in HIV care in KwaZulu-Natal, South Africa. Psychol Men Masc. 2016;17:265–73. https://doi.org/10.1037/men0000025 .

Berner-Rodoreda A, Ngwira E, Alhassan Y, Chione B, Dambe R, Bärnighausen T, Phiri S, Taegtmeyer M, Neuhann F. “Deadly”, “fierce”, “shameful”: notions of antiretroviral therapy, stigma and masculinities intersecting men’s life-course in Blantyre, Malawi. BMC Public Health. 2021. https://doi.org/10.1186/s12889-021-12314-2 .

Mantell JE, Masvawure TB, Mapingure M, Apollo T, Gwanzura C, Block L, Bennett E, Preko P, Musuka G, Rabkin M. Engaging men in HIV programmes: a qualitative study of male engagement in community-based antiretroviral refill groups in Zimbabwe. J Int AIDS Soc. 2019. https://doi.org/10.1002/jia2.25403 .

Misra S, Mehta HT, Eschliman EL, Rampa S, Poku OB, Wang W-Q, Ho-Foster AR, Mosepele M, Becker TD, Entaile P, Arscott-Mills T, Opondo PR, Blank MB, Yang LH. Identifying “what matters most” to men in Botswana to promote resistance to HIV-related stigma. Qual Health Res. 2021;31:1680–96. https://doi.org/10.1177/10497323211001361 .

Mooney AC, Gottert A, Khoza N, Rebombo D, Hove J, Suárez AJ, Twine R, MacPhail C, Treves-Kagan S, Kahn K, Pettifor A, Lippman SA. Men’s perceptions of treatment as prevention in South Africa: implications for engagement in HIV care and treatment. AIDS Educ Prev. 2017;29:274–87. https://doi.org/10.1521/aeap.2017.29.3.274 .

Moyo I, Macherera M, Mavhandu-Mudzusi AH. The lived experiences of men who have sex with men when accessing HIV care services in Zimbabwe. Health SA. 2021. https://doi.org/10.4102/hsag.v26i0.1462 .

Meskele M, Khuzwayo N, Taylor M. Mapping the evidence of intimate partner violence among women living with HIV/AIDS in sub-Saharan Africa: a scoping review. BMJ Open. 2021. https://doi.org/10.1136/bmjopen-2020-041326 .

Tenkorang EY, Asamoah-Boaheng M, Owusu AY. Intimate partner violence (IPV) against HIV-positive women in sub-Saharan Africa: a mixed-method systematic review and meta-analysis. Trauma Violence Abuse. 2021;22:1104–28. https://doi.org/10.1177/1524838020906560 .

Sileo KM, Fielding-Miller R, Dworkin SL, Fleming PJ. What role do masculine norms play in men’s HIV testing in sub-Saharan Africa?: a scoping review. AIDS Behav. 2018;22:2468–79. https://doi.org/10.1007/s10461-018-2160-z .

Naanyu V, Ruff J, Goodrich S, Spira T, Bateganya M, Toroitich-Ruto C, Otieno-Nyunya B, Siika AM, Wools-Kaloustian K. Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya. BMC Health Serv Res. 2020. https://doi.org/10.1186/s12913-020-05236-z .

Makoae LN, Seboni NM, Molosiwa K, Moleko M, Human S, Sukati NA, Holzemer WL. The symptom experience of people living with HIV/AIDS in southern Africa. J Assoc Nurses AIDS Care. 2005;16:22–32. https://doi.org/10.1016/j.jana.2005.03.005 .

McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2020. https://doi.org/10.1002/jrsm.1411 .

Download references

Acknowledgements

The manuscript was supported by the Fogarty International Center/National Institutes of Health through Award Number R21TW011247 (M. Relf, Contact MPI/L. Nyblade, MPI) and the Duke University Center for AIDS Research (CFAR), an NIH funded program (5P30AI064518). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Research reported in this publication was supported by the Fogarty International Center of the National Institutes for Health under award R21TW012007 and by the Duke Center for AIDS Research, a National Institutes of Health funded program under award number 5P30AI064518. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Author information

Authors and affiliations.

School of Nursing, Duke University, 307 Trent Drive, Box 3322, Durham, NC, 27710, USA

Sarah E. Janek & Michael V. Relf

Duke Global Health Institute, Durham, NC, USA

Sandy Hatoum & Michael V. Relf

Medical Center Library, Duke University, Durham, NC, USA

Leila Ledbetter

You can also search for this author in PubMed   Google Scholar

Contributions

All authors on this paper meet the four criteria for authorship as identified by the International Committee of Medical Journal Editors; all authors have contributed to the drafting or been involved in revising it, reviewed the final version of this manuscript before submission, and agree to be accountable for all aspects of the work. Specifically, using the CRediT taxonomy, the specific contribution of each author is as follows: Conceptualization & Methodology: S. Janek, L. Ledbetter, M. Relf. Formal Analysis: S. Hatoum, S. Janek, M. Relf. Funding Acquisition: M. Relf. Investigation: S. Hatoum, S. Janek, L. Ledbetter, M. Relf. Methodology: S. Janek, L. Ledbetter, M. Relf. Project administration: M. Relf. Supervision: M. Relf. Verification: S. Hatoum, S. Janek, M. Relf. Writing—manuscript draft: S. Janek. Writing—review & editing: S. Hatoum, S. Janek, L. Ledbetter, M. Relf.

Corresponding authors

Correspondence to Sarah E. Janek or Michael V. Relf .

Ethics declarations

Conflict of interest.

The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.

Additional information

Publisher's note.

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

Registration The protocol that guided this meta-synthesis was prospectively registered with Prospero (registration ID: CRD42022315871).

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 35 KB)

Rights and permissions.

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Janek, S.E., Hatoum, S., Ledbetter, L. et al. Understanding the Stigma Experience of Men Living with HIV in Sub-Saharan Africa: A Qualitative Meta-synthesis. AIDS Behav (2024). https://doi.org/10.1007/s10461-024-04329-8

Download citation

Accepted : 20 March 2024

Published : 22 May 2024

DOI : https://doi.org/10.1007/s10461-024-04329-8

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

• Meta-synthesis
• People with HIV
• Sub-Saharan Africa
• Qualitative methodology
• Find a journal
• Publish with us
• Track your research

Vegetables and Fruits

• Vegetables and fruits are an important part of a healthy diet, and variety is as important as quantity.
• No single fruit or vegetable provides all of the nutrients you need to be healthy. Eat plenty every day.

A diet rich in vegetables and fruits can lower blood pressure, reduce the risk of heart disease and stroke, prevent some types of cancer, lower risk of eye and digestive problems, and have a positive effect upon blood sugar, which can help keep appetite in check. Eating non-starchy vegetables and fruits like apples, pears, and green leafy vegetables may even promote weight loss. [1] Their low glycemic loads prevent blood sugar spikes that can increase hunger.

At least nine different families of fruits and vegetables exist, each with potentially hundreds of different plant compounds that are beneficial to health. Eat a variety of types and colors of produce in order to give your body the mix of nutrients it needs. This not only ensures a greater diversity of beneficial plant chemicals but also creates eye-appealing meals.

Tips to eat more vegetables and fruits each day

• Keep fruit where you can see it . Place several ready-to-eat washed whole fruits in a bowl or store chopped colorful fruits in a glass bowl in the refrigerator to tempt a sweet tooth.
• Explore the produce aisle and choose something new . Variety and color are key to a healthy diet. On most days, try to get at least one serving from each of the following categories: dark green leafy vegetables; yellow or orange fruits and vegetables; red fruits and vegetables; legumes (beans) and peas; and citrus fruits.
• Skip the potatoes . Choose other vegetables that are packed with different nutrients and more slowly digested  carbohydrates .
• Make it a meal . Try cooking new  recipes that include more vegetables. Salads, soups, and stir-fries are just a few ideas for increasing the number of tasty vegetables in your meals.

5 common questions about fruits and vegetables.

Vegetables, fruits, and disease, cardiovascular disease.

There is compelling evidence that a diet rich in fruits and vegetables can lower the risk of heart disease and stroke.

• A meta-analysis of cohort studies following 469,551 participants found that a higher intake of fruits and vegetables is associated with a reduced risk of death from cardiovascular disease, with an average reduction in risk of 4% for each additional serving per day of fruit and vegetables. [2]
• The largest and longest study to date, done as part of the Harvard-based Nurses’ Health Study and Health Professionals Follow-up Study, included almost 110,000 men and women whose health and dietary habits were followed for 14 years.
• The higher the average daily intake of fruits and vegetables, the lower the chances of developing cardiovascular disease. Compared with those in the lowest category of fruit and vegetable intake (less than 1.5 servings a day), those who averaged 8 or more servings a day were 30% less likely to have had a heart attack or stroke. [3]
• Although all fruits and vegetables likely contributed to this benefit, green leafy vegetables, such as lettuce, spinach, Swiss chard, and mustard greens, were most strongly associated with decreased risk of cardiovascular disease. Cruciferous vegetables such as broccoli, cauliflower, cabbage, Brussels sprouts , bok choy, and kale ; and citrus fruits such as oranges, lemons, limes, and grapefruit (and their juices) also made important contributions. [3]
• When researchers combined findings from the Harvard studies with several other long-term studies in the U.S. and Europe, and looked at coronary heart disease and stroke separately, they found a similar protective effect: Individuals who ate more than 5 servings of fruits and vegetables per day had roughly a 20% lower risk of coronary heart disease [4] and stroke, [5] compared with individuals who ate less than 3 servings per day.

Blood pressure

• The  Dietary Approaches to Stop Hypertension (DASH) study [6] examined the effect on blood pressure of a diet that was rich in fruits, vegetables, and low-fat dairy products and that restricted the amount of saturated and total fat. The researchers found that people with high blood pressure who followed this diet reduced their systolic blood pressure (the upper number of a blood pressure reading) by about 11 mm Hg and their diastolic blood pressure (the lower number) by almost 6 mm Hg—as much as medications can achieve.
• A randomized trial known as the Optimal Macronutrient Intake Trial for Heart Health (OmniHeart) showed that this fruit and vegetable-rich diet lowered blood pressure even more when some of the carbohydrate was replaced with healthy unsaturated fat or protein. [7]
• In 2014 a meta-analysis of clinical trials and observational studies found that consumption of a vegetarian diet was associated with lower blood pressure. [8]

Numerous early studies revealed what appeared to be a strong link between eating fruits and vegetables and protection against cancer . Unlike case-control studies, cohort studies , which follow large groups of initially healthy individuals for years, generally provide more reliable information than case-control studies because they don’t rely on information from the past. And, in general, data from cohort studies have not consistently shown that a diet rich in fruits and vegetables prevents cancer.

• For example, over a 14-year period in the Nurses’ Health Study and the Health Professionals Follow-up Study, men and women with the highest intake of fruits and vegetables (8+ servings a day) were just as likely to have developed cancer as those who ate the fewest daily servings (under 1.5). [3]
• A meta-analysis of cohort studies found that a higher fruit and vegetable intake did not decrease the risk of deaths from cancer. [2]

A more likely possibility is that some types of fruits and vegetables may protect against certain cancers.

• A study by Farvid and colleagues followed a Nurses’ Health Study II cohort of 90,476 premenopausal women for 22 years and found that those who ate the most fruit during adolescence (about 3 servings a day) compared with those who ate the lowest intakes (0.5 servings a day) had a 25% lower risk of developing breast cancer. There was a significant reduction in breast cancer in women who had eaten higher intakes of apples, bananas , grapes, and corn during adolescence, and oranges and kale during early adulthood. No protection was found from drinking fruit juices at younger ages. [9]
• Farvid and colleagues followed 90, 534 premenopausal women from the Nurses’ Health Study II over 20 years and found that higher fiber intakes during adolescence and early adulthood were associated with a reduced risk of breast cancer later in life. When comparing the highest and lowest fiber intakes from fruits and vegetables, women with the highest fruit fiber intake had a 12% reduced risk of breast cancer; those with the highest vegetable fiber intake had an 11% reduced risk. [10]
• After following 182,145 women in the Nurses’ Health Study I and II for 30 years, Farvid’s team also found that women who ate more than 5.5 servings of fruits and vegetables each day (especially cruciferous and yellow/orange vegetables) had an 11% lower risk of breast cancer than those who ate 2.5 or fewer servings. Vegetable intake was strongly associated with a 15% lower risk of estrogen-receptor-negative tumors for every two additional servings of vegetables eaten daily. A higher intake of fruits and vegetables was associated with a lower risk of other aggressive tumors including HER2-enriched and basal-like tumors. [11]
• A report by the World Cancer Research Fund and the American Institute for Cancer Research suggests that non-starchy vegetables—such as lettuce and other leafy greens, broccoli, bok choy, cabbage, as well as garlic, onions, and the like—and fruits “probably” protect against several types of cancers, including those of the mouth, throat, voice box, esophagus, and stomach. Fruit probably also protects against lung cancer. [12]

Specific components of fruits and vegetables may also be protective against cancer. For example:

• A line of research stemming from a finding from the Health Professionals Follow-up Study suggests that tomatoes may help protect men against prostate cancer, especially aggressive forms of it. [12] One of the pigments that give tomatoes their red hue—lycopene—could be involved in this protective effect. Although several studies other than the Health Professionals Study have also demonstrated a link between tomatoes or lycopene and prostate cancer, others have not or have found only a weak connection. [14]
• Taken as a whole, however, these studies suggest that increased consumption of tomato-based products (especially cooked tomato products) and other lycopene-containing foods may reduce the occurrence of prostate cancer. [12] Lycopene is one of several carotenoids (compounds that the body can turn into vitamin A) found in brightly colored fruits and vegetables, and research suggests that foods containing carotenoids may protect against lung, mouth, and throat cancer. [12] But more research is needed to understand the exact relationship between fruits and vegetables, carotenoids, and cancer.

Some research looks specifically at whether individual fruits are associated with risk of type 2 diabetes. While there isn’t an abundance of research into this area yet, preliminary results are compelling.

• A study of over 66,000 women in the Nurses’ Health Study, 85,104 women from the Nurses’ Health Study II, and 36,173 men from the Health Professionals Follow-up Study—who were free of major chronic diseases—found that greater consumption of whole fruits—especially blueberries, grapes, and apples—was associated with a lower risk of type 2 diabetes. Another important finding was that greater consumption of fruit juice was associated with a higher risk of type 2 diabetes. [15]
• Additionally a study of over 70,000 female nurses aged 38-63 years, who were free of cardiovascular disease, cancer, and diabetes, showed that consumption of green leafy vegetables and fruit was associated with a lower risk of diabetes. While not conclusive, research also indicated that consumption of fruit juices may be associated with an increased risk among women. (16)
• A study of over 2,300 Finnish men showed that vegetables and fruits, especially berries, may reduce the risk of type 2 diabetes. [17]

Data from the Nurses’ Health Studies and the Health Professional’s Follow-up Study show that women and men who increased their intakes of fruits and vegetables over a 24-year period were more likely to have lost weight than those who ate the same amount or those who decreased their intake. Berries, apples, pears, soy, and cauliflower were associated with weight loss while starchier vegetables like potatoes, corn, and peas were linked with weight gain. [1] However, keep in mind that adding more produce into the diet won’t necessarily help with weight loss unless it replaces another food, such as refined carbohydrates of white bread and crackers.

Gastrointestinal health

Fruits and vegetables contain indigestible fiber, which absorbs water and expands as it passes through the digestive system. This can calm symptoms of an irritable bowel and, by triggering regular bowel movements, can relieve or prevent constipation. [18] The bulking and softening action of insoluble fiber also decreases pressure inside the intestinal tract and may help prevent diverticulosis. [19]

Eating fruits and vegetables can also keep your eyes healthy, and may help prevent two common aging-related eye diseases—cataracts and macular degeneration—which afflict millions of Americans over age 65. [20-23] Lutein and zeaxanthin, in particular, seem to reduce risk of cataracts. [24]

• Bertoia ML, Mukamal KJ, Cahill LE, Hou T, Ludwig DS, Mozaffarian D, Willett WC, Hu FB, Rimm EB. Changes in intake of fruits and vegetables and weight change in United States men and women followed for up to 24 years: analysis from three prospective cohort studies. PLoS medicine . 2015 Sep 22;12(9):e1001878.
• Wang X, Ouyang Y, Liu J, Zhu M, Zhao G, Bao W, Hu FB. Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ . 2014 Jul 29;349:g4490.
• Hung HC, Joshipura KJ, Jiang R, Hu FB, Hunter D, Smith-Warner SA, Colditz GA, Rosner B, Spiegelman D, Willett WC. Fruit and vegetable intake and risk of major chronic disease. Journal of the National Cancer Institute . 2004 Nov 3;96(21):1577-84.
• He FJ, Nowson CA, Lucas M, MacGregor GA. Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: meta-analysis of cohort studies. Journal of human hypertension . 2007 Sep;21(9):717.
• He FJ, Nowson CA, MacGregor GA. Fruit and vegetable consumption and stroke: meta-analysis of cohort studies. The Lancet . 2006 Jan 28;367(9507):320-6.
• Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH. A clinical trial of the effects of dietary patterns on blood pressure. New England Journal of Medicine . 1997 Apr 17;336(16):1117-24.
• Appel LJ, Sacks FM, Carey VJ, Obarzanek E, Swain JF, Miller ER, Conlin PR, Erlinger TP, Rosner BA, Laranjo NM, Charleston J. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA . 2005 Nov 16;294(19):2455-64.
• Yokoyama Y, Nishimura K, Barnard ND, Takegami M, Watanabe M, Sekikawa A, Okamura T, Miyamoto Y. Vegetarian diets and blood pressure: a meta-analysis. JAMA internal medicine. 2014 Apr 1;174(4):577-87.
• Farvid MS, Chen WY, Michels KB, Cho E, Willett WC, Eliassen AH. Fruit and vegetable consumption in adolescence and early adulthood and risk of breast cancer: population based cohort study. BMJ . 2016 May 11;353:i2343.
• Farvid MS, Eliassen AH, Cho E, Liao X, Chen WY, Willett WC. Dietary fiber intake in young adults and breast cancer risk. Pediatrics . 2016 Mar 1;137(3):e20151226.
• Farvid MS, Chen WY, Rosner BA, Tamimi RM, Willett WC, Eliassen AH. Fruit and vegetable consumption and breast cancer incidence: Repeated measures over 30 years of follow‐up. International journal of cancer . 2018 Jul 6.
• Wiseman M. The Second World Cancer Research Fund/American Institute for Cancer Research Expert Report. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective: Nutrition Society and BAPEN Medical Symposium on ‘Nutrition support in cancer therapy’. Proceedings of the Nutrition Society . 2008 Aug;67(3):253-6.
• Giovannucci E, Liu Y, Platz EA, Stampfer MJ, Willett WC. Risk factors for prostate cancer incidence and progression in the health professionals follow‐up study. International journal of cancer . 2007 Oct 1;121(7):1571-8.
• Kavanaugh CJ, Trumbo PR, Ellwood KC. The US Food and Drug Administration’s evidence-based review for qualified health claims: tomatoes, lycopene, and cancer. Journal of the National Cancer Institute . 2007 Jul 18;99(14):1074-85.
• Muraki I, Imamura F, Manson JE, Hu FB, Willett WC, van Dam RM, Sun Q. Fruit consumption and risk of type 2 diabetes: results from three prospective longitudinal cohort studies. BMJ . 2013 Aug 29;347:f5001.
• Bazzano LA, Li TY, Joshipura KJ, Hu FB. Intake of fruit, vegetables, and fruit juices and risk of diabetes in women. Diabetes Care . 2008 Apr 3.
• Mursu J, Virtanen JK, Tuomainen TP, Nurmi T, Voutilainen S. Intake of fruit, berries, and vegetables and risk of type 2 diabetes in Finnish men: the Kuopio Ischaemic Heart Disease Risk Factor Study–. The American journal of clinical nutrition . 2013 Nov 20;99(2):328-33.
• Lembo A, Camilleri M. Chronic constipation. New England Journal of Medicine . 2003 Oct 2;349(14):1360-8.
• Aldoori WH, Giovannucci EL, Rockett HR, Sampson L, Rimm EB, Willett AW. A prospective study of dietary fiber types and symptomatic diverticular disease in men. The Journal of nutrition . 1998 Oct 1;128(4):714-9.
• Brown L, Rimm EB, Seddon JM, Giovannucci EL, Chasan-Taber L, Spiegelman D, Willett WC, Hankinson SE. A prospective study of carotenoid intake and risk of cataract extraction in US men–. The American journal of clinical nutrition . 1999 Oct 1;70(4):517-24.
• Christen WG, Liu S, Schaumberg DA, Buring JE. Fruit and vegetable intake and the risk of cataract in women–. The American journal of clinical nutrition . 2005 Jun 1;81(6):1417-22.
• Moeller SM, Taylor A, Tucker KL, McCullough ML, Chylack Jr LT, Hankinson SE, Willett WC, Jacques PF. Overall adherence to the dietary guidelines for Americans is associated with reduced prevalence of early age-related nuclear lens opacities in women. The Journal of nutrition . 2004 Jul 1;134(7):1812-9.
• Cho E, Seddon JM, Rosner B, Willett WC, Hankinson SE. Prospective study of intake of fruits, vegetables, vitamins, and carotenoidsand risk of age-related maculopathy. Archives of Ophthalmology . 2004 Jun 1;122(6):883-92.
• Christen WG, Liu S, Glynn RJ, Gaziano JM, Buring JE. Dietary carotenoids, vitamins C and E, and risk of cataract in women: a prospective study. Archives of Ophthalmology . 2008 Jan 1;126(1):102-9.

Terms of Use

The contents of this website are for educational purposes and are not intended to offer personal medical advice. You should seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The Nutrition Source does not recommend or endorse any products.

• Open access
• Published: 03 June 2024

The use of evidence to guide decision-making during the COVID-19 pandemic: divergent perspectives from a qualitative case study in British Columbia, Canada

• Laura Jane Brubacher   ORCID: orcid.org/0000-0003-2806-9539 1 , 2 ,
• Chris Y. Lovato 1 ,
• Veena Sriram 1 , 3 ,
• Michael Cheng 1 &
• Peter Berman 1  

Health Research Policy and Systems volume  22 , Article number:  66 ( 2024 ) Cite this article

Metrics details

The challenges of evidence-informed decision-making in a public health emergency have never been so notable as during the COVID-19 pandemic. Questions about the decision-making process, including what forms of evidence were used, and how evidence informed—or did not inform—policy have been debated.

We examined decision-makers' observations on evidence-use in early COVID-19 policy-making in British Columbia (BC), Canada through a qualitative case study. From July 2021- January 2022, we conducted 18 semi-structured key informant interviews with BC elected officials, provincial and regional-level health officials, and civil society actors involved in the public health response. The questions focused on: (1) the use of evidence in policy-making; (2) the interface between researchers and policy-makers; and (3) key challenges perceived by respondents as barriers to applying evidence to COVID-19 policy decisions. Data were analyzed thematically, using a constant comparative method. Framework analysis was also employed to generate analytic insights across stakeholder perspectives.

Overall, while many actors’ impressions were that BC's early COVID-19 policy response was evidence-informed, an overarching theme was a lack of clarity and uncertainty as to what evidence was used and how it flowed into decision-making processes. Perspectives diverged on the relationship between 'government' and public health expertise, and whether or not public health actors had an independent voice in articulating evidence to inform pandemic governance. Respondents perceived a lack of coordination and continuity across data sources, and a lack of explicit guidelines on evidence-use in the decision-making process, which resulted in a sense of fragmentation. The tension between the processes involved in research and the need for rapid decision-making was perceived as a barrier to using evidence to inform policy.

Conclusions

Areas to be considered in planning for future emergencies include: information flow between policy-makers and researchers, coordination of data collection and use, and transparency as to how decisions are made—all of which reflect a need to improve communication. Based on our findings, clear mechanisms and processes for channeling varied forms of evidence into decision-making need to be identified, and doing so will strengthen preparedness for future public health crises.

Peer Review reports

The challenges of evidence-informed decision-making Footnote 1 in a public health emergency have never been so salient as during the COVID-19 pandemic, given its unprecedented scale, rapidly evolving virology, and multitude of global information systems to gather, synthesize, and disseminate evidence on the SARS-CoV-2 virus and associated public health and social measures [ 1 , 2 , 3 ]. Early in the COVID-19 pandemic, rapid decision-making became central for governments globally as they grappled with crucial decisions for which there was limited evidence. Critical questions exist, in looking retrospectively at these decision-making processes and with an eye to strengthening future preparedness: Were decisions informed by 'evidence'? What forms of evidence were used, and how, by decision-makers? [ 4 , 5 , 6 ].

Scientific evidence, including primary research, epidemiologic research, and knowledge synthesis, is one among multiple competing influences that inform decision-making processes in an outbreak such as COVID-19 [ 7 ]. Indeed, the use of multiple forms of evidence has been particularly notable as it applies to COVID-19 policy-making. Emerging research has also documented the important influence of ‘non-scientific’ evidence such as specialized expertise and experience, contextual information, and level of available resources [ 8 , 9 , 10 ]. The COVID-19 pandemic has underscored the politics of evidence-use in policy-making [ 11 ]; what evidence is used and how can be unclear, and shaped by political bias [ 4 , 5 ]. Moreover, while many governments have established scientific advisory boards, the perspectives of these advisors were reportedly largely absent from COVID-19 policy processes [ 6 ]. How evidence and public health policy interface—and intersect—is a complex question, particularly in the dynamic context of a public health emergency.

Within Canada, a hallmark of the public health system and endorsed by government is evidence-informed decision-making [ 12 ]. In British Columbia (BC), Canada, during the early phases of COVID-19 (March—June 2020), provincial public health communication focused primarily on voluntary compliance with recommended public health and social measures, and on supporting those most affected by the pandemic. Later, the response shifted from voluntary compliance to mandatory enforceable government orders [ 13 ]. Like many other jurisdictions, the government’s public messaging in BC asserted that the province took an approach to managing the COVID-19 pandemic and developing related policy that was based on scientific evidence, specifically. For example, in March 2021, in announcing changes to vaccination plans, Dr. Bonnie Henry, the Provincial Health Officer, stated, " This is science in action " [ 14 ]. As a public health expert with scientific voice, the Provincial Health Officer has been empowered to speak on behalf of the BC government across the COVID-19 pandemic progression. While this suggests BC is a jurisdiction which has institutionalized scientifically-informed decision-making as a core tenet of effective public health crisis response, it remains unclear as to whether BC’s COVID-19 response could, in fact, be considered evidence-informed—particularly from the perspectives of those involved in pandemic decision-making and action. Moreover, if evidence-informed, what types of evidence were utilized and through what mechanisms, how did this evidence shape decision-making, and what challenges existed in moving evidence to policy and praxis in BC’s COVID-19 response?

The objectives of this study were: (1) to explore and characterize the perspectives of BC actors involved in the COVID-19 response with respect to evidence-use in COVID-19 decision-making; and (2) to identify opportunities for and barriers to evidence-informed decision-making in BC’s COVID-19 response, and more broadly. This inquiry may contribute to identifying opportunities for further strengthening the synthesis and application of evidence (considered broadly) to public health policy and decision-making, particularly in the context of future public health emergencies, both in British Columbia and other jurisdictions.

Study context

This qualitative study was conducted in the province of British Columbia (BC), Canada, a jurisdiction with a population of approximately five million people [ 15 ]. Within BC’s health sector, key actors involved in the policy response to COVID-19 included: elected officials, the BC Government’s Ministry of Health (MOH), the Provincial Health Services Authority (PHSA), Footnote 2 the Office of the Provincial Health Officer (PHO), Footnote 3 the BC Centre for Disease Control (BCCDC), Footnote 4 and Medical Health Officers (MHOs) and Chief MHOs at regional and local levels.

Health research infrastructure within the province includes Michael Smith Health Research BC [ 16 ] and multiple post-secondary research and education institutions (e.g., The University of British Columbia). Unlike other provincial (e.g., Ontario) and international (e.g., UK) jurisdictions, BC did not establish an independent, formal scientific advisory panel or separate organizational structure for public health intelligence in COVID-19. That said, a Strategic Research Advisory Council was established, reporting to the MOH and PHO, to identify COVID-19 research gaps and commission needed research for use within the COVID-19 response [ 17 ].

This research was part of a multidisciplinary UBC case study investigating the upstream determinants of the COVID-19 response in British Columbia, particularly related to institutions, politics, and organizations and how these interfaced with, and affected, pandemic governance [ 18 ]. Ethics approval for this study was provided by the University of British Columbia (UBC)’s Institutional Research Ethics Board (Certificate #: H20-02136).

Data collection

From July 2021 to January 2022, 18 semi-structured key informant interviews were conducted with BC elected officials, provincial and regional-level health officials, and civil society actors (e.g., within non-profit research organizations, unions) (Table 1 ). Initially, respondents were purposively sampled, based on their involvement in the COVID-19 response and their positioning within the health system organizational structure. Snowball sampling was used to identify additional respondents, with the intent of representing a range of organizational roles and actor perspectives. Participants were recruited via email invitation and provided written informed consent to participate.

Interviews were conducted virtually using Zoom® videoconferencing, with the exception of one hybrid in-person/Zoom® interview. Each interview was approximately one hour in duration. One to two research team members led each interview. The full interview protocol focused on actors’ descriptions of decision-making processes across the COVID-19 pandemic progression, from January 2020 to the date of the interviews, and they were asked to identify key decision points (e.g., emergency declaration, business closures) [see Additional File 1 for the full semi-structured interview guide]. For this study, we used a subset of interview questions focused on evidence-use in the decision-making process, and the organizational structures or actors involved, in BC's early COVID-19 pandemic response (March–August 2020). Questions were adapted to be relevant to a respondent’s expertise and particular involvement in the response. ‘Evidence’ was left undefined and considered broadly by the research team (i.e., both ‘scientific’/research-based and ‘non-scientific’ inputs) within interview questions, and therefore at the discretion of the participant as to what inputs they perceived and described as ‘evidence’ that informed or did not inform pandemic decision-making. Interviews were audio-recorded over Zoom® with permission and transcribed using NVivo Release 1.5© software. Each transcript was then manually verified for accuracy by 1–2 members of the research team.

Data analysis

An inductive thematic analysis was conducted, using a constant comparative method, to explore points of divergence and convergence across interviews and stakeholder perspectives [ 19 ]. Transcripts were inductively coded in NVivo Release 1.5© software, which was used to further organize and consolidate codes, generate a parsimonious codebook to fit the data, and retrieve interview excerpts [ 20 ]. Framework analysis was also employed as an additional method for generating analytic insights across stakeholder perspectives and contributed to refining the overall coding [ 21 ]. Triangulation across respondents and analytic methods, as well as team collaboration in reviewing and refining the codebook, contributed to validity of the analysis [ 22 ].

How did evidence inform early COVID-19 policy-making in BC?

Decision-makers described their perceptions on the use of evidence in policy-making; the interface between researchers and policy-makers; and specific barriers to evidence-use in policy-making within BC’s COVID-19 response. In discussing the use of evidence, respondents focused on ‘scientific’ evidence; however, they noted a lack of clarity as to how and what evidence flowed into decision-making. They also acknowledged that ‘scientific’ evidence was one of multiple factors influencing decisions. The themes described below reflect the narrative underlying their perspectives.

Perceptions of evidence-use

Multiple provincial actors generally expressed confidence or had an overall impression that decisions were evidence-based (IDI5,9), stating definitively that, "I don’t think there was a decision we made that wasn’t evidence-informed" (IDI9) and that "the science became a driver of decisions that were made" (IDI5). However, at the regional health authority level, one actor voiced skepticism that policy decisions were consistently informed by scientific evidence specifically, stating, "a lot of decisions [the PHO] made were in contrast to science and then shifted to be by the science" ( IDI6). The evolving nature of the available evidence and scientific understanding of the virus throughout the pandemic was acknowledged. For instance, one actor stated that, "I’ll say the response has been driven by the science; the science has been changing…from what I’ve seen, [it] has been a very science-based response" (IDI3).

Some actors narrowed in on certain policy decisions they believed were or were not evidence-informed. Policy decisions in 2020 that actors believed were directly informed by scientific data included the early decision to restrict informal, household gatherings; to keep schools open for in-person learning; to implement a business safety plan requirement across the province; and to delay the second vaccine dose for maximum efficacy. One provincial public health actor noted that an early 2020 decision made, within local jurisdictions, to close playgrounds was not based on scientific evidence. Further, the decision prompted public health decision-makers to centralize some decision-making to the provincial level, to address decisions being made 'on the ground' that were not based on scientific evidence (IDI16). Similarly, they added that the policy decision to require masking in schools was not based on scientific evidence; rather, "it's policy informed by the noise of your community." As parents and other groups within the community pushed for masking, this was "a policy decision to help schools stay open."

Early in the pandemic response, case data in local jurisdictions were reportedly used for monitoring and planning. These "numerator data" (IDI1), for instance case or hospitalization counts, were identified as being the primary mode of evidence used to inform decisions related to the implementation or easing of public health and social measures. The ability to generate epidemiological count data early in the pandemic due to efficient scaling up of PCR testing for COVID-19 was noted as a key advantage (IDI16). As the pandemic evolved in 2020, however, perspectives diverged in relation to the type of data that decision-makers relied on. For example, it was noted that BCCDC administered an online, voluntary survey to monitor unintended consequences of public health and social measures and inform targeted interventions. Opinions varied on whether this evidence was successfully applied in decision-making. One respondent emphasized this lack of application of evidence and perceived that public health orders were not informed by the level and type of evidence available, beyond case counts: "[In] a communicable disease crisis like a pandemic, the collateral impact slash damage is important and if you're going to be a public health institute, you actually have to bring those to the front, not just count cases" (IDI1).

There also existed some uncertainty and a perceived lack of transparency or clarity as to how or whether data analytic ‘entities’, such as BCCDC or research institutions, fed directly into decision-making. As a research actor shared, "I’m not sure that I know quite what all those channels really look like…I’m sure that there’s a lot of improvement that could be driven in terms of how we bring strong evidence to actual policy and practice" (IDI14). Another actor explicitly named the way information flowed into decision-making in the province as "organic" (IDI7). They also noted the lack of a formal, independent science advisory panel for BC’s COVID-19 response, which existed in other provincial and international jurisdictions. Relatedly, one regional health authority actor perceived that the committee that was convened to advise the province on research, and established for the purpose of applying research to the COVID-19 response, "should have focused more on knowledge translation, but too much time was spent commissioning research and asking what kinds of questions we needed to ask rather than looking at what was happening in other jurisdictions" (IDI6). Overall, multiple actors noted a lack of clarity around application of evidence and who is responsible for ensuring evidence is applied. As a BCCDC actor expressed, in relation to how to prevent transmission of COVID-19:

We probably knew most of the things that we needed to know about May of last year [2020]. So, to me, it’s not even what evidence you need to know about, but who’s responsible for making sure that you actually apply the evidence to the intervention? Because so many of our interventions have been driven by peer pressure and public expectation rather than what we know to be the case [scientifically] (IDI1).

Some described the significance of predictive disease modelling to understand the COVID-19 trajectory and inform decisions, as well as to demonstrate to the public the effectiveness of particular measures, which "help[ed] sustain our response" (IDI2). Others, however, perceived that "mathematical models were vastly overused [and] overvalued in decision-making around this pandemic" (IDI1) and that modellers stepped outside their realm of expertise in providing models and policy recommendations through the public media.

Overall, while many actors’ impressions were that the response was evidence-informed, an overarching theme was a lack of clarity and uncertainty with respect to how evidence actually flowed into decision-making processes, as well as what specific evidence was used and how. Participants noted various mechanisms created or already in place prior to COVID-19 that fed data into, and facilitated, decision-making. There was an acknowledgement that multiple forms of evidence—including scientific data, data on public perceptions, as well as public pressure—appeared to have influenced decision-making.

Interface between researchers and policy-makers

There was a general sense that the Ministry supported the use of scientific and research-based evidence specifically. Some actors identified particular Ministry personnel as being especially amenable to research and focused on data to inform decisions and implementation. More broadly, the government-research interface was characterized by one actor as an amicable one, a "research-friendly government", and that the Ministry of Health (MOH), specifically, has a research strategy whereby, "it’s literally within their bureaucracy to become a more evidence-informed organization" (IDI11). The MOH was noted to have funded a research network intended to channel evidence into health policy and practice, and which reported to the research side of the MOH.

Other actors perceived relatively limited engagement with the broader scientific community. Some perceived an overreliance on 'in-house expertise' or a "we can do that [ourselves] mentality" within government that precluded academic researchers’ involvement, as well as a sense of "not really always wanting to engage with academics to answer policy questions because they don’t necessarily see the value that comes" (IDI14). With respect to the role of research, an actor stated:

There needs to be a provincial dialogue around what evidence is and how it gets situated, because there’s been some tension around evidence being produced and not used or at least not used in the way that researchers think that it should be (IDI11).

Those involved in data analytics within the MOH acknowledged a challenge in making epidemiological data available to academic researchers, because "at the time, you’re just trying to get decisions made" (IDI7). Relatedly, a research actor described the rapid instigation of COVID-19 research and pivoting of academic research programs to respond to the pandemic, but perceived a slow uptake of these research efforts from the MOH and PHSA for decision-making and action. Nevertheless, they too acknowledged the challenge of using research evidence, specifically, in an evolving and dynamic pandemic:

I think we’ve got to be realistic about what research in a pandemic situation can realistically contribute within very short timelines. I mean, some of these decisions have to be made very quickly...they were intuitive decisions, I think some of them, rather than necessarily evidence-based decisions (IDI14).

Relatedly, perspectives diverged on the relationship between 'government' and public health expertise, and whether or not public health actors had an independent voice in articulating evidence to inform governance during the pandemic. Largely from Ministry stakeholders, and those within the PHSA, the impressions were that Ministry actors were relying on public health advice and scientific expertise. As one actor articulated, "[the] government actually respected and acknowledged and supported public health expertise" (IDI9). Others emphasized a "trust of the people who understood the problem" (IDI3)—namely, those within public health—and perceived that public health experts were enabled "to take a lead role in the health system, over politics" (IDI12). This perspective was not as widely held by those in the public health sector, as one public health actor expressed, "politicians and bureaucrats waded into public health practice in a way that I don't think was appropriate" and that, "in the context of a pandemic, it’s actually relatively challenging to bring true expert advice because there’s too many right now. Suddenly, everybody’s a public health expert, but especially bureaucrats and politicians." They went on to share that the independence of public health to speak and act—and for politicians to accept independent public health advice—needs to be protected and institutionalized as "core to good governance" (IDI1). Relatedly, an elected official linked this to the absence of a formal, independent science table to advise government and stated that, "I think we should have one established permanently. I think we need to recognize that politicians aren't always the best at discerning scientific evidence and how that should play into decision-making" (IDI15).

These results highlight the divergent perspectives participants had as to the interface between research and policy-making and a lack of understanding regarding process and roles.

Challenges in applying evidence to policy decisions

Perspectives converged with respect to the existence of numerous challenges with and barriers to applying evidence to health policy and decision-making. These related to the quality and breadth of available data, both in terms of absence and abundance. For instance, as one public health actor noted in relation to health policy-making, "you never have enough information. You always have an information shortage, so you're trying to make the best decisions you can in the absence of usually really clear information" (IDI8). On the other hand, as evidence emerged en masse across jurisdictions in the pandemic, there were challenges with synthesizing evidence in a timely fashion for 'real-time' decision-making. A regional health authority actor highlighted this challenge early in the COVID-19 pandemic and perceived that there was not a provincial group bringing new synthesized information to decision-makers on a daily basis (IDI6). Other challenges related to the complexity of the political-public health interface with respect to data and scientific expertise, which "gets debated and needs to be digested by the political process. And then decisions are made" (IDI5). This actor further expressed that debate among experts needs to be balanced with efficient crisis response, that one has to "cut the debate short. For the sake of expediency, you need to react."

It was observed that, in BC’s COVID-19 response, data was gathered from multiple sources with differing data collection procedures, and sometimes with conflicting results—for instance, 'health system data' analyzed by the PHSA and 'public health data' analyzed by the BCCDC. This was observed to present challenges from a political perspective in discerning "who’s actually getting the 'right' answers" (IDI7). An added layer of complexity was reportedly rooted in how to communicate such evidence to the public and "public trust in the numbers" (IDI7), particularly as public understanding of what evidence is, how it is developed, and why it changes, can influence public perceptions of governance.

Finally, as one actor from within the research sector noted, organizationally and governance-wise, the system was "not very well set up to actually use research evidence…if we need to do better at using evidence in practice, we need to fix some of those things. And we actually know what a lot of those things are." For example , "there’s no science framework for how organizations work within that" and " governments shy away from setting science policy " (IDI11). This challenge was framed as having a macro-level dimension, as higher-level leadership structures were observed to not incentivize the development and effective use of research among constituent organizations, and also micro-level implications. From their perspective, researchers will struggle without such policy frameworks to obtain necessary data-sharing agreements with health authorities, nor will they be able to successfully navigate other barriers to conducting action-oriented research that informs policy and practice.

Similarly, a research actor perceived that the COVID-19 pandemic highlighted pre-existing fragmentation, "a pretty disjointed sort of enterprise" in how research is organized in the province:

I think pandemics need strong leadership and I think pandemic research response needed probably stronger leadership than it had. And I think that’s to do with [how] no one really knew who was in charge because no one really was given the role of being truly in charge of the research response (IDI14).

This individual underscored that, at the time of the interview, there were nearly 600 separate research projects being conducted in BC that focused on COVID-19. From their perspective, this reflected the need for more centralized direction to provide leadership, coordinate research efforts, and catalyze collaborations.

Overall, respondents perceived a lack of coordination and continuity across data sources, and a lack of explicit guidelines on evidence-use in the decision-making process, which resulted in a sense of fragmentation. The tension between the processes involved in research and the need for rapid decision-making was perceived as a barrier to using evidence to inform policy.

This study explored the use of evidence to inform early COVID-19 decision-making within British Columbia, Canada, from the perspectives of decision-makers themselves. Findings underscore the complexity of synthesizing and applying evidence (i.e., ‘scientific’ or research-based evidence most commonly discussed) to support public health policy in 'real-time', particularly in the context of public health crisis response. Despite a substantial and long-established literature on evidence-based clinical decision-making [ 23 , 24 ], understanding is more limited as to how public health crisis decision-making can be evidence-informed or evidence-based. By contributing to a growing global scholarship of retrospective examinations of COVID-19 decision-making processes [ 25 , 26 , 27 , 28 ], our study aimed to broaden this understanding and, thus, support the strengthening of public health emergency preparedness in Canada, and globally.

Specifically, based on our findings on evidence-based public health practice, we found that decision-makers clearly emphasized ‘evidence-based’ or ‘evidence-informed’ as meaning ‘scientific’ evidence. They acknowledged other forms of evidence such as professional expertise and contextual information as influencing factors. We identified four key points related to the process of evidence-use in BC's COVID-19 decision-making, with broader implications as well:

Role Differences: The tensions we observed primarily related to a lack of clarity among the various agencies involved as to their respective roles and responsibilities in a public health emergency, a finding that aligns with research on evidence-use in prior pandemics in Canada [ 29 ]. Relatedly, scientists and policy-makers experienced challenges with communication and information-flow between one another and the public, which may reflect their different values and standards, framing of issues and goals, and language [ 30 ].

Barriers to Evidence-Use: Coordination and consistency in how data are collected across jurisdictions reportedly impeded efficiency and timeliness of decision-making. Lancaster and Rhodes (2020) suggest that evidence itself should be treated as a process, rather than a commodity, in evidence-based practice [ 31 ]. Thus, shifting the dialogue from 'barriers to evidence use' to an approach that fosters dialogue across different forms of evidence and different actors in the process may be beneficial.

Use of Evidence in Public Health versus Medicine: Evidence-based public health can be conflated with the concept of evidence-based medicine, though these are distinct in the type of information that needs to be considered. While ‘research evidence’ was the primary type of evidence used, other important types of evidence informed policy decisions in the COVID-19 public health emergency—for example, previous experience, public values, and preferences. This concurs with Brownson’s (2009) framework of factors driving decision-making in evidence-based public health [ 32 ]. Namely, that a balance between multiple factors, situated in particular environmental and organizational context, shapes decision-making: 1) best available research evidence; 2) clients'/population characteristics, state, needs, values, and preferences; and 3) resources, including a practitioner’s expertise. Thus, any evaluation of evidence-use in public health policy must take into consideration this multiplicity of factors at play, and draw on frameworks specific to public health [ 33 ]. Moreover, public health decision-making requires much more attention to behavioural factors and non-clinical impacts, which is distinct from the largely biology-focused lens of evidence-based medicine.

Transparency: Many participants emphasized a lack of explanation about why certain decisions were made and a lack of understanding about who was involved in decisions and how those decisions were made. This point was confirmed by a recent report on lessons learned in BC during the COVID-19 pandemic in which the authors describe " the desire to know more about the reasons why decisions were taken " as a " recurring theme " (13:66). These findings point to a need for clear and transparent mechanisms for channeling evidence, irrespective of the form used, into public health crisis decision-making.

Our findings also pointed to challenges associated with the infrastructure for utilizing research evidence in BC policy-making, specifically a need for more centralized authority on the research side of the public health emergency response to avoid duplication of efforts and more effectively synthesize findings for efficient use. Yet, as a participant questioned, what is the realistic role of research in a public health crisis response? Generally, most evidence used to inform crisis response measures is local epidemiological data or modelling data [ 7 ]. As corroborated by our findings, challenges exist in coordinating data collection and synthesis of these local data across jurisdictions to inform 'real-time' decision-making, let alone to feed into primary research studies [ 34 ].

On the other hand, as was the case in the COVID-19 pandemic, a 'high noise' research environment soon became another challenge as data became available to researchers. Various mechanisms have been established to try and address these challenges amid the COVID-19 pandemic, both to synthesize scientific evidence globally and to create channels for research evidence to support timely decision-making. For instance: 1) research networks and collaborations are working to coordinate research efforts (e.g., COVID-END network [ 35 ]); 2) independent research panels or committees within jurisdictions provide scientific advice to inform decision-making; and 3) research foundations, funding agencies, and platforms for knowledge mobilization (e.g., academic journals) continue to streamline funding through targeted calls for COVID-19 research grant proposals, or for publication of COVID-19 research articles. While our findings describe the varied forms of evidence used in COVID-19 policy-making—beyond scientific evidence—they also point to the opportunity for further investments in infrastructure that coordinates, streamlines, and strengthens collaborations between health researchers and decision-makers that results in timely uptake of results into policy decisions.

Finally, in considering these findings, it is important to note the study's scope and limitations: We focused on evidence use in a single public health emergency, in a single province. Future research could expand this inquiry to a multi-site analysis of evidence-use in pandemic policy-making, with an eye to synthesizing lessons learned and best practices. Additionally, our sample of participants included only one elected official, so perspectives were limited from this type of role. The majority of participants were health officials who primarily referred to and discussed evidence as ‘scientific’ or research-based evidence. Further work could explore the facilitators and barriers to evidence-use from the perspectives of elected officials and Ministry personnel, particularly with respect to the forms of evidence—considered broadly—and other varied inputs, that shape decision-making in the public sphere. This could include a more in-depth examination of policy implementation and how the potential societal consequences of implementation factor into public health decision-making.

We found that the policy decisions made during the initial stages of the COVID-19 pandemic were perceived by actors in BC's response as informed by—not always based on—scientific evidence, specifically; however, decision-makers also considered other contextual factors and drew on prior pandemic-related experience to inform decision-making, as is common in evidence-based public health practice [ 32 ]. The respondents' experiences point to specific areas that need to be considered in planning for future public health emergencies, including information flow between policy-makers and researchers, coordination in how data are collected, and transparency in how decisions are made—all of which reflect a need to improve communication. Furthermore, shifting the discourse from evidence as a commodity to evidence-use as a process will be helpful in addressing barriers to evidence-use, as well as increasing understanding about the public health decision-making process as distinct from clinical medicine. Finally, there is a critical need for clear mechanisms that channel evidence (whether ‘scientific’, research-based, or otherwise) into health crisis decision-making, including identifying and communicating the decision-making process to those producing and synthesizing evidence. The COVID-19 pandemic experience is an opportunity to reflect on what needs to be done to guild our public health systems for the future [ 36 , 37 ]. Understanding and responding to the complexities of decision-making as we move forward, particularly with respect to the synthesis and use of evidence, can contribute to strengthening preparedness for future public health emergencies.

Availability of data and materials

The data that support the findings of this study are not publicly available to maintain the confidentiality of research participants.

The terms 'evidence-informed' and 'evidence-based' decision-making are used throughout this paper, though are distinct. The term 'evidence-informed' suggests that evidence is used and considered, though not necessarily solely determinative in decision-making [ 38 ].

The Provincial Health Services Authority (PHSA) works with the Ministry of Health (MOH) and regional health authorities to oversee the coordination and delivery of programs.

The Office of the Provincial Health Officer (PHO) has binding legal authority in the case of an emergency, and responsibility to monitor the health of BC’s population and provide independent advice to Ministers and public offices on public health issues.

The British Columbia Centre for Disease Control (BCCDC) is a program of the PHSA and provides provincial and national disease surveillance, detection, treatment, prevention, and consultation.

Abbreviations

British Columbia

British Columbia Centre for Disease Control

Coronavirus Disease 2019

Medical Health Officer

Ministry of Health

Provincial Health Officer

Provincial Health Services Authority

Severe Acute Respiratory Syndrome Coronavirus—2

University of British Columbia

Rubin O, Errett NA, Upshur R, Baekkeskov E. The challenges facing evidence-based decision making in the initial response to COVID-19. Scand J Public Health. 2021;49(7):790–6.

Article   PubMed   Google Scholar  

Williams GA, Ulla Díez SM, Figueras J, Lessof S, Ulla SM. Translating evidence into policy during the COVID-19 pandemic: bridging science and policy (and politics). Eurohealth (Lond). 2020;26(2):29–48.

Google Scholar  

Vickery J, Atkinson P, Lin L, Rubin O, Upshur R, Yeoh EK, et al. Challenges to evidence-informed decision-making in the context of pandemics: qualitative study of COVID-19 policy advisor perspectives. BMJ Glob Heal. 2022;7(4):1–10.

Piper J, Gomis B, Lee K. “Guided by science and evidence”? The politics of border management in Canada’s response to the COVID-19 pandemic. Front Polit Sci. 2022;4

Cairney P. The UK government’s COVID-19 policy: what does “Guided by the science” mean in practice? Front Polit Sci. 2021;3(March):1–14.

Colman E, Wanat M, Goossens H, Tonkin-Crine S, Anthierens S. Following the science? Views from scientists on government advisory boards during the COVID-19 pandemic: a qualitative interview study in five European countries. BMJ Glob Heal. 2021;6(9):1–11.

Salajan A, Tsolova S, Ciotti M, Suk JE. To what extent does evidence support decision making during infectious disease outbreaks? A scoping literature review. Evid Policy. 2020;16(3):453–75.

Article   Google Scholar  

Cairney P. The UK government’s COVID-19 policy: assessing evidence-informed policy analysis in real time. Br Polit. 2021;16(1):90–116.

Lancaster K, Rhodes T, Rosengarten M. Making evidence and policy in public health emergencies: lessons from COVID-19 for adaptive evidence-making and intervention. Evid Policy. 2020;16(3):477–90.

Yang K. What can COVID-19 tell us about evidence-based management? Am Rev Public Adm. 2020;50(6–7):706–12.

Parkhurst J. The politics of evidence: from evidence-based policy to the good governance of evidence. Abingdon: Routledge; 2017.

Office of the Prime Minister. Minister of Health Mandate Letter [Internet]. 2021. https://pm.gc.ca/en/mandate-letters/2021/12/16/minister-health-mandate-letter

de Faye B, Perrin D, Trumpy C. COVID-19 lessons learned review: Final report. Victoria, BC; 2022.

First Nations Health Authority. Evolving vaccination plans is science in action: Dr. Bonnie Henry. First Nations Health Authority. 2021.

BC Stats. 2021 Sub-provincial population estimates highlights. Vol. 2021. Victoria, BC; 2022.

Michael Smith Health Research BC [Internet]. 2023. healthresearchbc.ca. Accessed 25 Jan 2023.

Michael Smith Health Research BC. SRAC [Internet]. 2023. https://healthresearchbc.ca/strategic-provincial-advisory-committee-srac/ . Accessed 25 Jan 2023.

Brubacher LJ, Hasan MZ, Sriram V, Keidar S, Wu A, Cheng M, et al. Investigating the influence of institutions, politics, organizations, and governance on the COVID-19 response in British Columbia, Canada: a jurisdictional case study protocol. Heal Res Policy Syst. 2022;20(1):1–10.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

DeCuir-Gunby JT, Marshall PL, McCulloch AW. Developing and using a codebook for the analysis of interview data: an example from a professional development research project. Field Methods. 2011;23(2):136–55.

Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(117):1–8.

Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract. 2000;39(3):124–30.

Sackett D. How to read clinical journals: I. Why to read them and how to start reading them critically. Can Med Assoc J. 1981;1245:555–8.

Evidence Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA Netw. 1992;268(17):2420–5.

Allin S, Fitzpatrick T, Marchildon GP, Quesnel-Vallée A. The federal government and Canada’s COVID-19 responses: from “we’re ready, we’re prepared” to “fires are burning.” Heal Econ Policy Law. 2022;17(1):76–94.

Bollyky TJ, Hulland EN, Barber RM, Collins JK, Kiernan S, Moses M, et al. Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. Lancet. 2022;6736(22):1–24.

Kuhlmann S, Hellström M, Ramberg U, Reiter R. Tracing divergence in crisis governance: responses to the COVID-19 pandemic in France, Germany and Sweden compared. Int Rev Adm Sci. 2021;87(3):556–75.

Haldane V, De Foo C, Abdalla SM, Jung AS, Tan M, Wu S, et al. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nat Med. 2021;27(6):964–80.

Article   CAS   PubMed   Google Scholar  

Rosella LC, Wilson K, Crowcroft NS, Chu A, Upshur R, Willison D, et al. Pandemic H1N1 in Canada and the use of evidence in developing public health policies—a policy analysis. Soc Sci Med. 2013;83:1–9.

Article   PubMed   PubMed Central   Google Scholar  

Saner M. A map of the interface between science & policy. Ottawa, Ontario; 2007. Report No.: January 1.

Lancaster K, Rhodes T. What prevents health policy being “evidence-based”? New ways to think about evidence, policy and interventions in health. Br Med Bull. 2020;135(1):38–49.

Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health. 2009;30:175–201.

Rychetnik L, Frommer M, Hawe P, Shiell A. Criteria for evaluating evidence on public health interventions. J Epidemiol Community Health. 2002;56:119–27.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Khan Y, Brown A, Shannon T, Gibson J, Généreux M, Henry B, et al. Public health emergency preparedness: a framework to promote resilience. BMC Public Health. 2018;18(1):1–16.

COVID-19 Evidence Network to Support Decision-Making. COVID-END [Internet]. 2023. https://www.mcmasterforum.org/networks/covid-end . Accessed 25 Jan 2023.

Canadian Institutes of Health Research. Moving forward from the COVID-19 pandemic: 10 opportunities for strengthening Canada’s public health systems. 2022.

Di Ruggiero E, Bhatia D, Umar I, Arpin E, Champagne C, Clavier C, et al. Governing for the public’s health: Governance options for a strengthened and renewed public health system in Canada. 2022.

Adjoa Kumah E, McSherry R, Bettany-Saltikov J, Hamilton S, Hogg J, Whittaker V, et al. Evidence-informed practice versus evidence-based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: a comprehensive systematic review of undergraduate studen. Campbell Syst Rev. 2019;15(e1015):1–19.

Download references

Acknowledgements

We would like to extend our gratitude to current and former members of the University of British Columbia Working Group on Health Systems Response to COVID-19 who contributed to various aspects of this study, including Shelly Keidar, Kristina Jenei, Sydney Whiteford, Dr. Md Zabir Hasan, Dr. David M. Patrick, Dr. Maxwell Cameron, Mahrukh Zahid, Dr. Yoel Kornreich, Dr. Tammi Whelan, Austin Wu, Shivangi Khanna, and Candice Ruck.

Financial support for this work was generously provided by the University of British Columbia's Faculty of Medicine (Grant No. GR004683) and Peter Wall Institute for Advanced Studies (Grant No. GR016648), as well as a Canadian Institutes of Health Research Operating Grant (Grant No. GR019157). These funding bodies were not involved in the design of the study, the collection, analysis or interpretation of data, or in the writing of this manuscript.

Author information

Authors and affiliations.

School of Population and Public Health, University of British Columbia, Vancouver, Canada

Laura Jane Brubacher, Chris Y. Lovato, Veena Sriram, Michael Cheng & Peter Berman

School of Public Health Sciences, University of Waterloo, Waterloo, Canada

Laura Jane Brubacher

School of Public Policy and Global Affairs, University of British Columbia, Vancouver, Canada

Veena Sriram

You can also search for this author in PubMed   Google Scholar

Contributions

CYL, PB, and VS obtained funding for and designed the study. LJB, MC, and PB conducted data collection. LJB and VS analyzed the qualitative data. CYL and LJB collaboratively wrote the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Laura Jane Brubacher .

Ethics declarations

Ethics approval and consent to participate.

This case study received the approval of the UBC Behavioural Research Ethics Board (Certificate # H20-02136). Participants provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

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

Supplementary Information

Additional file 1..

Semi-structured interview guide [* = questions used for this specific study]

Rights and permissions

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

Reprints and permissions

About this article

Cite this article.

Brubacher, L.J., Lovato, C.Y., Sriram, V. et al. The use of evidence to guide decision-making during the COVID-19 pandemic: divergent perspectives from a qualitative case study in British Columbia, Canada. Health Res Policy Sys 22 , 66 (2024). https://doi.org/10.1186/s12961-024-01146-2

Download citation

Received : 08 February 2023

Accepted : 29 April 2024

Published : 03 June 2024

DOI : https://doi.org/10.1186/s12961-024-01146-2

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

• Decision-making
• Public health
• Policy-making
• Qualitative

Health Research Policy and Systems

ISSN: 1478-4505

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

An official website of the United States government

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

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

• Publications
• Account settings

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

• Advanced Search
• Journal List
• v.53(4); 2010 Aug

Research questions, hypotheses and objectives

Patricia farrugia.

* Michael G. DeGroote School of Medicine, the

Bradley A. Petrisor

† Division of Orthopaedic Surgery and the

Forough Farrokhyar

‡ Departments of Surgery and

§ Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont

Mohit Bhandari

There is an increasing familiarity with the principles of evidence-based medicine in the surgical community. As surgeons become more aware of the hierarchy of evidence, grades of recommendations and the principles of critical appraisal, they develop an increasing familiarity with research design. Surgeons and clinicians are looking more and more to the literature and clinical trials to guide their practice; as such, it is becoming a responsibility of the clinical research community to attempt to answer questions that are not only well thought out but also clinically relevant. The development of the research question, including a supportive hypothesis and objectives, is a necessary key step in producing clinically relevant results to be used in evidence-based practice. A well-defined and specific research question is more likely to help guide us in making decisions about study design and population and subsequently what data will be collected and analyzed. 1

Objectives of this article

In this article, we discuss important considerations in the development of a research question and hypothesis and in defining objectives for research. By the end of this article, the reader will be able to appreciate the significance of constructing a good research question and developing hypotheses and research objectives for the successful design of a research study. The following article is divided into 3 sections: research question, research hypothesis and research objectives.

Research question

Interest in a particular topic usually begins the research process, but it is the familiarity with the subject that helps define an appropriate research question for a study. 1 Questions then arise out of a perceived knowledge deficit within a subject area or field of study. 2 Indeed, Haynes suggests that it is important to know “where the boundary between current knowledge and ignorance lies.” 1 The challenge in developing an appropriate research question is in determining which clinical uncertainties could or should be studied and also rationalizing the need for their investigation.

Increasing one’s knowledge about the subject of interest can be accomplished in many ways. Appropriate methods include systematically searching the literature, in-depth interviews and focus groups with patients (and proxies) and interviews with experts in the field. In addition, awareness of current trends and technological advances can assist with the development of research questions. 2 It is imperative to understand what has been studied about a topic to date in order to further the knowledge that has been previously gathered on a topic. Indeed, some granting institutions (e.g., Canadian Institute for Health Research) encourage applicants to conduct a systematic review of the available evidence if a recent review does not already exist and preferably a pilot or feasibility study before applying for a grant for a full trial.

In-depth knowledge about a subject may generate a number of questions. It then becomes necessary to ask whether these questions can be answered through one study or if more than one study needed. 1 Additional research questions can be developed, but several basic principles should be taken into consideration. 1 All questions, primary and secondary, should be developed at the beginning and planning stages of a study. Any additional questions should never compromise the primary question because it is the primary research question that forms the basis of the hypothesis and study objectives. It must be kept in mind that within the scope of one study, the presence of a number of research questions will affect and potentially increase the complexity of both the study design and subsequent statistical analyses, not to mention the actual feasibility of answering every question. 1 A sensible strategy is to establish a single primary research question around which to focus the study plan. 3 In a study, the primary research question should be clearly stated at the end of the introduction of the grant proposal, and it usually specifies the population to be studied, the intervention to be implemented and other circumstantial factors. 4

Hulley and colleagues 2 have suggested the use of the FINER criteria in the development of a good research question ( Box 1 ). The FINER criteria highlight useful points that may increase the chances of developing a successful research project. A good research question should specify the population of interest, be of interest to the scientific community and potentially to the public, have clinical relevance and further current knowledge in the field (and of course be compliant with the standards of ethical boards and national research standards).

FINER criteria for a good research question

Adapted with permission from Wolters Kluwer Health. 2

Whereas the FINER criteria outline the important aspects of the question in general, a useful format to use in the development of a specific research question is the PICO format — consider the population (P) of interest, the intervention (I) being studied, the comparison (C) group (or to what is the intervention being compared) and the outcome of interest (O). 3 , 5 , 6 Often timing (T) is added to PICO ( Box 2 ) — that is, “Over what time frame will the study take place?” 1 The PICOT approach helps generate a question that aids in constructing the framework of the study and subsequently in protocol development by alluding to the inclusion and exclusion criteria and identifying the groups of patients to be included. Knowing the specific population of interest, intervention (and comparator) and outcome of interest may also help the researcher identify an appropriate outcome measurement tool. 7 The more defined the population of interest, and thus the more stringent the inclusion and exclusion criteria, the greater the effect on the interpretation and subsequent applicability and generalizability of the research findings. 1 , 2 A restricted study population (and exclusion criteria) may limit bias and increase the internal validity of the study; however, this approach will limit external validity of the study and, thus, the generalizability of the findings to the practical clinical setting. Conversely, a broadly defined study population and inclusion criteria may be representative of practical clinical practice but may increase bias and reduce the internal validity of the study.

PICOT criteria 1

A poorly devised research question may affect the choice of study design, potentially lead to futile situations and, thus, hamper the chance of determining anything of clinical significance, which will then affect the potential for publication. Without devoting appropriate resources to developing the research question, the quality of the study and subsequent results may be compromised. During the initial stages of any research study, it is therefore imperative to formulate a research question that is both clinically relevant and answerable.

Research hypothesis

The primary research question should be driven by the hypothesis rather than the data. 1 , 2 That is, the research question and hypothesis should be developed before the start of the study. This sounds intuitive; however, if we take, for example, a database of information, it is potentially possible to perform multiple statistical comparisons of groups within the database to find a statistically significant association. This could then lead one to work backward from the data and develop the “question.” This is counterintuitive to the process because the question is asked specifically to then find the answer, thus collecting data along the way (i.e., in a prospective manner). Multiple statistical testing of associations from data previously collected could potentially lead to spuriously positive findings of association through chance alone. 2 Therefore, a good hypothesis must be based on a good research question at the start of a trial and, indeed, drive data collection for the study.

The research or clinical hypothesis is developed from the research question and then the main elements of the study — sampling strategy, intervention (if applicable), comparison and outcome variables — are summarized in a form that establishes the basis for testing, statistical and ultimately clinical significance. 3 For example, in a research study comparing computer-assisted acetabular component insertion versus freehand acetabular component placement in patients in need of total hip arthroplasty, the experimental group would be computer-assisted insertion and the control/conventional group would be free-hand placement. The investigative team would first state a research hypothesis. This could be expressed as a single outcome (e.g., computer-assisted acetabular component placement leads to improved functional outcome) or potentially as a complex/composite outcome; that is, more than one outcome (e.g., computer-assisted acetabular component placement leads to both improved radiographic cup placement and improved functional outcome).

However, when formally testing statistical significance, the hypothesis should be stated as a “null” hypothesis. 2 The purpose of hypothesis testing is to make an inference about the population of interest on the basis of a random sample taken from that population. The null hypothesis for the preceding research hypothesis then would be that there is no difference in mean functional outcome between the computer-assisted insertion and free-hand placement techniques. After forming the null hypothesis, the researchers would form an alternate hypothesis stating the nature of the difference, if it should appear. The alternate hypothesis would be that there is a difference in mean functional outcome between these techniques. At the end of the study, the null hypothesis is then tested statistically. If the findings of the study are not statistically significant (i.e., there is no difference in functional outcome between the groups in a statistical sense), we cannot reject the null hypothesis, whereas if the findings were significant, we can reject the null hypothesis and accept the alternate hypothesis (i.e., there is a difference in mean functional outcome between the study groups), errors in testing notwithstanding. In other words, hypothesis testing confirms or refutes the statement that the observed findings did not occur by chance alone but rather occurred because there was a true difference in outcomes between these surgical procedures. The concept of statistical hypothesis testing is complex, and the details are beyond the scope of this article.

Another important concept inherent in hypothesis testing is whether the hypotheses will be 1-sided or 2-sided. A 2-sided hypothesis states that there is a difference between the experimental group and the control group, but it does not specify in advance the expected direction of the difference. For example, we asked whether there is there an improvement in outcomes with computer-assisted surgery or whether the outcomes worse with computer-assisted surgery. We presented a 2-sided test in the above example because we did not specify the direction of the difference. A 1-sided hypothesis states a specific direction (e.g., there is an improvement in outcomes with computer-assisted surgery). A 2-sided hypothesis should be used unless there is a good justification for using a 1-sided hypothesis. As Bland and Atlman 8 stated, “One-sided hypothesis testing should never be used as a device to make a conventionally nonsignificant difference significant.”

The research hypothesis should be stated at the beginning of the study to guide the objectives for research. Whereas the investigators may state the hypothesis as being 1-sided (there is an improvement with treatment), the study and investigators must adhere to the concept of clinical equipoise. According to this principle, a clinical (or surgical) trial is ethical only if the expert community is uncertain about the relative therapeutic merits of the experimental and control groups being evaluated. 9 It means there must exist an honest and professional disagreement among expert clinicians about the preferred treatment. 9

Designing a research hypothesis is supported by a good research question and will influence the type of research design for the study. Acting on the principles of appropriate hypothesis development, the study can then confidently proceed to the development of the research objective.

Research objective

The primary objective should be coupled with the hypothesis of the study. Study objectives define the specific aims of the study and should be clearly stated in the introduction of the research protocol. 7 From our previous example and using the investigative hypothesis that there is a difference in functional outcomes between computer-assisted acetabular component placement and free-hand placement, the primary objective can be stated as follows: this study will compare the functional outcomes of computer-assisted acetabular component insertion versus free-hand placement in patients undergoing total hip arthroplasty. Note that the study objective is an active statement about how the study is going to answer the specific research question. Objectives can (and often do) state exactly which outcome measures are going to be used within their statements. They are important because they not only help guide the development of the protocol and design of study but also play a role in sample size calculations and determining the power of the study. 7 These concepts will be discussed in other articles in this series.

From the surgeon’s point of view, it is important for the study objectives to be focused on outcomes that are important to patients and clinically relevant. For example, the most methodologically sound randomized controlled trial comparing 2 techniques of distal radial fixation would have little or no clinical impact if the primary objective was to determine the effect of treatment A as compared to treatment B on intraoperative fluoroscopy time. However, if the objective was to determine the effect of treatment A as compared to treatment B on patient functional outcome at 1 year, this would have a much more significant impact on clinical decision-making. Second, more meaningful surgeon–patient discussions could ensue, incorporating patient values and preferences with the results from this study. 6 , 7 It is the precise objective and what the investigator is trying to measure that is of clinical relevance in the practical setting.

The following is an example from the literature about the relation between the research question, hypothesis and study objectives:

Study: Warden SJ, Metcalf BR, Kiss ZS, et al. Low-intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled trial. Rheumatology 2008;47:467–71.

Research question: How does low-intensity pulsed ultrasound (LIPUS) compare with a placebo device in managing the symptoms of skeletally mature patients with patellar tendinopathy?

Research hypothesis: Pain levels are reduced in patients who receive daily active-LIPUS (treatment) for 12 weeks compared with individuals who receive inactive-LIPUS (placebo).

Objective: To investigate the clinical efficacy of LIPUS in the management of patellar tendinopathy symptoms.

The development of the research question is the most important aspect of a research project. A research project can fail if the objectives and hypothesis are poorly focused and underdeveloped. Useful tips for surgical researchers are provided in Box 3 . Designing and developing an appropriate and relevant research question, hypothesis and objectives can be a difficult task. The critical appraisal of the research question used in a study is vital to the application of the findings to clinical practice. Focusing resources, time and dedication to these 3 very important tasks will help to guide a successful research project, influence interpretation of the results and affect future publication efforts.

Tips for developing research questions, hypotheses and objectives for research studies

• Perform a systematic literature review (if one has not been done) to increase knowledge and familiarity with the topic and to assist with research development.
• Learn about current trends and technological advances on the topic.
• Seek careful input from experts, mentors, colleagues and collaborators to refine your research question as this will aid in developing the research question and guide the research study.
• Use the FINER criteria in the development of the research question.
• Ensure that the research question follows PICOT format.
• Develop a research hypothesis from the research question.
• Develop clear and well-defined primary and secondary (if needed) objectives.
• Ensure that the research question and objectives are answerable, feasible and clinically relevant.

FINER = feasible, interesting, novel, ethical, relevant; PICOT = population (patients), intervention (for intervention studies only), comparison group, outcome of interest, time.

Competing interests: No funding was received in preparation of this paper. Dr. Bhandari was funded, in part, by a Canada Research Chair, McMaster University.

Study Found People Who Add Salt to Food Were More Likely to Develop Stomach Cancer?

Research also suggests stomach cancer is affecting an increasing number of young people, particularly women., madison dapcevich, published june 1, 2024.

About this rating

A 2024 observational study of more than 470,000 adults in Britain found that people with higher salt intake are more likely to develop certain stomach cancers than those who ate little or no salt. However, the researchers noted that the findings cannot be generalized to broader populations due to the study's limitations.

In May 2024, a post on Reddit's r/science subreddit claimed that people who always or often added salt to their food were much likely to develop stomach cancer than people who rarely or never did so.  The post had more than 2,700 upvotes at the time of this publication.

Through a Google keyword search , Snopes found several news publications that wrote about the study the Reddit post referenced, including News Medical Life Sciences , Newsweek , Technology Networks , and Medical News Today . The study , " Adding salt to food at table as an indicator of gastric cancer risk among adults: a prospective study ," was published in the peer-reviewed scientific journal Gastric Cancer on April 17, 2024. 

Researchers at the Center for Public Health, Medical University of Vienna analyzed the data of more than 470,000 adults from UK-Biobank , a large-scale British biomedical database. Questionnaires administered between 2006 and 2010 included questions like, "How often do you add salt to your food?" Responses were compared with measurements of study participants' salt excretion in urine, as well as data from national cancer registries. 

According to a news release published by the institution, people who said they regularly salted their food were "41% more likely to develop stomach cancer than those who left their saltshakers untouched" over 11 years. (An English-language version of the news release is also available on the science news website, EurekAlert.)

"Our results also stood up to the consideration of demographic, socioeconomic and lifestyle factors and were just as valid for prevailing comorbidities," study author Selma Kronsteiner-Gicevic said in the news release. 

Researchers noted several limitations with their research. For example, they could not evaluate the influence of certain characteristics such as sex, age, ethnicity or smoking status. It also was an observational study, which means other outside influences may not have been fully accounted for. Because the study participants volunteered, the findings cannot be generalized to the general U.K. population — or beyond — because of participation and age restrictions present with the UK Biobank cohort. 

Regardless of the limitations, the findings add to a growing body of evidence supporting salt's potential role in gastroenterological cancers. For example, research published in 2009 in the World Journal of Gastroenterology found that salt may "cause stomach cancer through directly damaging gastric mucus" and that "considerable evidence" suggests limiting salted foods is a "practical strategy for preventing gastric cancer" 

Similarly, in 2021 a systematic review published in the journal Frontiers in Nutrition  found that "High intakes of salt, pickled food, and processed meat are associated with significantly increased risks of gastric cancer; these increased risks are also seen when participants consumed moderate amounts of salt." 

In 2022, scientists concluded in the journal Nutrients that higher dietary salt intake increases the risk of gastric cancer.

As of this publication, stomach cancer is the fifth-most-common type of cancer worldwide, according to the World Cancer Research Fund International . The agency notes that there is strong evidence that consuming salt-preserved foods increases the risk of stomach cancer. 

Though the risk of stomach cancer increases with age, experts have noted an increase in gastrointestinal cancers, like those of the stomach, liver, pancreas, and colon, in younger people, particularly women . The cause is not entirely clear, but researchers speculated  in 2023 it could be connected to shifts in dietary habits, increased intake of processed foods and higher rates of obesity, as well as other unhealthy behaviors, diet and physical activity. 

The 2024 study authors say the findings will help highlight stomach health and its relationship to diets. 

"With our study, we want to raise awareness of the negative effects of extremely high salt consumption and provide a basis for measures to prevent stomach cancer," researcher Tilman Kühn said.

Adding Salt to Food Regularly Could Raise Risk of Stomach Cancer . 15 May 2024, https://www.medicalnewstoday.com/articles/salting-food-increased-stomach-gastric-cancer-risk.

Dapcevich, Madison. "Snopes Tips: Why Care If Research Is 'Peer-Reviewed'?" Snopes , 30 Mar. 2022, https://www.snopes.com//news/2022/03/30/snopes-tips-why-care-if-research-is-peer-reviewed/.

"Frequent Salting of Food Increases the Risk of Stomach Cancer." EurekAlert! , https://www.eurekalert.org/news-releases/1043914. Accessed 29 May 2024.

"High Salt Consumption Linked to 40% Higher Stomach Cancer Risk." News-Medical , 8 May 2024, https://www.news-medical.net/news/20240508/High-salt-consumption-linked-to-4025-higher-stomach-cancer-risk.aspx.

Jardim, Silvia Rodrigues, et al. "The Rise of Gastrointestinal Cancers as a Global Phenomenon: Unhealthy Behavior or Progress?" International Journal of Environmental Research and Public Health , vol. 20, no. 4, Feb. 2023, p. 3640. PubMed Central , https://doi.org/10.3390/ijerph20043640.

Kronsteiner-Gicevic, Selma, et al. "Adding Salt to Food at Table as an Indicator of Gastric Cancer Risk among Adults: A Prospective Study." Gastric Cancer , Apr. 2024. Springer Link , https://doi.org/10.1007/s10120-024-01502-9.

People Who Said They Always or Frequently Added Salt to Their Food Were 39% More Likely to Develop Stomach Cancer over an Observation Period of around 11 Years than Those Who Never or Rarely Added an Extra Pinch of Salt to Their Food - Google Search . https://www.google.com/search?q=People+who+said+they+always+or+frequently+added+salt+to+their+food+were+39%25+more+likely+to+develop+stomach+cancer+over+an+observation+period+of+around+11+years+than+those+who+never+or+rarely+added+an+extra+pinch+of+salt+to+their+food&oq=People+who+said+they+always+or+frequently+added+salt+to+their+food+were+39%25+more+likely+to+develop+stomach+cancer+over+an+observation+period+of+around+11+years+than+those+who+never+or+rarely+added+an+extra+pinch+of+salt+to+their+food&gs_lcrp=EgZjaHJvbWUyBggAEEUYOTIGCAEQRRg80gEHODIxajBqN6gCALACAA&sourceid=chrome&ie=UTF-8. Accessed 29 May 2024.

"Regularly Salting Your Food Could Increase Your Risk of Stomach Cancer." Applied Sciences from Technology Networks , http://www.technologynetworks.com/applied-sciences/news/regularly-salting-your-food-could-increase-your-risk-of-stomach-cancer-386642. Accessed 29 May 2024.

Reporter, Jess Thomson Science. "Adding Salt to Your Food May Significantly Increase Stomach Cancer Risk." Newsweek , 9 May 2024, https://www.newsweek.com/salty-food-increased-stomach-cancer-risk-1898803.

"Stomach Cancer Statistics." WCRF International , https://www.wcrf.org/cancer-trends/stomach-cancer-statistics/. Accessed 29 May 2024.

UK Biobank - UK Biobank . 21 May 2024, https://www.ukbiobank.ac.uk.

Vienna, Medical University of. "Center for Public Health | MedUni Vienna." Medical University of Vienna , https://www.meduniwien.ac.at/web/en/about-us/organisation/medical-science-divisions/center-for-public-health/. Accessed 29 May 2024.

---. "Frequent Salting of Food Increases the Risk of Stomach Cancer." Medical University of Vienna , https://public-health.meduniwien.ac.at/en/about-us/news/news/haeufiges-nachsalzen-beim-essen-erhoeht-risiko-fuer-magenkrebs-1/. Accessed 29 May 2024.

Wang, Xiao-Qin, et al. "Review of Salt Consumption and Stomach Cancer Risk: Epidemiological and Biological Evidence." World Journal of Gastroenterology : WJG , vol. 15, no. 18, May 2009, pp. 2204–13. PubMed Central , https://doi.org/10.3748/wjg.15.2204.

"Why Is Stomach Cancer Rising in Young Women?" Premium , 29 May 2024, https://www.nationalgeographic.com/premium/article/stomach-cancer-rising-young-women.

Wu, Bo, et al. "Dietary Salt Intake and Gastric Cancer Risk: A Systematic Review and Meta-Analysis." Frontiers in Nutrition , vol. 8, Dec. 2021. Frontiers , https://doi.org/10.3389/fnut.2021.801228.

Wu, Xiaomin, et al. "Effect of Dietary Salt Intake on Risk of Gastric Cancer: A Systematic Review and Meta-Analysis of Case-Control Studies." Nutrients , vol. 14, no. 20, Oct. 2022, p. 4260. PubMed Central , https://doi.org/10.3390/nu14204260.

By Madison Dapcevich

Madison Dapcevich is a freelance contributor for Snopes.

Article Tags

• Open access
• Published: 03 June 2024

Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study

• Michael Van der Voorden 1 ,
• Arie Franx 1 &
• Kees Ahaus 2  

BMC Health Services Research volume  24 , Article number:  700 ( 2024 ) Cite this article

Metrics details

Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals ( N  = 8) and patients ( N  = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach.

Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: ‘structure’, ‘culture’, ‘education’, ‘emotional’, and ‘physical and technology’. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients.

Conclusions

Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, ‘politics’. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations’ structure, culture and practices.

Peer Review reports

Every day, 830 women worldwide die as a result of complications during and following pregnancy and childbirth [ 1 ]. Most of these complications are considered preventable and often occur during hospitalization [ 1 , 2 , 3 , 4 ]. In Obstetrics, this mainly involves severe bleeding and infection after childbirth [ 1 ]. Preventable complications occur not only within Obstetrics but also within all specialties and therefore are a reason why patient safety has become an international priority [ 5 , 6 , 7 ]. In this regard, patient participation is increasingly used as a strategy to improve patient safety [ 8 , 9 , 10 ].

Recent research within the context of Obstetrics indeed shows the added value of patient participation in in-hospital patient safety [ 11 ] and more broadly [ 10 , 12 , 13 ]. A common example of patient participation, including Obstetrics patients, is shared decision-making, where the patient is expected to receive sufficient information from the professional and be supported in making medical choices [ 14 , 15 ]. This can help detect inconsistencies in care [ 16 ]. Another example is the use of a surgical safety checklist in cesarean deliveries [ 17 , 18 ], which can contribute to a reduction in errors and complications [ 17 , 19 ]. A third illustration is where patients are enabled to monitor their medication and thereby contribute to medication management [ 20 , 21 , 22 ], a reduction in medication errors, and improved outcomes [ 14 , 23 ].

Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged [ 24 ]. First, involving patients in safety initiatives can lead to anxiety in patients [ 25 ]. This includes situations where patients gain a better understanding of medication errors, which increases anxiety [ 24 ]. Second, the relationship between the patient and a professional can be negatively affected [ 26 ]. Sometimes this occurs because, when the patient and professional do negotiate, there are differences in opinions as to whether the patient’s wishes and needs are medically justified [ 24 ]. Third, more responsibility may be placed on the patient than the patient wants [ 24 , 27 ]. For example, patients may feel they have too much responsibility or that professionals have shifted too much responsibility onto them [ 24 ]. Fourth, patient participation in safety initiatives can take up more of the professional’s time [ 24 , 26 ] since a ‘participating’ patient may pose more questions to healthcare professionals.

To ultimately promote patient safety within an Obstetrics department, it is important to mitigate these negative effects of patient participation in patient safety. To this end, we firstly conducted a general review of the literature on actions that could be taken and classified these according to the model by Bate et al. [ 28 ]. This model has six categories of actions: ‘structure’, ‘political’, ‘cultural’, ‘educational’, ’emotional’, and ’physical and technology’ to promote healthcare improvements [ 28 ]. The reviewed literature looked at how to deal in general with common problems such as anxious patients [ 29 ] or an unsatisfactory patient-doctor relationship [ 30 ]. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

Study design

The aim of this study was to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

To achieve the goal of this research, qualitative research was employed. As a form of qualitative research, an exploratory interview study was conducted to uncover the actions of both patients and professionals within an Obstetrics department. The Standards for Reporting Qualitative Research checklist [ 31 ] was used to provide transparency (see Additional file 1 ).

Inclusion criteria and participants

This study was conducted within the Obstetrics Department of Erasmus Medical University Center in Rotterdam, the Netherlands. Interviews were held with both patients and birth care professionals to capture their thoughts on appropriate actions to mitigate the negative effects of patient participation on patient safety. Initially, 32 patients and 21 professionals were approached by email, phone, or face-to-face. The inclusion criteria for the patients were that the patient had been admitted to the Obstetrics department, were potentially willing to participate in an interview at least three weeks and no more than six weeks after childbirth, and had mastered the Dutch language sufficiently to fully participate. Inclusion criteria for the professionals were a position as a physician or clinical midwife, at least six months of employment in the Obstetrics department, and sufficient mastery of the Dutch language. A lack of time was the major reason given for nonparticipation by professionals. Patients mostly declined because of insufficient energy after childbirth. We continued to enroll participants until data saturation was achieved. This was achieved once eight patients and eight professionals had been interviewed (see Table  1 ). Data saturation is reached when the researcher begins to hear the same comments repeatedly within interviews [ 32 ]. Within this group of respondents, data saturation was reached because the same actions emerged in the last interviews. This occurred even after the clinical midwife was added alongside the gynecologists.

Data collection

Interviews were conducted between March 2020 and January 2021 by one researcher (MV). Due to COVID-19 concerns, safety measures were observed and the interviews took place on the basis of the patients’ and professionals’ preferences. Nine interviews were conducted face-to-face and seven were conducted by phone. The interviews lasted an average of 59 minutes (range: 43 to 101 minutes) with a focus on forms of individual patient participation. The four negative effects of patient participation on patient safety identified in an earlier study [ 24 ] were used as a starting point. The interview topic guide developed for this purpose [ 24 ] was also used for this study. In addition, in this study both patients and professionals were specifically asked about actions that could be taken to mitigate these negative effects. The in-depth interviews provided a sense of the local culture in this department. Following the interviews, a member check was carried out by asking the respondents to check for factual inaccuracies in the transcripts. Twelve of the sixteen participants took part in this check. None reported any factual inaccuracies, and no changes were made.

Data analysis

The texts of the interviews were transcribed, analyzed, and coded by one of the authors using ATLAS.ti V.8 for Windows. ATLAS.ti is a widely used tool to structure qualitative analysis [ 33 ] and we opted for deductive analysis because this was an appropriate approach to classify the proposed actions [ 28 ]) and generate an accessible overview of the actions identified. The model by Bate et al. [ 28 ] was used for this purpose, aiming to systematically identify the actions within the six different categories for healthcare improvement. Because the actions can influence each other and are interdependent, it is suitable to do this according to the classified themes that are interconnected. Firstly, it concerns structural, which involves organizing, planning, and coordinating quality efforts. Secondly, political addresses and deals with the politics of change surrounding any quality improvement effort. Thirdly, cultural entails giving quality a shared, collective meaning, value, and significance within the organization. Fourthly, educational is characterized by creating a learning process that supports improvement. Fifthly, emotional involves engaging and motivating people by linking quality improvement efforts to inner sentiments and deeper commitments and beliefs. Sixthly, it pertains to physical and technological, which involves designing physical infrastructure and technological systems that support and sustain quality efforts [ 28 ]. For the coding process, codes were initially assigned to the various actions mentioned by both patients and professionals, enabling us to provide an overview of the actions suggested. Furthermore, this approach provided insight into the level of consensus and the differences and similarities in the actions suggested by patients and by professionals. These actions were then classified according to the six categories proposed by Bate et al. [ 28 ]. All the actions suggested by our participants could be fitted within these categories.

The interviews yielded 18 actions, 13 of which were identified by both patients and professionals. These 18 actions could all be placed in one of five of the six categories proposed by Bate et al. Table  2 below provides a summary of the categories, suggested actions , and whether they were offered by patients, professionals, or both. For an overview of illustrative quotes that most effectively illustrate the story of the results, see Table  3 .

The first category ‘structure’ is about establishing working arrangements to prevent negative effects and to ensure patient participation in patient safety should negative effects arise.

Appoint a case manager

The respondents mentioned the importance of having a case manager in the primary process as a priority. As soon as patients experience a decrease in trust or the relationship between patient and professional is negatively affected, patients would like to know to whom they can go to discuss the situation. The case manager would then have the task of reassuring patients and ensuring transparency.

Make time for adequate attention

Both patients and professionals believed that when a patient’s confidence decreases or the relationship between patient and professional has been affected negatively, it is important that they can engage in a conversation about their anxiety. This requires the professionals to be able to free up time to accomplish this.

Provide information concerning responsibilities

To ensure that patients do not feel too much responsibility and that professionals hand over sufficient responsibility, professionals mentioned that it is important to adequately inform patients about the responsibilities of both patients and professionals. When patients know what they are responsible for, they feel more involved in their own care pathway. If errors or deviations in the care pathway are identified by patients, they generally become more anxious and trust may decrease. When this happens, it is important to keep the patient well-informed and provide clarity about the course of action.

Prepare well for childbirth

Patients considered this action important so that they can experience as little unnecessary anxiety as possible just before and during childbirth. In doing so, it should be made clear to patients exactly what to expect during childbirth. The interviews highlighted that good preparation for delivery can lead to a better patient experience.

Clarify role of partner or family

To maintain a sense of safety for patients in all situations, the professionals said that it is important that they establish protocols and standard information packages to ensure they discuss issues with the partner or contact person of the mother-to-be. Here, it is important that the professional takes responsibility for discussing this, so that the patient does not feel that the onus is on herself to pass on information.

The actions within ‘the culture’ category concern ensuring a patient-centered cultural shift, where it is important that professionals work together with the same values.

Patient-centered culture change

The suggested cultural changes related to patient-centeredness touch not only on actions within the culture theme, but also within other themes. From the interviews, it was clear that the respondents could conceive actions related to the mindset and motivation of the professionals. Further, what patients find important seems to be receiving minimal attention at present. In addition, patients were given minimal voice in the care process. To mitigate the negative effects, a cultural change is needed through which a patient’s values become the focus of their care.

Encourage patient participation

Professionals admitted that they do not always encourage patient participation because they frequently consider patients’ wants and needs as medically irresponsible and of little relevance to the outcome. As a result, professionals may shy away from patient participation. To mitigate the negative effects, it is important that patients are encouraged to participate in a desirable way. The professionals indicated that patients who want to proactively participate can be labeled as difficult.

Actively listen to the patient

Here, the professionals indicated that they are not used to actively listening to the patient. Both patients and professionals indicated that active listening is important to hear clearly why patients have anxieties.

Be transparent

Patients said that they are very dependent on the information they receive from professionals. Anxiety can be alleviated by openness and transparency. Moreover, patients indicated that it is important to provide full information when there are more questions. Provided this happens, patients indicate that there is less interference from them because they then know enough.

Work unambiguously

Unambiguous working was mentioned by both patients and professionals although both have different interpretations of this. From the patients’ point of view, it is mainly about unambiguous policies and not doing things that have not been agreed upon. For professionals, it is more about working with consistent values. That is, as soon as a negative effect arises, it is important that professionals have a consistent way of approaching patients.

Educational

Actions within the ‘educational’ category are about establishing an educational system that seeks to learn from negative effects in order to make improvements and avoid future negative effects.

Improve negotiation skills

The professionals reported that, at the point when patients and professionals start to create a birth plan and the patients and professionals negotiate the patient’s wants and needs and maybe fail to come to an agreement, they require conversational techniques that they do not always possess and therefore need to learn these skills.

Train on shared decision-making

Both patients and professionals indicated the need for training to enable them to take a more active role and participate more effectively in patient safety. This training should focus on shared decision-making, aiming to inform both patients and professionals on what responsibility they should take on and what is expected of them.

Ensure systematic feedback

Patients and professionals both indicated that healthcare organizations should use a standard questionnaire to continuously examine any negative outcomes and identify improvements that could be made to avoid these. Furthermore, this systematic feedback should be structurally fed back to the professionals in order that they can learn from it.

The ‘emotional’ theme is about sharing experiences and engaging patients by managing their expectations and showing leadership.

Share stories

The respondents mentioned that structurally listening to experiences and perceptions is an action that can prevent future negative effects. To establish this process, it is necessary to hold focus groups or open conversations with patients. This should lead to professionals being encouraged to work on making improvements.

Demonstrate leadership

Professionals reported that when the relationship between a patient and a professional has been negatively affected, it is important that the professional demonstrates leadership. This requires professionals to continuously explain why something is done, how it is done, and why it makes sense from the professional’s perspective to do it this way. Furthermore, professionals indicated that this requires listening to patients’ objections and that it is the role of professionals to actively address these objections.

Manage expectations

Respondents indicated that in situations where confidence decreases, it is important that patients know where they stand and that their confidence is restored. The professionals indicated that they often feel they have to live up to unrealistic expectations, such as in terms of facilities in the birthing room. As a result, patients and professionals may cease to get along. Patients reported here that it is important that boundaries and limitations are indicated in advance.

Physical and technology

The ‘physical and technology’ category is about ensuring that the negative effects of patient participation in patient safety are actually mitigated.

Create app for patients’ questions

Patient participation initiatives related to patient safety result in more questions arising from patients, requiring professionals to spend more time answering them. To make this more efficient, patients suggested developing an app so they could send questions to the professionals in advance. This was with the goal of reducing the time input by professionals. In addition, some professionals indicated that there should be an app that contains all the information that is important for the patient.

Clarify the patient journey

Both patients and professionals mentioned that it is important to reduce patients’ sense of bearing considerable responsibility, as this would contribute to managing their expectations during the patient journey. The professional will need to collaborate with an advisor to develop a patient journey that could provide an overview of when and where the patient should obtain appropriate information and therefore know what is expected.

In a previous study, we identified four different negative effects of patient participation in patient safety [ 24 ]. To ultimately promote patient safety in an Obstetrics department, this study aims to identify actions to mitigate the negative effects of patient participation in patient safety. These findings are relevant because the approach to addressing these negative effects of patient participation in patient safety within an Obstetrics department is currently lacking. Based on this, Obstetrics departments within hospitals can implement these actions in practice. Within this study, eighteen actions have been identified and four particularly relevant findings are discussed below.

Firstly, the results indicate that the common thread among the eighteen actions is a focus on ‘patient-centered culture change’. Currently, however, this department primarily view it from the perspective of the professionals, rather than adequately considering the viewpoint of the patients. Within this category ‘culture’, various actions emerged: patient-centered culture change, encourage patient participation, actively listen to the patient, be transparent, and work unambiguously. Within this paragraph, further exploration is conducted through comparisons to illustrate the importance of achieving a cultural shift towards the patient’s perspective within this context. An interesting angle here could come from the service dominant logic: that it is not only service providers that create value, but rather that service receivers do so for themselves in use or in collaboration with service providers [ 34 , 35 , 36 ]. This involves an evolution where service-dominant logic shifts the focus from goods to services [ 37 ]. This consideration, and what can be learned from service dominant logic, has resulted in an application called ‘value-in-use’. Hereby, value is created by the user during the usage of resources, processes (and/or their outcomes) [ 38 ]. Translating this to the Obstetrics department of this study, the conclusion could be that participation through patients in safety initiatives within birth care remains at a low level. The respondents indicated that the general line of thought and much of the reasoning is done from the perspective of professionals and does not adequately include the patients’ expertise, knowledge, and thinking. That the patient is not always perceived as a partner is not a surprising outcome, as this has been highlighted in several studies [ 39 , 40 ]. This is, for example, because patient-centered care in maternity care is perceived differently in practice [ 41 ]. Additionally, it is important to acknowledge that effecting such changes within organizations is challenging and requires significant engagement from patients [ 42 ] and professionals [ 43 ]. Continuing to invest in this area remains valuable, as the literature describes the positive contribution in terms of better outcomes, experiences, and reduced costs [ 44 , 45 ]. This reflection demonstrates that the underlying theme of this study, aiming for a cultural shift towards patient-centeredness, is valuable.

Secondly, recognizing the importance of achieving a cultural shift towards the patient’s perspective, this section delves deeper into how it is possible to accomplish this within an Obstetrics context.

This involves examining the link with the results of this study, falling under the categories of ‘educational’ and ‘emotional’. Several recent studies have examined how health care organizations can develop patient-centered care and how to implement this in practice [ 46 , 47 , 48 , 49 ]. A previous study [ 50 ] investigated the link between patient safety and patient-centered care within an Obstetrics department, concluding that professionals play an important role in achieving a culture of patient-centered care. In particular, professionals’ knowledge on doing so, demonstration of leadership, academic supervision, mentorship, and financial resources were cited as key components [ 50 ]. Looking at this study, demonstrate leadership was indicated by professionals and categorized under ‘emotional’. In practice, professionals often face various challenges in demonstrating leadership [ 51 , 52 ] Also within the organization where this study took place, efforts are being made to further formalize and strengthen the leadership role, where professionals perform both clinical and management tasks. Various studies indicate that doing so without proper training or preparation is difficult [ 53 , 54 ], and a structured approach is needed for it to succeed [ 52 ]. Additionally, share stories and manage expectations were mentioned in this study. The action of sharing stories could closely relate to systematically gathering feedback and actually taking action based on it in practice. Listening to the stories of obstetric patients aligns well with the idea of driving a culture change towards patient-centered care, by better understanding what they actually want rather than imposing guidelines [ 55 ]. At the same time, effectively listening to patients in general is complex and involves various challenges, such as professionals’ time constraints [ 56 ]. Moreover, it is noted that receiving feedback and actually acting upon it is also complex [ 57 ], thus intersecting with the educational category of actions. Thereby, managing patient expectations is crucial to prepare them for the choices that need to be made [ 58 ]. There often appears to be a difference between the expectations of an obstetric patient has for or during childbirth, particularly stemming from the established birth plan, and what actually occurs in practice. This while various professionals observe that unrealistic expectations are included in the birth plan [ 59 ]. In this regard, the expectations that patients have can influence patient satisfaction, underscoring the importance of professionals managing patient expectations [ 60 ]. This leads to the conclusion that actions in the ‘emotional’ category are complex and require more attention to implement in practice.

Having the right negotiation skills was categorized as an ‘educational’ action in this current study and again was only suggested by the professionals. The desired negotiation skills among professionals are essential for proper interaction with the patient, improving quality, as well as handling tensions or conflicts [ 61 ]. Since this is still insufficiently integrated into practice, there needs to be sufficient time and financial investment to make this possible through training(s) [ 62 ]. Other actions mentioned within the specific context of Obstetrics in other studies did not emerge as important actions in our study. In this study, two other ‘educational’ actions have been identified: training on shared decision-making and ensuring systematic feedback. Shared decision-making is already being experimented with and integrated within this Obstetrics department. However, both patients and professionals have indicated the need for training to better implement this in practice. The literature also suggests that Obstetric patients do not yet perceive shared decision making as adequately integrated [ 63 ]. One reason for this shortfall is the additional time commitment required from professionals on a daily basis [ 64 ]. Within this Obstetrics department, a significant amount of patient feedback is already being collected. However, there is currently no effective cycle in place to learn from and improve based on this feedback. Therefore, it can be argued that the feedback is not yet being adequately utilized.

Third, it is notable that within the categories ‘structure’ and ‘physical and technology’, actions emerge that intuitively seem embedded in practice. Under the category ‘structure’, the actions include appoint a case manager, make time for adequate attention, provide information concerning responsibilities, prepare well for childbirth, and clarify the role of partner or family. When it comes to appointing a case manager, this is something that is receiving increasing attention in the practice of the department and the hospital, particularly for patients who, in addition to being pregnant, also have (other) medical diseases. The case manager can be deployed as a point of contact at the individual level to align the care plan with the patient, as well as in collaboration with various other professionals [ 65 ]. It can be said that this is still perceived as relatively new within Dutch maternity care [ 66 ]. When it comes to making time for adequate attention, providing information concerning responsibilities, preparing well for childbirth, and clarifying the role of partner or family it may seem as if these actions are self-evident and therefore can be applied easily in the practice of an Obstetrics department. Given the often urgent nature of an Obstetrics department, time pressure in such situations can increase. A previous study [ 67 ] indicates that when time pressure is higher within an Obstetrics department, professionals feel a stronger need to make decisions themselves. This could explain why both patients and professionals have mentioned all three actions.

Under the category ‘physical and technology’, the actions include creating an app for patients’ questions and clarifying the patient journey. The suggestion of creating an app within this Obstetrics department is somewhat surprising, as such an app for patient questions may already be implemented within the hospital. However, it is possible that its usage is still minimal or that patients and professionals are not sufficiently familiar with it. In a study on the use of eHealth and mobile health within an Obstetric context, it is suggested that it is the role of professionals to involve pregnant women in order to lead to successful integration [ 68 ]. Additionally, the results suggest that for managing responsibilities and the expectations associated with them, it is essential to provide better insight into the patient journey. It could be valuable to make the patient journey transparent, with it being the responsibility of professionals to capture the perceptions, preferences, and expectations of the patient upfront [ 69 ].

Fourth, our study yielded 18 actions to mitigate the negative effects of patient participation in patient safety within an Obstetrics department in five of these six categories. That is, no one mentioned an action falling within the ‘politics’ category that Bate et al. define as: ‘dealing with conflicts and tensions between different interests and power relations’ . We offer two possible explanations for why politics was not mentioned in our study. First, many respondents within an Obstetrics department were unfamiliar with the topic being addressed in this study and, consequently, may not have been able to put it into a broader perspective and suggest actions in the political sphere. Second, the actions were primarily envisaged from the practical perspectives of the patients and professionals. As such, one could argue that politics as previously defined are largely absent. This can be seen as an interesting result because the literature often discusses tensions that can arise between patients and professionals when there are conflicting interests [ 70 , 71 , 72 ]. An example from the obstetric literature suggests that with patient participation in the form of promoting shared decision-making, tension can arise when the patient is challenged to make a choice. However, this may conflict with the clinician’s clinical experience or care standards [ 73 ]. Ultimately, this could affect patient safety if the patient prioritizes their own interests over the clinical ones. Another specific example from the obstetric literature shows that among Black American women, a study revealed a sense of powerlessness where doctors played a dominant role in the process [ 74 ]. Based on this, it could be argued that there is potentially a ‘politics’ element based on power relations and the interaction between patients and professionals. And it is plausible that in the future, consideration should be given to actions in the ‘politics’ domain, as such tensions may arise in practice.

Strengths and limitations

First, this study is an inventory off the actions to be taken from the input of both patients and professionals. Because the strength of this is that it allows the conclusion that most of the actions (13/18) were mentioned by both groups. Second, to our knowledge, this is the first study to examine, from the perspective of patient participation in patient safety, the mitigation of negative effects within an Obstetrics department. Thus, it contributes to closing a gap in the scientific literature. Despite these strengths, there are three limitations. Our sample size was limited both in terms of patients and professionals. Additionally, most of the patients were highly educated, and there was no equal distribution among professionals, thus potentially not reflecting the broader population. This might have introduced selection bias [ 75 ]. However, additional respondents were recruited until data saturation was achieved. Second, the generalizability of this research is limited, although this is not necessarily a goal in qualitative research [ 76 ]. That is, the actions identified come from a specific context and generate an overview of this. Third, by choosing to analyze the data deductively based on Bate et al.’s model [ 28 ], the results were shaped by the categories therein. Other models for deductive analysis might have revealed broader or different actions. Nevertheless, the model used does provide specific categories that can then be further elaborated by practitioners.

Eighteen different actions emerged within five categories from this study in a specific context of an Obstetrics department. No actions fit within the model’s sixth category of ‘politics’. The main finding from this study is that most of the actions highlight the need for a patient-centered culture change. Currently, this still relies heavily on the perspective of professionals and too little consideration is given to that of patients. Future studies could repeat our approach but in a different specific context to see whether other practical actions would be identified for further development. This could include looking at other respondents within the study population, such as other job groups of professionals or less educated patients.

Practical implications

A specialty or department must recognize that these negative effects occur in patient participation within the realm of patient safety. By doing so, space, money and time have to be created to elaborate on these actions by patients and professionals and integrate them into the organizations’ structure, culture and practices.

Data availability

All data generated or analyzed during this study are included in this published article.

Reference list

WHO. Maternal mortality. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality . Accessed 3 Feb 2023.

Hempel S, Newberry S, Wang Z, Shekelle PG, Shanman R, Johnsen B, Ganz DA. Review of the evidence on falls prevention in hospitals. Task 4 Final Report, Working Paper prepared for the Agency for health care Research and Quality. 2012. Contract No. HHSA2902010000171, PRISM No. HHSA29032001T, Task Order , 1 .

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5Part2):390–6.

Article   PubMed   Google Scholar  

Tzeng HM, Yin CY. Patient engagement in hospital fall prevention. Nurs Econ. 2015;33(6):326.

PubMed   Google Scholar  

Azyabi A, Karwowski W, Davahli MR. Assessing patient safety culture in hospital settings. Int J Environ Res Public Health. 2021;18(5):2466.

Article   PubMed   PubMed Central   Google Scholar  

Guinea S, Andersen P, Reid-Searl K, Levett-Jones T, Dwyer T, Heaton L, Bickell P. Simulation-based learning for patient safety: the development of the Tag Team Patient Safety Simulation methodology for nursing education. Collegian. 2019;26(3):392–8.

Article   Google Scholar  

Battles JB, Lilford RJ. Organizing patient safety research to identify risks and hazards. BMJ Qual Saf. 2003;12(suppl 2):ii2–7.

Google Scholar  

Radecki B, Keen A, Miller J, McClure JK, Kara A. Innovating fall safety: engaging patients as experts. J Nurs Care Qual. 2020;35(3):220–6.

Khan A, Coffey M, Litterer KP, Baird JD, Furtak SL, Garcia BM, Clifton EY. Families as partners in hospital error and adverse event surveillance. JAMA Pediatr. 2017;171(4):372–81.

Sarkhosh S, Abdi Z, Ravaghi H. Engaging patients in patient safety: a qualitative study examining healthcare managers and providers’ perspectives. BMC Nurs. 2022;21(1):374.

Park M, Giap TTT. Patient and family engagement as a potential approach for improving patient safety: a systematic review. J Adv Nurs. 2020;76(1):62–80.

Armstrong N, Herbert G, Aveling EL, Dixon-Woods M, Martin G. Optimizing patient involvement in quality improvement. Health Expect. 2013;16(3):e36–47.

Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010, January;85(1);53–62. Elsevier.

Poprzeczny AJ, Stocking K, Showell M, Duffy JM. Patient decision aids to facilitate shared decision making in obstetrics and gynecology: a systematic review and meta-analysis. Obstet Gynecol. 2020;135(2):444–51.

Edmonds BT. Shared decision-making and decision support: their role in obstetrics and gynecology. Curr Opin Obstet Gynecol. 2014;26(6):523–30.

Vincent C. Patient safety. Wiley; 2011.

Singh SS, Mehra N, Hopkins L. Surgical safety checklist in Obstetrics and gynaecology. Safety. 2012. 2, 1A.

Harris K, Russ S. (2021). Patient-completed safety checklists as an empowerment tool for patient involvement in patient safety: concepts, considerations and recommendations. Future Healthc J, 8(3), e567.

Harris K, Søfteland E, Moi AL, Harthug S, Storesund A, Jesuthasan S, Haugen AS, et al. Patients’ and healthcare workers’ recommendations for a surgical patient safety checklist–a qualitative study. BMC Health Serv Res. 2020;20:1–10.

Hall J, Peat M, Birks Y, Golder S, Entwistle V, Gilbody S, Wright J, et al. Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review. Qual Saf Health Care. 2010;19(5):e10–e10.

Mohsin-Shaikh S, Garfield S, Franklin BD. Patient involvement in medication safety in hospital: an exploratory study. Int J Clin Pharm. 2014;36:657–66.

Sharma AE, Rivadeneira NA, Barr-Walker J, Stern RJ, Johnson AK, Sarkar U. Patient engagement in health care safety: an overview of mixed-quality evidence. Health Aff. 2018;37(11):1813–20.

Roughead L, Semple S, Rosenfeld E. Literature review: medication safety in Australia. Syd Aust Comm Saf Qual Health Care. 2013.

Van der Voorden M, Ahaus K, Franx A. (2023). Explaining the negative effects of patient participation in patient safety: an exploratory qualitative study in an academic tertiary healthcare centre in the Netherlands. BMJ open, 13(1), e063175.

Entwistle V. Nursing shortages and patient safety problems in hospital care: is clinical monitoring by families part of the solution? Health Expectations: Int J Public Participation Health care Health Policy. 2004;7(1):1.

Entwistle VA, Mello MM, Brennan TA. Advising patients about patient safety: current initiatives risk shifting responsibility. Joint Comm J Qual Patient Saf. 2005;31(9):483–94.

Davis RE, Sevdalis N, Vincent CA. Patient involvement in patient safety. J Patient Saf. 2012;8(4):182–8.

Bate P, Mendel P, Robert G. Organizing for quality: the improvement journeys of leading hospitals in Europe and the United States. CRC; 2007.

Kendig S, Keats JP, Hoffman MC, Kay LB, Miller ES, Simas TAM, Lemieux LA, et al. Consensus bundle on maternal mental health: perinatal depression and anxiety. J Obstet Gynecol Neonatal Nursing. 2017;46(2):272–81.

Chipidza FE, Wallwork RS, Stern TA. Impact of the doctor-patient relationship. Prim care Companion CNS Disorders. 2015;17(5):27354.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.

Grady MP. Qualitative and action research: a practitioner handbook. Phi Delta Kappa International; 1998.

Smit B, Scherman V. Computer-assisted qualitative data analysis software for scoping reviews: a case of ATLAS. Ti. Int J Qualitative Methods. 2021;20:16094069211019140.

Vargo SL, Lusch RF. Service-dominant logic: continuing the evolution. J Acad Mark Sci. 2008;36:1–10.

Vargo SL, Maglio PP, Akaka MA. On value and value co-creation: a service systems and service logic perspective. Eur Manag J. 2008;26(3):145–52.

Vargo SL, Lusch RF. Relationship in transition: an introduction to the special issue on relationship and service-dominant logic. J Bus Market Manage. 2010;4:167–8.

Peng Y, Wu T, Chen Z, Deng Z. (2022). Value cocreation in health care: systematic review. J Med Internet Res, 24(3), e33061.

Grönroos C, Voima P. Critical service logic: making sense of value creation and co-creation. J Acad Mark Sci. 2013;41:133–50.

Gee RE, Corry MP. Patient engagement and shared decision making in maternity care. Obstet Gynecol. 2012;120(5):995–7.

Sahlström M, Partanen P, Rathert C, Turunen H. Patient participation in patient safety still missing: patient safety experts’ views. Int J Nurs Pract. 2016;22(5):461–9.

Adams T, Sarnak D, Lewis J, Convissar J, Young SS. (2018). What do clinicians who deliver maternity services think patient-centered care is and how is that different for vulnerable women? A qualitative study. Journal of pregnancy, 2018, 1–7.

Orebaugh M. Instigating and influencing patient engagement: a hospital library’s contributions to patient health and organizational success. J Hosp Librariansh. 2014;14(2):109–19.

Patel N, Rajasingam D. User engagement in the delivery and design of maternity services. Best Pract Res Clin Obstet Gynecol. 2013;27(4):597–608.

Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff. 2013;32(2):207–14.

James J. Patient engagement. Health Affairs Health Policy Brief. 2013;14:101377.

Bokhour BG, Fix GM, Mueller NM, Barker AM, Lavela SL, Hill JN, Lukas CV, et al. How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation. BMC Health Serv Res. 2018;18(1):1–11.

Santana MJ, Manalili K, Jolley RJ, Zelinsky S, Quan H, Lu M. How to practice person-centred care: a conceptual framework. Health Expect. 2018;21(2):429–40.

Alharbi TSJ, Ekman I, Olsson LE, Dudas K, Carlström E. Organizational culture and the implementation of person centered care: results from a change process in Swedish hospital care. Health Policy. 2012;108(2–3):294–301.

Carlström ED, Ekman I. Organisational culture and change: implementing person-centred care. J Health Organ Manag. 2012;26(2):175–91.

Severinsson IE, Haruna M, Rönnerhag M, Holm AL, Hansen BS, Berggren I. (2017). Evidence of linkages between patient safety and person-centred care in the maternity and obstetric context-An integrative review.

Denis JL, van Gestel N. Medical doctors in healthcare leadership: theoretical and practical challenges. BMC Health Serv Res. 2016;16:45–56.

Imran D, Rog K, Gallichio J, Alston L. The challenges of becoming and being a clinician manager: a qualitative exploration of the perception of medical doctors in senior leadership roles at a large Australian health service. BMC Health Serv Res. 2021;21:1–9.

Spehar I, Frich JC, Kjekshus LE. Clinicians in management: a qualitative study of managers’ use of influence strategies in hospitals. BMC Health Serv Res. 2014;14:1–10.

Spehar I, Frich JC, Kjekshus LE. Clinicians’ experiences of becoming a clinical manager: a qualitative study. BMC Health Serv Res. 2012;12:1–11.

Flanagan B, Lord B, Reed R, Crimmins G. Listening to women’s voices: the experience of giving birth with paramedic care in Queensland, Australia. BMC Pregnancy Childbirth. 2019;19:1–9.

McKenna L, Brown T, Oliaro L, Williams B, Williams A. (2020). Listening in health care. The handbook of listening, 373–383.

Kogan JR, Conforti LN, Bernabeo EC, Durning SJ, Hauer KE, Holmboe ES. Faculty staff perceptions of feedback to residents after direct observation of clinical skills. Med Educ. 2012;46(2):201–15.

Archer W, Latif A, Faull C. (2017). Communicating with palliative care patients nearing the end of life, their families and carers. Pharm J, 298(10.1211).

Farahat AH, Mohamed HES, Elkader SA, El-Nemer A. Effect of implementing a Birth Plan on womens’ childbirth experiences and maternal & neonatal outcomes. J Educ Pract. 2015;6(6):24–31.

Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol. 2002;186(5):S160–72.

Pan AJ, Pan AJ, Leary KR. Professional interactions: negotiation and expression for Future Physicians and Healthcare Providers. Univers J Educational Res. 2017;5(11):2101–6.

Eisemann BS, Wagner RD, Reece EM. Practical negotiation for medical professionals. Seminars in plastic surgery. Volume 32. Thieme Medical; 2018, November. pp. 166–71. 04.

Durand MA, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F, Elwyn G. (2014). Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PLoS ONE, 9(4), e94670.

Joseph-Williams, N., Lloyd, A., Edwards, A., Stobbart, L., Tomson, D., Macphail, S., ... & Thomson, R. (2017). Implementing shared decision making in the NHS: lessons from the MAGIC programme. Bmj, 357.

Minkman MM, Ligthart SA, Huijsman R. Integrated dementia care in the Netherlands: a multiple case study of case management programmes. Health Soc Care Commun. 2009;17(5):485–94.

Groenen CJ, van Duijnhoven NT, Faber MJ, Koetsenruijter J, Kremer JA, Vandenbussche FP. Use of social network analysis in maternity care to identify the profession most suited for case manager role. Midwifery. 2017;45:50–5.

Raoust GM, Bergström J, Bolin M, Hansson SR. (2022). Decision-making during obstetric emergencies: a narrative approach. PLoS ONE, 17(1), e0260277.

Goetz, M., Müller, M., Matthies, L. M., Hansen, J., Doster, A., Szabo, A., ... & Wallwiener, S. (2017). Perceptions of patient engagement applications during pregnancy: a qualitative assessment of the patient’s perspective. JMIR mHealth and uHealth, 5(5), e7040.

Sassen B. Nursing and the Patient Journey. Improving person-centered Innovation of nursing care: Leadership for Change. Cham: Springer Nature Switzerland; 2023. pp. 165–8.

Chapter   Google Scholar  

Busch IM, Saxena A, Wu AW. Putting the patient in patient safety investigations: barriers and strategies for involvement. J Patient Saf. 2021;17(5):358–62.

Saino C, Lauri SE, Eriksson. « Cancer Patient’s Views Experiences Participation Care Decis Making» Nurs Ethics. 2001;8(2):97–113.

Little P, Dorward M, Warner G, Moore M, Stephens K, Senior J, Kendrick T. Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care. BMJ. 2004;328(7437):441.

Diamond-Brown L. It can be challenging, it can be scary, it can be gratifying: obstetricians’ narratives of negotiating patient choice, clinical experience, and standards of care in decision-making. Soc Sci Med. 2018;205:48–54.

Rosenthal L, Lobel M. Explaining racial disparities in adverse birth outcomes: unique sources of stress for black American women. Soc Sci Med. 2011;72(6):977–83.

Tripepi G, Jager KJ, Dekker FW, Zoccali C. Selection bias and information bias in clinical research. Nephron Clin Pract. 2010;115(2):c94–9.

Polit DF, Beck CT. Generalization in quantitative and qualitative research: myths and strategies. Int J Nurs Stud. 2010;47(11):1451–8.

Download references

Acknowledgements

The authors would like to thank the Obstetrics Department of Erasmus University Medical Center and the individual patients and professionals involved for participating in this study and thereby providing relevant data.

The authors have not received a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and affiliations.

Department of Obstetrics and Gynaecology, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Netherlands

Michael Van der Voorden & Arie Franx

Department of Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, Rotterdam, Netherlands

You can also search for this author in PubMed   Google Scholar

Contributions

M.V.: Conceptualization, methodology, formal analysis, investigation, data curation, writing, original draft, review & editing A.F.: conceptualization, resources, review & editing, supervision K.A.: conceptualization, resources, review & editing, supervision.

Corresponding author

Correspondence to Michael Van der Voorden .

Ethics declarations

Ethics approval and consent to participate.

The study protocol (MEC-2020-0246) was approved by the institutional review board of Erasmus University Medical Center. Written informed consent was obtained from all participants. All methods were applied in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

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

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

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

Reprints and permissions

About this article

Cite this article.

Van der Voorden, M., Franx, A. & Ahaus, K. Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study. BMC Health Serv Res 24 , 700 (2024). https://doi.org/10.1186/s12913-024-11154-1

Download citation

Received : 22 November 2023

Accepted : 29 May 2024

Published : 03 June 2024

DOI : https://doi.org/10.1186/s12913-024-11154-1

Share this article

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

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

Provided by the Springer Nature SharedIt content-sharing initiative

• Patient participation
• Involvement
• Patient-centered care
• Patient safety
• Culture change
• Gynaecology
• Negative effects

BMC Health Services Research

ISSN: 1472-6963

• General enquiries: [email protected]

Eviction defense programs reach few Multnomah County tenants in need, study finds

A new study from Portland State University researchers found eviction rates are well above pre-pandemic levels.

Multnomah County renters are facing evictions at a rate nearly double that of pre-pandemic levels. While this trend can be explained by soaring housing costs, inflation, and a surge in eviction court filings put on hold during the state’s COVID-19 eviction moratorium, new research shows that this uptick can also be attributed to the shortfalls in legal and financial programs meant to help people threatened with eviction.

A “For Rent” sign in Southwest Portland, May 10. 2023.

Kristyna Wentz-Graff / OPB

A new Portland State University study found that, out of dozens of renters who were recently evicted in Multnomah County, only a quarter received eviction prevention help through nonprofit or government programs.

“It was pretty alarming to see how few tenants actually could access those programs,” said Alex Farrington, a researcher in PSU’s urban studies department who contributed to the report. “And some folks we talked to sort of tried to access or find resources and failed. So it wasn’t just that people didn’t seek them out.”

These findings come a year after Multnomah County voters rejected a ballot measure that would have ensured legal representation for anyone facing an eviction. At the time , county commissioners said this measure was unnecessary because the government already had adequate programs to support people at risk of losing their homes.

The PSU report says otherwise.

Researchers spoke with 68 renters who faced eviction since early 2020. The majority of tenants interviewed said they never sought help from eviction defense programs, largely because they didn’t know any resources were available. And half of those who did seek help weren’t able to access any due to numerous barriers.

“These results reveal that, despite the recent implementation of new forms of tenant support, these new programs often fail to reach many of the tenants who need them most,” the report reads.

There are several steps to eviction for people who haven’t paid rent.

First, renters receive a notice from their landlord informing them that they’ll be forcibly evicted if they don’t pay owed rent by a certain date. Anecdotal information tells researchers that it’s extremely common for renters to leave at this point, yet there is no formal record kept to track this. If the tenant doesn’t leave, the landlord files a civil complaint with the county court, and a court date is set. The court can dismiss this charge if the tenant pays before the trial, or it can instruct law enforcement to forcibly remove a renter from their apartment if there’s no payment.

Support for people facing eviction for not paying rent has fluctuated dramatically in the past five years, due to the COVID-19 pandemic’s financial impact. Between March 2020 and June 2021, the state imposed a moratorium on all evictions due to nonpayment. A state program then offered rent assistance to low-income tenants at risk of eviction until August 2022.

Evictions surged in the months – and years – since. In April 2019, landlords filed 468 eviction notices with the court This April, the courts saw nearly 900 eviction filings.

This uptick came despite the city and county putting money towards legal aid programs to support renters in eviction court. This can be a critical resource since low-income people facing eviction in court aren’t provided the kind of free legal defense criminal defendants are granted under the Constitution.

It’s a different story for landlords: In 2023, only 6% of tenants had legal representation in Multnomah County eviction court, while 56% of all landlords had a lawyer to fight on their behalf.

While a county ballot measure that would have used a capital gains tax to pay for legal defense for anyone facing an eviction failed in May 2023, the county pledged to fund additional legal and financial programs to help tenants at risk of losing their homes.

The county board put nearly 42 million dollars toward eviction prevention programs in the current year’s budget, with most of the money coming from federal pandemic assistance funds. Those short-term dollars have all but dried up. For this upcoming fiscal year, which begins July 1, the county has proposed spending $19 million on eviction prevention programs.

The PSU report doesn’t say these programs aren’t working to help tenants – they just aren’t reaching them.

“These resources can be really helpful,” said Farrington, “but it’s getting tenants in the door to have access to them in the first place that matters.”

And it’s not just recent resources that tenants aren’t attuned to. According to Farrington, several people surveyed were evicted during the statewide eviction moratorium, without ever knowing that a moratorium was in place. With legal support, they could have easily challenged the illegal eviction and remained housed.

The resources available to tenants now include free legal aid from the nonprofit Oregon Law Center, financial aid to cover rent funneled through community nonprofits, and information to educate tenants on their rights shared by advocacy groups like the Community Alliance of Tenants.

But even those resources can hit a dead end. Kim McCarty is the executive director of the Community Alliance of Tenants, which operates a hotline that tells renters how to get help in the face of an eviction. McCarty said that they regularly hear back from renters who tried to access help but were told that there weren’t enough resources or time to assist them.

“It’s a frightening message to be told – ‘Just hold on,’” McCarty said. “If someone thinks they’re about to lose their house, they don’t have the time to wait.”

This dynamic is reflected in the PSU study, which found that the pressure of a looming eviction can negatively impact renters’ physical and mental health. Many tenants surveyed noted increased anxiety, depression, insomnia, and high blood pressure caused by the added stress of an eviction notice. Farrington said this can explain why few tenants are able to get help.

“One reason that tenants have a hard time accessing resources is because the eviction process is so stressful and overwhelming and sort of all-consuming,” he said. “It’s kind of ridiculous to expect those tenants to themselves figure out how to connect to resources during that process.”

Multnomah County Chair Jessica Vega Pederson, who oversees the county’s budget, acknowledged this issue in an email to OPB.

“Too many tenants don’t know about available programs, due to a lack of outreach, a lack of responsiveness, or their challenges with searching for assistance with an unfamiliar situation,” Vega Pederson wrote. “This means that thousands of Oregonians every year must undergo traumatizing eviction experiences without getting the help they desperately need.”

Indeed, the study’s findings aren’t unique to Multnomah County. Farrington and other PSU researchers are also studying the outcomes for tenants in other parts of Oregon and are seeing a similar lack of knowledge or access to resources that could prevent an eviction.

The report urges the state and local governments to increase funding for emergency rent assistance to help those at risk of displacement, bolster educational outreach to at-risk tenants and establish a program guaranteeing legal assistance to anyone facing eviction.

Tenant advocate McCarty said the risk of not acting could only worsen another statewide crisis.

“Isn’t it clear that this is leading to visible homelessness?” she said. “If the number of evictions are increasing in any way, and we don’t have enough shelter beds to accommodate people who become homeless, it’s obvious. We should be addressing this further upstream.”

OPB’s First Look newsletter

Streaming Now

Here and Now