reflexivity in qualitative research pubmed

Reflexivity in Qualitative Research

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• 1 1 Saint Louis University, Saint Louis, MO, USA.
• PMID: 30849272
• DOI: 10.1177/0890334419830990

All qualitative research is contextual; it occurs within a specific time and place between two or more people. If a researcher clearly describes the contextual intersecting relationships between the participants and themselves (reflexivity), it not only increases the creditability of the findings but also deepens our understanding of the work. The issues surrounding the researchers' reflexivity are many and complex; however, journal space for discussing them may be very limited. Therefore the researcher has the responsibility of succinctly and clearly addressing these issues, so the reader can evaluate the research. Some of the ways that researchers can address reflexivity are discussed.

Keywords: Breastfeeding; health services research; qualitative methods.

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The Eye Regards Itself: Benefits and Challenges of Reflexivity in Qualitative Social Work Research

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Barbara Probst, The Eye Regards Itself: Benefits and Challenges of Reflexivity in Qualitative Social Work Research, Social Work Research , Volume 39, Issue 1, March 2015, Pages 37–48, https://doi.org/10.1093/swr/svu028

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Much has been written about the central role of reflexivity in qualitative research, yet there has been no empirical study of how researchers actually practice reflexivity and what it is like for them to do so. To address this question, a project was developed to gather information directly from qualitative social work researchers about the perceived benefits, challenges, and limitations of reflexivity. Participants, representing eight countries with the majority (65%) from the United States, included researchers using diverse methods with varying degrees of experience. In their interviews, these 34 scholars discussed the benefits of reflexive activities for both themselves and their research projects; obstacles that were personal, project-related, professional, and systemic; a discrepancy between valuation and actual use of reflexive practices; and the need to balance flexibility and rigor. The article concludes with directions for further inquiry and suggestions for assessing the adequacy of reflexivity in published studies.

“Reflexivity” is generally understood as awareness of the influence the researcher has on the people or topic being studied, while simultaneously recognizing how the research experience is affecting the researcher ( Gilgun, 2008 ). Reflexive engagement while planning, conducting, and writing about research promotes an ongoing, recursive relationship between the researcher's subjective responses and the intersubjective dynamics of the research process itself.

Although much has been written about the importance of reflexivity in qualitative research, there has been no empirical study of how researchers actually practice reflexivity and integrate it into their work. The literature has focused largely on definition (for example, Finlay, 2002a ; Pillow, 2003 ), utility (for example, Ben-Ari & Enosh, 2011 ), and typology (for example, Barusch, Gringeri, & George, 2011 ; D'Cruz, Gillingham, & Melendez, 2007 ; Longhoefer & Floersch, 2012 ), yet there has been no study of qualitative researchers themselves to find out how and why they engage in actions they consider “reflexive.” The purpose of this study was thus to examine the role of reflexivity in qualitative social work research through the eyes of those who practice it, with particular interest in perceptions of reflexivity's benefits, challenges, and limitations. Although the study is primarily descriptive, it also includes prescriptive elements and concludes with suggestions for scholars, editors, and consumers of qualitative research.

Reflexivity and Knowledge

The term “reflexive” is used to denote actions that direct attention back to the self and foster a circular relationship between subject and object. Nonreflexive actions , in contrast, are those that distinguish subject from object, cause from effect, in a linear or temporal relationship. Each approach rests on a different epistemology and leads to a different way of searching for knowledge. Epistemology, not methodology, determines the place of reflexivity in a particular study. A researcher may use qualitative or quantitative methods—for example, conduct a participatory or community-based project using surveys, observations, and focus groups—and, within that study, be more or less reflexive.

In research based on a positivist worldview, the “experimenter effect”—the impact of the researcher's presence—is generally considered to be a methodological problem, a form of reactivity in which a researcher's biases cause him or her to unconsciously influence participants, contaminating both process and outcome; the more rigorously this influence is minimized or isolated, the better the study. Within the constructivist paradigm, on the other hand, reactivity is not seen as a problem to be reduced or overcome but as an essential element in the cocreation of knowledge ( Ben-Ari & Enosh, 2011 ). The subject is always present in the object ( Finlay, 2002b ), and the researcher is always “written into the text” ( Lynch, 2000 ); thus, both research er and research ed shape the encounter, and “research” becomes the collaborative construction of knowledge rather than the discovery of knowledge assumed to already exist. The measure of rigor is the clarity with which both personal and relational subjectivity have been identified and revealed, not how thoroughly they have been “controlled for” ( Jootun, McGhee, & Marland, 2009 ). At the same time, as Lynch (2000) pointed out, the function of reflexivity in this process is not quite clear. Sometimes it is seen as a way to enhance objectivity by “bracketing” the researcher's subjectivity and thereby eliminating or reducing bias, while at other times it is seen as a means for exposing false claims of objectivity ( Lynch, 2000 ).

Awareness of one's subjectivity develops through an internal process that is supported by external activities ( Probst & Berenson, 2014 ). Both are aspects of reflexivity, which can be understood as a process of self-examination (exploring one's assumptions, emotional reactions, cultural positioning) through specific actions (keeping a journal, debriefing with others, and so on) within a field of inquiry that is also an object of awareness. Reflexive researchers are, in essence, gazing in two directions at the same time. As they attend to what is taking place in the field of study, they become aware of their own projections, attachments, assumptions, agendas, and biases—like an eye that sees itself while simultaneously seeing the world. Ideally, this double perspective is present throughout the research endeavor, from the selection of topics and populations to be studied to the presentation and dissemination of findings ( Probst & Berenson, 2014 ), affecting the way a project is conceptualized and the way it is experienced.

“Muddy” Nature of Reflexive Research

Reflexive analysis is challenging, fraught with danger. As Finlay warned, “The researcher treads a cliff edge where it is all too easy to fall into an infinite regress of excessive self-analysis at the expense of focusing on the research participants” ( Finlay, 2002b , p. 532). She likened reflexivity to a “swamp,” a murky and confusing terrain of self-analysis and self-disclosure rife with “endless narcissistic personal emoting or interminable deconstructions of deconstructions” ( Finlay, 2002a , p. 226) where the researcher can become hopelessly lost. Others agreed, describing reflexivity as “muddy,” “messy,” a teeming mass of endlessly layered subjectivity that requires the researcher to “come clean” ( Brown, 2006 ; Pillow, 2003 ; Valandra, 2012 ).

Pillow (2003) cautioned against excessive reflexivity, “wading in the morass of our own positionings” (p. 175), and argued that reflexivity is not a way to solve the “problem” of subjectivity. “We do not escape from the consequences of our positions by talking about them endlessly,” she wrote ( Pillow, 2003 ); reflexivity can be misused to imply that issues of inequity, bias, and misunderstanding have been adequately addressed just because the researcher is aware of them. At the same time, she stated, “I do not believe that the solution is then to stop talking about our positions” ( Pillow, 2003 , p. 177). She raised a concern, as others also have (for example, Finlay, 2002a ), about whether reflexivity is a distraction, focusing on the researcher's internal processes and shifting attention away from the people or phenomenon being studied.

Access to one's motivations, biases, and reactions—the “stuff” of reflexivity—may not be as simple as it sounds, however. The very things that most need to be seen are often the most deeply hidden ( Gemignani, 2011 ). The intellectual conviction that self-awareness is important may not be sufficient to expose masks and blind spots to self-scrutiny. A particular kind of skill and stamina may be needed, because confronting one's limitations, vulnerabilities, and mistakes is not an easy task, even for the most sincere researcher. Both novice and seasoned researchers may feel uncomfortable, threatened, and even resistant, though perhaps for different reasons, to the idea of critically interrogating their own positions and emotional experiences ( Hsiung, 2008 ); researching sensitive topics can also trigger unexpected and powerful reactions ( Gilgun, 2008 ) that are not so easily “managed away” by writing a memo. Because the process is so idiosyncratic, the researcher cannot know in advance what will require reflexivity or what tool will serve best, so it may be difficult to build reflexivity into a study design. Here again, reflexivity asserts its “messy” nature.

Evaluating Reflexivity

Perhaps the “muddiest” issue is whether reflexivity produces better research. Gilgun (2008) argued that reflexivity opens the researcher to a fuller, more “connected knowing,” and Ben-Ari and Enosh (2011) described how reflexivity between interviewer and interviewee can be used for the construction of new knowledge. Others, however, have cautioned against assuming that just because we are reflexive our work is truer, better, or more valuable. Reflexivity is not, as Pillow (2003) warned, a cure for the problem of representing someone else's reality. Finlay (2002a) made a similar point: A researcher's apparent openness does not guarantee that the voices of participants have been faithfully represented.

Lynch (2000) also questioned the notion that reflexivity contrasts with or transforms an “unreflexive” condition into something with greater “critical potency and emancipatory potential” (p. 36), and thus more valuable or true. There is no inherent advantage to being reflexive, he noted, unless something useful comes from it, nor does a reflexive approach necessarily bring the researcher closer to the meaning of a phenomenon ( Lynch, 2000 ). He especially challenged the sense of virtuousness and “epistemological hubris that often seems to accompany self-consciously reflexive claims” ( Lynch, 2000 , p. 47).

The relation of reflexivity to rigor is part of the broader question of how qualitative researchers can “produce credible work when objectivity is no longer assumed or even pursued” ( Barusch et al., 2011 , p. 11). Criteria for qualitative rigor tend to emphasize the relational aspects of knowledge construction, including transparency, reciprocity, and critical self-reflection. And yet, in their review of qualitative social work articles, Barusch and colleagues found a surprising absence of reflexive practice, with only 14% of authors they surveyed disclosing information about background or positioning. This does not mean, of course, that the other 86% of researchers were not reflexive. They may very well have been reflexive in their data collection and analysis but did not include that information in published reports.

Gringeri, Barusch, and Cambron (2013) reported a similar discrepancy in their review of social work publications. Although they cited theory and reflexivity as the “twin pillars of rigorous qualitative research” ( Gringeri et al., 2013 , p. 61), they found that only 16% of the articles in their sample incorporated reflexive accounts. Perplexed by social workers' reluctance to situate themselves in their research and by an apparent discrepancy between what researchers claim to value and what they claim to do, Gringeri et al. (2013) concluded that “the low rate of reflexivity in social work articles requires our attention” (p. 61).

Clearly, there is a paradox worth examining. On the one hand, reflexivity is cited as an important tool for enhancing the rigor and trustworthiness of a qualitative study ( Gilgun, 2010 ; Gringeri et al., 2013 ; Longhofer & Floersch, 2012 ). It is often invoked, in fact, as the qualitative equivalent of tests of validity, something qualitative researchers can point to as an evidentiary trail in their justification of claims to knowledge. On the other hand, there is a persistent uncertainty about reflexivity's contribution to rigor or knowledge. It seems difficult to study the topic in a systematic way. As Lynch (2000) and others noted, there are different kinds of reflexivity—awareness of social positioning and power relations, documentation of choices, cybernetic feedback loops, stepping back to “break the frame,” methodological self-consciousness or self-criticism—corresponding to different philosophical perspectives, research aims, and types of analysis. Varying from researcher to researcher, and from situation to situation even for the same researcher, reflexivity appears to be inherently emergent and personal, eluding manualization.

Still, the question remains whether or how one can determine that a researcher has been “reflexive enough.” Is it possible to evaluate the reflexivity of a study without mechanizing something that is inherently idiosyncratic and co-constructed—that is, without imposing criteria from a dissonant epistemology? If so, how can that be done? And if not, how can both reader and researcher feel comfortable that sufficient reflexivity has been used?

By asking qualitative researchers to be reflexive about their own reflexivity, this study opens the door to investigation of these important questions. Providing insight into barriers and benefits of reflexive research, this article offers suggestions for enhancing, supporting, and evaluating the use of reflexivity in social work research.

The study was undertaken to gather information about how qualitative social work researchers experience and incorporate reflexivity into their work. It sought to identify specific actions researchers take to support or enact reflexivity ( Probst & Berenson, 2014 ) and to explore how they view the benefits, challenges, and limitations of reflexivity. Research questions included the following:

Benefits : What do qualitative social work researchers perceive to be the benefits of reflexivity? Beneficial for what or for whom?

Supports : Are there personal factors or external conditions that foster the use of reflexivity?

Challenges : What are the obstacles or drawbacks? When reflexivity is not used, why not?

Potential dissonance : Are there any differences between how qualitative social work researchers think about reflexivity and how they actually use it? If so, what might be the source of that dissonance?

A realist epistemology served as the framework for the research, because participants' responses were taken as offered (that is, literally) and analyzed thematically across the data set. Because qualitative research was itself the topic of study, a qualitative approach to data collection, analysis, and interpretation seemed appropriate. Within the qualitative paradigm, thematic analysis ( Boyatzis, 1998 ; Braun & Clarke, 2006 ) was chosen for its flexible yet grounded approach. Thematic analysis is an inductive method for identifying, analyzing, and reporting patterns within the data, allowing the researcher to use a bounded theoretical question as a starting point for identifying themes that can shed light on an identified area of interest; themes can thus be theory driven or data driven.

Participation in the project was offered through flyers, sign-up sheets, and e-mail to members of the Listserv for the Qualitative Special Interest Group (SIG) of the Society for Social Work and Research (SSWR), individuals on the e-mail list for Social Work Day of the International Congress on Qualitative Inquiry, and other researchers who had expressed interest during workshops and conversations at SSWR's annual conference in January 2012. The only inclusion criterion was experience conducting qualitative social work research, and all who volunteered were interviewed. Because there is no information about the total number of people on either Listserv, the response rate is not known.

A total of 34 people took part. Of these, 65% ( n = 22) were from the United States, with the remaining 35% ( n = 12) from the United Kingdom (England, Ireland, and Scotland), Australia, New Zealand, Canada, and Israel. Based on self-reported descriptions of their research experience, half were rated as highly experienced ( n = 17), and approximately one-fourth each of medium ( n = 9) and limited ( n = 8) experience. Most of those in the third group were doctoral students nearing completion of their dissertations. Among the participants, 30% ( n = 10) were male and 70% ( n = 24) were female. When asked about the specific qualitative approaches they used (for example, ethnography, grounded theory), all described projects that spanned various approaches, with the most common kinds of research experience being focus groups, thematic analysis, narrative studies, content analysis, and grounded theory. Because no one self-identified as adhering to a single methodology, categories were nonexclusive and it was not possible to link responses to particular qualitative methods.

Data Collection

Individual interviews lasting 45 to 60 minutes were conducted in person, via Skype, or by telephone. Informed consent was obtained before each interview; interviews were audio-recorded and transcribed. After providing background information, participants were asked what reflexivity meant to them and why they were interested in the study. To guard against premature closure based on assumptions about what reflexivity “ought” to look like, an inclusive approach was selected to capture data that might otherwise slip through the semantic net; thus, a range of experiences and practices were explored, as was the use of these practices in both individual and group projects. Finally, participants were asked what they felt were the benefits, obstacles, and potential drawbacks to reflexivity.

Author Positioning

I have an ongoing interest in reflexivity stemming from my professional work and personal mindfulness practice, and have conducted a number of sessions on reflexivity in qualitative research at professional conferences. I knew approximately one-third of the people interviewed, although only in broad professional contexts and, with one exception, not well. This shared community was useful for recruitment. A number of people said they wanted to help a colleague or, as several joked, store up “good research karma.” Engagement was not a problem. Participants were interested in talking about their work, and many stated at the end of the interview that they had found the experience extremely useful.

Studying members of a group to which one belongs has both advantages and perils, of course. As Chew-Graham, May, and Perry (2002) noted, when interviewing someone who is a member of the same profession or known to the interviewer in a professional context, access may be easier, yet prior knowledge can affect the way that the researcher is perceived, the kind of material that is offered, and the way that material may be interpreted. Because of their common profession, interviewees may assume that the researcher sees things the same way they do. Perception of the researcher as a peer with a common language and shared understanding can make participants less cautious and guarded, resulting in more genuine data or, in contrast, cause them to compete, seek to impress, or collude with the researcher in “a case of shared conceptual blindness” ( Chew-Graham et al., 2002 , p. 288).

As researchers, our study participants understand what participating in a study will entail because they know the “tricks of the trade”; they know the data may be interpreted in ways that they did not intend, and they understand what “confidentiality” and “anonymity” mean in practice. This meant, for many of them, that they were cautious in how they presented themselves. ( Wiles et al., 2006 , p. 293)

Concerns expressed by participants in Wiles et al.'s study (2006) , such as fear that the researcher would “steal” their ideas or reveal their criticism of fellow researchers, did not arise in this study; at least, these concerns were not voiced. It is certainly possible, of course, that some of the other issues raised by both Chew-Graham et al. (2002) and Wiles et al. (2006) were taking place below the surface. Assumptions of a shared understanding may have masked important nuances, and some participants may have presented themselves as more reflexive than they really were. The topic itself (described on the informed consent form) may have conveyed the assumption that reflexivity is a hallmark of “good” qualitative research and evoked the desire to seem like “good” researchers in the interviewer's eyes. Although it is never possible to entirely rule out social desirability bias, numerous comments about not being sure what reflexivity “really was” or wishing they had time to “do it more” seemed to indicate an overall candor in interviewees' responses.

From time to time I also offered examples of my own reflexivity. For instance, I shared with several people the mortification I felt in discovering that I was competing with my own study participants, feeling jealous when they seemed “more reflexive” than I was and then wanting to impress them by performing the identity of “expert researcher.” In this way, a parallel process took place between collecting data about reflexivity in qualitative research while also experiencing reflexivity in qualitative research.

Data Analysis

Following data collection, iterative thematic coding was carried out in stages. The data set was divided into three segments, each including a heterogeneous group of participants irrespective of when the interviews took place; one set of interviews was used for developing a theme book and other two for successive testing and refining of the themes. In the first stage, one-third of the interviews were independently coded by the researcher and a doctoral intern, who then compared and collapsed themes into a collaborative preliminary code book. This tentative list of codes was checked against a second group of interviews to confirm, refine, and elaborate on the codes and to highlight fresh ideas that were not yet represented. Themes endorsed or articulated by this second group were noted, along with additional nuances or alternative viewpoints. A revised code book was developed and organized into a chart.

The chart was shown to the third group of qualitative researchers so participants and individuals similar to participants could review the preliminary findings. Volunteers for these follow-up interviews were solicited at SSWR and through the SIG Listserv. Of the eight people who took part in this third set of interviews, three had been interviewed previously and five had not. Four were experienced, three were mid-level, and one was relatively new. All but one were from the United States; 75% were female.

During this process, which served as both peer review and member check, participants were asked to comment on anything they felt was omitted, unclear, or did not “ring true,” as well as any thoughts about their own experience of reflexivity. A number of additional points emerged from these conversations, and the outline was expanded accordingly. With this outline as a template, the interviews were reviewed again for further refinement. Finally, findings were organized into a conceptual diagram (see Figure 1 ) to illustrate relationships among key elements.

Reflexivity in Qualitative Research

Respondents spoke candidly about the benefits and the difficulties of reflexivity. Although benefits are described below in a somewhat dichotomous manner as either “for oneself” or “for the project” and challenges are noted as either personal or systemic, these distinctions are for ease of exposition only, because most participants saw these processes as fluid and overlapping.

Benefits of Reflexivity

Benefits of reflexivity included accountability, trustworthiness, richness, clarity, ethics, support, and personal growth—beneficial for the integrity of the research process, the quality of the knowledge generated, the ethical treatment of those being studied, and the researcher's own well-being and personal growth.

For the Research Project

Participants considered reflexivity essential for rigor because it made positionality, subjectivity, and reactivity more transparent. “Being aware of your positioning in relation to the research” and “knowing that there's no neutrality, however much people might claim they can remain neutral in their research” provided a baseline of honesty and served as a check against naïve claims of purity or objectivity. Being reflexive “helps me remember what my voice is because, while my voice is important, I need to see past it or hear past it.” Reflexivity also provided a way to document choices, keep track of an evolving process, and leave a trail that could be retraced later if choices needed to be revisited. Memos and journals helped to guard against forgetting or distorting what took place in earlier stages of a project and served as a reminder to keep an open mind.

In particular, reflexivity was seen as important for epistemological rigor. “To be aware of how you conceptualize, why you conceptualize in that way,” to think about “how do I know this, or why am I saying this,” and to examine “the kind of questions you ask and what things may have happened in the actual interviewing” were essential for participants “because you're making a case all the time for your version of knowledge, and are you cutting off other people all the time from their version?” Without recursive self-inquiry, assumptions masked as professional expertise might infiltrate one's work, undermining its authenticity or value. “It's like, is the unexamined life worth living, is the unexamined study worth doing?”

Closely related were the benefits of reflexivity for ethics. Ethics included the honesty of the investigator about his or her agenda, hopes, and potential for personal gain, and extended to openness about power relations, often covert, between researcher and those being studied. Participants saw reflexivity as a way to promote trust, equity, integrity, and respect for those being studied, as well as a way to guard against the self-deception and further inequity that can result when power imbalance is not acknowledged.

“You can't look at other people's lives without looking at what else is going on in you” because “reflexivity means testing the knowledge–power relationship that's going on in that process all the time.” Participants were keenly aware of power issues in the research process, the question of whose knowledge or authority was being upheld, and the distaste of benefiting from someone else's story. Reflexivity could help to bring these issues into the light and to work through specific ethical dilemmas that might arise. “It's a way of trying to be as honest as we can about what we're doing, a way of testing ourselves that we're being honest about what we're bringing and what we're drawing from the research.”

Many also considered reflexivity helpful for the development of professional knowledge. “Using reflexivity allows me to think through, test, wonder, and use it as a base to explore, all of those things, reflecting on what I heard in an interview, and then looking at it from multiple places in myself.” Both self-reflection and feedback from others offered new layers of meaning, depth, and nuance.

For the Researcher

Self-awareness was also seen as beneficial for the researcher. It provided a framework for processing, sustaining, renewing, and gaining insight both into the research and oneself. As a tool for managing the research experience, it could serve as a way to discharge and work through intense, surprising, or upsetting issues and thus avoid becoming sidetracked or emotionally depleted. Some participants saw reflexivity as a way to normalize one's reactions, put them into context, and create appropriate distance; others noted that it could also help to un normalize experience and support the effort to “lean into the discomfort” and open new perspectives. “Stepping back from the data, thinking about what's in there and how I'm reacting to it” was seen as a helpful counterweight to the tendency to become overimmersed or overidentified. “You have to know who you are, how you're interacting, and what you're feeling and what role you're playing in the data collection and your analysis.” A qualitative researcher without self-awareness cannot, participants agreed, be a good researcher.

By Type of Reflexive Activity

Speaking with others provided an opportunity to “bounce ideas off people who are less directly immersed” and can “call me on things about my understanding that I may have missed or taken for granted.” Other people can bring awareness of blind spots and “sticky moments,” opening up multiple or alternative viewpoints. Debriefing and working through problems with others was seen as a “way to hold myself accountable and to manage my own bias and reactivity, to see what you're unable to see in your own work,” thus adding to transparency and trustworthiness.

Research unfolds over time and I find that it is easy to forget initial ideas and thoughts as I become more familiar with something. There are things that are potentially relevant to the project but not immediately pertinent at the moment, so it provides a record of experiences to refresh my memory.

Thinking about the context acts as an orienting tool that allows me to be mindful of my own role throughout the research process. Being aware of all I take into the research process and how my history, perspectives, etc., influence what I ask, how I hear the answers, and what I choose to report in the findings.

Returning reflexively to the literature “can affirm or challenge your material and make you examine it more critically.” Pondering what has already been written helped to position the researcher, identify limits to his or her understanding, and situate findings in existing knowledge. “We must know what we already know, what we need to know, how our work conflicts with or agrees with that knowledge. Research is about building knowledge, which means knowing what is already there and how our work fits in.”

Reflexivity could be especially important when working as part of an interdisciplinary research team where members approach knowledge differently ( Malacrida, 2007 ; Paulus, Woodside, & Zeigler, 2010 ). Shared awareness of the criteria each uses to formulate categories—the assumptions, filters, and professional stance inherent in each discipline—contributes to the trustworthiness of study findings. The aim of collaborative reflexivity between team members was not seen as reaching consensus, but as articulating the differing assumptions and agendas that contribute to multifaceted understanding. As one respondent noted, “Team reflexivity is something different, it's not just a collection of each person's individual reflexivity.”

Challenges to Reflexivity

Obstacles and drawbacks to reflexivity were personal, project-related, and systemic.

Personal Challenges

When you first start, it is scarier or feels riskier than after you have been doing it for a while because of our nature to judge ourselves, and if you are really going to be reflexive, you need to find a way to be okay with our own foibles, mistakes, things you didn't do quite so well.

The line between openness and intolerable rawness could be difficult to navigate. “Sometimes asking others for comments opens up more than I had anticipated. Being open to unexpected or critical feedback is sometimes quite painful.”

Many respondents reported using additional supports such as mindfulness, contemplation, psychotherapy, creative writing, or “venting” with friends. They differed, however, in whether they felt reflexivity aggravated or mitigated the sense of being overwhelmed and flooded. Some felt that this would happen anyway and that self-awareness helped to manage the feelings, making them less traumatic; others felt that focusing on areas of personal sensitivity made the researcher more vulnerable and traumatized.

Project-related Challenges

Time constraints were the most frequently cited obstacle. Reflexivity took time and self-discipline, participants agreed, especially after long days of field observation, and was not always feasible because of pressure to move at a rapid pace or attend to other commitments. “The first challenge is time. The second challenge for me probably would be not being patient enough to let it unfold because I think being reflexive and taking time to do it well can be a slow and painful process.”

I've seen some material where self-reflexivity almost goes into what I would call self-indulgence, and I don't like it. Some of the stuff that people write about is really just biographical. I don't need to know that. I don't need to hear the person in the publication—I don't need to hear all of their doubts and all of their going back and forth, and all of that; it just doesn't work, to me.

Objections to reflexivity as self-indulgence had to do with published reports, however, not necessarily with its use during the research process, which might or might not find its way into the written presentation. Here again, there was a difference of opinion, with some feeling that the more rigorously one engaged in reflexivity, the less the likelihood of inappropriate “navel gazing” and narcissistic distortion.

External or Systemic Challenges

A lack of valuation by colleagues, administrators, funders, and journals was a major concern. Many participants felt that explicit endorsement of reflexivity could threaten their credibility with tenure committees operating from a quantitative model; one person even said that he had been advised to remove a highly reflexive published article from his portfolio. This kind of vigilance could make people feel defensive, torn, devaluing the sense of themselves as professionals. In addition, the pressure to publish made it tempting to move projects forward quickly or to jettison reflexive activities that were unlikely to be included in the final report.

Isolation from supportive peers engaged in similar reflexive research was a related concern. “You need colleagues who believe in and practice reflexivity to be able to maintain your own resilience.” This was not always possible, however, because “coresearchers and peers aren't always as keen to participate in reflexivity as I am … if you're working on a group project and members of your group are not naturally reflexive or the need for process isn't shared.” The biggest challenge was “believing in reflexivity enough to be able to put up with accusations of taking too long, not meeting deadlines, or being self-indulgent.”

Other participants cited a lack of training, preparation, or the availability of clear or consistent guidelines for assessing whether one has been adequately reflexive. Knowing when to disclose personal reflections was a related concern. Sharing one's biases or doubts was not always useful, especially if those being studied were hostile or might be influenced by what they learned about the researcher. For many participants, there was a discrepancy between valuation of reflexivity—what they believed they ought to do—and their actual use of reflexive practices. Reasons for this discrepancy were linked to the obstacles and limitations they encountered in their attempt to put into practice the self- and collaborative reflection they believed was so important for their work.

Clearly, interest in qualitative research and respect for the qualitative paradigm continue to grow. More social work graduate students are attracted to qualitative research; more professional journals accept qualitative studies; and more time is devoted to qualitative research at professional conferences. Thus, it is vital for qualitative scholars to be able to articulate what they have learned and to transmit that knowledge to the next generation of researchers who will need to become skilled users and skilled producers of qualitative scholarship.

As many participants in this study noted, however, the quantitative paradigm with its equation of measurement with evidence continues to dominate academia. Subjectivity, ambivalence, partial and multiple meanings, and the constructed nature of knowledge carry little currency within this paradigm. Time constraints and pressure to produce research with “hard” findings, especially in tenure-track positions, may inhibit the incorporation of reflexivity into both the research process and the written report. It is difficult to know, of course, whether the scarcity of reflexive accounts in published studies ( Barusch et al., 2011 ; Gringeri et al., 2013 ) means that reflexivity was absent from the research process itself. It is possible, as Gringeri et al. (2013) suggested, that researchers have indeed been reflexive but do not include those reflexive accounts in their manuscripts because they believe journal editors and reviewers do not expect it, or because they believe it would decrease their chances of publication and professional advancement. Barusch et al. (2011) offered a similar suggestion that social work authors may fear that self-disclosure would be “unprofessional” or inconsistent with journal editors' expectations and preferences, a finding supported by this study.

Lack of training also appears to be an issue. Several participants commented that they would like to “do more reflexivity” but had not been formally or adequately trained, pointing to a need to examine, and perhaps modify, how qualitative research is taught. It is not enough to espouse reflexivity as a value; students must be given models, tools, opportunities to learn by doing, and a place for including reflexive accounts in dissertations.

The skillful use of reflexivity can pose a number of additional challenges. One difficulty, noted by several respondents, is that we can only reflect on what strikes us as requiring reflection, what we become aware of with our conscious minds, although other forces may be operating and affecting the research. One can only be reflexive up to a point on one's own, and the very things one most needs to examine may be those that are most deeply hidden. Supervision and peer debriefing can help, as several respondents noted.

Another question has to do with the relationship between reflexivity, the disclosure of oneself to oneself , and disclosure to others . To what extent should the fruits of self-awareness and self-interrogation be shared with those one is studying? From one perspective, transparency with participants can help to build trust, repair power imbalance, and foster the co-creation of knowledge. At the same time, self-disclosure moves the researcher more forcefully “into the room,” perhaps too much so, just as self-disclosure by the therapist in psychotherapy can move the work forward or divert it ( Gemignani, 2011 ). Put another way, what should researchers do with the products of their self-reflections? Is there a way to put reflexivity's output to use that can effectively balance its benefits and limitations?

Other themes that invite further exploration include the following:

Professional expectations and issues of status : What is the impact of professional pressures and expectations on using and revealing reflexivity in one's research? Are there tacit messages and unspoken barriers? If so, how might this be addressed at the institutional or professional level? For instance, how explicit or flexible should policies be about the way research is taught and the way it is evaluated by tenure committees?

Electronic reporting in journals : What are the possibilities for including description of reflexive practices in published work, given the expansion of journals into electronic formats? While keeping to page limits for the main document, are there ways to offer electronic links to supplementary material about the reflexive “back story”? Should this become standard practice for qualitative manuscripts?

Supporting reflexivity outside the research project : Are there informal actions or personal qualities, extrinsic to the research process itself, that foster reflexivity? Without intruding on students' or scholars' privacy (for example, without making psychotherapy, collaboration, or mindfulness a requirement), how might these beneficial practices be supported? What are the ethical and practical challenges of doing so?

Reflexivity is an important tool that enables the researcher to stay engaged in critical self-awareness throughout the research process. It is the embodiment of an epistemology in which the knower is always present, a way of looking that gazes outward at what is taking place while sustaining an inward gaze at the looker. More than just a vehicle for honesty or management of the research experience, reflexivity offers a means for using self-knowledge to inform and enhance the research endeavor. As such, it has broad applicability for social work research regardless of methodology. That is, it is equally relevant and valuable for qualitative, quantitative, and mixed methods projects (see, for instance, Ryan & Golden, 2006 ).

Assessing the adequacy of a study's reflexivity remains problematic, however. As noted earlier, the absence of explicit mention of an author's reflexivity does not mean there was none. What, then, to look for? The notion of establishing benchmarks applicable across a range of designs risks objectification of what is inherently idiosyncratic, yet editors and readers need guidelines for determining if reflexivity is present. The following questions are far from a blueprint but represent a sample of what might be asked:

Agenda : Is there note of the author's background, previous scholarship, or the genesis of the project, other than the usual “gap in the literature”? Why was the study undertaken? Why does it matter, and to whom?

Process : Was there more than one step in the analysis? Were there any opportunities to reassess or revise?

Intersubjectivity : Who else was included in interpretation of the data? Was anyone invited to co-construct or review the findings? How convincing are the author's claims of trustworthiness, beyond his or her own perspective?

Self-interrogation : Are any contradictory or disconfirming data presented, or does everything fit (too) neatly into tidy categories?

Audit trail : Is there mention of how the author kept track of choices, hunches, and interpretations?

Although few manuscripts will offer explicit evidence on all these points, the absence of any evidence does raise a question about whether reflexivity was incorporated into the research.

Despite its “messiness,” reflexivity remains a fundamental way, particularly in qualitative studies, to bolster credibility by parsing the research endeavor into its mutually affecting parts and documenting the pathways through which knowledge was generated. This is particularly critical in social work research, because decisions about policies and practices affecting the nation's most vulnerable populations rely heavily on the strength of research findings. Consumers of social work research, as well as those whom their work ultimately serves, should be able to trust the authenticity of the knowledge offered to them. The practice of reflexivity can support this aim.

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• Open access
• Published: 16 May 2024

Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts

• Jeremy Segrott   ORCID: orcid.org/0000-0001-6215-0870 1 ,
• Sue Channon 2 ,
• Amy Lloyd 4 ,
• Eleni Glarou 2 , 3 ,
• Josie Henley 5 ,
• Jacqueline Hughes 2 ,
• Nina Jacob 2 ,
• Sarah Milosevic 2 ,
• Yvonne Moriarty 2 ,
• Bethan Pell 6 ,
• Mike Robling 2 ,
• Heather Strange 2 ,
• Julia Townson 2 ,
• Qualitative Research Group &
• Lucy Brookes-Howell 2  

Trials volume  25 , Article number:  323 ( 2024 ) Cite this article

Metrics details

Background/aims

The value of using qualitative methods within clinical trials is widely recognised. How qualitative research is integrated within trials units to achieve this is less clear. This paper describes the process through which qualitative research has been integrated within Cardiff University’s Centre for Trials Research (CTR) in Wales, UK. We highlight facilitators of, and challenges to, integration.

We held group discussions on the work of the Qualitative Research Group (QRG) within CTR. The content of these discussions, materials for a presentation in CTR, and documents relating to the development of the QRG were interpreted at a workshop attended by group members. Normalisation Process Theory (NPT) was used to structure analysis. A writing group prepared a document for input from members of CTR, forming the basis of this paper.

Actions to integrate qualitative research comprised: its inclusion in Centre strategies; formation of a QRG with dedicated funding/roles; embedding of qualitative research within operating systems; capacity building/training; monitoring opportunities to include qualitative methods in studies; maximising the quality of qualitative research and developing methodological innovation. Facilitators of these actions included: the influence of the broader methodological landscape within trial/study design and its promotion of the value of qualitative research; and close physical proximity of CTR qualitative staff/students allowing sharing of methodological approaches. Introduction of innovative qualitative methods generated interest among other staff groups. Challenges included: pressure to under-resource qualitative components of research, preference for a statistical stance historically in some research areas and funding structures, and difficulties faced by qualitative researchers carving out individual academic profiles when working across trials/studies.

Conclusions

Given that CTUs are pivotal to the design and conduct of RCTs and related study types across multiple disciplines, integrating qualitative research into trials units is crucial if its contribution is to be fully realised. We have made explicit one trials unit’s experience of embedding qualitative research and present this to open dialogue on ways to operationalise and optimise qualitative research in trials. NPT provides a valuable framework with which to theorise these processes, including the importance of sense-making and legitimisation when introducing new practices within organisations.

Peer Review reports

The value of using qualitative methods within randomised control trials (RCTs) is widely recognised [ 1 , 2 , 3 ]. Qualitative research generates important evidence on factors affecting trial recruitment/retention [ 4 ] and implementation, aiding interpretation of quantitative data [ 5 ]. Though RCTs have traditionally been viewed as sitting within a positivist paradigm, recent methodological innovations have developed new trial designs that draw explicitly on both quantitative and qualitative methods. For instance, in the field of complex public health interventions, realist RCTs seek to understand the mechanisms through which interventions generate hypothesised impacts, and how interactions across different implementation contexts form part of these mechanisms. Proponents of realist RCTs—which integrate experimental and realist paradigms—highlight the importance of using quantitative and qualitative methods to fully realise these aims and to generate an understanding of intervention mechanisms and how context shapes them [ 6 ].

A need for guidance on how to conduct good quality qualitative research is being addressed, particularly in relation to feasibility studies for RCTs [ 7 ] and process evaluations embedded within trials of complex interventions [ 5 ]. There is also guidance on the conduct of qualitative research within trials at different points in the research cycle, including development, conduct and reporting [ 8 , 9 ].

A high proportion of trials are based within or involve clinical trials units (CTUs). In the UK the UKCRC Registered CTU Network describes them as:

… specialist units which have been set up with a specific remit to design, conduct, analyse and publish clinical trials and other well-designed studies. They have the capability to provide specialist expert statistical, epidemiological, and other methodological advice and coordination to undertake successful clinical trials. In addition, most CTUs will have expertise in the coordination of trials involving investigational medicinal products which must be conducted in compliance with the UK Regulations governing the conduct of clinical trials resulting from the EU Directive for Clinical Trials.

Thus, CTUs provide the specialist methodological expertise needed for the conduct of trials, and in the case of trials of investigational medicinal products, their involvement may be mandated to ensure compliance with relevant regulations. As the definition above suggests, CTUs also conduct and support other types of study apart from RCTs, providing a range of methodological and subject-based expertise.

However, despite their central role in the conduct and design of trials, (and other evaluation designs) little has been written about how CTUs have integrated qualitative work within their organisation at a time when such methods are, as stated above, now recognised as an important aspect of RCTs and evaluation studies more generally. This is a significant gap, since integration at the organisational level arguably shapes how qualitative research is integrated within individual studies, and thus it is valuable to understand how CTUs have approached the task. There are different ways of involving qualitative work in trials units, such as partnering with other departments (e.g. social science) or employing qualitative researchers directly. Qualitative research can be imagined and configured in different ways—as a method that generates data to inform future trial and intervention design, as an embedded component within an RCT or other evaluation type, or as a parallel strand of research focusing on lived experiences of illness, for instance. Understanding how trials units have integrated qualitative research is valuable, as it can shed light on which strategies show promise, and in which contexts, and how qualitative research is positioned within the field of trials research, foregrounding the value of qualitative research. However, although much has been written about its use within trials, few accounts exist of how trials units have integrated qualitative research within their systems and structures.

This paper discusses the process of embedding qualitative research within the work of one CTU—Cardiff University’s Centre for Trials Research (CTR). It highlights facilitators of this process and identifies challenges to integration. We use the Normalisation Process Theory (NPT) as a framework to structure our experience and approach. The key gap addressed by this paper is the implementation of strategies to integrate qualitative research (a relatively newly adopted set of practices and processes) within CTU systems and structures. We acknowledge from the outset that there are multiple ways of approaching this task. What follows therefore is not a set of recommendations for a preferred or best way to integrate qualitative research, as this will comprise diverse actions according to specific contexts. Rather, we examine the processes through which integration occurred in our own setting and highlight the potential value of these insights for others engaged in the work of promoting qualitative research within trials units.

Background to the integration of qualitative research within CTR

The CTR was formed in 2015 [ 10 ]. It brought together three existing trials units at Cardiff University: the South East Wales Trials Unit, the Wales Cancer Trials Unit, and the Haematology Clinical Trials Unit. From its inception, the CTR had a stated aim of developing a programme of qualitative research and integrating it within trials and other studies. In the sections below, we map these approaches onto the framework offered by Normalisation Process Theory to understand the processes through which they helped achieve embedding and integration of qualitative research.

CTR’s aims (including those relating to the development of qualitative research) were included within its strategy documents and communicated to others through infrastructure funding applications, annual reports and its website. A Qualitative Research Group (QRG), which had previously existed within the South East Wales Trials Unit, with dedicated funding for methodological specialists and group lead academics, was a key mechanism through which the development of a qualitative portfolio was put into action. Integration of qualitative research within Centre systems and processes occurred through the inclusion of qualitative research in study adoption processes and representation on committees. The CTR’s study portfolio provided a basis to track qualitative methods in new and existing studies, identify opportunities to embed qualitative methods within recently adopted studies (at the funding application stage) and to manage staff resources. Capacity building and training were an important focus of the QRG’s work, including training courses, mentoring, creation of an academic network open to university staff and practitioners working in the field of healthcare, presentations at CTR staff meetings and securing of PhD studentships. Standard operating procedures and methodological guidance on the design and conduct of qualitative research (e.g. templates for developing analysis plans) aimed to create a shared understanding of how to undertake high-quality research, and a means to monitor the implementation of rigorous approaches. As the QRG expanded its expertise it sought to develop innovative approaches, including the use of visual [ 11 ] and ethnographic methods [ 12 ].

Understanding implementation—Normalisation Process Theory (NPT)

Normalisation Process Theory (NPT) provides a model with which to understand the implementation of new sets of practices and their normalisation within organisational settings. The term ‘normalisation’ refers to how new practices become routinised (part of the everyday work of an organisation) through embedding and integration [ 13 , 14 ]. NPT defines implementation as ‘the social organisation of work’ and is concerned with the social processes that take place as new practices are introduced. Embedding involves ‘making practices routine elements of everyday life’ within an organisation. Integration takes the form of ‘sustaining embedded practices in social contexts’, and how these processes lead to the practices becoming (or not becoming) ‘normal and routine’ [ 14 ]. NPT is concerned with the factors which promote or ‘inhibit’ attempts to embed and integrate the operationalisation of new practices [ 13 , 14 , 15 ].

Embedding new practices is therefore achieved through implementation—which takes the form of interactions in specific contexts. Implementation is operationalised through four ‘generative mechanisms’— coherence , cognitive participation , collective action and reflexive monitoring [ 14 ]. Each mechanism is characterised by components comprising immediate and organisational work, with actions of individuals and organisations (or groups of individuals) interdependent. The mechanisms operate partly through forms of investment (i.e. meaning, commitment, effort, and comprehension) [ 14 ].

Coherence refers to how individuals/groups make sense of, and give meaning to, new practices. Sense-making concerns the coherence of a practice—whether it ‘holds together’, and its differentiation from existing activities [ 15 ]. Communal and individual specification involve understanding new practices and their potential benefits for oneself or an organisation. Individuals consider what new practices mean for them in terms of tasks and responsibilities ( internalisation ) [ 14 ].

NPT frames the second mechanism, cognitive participation , as the building of a ‘community of practice’. For a new practice to be initiated, individuals and groups within an organisation must commit to it [ 14 , 15 ]. Cognitive participation occurs through enrolment —how people relate to the new practice; legitimation —the belief that it is right for them to be involved; and activation —defining which actions are necessary to sustain the practice and their involvement [ 14 ]. Making the new practices work may require changes to roles (new responsibilities, altered procedures) and reconfiguring how colleagues work together (changed relationships).

Third, Collective Action refers to ‘the operational work that people do to enact a set of practices’ [ 14 ]. Individuals engage with the new practices ( interactional workability ) reshaping how members of an organisation interact with each other, through creation of new roles and expectations ( relational interaction ) [ 15 ]. Skill set workability concerns how the work of implementing a new set of practices is distributed and the necessary roles and skillsets defined [ 14 ]. Contextual integration draws attention to the incorporation of a practice within social contexts, and the potential for aspects of these contexts, such as systems and procedures, to be modified as a result [ 15 ].

Reflexive monitoring is the final implementation mechanism. Collective and individual appraisal evaluate the value of a set of practices, which depends on the collection of information—formally and informally ( systematisation ). Appraisal may lead to reconfiguration in which procedures of the practice are redefined or reshaped [ 14 , 15 ].

We sought to map the following: (1) the strategies used to embed qualitative research within the Centre, (2) key facilitators, and (3) barriers to their implementation. Through focused group discussions during the monthly meetings of the CTR QRG and in discussion with the CTR senior management team throughout 2019–2020 we identified nine types of documents (22 individual documents in total) produced within the CTR which had relevant information about the integration of qualitative research within its work (Table  1 ). The QRG had an ‘open door’ policy to membership and welcomed all staff/students with an interest in qualitative research. It included researchers who were employed specifically to undertake qualitative research and other staff with a range of study roles, including trial managers, statisticians, and data managers. There was also diversity in terms of career stage, including PhD students, mid-career researchers and members of the Centre’s Executive team. Membership was therefore largely self-selected, and comprised of individuals with a role related to, or an interest in, embedding qualitative research within trials. However, the group brought together diverse methodological perspectives and was not solely comprised of methodological ‘champions’ whose job it was to promote the development of qualitative research within the centre. Thus whilst the group (and by extension, the authors of this paper) had a shared appreciation of the value of qualitative research within a trials centre, they also brought varied methodological perspectives and ways of engaging with it.

All members of the QRG ( n  = 26) were invited to take part in a face-to-face, day-long workshop in February 2019 on ‘How to optimise and operationalise qualitative research in trials: reflections on CTR structure’. The workshop was attended by 12 members of staff and PhD students, including members of the QRG and the CTR’s senior management team. Recruitment to the workshop was therefore inclusive, and to some extent opportunistic, but all members of the QRG were able to contribute to discussions during regular monthly group meetings and the drafting of the current paper.

The aim of the workshop was to bring together information from the documents in Table  1 to generate discussion around the key strategies (and their component activities) that had been adopted to integrate qualitative research into CTR, as well as barriers to, and facilitators of, their implementation. The agenda for the workshop involved four key areas: development and history of the CTR model; mapping the current model within CTR; discussing the structure of other CTUs; and exploring the advantages and disadvantages of the CTR model.

During the workshop, we discussed the use of NPT to conceptualise how qualitative research had been embedded within CTR’s systems and practices. The group produced spider diagrams to map strategies and actions on to the four key domains (or ‘generative mechanisms’ of NPT) summarised above, to aid the understanding of how they had functioned, and the utility of NPT as a framework. This is summarised in Table  2 .

Detailed notes were made during the workshop. A core writing group then used these notes and the documents in Table  1 to develop a draft of the current paper. This was circulated to all members of the CTR QRG ( n  = 26) and stored within a central repository accessible to them to allow involvement and incorporate the views of those who were not able to attend the workshop. This draft was again presented for comments in the monthly CTR QRG meeting in February 2021 attended by n  = 10. The Standards for QUality Improvement Reporting Excellence 2.0 (SQUIRE) guidelines were used to inform the structure and content of the paper (see supplementary material) [ 16 ].

In the following sections, we describe the strategies CTR adopted to integrate qualitative research. These are mapped against NPT’s four generative mechanisms to explore the processes through which the strategies promoted integration, and facilitators of and barriers to their implementation. A summary of the strategies and their functioning in terms of the generative mechanisms is provided in Table  2 .

Coherence—making sense of qualitative research

In CTR, many of the actions taken to build a portfolio of qualitative research were aimed at enabling colleagues, and external actors, to make sense of this set of methodologies. Centre-level strategies and grant applications for infrastructure funding highlighted the value of qualitative research, the added benefits it would bring, and positioned it as a legitimate set of practices alongside existing methods. For example, a 2014 application for renewal of trials unit infrastructure funding stated:

We are currently in the process of undertaking […] restructuring for our qualitative research team and are planning similar for trial management next year. The aim of this restructuring is to establish greater hierarchical management and opportunities for staff development and also provide a structure that can accommodate continuing growth.

Within the CTR, various forms of communication on the development of qualitative research were designed to enable staff and students to make sense of it, and to think through its potential value for them, and ways in which they might engage with it. These included presentations at staff meetings, informal meetings between project teams and the qualitative group lead, and the visibility of qualitative research on the public-facing Centre website and Centre committees and systems. For instance, qualitative methods were included (and framed as a distinct set of practices) within study adoption forms and committee agendas. Information for colleagues described how qualitative methods could be incorporated within funding applications for RCTs and other evaluation studies to generate new insights into questions research teams were already keen to answer, such as influences on intervention implementation fidelity. Where externally based chief investigators approached the Centre to be involved in new grant applications, the existence of the qualitative team and group lead enabled the inclusion of qualitative research to be actively promoted at an early stage, and such opportunities were highlighted in the Centre’s brochure for new collaborators. Monthly qualitative research network meetings—advertised across CTR and to external research collaborators, were also designed to create a shared understanding of qualitative research methods and their utility within trials and other study types (e.g. intervention development, feasibility studies, and observational studies). Training events (discussed in more detail below) also aided sense-making.

Several factors facilitated the promotion of qualitative research as a distinctive and valuable entity. Among these was the influence of the broader methodological landscape within trial design which was promoting the value of qualitative research, such as guidance on the evaluation of complex interventions by the Medical Research Council [ 17 ], and the growing emphasis placed on process evaluations within trials (with qualitative methods important in understanding participant experience and influences on implementation) [ 5 ]. The attention given to lived experience (both through process evaluations and the move to embed public involvement in trials) helped to frame qualitative research within the Centre as something that was appropriate, legitimate, and of value. Recognition by research funders of the value of qualitative research within studies was also helpful in normalising and legitimising its adoption within grant applications.

The inclusion of qualitative methods within influential methodological guidance helped CTR researchers to develop a ‘shared language’ around these methods, and a way that a common understanding of the role of qualitative research could be generated. One barrier to such sense-making work was the varying extent to which staff and teams had existing knowledge or experience of qualitative research. This varied across methodological and subject groups within the Centre and reflected the history of the individual trials units which had merged to form the Centre.

Cognitive participation—legitimising qualitative research

Senior CTR leaders promoted the value and legitimacy of qualitative research. Its inclusion in centre strategies, infrastructure funding applications, and in public-facing materials (e.g. website, investigator brochures), signalled that it was appropriate for individuals to conduct qualitative research within their roles, or to support others in doing so. Legitimisation also took place through informal channels, such as senior leadership support for qualitative research methods in staff meetings and participation in QRG seminars. Continued development of the QRG (with dedicated infrastructure funding) provided a visible identity and equivalence with other methodological groups (e.g. trial managers, statisticians).

Staff were asked to engage with qualitative research in two main ways. First, there was an expansion in the number of staff for whom qualitative research formed part of their formal role and responsibilities. One of the three trials units that merged to form CTR brought with it a qualitative team comprising methodological specialists and a group lead. CTR continued the expansion of this group with the creation of new roles and an enlarged nucleus of researchers for whom qualitative research was the sole focus of their work. In part, this was linked to the successful award of projects that included a large qualitative component, and that were coordinated by CTR (see Table  3 which describes the PUMA study).

Members of the QRG were encouraged to develop their own research ideas and to gain experience as principal investigators, and group seminars were used to explore new ideas and provide peer support. This was communicated through line management, appraisal, and informal peer interaction. Boundaries were not strictly demarcated (i.e. staff located outside the qualitative team were already using qualitative methods), but the new team became a central focus for developing a growing programme of work.

Second, individuals and studies were called upon to engage in new ways with qualitative research, and with the qualitative team. A key goal for the Centre was that groups developing new research ideas should give more consideration in general to the potential value and inclusion of qualitative research within their funding applications. Specifically, they were asked to do this by thinking about qualitative research at an early point in their application’s development (rather than ‘bolting it on’ after other elements had been designed) and to draw upon the expertise and input of the qualitative team. An example was the inclusion of questions on qualitative methods within the Centre’s study adoption form and representation from the qualitative team at the committee which reviewed new adoption requests. Where adoption requests indicated the inclusion of qualitative methods, colleagues were encouraged to liaise with the qualitative team, facilitating the integration of its expertise from an early stage. Qualitative seminars offered an informal and supportive space in which researchers could share initial ideas and refine their methodological approach. The benefits of this included the provision of sufficient time for methodological specialists to be involved in the design of the proposed qualitative component and ensuring adequate costings had been drawn up. At study adoption group meetings, scrutiny of new proposals included consideration of whether new research proposals might be strengthened through the use of qualitative methods where these had not initially been included. Meetings of the QRG—which reviewed the Centre’s portfolio of new studies and gathered intelligence on new ideas—also helped to identify, early on, opportunities to integrate qualitative methods. Communication across teams was useful in identifying new research ideas and embedding qualitative researchers within emerging study development groups.

Actions to promote greater use of qualitative methods in funding applications fed through into a growing number of studies with a qualitative component. This helped to increase the visibility and legitimacy of qualitative methods within the Centre. For example, the PUMA study [ 12 ], which brought together a large multidisciplinary team to develop and evaluate a Paediatric early warning system, drew heavily on qualitative methods, with the qualitative research located within the QRG. The project introduced an extensive network of collaborators and clinical colleagues to qualitative methods and how they could be used during intervention development and the generation of case studies. Further information about the PUMA study is provided in Table  3 .

Increasing the legitimacy of qualitative work across an extensive network of staff, students and collaborators was a complex process. Set within the continuing dominance of quantitative methods with clinical trials, there were variations in the extent to which clinicians and other collaborators embraced the value of qualitative methods. Research funding schemes, which often continued to emphasise the quantitative element of randomised controlled trials, inevitably fed through into the focus of new research proposals. Staff and external collaborators were sometimes uncertain about the added value that qualitative methods would bring to their trials. Across the CTR there were variations in the speed at which qualitative research methods gained legitimacy, partly based on disciplinary traditions and their influences. For instance, population health trials, often located within non-health settings such as schools or community settings, frequently involved collaboration with social scientists who brought with them experience in qualitative methods. Methodological guidance in this field, such as MRC guidance on process evaluations, highlighted the value of qualitative methods and alternatives to the positivist paradigm, such as the value of realist RCTs. In other, more clinical areas, positivist paradigms had greater dominance. Established practices and methodological traditions across different funders also influenced the ease of obtaining funding to include qualitative research within studies. For drugs trials (CTIMPs), the influence of regulatory frameworks on study design, data collection and the allocation of staff resources may have played a role. Over time, teams gained repeated experience of embedding qualitative research (and researchers) within their work and took this learning with them to subsequent studies. For example, the senior clinician quoted within the PUMA case study (Table  3 below) described how they had gained an appreciation of the rigour of qualitative research and an understanding of its language. Through these repeated interactions, embedding of qualitative research within studies started to become the norm rather than the exception.

Collective action—operationalising qualitative research

Collective action concerns the operationalisation of new practices within organisations—the allocation and management of the work, how individuals interact with each other, and the work itself. In CTR the formation of a Qualitative Research Group helped to allocate and organise the work of building a portfolio of studies. Researchers across the Centre were called upon to interact with qualitative research in new ways. Presentations at staff meetings and the inclusion of qualitative research methods in portfolio study adoption forms were examples of this ( interactive workability ). It was operationalised by encouraging study teams to liaise with the qualitative research lead. Development of standard operating procedures, templates for costing qualitative research and methodological guidance (e.g. on analysis plans) also helped encourage researchers to interact with these methods in new ways. For some qualitative researchers who had been trained in the social sciences, working within a trials unit meant that they needed to interact in new and sometimes unfamiliar ways with standard operating procedures, risk assessments, and other trial-based systems. Thus, training needs and capacity-building efforts were multidirectional.

Whereas there had been a tendency for qualitative research to be ‘bolted on’ to proposals for RCTs, the systems described above were designed to embed thinking about the value and design of the qualitative component from the outset. They were also intended to integrate members of the qualitative team with trial teams from an early stage to promote effective integration of qualitative methods within larger trials and build relationships over time.

Standard Operating Procedures (SOPs), formal and informal training, and interaction between the qualitative team and other researchers increased the relational workability of qualitative methods within the Centre—the confidence individuals felt in including these methods within their studies, and their accountability for doing so. For instance, study adoption forms prompted researchers to interact routinely with the qualitative team at an early stage, whilst guidance on costing grants provided clear expectations about the resources needed to deliver a proposed set of qualitative data collection.

Formation of the Qualitative Research Group—comprised of methodological specialists, created new roles and skillsets ( skill set workability ). Research teams were encouraged to draw on these when writing funding applications for projects that included a qualitative component. Capacity-building initiatives were used to increase the number of researchers with the skills needed to undertake qualitative research, and for these individuals to develop their expertise over time. This was achieved through formal training courses, academic seminars, mentoring from experienced colleagues, and informal knowledge exchange. Links with external collaborators and centres engaged in building qualitative research supported these efforts. Within the Centre, the co-location of qualitative researchers with other methodological and trial teams facilitated knowledge exchange and building of collaborative relationships, whilst grouping of the qualitative team within a dedicated office space supported a collective identity and opportunities for informal peer support.

Some aspects of the context in which qualitative research was being developed created challenges to operationalisation. Dependence on project grants to fund qualitative methodologists meant that there was a continuing need to write further grant applications whilst limiting the amount of time available to do so. Similarly, researchers within the team whose role was funded largely by specific research projects could sometimes find it hard to create sufficient time to develop their personal methodological interests. However, the cultivation of a methodologically varied portfolio of work enabled members of the team to build significant expertise in different approaches (e.g. ethnography, discourse analysis) that connected individual studies.

Reflexive monitoring—evaluating the impact of qualitative research

Inclusion of questions/fields relating to qualitative research within the Centre’s study portfolio database was a key way in which information was collected ( systematisation ). It captured numbers of funding applications and funded studies, research design, and income generation. Alongside this database, a qualitative resource planner spreadsheet was used to link individual members of the qualitative team with projects and facilitate resource planning, further reinforcing the core responsibilities and roles of qualitative researchers within CTR. As with all staff in the Centre, members of the qualitative team were placed on ongoing rather than fixed-term contracts, reflecting their core role within CTR. Planning and strategy meetings used the database and resource planner to assess the integration of qualitative research within Centre research, identify opportunities for increasing involvement, and manage staff recruitment and sustainability of researcher posts. Academic meetings and day-to-day interaction fulfilled informal appraisal of the development of the group, and its position within the Centre. Individual appraisal was also important, with members of the qualitative team given opportunities to shape their role, reflect on progress, identify training needs, and further develop their skillset, particularly through line management systems.

These forms of systematisation and appraisal were used to reconfigure the development of qualitative research and its integration within the Centre. For example, group strategies considered how to achieve long-term integration of qualitative research from its initial embedding through further promoting the belief that it formed a core part of the Centre’s business. The visibility and legitimacy of qualitative research were promoted through initiatives such as greater prominence on the Centre’s website. Ongoing review of the qualitative portfolio and discussion at academic meetings enabled the identification of areas where increased capacity would be helpful, both for qualitative staff, and more broadly within the Centre. This prompted the qualitative group to develop an introductory course to qualitative methods open to all Centre staff and PhD students, aimed at increasing understanding and awareness. As the qualitative team built its expertise and experience it also sought to develop new and innovative approaches to conducting qualitative research. This included the use of visual and diary-based methods [ 11 ] and the adoption of ethnography to evaluate system-level clinical interventions [ 12 ]. Restrictions on conventional face-to-face qualitative data collection due to the COVID-19 pandemic prompted rapid adoption of virtual/online methods for interviews, observation, and use of new internet platforms such as Padlet—a form of digital note board.

In this paper, we have described the work undertaken by one CTU to integrate qualitative research within its studies and organisational culture. The parallel efforts of many trials units to achieve these goals arguably come at an opportune time. The traditional designs of RCTs have been challenged and re-imagined by the increasing influence of realist evaluation [ 6 , 18 ] and the widespread acceptance that trials need to understand implementation and intervention theory as well as assess outcomes [ 17 ]. Hence the widespread adoption of embedded mixed methods process evaluations within RCTs. These broad shifts in methodological orthodoxies, the production of high-profile methodological guidance, and the expectations of research funders all create fertile ground for the continued expansion of qualitative methods within trials units. However, whilst much has been written about the importance of developing qualitative research and the possible approaches to integrating qualitative and quantitative methods within studies, much less has been published on how to operationalise this within trials units. Filling this lacuna is important. Our paper highlights how the integration of a new set of practices within an organisation can become embedded as part of its ‘normal’ everyday work whilst also shaping the practices being integrated. In the case of CTR, it could be argued that the integration of qualitative research helped shape how this work was done (e.g. systems to assess progress and innovation).

In our trials unit, the presence of a dedicated research group of methodological specialists was a key action that helped realise the development of a portfolio of qualitative research and was perhaps the most visible evidence of a commitment to do so. However, our experience demonstrates that to fully realise the goal of developing qualitative research, much work focuses on the interaction between this ‘new’ set of methods and the organisation into which it is introduced. Whilst the team of methodological specialists was tasked with, and ‘able’ to do the work, the ‘work’ itself needed to be integrated and embedded within the existing system. Thus, alongside the creation of a team and methodological capacity, promoting the legitimacy of qualitative research was important to communicate to others that it was both a distinctive and different entity, yet similar and equivalent to more established groups and practices (e.g. trial management, statistics, data management). The framing of qualitative research within strategies, the messages given out by senior leaders (formally and informally) and the general visibility of qualitative research within the system all helped to achieve this.

Normalisation Process Theory draws our attention to the concepts of embedding (making a new practice routine, normal within an organisation) and integration —the long-term sustaining of these processes. An important process through which embedding took place in our centre concerned the creation of messages and systems that called upon individuals and research teams to interact with qualitative research. Research teams were encouraged to think about qualitative research and consider its potential value for their studies. Critically, they were asked to do so at specific points, and in particular ways. Early consideration of qualitative methods to maximise and optimise their inclusion within studies was emphasised, with timely input from the qualitative team. Study adoption systems, centre-level processes for managing financial and human resources, creation of a qualitative resource planner, and awareness raising among staff, helped to reinforce this. These processes of embedding and integration were complex and they varied in intensity and speed across different areas of the Centre’s work. In part this depended on existing research traditions, the extent of prior experience of working with qualitative researchers and methods, and the priorities of subject areas and funders. Centre-wide systems, sometimes linked to CTR’s operation as a CTU, also helped to legitimise and embed qualitative research, lending it equivalence with other research activity. For example, like all CTUs, CTR was required to conform with the principles of Good Clinical Practice, necessitating the creation of a quality management system, operationalised through standard operating procedures for all areas of its work. Qualitative research was included, and became embedded, within these systems, with SOPs produced to guide activities such as qualitative analysis.

NPT provides a helpful way of understanding how trials units might integrate qualitative research within their work. It highlights how new practices interact with existing organisational systems and the work needed to promote effective interaction. That is, alongside the creation of a team or programme of qualitative research, much of the work concerns how members of an organisation understand it, engage with it, and create systems to sustain it. Embedding a new set of practices may be just as important as the quality or characteristics of the practices themselves. High-quality qualitative research is of little value if it is not recognised and drawn upon within new studies for instance. NPT also offers a helpful lens with which to understand how integration and embedding occur, and the mechanisms through which they operate. For example, promoting the legitimacy of a new set of practices, or creating systems that embed it, can help sustain these practices by creating an organisational ambition and encouraging (or requiring) individuals to interact with them in certain ways, redefining their roles accordingly. NPT highlights the ways in which integration of new practices involves bi-directional exchanges with the organisation’s existing practices, with each having the potential to re-shape the other as interaction takes place. For instance, in CTR, qualitative researchers needed to integrate and apply their methods within the quality management and other systems of a CTU, such as the formalisation of key processes within standard operating procedures, something less likely to occur outside trials units. Equally, project teams (including those led by externally based chief investigators) increased the integration of qualitative methods within their overall study design, providing opportunities for new insights on intervention theory, implementation and the experiences of practitioners and participants.

We note two aspects of the normalisation processes within CTR that are slightly less well conceptualised by NPT. The first concerns the emphasis within coherence on identifying the distinctiveness of new practices, and how they differ from existing activities. Whilst differentiation was an important aspect of the integration of qualitative research in CTR, such integration could be seen as operating partly through processes of de-differentiation, or at least equivalence. That is, part of the integration of qualitative research was to see it as similar in terms of rigour, coherence, and importance to other forms of research within the Centre. To be viewed as similar, or at least comparable to existing practices, was to be legitimised.

Second, whilst NPT focuses mainly on the interaction between a new set of practices and the organisational context into which it is introduced, our own experience of introducing qualitative research into a trials unit was shaped by broader organisational and methodological contexts. For example, the increasing emphasis placed upon understanding implementation processes and the experiences of research participants in the field of clinical trials (e.g. by funders), created an environment conducive to the development of qualitative research methods within our Centre. Attempts to integrate qualitative research within studies were also cross-organisational, given that many of the studies managed within the CTR drew together multi-institutional teams. This provided important opportunities to integrate qualitative research within a portfolio of studies that extended beyond CTR and build a network of collaborators who increasingly included qualitative methods within their funding proposals. The work of growing and integrating qualitative research within a trials unit is an ongoing one in which ever-shifting macro-level influences can help or hinder, and where the organisations within which we work are never static in terms of barriers and facilitators.

The importance of utilising qualitative methods within RCTs is now widely recognised. Increased emphasis on the evaluation of complex interventions, the influence of realist methods directing greater attention to complexity and the widespread adoption of mixed methods process evaluations are key drivers of this shift. The inclusion of qualitative methods within individual trials is important and previous research has explored approaches to their incorporation and some of the challenges encountered. Our paper highlights that the integration of qualitative methods at the organisational level of the CTU can shape how they are taken up by individual trials. Within CTR, it can be argued that qualitative research achieved high levels of integration, as conceptualised by Normalisation Process Theory. Thus, qualitative research became recognised as a coherent and valuable set of practices, secured legitimisation as an appropriate focus of individual and organisational activity and benefitted from forms of collective action which operationalised these organisational processes. Crucially, the routinisation of qualitative research appeared to be sustained, something which NPT suggests helps define integration (as opposed to initial embedding). However, our analysis suggested that the degree of integration varied by trial area. This variation reflected a complex mix of factors including disciplinary traditions, methodological guidance, existing (un)familiarity with qualitative research, and the influence of regulatory frameworks for certain clinical trials.

NPT provides a valuable framework with which to understand how these processes of embedding and integration occur. Our use of NPT draws attention to the importance of sense-making and legitimisation as important steps in introducing a new set of practices within the work of an organisation. Integration also depends, across each mechanism of NPT, on the building of effective relationships, which allow individuals and teams to work together in new ways. By reflecting on our experiences and the decisions taken within CTR we have made explicit one such process for embedding qualitative research within a trials unit, whilst acknowledging that approaches may differ across trials units. Mindful of this fact, and the focus of the current paper on one trials unit’s experience, we do not propose a set of recommendations for others who are working to achieve similar goals. Rather, we offer three overarching reflections (framed by NPT) which may act as a useful starting point for trials units (and other infrastructures) seeking to promote the adoption of qualitative research.

First, whilst research organisations such as trials units are highly heterogenous, processes of embedding and integration, which we have foregrounded in this paper, are likely to be important across different contexts in sustaining the use of qualitative research. Second, developing a plan for the integration of qualitative research will benefit from mapping out the characteristics of the extant system. For example, it is valuable to know how familiar staff are with qualitative research and any variations across teams within an organisation. Thirdly, NPT frames integration as a process of implementation which operates through key generative mechanisms— coherence , cognitive participation , collective action and reflexive monitoring . These mechanisms can help guide understanding of which actions help achieve embedding and integration. Importantly, they span multiple aspects of how organisations, and the individuals within them, work. The ways in which people make sense of a new set of practices ( coherence ), their commitment towards it ( cognitive participation ), how it is operationalised ( collective action ) and the evaluation of its introduction ( reflexive monitoring ) are all important. Thus, for example, qualitative research, even when well organised and operationalised within an organisation, is unlikely to be sustained if appreciation of its value is limited, or people are not committed to it.

We present our experience of engaging with the processes described above to open dialogue with other trials units on ways to operationalise and optimise qualitative research in trials. Understanding how best to integrate qualitative research within these settings may help to fully realise the significant contribution which it makes the design and conduct of trials.

Availability of data and materials

Some documents cited in this paper are either freely available from the Centre for Trials Research website or can be requested from the author for correspondence.

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Acknowledgements

Members of the Centre for Trials Research (CTR) Qualitative Research Group were collaborating authors: C Drew (Senior Research Fellow—Senior Trial Manager, Brain Health and Mental Wellbeing Division), D Gillespie (Director, Infection, Inflammation and Immunity Trials, Principal Research Fellow), R Hale (now Research Associate, School of Social Sciences, Cardiff University), J Latchem-Hastings (now Lecturer and Postdoctoral Fellow, School of Healthcare Sciences, Cardiff University), R Milton (Research Associate—Trial Manager), B Pell (now PhD student, DECIPHer Centre, Cardiff University), H Prout (Research Associate—Qualitative), V Shepherd (Senior Research Fellow), K Smallman (Research Associate), H Stanton (Research Associate—Senior Data Manager). Thanks are due to Kerry Hood and Aimee Grant for their involvement in developing processes and systems for qualitative research within CTR.

No specific grant was received to support the writing of this paper.

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Segrott, J., Channon, S., Lloyd, A. et al. Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts. Trials 25 , 323 (2024). https://doi.org/10.1186/s13063-024-08124-7

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“I do not know the advantages of having a general practitioner” - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care

• Lisa Kümpel   ORCID: orcid.org/0000-0003-3214-6189 1 ,
• Sarah Oslislo 1 ,
• Rebecca Resendiz Cantu 2 ,
• Martin Möckel   ORCID: orcid.org/0000-0002-7691-3709 2 ,
• Christoph Heintze   ORCID: orcid.org/0000-0002-2179-8192 1 &
• Felix Holzinger   ORCID: orcid.org/0000-0002-8400-7757 1  

BMC Health Services Research volume  24 , Article number:  629 ( 2024 ) Cite this article

Metrics details

Emergency departments (ED) worldwide have to cope with rising patient numbers. Low-acuity consulters who could receive a more suitable treatment in primary care (PC) increase caseloads, and lack of PC attachment has been discussed as a determinant. This qualitative study explores factors that contribute to non-utilization of general practitioner (GP) care among patients with no current attachment to a GP.

Qualitative semi-structured telephone interviews were conducted with 32 low-acuity ED consulters with no self-reported attachment to a GP. Participants were recruited from three EDs in the city center of Berlin, Germany. Data were analyzed by qualitative content analysis.

Interviewed patients reported heterogeneous factors contributing to their PC utilization behavior and underlying views and experiences. Participants most prominently voiced a rare need for medical services, a distinct mobility behavior, and a lack of knowledge about the role of a GP and health care options. Views about and experiences with GP care that contribute to non-utilization were predominantly related to little confidence in GP care, preference for directly consulting medical specialists, and negative experiences with GP care in the past. Contrasting their reported utilization behavior, many interviewees still recognized the advantages of GP care continuity.

Understanding reasons of low-acuity ED patients for GP non-utilization can play an important role in the design and implementation of patient-centered care interventions for PC integration. Increasing GP utilization, continuity of care and health literacy might have positive effects on patient decision-making in acute situations and in turn decrease ED burden.

Trial registration

German Clinical Trials Register: DRKS00023480; date: 2020/11/27.

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Many countries record rising numbers of patients in emergency departments (ED) [ 1 , 2 ]. A substantial share of these ED consulters present with low-acuity care needs and could potentially receive a more suitable treatment in primary care (PC) [ 3 , 4 ]. Concerning these cases, achieving a shift toward a more appropriate use of general practitioner (GP) care could benefit not only the patients concerned but also the entire ED care system, as crowded EDs are associated with poorer quality of care [ 5 ].

The use of ED care for low-acuity complaints is influenced by multiple factors. Among others, a lack of knowledge about alternative acute care options was identified [ 6 , 7 ] and attributed to a lack of health literacy [ 8 , 9 ]. There is evidence that lower levels of heath literacy are associated with higher subjectively perceived treatment urgency [ 9 ]. In this context, GP care has been advocated not only as an adequate alternative treatment option for low-acuity health issues but also as an important source of health information and facilitator for care coordination, helping patients navigate in the sometimes complex structures of the health care system [ 10 , 11 ]. Consequently, it is assumed that patients with no continuous GP attachment are more likely to visit the ED for low-acuity care needs [ 12 ]. Integrating GP care by reducing access barriers could reduce demand for ED services by both providing a fixed first point of contact and promoting continuity of care, which in turn facilitates the management of long-term health care needs [ 13 , 14 , 15 , 16 ].

With regard to these findings, it is problematic that every tenth person in Germany has no GP [ 17 ]. In our health care system, there is no obligation to register for GP care at a practice and attachment is completely voluntary. Patients are free to choose or change providers anytime, and anyone can likewise visit the ED at own discretion without following any gatekeeping procedure [ 18 ]. Having the current absence of regulations and patient steering in mind, it is important to explore the roots of lacking PC integration. This is a prerequisite for the development of concepts to promote attachment and thus to potentially influence future ED utilization behavior [ 19 ]. Accordingly, our research questions for this qualitative interview study of ED patients without current attachment to a GP were as follows: What factors are associated with their health care utilization behavior and non-utilization of GP care? Which views and previous experiences of GP care could contribute to GP non-utilization and lack of attachment?

EMAPREPARE study

This qualitative evaluation was conducted as part of the multicenter mixed-methods study EMAPREPARE (Emergency and Acute Medicine– Primary Care Demands in Patients Resorting to Emergency Departments), which is a subproject of the research network EMANet (Emergency and Acute Medicine Network for Health Care Research Berlin). EMAPREPARE explores the redirection potential of low-acuity ED patients without a GP. The project includes a pilot intervention and complementary qualitative interviews. The results and implications of the intervention have been reported in a previous publication [ 20 ]. Our paper presents findings on participants’ views and experiences of GP care from the qualitative interview study accompanying the intervention. The core team of researchers for this project consisted of L.K. and S.O. (female health scientists), F.H. and C.H. (male general practitioners and senior researchers), and R.R.C. (female ED physician). The EMAPREPARE study was registered a priori in the German Clinical Trials Register (trial registration number: DRKS00023480, registration date 27/11/2020) [ 21 ]. Qualitative data are reported in this article according to the COREQ guidelines (Additional file 2 ) [ 22 ].

Participants

Interviewees were selected as a subsample of the EMAPREPARE cohort. Recruitment was conducted in three inner city EDs in Berlin, including two university medical centers. Patients were recruited in the ED waiting room, informed about the project’s aims, and asked for written informed consent to participate in the study and an optional qualitative interview. Consent included audio recording, storage and pseudonymized analysis of the interview material. The EMAPREPARE inclusion criteria needed participants to be of age (≥ 18 years) and fluent in German. Patients also had to be self-referred walk-in outpatient cases, triaged in the Manchester Triage System (MTS) lower priority categories 3–5 [ 23 ]. A further eligibility prerequisite was that patients did not have a regular GP, meaning no current self-reported attachment to a particular practice, or regular recent visits. Patients were excluded if they were not able to formally give informed consent. Researchers had no relationship with the participants prior to the study. The patients’ reasons for refusing to participate in the study were not recorded.

Recruitment for the interviews was based on the principle of purposive sampling [ 24 ]. We tried to balance gender and intentionally over-represented participants willing to make use of the GP appointment service, which was part of the pilot intervention. Further information on sampling details can be found in a previous paper [ 20 ]. Patients who consented to a qualitative interview were called after ED discharge to schedule an interview appointment within two weeks after ED presentation to facilitate recall.

Data collection

A semi-structured interview guide based on the literature was compiled with the intention to capture and understand patients’ views and experiences [ 25 ]. The questions were thoroughly discussed within the study team and in an interdisciplinary methods working group at the institute, and pilot tested in two interviews. After the first two interviews, the guide was revised further. The final interview guide consisted of three parts (see Additional file 1 for complete interview guide). The results presented here correspond to the first part of the interview guide, which addressed patients’ experiences and views about GP care (see Table  1 ), while parts two and three covered participants’ views on the EMAPREPARE intervention, with results reported elsewhere [ 20 ]. During the interviews, questions were individually adapted to the conversation flow.

Interviews were carried out between March 2021 and January 2022 by L.K. and S.O. by telephone (to avoid COVID-19 infection risk) and were concluded after thirty-two interviews once no more new themes emerged, indicating content saturation [ 26 ]. The interviewees did not receive any questions in advance, and interviews were conducted only once with each patient. Interviews were audio-recorded, and field notes were taken to document additional impressions or specifics of interview circumstances. Recordings were then transcribed verbatim and pseudonymized by L.K. and S.O., the transcripts were not returned to the patients for corrections and/or comments.

Data analysis

The transcripts of the interviews were analyzed by qualitative content analysis according to Mayring using a combined deductive and inductive approach for coding text segments. This interpretative but rule-guided process is based on coding guidelines. The method allows focusing on essential interview topics and facilitates thematic structuring and summarizing of the content [ 27 ]. Due to the exploratory nature of the study, no pre-existing framework was used to guide analysis. The first draft of the coding tree was based on the themes of the interview guide, and additional themes were then inductively derived from the material during coding. This allowed for consideration of both theoretical aspects and interview content. All derived codes had defined coding rules and anchor examples. Transcription, coding, and data analysis were performed in MAXQDA 2020. The majority of interviews were independently coded by two scientists (L.K. and S.O., experienced in qualitative research) to enable comparison and discussion of discrepancies. As interviews were conducted in German, quotes were translated to English by the authors for presentation in this paper.

Sample characteristics

Thirty-two interviews were conducted. An overview of the participants’ characteristics is given in Table  2 . The interviews had a mean duration of 20 min.

After categorizing the interview data, diverse factors contributing to the non-utilization of GP care emerged. These factors were in turn associated with thematic categories related to patient characteristics and underlying views and experiences with past GP care (see Table  3 ). In the following, these thematic categories are presented in detail with exemplary interview quotes.

Patient characteristics related to non-utilization of GP care

Rare need for medical care.

With regard to the reasons for the low relevance of GP care for their individual care context, interviewees most prominently described a rare need for regular medical care in the past due to their good state of health.

“There is no doctor I have consulted more than five times, except for my gynecologist.” (P23). “So, I have not really been ill until now and therefore I do not have a GP I regularly visit.” (P20).

Distinct mobility behavior

Apart from the rare need for regular medical care, many patients attributed the lack of continuity in their GP utilization patterns to attachment difficulties rooted in their individual mobility patterns.

“Before I came to Germany, I had a GP, but since I moved, I no longer have a GP.” (P28). “I have simply moved too often. Quite often within Berlin, in different cities, abroad.” (P1). “My parents still have the same GP that I had as a child. That has changed in modern times because people are much more mobile and move around more often. You no longer stay in one place for twenty to thirty years and have all your doctors in the neighborhood for your whole life.” (P18).

Due to circumstances such as the aforementioned infrequent need for medical care and distinct mobility behavior, many participants depicted a rather situational consultation pattern with sporadic visits to various physicians based on short-term needs. In this context, a personal relationship and continuous attachment to a specific GP practice were frequently described as less relevant than solving acute health problems by consulting a doctor selected on an as-needed basis.

“There is a GP practice where I go when something comes up. However, I do not consider this my GP of choice.” (P26). “Otherwise, I just do not have any relationship [to a GP] at all because I always just sat down in the acute consultation of some doctor. I described the problem and was treated once-off.” (P25). “As I said, I do not really have a GP in the true sense. I have been to GPs here and there, depending on which district I was living in at the time, and whether it was an urgent matter or not” (P18).

Lack of knowledge about the role of a GP and health care options

Many of the interviewed patients reported a self-perceived lack of knowledge about the responsibility of a GP.

“I do not truly understand [what a GP does], I am of course familiar with the word though.” (P1). “I do not know the advantages of having a GP. That is why I never truly thought about it.” (P26). “It is probably good to have an overview of the types of occasions for which people go to the GP. […] because it is not at all clear to me, actually.” (P11).

Some interviewees explicitly mentioned this lack of knowledge about GP care as a factor that made it difficult for them to navigate the care system and find the right doctor for their specific health problems.

“Then it is difficult for me to say, if I have an issue with my ears, whether I should go straight to an ear, nose and throat specialist, or whether I should go to the GP first.” (P13). “And it is not so clear to me now to what extent the tasks of the GP overlap or differ from the tasks of the respective specialists to whom I have turned thus far. If I were aware of what a GP actually does differently and how this could be of use to me, then I naturally would be open to it.” (P2).

In this context, one patient with a migration history depicted his limited understanding of German health care structures and the role of the GP within the system.

“Because I cannot understand the health system in Germany. It is very different from my country and completely ineffective. In my country you automatically have a GP. Everyone has.” (P28).

Views about and experiences with previous GP care

Little confidence in gp care.

Several interviewees also attributed their low utilization of GP care to a lack of confidence in the skills and knowledge of GPs compared to other specialists.

“I always have such a bad feeling about GPs, so sorry about that.” (P4). “From my experience, it is always the case that the normal doctors [GPs] are a little less experienced and can help a little less with acute cases. They can give great check-ups, they can give great recommendations […], little things like that. Unfortunately, this is not the case for acute cases. They have no experience.” (P4). “I also understand that the GPs are often not extremely qualified here […], the specialists are usually much more qualified and I do not expect anything.” (P16).

Some patients also considered consulting a GP time-consuming, complicated, and a pointless additional step in the care process. In this regard, patients portrayed the GP as a mere intermediary to medical specialists.

“My general experience is that going through GPs just delays everything even more. However, that is probably a perspective you have as a young person.” (P11). “I […] find it cumbersome to be sent from a GP to a specialist. It is an outdated concept for me.” (P25).

Preference of consulting specialists

Consequently, direct consultation with medical specialists was a pattern of utilization frequently depicted in the interviews.

“When I look back, whenever I went to the doctor, it was usually directly to specialists.” (P12). “If I am concerned about a specific problem anyway, then I can also sit down in the emergency consultation hour of the specialist.” (P2).

In addition to the aforementioned view that GP care is an intermediary step to be bypassed, some patients explicitly expressed a belief in the professional superiority of medical specialists over GPs.

“Because I often have the feeling that when I go to the GP, he does not really know what to do either, and that I always end up with a specialist.” (P7).

Negative experiences with GP care

Regarding past contacts with GP care and their potential role in explaining current individual consultation decisions, some respondents described negative experiences. An important theme in this context was frustration about long waiting times for appointments and in practice.

“ […] I have also always experienced GP surgeries as very crowded.” (P3). “You cannot always get to an acute consultation right away. You also have to wait.” (P25).

In addition, many participants described previous access problems, such as not being able to obtain a timely GP appointment, or futile attempts to find a practice that would accept new patients.

“I felt very rejected. I called different doctors’ offices and they said, “Do not come!” (P15). “For three or four months I was looking for a GP, but the answer is always that they do not take new patients.” (P29).

Participants also reported that they had not been satisfied with the treatment they received in the past from the GP.

“When I think about my GP experience, they were less able to help me there.” (P21).

“Thus far, my experience has not been so good, which is why I went straight to the ED. When I had truly severe pain, they [GPs] only ever prescribed me painkillers.” (P27).

Some interviewees described experiencing GP care as impersonal, including the impression that the respective GP was overworked and did not take enough time for consultations.

“[…] because the GPs are so overburdened.” (P16). “That is always so sobering, you ask yourself, has he [GP] truly listened to what you have to say? You tell him and he types on the computer and you get a prescription and that is it. This personal factor is also missing. It does not exist like that anymore.” (P19).

Views on the concept of having a regular GP

Participants interviewed were also asked what the concept of ‘having a regular GP’ implied for them. While most patients had a general idea of this, for some it seemed to be a completely foreign concept.

“So probably, it [having a regular GP] just means that someone has a regular doctor that they always go to.” (P1). “I do not know [what it means to “have a regular GP”].” (P23). “I do not truly understand it, the term is familiar to me, of course, and I have observed with my grandmother, for example, that she had something like a GP who actually also came to her home. In addition, she knew him for decades.” (P1).

Although some patients did not understand the concept or need for a GP, most interviewees indicated that they could see clear benefits from the continuity of GP-based care. Having a fixed contact person in case of illness who knows the individual medical history was frequently mentioned as the main advantage.

“To have a doctor where you can go if something is wrong and who also knows you and already has the data.” (P30). “I would say someone who actually knows me. Someone I do not just go to when I have cut off my finger, but who actually knows my history and accompanies me like that. Maybe not through life, but at least for a period of life. Who can then perhaps also assess what the better treatment options are, because I have certain previous illnesses, or because they know that I take certain other medicines or have taken certain other medicines until recently?” (P6).

Summary of findings

In the interviewed sample of low-acuity ED patients without a regular GP, a number of central contributing factors for GP non-utilization and an associated lack of continuity of care were identified. Patients’ characteristics and lifestyles are linked to underlying views about PC and individual past experiences. In particular, a rare need for medical care due to good general health, mobility, and a lack of knowledge about the role and responsibilities of GPs and health care options were identified as important factors for GP non-utilization. Little confidence in PC providers emerged as a widespread view, possibly contributing to a preference for specialist care. Interviews suggested that this constellation is often due to negative experiences with GP care in the past.

Results in context

Implications of sample composition and study setting.

Our study investigated factors that contribute to GP non-utilization in low-acuity ED patients. With regard to our interview sample, it is important to note that it consisted of relatively young patients, corresponding to the overall mean age of 30.6 years in the EMAPREPARE cohort. Regarding the prevalence of a first-generation migration history ( ∼  30%), the qualitative sample likewise reflects the composition of the larger cohort from which it was recruited. The two mentioned sample characteristics have been identified in previous studies as factors that increase the odds of not having a GP [ 17 ]. Furthermore, previous work has described young age and not having a GP as factors contributing to low-acuity ED usage, which is also consistent with our findings [ 28 , 29 ]. However, other population groups have also been identified as contributive to rising ED utilization, particularly older people and people living in nursing homes, which is not reflected by our results as to the selection criteria of the study [ 30 ].

The results might also reflect specifics of the urban study setting with a high availability of specialists and care choices, where patients are less tied to one provider and have many options, which may play a role in GP care utilization and attachment motives. Other studies also found that low-acuity ED patients in urban settings, compared to rural settings, are less connected to GP care [ 31 ] and show lower commitment to their PC provider [ 11 ].

Understanding utilization motives and potential implications

Need to adapt gp care to individual life situations and to diminish access barriers.

Many of the comparably young patients from our cohort reported being rarely ill and having no regular need for medical care. Concerning age, findings by Tillmann et al. show that young people are often attached to a pediatrician during their childhood and might miss the transition to GP care as young adults. The authors stress the importance of improving this transition to support GP attachment [ 17 ].

Even though utilization of GP care was depicted as rare and sporadic in many interviews, some of the participants notably consulted a GP in the past 6 months (see Table  2 ). This utilization was prevailingly described as situational, with no attachment or long-term continuity. Accordingly, a qualitative study on the attachment of patients to GP practices by Frederiksen et al. highlighted that patients with higher morbidity and vulnerability have a greater need to have a regular GP [ 32 ]. This is consistent with our findings.

Against the backdrop of patient characteristics associated with non-utilization, such as young age, good health and related situational contacts with GP care, it is worth taking a closer look at negative experiences with PC depicted by the participants. Access problems (waiting times, appointment scheduling problems) play an important role in this context. Difficulties in obtaining a timely appointment at a GP practice were also described in a qualitative study from France by Durand et al. and identified as a reason for seeking low-acuity ED care [ 33 ]. Access problems may also be related to the problem of patient mobility, which in turn is a feature associated with younger age groups. For people who move between neighborhoods or cities, it might be quite burdensome to connect to a GP and to schedule appointments. The interviews describe experiences of rejection by practices, even for acute complaints. In a recent qualitative study, Korczak et al. investigated determinants of low-acuity ED presentations and found three main factors specifically associated with GP care: having no GP, failure to attend an appointment, and negative previous experiences with a GP practice. In turn, the main reason for not having a GP identified by this study was that patients move around or do not understand the health care system and the most appropriate care paths. The authors suggested that there should be services to enable patients to find a GP who meets their individual needs, arguing that this would increase GP attachment and continuity of care in the long term [ 34 ]. A targeted GP attachment program, as piloted in the interventional module of EMAPREPARE, could help to connect patients with GPs [ 20 ].

Another aspect underlying the deliberate non-utilization of GP care, which came up repeatedly in our interviews, was little confidence in GP care, which was related to negative experiences with PC in the past. In an Australian study, Wong and Hall examined how ED patients’ experiences with GP care affected their ED attendance and found that patients who had negative experiences with GP care in the past were more likely to visit the ED [ 35 ]. A general lack of trust in GP treatment can also play a role in ED utilization decisions [ 31 ]. Previous research by our study group has also stressed the potentially negative influence of GP-aversive views and negative PC experiences on utilization behavior [ 36 ].

Need for patient education

Patients often do not know where to access appropriate care for their needs, or struggle to obtain suitable medical attention. A surprising finding in our data was that many interviewed patients were not familiar with the role and tasks of a GP and the concept of having a regular GP practice. Even if these statements cannot be generalized – especially regarding other settings and populations – they could indicate a lack of health literacy in this patient group. While we did not survey health literacy in our study population, other works however have shown lower health literacy in low-acuity ED patients than in the general population [ 37 , 38 ]. On that score, Strauß et al. found that health literacy in low-acuity ED patients was positively related to GP attachment. Therefore, they assumed that improving GP attachment among these patients would help them to receive personalized information from their GP about different health care options and therefore make more adequate ED utilization decisions [ 10 ]. Likewise, Oedekoven et al. stressed the importance of GPs as a source of health-related information [ 39 ].

In line with the theme that non-utilization of GP care is associated with knowledge deficits about the functions and potential of PC, our interviews indicated that beliefs about the professional superiority of specialists frequently seem to play a role in not having a regular GP. Promoting information about the role of GPs and their care capabilities seems crucial in this context. However, it is certainly a challenge to reach people who have no contact with PC. Himmel et al. suggested that– especially for younger patients who are frequently not attached to a GP– health insurance personnel could educate patients about the benefits of having a GP and continuity of care [ 40 ]. Other authors have likewise stressed that specific information on the importance of having a regular GP could help to increase patients’ commitment to PC [ 11 ]. For patients with utilization patterns that are detached from PC, the ED may appear to be a particularly attractive care pathway or may be perceived as without alternatives. A patient-oriented approach to promoting and improving health literacy is therefore important to support informed decision-making processes [ 9 ]. Altogether, we must stress that our results highlight the need to improve the public perception of GPs’ important coordinating role in the healthcare system as well as their medical expertise.

Attachment to a GP and continuity of care

Interestingly, our interviews revealed that many patients embrace the theoretical concept of having a regular GP and the associated advantages of having a health care provider who knows their medical history and is available as a point of contact for any medical problems that arise. However, translating this agreement in principle into actual utilization reality is not achieved, with barriers mentioned in our interviews likely playing a central role.

Numerous works have emphasized the link between continuity of care and potentially inadequate ED utilization, and promoting PC attachment appears to be a promising leverage point for streamlining utilization [ 41 , 42 , 43 ]. A study by van den Berg et al. showed that patients with regular GP attachment are more likely to consider PC as a primary care option in an acute situation [ 12 ]. Other works have stressed that in addition to continuity of care, the doctor-patient relationship plays a central role in the decision to either consult a GP or turn to the ED for a problem that is perceived as urgent [ 41 , 42 ]. In line with this, Strauß et al. reported that both the quality of a GP-patient relationship and the experienced continuity of care are crucial factors in reducing ED utilization beyond mere attachment to a GP [ 10 ]. Our own research points in a similar direction [ 20 ]. Notably, the importance of continuity of care extends well beyond the acute care context, and some studies even suggest potential benefits in terms of mortality [ 42 , 44 , 45 ].

Our findings of a fundamental openness to attach to primary care in this patient group however raise the question of how this can best be promoted. The study’s approach is based on voluntary participation in an appointment scheduling service, but this is by no means the only conceivable measure. Internationally, many health care systems (e.g. Denmark) are based on mandatory registration with a particular practice, frequently associated with gatekeeping regulations [ 46 ]. Respective policy changes toward a primary care-based healthcare system could alleviate many of the issues raised in our study, with our findings suggesting that this could potentially be well accepted. However, as this was not part of our research question, further investigation is required.

Strengths and limitations

This qualitative study provides new insights into the views and experiences of low-acuity ED patients without PC integration toward GP care, and their complex reasons for non-utilization. While conducting our study, measures such as independent coding and reflection of results with independent researchers were taken to reduce interviewer bias, but such cannot be completely eliminated [ 47 , 48 ]. Other caveats include possible bias due to social desirability among interview respondents [ 49 ] and selection effects related to patients who may have felt offended when approached by a project about redirection to a GP and the appropriateness of their visit, and therefore refused to participate in the study. A member check with interviewed patients was not performed. Furthermore, qualitative research is inherently subjective, and characteristics of the sample must be considered when reflecting on the results [ 50 ]. Due to the inclusion criteria of the pilot study, our qualitative results only reflect the views of a selected population of patients without GP attachment. However, for context and potential contrast with a less selective patient sample, we can refer to a previous qualitative study by our research group [ 36 ]. The fact that only patients who had sufficient German language skills were able to take part in the study may also limit transferability to unselected ED users. Moreover, it must be stressed that GP attachment is not formalized (and therefore not associated with e.g. a registration process) in Germany, and ‘having a GP’ or not is a personal subjective definition for the individual patient. As described, part of our sample had made use of GP care in the recent past, but nevertheless participants described themselves as ‘unattached’ to a GP. Apart from the fact that our results reflect peculiarities of the German health care system with its absence of gatekeeping regulations, the urban study setting, as mentioned above, might also have distinctly impacted the results and limits the conclusions derived from it. This requires further research to correspondingly explore the issue in rural settings, for example.

Conclusions

Factors that contribute to non-utilization of GP care in low-acuity ED patients are multifaceted. Patients’ personal life situations, health literacy, and experiences with GPs, play an important role in their behavior when seeking medical care and choosing acute care options. As the themes identified were found to be interrelated, this study highlights individual non-utilization as a complex configuration, for which the insights derived from our data provide a framework useful for understanding and better description. This can be very helpful in targeting future intervention approaches to promote PC attachment and continuity of care and in turn strengthen GP-mediated health literacy. Our EMAPREPARE pilot intervention is a first step in this direction, providing both information material about alternative care paths and an optional GP appointment scheduling service [ 20 ].

Data Availability

The datasets used and analyzed in this study are available from the corresponding author upon reasonable request.

Abbreviations

emergency department

primary care

general practitioner

Emergency and Acute Medicine Network for Health Care Research Berlin

Emergency and Acute Medicine– Primary Care Demands in Patients Resorting to Emergency Departments

Manchester Triage System

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Acknowledgements

We would like to thank all patients who participated in our study and the study team for their persistent recruitment efforts at the ED.

This study is funded by the Federal Ministry of Education and Research (BMBF), grant number 01GY1914. The funding body had no role in the design and conduct of the study, data collection, analysis, and interpretation of the data, or in the preparation, review and approval of the manuscript. We acknowledge financial support from the Open Access Publication Fund of Charité– Universitätsmedizin Berlin.

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Contributions

M.M. initiated the network EMANet and is the principal investigator and speaker of the network. S.O. (health scientist), F.H. (GP and senior researcher), R.R.C. (ED physician) and C.H. (GP and senior researcher) designed the subproject EMAPREPARE. S.O., F.H. and R.R.C. developed the study protocol and research questions for the qualitative study module. S.O and L.K. (health scientists) developed the interview guide. L.K. and S.O. carried out the interviews and transcribed audio files. L.K. and S.O. analyzed and interpreted the data. L.K. drafted the manuscript for this paper. S.O., F.H., R.R.C., C.H. and M.M. critically revised the manuscript. All the authors have read and approved the final version of this manuscript. All authors qualify as authors according to ICMJE guidelines.

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Correspondence to Lisa Kümpel .

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The ethics committee of Charité– Universitätsmedizin Berlin approved the EMAPREPARE study (EA1/120/20). Written informed consent was obtained from all study participants, and methods were carried out in accordance with relevant guidelines and regulations.

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Kümpel, L., Oslislo, S., Resendiz Cantu, R. et al. “I do not know the advantages of having a general practitioner” - a qualitative study exploring the views of low-acuity emergency patients without a regular general practitioner toward primary care. BMC Health Serv Res 24 , 629 (2024). https://doi.org/10.1186/s12913-024-10977-2

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Original research article, exploring cambodian adolescents' perceptions on sex: a qualitative investigation.

• 1 School of Nursing, Research Institute of Nursing Science, Sustainable Development Center, Jeonbuk National University, Jeonju, Republic of Korea
• 2 Seoul Samsung Medical Center, Seoul, Republic of Korea
• 3 St. David’s School of Nursing, Texas State University, Round Rock, TX, United States
• 4 Jersey City Medical Center, Jersey City, NJ, United States

Introduction: Involvement in sexual activities increases during adolescence in many countries, including Cambodia. The objective of this study is to explore the perspectives and interpretations of sex held by Cambodian adolescents within the context of their social norms and culture.

Methods: A qualitative research design was used to conduct in-depth interviews with a purposive sample of 91 Cambodian adolescents aged between 15 and 19 years. Participants were recruited from rural areas, and data was collected through face-to-face interviews using semi-structured interview guides. Thematic analysis was used to analyze the data.

Results: Four themes as perspectives of sex were identified: (1) Desire: Releasing sexual desire and stress; (2) relationship: an emotional connection and demonstration of love; (3) roles: responsibilities within a woman's marital duties; and (4) values: the value of virginity and future engagement. Cambodian adolescents' perspectives and interpretations of sex were deeply influenced by their social norms and cultural values. Men typically perceived sex through the lens of instinct and pleasure, while women often emphasized a deep sense of familial duty and held premarital sex to be morally unacceptable.

Discussion: The findings suggest that interventions aimed at improving the sexual health of Cambodian adolescents should be designed with an understanding of the social norms and cultural values that shape their perspectives and interpretations of sex. Such interventions should focus on promoting safe sex practices and providing accurate and comprehensive sexual education.

1 Introduction

Adolescence is the period between 10 and 19 years of age that marks the transition from childhood to adulthood ( 1 ). Adolescents experience rapid changes not only in their physical growth but also in cognitive, emotional, and psychosocial development while pursuing sex and intimate relationships ( 1 ). Adolescence is considered a healthy period of life; however, negative sexual and reproductive health (SRH) outcomes can threaten the well-being of adolescents, especially in low- and middle-income countries ( 2 ). Young people typically engage in sexual activities as they reach adolescence, with limited knowledge about SRH, leading to the highest rates of sexually transmitted infections (STIs) and HIV infections ( 2 ).

The global adolescent population has increased, with the majority of adolescents living in Southeast Asia ( 3 ). Cambodia has the largest adolescent and young adult population in Southeast Asia, with two-thirds of its 14.7 million people under the age of 30 ( 4 ). However, Cambodia lags behind its neighboring countries in implementing effective strategies to improve SRH. Cambodian youth face numerous obstacles to sustainable SRH, including lack of SRH literacy and limited access to modern contraceptives ( 4 ). Only 6.7% of Cambodian youth reported having visited a local health center, hospital, or clinic to seek reproductive health care ( 3 ). Furthermore, the rate of condom use among young Cambodian men decreased from 26% in 2010 to 18% in 2014 ( 5 ). This means that challenges, such as unexpected pregnancies and STIs, are on the rise.

However, essential health services are expensive, particularly in rural areas, due to user fees and transportation, as well as food and accommodation costs. Geographical factors, including the time required to travel to facilities and transportation availability, are barriers to health care access ( 6 ). Therefore, eliminating financial and geographical barriers is critical to increasing health care utilization. In addition, sex education must be taught among adolescents, particularly on how to practice safe sex. Since mid-1997, the Reproductive Health Association of Cambodia has used peer educators, group discussions, one-on-one discussions, local theaters or quiz shows, various educational materials, and youth centers to convey reproductive health messages and information to young people. In 2007, the project distributed condoms and offered STI services to youth under the age of 25 ( 7 ). However, condom use declined over the following four years ( 5 ). This implies that the program must be revised the program to boost its effectivity.

Sex is often linked to the concept of marriage, with some regarding it as conditional on marriage, especially in rural areas. Young, unmarried individuals in urban Cambodia are 60% more likely to engage in pre-marital sexual intercourse compared with those who live in rural areas ( 5 ). Our study also supports this finding, stating that many of the respondents from rural Cambodia oppose premarital sex. After marriage, the purposive act of having a child has emerged as another primary reason for sex. Most rural households depend on agriculture and related subsectors to survive. Since launching its official rice export policy in 2010, Cambodia has emerged as a major player in the international rice commodity trade ( 8 ). Therefore, agricultural human resources are necessary for survival, and children are a form of accessible and inexpensive labor.

Cambodia's traditional wedding culture welcomes forced marriages and teenage pregnancies. For many Cambodians, marriage enhances their social and economic status ( 9 ). In addition to robbing a girl of her childhood, education, and future independence, child marriage also exposes her to the risk of fatal health complications associated with early childbearing. Additionally, forced child marriage exposes girls to repeated sexual and physical violence, which can have devastating effects on their mental and physical health and undermine gender equality ( 10 ). This practice deprives Cambodian women of sexual agency after marriage.

Most of the social norms underpinning this marriage system are patriarchal. For young girls, early marriage signifies an early transition to adulthood, socially imposed sexual norms, mandatory obedience, filial piety, and lack of economic freedom ( 11 ). In Cambodia, women are constantly exposed to sexual violence as a result of their subordinate status in a patriarchal society. This system renders women vulnerable to exploitation at the hands of their husbands, fathers, neighbors, authorities, and other male figures ( 12 ). Furthermore, social and cultural practices prevent women from exercising their rights to self-determination. These social norms are linked to Cambodia's early and forced marriage systems ( 5 ), as well as the Khmer cultural principle known as Chbab Srey ( 13 ). Cambodian culture encourages marriage at a young age, when women are typically unable to decide for themselves. Chbab Srey is considered crucial in Khmer culture and is taught in schools and Khmer literature. It codifies women's status at home and conveys the idea that married women should be respectful and submissive toward their husbands ( 13 ). Failure to comply with Chbab Srey results in social sanctions and exclusions ( 14 ). Moreover, most women are dependent (financially or otherwise) on their husbands, especially if they have children. In this social system, women have no option but to obey men ( 12 ).

Essentially, having children means preparing for old age. In Cambodia, filial piety means that most residents believe their children should devote themselves to their parents' welfare.

Many Asian cultures view sexuality as taboo and forbid sexual activities outside of marriage. However, increased access to media access has strengthened permissive attitudes toward dating and premarital sex among adolescents ( 2 ). In Cambodia, men enjoy more freedom than women. Women in Cambodia often repress their potential, whereas men enjoy the innate privileges afforded by their gender ( 5 ). A famous Cambodian Khmer proverb, “fruits should not ripen before they change color,” advises young women to maintain their virginity until marriage ( 15 ). In Cambodia, a woman's virginity is considered a sacred virtue reserved for their future spouses. Furthermore, a girl who loses virginity is a disgrace to her family, regardless of whether it was caused by sexual abuse, and will remain a loss of “virtue” ( 9 ). Cambodian society also disapproves of children born outside of wedlock, compelling young pregnant girls to marry ( 12 ). The 1975–1979 Cambodian Civil War disrupted social and family norms and precipitated rapid lifestyle changes. This period saw a decline in traditional monogamy and increased sexual promiscuity, often resulting from increased access to sex workers, who are individuals receiving monetary compensation in exchange for consensual sexual services ( 16 ). Almost half of the participants (45.0%) had their first sexual experience with a sex worker, and over half (58.3%) had engaged in sexual intercourse with multiple sex partners, including their wives ( 16 ). In Phnom Penh, Cambodia, the prevalence of HIV among sex workers ranged from 9.2% to 23% ( 17 ). Alarming statistics revealed that over 40% of new HIV infections are identified among adolescents ( 18 ). Furthermore, most Cambodian men engage in unprotected sex, such as not wearing a condom, with their wives, despite being uncertain about their HIV status ( 19 ). Some reasons for not practicing safe sex were poor sexual sensitivity, lack of prophylactic knowledge, and the belief that condom use indicates a lack of spousal trust ( 19 ). A recent study in Cambodia revealed that 68% of young males aged 16–24 years old were sexually active, and 27% of them had sexual contact with sex workers within the previous year, placing them at a high risk of contracting HIV ( 20 ).

In a qualitative study among Cambodian adults, sex was perceived as a woman's obligation but a man's personal pleasure ( 21 ). However, the sexual behaviors and perceptions of Cambodian adolescents are gradually changing and are influenced by cultural perceptions and subjective factors. As such, the patriarchal culture practiced in Cambodia may have substantially influenced these perceptions and behaviors. The purpose and meaning of sex in adolescents may be associated with early sexual initiation and practice of unprotected sex. This may also be related to efforts to maintain virginity, all of which can help develop programs to prevent STIs and improve reproductive health. This study was conducted to explore the perceptions of Cambodian adolescents toward sex to understand the cultural influence on sexual behaviors.

2 Materials and methods

2.1 study design, participants, and setting.

A descriptive qualitative approach was used to investigate the significance of sex to Cambodian adolescents. Three rural provinces in Cambodia, Kandal, Kompong Speu, and Kampong Chhnang, were selected through convenience sampling. This study was conducted between July and August 2017 in the high schools of these provinces. To be included in this study, participants must be (a) Cambodian residents, (b) third-year high school students, (c) aged 17–19 years, and (d) unmarried. The study aims, research processes, and interview questions were approved by the Cambodian Ministry of Education, Youth, and Sports. Furthermore, the respective high school principals approved the study after they were informed of its purpose, eligibility criteria, participation process, and student recruitment. The schools provided a private room to ensure confidentiality. The interviews were digitally audio recorded with participants' permission. Ethical permission for the study was obtained from the Jeonbuk National University Institutional Human Subjects Review Committee (2017-06-014-002) and Cambodia National Ethics Committee for Health Research of the Ministry of Health.

2.2 Data collection

The study team included two non-Cambodian (two females) and two Cambodian (one male and one female) researchers. Third-year students were briefly introduced to the study and its purpose. The participants were informed of their right to information privacy, confidentiality, and withdrawal at any time. Only those who agreed to participate were given a date and time for the interview. Informed consent was obtained from the participants, and interviews were conducted in Khmer using an in-depth interview guide and open-ended questions, such as “Can you explain your understanding of the concept of sex?” to explore the general perception of ex among adolescents. Additional probing questions were used to elicit rich and detailed perspectives from the participant, such as (1) “Tell me more about that …”, (2) “Tell me what you meant by…”, and (3) “How did that make you feel?” Two non-Cambodian investigators completed the data collection, while the Cambodian investigator assisted as a bilingual Khmer/English interpreter throughout the process. A male interpreter assisted the male participants, whereas a female interpreter assisted the female participants. So as to reduce bias between the researchers, the primary investigator participated in the male and female interviews. The gender identity of the primary investigator (PI) was female, and she participated in interviews while maintaining a neutral stance. To mitigate potential gender-related biases in the interviews, the PI adhered to the principles of qualitative research and research ethics, ensuring transparency throughout the process. These deliberate efforts were undertaken to uphold rigorous and unbiased research practices. Given that the research team conducted the interviews while traveling together, after each daily interview, the research team gathered to share the interview progress and monitor the follow-up. Each interview lasted between 40 and 80 min, and data were collected until data saturation. As a token of appreciation, each participant was given 20,000 Cambodian riels (equivalent to US$5) in a sealed envelope upon completing the interview. A total of 48 male and 43 female students participated in the interviews.

2.3 Data analysis

Each participant was assigned a pseudonym to ensure their privacy and confidentiality. The digitally recorded interviews were transcribed by a native Khmer speaker and translated into English. The interviews were then analyzed using thematic qualitative analysis ( 22 ). First, data familiarity was achieved by repeatedly reading the English transcripts. The initial concepts that represented the most critical features of the data were then coded to produce themes. The codes relevant to each theme were classified into subthemes. Next, a thematic “map” was created on the basis of whether the potential themes worked with the extracted codes and entire dataset. Themes were then assigned definitions and names to refine their characteristics. Finally, a written analysis was conducted after reviewing themes related to the literature and interview questions. Thereafter, the transcripts were read and reviewed to ensure that the codes adequately represented the aims of the study in the Cambodian context. The ATlas.ti software (version 6.0) was used to mark the code.

2.4 Ensuring research rigor

In order to enhance the rigor of our qualitative research, we maintained a high degree of transparency and reflexivity throughout the study. Transparency was achieved by meticulously documenting and reporting our research process, allowing for the scrutiny of our methods and decision-making. This documentation included detailed notes on data collection, coding processes, and analytical decisions. Reflexivity was a critical component of our study, as we recognized the potential impact of our own perspectives and experiences on the research process. To address this, we consistently engaged in self-reflection and acknowledged our positionalities, which were used to inform our interpretation of the data. This reflexive approach helped ensure that our findings were as objective as possible.

The average age of the participants was 17.9 and 18.7 years for females and males, respectively. Most participants identified as Buddhists. Their average monthly spending money was US$89 for females, whereas US$113 for males. Most participants lived with their parents ( Table 1 ). Regarding what sex meant to them, the following themes emerged from the data analysis: (1) desire: Releasing sexual desire and stress; (2) relationship: an emotional connection and demonstration of love; (3) roles: responsibilities within a woman's marital duties; and (4) values: the value of virginity and future engagement. Table 2 displays the themes, sub-themes, and corresponding codes.

Table 1 . Characteristics of the participants.

Table 2 . The results of the analysis: theme, sub-themes, codes.

3.1.1 Releasing sexual desire and stress

Many participants, including females, agreed that they found sex enjoyable. One male student mentioned that humans, similar to animals, naturally desire fulfilling their sexual needs. Sex is also regarded as a form of stress relief or evening entertainment.

“And maybe it is our desire. It is normal for men and women to desire sex.” (Soren, female, aged 18)

“For general people, some just want to have fun for a while, and they need to fulfill their desire.” (Nita, female, aged 19)

“The purpose of sex is to fulfill our sexual desires, and humans have similar feelings as animals. We want to have fun, so we do it to satisfy our desires.” (Kosal, male, aged 19)

3.2 Relationships

Male and female participants expressed that sex was a way to strengthen relationships and that the act of sex became a medium for expressing love toward one another. This theme was used to examine the romantic responses of students to sexual encounters.

3.2.1 A way to connect with one another

One female student believes that sex is a ritual in which two people accepted each other as life partners. She noted that sex serves as a physical promise to their partners, signifying their romantic bond that would endure for the rest of their lives. One male student provided a similar answer, stating that sex evokes feelings of love and happiness. He added that he felt at ease after engaging in sexual activity with his significant other.

“The meaning of sex is the accepting of a person into my life and us becoming one.” (Chanthavy, female, aged 18)

“We need sex to feel happy, in love, and connected with a partner, and able to sleep.” (Khemera, male, aged 18)

3.2.2 A way to show love

Many female students claimed that they express their affection through sex. To them, the act represents love, trust, honesty, faith, and the commitment to never betray their partners. Furthermore, many were willing to have sex with someone they genuinely loved.

“I am aware that sometimes it is the display of love. If we are just friends, I will not allow touching or having intimate relationships. However, for the person I love, I will allow it. I will be willing to sacrifice my body to fulfill his desires. This is the meaning of the love that I have shown him. Love is shown through sexual intercourse.” (Bopha, female, aged 18)

“I want to show him my faithfulness and sincerity that I will never betray him.” (Chenda, female, aged 17)

3.3.1 Conditional acts: after marriage

As provisions of sexual intercourse have been frequently discussed, this theme focuses specifically on marital sex. Some female participants believe that marriage authorizes them to give their husbands something they had previously protected and treasured. Despite the fact that modern norms indicate an increase in the prevalence of premarital sex, many still regard sex as an act of love between husband and wife, such that they should not hesitate to give themselves in such a physical manner in a marital context.

“It’s meaningful when both of them decide to get married and they can wait till the last night.” (Kiry, male, aged 18)

“[Sex is] to show the love and at that time we should not be afraid of anything because we are already husband and wife. So, what I have kept I will give to my husband.” (Deavy, female, aged 16)

3.3.2 Purposive acts: reproductive means

Many participants mentioned children on this theme. They believe that the purpose of marriage is to have children, which requires sexual intercourse. For these participants, children are the result of their love and an investment in their old age. Some participants claimed that children unite a couple and serve as a means to continue their lineage. One participant felt that he needed someone to care for him as he aged. He regarded the child as a resource to support him during old age.

“The meaning of sex… is the desire of a man who wants to be with a woman and to have a baby.” (Kunthea, female, aged 18)

“I think after marriage we have sex because we want to have children to protect our lineage and receive the result of our love.” (Chantou, female, aged 18)

“I think, [the purpose of sex is] to have kids for the next generation. When I get older, they can take care of me.” (Mony, female, aged 18)

3.3.3 Dutiful acts: wifely responsibilities

Some female students felt that sex would be their duty, as husbands took their wives for that purpose. Some women claimed that marriage was the act of giving life to their husbands. These participants believe that they are willing to sacrifice everything for their husbands after marriage because these men would provide for them for the rest of their lives. As part of this sacrifice, their husbands' sexual desires must be fulfilled.

“Because it is his desire, I will fulfill it, as we mentioned earlier, whatever he likes and we serve him, something like that.” (Bopha, female, aged 18)

“The wife should fulfill her duty as a wife because the husband gets a wife to fulfill his needs.” (Kanya, female, aged 18)

Additional questions were posed to the female participants. They were asked what they would do if their husbands asked for sex several times a day. While many female participants regarded sex as their duty, they generally responded negatively to the prospect of excessive demand for sex. They felt that excessive sexual intercourse would lead health problems in their reproductive system. Others thought that this would hinder their ability to complete daytime tasks. Many female respondents claimed that unlike previous generations, most modern women participated in economic activities. These obligations, in conjunction with familial duties, meant that they cannot comply with the frequent demands for sex.

“It is because I cannot have sex with him more than once a day. Sometimes, it exhausts me, and my health deteriorates. My health is more important, so I have to think of it.” (Maly, female, aged 18)

“The woman in this present day is not like before, [and] most women now also work outside to earn money. In the olden times she was just a housewife, and had to stay at home, but now it is different.” (Neary, female, aged 19)

This theme explains the different perceptions of sexual relationships, as they pertain to sex with a wife, sex worker, or girlfriend. A few male students were pleased with the prospect of sexual intimacy with pure and virgin wives. However, they felt psychologically burdened by engaging in premarital sex with a girlfriend due to unclear responsibilities and uncertain future. Furthermore, they were not sufficiently satisfied when engaging in sexual activities with workers.

3.4.1 Wife vs. sex worker: the value of virginity

Several male students clearly distinguished between potential wives and sex workers. However, they focused on virginity as the key factor. According to them, being a virgin is synonymous with having a clean body, which makes sex more pleasurable. These male participants claimed that while their wives would be pure, sex workers would not. Thus, sexual experiences with sex workers are less gratifying. One participant said:

“Having sex with the sex worker is not romantic because all of them have already lost their virginity and have less sexual pleasure, which is unlike wives or girlfriends who have a clean body because they allow sex only with the person they love. I can say it is more romantic.” (Dara, male, aged 19)

A few female students mentioned virginity. They believe that they had to offer pure bodies to their future husbands as a bond to unite them.

“I think he believes in me, [that] I have never done bad things before. And my virginity will be given to him so that he knows his baby is really his and understands that the baby that comes from his blood that belongs to him.” (Sothy, female, aged 18)

3.4.2 Girlfriend or wife: the burden of future engagement

While discussing their girlfriends, a few of the male students focused on the possibility of marriage. They expressed anxiety about having premarital sex due to the uncertainty of the relationship in the future. These male participants explained that engaging in sexual activities with a girlfriend may lead to unexpected pregnancies or STIs. Furthermore, they described it as being out of wedlock; thus, less meaningful to them.

“Having sex with a girlfriend, we are not sure if we can be responsible or marry her. Unlike having sex with a wife, which is to have children and create a family together.” (Manndy, male, aged 19)

4 Discussion

This study investigated the social and cultural perspectives on sex among adolescents in Cambodia. The influence of Cambodian culture on adolescents' sexual concepts and behaviors is a key outcome of this research. This study demonstrated differences and similarities in attitudes and perspectives of young men and women regarding sex.

Our study found males and females agreed that sexual intercourse grants them happiness and satisfaction, whereas for women, it is a marital obligation. Most of the respondents who focused on sex for physical pleasure were male. Men often focus on the physical aspects of sex, whereas women focus on the emotional aspects. Some male students acknowledged the emotional exchanges involved in sexual intercourse. These participants agreed that sex strengthened their relationship with their partners, allowing them to express their love for one another and feel connected.

Previous study reported that sex was considered a women's obligation ( 21 ). Our study result also revealed some female adolescents expressed that wives were obligated to have sex with their husbands. Others felt a strong sense of duty toward their role as wives, particularly concerning sexual matters. These beliefs are driven by societal and cultural norms that encourage acquiescence toward a husband's sexual desires ( 23 ).Some male participants ascribed different values to sex, depending on their sexual partner (wife, girlfriend, or sex worker). In Cambodian culture, a girl's values vary on the basis of her purity ( 24 ), and women are taught that a wife should retain her vaginal purity until marriage. Our study found many believed that a “pure” woman is dedicated entirely to her husband, which increases sexual gratification. Male adolescents expressed that they would feel more comfortable having sex with a future wife than with their girlfriends. Among the various sexual services, paid services for sex workers were the only ones available to experience sexual release. Interestingly, not all women view sex workers negatively. Previous literature reported that some wives believe they are incapable of sexually pleasing their husbands; thus, they encourage their husbands to have sexual relations with other women to avoid divorce ( 23 ). Additionally, men often perceive sex as innate and vital for personal happiness. In Cambodia, engaging with sex workers is a prevalent cultural norm, and Cambodian society does not view it negatively ( 19 ). However, sex workers, of which there are an estimated 40,000 nationwide, are considered a high-risk group for STIs ( 25 ). Recently, the prevalence of STIs in Cambodia has significantly decreased as a result of the government's national efforts to protect sex workers from STIs ( 26 ). However, despite those efforts, men often spread STIs to their wives when they do not use condoms during sexual intercourse ( 19 ).

To prevent STI transmission in Cambodia, the perception of sexual labor must be altered. The fulfillment of masculine needs is often used to justify engaging with sex workers; however, these men must be made aware of the dangers of STIs. Furthermore, those at risk of spreading STIs should be educated on the essential use of condoms during intercourse, even with their wives, to prevent transmission. Thus, rather than demonizing sex workers, STI cross-infection must be minimized.

Cambodia has a unique culture that includes sexual behavior among adolescents and young adults. Although Cambodian society has changed under the influence of Western culture, this study revealed that some Cambodian adolescents retain traditional attitudes toward sexual behavior. Furthermore, Cambodian men have more sexual and general freedom, whereas women are expected to retain their “purity” for their future husbands. Additionally, male sex before marriage is widely accepted by male and female adolescents.

The level of sexual concept varies depending on the meaning and purpose of sex, and in some cases, the risk of exposure to early sexual experience, lack of condom use, and maintenance of multiple sex partners may increase. Indiscriminate sex, caused by low-level sexual concepts, can be a shortcut to facing uncomfortable situations (e.g., STIs, unexpected pregnancies, and so on.) Adolescents and young adults should be taught that seeking sexual health care is necessary and normal to protect their health and that of their loved ones. Systems should also be established wherein adolescents can access regular check-ups. As in many developing countries, access to health care in Cambodia is constrained by poverty. By understanding Cambodian youth's perspective on sex, we can better understand the prevalence of STIs and the causes of unexpected pregnancies among adolescents in Cambodia. Several educational programs and resources are available to inform Cambodian citizens about safe sex practices and encourage the use of health services. However, STIs continue to spread from husbands to wives. Therefore, revised and culturally accepted sex education and intervention programs must be implemented to prevent the spread of STIs. Ultimately, adolescents in Cambodia must be taught appropriate SRH education.

5 Strengths and limitation of the study

A notable strength of this study is its adherence to rigorous qualitative research methodology, conducted across three regions capturing the perspectives of approximately 100 high school seniors. They eloquently expressed their thoughts and viewpoints, allowing for a comprehensive understanding of perspectives within Cambodia's unique culture and societal context. This can be considered a pioneering study in this regard. However, this study interviewed adolescents in rural areas only. Therefore, future study should include adolescents in urban areas to capture any changes in perception on sex among Cambodian adolescents nowadays. While language limitations may arise due to the principal investigator being a non-Cambodian researcher, over five years of residence in Cambodia and extensive research conducted within the country contribute to overcoming this challenge, supported by knowledgeable and skillful local scholars.

6 Conclusion

This study was conducted to comprehend the perspectives on sexuality among Cambodian adolescents. The research findings revealed differences between the viewpoints of males and females, but they were not significantly different from those of adults. To prevent HIV, STIs, and teenage pregnancy, there is a need for comprehensive sexual education promoting healthy attitudes towards sexuality and practicing protected sex. As the internet and social media continue to advance, contemporary adolescents exposed to these mediums require ICT-based educational resources and content. To support this, various research initiatives and policies should be in place.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Jeonbuk National University Institutional Human Subjects Review Committee (2017-06-014-002) and Cambodia National Ethics Committee for Health Research of the Ministry of Health. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

Author contributions

YY: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. JK: Writing – original draft, Writing – review & editing. GP: Writing – original draft, Writing – review & editing. RT: Writing – original draft, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article.

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (2016S1A2A2912566).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: adolescents, cambodia, HIV, sexual health, STIs

Citation: Yang Y, Kim J, Park G and Thapa R (2024) Exploring Cambodian adolescents' perceptions on sex: a qualitative investigation. Front. Reprod. Health 6:1275941. doi: 10.3389/frph.2024.1275941

Received: 10 August 2023; Accepted: 8 May 2024; Published: 16 May 2024.

Reviewed by:

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

*Correspondence: Gloria Park, [email protected]

This article is part of the Research Topic

Reproductive Health and Mental Health in LMICs: Adolescent Health