The life history interviews ran for 40 – 60 minutes. The timing for sessions 2 and 3 is not provided.
Interviews are the most common data collection technique in qualitative research. There are four main types of interviews; the one you choose will depend on your research question, aims and objectives. It is important to formulate open-ended interview questions that are understandable and easy for participants to answer. Key considerations in setting up the interview will enhance the quality of the data obtained and the experience of the interview for the participant and the researcher.
Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Danielle Berkovic is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.
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Research, Record, and Transcribe Better
Updated on: June 22, 2024
A qualitative research interview is an invaluable tool for researchers. Whether one’s studying social phenomena, exploring personal narratives, or investigating complex issues, interviews offer a means to gain unique insights.
“The quality of the data collected in a qualitative research interview is highly dependent on the quality and appropriateness of the questions asked.”
But how do you prepare the right questions to ensure your interviews yield rich data? In this guide, we’ll explore the types of qualitative research interviews and provide tips for crafting effective questions.
Table of Contents
Before diving into question preparation, it’s important to select the type of qualitative research interview that’s best suited for the study at hand.
There are three types of qualitative research interviews:
Structured interviews involve asking the same set of pre-written questions to every participant. This approach ensures consistency, making it easier to compare data between participants or groups later.
When conducting structured interviews, keep these guidelines in mind:
Question : Thinking back to your childhood days in Chelsea, can you remember what kind of local music was popular at the time?
Structured interviews are ideal when you need uniform data collection across all participants. They are common in large-scale studies or when comparing responses quantitatively.
Read more: Advantages & Disadvantages of Structured Interviews
The second type of qualitative interviews are semi-structured interviews. In these interviews, the interview guide outlines the topics to be explored, but the actual questions are not pre-written.
This approach allows interviewers the freedom to phrase questions spontaneously and explore topics in more depth.
Question : What problems did the participant face growing up in the community?
Semi-structured interviews strike a balance between flexibility and structure. They offer a framework within which interviewers can adapt questions to participants’ responses, making them suitable for in-depth exploration.
In unstructured interviews, often referred to as informal conversational interviews , are characterized by a lack of formal guidelines, predefined questions, or sequencing.
Questions emerge during the interview based on the conversation’s flow and the interviewee’s observations. Consequently, each unstructured interview is unique, and questions may evolve over time.
Unstructured interviews are highly exploratory and can lead to unexpected insights. They are particularly valuable when studying complex or novel phenomena where predefined questions may limit understanding.
Once you’ve chosen the type of interview that suits your research study, the next step is to decide what information you need to collect.
Patton’s six types of questions offer a framework for shaping your inquiries:
Based on these categories, create a list of the specific information you aim to collect through the interview. This step ensures that your questions align with your research objectives.
After deciding the type of interview and nature of information you’d like to gather, the next step is to write the actual questions.
Open-ended questions are the backbone of qualitative research interviews. They encourage participants to share their experiences and thoughts in-depth, providing rich, detailed data.
Avoid ‘yes’ or ‘no’ questions, as they limit responses. Instead, use open-ended questions that grant participants the freedom to express themselves. Here are some examples –
How do you feel about working at ABC Corp. during your initial years there?
Can you describe the attitudes and approach to work of the other people working with you at the time?
Tell me more about your relationship with your peers.
Read More: 100 Open-Ended Qualitative Interview Questions
Unstructured Questions allow the interviewee to guide the conversation, letting them focus on what they think is most important.
These questions make the interview longer, but also provide richer and deeper insight.
Probing questions are used to get more information about an answer or clarify something. They help interviewers dig deeper, clarify responses, and gain a more comprehensive understanding.
Tell me more about that.
And how did you feel about that?
What do you mean when you say [xxx]?
Probing questions enhance the depth and clarity of the data collected, however they should be used judiciously to avoid overwhelming participants.
As your interview approaches its conclusion, it’s beneficial to have a general last question that allows the interviewee to share any additional thoughts or opinions they feel are relevant.
For instance, you might ask:
Thank you for all that valuable information. Is there anything else you’d like to add before we end?
This open-ended question provides participants with a final opportunity to express themselves fully, ensuring that no critical insights are left unshared.
Preparing questions for qualitative research interviews requires a thoughtful approach that considers the interview type, desired information, and the balance between structured and unstructured questioning.
Here’s a great guide from the Harvard University on the subject.
Read More: How to Transcribe an Interview – A Complete Guide
hlabishi says
April 8, 2015 at 12:37 pm
I found the information valuable. It will assist me a lot with my research work.
Harpinder says
June 8, 2015 at 10:40 pm
I am going for my pilot study. Above information is really valuable for me. Thank you.
September 28, 2015 at 10:21 am
thank you for Patton’s 6 types of questions related to: 1. Behavior or experience. 2. Opinion or belief. 3. Feelings. 4. Knowledge. 5. Sensory. 6. Background or demographic. Really helpful
IBRAHIM A. ALIYU says
October 7, 2015 at 6:04 pm
Very interesting and good guides, thanks a lot
Dumisani says
July 31, 2017 at 7:55 am
Very informative. Thank you
Yongama says
June 5, 2018 at 11:57 pm
this is a good information and it helped me
Joshua Nonwo says
June 3, 2019 at 11:02 pm
vital information that really help me to do my research. thank you so much.
June 12, 2019 at 7:36 pm
Thanks a lot. Example of structured interview broadens My mind in formulating my structured research question. Indeed very helpful.
mwiine says
November 29, 2019 at 6:31 am
thanx, a lot. the information will guide me in my research.
Kayayoo isaac says
November 29, 2019 at 7:54 am
Thanks for the information, it was very much helpful to me in the area of data collection.
leslie says
December 27, 2019 at 4:29 pm
very useful thanks.
louisevbanz says
January 20, 2020 at 3:19 pm
I’d like put the writers of this in my references. May I ask who the writers are and what year was this published? Thank you very much.
Daniel says
June 1, 2020 at 6:21 pm
Thank you very much. Helpful information in my preparations for structured interviews for my research .
abby kamwana says
December 8, 2020 at 9:03 am
This is the information i was looking for thank you so much!.
Cosmas W.K. Mereku (Prof.) says
June 15, 2021 at 8:59 am
I am teaching 42 MPhil and 6 PhD postgraduate music students research methods this academic year. Your guide to qualitative research interview questions has been very useful. Because the students are in different disciplines (music education, music composition, ethnomusicology and performance), all the types of questions discussed have been very useful. Thank you very much.
Gerald Ibrahim b. says
June 16, 2021 at 12:45 pm
One of my best article ever read..thanks alot this may help me in completing my research report…
Corazon T. Balulao says
March 1, 2022 at 7:47 am
Thank you so much for sharing with us it helps me a lot doing mt basic research
antoinette says
March 28, 2022 at 7:35 am
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November 21, 2023 at 5:55 am
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Learn how to transcribe interviews in qualitative research with ease. This guide covers the process of transcribing interviews for qualitative research, best practices, benefits, and challenges. We will also discuss some of the best tools for transcribing interviews in qualitative research.
Imagine capturing lightning in a bottle. That's what transcribing interviews in qualitative research is like. It's the art of turning fleeting conversations into lasting, analyzable data.
But why do researchers spend hours typing up talks? It's more than just record-keeping. Transcription captures the essence of conversations - words, tone, pauses, and unspoken cues. This process is key to uncover deep insights and drawing meaningful conclusions.
If you’re wondering “how to transcribe data in qualitative research”, you’ve landed at the right place. This guide will walk you through the transcription process, offering tips and helping you sidestep common pitfalls. Whether you're a seasoned pro or just starting, you'll find practical ways to sharpen your skills.
Qualitative research is a method used to explore and understand human behavior, experiences, and social phenomena. Unlike quantitative research, which deals with numbers and statistics, qualitative research focuses on words, stories, and observations.
In qualitative studies, researchers often use interviews to gather data. These interviews help uncover the 'why' and 'how' behind people's actions and thoughts. The goal is to gain deep insights into complex issues that can't be easily measured with numbers alone.
Qualitative data transcription specifically refers to converting spoken words from research events such as interviews or focus groups into written text. It often employs verbatim transcription, which involves writing down every word exactly as spoken, including pauses and non-verbal sounds.
In qualitative research, the most common types are verbatim and intelligent transcription. Verbatim captures everything exactly as spoken, while intelligent transcription focuses on content by omitting unnecessary filler words or correcting grammar.
There are three main types of transcription:
Transcription can be done through various methods. The basic approach is to listen and type, playing the audio and typing what is heard. Transcription software can make the process faster and easier, offering features like automatic timestamps or AI-assisted transcription. Some researchers use a foot pedal method, which allows control of audio playback without taking hands off the keyboard.
Transcription is crucial in various qualitative research contexts. In interview analysis, it allows researchers to examine individual responses in detail. For focus group discussions, transcripts help capture multiple viewpoints and group dynamics. In observational research, transcribing audio notes helps create detailed field notes. Transcripts form a key part of case study data and are valuable in ethnographic research for preserving field conversations.
Transcribing interviews offers numerous benefits:
Transcription presents several challenges:
When transcribing for research, protecting participant confidentiality and complying with data protection laws are essential. This involves removing identifying details, using pseudonyms, and securely storing data. Researchers must obtain explicit consent, inform participants about data use, and ensure participants' rights to access or delete their data. Secure storage, limited access, and ethical handling of sensitive information are crucial aspects of the transcription process.
Transcribing interviews for qualitative research is a key step in qualitative research. The best way to transcribe depends on your project needs and resources. Here are some tips:
Using the right tools can significantly impact the transcription process. Invest in good-quality headphones to hear every word and nuance in the recording. Transcription software with playback controls, such as adjustable speeds and foot pedal compatibility, can speed up your work. Popular tools like Express Scribe or Otter.ai help streamline this process, especially when handling long interviews.
The choice between verbatim and intelligent transcription depends on your research focus. Verbatim transcription captures every sound, including fillers and non-verbal cues, ideal for analyzing speech patterns or emotions while intelligent transcription focuses on content, omitting fillers for cleaner, more readable text.
Consistency in format is key for a smooth analysis later on. Use a standard layout for all transcripts, including speaker labels, timestamps, and clear paragraphing. For instance, label each speaker as "Interviewer" and "Participant" or by name if needed. This helps when you’re coding data later, allowing you to trace back comments to specific moments in the interview.
Transcription is a mentally intensive task, especially for longer interviews. Listening to recordings repeatedly while typing out every detail can be exhausting. Taking regular breaks helps maintain focus and accuracy. A good rule of thumb is to take a 10-minute break after 30–45 minutes of transcribing. This prevents errors from creeping in due to fatigue.
Once the transcript is done, it’s crucial to review it for any mistakes or missed content. Playback the recording while reading along with your transcript to ensure nothing important is omitted. Checking for proper punctuation, correct speaker identification, and clarity helps improve the transcript’s overall quality. This step ensures that your transcript is an accurate reflection of the original interview.
In this section, we will discuss everything related to how to transcribe data in qualitative research.
Transcribing a qualitative interview involves listening to the audio and writing down the conversation verbatim. Begin by ensuring a quiet space and breaking the audio into manageable sections. Focus on capturing the participants’ words, including pauses, filler words, and emotions. You may use transcription software for assistance, but review the text manually for accuracy.
To transcribe a qualitative interview, play the audio in small sections, pausing frequently to capture the exact words of the interviewee and interviewer. Include verbal nuances, hesitations, and filler words, as they may offer insights. Proofread the transcription to ensure completeness and accuracy, reflecting the natural flow of conversation.
Transcribing an interview in qualitative research requires converting spoken language from audio into written form. Start by playing the interview audio and carefully transcribing it verbatim, including pauses, repeated phrases, and non-verbal sounds. Researchers may also choose to omit filler words or irrelevant speech depending on the research purpose.
To transcribe audio to text for qualitative research, first, play the audio and transcribe it word-for-word using either manual typing or transcription software. Make sure to capture every detail, including intonations and non-verbal cues like laughter. Once done, review the text for accuracy and format it according to your research needs.
Manual transcription involves listening to an audio recording and typing out the conversation or speech by hand. Use a word processor, and pause the audio frequently to ensure accuracy. It's a time-consuming but precise process, especially useful when you need to capture subtle details, emotions, or context in qualitative research.
Now that you understand how to transcribe data in qualitative research, let's move on to some tools that can make this process easier. These tools save time and improve accuracy and consistency in the transcription process.
Looppanel is a state-of-the-art tool designed for transcribing interviews for qualitative research. The platform comes with a user-friendly interface and simplifies the qualitative research process. It offers a range of features that can significantly streamline your workflow, from interview scheduling to automatic transcription and analysis.
Pricing: Free, with paid plans starting at $30 Per month.
Open Looppanel and signup using your credentials. Create your workspace and add your team members (if any).
With Looppanel, you can conduct interviews directly through the platform. Just enter your meeting link on the top right corner of your workspace and hit “Start recording.”
The platform supports video calls and screen sharing, making it ideal for remote qualitative research. The platform also allows for real-time note-taking during the interview.
Once your interview is complete, Looppanel's AI-powered transcription service goes to work. It quickly generates accurate transcripts of your interviews, saving you the time and effort of manual transcription.
After the automatic transcription is complete, you can review and edit the transcript directly in Looppanel. This allows you to correct any errors and add any additional context or notes.
You can also highlight key quotes, add tags, and create clips from your interviews. These features make it easy to identify themes and patterns across multiple interviews.
Once you've completed your analysis, you can easily export your findings or share them with team members directly through Looppanel.
Looppanel's intuitive interface and comprehensive feature set make it a powerful tool for qualitative researchers looking to streamline their process from start to finish.
Dovetail is another robust platform that offers a suite of tools for qualitative researchers. It stands out for its focus on collaborative analysis and rich data visualization capabilities.
Pricing: $29 Per Month
Atlas.ti is a well-established name in qualitative data analysis software, known for its comprehensive feature set and robust analytical capabilities.
Pricing: License starting from $48 per 6 months.
Here's what Atlas.ti offers:
Presenting qualitative data effectively is key to a strong manuscript. Let's dive deeper into some strategies:
Organize your findings under clear, descriptive headings. This helps readers navigate your results easily. For example, use headings like "Participant Experiences" or "Emerging Themes" to guide your readers.
Blend your analysis with direct quotes from participants. A good rule of thumb is to use one or two quotes per main point. This brings your data to life and supports your interpretations.
Give enough background for readers to understand the significance of your data. This might include brief descriptions of participants or settings. For instance: "Sarah, a 45-year-old teacher with 20 years of experience, noted that..."
Visual representations can help summarize complex information. A table showing themes and subthemes, or a diagram illustrating relationships between concepts, can be very effective.
Use pseudonyms or participant codes to protect identities. Be consistent throughout your manuscript. For example, you might use "P1, P2, P3" or choose fictional names.
Remember, your goal is to present a clear, compelling story about your findings that are grounded in your data.
To represent data effectively in qualitative research, use a combination of vivid descriptions, participant quotes, and organized visuals. Start by crafting detailed narratives that capture the context and emotions behind the data, making the findings relatable and engaging. Incorporate relevant quotes to bring participants’ voices into the analysis—using short quotes in-line and longer quotes as block text for emphasis. To enhance clarity, organize key findings into thematic tables or diagrams, helping readers quickly understand patterns and relationships across the data. This approach balances depth, participant authenticity, and structured insights.
Analyzing interview transcripts is a crucial and often complex process. To analyze interview transcripts in qualitative research, start by reading through all transcripts to get a broad understanding of the data. Develop a coding scheme based on your research questions, using descriptive and interpretive codes. Apply these codes consistently across the data, then identify broader themes that connect different codes. Refine your codes and themes as needed, looking for patterns, relationships, and key insights. Lastly, interpret the data in the context of your research questions and existing theories, considering that qualitative analysis is an iterative process that may require revisiting earlier steps.
Transcribing interviews is a crucial step in qualitative research. It turns spoken words into written text, allowing for in-depth analysis. Good transcription captures not just what was said, but how it was said. This process involves listening carefully, typing accurately, and noting important non-verbal cues. Whether you're using manual methods or automatic tools, the goal is the same: to create a faithful record of the interview that serves your research needs.
A verbatim transcript in qualitative research captures every word, filler, and sound as spoken, without correcting grammar. Include non-verbal cues (e.g., laughter), phonetic spelling for unclear words, false starts, and time stamps. The goal is to preserve both content and delivery for accurate analysis.
For formatting, use a consistent structure with a header (date, participant code), line numbering, labeled speakers, and time stamps. Note non-verbal cues in brackets and use uniform fonts and spacing for easy readability.
When interpreting data, include participant details, interview setting, non-verbal cues, cultural factors, and the broader research context. This ensures a fuller, more accurate analysis.
Data transcription is the process of converting audio or video recordings into written text. Qualitative research typically involves writing out interviews word-for-word. A good transcript captures not just the spoken words but also pauses, hesitations, tone of voice, and non-verbal sounds like laughter or sighs.
The choice of the transcriber depends on the project's needs, timeline, and resources. Researchers may choose to transcribe themselves for a nuanced understanding, though it's time-consuming. Research assistants can help save time, while professional services offer speed and precision but at a higher cost. Automated tools provide a budget-friendly option but often require additional editing.
Accurate transcription is fundamental to qualitative research integrity. It ensures data stays true to the source, enabling reliable analysis and credible research findings. Good transcripts allow researchers to revisit and reanalyze data, providing a solid foundation for evolving research questions or methods.
More from looppanel, transcription in qualitative research: a comprehensive guide for ux researchers.
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Journal of Medical Internet Research (Jul 2024)
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BackgroundIn-depth interviews are a common method of qualitative data collection, providing rich data on individuals’ perceptions and behaviors that would be challenging to collect with quantitative methods. Researchers typically need to decide on sample size a priori. Although studies have assessed when saturation has been achieved, there is no agreement on the minimum number of interviews needed to achieve saturation. To date, most research on saturation has been based on in-person data collection. During the COVID-19 pandemic, web-based data collection became increasingly common, as traditional in-person data collection was possible. Researchers continue to use web-based data collection methods post the COVID-19 emergency, making it important to assess whether findings around saturation differ for in-person versus web-based interviews. ObjectiveWe aimed to identify the number of web-based interviews needed to achieve true code saturation or near code saturation. MethodsThe analyses for this study were based on data from 5 Food and Drug Administration–funded studies conducted through web-based platforms with patients with underlying medical conditions or with health care providers who provide primary or specialty care to patients. We extracted code- and interview-specific data and examined the data summaries to determine when true saturation or near saturation was reached. ResultsThe sample size used in the 5 studies ranged from 30 to 70 interviews. True saturation was reached after 91% to 100% (n=30-67) of planned interviews, whereas near saturation was reached after 33% to 60% (n=15-23) of planned interviews. Studies that relied heavily on deductive coding and studies that had a more structured interview guide reached both true saturation and near saturation sooner. We also examined the types of codes applied after near saturation had been reached. In 4 of the 5 studies, most of these codes represented previously established core concepts or themes. Codes representing newly identified concepts, other or miscellaneous responses (eg, “in general”), uncertainty or confusion (eg, “don’t know”), or categorization for analysis (eg, correct as compared with incorrect) were less commonly applied after near saturation had been reached. ConclusionsThis study provides support that near saturation may be a sufficient measure to target and that conducting additional interviews after that point may result in diminishing returns. Factors to consider in determining how many interviews to conduct include the structure and type of questions included in the interview guide, the coding structure, and the population under study. Studies with less structured interview guides, studies that rely heavily on inductive coding and analytic techniques, and studies that include populations that may be less knowledgeable about the topics discussed may require a larger sample size to reach an acceptable level of saturation. Our findings also build on previous studies looking at saturation for in-person data collection conducted at a small number of sites.
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Scientific Reports volume 14 , Article number: 21440 ( 2024 ) Cite this article
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Loss to follow-up (LTFU) from Option B plus, a lifelong antiretroviral therapy (ART) for pregnant women living with human immunodeficiency virus (HIV), irrespective of their clinical stage and CD4 count, threatens the elimination of vertical transmission of the virus from mothers to their infants. However, evidence on reasons for LTFU and resumption after LTFU to Option B plus care among women has been limited in Ethiopia. Therefore, this study explored why women were LTFU from the service and what made them resume or refuse resumption after LTFU in Ethiopia. An exploratory, descriptive qualitative study using 46 in-depth interviews was employed among purposely selected women who were lost from Option B plus care or resumed care after LTFU, health care providers, and mother support group (MSG) members working in the prevention of mother-to-child transmission unit. A thematic analysis using an inductive approach was used to analyze the data and build subthemes and themes. Open Code Version 4.03 software assists in data management, from open coding to developing themes and sub-themes. We found that low socioeconomic status, poor relationship with husband and/or family, lack of support from partners, family members, or government, HIV-related stigma, and discrimination, lack of awareness on HIV treatment and perceived drug side effects, religious belief, shortage of drug supply, inadequate service access, and fear of confidentiality breach by healthcare workers were major reasons for LTFU. Healthcare workers' dedication to tracing lost women, partner encouragement, and feeling sick prompted women to resume care after LTFU. This study highlighted financial burdens, partner violence, and societal and health service-related factors discouraged compliance to retention among women in Option B plus care in Ethiopia. Women's empowerment and partner engagement were of vital importance to retain them in care and eliminate vertical transmission of the virus among infants born to HIV-positive women.
Introduction.
Lost to follow-up is a major challenge in the prevention of mother-to-child transmission (PMTCT) of HIV among HIV-exposed infants (HEI). Globally, about 1.5 million children under 15 years old were living with HIV, and 130,000 acquired the virus in 2022 1 . In the African region, an estimated 1.3 million children aged 0–14 were living with HIV at the end of 2022, and 109,000 children were newly infected 2 . Five out of six paediatric HIV infections occurred in sub-Saharan Africa in 2022 3 . Most of these infections are due to mother-to-child transmission (MTCT), accounting for around 90% of all new infections 4 , 5 . Without any intervention, between 15 and 45 percent of infants born to HIV-positive mothers are likely to acquire the virus from their mothers, with half dying before their second birthday without treatment 3 . Almost 70% of new HIV infections were due to mothers not receiving ART or dropping off during pregnancy or breastfeeding 3 .
In Ethiopia, the burden of MTCT of HIV is high, with a pooled prevalence ranging from 5.6% to 11.4% 6 , 7 , 8 , 9 , 10 . Ethiopia adopted the 2013 World Health Organization’s Option B plus recommendations as the preferred strategy for the PMTCT of HIV in 2013 11 , 12 , 13 , 14 . Accordingly, a combination of triple antiretroviral (ARV) drugs was provided for all HIV-infected pregnant and/or breastfeeding women, irrespective of their CD4 count and World Health Organization (WHO) clinical staging 11 , 13 . Besides, the drug type was switched from an EFV-based to a DTG-based regimen to enhance maternal life quality and decrease LTFU from Option B plus care 11 , 15 . The Efavirenz-based regimen consists of Tenofovir (TDF), Lamivudine (3TC), and Efavirenz (EFV), while the DTG-based regimen consists of TDF, 3TC, and DTG 13 , 15 , 16 . The change in regimen was due to better tolerability and rapid viral suppression, thereby retaining women in care and achieving MTCT of HIV targets 17 , 18 .
The trend of women accessing ART for PMTCT services increases, and new HIV infections decrease over time 3 , 19 , 20 . However, the effectiveness of Option B plus depends not only on service coverage but also on drug adherence and retention in care 4 , 15 , 21 . In this regard, quantitative studies conducted in Ethiopia showed that the prevalence of LTFU from Option B plus ranged from 4.2% to 18.2% 22 , 23 , 24 . Besides, the overall incidence of LTFU ranged from 9 to 9.4 per 1000 person-months of observation 25 , 26 , which is a challenge for the success of the program.
Qualitative studies also revealed that the main reasons for LTFU among women were maternal educational status, drug side effects, lack of partner and family support, lack of HIV status disclosure, poverty, discordant HIV test results, religious belief, stigma, and discrimination, long distance to the health facility, and history of poor adherence to ART 27 , 28 , 29 , 30 , 31 , 32 . Reasons for resumption to care were a decline in health status, a desire to have an uninfected child, and support from others 30 , 33 . Unless the above risk factors for LTFU are managed, the national plan to eliminate the MTCT of HIV by 2025 will not be achieved 34 .
Currently, because of its fewer side effects and better tolerability, a Dolutegravir (DTG)-based regimen is given as a preferred first-line regimen to pregnant and/or breastfeeding women to reduce the risk of LTFU 13 , 16 . The goal is to reduce new HIV transmissions and achieve Sustainable Development Goal (SDG) 3.3 of ending Acquired Immunodeficiency Syndrome (AIDS) as a public health threat by 2030 35 , 36 , 37 . As mentioned above, there is rich information on the prevalence and risk factors of LTFU among women on Option B plus care before the DTG-based regimen was implemented. Besides, the previous qualitative studies addressed the reasons for LTFU from providers’ and/or women’s perspectives rather than including mother support group (MSG) members. However, there was a lack of evidence that explored the reasons for LTFU and resumption of care after LTFU from the perspectives of MSG members, lost women, and healthcare workers (HCWs) providing care to women. Therefore, this study aimed to explore the reasons why women LTFU and resumed Option B plus care after the implementation of a DTG-based regimen in Ethiopia.
Study design and setting.
An exploratory, descriptive qualitative study 38 was conducted between June and October 2023. This study was conducted in two regions of Ethiopia: Central Ethiopia and South Ethiopia. These neighbouring regions were formed on August 19, 2023, after the disintegration of the Southern Nations, Nationalities, and Peoples' Region after a successful referendum 39 . The authors included these nearby regions to get an adequate sample size and cover a wider geographic area. In these regions, 140 health facilities (49 hospitals and 91 health centers) provided PMTCT and ART services to 28,885 patients at the time of the study, of whom 1,236 were pregnant or breastfeeding women (675 in South Ethiopia and 561 in Central Ethiopia).
Study participants were women who were lost from PMTCT care or resumed PMTCT care after LTFU, MSG members, and HCWs provided PMTCT care. Mother support group members were HIV-positive women working in the PMTCT unit to share experiences and provide counselling services on breastfeeding, retention, and adherence, and to trace women when they lost Option B plus care 11 , 40 . Healthcare workers were nurses or midwives working in the PMTCT unit to deliver services to women enrolled in Option B plus care.
Purposive criterion sampling was employed to select study participants from twenty-one facilities (nine health centers and twelve hospitals) providing PMTCT service. A total of 46 participants were included in the study. The interview included 15 women (eleven lost and four resumed care after LTFU), 14 providers, and 17 MSG members. Healthcare workers and MSG members were chosen based on the length of time they spent engaging with women on Option B plus care; the higher the work experience, the more they were selected to get adequate information about the study participants. Including the study participants in each group continued until data saturation.
The principal investigator, with the help of HCWs and MSG members, identified lost women from the PMTCT registration books and appointment cards. A woman's status was recorded as LTFU if she missed the last clinic appointment for at least 28 days without documented death or transfer out to another facility 15 . Providers contacted women based on their addresses recorded during enrolment in Option B plus care, either via phone (if functional) or by conducting home visits for those unable to be reached. Informed written consent was obtained, and the research assistants conducted in-depth interviews at women’s homes or health facilities based on their preferences. After an interview, eleven women who lost care were counselled to resume PMTCT care, but nine returned to care and two refused to resume care. Besides, the principal investigator, HCWs, and MSG members identified women who resumed care after LTFU, called them via phone to visit the health facility at their convenience, and conducted the interview after obtaining consent. The research team covered transportation costs and provided adherence counselling to women post-interview. A woman resumed care if she came back to PMTCT care on her own or healthcare workers’ efforts after LTFU.
One-on-one, in-depth interviews were conducted with eligible MSG members and HCWs at respective health facilities. A semi-structured interview guide translated into the local language (Amharic) was used to collect data. The guide comprises the following constructs: why women are lost to follow-up from PMTCT care, what made them resume caring after LTFU, and why they did not resume Option B plus care after LTFU with probing questions (Supplementary File 1 ). The interview was conducted for 18 to 37 min with each participant, and the duration was communicated to study participants before the interview. The interview was audio-taped, and field notes were taken during the interviews.
Thematic analysis was used to analyze the data. The research assistants transcribed the interviews verbatim within 48 h of data collection and translated them from the local language (Amharic) to English for analysis. The principal investigator read the translated document several times to get a general sense of the content. An inductive approach was applied to allow the conceptual clustering of ideas and patterns to emerge. The authors preferred an inductive approach to analyze data since there were no pre-determined categories. The core meaning of the phrases and sentences relevant to the research aim was searched. Codes were assigned to the phrases and sentences in the transcript, which were later used to develop themes and subthemes. The subthemes were substantiated by quotes from the interviews. The interviews developed two themes: reasons for LTFU and the reasons for resumption after LTFU. The findings were triangulated from healthcare workers, MSG members, and client responses. Open code software version 4.03 was used to assist in data management, from open coding to the development themes and sub-themes.
We successfully interviewed 46 participants (14 providers, 15 women, and 17 MSG members) until data saturation. The mean (± standard deviation [SD]) of age was 25.53 (± 0.99) years for women, 32.5 (± 1.05) years for MSG members, and 32.2 (± 1.05) years for care providers. Three out of fifteen women did not disclose their HIV status to their partner, and 5/15 women’s partners were discordant. The mean (± SD) service years in the PMTCT unit were 10.3 (± 1.3) for MSG members and 3.29 (± 0.42) for care providers (Supplementary File 2 ).
Women who started ART to prevent MTCT of HIV were lost from care due to different reasons. Societal and individual-related factors and health facility-related factors were the two main dimensions that made women LTFU. The societal and individual-related factors were socioeconomic status, relations with husbands or families, lack of support, HIV-related stigma and discrimination, lack of awareness and perceived antiretroviral (ARV) side effects, and religious belief. Health facility-related factors such as lack of confidentiality, drug supply shortages, and inadequate service access led to women's loss from Option B plus care (Supplementary File 3 ).
Socioeconomic status.
Lack of money to buy food was a major identified problem for women’s LTFU. Women who did not have adequate food to eat became undernourished, which significantly increased the risk of LTFU. Besides, they did not want to swallow ARV drugs with an empty stomach and thus did not visit health facilities to collect their drugs.
“My life is miserable. I have nothing to eat at my home. How would I take the drug on an empty stomach? Let the disease kill me rather than die due to hunger. This is why I stopped to take the medicine and LTFU.” (W-02, 30-year-old woman, divorced, daily labourer)
Women also disappeared from PMTCT care due to a lack of money to cover transportation costs to reach health facilities.
I need a lot of money to pay for transportation that I can’t afford. Sometimes I came to the hospital borrowing money for transportation. It is challenging to attend a follow-up schedule regularly to collect ART medications.” (W-11, 26-year-old woman, married, housewife)
Fear of violence and divorce by sexual partners were identified as major reasons for the LTFU of women from PMTCT care. Due to fear of partner violence and divorce, women did not want to be seen by their partners while visiting health facilities for Option B plus care and swallowing ARV drugs. As a result, they missed clinic appointments, did not swallow the drugs, and consequently lost care.
“Due to discordant test results, my husband divorced me. Then I went to my mother's home with my child. I haven’t returned to take the drug since then and have lost PMTCT care.” (W-03, 25-year-old woman, divorced, commercial sex worker)
Women did not disclose their HIV status to their discordant sexual partners and family members due to fear of stigma and discrimination. As a result, they did not swallow drugs in front of others and were unable to collect the drugs from health facilities.
“I know a mother who picked up her drugs on market day as if she came to the market to buy goods. No one knows her status. She hides the drug and swallows it when her husband sleeps.” (P-05, 29-year-old provider, female, 3 years of experience in the PMTCT unit) “I don't want to be seen at the ART unit. I have no reason to convince the discordant husband to visit a health facility after delivery. My husband kills me if he knows that I am living with HIV. This is why I discontinued the care.” (W-12, 18-year-old woman, married, housewife)
Women who lack partner support in caring for children at home during visits to health facilities find it difficult to adhere to clinic visits. Besides, women who did not get financial and psychological support from their partners faced difficulties in retaining care.
“Taking care of children is not business for my husband. How could I leave my two children alone at home? Or can I bring them biting with my teeth?” (W-05, 24-year-old woman, divorced, daily labourer) “ I didn't get any financial or psychological support from my husband. This made me drop PMTCT care.” (W-15, 34-year-old woman, married, daily labourer) Lack of support
Women living with HIV also had complaints of lack of support from the government, non-governmental organizations (NGOs), and HIV-related associations in cash and in kind. As a result, they were disappointed to remain in care.
"Previously, we got financial and material support from NGOs. Besides, the government arranged places for material production and goods sale to improve our economic status. However, now we didn't get any support from anywhere. This made our lives hectic to retain PMTCT care.” (W-06, 29-year-old woman, married, daily labourer)
Fear of stigma and discrimination by sexual partners, family members, and the community were mentioned as reasons for LTFU. Gossip, isolation, and rejection from societal activities were the dominant stigma experiences the women encountered. As a result, they did not want to be seen by others who knew them while collecting ARV drugs from health facilities, and consequently, they were lost from care and treatment.
“Despite getting PMTCT service at the nearby facility, some women come to our hospital traveling long distances. They don't want to be seen by others while taking ARV drugs there due to fear of stigma and discrimination by the community.” (P-10, 34-year-old provider, female, 2 years of experience in the PMTCT unit) “I am a daily labourer and bake ‘injera’ (a favourite food in Ethiopia) at someone's house to run my life. If the owner knew my status, I am sure she would not allow me to continue the job. In that case, what would I give my child to eat?” (W-12, 18-year-old woman, married, housewife) “My family did not know that I was living with the virus. If they knew it, I am sure they would not allow me to contact them during any events. Thus, I am afraid of telling them that I had the virus in my blood.” (W-05, 24-year-old woman, divorced, daily labourer)
Sometimes women went to another area for different reasons without taking ARV drugs with them. As per the Ethiopian national treatment guidelines 13 , they could get the drugs temporarily from any nearby facility that delivers PMTCT service. However, those who did not know that they could get the drugs from other nearby PMTCT facilities lost their care until their return. Others were lost, considering that ARV drugs harm the health status of their babies.
“One mother refused to retain in care after the delivery of a congenitally malformed baby (no hands at birth). She said, 'This abnormal child was born due to the drug I was taking for HIV. I delivered two healthy children before taking this medication. I don't want to re-use the drug that made me give birth to a malformed baby." (P-14, 32-year-old provider, female, 4 years of experience in the PMTCT unit)
When they did not encounter any health problems, women were lost from care, considering that they had become healthy and not in need of ART. Some of them also believe that having HIV is a result of sin, not a disease. Besides, some women believed that it was not possible to have a discordant test result with their partner.
“I didn't commit any sexual practice other than with my husband. His test result is negative. So, from where did I get the virus? I don't want to take the drug again.” (W-02, 30-year-old woman, divorced, daily labourer)
Some study participants mentioned religious belief as a reason for LTFU and a barrier to resumption after LTFU. Women discontinued Option B plus care due to their religious faith and refused to resume care as they were cured by the Holy Water and prayer by religious leaders.
“I went to Holy Water and was there for two months. My health status resumed due to prayer by monks and priests there. Despite not taking the drugs during my stay, God cured me of this evil disease with Holy Water. Now I am healthy, and there is no need to take the medicine again.” (W-09, 25-year-old woman, married, daily labourer)
Some women believed that God cured them and made their children free of the virus despite not taking ART for themselves and not giving ARV prophylaxis for their infants.
“Don't raise this issue again (when MSG asked to resume PMTCT care). I don't want to use the medicine. I am cured of the disease by the word of God, and my child is too. My God did not lie in His word.” (MSG-16, 32-year-old MSG, married, 16 years of service experience “Don't come to my home again. I don't have the virus now. I have been praying for it, and God cured me.” (W-03, 25-year-old woman, divorced, commercial sex worker)
Shortage of drug supply.
Women were not provided with all HIV-related services free of charge and were required to pay for therapeutic and prophylactic drugs for themselves and their infants. Most facilities face a shortage of prophylactic drugs, primarily cotrimoxazole and nevirapine syrups, for infants and women, and other drugs used to treat opportunistic infections. As a result, women lost their PMTCT care when told to buy prophylactic syrups for infants and therapeutic drugs to treat opportunistic infections for themselves.
“Lack of cotrimoxazole syrup is one of the major reasons for women to miss PMTCT clinic visits. In our facility, it was out of stock for the last three months. Women can't afford its cost due to their economic problems.” (MSG-03, 34-year-old provider, married, 12 years of service experience)
Most women travelled long distances to reach health facilities to get PMTCT service due to the absence of a PMTCT site in their area. Due to a lack of transportation access and/or cost, they were forced to miss clinic visits for PMTCT care.
“In this district, there were only two PMTCT sites. Women travelled long distances to get the service. To reach our facility, they must travel half a day or pay more than three hundred Ethiopian birr for a motorbike that some cannot afford. Thus, women lost the service due to inadequate service access.” (P-06, 30-year-old provider, male, 2 years of experience in the PMTCT unit)
In almost all facilities, PMTCT service was not given on weekends and holidays, despite women's interest in being served at these times. When ARV drugs were stocked out at their homes, they did not get the drugs if facilities were not providing services on weekends and holidays. When appointment date was passed, they lost care due to fear of health workers’ reactions.
Despite maintaining ethical principles to retain women in care, breaches of confidentiality by HCWs were one of the reasons for LTFU by women. Women were afraid of meeting someone they knew or that their privacy would not be respected. As a result, they lost from PMTCT care.
“I don’t want to visit the facility. All my information was distributed to the community by a HCW who counselled me at the antenatal clinic.” (W-09, 25-year-old woman, married, daily labourer)
Healthcare workers' commitment to searching for lost women, partners’ encouragement, and women’s health status were key reasons for resuming women's Option B plus services after LTFU.
The majority of lost women resumed Option B plus care after LTFU when healthcare workers called them via phone or conducted home visits for those who could not be reached by phone call.
“We went to a woman’s home, who started ART during delivery and lost for four months, travelling about 90 kilometers. She just cried when she saw us. She said, 'As long as you sacrificed your time traveling such a long distance to return me and save my life, I will never disappear from care today onward.' Then, she returned immediately and was linked to the ART unit after completing her PMTCT program.” (P-13, 32-year-old provider, male, 5 years of experience in the PMTCT unit) “We have an appointment date registry for every woman. We waited for them for seven days after they failed to arrive on the scheduled appointment date. From the 8th day onward, we called them via phone if it was available and functional. If we didn't find them via phone, we conducted home visits and returned them to care.” (P-02, 24-year-old provider, female, 3 years of experience in the PMTCT unit)
Women who got their partners' encouragement did not drop out of PMTCT care. Besides, most women returned to care and restarted their ARV drugs due to partner encouragement.
“I did not disclose my HIV status to my husband, which was diagnosed during the antenatal period. I lost my care after the delivery of a male baby. When my husband knew my status, rather than disagreeing, he encouraged me to resume the care to live healthily and to prevent the transmission of HIV to our baby. This was why I resumed care after LTFU.” (W-14, 28-year-old woman, divorced, daily labourer)
Some women returned to Option B plus care on their own when they felt sick and wanted to stay healthy.
“When I felt healthy, I was away from care for about eight months. Later on, when I sought medical care for the illness, doctors gave me medicine and linked me to this unit (the PMTCT unit). I returned because of sickness.” (W-06, 29-year-old woman, married, daily labourer)
This qualitative study assessed the reasons why women left the service and why they resumed care after LTFU. The study aimed to enhance program implementation by providing insights into reasons for LTFU and facilitators for resumption from women's, health professionals', and MSG members' perspectives. We found that financial problems, partner violence, lack of support, HIV-related stigma and discrimination, lack of awareness, religious belief, shortage of drug supply, poor access to health services, and fear of confidentiality breaches by healthcare providers were major reasons for LTFU from PMTCT care. Healthcare workers’ commitment, partner encouragement, and feeling sick made women resume PMTCT care after LTFU.
In this study, fear of partner violence and divorce were identified as major reasons that made women discontinue the PMTCT service. Men are the primary decision-makers regarding healthcare service utilization, and the lack of male involvement in the continuity of PMTCT care decreases maternal health service utilization, including PMTCT services 41 , 42 . In addition, economic dependence on men threatened women not to adhere to clinic appointments without their partner’s willingness due to fear of violence and divorce 28 . Thus, strengthening couple counselling and testing 13 , male involvement in maternal health services, and women empowerment strategies like promoting education, property ownership, and authority sharing to reach decisions on health service utilization were crucial to retaining women in PMTCT care. Besides, legal authorities and community and religious leaders should be involved in preventing domestic violence and raising awareness about the negative effects of divorce on child health.
Financial constraints to cover daily expenses were major reasons expressed by women for LTFU from PMTCT care. Consistent with other studies, this study revealed that a lack of money to cover transportation costs resulted in poor adherence to ART and subsequent loss of PMTCT care 27 , 29 , 43 . As evidenced by other studies, lack of food resulting from financial problems was a major reason for LTFU in the study area 30 . As a result, women prefer death to living with hunger due to food scarcity, which led them to LTFU. Besides, women of poor economic status spent more time on jobs to get money to cover day-to-day expenses than thinking of appointment dates. Thus, governments and organizations working on HIV prevention programs should strengthen economic empowerment programs like arranging loans to start businesses and creating job opportunities for women living with HIV.
Despite continuous information dissemination via different media, fear of stigma and discrimination was a frequently reported reason for LTFU among women in PMTCT care. Consistent with other studies conducted in Ethiopia and other African countries, our study identified that fear of stigma and discrimination by partners, family, and community members are significant risk factors for LTFU 27 , 28 , 29 , 31 . As a result, women did not usually disclose their HIV status to their partners 28 , 32 so that they could not get financial and psychological support. This highlights the need to intensify interventions by different stakeholders to reduce HIV-related stigma and discrimination in the study area. Women's associations, community-based organizations, and religious, community, and political leaders should continuously work on advocacy and awareness creation to combat HIV-related stigma and discrimination.
Our study revealed that a lack of support for women made them discontinue life-saving ARV drugs. In developing countries like Ethiopia, most women living with HIV have low socio-economic status to run their lives, and thus they need support. However, as claimed by the majority of study participants, the government and organizations working on HIV programs were decreasing support from time to time. This was in line with qualitative studies such that lack of support by family members or partners 27 was identified as a barrier to adherence to and retention in PMTCT care 27 , 28 , 29 , 30 , 32 . Organizations working on HIV programs need to design strategies so that poor women get support from partners, family members, the community, religious leaders, and the government to stay in PMTCT care. Moreover, some women thought incentives and support must be given to retain them in Option B plus care. Thus, HCWs should inform women during counselling sessions that they should not link getting PMTCT care to incentives or support.
Women infected with HIV want to be healthy and have HIV-free infants, which could be achieved by proper utilization of recommended therapy as per the protocol 27 , 43 . However, women’s religious beliefs were found to interfere with adherence to the recommended treatment protocol, made them LTFU, and refused resumption after LTFU. Although religious belief did not oppose the use of ARV drugs at any time, women did not take the medicine when they went to Holy Water and prayer. As evidenced by previous studies, lost women perceived that they were cured of the disease with the help of God and refused to resume PMTCT care 27 , 30 . This finding suggests the need for sustained community sensitization about HIV and its treatment, engaging religious leaders. They need to inform women on ART that taking ARV drugs does not contradict religious preaching, and they should not discontinue the drug at any religious engagement.
Once on ART, women should not regress from care and treatment due to problems related to the facility. Unlike the study conducted in Malawi, which reported a shortage of drugs as not a cause of LTFU 29 , in the study area there was a shortage of drugs and supplies to give appropriate care to women and their infants and to retain them in care. They did not get all services related to HIV free of charge and were requested to pay for them, including the cotrimoxazole syrup given to their infants. The finding was consistent with the study conducted in Malawi, where the irregular availability of cotrimoxazole syrup was mentioned as a risk factor for LTFU 32 .
On some occasions, there may also be a shortage of ARV prophylaxis (Nevirapine and Zidovudine syrups) at some facilities for their infants that they couldn’t get from private pharmacies. Services related to PMTCT care were expected to be free of charge for mothers and their infants throughout the care. Ensuring an adequate supply of prophylactic and therapeutic drugs should be considered to prevent the MTCT of HIV and control the spread of the disease among communities via appropriate resource allocation. Facilities should have an adequate supply of ARV prophylaxis and should not request that women pay for diagnostic services. Besides, they always need to provide cotrimoxazole syrup free of charge for HIV-exposed infants.
Lack of awareness of a continuum of PMTCT care among women is a major challenge to retaining them in care. Women who experienced malpractice against standard care practice and had misconceptions about the disease were at higher risk for LTFU. Those women who forgot to take ARV drugs due to different reasons (maybe due to poor counselling) did not get the benefits of ART. Improved counselling and appropriate patient-provider interaction increase women’s engagement in care and reduce the risk of LTFU 28 , 44 . Thus, proper counselling on adherence, malpractice, and misconceptions should be strengthened by healthcare providers in PMTCT units to create optimal awareness for retention.
Maintaining clients’ confidentiality is the backbone of achieving HIV-related treatment goals. However, some women disappear from PMTCT care due to a lack of confidentiality by HCWs delivering the service. Although not large, women claimed a lack of privacy during counselling, and disclosing their HIV status in the community was practiced by some healthcare professionals. The finding was consistent with the study conducted in developing countries, including Ethiopia, where lack of privacy and fear regarding breaches of confidentiality by healthcare workers were identified as risk factors for LTFU 31 , 32 , 44 . Thus, HCWs should deliver appropriate counselling services and maintain clients’ confidentiality to develop trust among women.
The validity of the findings of this study was strengthened by the triangulating data collected from women, MSG members, and HCWs delivering PMTCT service. Besides, the study included women from the community who had already been lost from care during the study, which minimized the risk of recall bias. However, we recognized the following limitations. First, the study did not explore the husband’s perspective to validate the findings from women and HCWs. Second, the study may have different reasons for LTFU for women who were unreached or unwilling to participate compared to those who agreed to be interviewed. Thus, further studies are advised to include the husband’s perception to validate their concern and to address all women who have lost care.
Financial constraints to cover transportation costs, fear of partner divorce and violence, HIV-related stigma and discrimination, lack of psychological support, religious belief, shortage of drug supply, inadequate service access, and breach of confidentiality by HCWs were major reasons for women’s lost. Healthcare workers’ commitment to searching for lost women, partners’ encouragement to resume care, and women’s desire to live healthily were explored as reasons for resumption after LTFU. Women empowerment, partner engagement, involving community and religious leaders, awareness creation on the effect of HIV-related stigma and discrimination for the community, and service delivery as per the protocol were of vital importance to retain women on care and resume care after LTFU. Besides, HCWs should address false beliefs related to the disease during counseling sessions to retain women in care.
All data generated or analysed during this study are included in this article and its Supplementary Information files.
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The authors acknowledge the staff of the South Ethiopia and Central Ethiopia Regional Health Bureaus for their technical and logistic support. Moreover, the authors sincerely thank the research assistants who translated and transcribed the interview. The authors would also like to thank the study participants who were involved in the study.
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Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
Wolde Facha, Takele Tadesse & Eskinder Wolka
School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
Ayalew Astatkie
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W.F. was involved in the study's conception, design, execution, data acquisition, analysis, interpretation, and manuscript drafting. T.T., E.W., and A.A. were involved in the project concept, guidance, and critical review of the article. All the authors have reviewed and approved the final manuscript and agreed to publish it in scientific reports.
Correspondence to Wolde Facha .
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The authors declare no competing interests.
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Child and Adolescent Psychiatry and Mental Health volume 18 , Article number: 117 ( 2024 ) Cite this article
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While research has emphasized the importance of parental support for LGBTQIA + youth wellbeing, there remains limited understanding of parental experiences with nonbinary children, particularly those prepubescent. This study aimed to explore how parents of nonbinary children ages 5–8 learn to support their child’s identity, examining initial reactions, emotional processes, supportive behaviors, societal responses, and associated challenges and rewards.
A qualitative study was conducted using Reflexive Thematic Analysis (RTA) within a framework of ontological relativism and epistemological constructivism. Nine parents of nonbinary children aged 5–8 from the Northeastern United States participated in semi-structured interviews lasting 60–80 min. Questions explored various aspects of parenting nonbinary children, including the child’s gender identity, parental feelings, experiences sharing the child’s identity, and challenges and rewards of raising a gender-diverse child. The research team, comprising individuals who identify as trans, genderqueer, and nonbinary, employed collaborative coding and thematic development.
Four main themes were constructed: (1) Parents hear and support their child’s nonbinary identity , this theme highlights immediate acceptance and efforts parents make to affirm their child’s gender; (2) Parents learn about ways cisnormative society harms their child , here, parents recognize the societal pressures and barriers their children face; (3) Parents take significant and proactive steps to affirm their child , this theme documents the actions parents take to support their child in environments that invalidate their identity; and (4) Gender is just one aspect of who my child is , this theme reflects on parental insights of gender as just one part of their child’s overall personhood.
This study provides insights into the experiences of parents supporting young nonbinary children, emphasizing the importance of affirming expressed identity, the parent-child relationship, and proactive support in navigating cisnormative societal structures. Findings highlight the transformative experience of parenting nonbinary children, with parents often challenging their own preconceptions of gender and coming to more nuanced understandings. These results can inform supportive interventions and policies for nonbinary children and their families, and we hope to contribute to a growing body of research that shifts narratives towards joy, resilience, and community in trans and nonbinary experiences.
Over the past three decades, cultural discourse around ‘intensive parenting’ [ 1 ] has emphasized the need to dedicate significant time, energy, and resources to raising children in a way that prioritizes their ability to communicate needs and self-advocate [ 2 ]. While current literature highlights the importance of parental support for the wellbeing of LGBTQIA + youth [ 3 , 4 , 5 ], there is still very little research focused on the experiences of parents of trans and nonbinary (TNB) children [ 6 ].
In this context, Hidalgo et al. [ 7 ] propose a gender-affirmative model of supportive parenting that views genderqueernes not as a disorder but as a culturally influenced variation shaped by biology, development and socialization. This model acknowledges that gender is fluid rather than binary and suggests that the struggles children experience with identity often stem from societal prejudices like transphobia and the institution of cisnormativity, an element of the social, political and economic system in our society designed to force individuals into a gender and sex binary, while punishing behavior and expression that deviates from it. Legal and medical professionals are primary enforcers of cisnormativity. Despite being society’s supposed experts on gender and sex, as a field they fail to acknowledge the self-determination of gender and conceptualize sex as a spectrum [ 8 ]. This begins with the assessment of genitals at birth and the 'corresponding' gender assignment [ 9 , 10 ].
Amidst the ongoing discourse on gender fluidity, we are witnessing a significant amount of anti-transgender violence. Trans people–especially TNB children– are increasingly becoming the targets of political campaigns, fearmongering, and public debates that challenge their right to exist. In 2023, the number of anti-trans legislation in the U.S. surged dramatically, from 174 (26 passed) to 604 (87 passed), more than tripling the record set the year before. By July 2024, 635 bills had been introduced into state legislatures, with 123 active and 47 passed [ 11 ]. These laws aim to exclude TNB children from accessing healthcare, updating legal documents to reflect their gender, using appropriate bathroom facilities, and participating in school activities such as sports and clubs [ 12 ].
Given these vicious attacks on children, the role of the family in supporting their TNB child has become increasingly critical. Research consistently demonstrates that family dynamics significantly impact the psychological health of LGBTQIA + youth, with supportive environments providing a buffer against stigma, and promoting overall wellness [ 3 , 4 , 5 ]. Recent longitudinal studies underscore that while TNB youth face increased risks for adverse mental health outcomes, their wellbeing improves significantly within supportive family contexts [ 13 ]. Central to this support is the acceptance and understanding of nonbinary identities and expressions, including the adoption of gender-neutral language by family members, which enhances the child’s perception of acceptance from their parents [ 14 , 15 , 16 ].
The sharing of pronouns is becoming increasingly popular in the U.S. and beyond, including Western countries like the UK and Canada, as well as parts of Asia, especially among younger generations and progressive circles [ 17 , 18 , 19 , 20 , 21 ]. A 2020 Pew Research Center survey found that over half of Americans are aware of pronouns that are not ‘she/her’ and ‘he/him’, with younger people being more likely to use them. This trend reflects a growing global awareness of gender existing beyond the binary, as well as the importance of validating these identities through inclusive language. As awareness and popularity of gender diversity grows, it has become popular to share pronouns in introductions and email signatures [ 22 ], and transphobic people have been attempting to politicize pronouns in an effort to villainize TNB people. The adoption of gender-neutral pronouns, like the singular ‘they’, which gained recognition when Merriam-Webster named it the word of the year in 2019, underscores an ongoing challenge to binary norms.
In this paper, we define ‘nonbinary’ as an umbrella term encompassing individuals who self-identify as a gender outside the gender binary, and/or does not identify as always and completely being just a man or a woman, recognizing gender as existing along a spectrum. Various expressions of nonbinary identities are present, such as identifying as both a boy and a girl, experiencing gender as fluid or fluctuating, feeling a partial connection to one gender without fully aligning with it (known as demigender), embracing multiple gender identities, adhering to two-spirit traditions rooted in Indigenous cultures, adopting gender concepts from ‘unrelated domains’ (known as xenogender), or ‘lack of’ a gender [ 23 ]. While terms like ‘trans’ and ‘nonbinary’ originate from Western contexts, they strive to encompass a diverse and evolving spectrum of gender identities. It is important to note that while many nonbinary individuals may identify as trans, not all do.
For nonbinary people, recognition and affirmation is deeply intertwined with language use. Employing gender-affirming language—such as neutral labels, pronouns, and grammatical structures—in environments like schools, workplaces, healthcare facilities, and the home, is crucial for encouraging “self-definition,” as well as “visibility and understanding” of nonbinary identities [ 24 ]. In Budge and colleagues [ 14 ]’ five-year study of families with a TNB member, pronouns were best understood by the end of the research period. Their findings suggest that conducting regular family check-ins on gender identity, pronouns, and gender expression can significantly enhance family members’ understanding of the individual’s needs. Matsuno and colleagues [ 25 ] found that support can be further conceptualized as advocating for the child’s rights across various settings, expressing love verbally and nonverbally, and actively seeking community and professional resources for the growth of both the parent and the child.
Some studies have documented that initial parental reactions to their child’s TNB identity such as shock, fear, and worry, often hinder their acceptance and support [ 26 , 27 ]. These emotional barriers, compounded by cisnormativity and transphobia in society, may lead to reluctance in acknowledging or understanding TNB identities [ 28 ]. Moreover, entrenched beliefs in binary and immutable gender norms further complicate parental efforts to support nonbinary children. In fact, Matsuno and colleagues [ 4 ]’ study found that among parents of TNB youth, half of those who were unsupportive had nonbinary children, indicating potentially greater challenges in support within this demographic.
McGuire and colleagues [ 29 ] theorized that the presence of a TNB individual in a family leads to other members of the family challenging existing theories about essentialist and social constructionist notions of gender and sexuality. Given that gender is “messy, plural and in constant evolution” [ 30 ], these authors argue that describing it requires “dynamic approaches […] that can account for within-person variability over time” ( [ 29 ] p.63). This perspective underscores the evolving nature of gender identities within families and highlights the need for flexible mental frameworks that are welcoming to the diverse expressions of nonbinary individuals.
Addressing emotional barriers, transphobia, and cisnormativity necessitates parents being equipped with the knowledge and skills to navigate the social exclusion of nonbinary identities effectively [ 27 , 28 ]. Facilitators of supportive parental behaviors include building social support networks, and accessing informational resources [ 4 ]. Connecting with others, whether online or in person, is crucial for parents of TNB youth, highlighting the importance of making support groups accessible [ 31 ]. Exposure to positive portrayals of gender diversity also plays a crucial role in fostering affirming parental attitudes and behaviors [ 32 , 33 ]. Schools often lack knowledge about gender diversity and inclusive practices suitable for all children, regardless of their gender identity. Therefore, in these environments, parents have to ‘make room’ for their children by informing school staff about their child’s chosen names, pronouns, individual needs, and sometimes even providing basic education on gender identity and diversity [ 34 ].
The trans family systems framework, proposed by Robinson and Stone [ 35 ], challenges traditional family dynamics by integrating trans identities as an analytical category [ 36 ]. This category questions the sex/gender distinction, challenges biological determinism, exposes the production of normativity, and disrupts cisnormative gender practices. The trans family systems approach explores how either investments in or divestments from cisnormativity shape both family interactions and individual experiences. The concept of cisgender divestments [ 35 ] describes how family members resist cisnormative gender norms to support their gender-diverse children. Actions such as providing a variety of toys, clothes, and activities (i.e., ‘gender buffet’ [ 37 ]), and validating TNB identities (i.e., ‘giving gender’ [ 38 ]), can be seen as forms of cisgender divestment.
Parents are not only socializing their children, rather, parents are also re-socializing themselves. This means that many caregivers are rethinking their own relationship to gender as they engage in ‘gender-expansive childhood socialization’ [ 39 ]. Initially, children are often required to ‘prove’ their identity. Subsequently, these same parents of TNB children often find themselves explaining their children’s gender to others [ 40 ]. Many caregivers transition from confusion and uncertainty to ‘pride’ and ‘empowerment,’ becoming advocates for TNB people beyond their children [ 29 ]. Learning to affirm one’s TNB child not only enhances family cohesion, but also contributes to a broader divestment from cisnormativity.
The evolution of parental responses to nonbinary identities reflects a broader societal shift from pathologizing to affirming non-normative identities. According to de Bres [ 41 ]’ critical review of research on parents of gender-diverse children, early studies from the 1990s and 2000s predominantly took a pathologizing stance toward gender diversity in children, often validating parents’ negative reactions. During the 2010s, research began to shift towards a more affirming perspective, although it still frequently equated the experiences of a ‘parental transition’ to a process of grief [ 42 ], continuing a level of pathologization. Hidalgo and Chen [ 43 ] assert that parents experience both external stressors (e.g., school discrimination, rejection by family and friends, and verbal abuse) and internal stressors (e.g., negative messages about gender diversity and ‘fitting in’ difficulties) while supporting their nonbinary child’s identity. Parents worry about their child’s well-being in a society that often invalidates gender diversity. Supportive parents might also face stigma and a reduction in social safety, such as losing connections with family, friends, and religious communities. Additionally, they must address their own cisnormative beliefs and navigate barriers in educational and healthcare settings. These challenges can impact their ability to support their nonbinary child [ 25 ].
Since the late 2010s, there have been numerous documented stories of parents highlighting their support for TNB children by shielding them from societal stigma, embracing a gender-affirming approach, and normalizing gender diversity in their home and broader community [ 41 ]. Recent studies have shown how parents are reframing the narrative of grief, instead focusing on the rewards of parenting a TNB child, which include ‘greater critical awareness’ [ 44 ], ‘expanded knowledge’ [ 45 ], and ‘personal growth as a parent’ [ 46 ]. Abreu et al. [ 47 ] describe this shift as “using radical hope to create meaning and purpose for their child’s existence and envisioning positive future possibilities for them” (p.7). Exploring positive experiences in parenting TNB children can counterbalance the traditional focus on challenges, reflecting many parents’ narratives of joy and transformation.
In summary, the literature underscores the critical role of family support in shaping the wellbeing of nonbinary youth, highlighting the transformative power of parental acceptance and understanding. However, existing research predominantly focuses on trans boys and girls, primarily adolescents, and their families. Little attention has been paid to families with young children who identify beyond the gender binary. Our study aims to “contribute something to a rich tapestry of understanding” Footnote 1 by exploring, in a general sense, the experiences of parents of nonbinary children, guided by our research question, ‘How do parents of nonbinary children learn to support their child?’ Specifically, we seek to understand initial reactions to their children sharing their gender, and changes over time, as well as emotional processes, supportive behaviors, societal responses, and the challenges and rewards for parents in this context. By exploring these dynamics, we aim to contribute insights that can inform supportive interventions and policies tailored to meet the needs of young nonbinary children and their families.
Our study Footnote 2 , Footnote 3 was initially conceived by [AUTHOR 3– MASKED] and further developed with [AUTHOR 1– MASKED] during a summer scholars’ program that supports juniors and seniors in conducting ten-week research projects with faculty mentors. [AUTHOR 3– MASKED], a Brown trans, genderqueer, and nonbinary Mexican immigrant who holds a doctoral degree from the largest university in Latin America, also serves as an Assistant Professor at a private ‘little ivy’ university in the U.S. [AUTHOR 1– MASKED] is a white, trans, genderqueer, and nonbinary undergraduate student at the same institution Footnote 4 .
The research question for this study was addressed within a paradigmatic framework of ontological relativism and epistemological constructivism. This fully qualitative approach (i.e., ‘Big Q’), combined with Reflexive Thematic Analysis (RTA), fosters a nuanced and reflective research practice. Unlike more structured and positivistic methods, ontological relativism views reality as diverse and shaped by human actions and interactions [ 48 ]. Interpretations of reality differ across cultures and contexts, acknowledging that reality is not fixed. This study is based on the idea that people construct meaning from their experiences (constructionism) and express this through their individual perspectives (relativism). Epistemological constructivism posits that knowledge is dynamic and evolves as individuals reflect on their beliefs and experiences, contributing to collective understanding. This qualitative analysis values the symbolic power of language in data collection, recognizing its role in meaning-making [ 48 ].
Parents were eligible to participate in our study if their child identified beyond the gender binary (see page 1), was aged between 3 and 8 years, and lived in the Northeastern U.S. (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont) to make transportation expenses feasible. Prepaid train rides, parking fees, and/or bus fare were provided.
Between July and August 2022, we created a database and contacted organizations supporting LGBTQIA + individuals/families. In October 2022, specialists from the National Institutes of Health Clinical and Translational Science Program (NIH CTSI) launched a one-month Facebook targeted advertising campaign (UL1TR002544) and posted an advertisement on Craigslist from October 2022 to March 2023. Eleven parents completed a Qualtrics questionnaire, and nine met the inclusion criteria (see Table 1 ), proceeding to the scheduling of an in-person visit. Families received a $50 USD gift card as compensation. Despite efforts to sample a diverse population, seven participating parents were white, one was Asian-white, and one was Asian. Additionally, all were married, lived in the Greater Boston Area, and earned between the categories of $50,000 to $74,999 USD, and $150,000 USD and above, with a mode of $150,000 USD and above. For reference, the median household income in Boston was $81,744 in 2021 Footnote 5 . Although we desired to interview parents of children ages 3–5, we only recruited those with children ages 5–8.
The semi-structured interview consisted of 10 predetermined questions, with consent documented from all participants. The interviews typically lasted 70 minutes on average, ranging from 60 to 80 minutes. Questions were designed to explore various aspects of parenting children who identify beyond the gender binary, including describing the child’s gender (e.g., ‘How would you describe your child’s gender?’), changes in gender identity over time (e.g., ‘Has their gender changed over time?’), parental feelings towards the child’s gender identity (e.g., ‘How do you feel about them being [preferred term for child’s gender]?’), experiences sharing the child’s gender identity with others (e.g., “How have people in your child’s life reacted to them being [preferred term]?’), as well as the challenges and rewards of raising a gender-diverse child (e.g., ‘What has been the most rewarding part of raising a [preferred term] child?’). The study adhered to ethical standards set by institutional and national research committees, following the principles of the 1964 Helsinki declaration and its subsequent amendments or comparable ethical standards.
[AUTHOR 2 - MASKED], a white graduate student who identifies as trans, genderqueer, and nonbinary, transcribed the interviews. In summer 2023, [AUTHOR 3– MASKED], along with [MASKED], conducted a 5-day workshop on Reflexive Thematic Analysis (RTA). Although exclusively mentioning our skin color, gender identities and educational attainment may resemble a ‘brief confessional’ - see the first paragraph of the Method-ology section and [ 49 ] -, on the workshop’s first day, each author spent a 4-hour period crafting their own reflexivity statement, dedicating the initial hour and a half to writing and the remaining time to sharing. These statements proved invaluable throughout the analysis.
Under AUTHOR 3’s guidance, who regularly practices this exercise each semester, the other authors were prompted to reflect on their intersecting identities, social privileges, and marginalities. They were asked to consider how these positions influence their perspectives in the research, and how it may affect how they are perceived by others. Additionally, they reflected on how their backgrounds, life experiences, and beliefs shape their worldview. Next, the authors examined their relationship with knowledge, scholarship, and research practice, considering their research training, experiences, and understanding of ‘good quality’ research, as well as institutional pressures including the capitalist demand to ‘publish or perish.’ They also explored their methodological preferences and how these choices impact the research process and outcomes. Finally, AUTHOR 3 encouraged them to revisit reflexivity regarding their identities and experiences in relation to the project and nonbinary children. They considered how their positions intersect with this topic and examined any assumptions about individuals inside and outside the gender binary. These statements, while lengthy, fostered a sense of closeness and safety among the group. Ideally, they would be included here, but due to the constraints of academic publishing and the emphasis on brevity, interested readers can contact the corresponding author for access.
In summary, the three of us identify as trans, genderqueer, and nonbinary individuals, and share the following beliefs: (a) reality and truth are constructed, contingent, and multiple; (b) gender is experienced in a unique way by everyone; (c) nonbinary individuals know who they are [ 50 ]; and (d) we prioritize compassion and curiosity over comprehension [ 51 ].
Thematic Analysis is a method for identifying, analyzing, and interpreting patterns across qualitative data. Reflexive Thematic Analysis (RTA) differentiates itself by valuing “.a subjective, situated, aware and questioning researcher, a reflexive researcher.” ( [ 48 ], loc. 1246). We followed the six-phase RTA process: familiarizing ourselves with the interviews, engaging in collaborative coding , developing , reviewing , refining themes, and finally, producing this analytic report.
While familiarizing ourselves with the data is an ongoing process with no single approach, coding is structured and systematic. We carefully read each interview at least twice, identifying and labeling segments relevant to our research question (‘How do parents of nonbinary children learn to support their child?’). Not all segments were coded, as codes are “.ultimately guided by your research question and purpose.” ( [ 48 ], loc. 2953).
Collaborative coding enhanced our understanding, interpretation, and reflexivity, rather than achieving consensus on codes. The three authors worked together, discussing and reflecting on their ideas and assumptions. Our aim was to “.gain richer or more nuanced insights collaboratively, not t o reach agreement on every code.” ( [ 48 ], loc. 3028). This structured exploration ensured a thorough analysis for theme development and attempted to safeguard against accusations of cherry-picking .
We used an inductive approach with predominantly semantic codes. Pure induction is impossible as “.we bring various perspectives, theoretical and otherwise, to our meaning-making,” and as a result “our engagement with data is never purely inductive” ( [ 48 ], loc. 3027). Semantic codes capture expressed meanings, often mirroring participants’ language, unlike latent coding, which prioritizes underlying meanings that are not explicitly stated.
Developing initial themes from our codes involved several processes. We explored areas of similar meaning within the data, clustering potentially connected codes into candidate themes, and examining these patterns of meaning. Each cluster was considered independently, in relation to the research question, and within the broader analysis. We recognized that data “do[es] not speak for [itself];” as researchers, we interpret and tell the story of our data [ 48 ].
Phase four provided a crucial check on initial theme development through re-engagement with coded data extracts and the entire dataset. This iterative process ensured that our analysis effectively addressed our research question with a compelling narrative, remaining grounded in the data. We ensured each theme captured a distinct core point and offered rich diversity and nuance, verifying that themes were coherent, distinct, and comprehensive.
We constructed four themes that emerged from the accounts of participating parents. The first theme, Parents hear and support their child’s nonbinary identity , details how children share their nonbinary identity with their parents and documents parents’ initial reactions and meaning-making processes. The second theme, Parents learn about ways cisnormative society harms their child , captures how parents learn about the struggles their child faces living in a cisnormative society as a nonbinary person. The third theme, Parents take significant and proactive steps to affirm their child , documents participants taking action to support their child in environments that do not validate their gender identity. The fourth and final theme, Gender is just one aspect of who my child is , discusses insights and conclusions drawn by parents about their child, as well as gender identity. These themes are discussed in detail below.
Theme 1: Parents hear and support their child’s nonbinary identity.
Among all parents, a universally reported experience was receiving a clear and straightforward declaration from their children about their nonbinary identity. Some examples of these explicit statements include: “They always say, I’m not a girl or a boy” (Dahlia), “[They] tell me that [they are] both a boy and a girl” (Helena), and “They describe themself as ‘they/them’” (Iris). All parents were told by their child the way they had been referred to and understood thus far was not correct (i.e., as exclusively a girl or a boy).
All but one parent’s reaction to their child informing them of their gender identity was immediate support for their desired changes (e.g., pronouns and name): “‘Can you call me they/them?’ ‘Okay, great’” (Iris); “Awesome! Whatever you want, we will follow you and affirm you” (Fiona); “We just said ‘okay,’ and we did it” (Grace). The overwhelming support from these parents reflects other child-led approaches, placing affirmation of the child’s lived experience at the center of their parenting style, and validating their emotions and desires even without necessarily understanding them [ 2 ].
Some parents initially found it challenging to adjust to using their child’s new pronouns or name, but they all made their best effort. Bianca candidly shared that her husband struggled a lot with they/them pronouns, “not for lack of love or trying, [he] just didn’t have [.] much practice”. The time and effort all parents had to spend to retrain their brain to meet the expressed needs of their child follows the previously mentioned movement towards ‘intensive parenting’ [ 1 ].
Despite the dominant paradigm of a gender binary in Western society, no parents reported skepticism of the validity of their child’s nonbinary identities. In fact, the majority of the parents were active in divesting from cisnormativity [ 35 ], with six parents explicitly making an effort to raise their children in ways that were not constrained by traditional gender norms. Adrienne explained that she was “quite strongly opposed to having a very gendered upbringing,” and Grace shared a similar sentiment, emphasizing that she wanted her children to “play with whatever [toys] they want,” and that she would buy “whatever clothing” for them. The actions described by these parents exemplify forms of cisgender divestment [ 35 ] and a movement away from strict ideas of what a child assigned male at birth (AMAB) or assigned female at birth (AFAB) should look like or how they should act.
Despite the traditional paradigm of a gender binary in society, no parents reported skepticism of the validity of nonbinary identities. In contrast, the majority of the parents valued divesting from cisnormativity [ 35 ], with six parents explicitly making an effort to raise their children in ways that were not constrained by traditional gender norms. Adrienne explained that she was “quite strongly opposed to having a very gendered upbringing,” and Grace shared a similar sentiment, emphasizing that she wanted her children to “play with whatever [toys] they want,” and that she would buy “whatever clothing” for them. The actions described by these parents exemplify forms of cisgender divestment [ 35 ] and a movement away from strict ideas of what a child assigned male at birth (AMAB) or assigned female at birth (AFAB) should look like or how they should act.
Additionally, four parents spoke with their child about gender being more than just boy or girl before their child named themselves nonbinary. Adrienne had “a book about gender identity,” and Fiona had “books that have nonbinary characters and just talk about gender identity and expression.” Bianca “read some books where there was they [pronouns] as an option” and “talked about what that meant ‘’ with her child. Grace could not “point to a moment when [they] started talking about gender and pronouns because it’s [always] been incorporated.” Alternatively, a few parents made no mention of proactively sharing gender-diverse stories, with Christine describing their early conversations around gender as “talking about boys and girls […] talking within the binary, because […] that’s sort of the usual thing.”
Overall, the majority of these parents demonstrated active efforts to divest from expectations of cisnormativity, even before learning their child was nonbinary, with some even deconstructing the gender binary through supportive environments that benefit TNB youth [ 35 , 37 , 38 ]. However, not sharing previous efforts to divest from cisnormativity is also a common experience among both the parents in our study, and parents of TNB children in other studies [ 29 , 40 ]. There is no evidence supporting the absurd notion that home environments can ‘turn children trans’ [ 52 ], and the briefly popular theory of ‘rapid onset gender dysphoria’ has been debunked [ 53 ]. Conversely, supportive home environments help TNB children freely explore and come to understand themselves ( [ 23 , 52 , 53 ], and actually fosters a ‘stronger attachment’ between parent and child [ 42 ].
While all parents supported their child’s gender identity, some still grappled with doubts and concerns along the way. Iris and Grace questioned whether their child understood what they were saying or was simply using they/them pronouns “because [a peer] said it” (Grace). Grace “didn’t know” whether the desired name/pronoun changes “would stick,” a sentiment echoed by Adrienne’s husband. Additionally, there were concerns about whether the child was “transitioning too young.” Christine expressed caution, not wanting to “act too quickly,” or “be seen to be pushing something on the child,” while Emiko mentioned concerns about their child being perceived as “too young” possibly reflecting societal worries. This experience is not uncommon among parents of TNB children [ 29 ]. These parents faced a challenging situation; there is no script for raising nonbinary individuals -as we will discuss further-, and currently, there is a widespread fear-mongering targeting parents of TNB children [ 53 ]. Despite these doubts and uncertainties, all but one parent in the study immediately affirmed their child. Many parents expressed worries about their child’s future as a nonbinary person in society, but they understood this as a concern to bear with their spouse, not one with which to burden their child.
Two factors which may have helped parents overcome their doubts, or at least put them aside, are their observations of cisgender nonconformity in their children before the children shared their nonbinary identity, and the insistence of the children themselves.
Bianca, Fiona, Emiko, and Iris’s children who were AMAB all enjoyed wearing dresses, an example of physical presentation not stereotypically associated with their assigned gender. Other parents noted verbal expressions: Adrienne’s child would “call themself a boy or a girl […] depending on what [they] felt more like,” while Christine recalled her child, AFAB, stating plainly that they “don’t always feel like a girl.” Therefore, when these children expressed a desire to use different names or pronouns, it did not necessitate a complete overhaul of how the parents understood them. Reflecting on her reactions to her child sharing their nonbinary identity, Grace shared that she “[was not] really surprised,” Adrienne stated that “[she] had often suspected [her child’s] idea of gender was not [rigid],” and Emiko adding that she felt her child “has never cared about [society’s] gender boundaries.”
Multiple parents mentioned that seeing their child “feel strongly” (Bianca) about their gender identity, “even in the face of lots of situations where it would have been easier [to not identify as nonbinary]” (Dahlia), helped affirm their support. Christine noted that her child’s insistence made it “increasingly clear” to her that their gender identity was both “very important to them” and “that it was real,” and Emiko added “[they] have a sense of agency.”
Although the parents may not fully comprehend their child’s identity, they showed respect for their child as a self-advocate and are committed to centering their child’s expressed needs [ 1 , 2 ]. This can be seen as a way of prioritizing compassion and curiosity over comprehension [ 51 ].
Theme 2: Parents learn about ways cisnormative society harms their child.
With that said, aside from a parent who also identifies as nonbinary, the parents lacked prior understanding of the specific needs of a nonbinary child. We are all familiar with parenting scripts tailored for raising cisgender children, reinforced by abundant resources and support networks, both formal and informal. However, the same cannot be said for parents of nonbinary children. Christine shared her experience of researching how to “best support” her child, finding that there “[is not] a lot out there.” The unique nuances and challenges faced by nonbinary children have not been sufficiently discussed or documented to establish rudimentary frameworks or ‘best practices’ [ 2 ]. As a result, these parents found themselves having to find other ways to learn about their child’s needs, largely through conversations with them as well as observing their child’s reaction to experiences, for example, Fiona described herself as a “sponge” absorbing so much new information. Despite their affirmation of the child’s gender identity and use of validating language, it became evident to the parents that their support needed to extend beyond the home.
One common experience for parents was observing their child feeling pressure to “[not] rock the boat” by “bucking” (Fiona) societal norms of gender presentation. Fiona’s AMAB child enjoyed wearing dresses and having their nails painted at home, but intentionally wanted both off before going to school. Helena’s AMAB child was generally open about their feminine expression, “I am a girl, or I feel like a girl,” they would say, yet emphasize, “but it’s secret and I only want you and daddy [to know].” Emiko described an interaction where her AMAB child said, “Most people think that I’m a boy, so if I wear a dress, they’re confused.” The parent followed up, asking “Is that what’s stopping you from wearing a dress?” to which the child responded, “A little bit.” Grace reported her child hesitating about sharing their pronouns with their transphobic grandmother, saying “I don’t want my relationship with grandma to suffer because I’m nonbinary.” This really struck Grace, “the kid is eight years old saying that to me.” All the parents with these experiences shared some understanding gained about their child. Helena reflected that her child “has some awareness […] that being nonbinary is different.” Fiona understood that her child “was self-conscious […] about what people would think,” and Emiko, similarly, saw that her child was feeling pressure from a “societal ‘you should do this.’” It became very clear to the parents that their children were keenly aware of cisnormativity and felt pressure to conform.
Parents also observed barriers to inclusion that exist in what are mundane, day-to-day moments for cisgender people. Some reported their children getting frustrated when confronted with the categorizations, including bathrooms, sections in stores, and birthday party goodie bags. Parents also witnessed their children’s worry and frustration in the context of various forms of potential and realized micro- and macro-aggressions, including experiences of minority stress [ 54 ]. For instance, not wearing button up shirts in public “because they were worried that they would be called he” (Bianca), deciding it was “not worth it” to attend to an otherwise ideal camp that was separated into ‘boys’ and ‘girls’ (Emiko), feeling like they “have to” wear a pin that says ‘They/Them’ to avoid being misgendered at school (Grace), and frequently correcting people in public (Adrienne, Bianca, Grace), among many other experiences. Bianca best summarizes what all parents come to understand: their children are made “very upset” about the fact that “the world is not set up to include them.”
When these children leave their homes, they confront a world that overwhelmingly does not validate their identity. Through conversations and observed experiences, parents came to understand distress, anger, and shame their children feel at being constantly invalidated, and gained insights into what kinds of support and affirmation their children need.
Theme 3: Parents take significant and proactive steps to affirm their child.
As expanded on in the second theme ( Parents learn about ways cisnormative society harms their child) , parents came to recognize the importance of their child’s gender being affirmed and that society is not currently set up to do that. These parents observe their child often having to either self-advocate or endure micro- and macro-aggressions. Following the pattern of intensive parenting, these parents felt a strong desire to advocate for and protect their children, “to make things a little smoother for [their] life” (Iris). It is understood that parental support has a strong influence on the mental health and wellbeing of TNB people [ 14 , 15 ], highlighting the importance of this approach by parents.
One area of identity affirmation parents recognized as lacking for their children was in models of nonbinary identities. The parents express an understanding that their child rarely, if at all, sees people who share that aspect of their identity. Bianca wanted her child to get more “exposure” to people who “exist outside of this rigid gender binary,” and as Christine points out, “they see plenty of cisgender people. I’m not worried about them not having cisgender role models.” As a result, parents take steps to correct this. Christine took a book that did not explicitly address nonbinary experiences and “spent six hours whiting out and writing new words over every part of it.” Adrienne started going out of her way to attend a queer rock-climbing club in an effort to “cultivate a [queer] community” for her child, and introduced them to a nonbinary person she met there. Iris and Dahlia also made explicit efforts to provide their children with gender-diverse representation.
Same-gender models are understood to be important in one’s development and understanding of gender [ 55 , 56 ]. While children imitate individuals with traits they identify with, and not just people of their gender [ 55 ], much research has reaffirmed the importance of same-gender models. Although these studies have generally focused on girls and young women, research from nonbinary author Koonce [ 57 ] states from their professional experience “.it is in the mirroring of others that [non-binary identities] truly take form” (location 3,021). Kuper and colleagues [ 56 ] add that exposure to models with diverse gender presentations is crucial in supporting ongoing gender exploration.
Parents come to understand that the act of negotiating one’s way through transphobic and cisnormative systems is a “heavy lift” (Bianca). They do not want their child to have to be “constantly” (Bianca) educating and correcting people, especially “[not] by themselves” (Christine). Parents would rather take on the “forefronting” (Dahlia) and “emotional labor” (Christine) themselves. The overwhelming sentiment from parents is that “[their child] should not be expected to do” (Grace) the work of making space for themselves.
Despite the diverse realities of the children and experiences of the parents, a pattern emerged: parents respected their child’s ability to know and communicate their desires and leveraged their abilities and resources as adults to support them. A common example involved pronouns in public. According to Garcia [ 58 ], ‘gender math’ refers to the complex calculations parents must make when attempting to prioritize their child’s well-being while simultaneously accounting for restrictive systems of cisnormativity. For decisions regarding sharing their child’s gender identity, Bianca and her child devised a collaborative scale-ranking system to gauge the significance of individuals. “Is this an important person that we need to [understand your gender]? Is this person not worth it? Can this person potentially be toxic?” In similar fashion, Emiko and her child “came up with a system” to organize how much they care about the person in question, and gave us the example, “Do we care about the gas station attendant? Not really.” Powell and colleagues [ 42 ] similarly found that sharing the child’s gender with extended family was “often led by the child” (p.4). Additionally, a parent in their study shared that when they had made the decision without their child’s consent it “caused a big problem” (p.4). This kind of collaborative approach empowers the child to make decisions while also providing the assurance of a supportive caregiver during challenging circumstances.
In situations where the child was subject to explicit invalidation and/or transphobia, parents very readily took strong action. Adrienne shared that her child’s grandma refused to correctly gender the child. In response, she “nearly asked her to leave,” and was currently undergoing a “grandma rehabilitation plan.” Adrienne made sure it was clear to both the grandparent and the child that transphobic behavior was “[not] welcome under this roof.” Christine and Grace shared instances of invalidating behavior by their child’s classmates relating to gender which prompted them both to contact their child’s teachers, demanding that they “do better” (Christine) to make their child feel safe and included in the classroom. Ehrensaft [ 59 ] advocates for parental involvement in actively dismantling social pathologies that adversely affect trans youth such as gender policing and harassment. She recommends methods such as direct intervention within broader institutional spheres, encompassing schools, social institutions, and policy-making bodies.
While strategies were initially discussed between the parent and child, many parents became exceptionally proactive in their support. The parents’ efforts extended beyond casual conversations. While correction after an instance of misgendering or other aggression is crucial, the parents recognized the importance of minimizing these experiences before they occur. Bianca decided to coach her child’s soccer team “because [they] wanted to make sure [the team] was a safe space [for their child]” and that all the children “could hear role modeling of using ‘they’ [pronouns].” Emiko reached out to her child’s teachers and sports coaches, urging them to adopt inclusive language and suggesting alternatives to gendered terms: “You could use, ‘alright players,’ or ‘alright team.’” Fiona found a “How to They/Them book” immensely helpful, sent it to everyone in her family and is “making [them] read it.” Christine and her husband expended “a lot of emotional labor” to get their family on the “right page.” She shares that advocating for her child has been “a huge time investment on [her] part,” but that she is “fighting the good fight,” echoing a sentiment shared by all parents.
Theme 4: Gender is just one aspect of who my child is.
In society, there’s a prevalent notion that undergoing a gender ‘transition’ entails a departure from one’s ‘pre-transition’ self. This misconception is especially pronounced in expectations regarding clothing and presentation, where there is a common belief that AMAB individuals who are TNB must present as feminine, and vice versa. However, this presumption extends beyond outward appearance to encompass behavior and preferences as well. It originates from the entrenched concept of gender binary, whereby deviation from assigned gender norms is often perceived as a desire to conform to the norms of the ‘opposite gender.’ Through the parents’ demonstrated willingness to let their child’s expressed emotions and demonstrated actions alter their preconceived notions and internalized frameworks, the parents came to understand that very little about their child’s ‘being’ changed after sharing their nonbinary identity [ 2 , 42 ]. These experiences helped the parents expand their understanding of what gender is, but also what gender is not: a determining characteristic of a person’s identity.
In Grace’s experience, her child’s nonbinary identification “did not change anything about [their] clothes or identity or books or anything.” In comparing her child pre- and post-nonbinary identification, Adrienne explains “they wear the same things they’ve always worn. The main [difference] is they tell people that they’re nonbinary.” Instead of basing presentation off of gender, Bianca observed her child dressing “for practical reasons,” namely the weather and season, and Helena shared her child’s understanding of clothes being as plain as “[these shoes] are on my feet and I’m wearing them.” Fiona shared that at first when learning that her AMAB child was nonbinary, her brain struggled holding it as they felt that her child “seem[ed] like such a boy.” Fiona had to open her mind to what nonbinary could mean through meeting people of diverse gender identities and presentations, and reading books, and arrived at the conclusion that “if there are 7 billion people, [there are] 7 billion [gender] identities.”
A big takeaway explicitly communicated by six parents, is that gender is just a part of how they understand their child as a person. Powell and colleagues [ 42 ] had the same finding with parents of TNB children between the ages of 10 and 18. Parents acknowledge that while the identification with naming a nonbinary identity (nonbinary, boy-girl, etc.) holds personal, practical, and political significance, and while it can be and is a very important identity to many people, it does not provide a singular definition of their child. Iris identifies her child’s nonbinary identity as just “another characteristic, [but] not what defines [their child].” Dahlia adds that “[gender] is a piece of information, but it’s not the most interesting or important thing about who they are.” Christine understands the nonbinary identity to be a component of their child’s identity in addition to “loving Lego and loving dresses, and jumping off stuff, and hitting stuff with other stuff. It’s just part of their kernel, you know?” Expressions like the highlighted quote are not meant to invalidate or diminish the nonbinary experience. Instead, they seek to understand gender as an integral aspect of the child’s being, one that significantly influences their interactions within society. Nevertheless, this acknowledgment does not necessitate a complete overhaul of their core identity. In reflecting, Iris shares, “I try to think of them as a person that I’m finding out about and not a set of expectations,” and that she tries to “not to make [gender] a big deal […] a guiding thing that I have taken from [my child].” Adrienne adds, “It’s the same child that I’ve always known, just using different pronouns,” and Bianca is glad that her child feels that “[they] can be anything [they] want. But [does not] have to be not something.” These parents came to recognize that their child’s nonbinary gender was simply an extension of who the child already was. Bianca found this experience “really joyous,” and for Helena, seeing their child being themself was “indescribably heartwarming.” Dahlia feels that it is “such a gift,” and “rewarding to know that they know” they can be their true self, and Fiona echoes that she feels “happy… that they’ve discovered that this can be their identity.”
We examined how parents of nonbinary children learn to support their child through the lenses of ontological relativism and epistemological constructivism. We interpreted these parents’ experiences, taking on the role of ‘subjective storytellers’ [ 48 ]. Despite space limitations, our aim was to offer a comprehensive exploration and contribute nuanced insights to the limited, yet growing, understanding of parental support for gender affirmation among TNB youth [ 6 , 13 , 14 , 25 , 31 , 47 , 52 ]. Our aim was not merely to ‘fill a gap’ but to enrich the broader understanding that we and others are collectively developing [ 48 ]. Our strength lay in adhering to a ‘Big Q’ approach that challenges the structured and positivist paths towards absolutisms.
As a result, RTA was the perfect methodology for our study. We were interested in “…process and meaning, over cause and effect; a critical and questioning approach to life and knowledge; the ability to reflect on the dominant assumptions embedded in [our] cultural context—being a cultural commentator as well as a cultural member; the ability to read and listen to data actively and analytically […] a desire for understanding that is about nuance, complexity, and even contradiction, rather than finding a nice tidy explanation…” ( [ 48 ], loc. 1334). We made active efforts to reflect on dominant assumptions and divest from cisnormativity in our daily lives [ 35 ]. Moreover, we, the authors–cultural commentators– are still learning what it means to be trans, genderqueer, and nonbinary–cultural members– in a society that has traditionally only had space for men and women. We are collectively working on this tapestry of understanding.
While all parents supported their child’s gender identity, some struggled with doubts and concerns, highlighting the nuances and even contradictions in their experiences. Parents faced a complex situation with no clear guidance on raising nonbinary children, amidst widespread fear-mongering targeting parents of TNB children [ 47 , 53 ]. Although we focus on parents and avoid pathologizing and stigmatizing rhetoric, it is a matter of fact that TNB children are facing intense violence and legislative attacks, with more anti-trans laws introduced in the past nine years than in the previous 240, aiming to restrict their healthcare, legal recognition, participation in school activities, and more [ 9 , 12 , 60 ]. In the face of this anti-trans violence and exclusionary legislation, recent scholarship emphasizes that trans communities extend beyond struggle and hardship, embracing resilience and thriving through radical hope [ 47 , 61 , 62 , 63 ].
de Bres [ 41 ]’s recommendations fit well within this call to shift the narrative towards joy. This is why we aimed to ask similar questions and create a realistic but uplifting account that acknowledges struggles but celebrates the joys of parenting a nonbinary child. As de Bres [ 41 ] reminds us, the questions researchers ask shape the responses they receive. Common questions like ‘When did you first notice your child was gender-diverse?’ often prompts a ‘coming-out’ narrative. Shifting to asking questions such as ‘What has been the most rewarding part of raising a [preferred term] child?’ can prompt reflection through a more joy- and strengths-based lens.
One of our primary insights was the discovery that parents approached parenting a nonbinary child within minimal preconceptions. This finding was surprising, considering prevalent societal narratives, often steeped in fearmongering as previously discussed. While we recognize that not all initial parental reactions may have been disclosed during interviews, those that were shared demonstrated a nuanced understanding of nonbinary identities. Parents deconstructed much of society’s cisnormativity and debunked transphobic misconceptions. Particularly notable was their collective sentiment that their child’s nonbinary identity is ‘just’ simply another integral aspect, as natural as their love for activities like soccer or building with Legos, and as natural as their other children identifying as girls or boys.
Furthermore, we were impressed by their comprehension of the fluidity inherent in their children’s nonbinary identities, embracing expressions that may encompass elements considered traditionally masculine or feminine. This included recognizing that their child’s desire to wear a dress and paint their nails on one day and wear pants and a t-shirt another is not merely an ‘exploration’ but a genuine expression of their gender.
We were heartened by the rapid evolution in societal acceptance of genderqueer identities in recent years. As early as 2020, during our collective virtual interactions due to the COVID-19 pandemic, we began to regularly encounter individuals displaying pronouns next to their names -a small but significant shift. Four years later we observe a growing recognition and understanding of ‘they/them’ pronouns, alongside remarkable parental support for young children in the Northeast who identify as nonbinary. Beyond just gender, this progress inspires hope for a world that embraces ambiguity and rejects rigid absolutes, celebrating the diverse spectrum of human experience rather than confining individuals to either one thing or another.
Throughout our exploration of parental experiences, we were struck by their responsiveness to their children’s desires and needs. While following a child’s lead is not a new concept, these parents had minimal pre-existing knowledge of TNB experiences. Their support required a leap into uncharted territory, yet with open minds and attentive listening, they made decisions that appeared highly supportive and affirming of their child’s gender identity to us. Witnessing this support brought us profound joy and optimism amidst pervasive fear mongering rhetoric and transphobic narratives.
Research consistently highlights improved outcomes for TNB individuals when their families support their gender identities. While the relationship between familial support and wellbeing is nuanced, it remains clear that supportive parenting plays a pivotal role. Even within a transphobic and cisnormative society that often lacks understanding of pronoun usage and genderqueer identities, and remains fixated on binary norms, these parents demonstrate that by valuing their nonbinary children’s communications of needs, they can profoundly make them feel seen, loved, and supported.
In conclusion, our pioneering study focuses uniquely on the experiences of parents of nonbinary children, applying rigorous ‘Big Q’ principles and emphasizing narratives of joy. Utilizing RTA, we hope to contribute valuable insights to understanding and supporting young nonbinary children and their families. Christine’s words resonate deeply: “Sometimes I just say to my husband, ‘We’re doing it, this child’s heart is intact. This child’s heart is strong, and intact. And, no matter what, we’re doing it right if their heart is intact’.” This sentiment underscores our commitment to providing shared experiences and celebrating the resilience of TNB communities throughout our research. Our work adds to the growing body of research aimed at promoting understanding and support for nonbinary individuals.
We hope our findings contribute to the shift away from adult-centric perspectives and towards respecting children’s ability to be cognizant of their own needs, as well as understand themselves in the context of broader society. As our study shows, children will be who they are, and will express themselves, despite any barriers. Banning learning or restricting ideas does not control children; it only harms them. Violence against children should never be normalized. Families and youth deserve legal autonomy, and everyone should be educated about the diversity that exists in this world. We are optimistic that these experiences will inspire advocates and lawmakers to recognize children as experts in their own lives, as the parents in our study did.
Our research highlights how parents can deconstruct binary conceptions of gender in favor of more open-minded perspectives, positively impacting both family dynamics and children’s well-being. We are hopeful that these narratives will encourage adults who work with children -therapists, social workers, teachers, coaches, pediatricians, and others- to re-examine their own understanding of gender. To parents who may be struggling or worried about their nonbinary child: we hope our work offers guidance and hope. The gender binary can be unlearned, and new pronouns can be practiced. You can learn from your child and from the growing resources available. Your child knows themself. You will continue to learn about them and their identity, just as they do, and just as every person does.
The authors confirm that the data supporting the findings of this study are available within the article. Due to the sensitive nature of the research and limitations of participant consent, the supporting data is not available for sharing beyond what is presented in the article.
In qualitative research “… you are not seeking to show that you have found an empty cell in the spread-sheet of ultimate truth about the topic, which your study will fill in. We think it’s useful to get beyond the filling the gap idea, and conceptualize our qualitative analyses as contributing something to a rich tapestry of understanding that we and others are collectively working on, in different places, spaces and times” (Braun & Clarke, 2022, loc.5192).
The term ‘method’ risks becoming “...a practically orientated descriptive summary, rather than a more theoretically-oriented and reflexive discussion of what, why and how one did the research” (Braun & Clarke, 2022, loc.5232).
“How Do Children Identifying Beyond the Gender Binary and Their Parents Understand Gender?” (IRB ID: CR-01-STUDY00002649).
We emphasize the significance of dynamic and reflective positionality in research, advocating to move beyond static researcher-centered perspectives towards amplifying marginalized communities (Salinas-Quiroz et al., 2024). We also recognize challenges posed by word limits and traditional research guidelines yet stress the continual integration of reflexivity to enrich qualitative inquiry.
Although we collected demographic data, it will not be fa central part of our analysis. The research on demographic factors related to TNB identities is limited, and our sample size is too small to draw significant conclusions about ‘potential correlations.’ Moreover, it’s important to consider broader historical contexts. While there is a common belief that white, wealthy individuals with higher education levels are more socially progressive, focusing solely on these factors overlooks how legal, medical, and academic institutions have systematically reinforced racial, gender and class hierarchies. Emphasizing these demographics risks overshadowing the richness of individual experiences, which is the true strengths of qualitative research.
lesbian, gay, bisexual, transgender, queer or questioning, intersex, and sexual. The + represent other identities that are noy included in the acronym
Transgender and nonbinary
Reflexive Thematic Analysis
Transgender and Gender Diverse
Assigned Male At Birth
Assigned Female At Birth
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We are most thankful to Jocelyn Demos Utrera for helping us with the conceptualization, data curation, investigation and methodology.
This research was supported by [MASKED], and [AUTHOR 3– MASKED]’s start-up research funds (Faculty Research Funds), [MASKED].
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Noah Sweder & Fernando Salinas-Quiroz
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The aim of the research is to shed light on the experiences of a group of nursing students enrolled in a yoga elective course who practiced yoga regularly for 14 weeks, regarding yoga and the phenomenon of doing yoga, with a qualitative approach.
This qualitative study was conducted at a public university in Izmir, Turkey. The study sample consisted of 61 students enrolled in the 1st-year yoga course at the Department of Nursing, Faculty of Health Sciences. Except for two students, 59 of them participated in the study. Participants attended a face-to-face yoga course once a week for 1.5 h over a 14-week period. Each session comprised 30 min of theoretical instruction and 60 min of practice. In data collection, an interview form containing five questions was used to understand nursing students' experiences and thoughts about practicing yoga. In addition, A4 sized papers in different colors were presented to the participants. The participants were asked to draw and/or cut a shape by choosing the paper in the color that most evokes yoga. Then they were asked to explain why they chose this color and why they drew this shape. Participants were given one hour. After the data were collected, the pictures drawn by the participants and their descriptions of their drawings were transferred to the computer and included in the analysis. Qualitative data were hand-coded by the researchers. Within in-vivo coding, code names were formed from the participants' expressions. The findings analyzed by content analysis were interpreted with the literature under the themes by presenting quotations.
It was determined that the participants used nature figures (sun, cloud, tree, sky, flower) (f = 75), people doing yoga (f = 12), and sound, light and other figures (bird sound, wave sound, candle, light bulb, traffic light, heart, eye, left key, peace, swing, India, circle, etc.) (f = 29) in the shapes they drew and cut out on A4 sized papers in different colors to describe their experiences and thoughts about practicing yoga. The participants mostly chose blue-green-yellow colors ( n = 41). With qualitative question analysis, a list of codes was created from the answers given by the students to the questions for the phenomenon of “doing yoga” (number of codes = 98). After the analysis of the data, four categories were reached. The category names and frequency numbers explaining the phenomenon of practicing yoga were distributed as “symbol of health and serenity (f = 345)”, “the way to place goodness in your heart (f = 110)”, “the most effective way to meet the self (f = 93)” and “no guarantee of relaxation (f = 71)”, respectively.
The results indicate that yoga is perceived by nursing students as a multifaceted practice that evokes a range of emotional and physical responses. Most participants associate yoga with symbols of health, serenity, and self-awareness, often using natural elements and blue-green-yellow the colors to represent these feelings. However, there is also recognition that yoga may not guarantee relaxation for everyone, as some students reported difficulties in meditation, physical discomfort, and challenges in focusing. The study highlights the variability in how individuals experience yoga, emphasizing both its positive effects on well-being and the potential challenges in practice. These findings suggest that while yoga is widely valued for its calming and health-promoting benefits, it may not be universally effective in achieving relaxation or mindfulness.
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Yoga is a practice that has been subject to many different interpretations and translations over thousands of years. Patanjali's phrase "Yogas Chitta Vrittis Nirodha" translates to "Yoga is the cessation of the fluctuations of the mind" in English [ 1 ]. Hagen & Hagen (2024) have emphasized that yoga is commonly understood in society as a tool for mental calmness and balance[ 2 ]. This provides a comprehensive model for personal development, contributing to the individual's balanced harmony in every aspect—mental, physical, emotional, and spiritual [ 3 , 4 ]. By developing inner awareness as well as meta-awareness, yoga offers a roadmap for individuals to see and understand their own state and surroundings more clearly [ 5 ]. Yoga enhances physical functionality by alleviating pain and discomfort, thereby reducing physical ailments. Moreover, yoga offers physical health benefits, including increased strength and flexibility, as well as improved posture [ 6 , 7 , 8 , 9 , 10 ].
According to Bhavanani (2014), yoga extends beyond mere physical or mental health; it also addresses emotional, social, and spiritual needs [ 11 ]. By increasing personal awareness, it can strengthens both inner attachment and social connections [ 6 , 9 , 12 ]. Research shows that participants' self-confidence increases during yoga practice, and they might gain better skills to manage their mental health. This underscores not only the physical advantages of yoga but also its significant contributions to mental and emotional well-being [ 8 , 9 , 13 , 14 ]. Yoga can fosters heightened bodily awareness, elevates mood, and enhances overall well-being. It also promotes self-acceptance, personal fulfillment, and social harmony. This holistic process provides psychological relief and mental tranquility, aiding in the management of common mental health issues such as anxiety and depression [ 11 ].
Today, young adults increasingly experience stress, pressure, and mental health issues [ 15 ]. Research links young people's stress levels to high demands at school and the pressure to meet these demands [ 16 ]. Additionally, lack of physical activity and sleep problems also can contribute to their difficulties in coping with these issues [ 17 , 18 ]. Academic expectations from parents, especially those from middle-class families, can further increase the pressure on young people, leading them to evaluate their self-worth solely based on their achievements. This adds to the existing academic pressures, causing young people to worry more about future educational and career opportunities [ 19 ].
Yoga can physically contribute to nervous system balance by decreasing stress-related sympathetic activity and stimulating the parasympathetic system. Consequently, it can positively impact stress and mental health issues, particularly in young people. Nursing students, who often undergo a stressful educational period, can also benefit from these effects [ 20 , 21 , 22 , 23 , 24 ]. Therefore, it is recommended to integrate mindfulness programs, including breathing techniques, meditation, and yoga, into the nursing curriculum [ 21 , 22 ]. In the literature, a yoga course was integrated into the nursing curriculum in Turkey for the first time by Erkin and Aykar (2021) [ 20 ]. Most studies with students in the field of yoga in the literature are quantitative, although yoga has been studied in college students using qualitative methods, no studies found in nursing. This is one of the starting points of this research. The aim of the research is to shed light on the experiences of a group of nursing students enrolled in a yoga elective course who practiced yoga regularly for 14 weeks, regarding yoga and the phenomenon of doing yoga, with a qualitative approach. This qualitative study tries to fill this gap in the literature by explaining the imaginary meanings that nursing students attending yoga courses attribute to the yoga experience.
The research, designed in a qualitative type, was conducted during the 2018–2019 academic year. In line with the qualitative research approach, a purposeful sampling method was used. The qualitative method sees the experience of reality as subjective, varying from person to person. Moreover, it is a reliable method for studying a little known or understood area. Therefore, a qualitative descriptive design was adopted to explore students’ knowledge and perspectives [ 25 ].
Participants attended a face-to-face yoga course once a week for 1.5 h over a 14-week period. Each session comprised 30 min of theoretical instruction and 60 min of practice. The content of the yoga course is detailed in Table 1 . The theoretical component included a weekly 30-min PowerPoint presentation covering topics such as the history of yoga, meditation, breathing techniques (pranayama), yoga poses (asanas), chakras, mindfulness, and compassion. The practical sessions were conducted in a tranquil and dimly lit room, following a structured 60-min schedule: 15 min of pranayama (e.g., ocean breath, equal breathing, cooling breath, humming bee breath, alternate nostril breath, kapalbhati pranayama), 30 min of hatha yoga asanas involving gentle stretching and strengthening exercises with each pose held for 5–10 breaths and repeated five times, 5 min of meditation, and 10 min of shavasana. These sessions were led by a yoga instructor (first author) registered with the Yoga Alliance. No home practice was required. According to the course rules, students were allowed up to 20% absenteeism. At the end of the 14-week period, it was determined that students were absent for an average of 1.5 weeks. There was only one change in the planned yoga protocol. Although it was initially planned to use one breathing technique every two weeks, all breathing techniques were combined based on the students’ feedback and used in the sessions after students learned all the techniques (after the 6th week). Class attendance was encouraged through messages in a WhatsApp group. However, attendance was not included in the scoring.
The sample of the research was planned to consist of first-year students enrolled in the elective course "Yoga" in the Nursing Department of the Faculty of Health Sciences at İzmir Democracy University in Izmir ( N = 61). Two students did not participate in the study because the topic and objectives did not interest them. Data were collected from a total of 59 nursing students on a voluntary basis. After the yoga course, the last week interviews were conducted with 59 participants who voluntarily agreed to participate in the study. Of the participants (n:59), 40 were female and 19 were male, with ages ranging from 18 to 21. Forty-six participants described their health perception as "good," nine as "very good," and four as "poor." (Appendix 1).
Data collection was conducted using a structured interview form alongside a creative activity where participants were asked to draw a picture and write a text representing the concept of doing yoga. Data were collected through structured interviews guided by a pre-developed interview Schedule (see Appendix 1). The structured interview form developed for this study included seven open-ended questions and prompts designed to elicit detailed responses from the participants regarding their experiences with the yoga course. Prior to commencing data collection with the main participant group, the interview schedule was pilot tested with five nursing students who met the inclusion criteria but were not part of the final sample. This pilot testing allowed for refinement of the interview questions and ensured clarity and comprehensiveness.
After obtaining the necessary permissions for the research, the students engaged in the yoga course were comprehensively briefed on the study’s objectives, content, methodology, and the individuals responsible for its execution. The last week of "Yoga" course (14th week), students asked to draw a picture and write a text representing the concept of doing yoga. Each student was given colored A4 papers and, for those who wished to use them, colored pencils in the classroom environment. Before starting to draw, students were asked to write their gender on the back of the paper, but not their name or surname. In addition to the picture they drew, they were asked to write their thoughts about yoga and what they drew regarding the concept of doing yoga on a separate piece of paper or in appropriate spaces on their drawing paper. Besides students filled the interview form. They also filled out a structured interview form to capture their experiences and thoughts about practicing yoga. Participants were given one hour to complete the task. After the data were collected, the drawings and their related descriptions made by the participants were digitized and included in the analysis [ 26 ]. For security purposes, the data were stored in Google Drive™ accessible to authors.
To examine subjective experiences, the techniques of "drawing" and "description" were used together, attempting to integrate the strengths of both methods. Participants were provided with A4 papers in different colors and asked to choose the color that most reminded them of yoga. Starting from the theme of "The meaning of doing yoga for them," participants were asked to draw pictures representing their perceptions and to write descriptions related to their drawings. In a similar approach referred to as "projective technique" in the literature, the drawing is accepted as a tool for reflecting emotions. Projection means expression and is based on the assumption that "an individual's behavior is a reflection of their personality" [ 26 , 27 ].
The data were analyzed using an inductive approach. Inductive analysis involves coding the data to categorize it, identifying relationships between these categories, and reaching a holistic picture based on this. The key point in data analysis in this study was to create categorical labels embedded in the data [ 26 , 27 ]. In this study, a code list was developed, data were coded, categories were created, and data were reported within these categories. Data analysis was conducted by the researchers through coding. For some themes, in-vivo coding, which is included in the qualitative research methodology of grounded theory, was used as an inductive coding process. In vivo coding involves creating a theme tag using the code that comes directly from the data, i.e., the participant's own expressions [ 28 ].
All these processes were carried out in collaboration with two field experts (ÖE, AÇ). Similar codes were grouped together to form a certain number of categories and reported to establish the main idea in the data. Comparing codes and categories with the literature aimed to contribute to the validity of the data analysis. At the end of the data collection phase, a conceptual model related to the topic was developed by the researchers [ 26 ]
The research team acknowledges the importance of reflexivity in qualitative research. The first researcher, who has a PhD degree in public health nursing with 16 years of experience in nursing, is an instructor of yoga courses for undergraduate nursing students. The researcher maintained a critical awareness of their own biases and assumptions that could potentially influence the data analysis throughout the research process. We aimed to minimize bias by employing a systematic thematic analysis approach and by regularly discussing the emerging themes with a second author, who is a specialist on qualitative research and has a qualitative PhD thesis in public health nursing. This cooperation contributed to ensuring the findings’ objectivity and reliability. Regretfully, it was not possible to get direct participant input on the findings because of the anonymous nature of the data collection process. The third researcher, who is a master’s degree student in public health nursing with 3 years of clinical experience in nursing, is an instructor of yoga. Nonetheless, we think that the utilization of rich participant quotes in conjunction with the iterative analytic process guarantees that the results truly reflect the participants’ experiences with the yoga course.
Before starting data collection, information about the research was provided to the school administration, permission was obtained, and contact was made with the participants. Approval was obtained from the Ethics Committee of Manisa Celal Bayar University (02/12/2019, no:20.478.486). Participation was based on voluntariness and willingness, and students were informed about sensitive points related to the teacher-student relationship (such as participation or non-participation in the research not affecting their performance evaluations, etc.). Written informed consent to participate was obtained from all of the participants in this study.
In qualitative research, the researcher investigating the problem is at the center of the research. The main measurement tool in the research is the researcher themselves. Therefore, the issue of objectivity has always been at the center of methodological debates in social sciences. In qualitative research, the concept of "trustworthiness" is considered instead of validity and reliability [ 27 ]. Various criteria of trustworthiness were considered in the processes of this research.
During the data analysis phase, in the creation of the code list, and in the interpretation of the findings, a comprehensive perspective was attempted to be reflected through a thorough literature review on the subject. All records in the data collection and analysis processes were kept systematically. Quotations were made from all data sources. The frequencies of the drawings and descriptions were determined, and those with high frequencies and those that were strikingly related to the topic were included. The data collection and data analysis processes were reported in detail as far as space limitations allowed, and original quotations from the data were included. Furthermore, in the quotations, descriptions written by the participants in their own handwriting were also used.
The number of participants in the study was 56. This number is considered sufficient for an in-depth exploration of the research topic. Students were instructed to create an illustration and compose a text depicting the concept of practicing yoga. Each student received colored A4 paper, and colored pencils were provided for those who wished to use them within the classroom setting. Prior to beginning their drawings, students were asked to indicate their gender on the back of the paper, ensuring that they did not include their name or surname. Alongside their drawings, students were required to write their reflections on yoga and describe what they had drawn related to the practice of yoga, either on a separate sheet of paper or in suitable spaces on their drawing paper. Additionally, students completed an interview form. Participants were allotted one hour to finish the assignment. This approach allowed for a thorough and comprehensive examination of the participants’ perspectives. To enhance transferability, purposive sampling was employed in the study. In purposive sampling, participants are selected to have specific characteristics relevant to the research topic. This approach ensured that the participants’ perspectives would represent the research topic effectively. To ensure dependability, interview questions, data collection, and analysis were consistently applied throughout the entire research process. In this study, to achieve confirmability, all stages of the research were described openly and transparently, aiming to reduce the impact of researcher bias. All transcripts and notes used in the study were stored for reference.
The reporting process of the study adhered to the COREQ (CONsolidated criteria for Reporting Qualitative research) guidelines, as outlined by Tong et al. (2007) [ 29 ]. The study follows CLARIFY 2021 guidelines for reporting yoga research [ 30 ].
Participants expressed their experiences and thoughts about practicing yoga by drawing and cutting shapes on A4-sized papers of different colors. It was determined that they used nature figures (sun, cloud, tree, sky, flower) (f = 75), figures of people practicing yoga (f = 12), and other figures such as sound, light, and others (bird sound, wave sound, candle, light bulb, traffic light, heart, eye, key, peace, swing, India, circle, etc.) (f = 29). Participants mostly chose blue-green-yellow colors ( n = 41).
A code list was created from the responses of students to questions about the concept of "practicing yoga" through qualitative question analysis (number of codes = 98). After analyzing the data, four categories were reached. The categories describing the concept of practicing yoga were distributed as follows in terms of symbols and frequency numbers: "symbol of health and tranquility (f = 345)", "the way to place goodness in your heart (f = 110)", "the most effective way to meet oneself (f = 93)", and "no guarantee of relaxation (f = 71)" (Fig. 1 ).
Concepts and codes identified in the qualitative analysis of nursing students' perception of the phenomenon of "practicing yoga"
The subcategories that received the most references from nursing students in explaining the phenomenon of practicing yoga under this category are "Serenity and Peace (f = 169)", "Comfort (f = 120)", "Health, Well-being, Happiness, and Energy (f = 56)". Below is the picture and description of the participant related to the subcategory "Symbol of Health and Serenity" (Fig. 2 ): "The reason for choosing the shape of a cloud and the color blue is that it brings me peace, reminds me to take deep breaths and be grateful. It reminds me that there are beautiful things in life and that I need to enjoy life." Additionally, "when you start doing yoga, your thoughts change, you feel rested, and your heart fills with peace." Participant 7, Female.
Cloud figure (blue) -participant 7
Participant 22 wrote the following in the interpretation of the figure they drew (Fig. 3 ): "The color blue always makes me feel happy and peaceful. I chose this color because yoga makes me feel peaceful and happy. For example, when I feel restless and unhappy, going to the beach, seeing the sea, seeing blue calms me down. Also, when I think of yoga, I imagine an endless deep blue sea. A sea with birds flying over it and a deep blue sky. A painting with sunny weather" Participant 22.
Interpretation by participant 22 (blue)
Participant 35's drawn figure is a butterfly, and their description is as follows (Fig. 4 ): “When I think of yoga, I think of a butterfly. Because when I do yoga, I feel as free and light as a butterfly. I imagine my wings taking me wherever I want inside. The green color relaxes me and makes me happy. The wings of the butterfly in my soul's greenery take me to purity…”.
Butterfly figure (green) -participant 35
Participant 9, in the chosen color and the comment on their drawing, expressed the following regarding the sub-category "Symbol of Health and Serenity" (Fig. 5 ): "I chose this color for its energy. Since energy is important in yoga, I chose orange. I chose this shape because I believe yoga is best done in a natural environment. Yoga reminds me of serenity, the feeling of being in emptiness, and relaxation (Fig. 5 )."
Tree figure and comment (orange) -participant 9
Participant 19, in the chosen figure and the comment on their drawing, stated the following (Fig. 6 ): "Because yoga reminds me of mental and physical health. In my opinion, health is manifested in the combination of blue and green colors. That is, balance in nature is something that exists in the soul and body." Participant 19 depicted a ladder figure in combination with blue and green, defining yoga as "soul and body therapy" (Fig. 6 ).
The place where the moon meets the sun (turquoise)-participant 19
The meaning of the phenomenon of doing yoga by participant 11, an 18-year-old female nursing student, was labeled as "being aware of placing goodness in heart" as the category tag. This category, referred to 110 times by the participants, includes the subcategories of "Purification (f = 65)" and "Being a virtuous person (f = 45)". Participants mentioned virtues such as "patience, tolerance, love for all creatures, flexibility, equality, non-prejudice, peace, optimism, freedom" contributing to the concept.
Participant 51, an 18-year-old male who described his health as poor, used the light bulb figure to express "happiness, peace, security" and commented, "It causes positive effects on people" (Fig. 7 ). Participant 51 expressed the following regarding the subcategory " The way to place goodness in your heart" in the figure and comment (Fig. 7 ): "The light bulb illuminating the environment is connected to yoga. Yoga enlightens a person's mind."
Light bulb (yellow) -participant 51
Participant 39, a 19-year-old male, mentioned that practicing yoga leads to "thinking more compassionately." Participant 21, a female, stated, "Yoga is something that requires patience."
Here is the drawn peace figure and comment by participant 46, related to this category (Fig. 8 ). This participant said, "I chose pink because it opens up and gives peace. Of course, there is also light pink, not just dark pinks. I chose this sign because where there is yoga, there is love for all living beings, and where there is love, peace is inevitable."
Peace figure (pink) -participant 46
For nursing students, practicing yoga means creating "awareness" and is the most effective way to meet oneself (f = 93). Participant 43, a 19-year-old female with a poor health perception, described feeling "calmer, more aware, and internally peaceful" when practicing yoga, as shown in Fig. 9 . Under the category of "the most effective way to meet oneself," Participant 43's figure and comment about yoga are as follows (Fig. 9 ): "…I chose this color because it gives me peace. The other colors make me restless, but this color makes me feel like I can breathe. Yellow is like an endless void to me. A color that makes me experience everything with all its reality. It's like a sky where you can escape from the chaos of the world and get lost in it…".
The world and heart (yellow) -participant 43
Participant 8 chose a cloud figure, describing yoga as "like rising above the clouds" and wrote the following about yoga practice: "Finding oneself in life, being at peace with oneself… [someone who starts practicing yoga] starts to know themselves, their love for life increases." Participant 8, Female.
Participant 33, a female who chose yellow for its calmness and non-straining quality, described the effect of yoga as "self-discovery" and wrote the following (Fig. 10 ): "You awaken your sleeping mind and body, and find the 'self' within you." Participant 33, Female.
Flower and human (yellow)- participant 33
The statement from participant 48 is as follows (Fig. 11 ): "In this image, what I want to convey is; the individual who practices yoga finds themselves, reaches their essence, and becomes aware of their own existence after a long and perhaps short journey. I chose the color orange because it reminds me that energy exists, is alive, and can be transmitted at any moment. For me, yoga is an indicator of energy. After yoga, the body revives and rejuvenates."
The road (orange)- participant 48
Among the nursing students ( n = 59), 16 (27.1%) indicated that they do not recommend yoga. The subcategories of this category include "difficulty in relaxing during meditation/emptying the mind (f = 23)", physical complaints (f = 21)", "difficulty in focusing (f = 18)", and "negative perceptions (f = 9)". Participants used expressions such as "headache, neck pain, back pain, dizziness, exhausting, feeling bad, difficult, fear, nervousness, inability to relax, disbelief" in relation to this category. A 19-year-old male participant, participant 41, stated about yoga, "I cannot meditate, I do not feel comfortable." Participant 44, a 19-year-old female participant who rated her health as poor, stated during yoga, "I cannot fully control my breathing and do meditation, I cannot empty my mind, so I cannot achieve complete peace."
Yoga, often conceptualized in the Western world as a physical practice [ 31 ], is considered a practice that can calm the mind and access a higher state of consciousness where individual and universal consciousness merge, using the body [ 32 ], in yoga traditions, the physical, mental, and spiritual dimensions of the individual are intricately connected [ 1 ]. When we relate the benefits of yoga to traditional yoga theories and systems, it can be interesting to explore its connection with the chakra system and colors. The main focus of yoga can be to regulate the functioning of chakras while awakening the associated energies [ 33 , 34 ]. It was thought that the free association of the students' drawings and descriptions could provide guidance in determining their experiences related to the concept of yoga. In this study, where the experiences of nursing students who took the elective yoga course were evaluated with a qualitative approach, participants mostly chose blue, green, and yellow-colored papers, symbolizing nature. When viewed from the perspective of the chakra-yoga system explained in the yoga course, it was thought that the participants might have resonated with certain energy centers or chakras. Blue, green, and yellow colors are respectively associated with the throat chakra, heart chakra, and solar plexus chakra [ 35 ]. The throat chakra is associated with communication, speech power, intellectual development, creativity, and expression [ 36 ]. Participants 7 and 22, who currently perceive their health as good, and participant 19, who chose blue and turquoise colors, may reflect a desire for in-depth communication and original expression, or a need for improvement in these areas. During yoga practice, especially breathing exercises and poses focusing on the throat region can be worked on this chakra, thus enhancing students' capacity for clearer communication and expressing inner truths [ 37 , 38 ].
The philosophy of yoga emphasizes the importance of harmony and unity with nature, which is why many yoga asanas (poses) are named after elements from nature, such as the tree pose, which symbolizes the stability and balance of a tree through its strong roots and upward-reaching branches [ 39 ]. In this study, visuals related to yoga such as the sun, clouds, trees, sky, and flowers were found. Participant 9 recalling and drawing a tree figure during yoga experiences indicates their awareness of this symbolic relationship. Research has shown that spending time in nature has positive effects on people's mood and mental health [ 40 , 41 ]; similarly, many yoga philosophies emphasize the importance of being in harmony with nature [ 42 ]. Therefore, a student's preference for a natural environment while practicing yoga and associating this practice with a tree in nature is thought to reflect both the healing power of nature and the relationship of yoga poses with elements in nature. This symbiotic relationship reminds us of how interconnected humans are with nature and how yoga practice can strengthen this connection. This aspect of yoga can also encourage individuals to strengthen their relationship with nature and adopt a more respectful attitude towards the environment. This can be seen as a reflection of the principle of 'ahimsa' or non-harming, which is one of the foundational principles of yoga philosophy [ 43 ].
Deep breathing practices are fundamental components of yoga and meditation. Consciously controlling breathing can activate the parasympathetic nervous system and trigger the relaxation response [ 44 , 45 ]. Additionally, breath awareness is part of mindfulness practice and brings the individual into the present moment. Feeling gratitude helps a person recognize the positive aspects of their life and develop a more positive life perspective [ 46 ]. Gratitude practice can improve mental health and allow for greater enjoyment of life [ 47 ]. Participant 7's choice of a cloud shape and blue color is explained by the feeling of tranquility it brings, reminding them to take deep breaths and be thankful, and to remember that there are beautiful things in life that they should enjoy. Participant 7's statement confirms this. The shape of a cloud and the choice of the color blue directing them to take deep breaths, be thankful, remember that there are beautiful things in life, and enjoy life, can contribute to the participant's spirituality [ 48 ]. Such an approach can be balancing both mentally and emotionally, especially for students under academic pressure [ 49 ].
Yoga, meditation, and breathwork (pranayama) practices can be effective in creating a deep sense of peace by bringing individuals to the present moment and calming their inner dialogue [ 50 , 51 ]. Participant 22's statement, " The color blue always makes me feel happy and peaceful. I chose this color because yoga makes me feel peaceful and happy. For example, when I feel restless and unhappy, going to the beach, seeing the sea, and seeing blue calms me down ," also indicates the participant's association of yoga practice with feelings of peace and happiness, demonstrating the potential of yoga experience to provide inner tranquility and balance. Furthermore, the participant's desire to go to the beach and see the sea may refer to the healing and calming effect of nature [ 52 ]. Participant 19 states, " Yoga reminds me of spiritual and physical health. For me, health lives in the colors blue and green, meaning it is something in nature and in the spirit of nature ," and Participant 35 says, " When I think of yoga, I think of a butterfly because when I do yoga, I feel as light as a butterfly. I think my wings take me wherever I want inside me. The color green relaxes me, makes me happy, and the green inside me takes me to purity. " These statements may be associated with the heart chakra represented by the color green. This chakra is considered the center of love, compassion, and connection [ 36 ], and therefore, the association of green with this chakra may symbolize the participant's feelings of relaxation and happiness during yoga practice [ 48 ]. The phrase " the green inside me takes me to purity " in Participant 35's statement indicates that green represents purity and healing in the heart chakra, and the opening of this chakra allows the person to feel more peaceful and purer [ 53 ]. In this context, Participant 35's positive feelings toward green and the sense of relaxation may be a result of balancing and opening the heart chakra, contributing to their emotional experiences such as lightness and tranquility in yoga practices [ 54 ].
Participant 51, despite describing their health as poor, mentioning positive effects such as " Happiness, peace, trust " through the figure of a light bulb during yoga practices, can be explained by the illuminating effect of yoga on the mind. Just as a light bulb illuminates its surroundings, yoga enlightens the individual's mental and spiritual state, capable of transforming negative thoughts and emotions into positive ones. This contributes to achieving a general state of well-being and a positive mood by providing both physical and mental relaxation [ 55 ]. Participant 39 mentioned the effect of " thinking more humanely " while practicing yoga. Participant 21 commented that " yoga requires patience ." Participant 46 chose pink because " It opens up and gives peace within me, where there is yoga, there is love for all living beings, and where there is love, peace is inevitable. " Yoga can facilitates a tranquil mental state, reducing stress and tension, thereby promoting harmonious relationships and fostering peace within individuals and their social interactions. Central to yoga philosophy are humanism and the pursuit of a peaceful life [ 56 ] qualities reflected in participants' experiences, affirming yoga's role in cultivating positive personal and societal outcomes.
In the chakra system, colors and their associated energy centers are believed to promote balance and harmony in our daily lives and physical well-being [ 33 ]. Students' selection of these colors related to chakras may reflect their own energy balances and personal development needs, often unconsciously. Yoga practice can equips individuals with tools to enhance the harmony and integrity of these energy centers [ 57 ]. Participant 43, with a negative perception of health, reported becoming " A calmer person, awareness increases, and inner peace occurs; I chose this color (yellow) because it gives me peace. While other colors make me uneasy, when I look at this color, it feels like it gives me breath, and it continues to an endless void. Yellow, for me, is like escaping from the chaos of the world and getting lost in an endless sky ." Participants finding the color yellow soothing and describing it as providing a sense of freedom and freshness like an endless sky can be associated with the solar plexus chakra, typically represented by the color yellow [ 35 ]. This chakra is linked to self-confidence, willpower, and self-realization. [ 58 ]. Participant 33 described the experince of yoga with a flower and human figure as " Self-discovery ," stating, " you awaken your sleeping mind and body and find the 'self' within ." Participant 8 drawn a cloud figure, describing yoga as " like rising above the clouds," saying, "finding yourself in life, being at peace with yourself… [someone who starts practicing yoga] begins to know themselves, their love for life increases ."These statements and figures reinforce the basic themes of "self-discovery" and "being at peace with oneself" in yoga practice [ 59 ], indicating an important relationship between one's yoga practice, personal growth, and quest for inner peace [ 60 ]. Participant 48 believes that " After a long and perhaps short journey of practicing yoga, individuals find themselves, reach their essence, and become aware of their existence. I chose this color (orange) because it reminds me that energy exists, is alive, and can be transmitted at any moment. For me, yoga is a sign of energy; after yoga, the body revitalizes and refreshes. " The choice of orange suggests a strong relationship between yoga practice and energy, as this color, can be associated with the Sacral chakra, symbolizes vitality, creativity, and emotional balance [ 36 ].
In this study, there seem to be mixed views among some participants regarding yoga practice. While yoga and meditation are generally recommended as tools for reducing stress and enhancing personal well-being [ 24 , 61 , 62 ], some students (participants 41–44) have reported not finding this practice beneficial. For example, some participants have advised against practicing yoga due to physical discomfort (head, neck, and back pain, dizziness), inability to empty the mind during meditation, difficulty in focusing, and negative perceptions. The comments of participants 41 and 44 are thought to indicate their individual experiences regarding their inability to meditate and the discomfort they feel during yoga practice. Yoga and meditation practices can create different experiences in each individual; while they can be relaxing and healing for some, they can be challenging and discomforting for others [ 63 ]. This suggests that yoga and meditation can not universal solutions but practices that should be compatible with an individual's personal preferences, experiences, and health conditions [ 26 ].
Participants' health conditions can influence their experiences during yoga practice. Participants who feel unwell or have a specific health problem may find the practice challenging. This underscores the importance for educators and health professionals to provide stress management and relaxation techniques tailored to individual needs [ 64 ].
The qualitative data collected in this study regarding the phenomenon of yoga is in Turkish. However, selecting an international journal for publication and translating the text into English may have limited the full conveyance of the figures and participants' expressions to the readers due to the unique cultural characteristics of the language. The concepts of yoga and chakras, meditation, and similar topics, which were theoretically as well as practically conveyed to the participants during the 14-week course content, may have influenced the participants' views on the phenomenon of yoga. The use of a qualitative design tradition in the research both limited the generalizability of the findings and contributed to the originality of the study.
This study has identified four themes that explain the phenomenon of practicing yoga. These are respectively; "symbol of health and tranquility", "way to place goodness in the heart", "most effective way to meet the self", and "no guarantee of relaxation" themes. The findings will contribute to a more comprehensive understanding of student experiences and ultimately understand their positive and negative experiences. By delving into the student perspective, this research aims to provide valuable insights for educators and healthcare professionals. Most of the research on the phenomenon of practicing yoga is conducted abroad, and it is a less studied area in Turkey. Although yoga, which is becoming increasingly popular in our country, is known to be a practice that makes a person feel good; research on how individuals feel about practicing yoga and how they think about it is specific to the subject. Participants associated practicing yoga with symbols and colors found in nature, emphasizing the importance of its effects on the body, mind, and spirituality. In addition, findings regarding the experiences of individuals practicing yoga, a practice that is also becoming increasingly popular in Turkey, have been obtained. Although it is seen that qualitative approaches such as in-depth interviews and content analysis are used in almost all of the qualitative studies on the subject [ 48 , 65 , 66 ], no study has been found that examines individuals' perceptions by drawing pictures and interpreting them. In this respect, the current research's unique research method can contribute to the literature.
The authors extend their sincere gratitude to the nursing students who willingly took part in this study. Their participation is greatly valued and appreciated.
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Department of Public Health Nursing, Faculty of Health Sciences, Izmir Democracy University, Izmir, Turkey
Özüm Erki̇n
Department of Public Health Nursing, Faculty of Health Sciences, Manisa Celal Bayar University, Manisa, Turkey
Aynur Çeti̇nkaya
Begüm Güler
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ÖE and AÇ contributed to study design. AÇ contributed to analyze data. ÖE, AÇ and BG write the manuscript. All authors read and approved the final manuscript.
Correspondence to Begüm Güler .
Ethical approval for the study was obtained from Manisa Celal Bayar University Non-invasive Clinical Research Ethics Committee (Decision no:20.478.486, Date:02/13/2019). We adhered to the principles of the Declaration of Helsinki and relevant guidelines. Written informed consent was obtained from all participants in this study. Participants were ensured to provide their consent voluntarily and without coercion. Written informed consent to participate was obtained from all of the participants in this study. Before the research, the purpose of the study was explained to the students and that they could leave the study at any time. At the beginning of the study, it was informed that participation in the study was voluntary and that no grade would be given. The evaluation of this course consisted of 10 open-ended questions as part of the year-end assessment. Students were asked to name 10 yoga poses they knew, describe the posture, explain the benefits, indicate the indications and contraindications, and identify the associated chakras. The grade distribution of the students was as follows: AA (n:31), BA (n:16), BB (n:6), CB (n:6). Necessary precautions were taken to protect the confidentiality of the data, the identity information of the participants was not included in the data collection tools and all personal details in the data collection forms were kept confidential. The identifying images or other personal details of participants are presented in a way that does not compromise anonymity.
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The authors declare no competing interests.
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Erki̇n, Ö., Çeti̇nkaya, A. & Güler, B. The phenomenon of yoga in the imagination of Turkish nursing students: "The way to place goodness in the heart". BMC Nurs 23 , 655 (2024). https://doi.org/10.1186/s12912-024-02288-y
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Don't ask, instruct (command!) Ask one question at a time; get the detail in the probes. Ask questions that can be answered. Repeat, and redirect. Use your naïveté to your advantage. Ask how, not why questions. Make people respondents, not key informants (individuals are unreliable) Don't ask respondents to be analysts.
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As the interview progresses, avoid asking leading questions (i.e., questions that assume something about the interviewee or their response). Make sure that you speak clearly and slowly, using plain language and being ready to paraphrase questions if the person you are interviewing misunderstands.
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time allows flexibility within the interview process. Various types of interview questions are described and working examples are included. Keywords: Qualitative Research, Qualitative Interview, Interview Guide, Interview Questions . Background . From this stance, the processes of phenomena of the world should be described
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Any senior researcher, or seasoned mentor, has a practiced response to the 'how many' question. Mine tends to start with a reminder about the different philosophical assumptions undergirding qualitative and quantitative research projects (Staller, 2013). As Abrams (2010) points out, this difference leads to "major differences in sampling ...
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The aim of the research is to shed light on the experiences of a group of nursing students enrolled in a yoga elective course who practiced yoga regularly for 14 weeks, regarding yoga and the phenomenon of doing yoga, with a qualitative approach. This qualitative study was conducted at a public university in Izmir, Turkey. The study sample consisted of 61 students enrolled in the 1st-year yoga ...