when is qualitative research appropriate to use

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Speaker 1: In this video, we're going to unpack the oftentimes misunderstood topic of qualitative content analysis. We'll explain what it is, discuss its strengths and weaknesses, and look at when to use this analysis method. By the end of this video, you'll have a solid big picture view of content analysis so that you can make a well-informed decision for your project. By the way, if you're currently working on a dissertation, thesis, or research project, be sure to grab our free dissertation templates to help fast-track your write-up. These tried and tested templates provide a detailed roadmap to guide you through each chapter, section by section. If that sounds helpful, you can find the link in the description below. So, what exactly is content analysis? Well, at the simplest level, content analysis is a qualitative analysis method that focuses on analyzing recorded communication taken from artifacts. For example, extracts from books, newspaper articles, interviews, audio and video recordings, or even blogs. Importantly, content analysis can be used on both primary and secondary data. In other words, data you collected yourself or data that was already in existence. This makes it quite a flexible qualitative analysis method as you have more choices in terms of data sources. By the way, if you're new to qualitative analysis, be sure to check out our primer video up here. Now, let's go a little deeper. At the highest level, there are two types of content analysis, or rather, two ways to perform content analysis. These are conceptual content analysis and relational content analysis. These two approaches are quite different in terms of how they work, so let's take a look at each of them. First up is conceptual content analysis. In this case, the analysis is focused on the explicit data. You look at the actual appearance of particular words and phrases without offering interpretation of them. So, the main concern here is the frequency of words and phrases. In other words, the number of times they appear in the selected data set. For example, you might be researching changes in attitudes to women's rights issues. In this case, you could look at the frequency of words like equal pay, gender equality, and patriarchy in popular culture over a certain period of time. So, in short, conceptual content analysis is explicit, non-interpretational, and surface-level focused. It's also somewhat quantitative in nature. In other words, it considers some numbers, even though it's still a qualitative analysis method at its core. Next up is relational content analysis. Here, the focus is on the meaning and the use of words and phrases. This meaning is derived from looking at the relationships between the various words and phrases to those around them. Contrary to conceptual analysis, the one we just looked at, the focus here is on the implicit data, or the information interpreted from looking at how certain words are used in relation to others. For example, if a research project is aimed to analyze polling data around a particular political candidate to understand general sentiment, relational content analysis could be used to look at the words used around mentions of that candidate, for example, ethical, trustworthy, dubious, etc. to determine patterns and themes of meaning that could indicate popularity and sentiment. So, in short, relational content analysis is implicit, interpretational, and is focused on meaning. It's also worth mentioning that there are multiple approaches to relational analysis, but we won't dig into them in this introductory video. If you're interested, you can check out our detailed blog post covering all of that. The link is in the description. To recap then, content analysis can be undertaken using either a conceptual approach, where you're interested in the frequency of concepts, or a relational approach, where you're interested in the meaning of language based on the connections, or relationships, between words and phrases. Now that we have a clearer picture of what content analysis is, it's important to discuss the strengths and weaknesses so that you can make the right choice in terms of analysis methods for your research project. One of the main strengths of content analysis is its flexibility, as it can be used on a wide range of data types, including written records, interview recordings, and speech transcripts, as well as non-text-based data. This means you have more choices in terms of the data sources you can draw on, allowing you to develop a rich dataset. Additionally, content analysis tends to be very unobtrusive, since quite often, the analysis can be performed on data that already exists. This means that there are fewer ethical issues to consider, and it's easier to access the data you need. All that said, as with any analysis method, content analysis has its drawbacks. First, there's the problem of reliability. After all, drawing conclusions from the frequency of words and phrases, or their relationship to each other, can be a subjective process, and not quite scientifically rigorous enough. This is especially true if more than one researcher is working on the dataset. Content analysis can also sometimes be considered as rather reductive. In other words, the focus on particular words and phrases can of course result in you missing context, nuance, and culture-specific meanings. Lastly, the results from a content analysis can't usually be easily generalized. Since content analysis is often time-intensive, it can be difficult to analyze a dataset large enough to draw broad conclusions about the research topic. Of course, this can be said for many qualitative methods, but it's worth keeping in mind if you're considering using content analysis. Hey, if you're enjoying this video so far, please help us out by hitting that like button. You can also subscribe for loads of plain language, actionable advice. If you're new to research, check out our free dissertation writing course, which covers everything you need to get started on your research project. As always, links in the description. Now that we've got a clearer picture of what content analysis is, the logical next question is, when should you use it? As a qualitative method focused on recorded communication, content analysis is often most appropriate for research topics focused on changes and patterns in communication around social, economic, or political issues. For example, a research project that involves analyzing government policy regarding healthcare in the UK might look at the use of phrases like healthcare, the NHS, and hospitals in political commentary. An analysis could then be done on the frequency of these phrases and or their relationship to other associated words and phrases. On the other hand, research that's focused on the use of language in context might not be the best fit for content analysis. In other words, if your research is about the particular impact of language in specific social contexts, then content analysis could potentially be too narrowly focused. For example, if you're wanting to assess how political speech is used in impoverished environments to impact beliefs and opinions, a more context-oriented analysis method, such as discourse analysis, could be more appropriate. Simply put, make sure that you always consider the nature of your research aims when you're deciding on an analysis method. Okay, that was a lot, so let's do a quick recap. Content analysis is a qualitative analysis method that draws findings from analysis of recorded communication, which can include both primary and secondary data. As we discussed, content analysis can be approached in two ways. Conceptual analysis, where the focus is on the frequency of concepts, and relational analysis, where the focus is on the meaning of and relationship between concepts. As with any analysis method, content analysis has its own set of strengths and weaknesses. As a result, content analysis is generally most appropriate for research focused on changes and patterns in recorded communication. If you got value from this video, please hit that like button to help more students find this content. For more videos like this, check out the Grad Coach channel, and subscribe for plain language, actionable research tips and advice every week. Also, if you're looking for one-on-one support with your dissertation, thesis, or research project, be sure to check out our private coaching service, where we hold your hand throughout the research process, step by step. You can learn more about that and book a free initial consultation at gradcoach.com.

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• Associations between growth, maturation and injury in youth athletes engaged in elite pathways: a scoping review
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• http://orcid.org/0000-0002-1915-9324 Gemma N Parry 1 ,
• http://orcid.org/0000-0003-1460-0085 Sean Williams 1 ,
• Carly D McKay 1 ,
• David J Johnson 1 , 2 ,
• http://orcid.org/0000-0003-1377-0234 Michael F Bergeron 3 ,
• Sean P Cumming 1
• 1 Department of Health , University of Bath—Claverton Down Campus , Bath , UK
• 2 West Ham United Football Club , London , UK
• 3 Performance Health , WTA Women’s Tennis Association , St. Petersburg , Florida , USA
• Correspondence to Dr Gemma N Parry; gp799{at}bath.ac.uk

Objective To describe the evidence pertaining to associations between growth, maturation and injury in elite youth athletes.

Design Scoping review.

Data sources Electronic databases (SPORTDiscus, Embase, PubMed, MEDLINE and Web of Science) searched on 30 May 2023.

Eligibility criteria Original studies published since 2000 using quantitative or qualitative designs investigating associations between growth, maturation and injury in elite youth athletes.

Results From an initial 518 titles, 36 full-text articles were evaluated, of which 30 were eligible for final inclusion. Most studies were quantitative and employed prospective designs. Significant heterogeneity was evident across samples and in the operationalisation and measurement of growth, maturation and injury. Injury incidence and burden generally increased with maturity status, although growth-related injuries peaked during the adolescent growth spurt. More rapid growth in stature and of the lower limbs was associated with greater injury incidence and burden. While maturity timing did not show a clear or consistent association with injury, it may contribute to risk and burden due to variations in maturity status.

Conclusion Evidence suggests that the processes of growth and maturation contribute to injury risk and burden in elite youth athletes, although the nature of the association varies with injury type. More research investigating the main and interactive effects on growth and maturation on injury is warranted, especially in female athletes and across a greater diversity of sports.

• Athletic Injuries
• Sporting injuries

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Data relevant to the study have been uploaded as supplementary information.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bjsports-2024-108233

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Growth and maturation during adolescence have been identified as risk factors for potential injury in young athletes.

WHAT THIS STUDY ADDS

This review identified 30 contemporary studies. Injury incidence and burden appear most closely related to maturity status and tempo of growth, with growth-related injuries peaking during the adolescent growth spurt. Practitioners are advised to consider measures of growth and maturation alongside clinical and field-based measurements.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Several methodological limitations and inconsistencies exist in the current evidence. Greater consistency and agreement on measurement practices could benefit future research quality, with the inclusion of female and non-football populations to address large gaps in the literature.

Introduction

The relationship between growth, maturation and injury risk in youth athletes is a topic of increasing interest in sports medicine, with a particular focus on the adolescent growth spurt 1 . Initiated by changes in the endocrine system, adolescence is the transitional phase between childhood and adulthood, during which the body undergoes rapid changes in size, shape and composition. 2 It also involves transformation of the circulatory, respiratory and metabolic systems, resulting in substantial changes in athletic and functional capacity. 3 Although the processes of growth and maturation have been proposed as risk factors for injury in young athletes, the evidence to support this contention is limited. 4 Limitations within the research are, however, noted, including heterogeneity across samples, research designs and analytical methods, poor reporting quality and high loss to follow-up. 4

Associating growth and maturation with injury in youth athletes is a logical premise. 5 Physeal injuries are a unique consideration for those working with youth populations. 6 Rapid asynchronous growth in skeletal, muscular and ligamentous structures creates increased ligament stress transfer through relatively weaker physeal plates and bone layers, increasing risk for such injuries. Age-related changes in bone mineral density, imbalances between flexibility and strength and alterations in joint stiffness further contribute towards an increased susceptibility to fractures at the growth plate and apophyses. 5 7 Apophyseal and physeal injuries also follow a distal-to-proximal 8 gradient, consistent with the sequential and asynchronous nature of adolescent growth. 8 9 For example, Sever’s disease at the posterior calcaneus tends to present in advance of Osgood-Schlatter’s or Sinding-Larsen at the knee, which, in turn, present in advance of apophyseal injuries at the sites of the iliac crest and ischial tuberosity of the hip. Apophyseal injuries are attributed to the softening or malformation of the articular cartilage, the latter of which is associated with more rapid growth during adolescence. 7 From a perceptual-motor perspective, rapid and asynchronous changes in skeletal, muscular and ligamentous structures, coupled with developmental changes in neurocognitive processing, have also been linked to temporary disruptions in mobility and motor-coordination, which may further increase injury risk. 5

The introduction of injury surveillance and growth and maturation profiling systems in many elite performance pathways (eg, national athlete development programmes, professional sport academies) has afforded a more systematic and rigorous approach to monitoring physical development and health in young athletes. 10 Implemented in parallel and delivered by trained professionals and clinicians, these organised strategies have enabled the capture of high-quality longitudinal data in young athletes, stimulating further research related to growth, maturation and injury. Characterised by early specialisation and maintained elevated levels of training and competition, elite performance pathways may also provide a more conducive environment from which to observe and investigate associations between physical development and injury in youth. 1 Considering these advances, this scoping review endeavours to synthesise and expand on a previous systematic review, 4 with the aim of providing clinicians, researchers and other stakeholders with a description of contemporary research related to growth, maturation and injury in youth athletes engaged in current elite sports pathways, with a particular emphasis on the operationalisation of growth and maturation, methodological quality and assessment, sample populations, emerging evidence, knowledge gaps and limitations within the extant literature.

Equality diversity and inclusion statement

The author and article screening teams were gender-balanced and included senior and junior academic staff from multiple disciplines and professions. Articles were restricted to those published in English but were not excluded based on country of origin. Gender equity in the study of physical development and injury in young athletes is addressed in the discussion.

Information sources and search strategy

This review was commissioned by the International Olympic Committee to describe the extent, type and quality of contemporary research and evidence pertaining to growth, maturation and injury in ‘elite youth athletes’, contributing towards a consensus statement on the health, safety and sustainability of young athletes competing at the Olympic games. A definition of ‘elite youth athletes’ as ‘highly trained and invested youth athletes routinely participating at national level (Tier 3) to world-class (Tier 5) athletic competitions’ was established in advance of the review 11 12 and extended to include dancers enrolled in professional dance schools.

The search was conducted, in general, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews, PRISMA-ScR ( online supplemental figure S1 ). All 20+2 PRISMA-ScR reporting items were met, except for protocol registration. Five databases (SPORTDiscus, Embase, PubMed, MEDLINE and Web of Science) were searched for relevant articles. As the review aimed to inform a contemporary consensus statement regarding the health and well-being of elite young athletes, the article search was restricted to peer-reviewed publications written in English from 1 January 2000 to 30 May 2023. A series of unique search terms were employed to identify relevant articles. The Boolean Operators “OR” and “AND” were used to broaden the search results, define the population of interest (ie, elite youth athletes), limit the intended outcomes of our search (ie, injury) and link the search terms. An asterisk (*) was applied to some keywords to search the database for all endings of the word or phrase (eg, matur*). The final search strategy being: (1) “elite” AND “youth” AND “athlete”, (2) AND “growth” OR “matur*” OR “pubert*”, (3) AND “Injur*” OR “medial epicondyle apophysitis” OR “Proximal Humeral Epiphysitis” OR “stress fracture” OR “growth plate fracture” OR “Pars” OR “Femoroacetabular impingement” OR “apophysitis” OR “Sever’s” OR “Osgood” OR “osteochondrosis” OR “osteochondritis dissecans” OR “spondylolysis”.

Supplemental material

Eligibility criteria and description of eligible studies.

Inclusion criteria were articles based on primary research, using original data and related to elite youth athletes. To meet the definition of ‘elite’ and be included in the review, the samples within each study had to be described in a manner that aligned with the criteria for routine participation in national (Tier 3) to world-class (Tier 5) competition. 12 For example, athletes who were members of professional sports academies or national development programmes were considered to have met these criteria. Studies using quantitative designs had to include measures of injury and growth and/or maturation. Qualitative studies investigating associations between growth, maturation and injury in elite youth athletes were eligible for inclusion. Review articles and case studies were excluded. Two independent reviewers (GNP, SC) completed the review process in May 2023. Each reviewer screened the articles, first at the level of title and abstract and then at the level of full text, to judge if the eligibility criteria were met. Disagreements were resolved through discussion and final consensus.

Data synthesis

To ensure consistency in the operationalisation of growth and maturation, the following definitions were adopted. 2 Growth was defined as rate of change in size of the body, its parts, or the proportions of various parts (eg, cm per annum, kg per annum). Maturation refers to the processes of progress towards the mature state occurring in multiple biological systems (eg, endocrine, sexual, skeletal and somatic) and was defined in terms of status, tempo and timing. Status denoted the stage of maturation attained at a specific time point, (eg, pre-peak height velocity (PHV), circa-PHV, post-PHV) whereas tempo described the rate at which maturation occurs. Timing was defined as the age at which maturational events (eg, PHV) occurred and/or the degree to which an athlete was advanced, on-time or delayed in maturation relative to age-specific and sex-specific standards. The data extracted from the eligible studies were summarised descriptively ( online supplemental table S1 ) and appraised with respect to methodological quality.

Study selection

The initial search retrieved 871 citations of which 518 remained after removing duplicates. Full texts of 37 articles were reviewed to determine eligibility, 30 of which were eligible for final inclusion. The eligible articles included 28 quantitative and 2 qualitative studies ( figure 1 ).

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Study selection process based on inclusion and exclusion criteria.

Data collection and risk of bias assessment/analysis of quality

Descriptive data were extracted from eligible studies, comprising study design, population, measures and operationalisation of growth and maturation, and injury definition and outcomes (eg, incidence, burden) ( online supplemental table S1 ). The methodological quality of the quantitative studies (n=28), as judged on the Downs and Black Scale, 13 ranged from 7 to 19 out of 32 points ( online supplemental table S2 ). The Downs and Black Scale is a 28-item checklist used to assess the methodological quality of both randomised and non-randomised studies, evaluating factors such as reporting, external validity, internal validity (bias and confounding) and statistical power. The median quality score of these articles was low (14/32), attributable to study design and the absence of explicit explanations regarding variables of interest and consideration of confounding factors. While some articles included large samples, the distribution of participants by maturity status and/or timing categories was typically non-normal, resulting in inadequate statistical power in several studies. Most studies focused on soccer (n=19) and were exclusive to male participants (n=24). Only four quantitative studies included male and female athletes, and none considered female-only cohorts. The two qualitative papers appraised using the Joanna Briggs Institute (JBI) critical appraisal checklist for qualitative research 14 15 both met 8 out of the 10 criteria, with each noting a failure to consider potential researcher influence on the study findings as a limitation. A breakdown of the individual item scores for each article using the Downs and Black and JBI checklists is available in online supplemental file 2 .

Maturity status and injury

17 quantitative studies 8 16–31 adopting prospective designs and two qualitative studies 32 33 investigated associations between maturity status and injury ( table 1 ). 16 of the quantitative studies 8 16–20 22–31 employed non-invasive estimates of somatic maturation with estimated age at PHV (EA PHV) (n=11) and percentage of predicted (%PAH) or attained adult height (% AAH) (n=5) the most common methods. One study used an estimate of sexual maturation to classify youth handball players as mature or immature. Wik and colleagues 30 employed estimates of both skeletal and somatic maturation in study of maturation and injury in male track and field athletes. Most studies categorised athletes into groups based on maturity status, however, five studies treated maturation as a continuous variable. 19 24 26 27 30 Samples sizes varied from n=21 24  to n=502. 17 The methodological quality of the quantitative studies ranged from poor 29 to fair. 34 Two qualitative studies 32 33 investigated coaches’ and practitioners’ perceptions of how maturational status was related to injury risk in male and female gymnasts. Both of these studies achieved JBI scores of 8 out of 10, indicating a high quality of qualitative research.

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Associations between maturational status and injury for all eligible studies

The maturational stage associated with the adolescent growth spurt (ie, circa-PHV) appears to yield the greatest increase in injury incidence per 1000 hours, in papers reporting competition, training and overall time loss. When broad definitions of injury were observed, circa-PHV status was associated with greater incidences of overall, 25 non-contact 19 20 and traumatic 28 29 injuries in academy soccer, and higher incidences of all-complaint injuries in both male and female elite youth gymnasts with the peak approximating 90% PAH. 24 While the evidence suggests a general trend towards increased injury incidence and burden with advancing maturation, 16 17 21 the nature of reported associations varied relative to injury type. 8 17 Circa-PHV and pre-PHV status were associated with a higher incidence or prevalence of injuries classified as growth-related in track and field, 34 handball 21 and soccer, 8 17 but not squash. 18 Both qualitative studies also identified the growth spurt as a maturational stage where incidence and burden for growth-related and lower back injuries was greater. 32 33 Moreover, growth-related injuries followed a distal-to-proximal gradient aligned with the sequential and asynchronous nature of adolescent growth. 8 Specifically, these injuries tended to present first in the more distal segments of the lower limbs, before presenting in the more proximal segments of the lower extremities, and finally the trunk and pelvis. Consistent with this pattern, a higher probability for non-contact lower extremity injuries was observed in U13–14 soccer players during the earlier phases of the adolescent growth spurt. 26 A greater number of years to EA PHV was, however, associated with an increased probability for traumatic and overuse injuries in male and female alpine skiers. 27 Mature athletes, or those advanced in maturity status (post-PHV), exhibited the lowest incidence and burden of growth-related injuries, 8 22 23 34 yet evidenced a higher incidence and burden for muscular, cartilaginous and ligamentous injuries in soccer, 8 23 but not in handball where these injuries were higher in immature athletes. 21 Maturity status was unrelated to patellar tendinopathy in male and female ballet dancers. 31

Associations between advancing maturity status and injury burden were observed in several studies. As with injury incidence, associations with burden varied by time-loss definitions and injury type. Six studies in soccer 16 17 19 20 22 23 that used various definitions of time loss reported an increase in injury burden with advancing maturity, with one study documenting peak burden for non-contact injuries at 95% PAH. 19 There were notably higher burdens of growth-related injuries in athletes during the pre and circa-PHV stages in soccer. 17 22 23 The post-PHV stage is associated with a reduced burden for growth-related injury burden, 17 22 but an increase in burden for non-contact 19 and muscle and joint-related injury, 22 although these findings are currently limited to male soccer players.

Maturity timing and injury

10 quantitative studies 20 22 28 35–41 using prospective designs ( table 2 ) investigated associations between maturity timing and injury. Six studies employed estimates of somatic maturation with EA PHV (n=4) 29 40 41 and %PAH 20 37 (n=2) the preferred methods. There was substantial heterogeneity in the criteria used to define early maturation, on-time maturation and late maturation across methods. Four studies 35 36 38 39 employed estimates of skeletal age via hand-wrist radiographs. To define early maturation, on-time maturation and late maturation, three studies 35 36 38 used the traditional criterion of ±1 years SA-CA (skeletal age-chronological age); whereas one study used ±0.5 years SA-CA. 39 Nine studies 20 22 28 35–39 41 included male athletes and one study included males and females. 40 Eight of the studies involved soccer, 20 22 29 35–39 with single studies in track and field 41 and alpine skiing. 40 Sample sizes ranged n=26 29  to n=233. 38 The methodological quality of the studies was generally low, ranging from poor 29 to fair. 39

Associations between maturational timing and injury for all relevant selected studies

Associations between the timing of maturity and injury were observed across several, 22 29 36 38 39 but not all 20 35 37 studies of male soccer players. The nature and direction of these associations did, however, vary depending on injury type and the age range of the sample. A closer inspection of the findings suggested that the impact of maturity status was more important than the timing of maturity itself when investigating injury susceptibility in young athletes. Consistent with this hypothesis, U14 and U13–U19 players categorised as early-maturing presented a higher incidence of injuries associated with more advanced stages of maturation, including reinjury, injury to ligaments, tendons and muscles and injuries to the groin, head or face, and overall injuries. 36 38 Early-maturing U14 players also reported higher burdens for time loss, muscle, hamstring and joint/ligament-related injuries. 39 In contrast, players categorised as ‘on-time’, presented higher incidence rates for injuries associated with the early-to-mid stages of adolescence, including lower limb apophyseal injuries, anterior inferior iliac spine avulsions, Osgood-Schlatter’s, Sever’s and knee-related injuries in on-time than early maturing. 36 38 In comparison to late-maturing players, on-time U14 players presented higher rates of incidence for, groin injuries, tendinopathies and moderate injuries, 36 and higher burdens for joint/ligament, knee, anterior inferior iliac spine, growth-related and time-loss injuries. 22 39 Late-maturing players presented higher incidence rates for osteochondrosis, thigh, growth-related and major injuries than early-maturing players, and a higher incidence of tendinopathies and osteochondral disorder of the knee than early and on-time players. 36 38 Late-maturing track and field athletes also presented a higher incidence for foot, ankle and lower limb injuries compared with their peers. 41 Despite late-maturing alpine skiers presenting a higher prevalence of traumatic and overuse injuries, respectively, these values did not differ statistically from early-maturing skiers. 40

Growth and maturity tempo and injury

Nine quantitative studies 19 23 25 27 34 42–45 adopting prospective designs ( table 3 ) and two qualitative studies 32 33 investigated associations between rate of growth and/or maturation and injury. Rate of change in stature (n=9) and leg length (n=5) were the most frequent growth measures. Four studies assessed growth tempo in body mass and mass-for-stature. Singular studies considered growth of the foot, 42 torso 30 and tempo of skeletal maturation. 34 Six studies 19 23 25 43–45 involved male soccer players with the remaining studies involving male track and field athletes, 34 and dancers 42 and alpine skiers 27 of both sexes. Samples sizes ranged from n=46 42  to n=378. 45 The methodological quality of the studies was generally low, ranging from poor 43 to fair. 34 45

Associations between growth and maturation indices and injury for all relevant selected studies

More rapid gains in stature were associated with a higher incidence and/or probability of overall, 25 43 45 non-contact 19 and overuse 44 injuries in male academy soccer players, and bone and growth plate injuries in male track and field athletes. 34 Greater growth in stature was, however, associated with a reduced probability for acute injuries in U13–15 academy soccer players 44 and overall injuries in male and female alpine skiers. 27 More rapid gains in stature during PHV was associated with a higher burden for overall, knee and growth-related injuries, but not muscle, joint/ligament, knee or ankle injuries in U14 academy soccer players. 22 A non-linear (inverted-U) association between growth in stature and burden for non-contact injuries was reported in U13–U16 male soccer players, with peak estimated injury burden occurring at 4.17 cm per year. 19 More rapid growth of the lower limbs was associated with a higher probability for overall injuries in alpine skiing 27 and track and field, 34 overuse 44 injuries in soccer, and bone and growth plate in track and field. 34 As with stature, a non-linear association was observed between growth rate of the lower limbs with peak estimated injury burden occurring at a growth rate of 5.27 cm per year. 19

Rate of growth in body mass did not differentiate between injured and non-injured alpine skiers 27 and was not associated with injury probability in track and field athletes 34 and U10–15 soccer players. 44 Greater seasonal gains in body mass were observed in injured vs non-injured Italian soccer players; however, growth in mass did not emerge as a predictor of injury in a subsequent regression model. 25 With respect to mass-for-stature, more rapid gains in body mass index (BMI) were observed between injured vs non-injured Dutch soccer players, 43 but not their Italian counterparts. 25 Rate of change in BMI was unrelated to overall injury risk injury in alpine skiing 27 and overall, gradual and sudden-onset, bone and growth plate injuries in track and field. 34

In both qualitative studies, 32 33 more rapid gains in stature and mass were perceived as risk factors for injury in young gymnasts, with specific reference to stress fractures, growth-related, shoulder and lower back injuries. The risk was also perceived to be higher when accompanied with high or sudden spikes in training and competition loads, and restricted eating.

Trunk growth was unrelated to probability for overall, gradual onset, sudden onset, bone or growth plate-related injuries in track and field athletes. 34 More rapid growth of the foot was, however, associated with a higher risk for lumbar and lower extremity injury risk in male and female dancers. 42 Finally, more rapid changes in skeletal maturation were associated with an increased risk of bone injuries in a track and field athletes, yet was unrelated to risk of gradual-onset and sudden-onset, growth plate and overall injuries. 34

This review described contemporary research and emerging evidence related to growth, maturation and injury in youth athletes engaged in elite performance pathways. A total of 30 articles were deemed eligible for inclusion in this review with the majority involving male soccer players. The disparity between sports reflects the popularity of soccer, as a sport, and the significant investment by professional clubs and national governing bodies in the monitoring of physical development and health of young players. 10 Implemented in parallel, injury surveillance and growth and maturity profiling systems have enabled researchers to collect high-quality longitudinal data, consider the implications of growth and maturation across diverse injury types and perform more sophisticated methods of analysis. Those investigating the associations between growth, maturation and injury in young athletes should look to soccer for examples of good practice (see Monasterio, 8 22 23 39 Rommers, 44 45 Materne 38 and Hall 17 ), such as the aggregation of data across age groups, clubs and/or multiple seasons and consideration of different injury types and interactional effects. Wik’s investigation of both maturity status and tempo as risk factors across multiple injury types in track and field also serves as a good example of innovative practice within this field. 34

The lack of studies involving and/or exclusive to female athletes is a particular concern. The eligible studies that considered physical development and injury in female athletes all had comparatively small sample sizes and, thus, it is difficult to draw firm conclusions from the evidence. Injury research related to male athletes does not always generalise to female athletes. 46 The sex differences in human anatomy and physiology that emerge during puberty may predispose male and female athletes to variable levels of injury risk. 7 Whereas some studies have found female athletes to be at greater or reduced risk for certain types of injury, 46 47 others suggest more comprehensive research and data are still required to effectively inform injury prevention and treatment strategies specific to female athletes. 48 There is a need for sport’s national governing bodies to prioritise and invest in research related to physical development and injury in female athletes. Care must, however, be taken in the design and implementation of growth and maturity profiling strategies for female athletes with particular sensitivity around the collection, communication and use of data. 49 Data pertaining to physical development should be used to understand and support the health and development of the athletes and not as a criteria for the selection and exclusion of athletes. 49 Clinicians and researchers should seek to identify those injuries that female and, to a lesser extent, male athletes may be more or less susceptible to at different stages of maturation and consider strategies for the early detection and mitigation of conditions such as relative energy deficiency RED-S which can compromise physical development and the immediate and long-term health of youth athletes. 49 Researchers should also investigate the extent to which the processes of growth and maturation contribute to the elevated risk of medial collateral ligament (MCL) and anterior cruciate ligament (ACL) injuries observed in female athletes during adolescence. 7

The evidence reviewed suggests that susceptibility to injury in youth athletes varies relative to maturity status. Adopting a broad definition of injury, incidence and burden generally increases with advancing maturation. The nature of the association between maturity status and injury does, however, vary relative to injury type. The adolescent growth spurt signalled a marked increase in the incidence and burden of growth-related injuries, confirming the beliefs and experiences of coaches and medical practitioners. 32 33 Growth-related injuries were most prevalent at the onset and during the growth spurt, with apophyseal, osteochondrosis and avulsion prominent in numerous sport contexts. 8 18 21 22 33 34 Growth-related injuries also followed a distal-to-proximal gradient consistent with the sequential and asynchronous nature of adolescent growth, before declining in both incidence and burden post-PHV. In contrast, the incidence of muscular, cartilaginous and ligamentous injuries generally increased with advancing maturity status and were most prevalent in athletes categorised as mature and/or post-PHV. Increased susceptibility for such injuries post-PHV has been attributed to several factors associated with growth and maturation, including disruptions in neuromuscular control, insufficient muscle capacity, imbalance in muscle and tendon growth, and increase in moments of inertia in athletes’ segments. 8 Despite much of the data within the eligible studies being normalised to exposure per 1000 hours, uncertainties remain regarding the standalone impact of maturational status on injury incidence and burden, given the variations in activity content (eg, modality, frequency, intensity, location) that may comprise an individual’s exposure hours.

The absence of a consistent pattern of association between timing and injury suggested that maturing in advance or delay of one’s peers (ie, timing) was not an inherent risk for injury. Rather, the extent to which timing impacts an athlete’s maturational status and/or proximity to PHV appeared to be of greater relevance. Compatible with this logic, early maturing athletes presented a higher incidence and burden for injuries associated with more advanced stages of maturity (eg, tendinopathies, groin strains, joint and ligament injuries, functional muscle disorders). 22 36 38 39 Conversely, on-time and late maturing reported a higher incidence and burden for injuries associated with the earlier stages of the growth spurt (eg, lower limb apophyseal injuries, osteochondrosis, AIIS, Osgood-Schlatter’s, Sever’s). 22 36 38 39 41 Due to inherent maturity selection biases that exist in sport, 3 50–52 late-maturing athletes were under-represented in several of the eligible studies 22 36 38 39 resulting in insufficient statistical power to make effective comparisons across groups. As late maturing athletes experience the growth spurt at an age when training intensities and volumes are typically higher, they may be more susceptible to injuries associated with growth or overloading. 53 Any elevated injury risk associated with later maturation may, however, be mitigated by a lower rate of growth at PHV. Future studies may need to aggregate data across teams, sport or consecutive seasons to test this hypothesis or focus on sports or activities where late developers are more likely to be represented (ie, gymnastics, ballet, diving).

More rapid gains in stature and length of the lower limbs were associated with a higher incidence of overuse, non-contact and growth-related injuries across several sports. Monasterio et al , also observed more rapid growth in stature to be associated with a higher burden for overall and growth-related injuries during PHV. 22 Johnson et al , did, however, report a non-linear associations between burden and rate of growth in stature and of the lower limbs, with peak burdens occurring post-PHV and at a rate of approximately 4-to-5 cm per year. 19 The delayed effect of injuries sustained during PHV on injury burden post-PHV may explain the discrepancy in these results. No clear or consistent associations were observed between rate of growth in mass and mass-for-stature with injury. Pubertal gains in mass and mass-for-stature may have greater injury implications for athletes participating sports that involve frequent landing, jumping, pivoting and high intensity accelerations and decelerations. 5 They may also have greater impact for risk in female athletes who experience larger gains in absolute and relative fat-mass, and corresponding smaller gains in absolute and relative strength during puberty. 2 50 Further research on the growth and injury in female athletes is needed with a particular focus on the preventative benefits of targeted functional movement and neuromuscular strength training interventions. 54–56

Intervention studies designed to mitigate growth-related injuries in young athletes are currently lacking. However, in the interim, growth and maturity profiling can provide valuable information pertaining to maturational status, timing and growth rate of individual athletes, enabling practitioners to identify athletes at heightened risk for specific injuries and adapt their training and conditioning accordingly. 1 For example, the Athletic Skills Model (ASM) describes a maturity-matching strategy whereby athletes identified as circa-PHV are assigned to training groups with an increased emphasis on movement competency, core and lower body strength, mobility, balance, coordination, coupled with reductions training load, intensity and movement repetition. 57 A recent intervention aligned to theASM principles resulted in marked reductions in non-contact injury incidence and burden among academy soccer players identified as circa-PHV and at-risk. 58 Although promising, further encompassing research is required to validate these findings.

Strengths and limitations

The inclusion of several contemporary studies conducted across multiple clubs or seasons was a strength of this review. 8 17 22 23 36 38 39 44 45 With comparatively large samples and more rigorous approaches to data capture, these studies enabled more comprehensive and detailed investigations of growth, maturation and injury. These studies also provided valuable insight as to the complex, multifaceted and dynamic nature of the relationship between physical development and injury in youth. The myriad of methodological limitations highlighted by Swain et al 4 persist, making it challenging to generalise findings or draw firm conclusions from the existing literature on this topic. Although the quality of the two qualitative studies was deemed excellent, the methodological quality of the quantitative studies was generally low, ranging from poor to fair. To improve research quality and robustness, there is a need to develop a contemporary consensus statement on standardised evidence-informed best practices for assessing and estimating growth and maturation in young athletes. This review was commissioned by the IOC as a wider contribution towards a consensus statement, and as such adopted a harmonised methodology. Researchers may wish to consider alternative methodologies in additional future reviews. Building on previews reviews and commentaries, 3 4 59–61 particular attention should be paid to the operationalisation of growth and maturation and the criteria used to determine maturity status, timing and tempo of growth. It is equally important to consider the rationale for measurement, analytical quality control, frequency of measurement, the education of key stakeholders and how data are communicated to athletes, parents/guardians and coaches. 49 The validity and reliability of the various methods used to estimate maturation should also be considered with a particular focus on non-invasive estimates of somatic maturation. 3 62 63

The evidence reviewed indicates that variability in growth and maturation plays a contributing role in the risk of injury among youth athletes engaged in high performance pathways. The associations involved are intricate and diverse, requiring further research to comprehend the precursors, mechanisms and contextual factors that may predispose athletes to a higher risk of specific injuries (eg, those related to motor competence, functional capacity, training/competition load and content). It is recommended that sport’s governing bodies simultaneously implement comprehensive injury surveillance and growth and maturity profiling systems for youth, along with educational content and a current consensus statement on best/standardised practice in the estimation and monitoring of growth and maturation. Such an approach has the potential to enhance our understanding of the connections between growth, maturation and injury and provide the empirical basis for the subsequent development and implementation of injury prevention programmes.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Research was approved by The University of Bath ethics committee #0122-80.

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X @GemmaNParry, @statman_sean, @Dr_CMCKay, @DrMBergeron_01, @phd_Sean

Contributors GNP, SC and SW conceptualised and planned the study design. GNP and SC led the study. GNP and SC contributed to article screening. GNP is guarantor and accepts full responsibility for the work and/or the conduct of the study. GNP and SC has access to the data, and controlled the decision to publish. GNP, SC and SW wrote the first draft of the article. All coauthors reviewed, revised and approved the final manuscript.

Funding The research was funded via a consultancy award from the International Olympic Committee

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Published: 31 August 2024

Experiences, barriers and perspectives of midwifery educators, mentors and students implementing the updated emergency obstetric and newborn care-enhanced pre-service midwifery curriculum in Kenya: a nested qualitative study

• Duncan N. Shikuku 1 , 2 ,
• Sarah Bar-Zeev 3 ,
• Alice Norah Ladur 2 ,
• Helen Allott 2 ,
• Catherine Mwaura 4 ,
• Peter Nandikove 5 ,
• Alphonce Uyara 6 ,
• Edna Tallam 7 ,
• Eunice Ndirangu 8 ,
• Lucy Waweru 9 ,
• Lucy Nyaga 9 ,
• Issak Bashir 10 ,
• Carol Bedwell 2 &
• Charles Ameh 2 , 11 , 12  

BMC Medical Education volume  24 , Article number:  950 ( 2024 ) Cite this article

Metrics details

Introduction

To achieve quality midwifery education, understanding the experiences of midwifery educators and students in implementing a competency-based pre-service curriculum is critical. This study explored the experiences of and barriers to implementing a pre-service curriculum updated with emergency obstetric and newborn care (EmONC) skills by midwifery educators, students and mentors in Kenya.

This was a nested qualitative study within the cluster randomised controlled trial investigating the effectiveness of an EmONC enhanced midwifery curriculum delivered by trained and mentored midwifery educators on the quality of education and student performance in 20 colleges in Kenya. Following the pre-service midwifery curriculum EmONC update, capacity strengthening of educators through training (in both study arms) and additional mentoring of intervention-arm educators was undertaken. Focus group discussions were used to explore the experiences of and barriers to implementing the EmONC-enhanced curriculum by 20 educators and eight mentors. Debrief/feedback sessions with 6–9 students from each of the 20 colleges were conducted and field notes were taken. Data were analysed thematically using Braun and Clarke’s six step criteria.

Themes identified related to experiences were: (i) relevancy of updated EmONC-enhanced curriculum to improve practice, (ii) training and mentoring valued as continuous professional development opportunities for midwifery educators, (iii) effective teaching and learning strategies acquired – peer teaching (teacher-teacher and student-student), simulation/scenario teaching and effective feedback techniques for effective learning and, (iv) effective collaborations between school/academic institution and hospital/clinical staff promoted effective training/learning. Barriers identified were (i) midwifery faculty shortage and heavy workload vs. high student population, (ii) infrastructure gaps in simulation teaching – inadequate space for simulation and lack of equipment inventory audits for replenishment (iii) inadequate clinical support for students due to inadequate clinical sites for experience, ineffective supervision and mentoring support, lack/shortage of clinical mentors and untrained hospital/clinical staff in EmONC and (iv) limited resources to support effective learning.

Findings reveal an overwhelmed midwifery faculty and an urgent demand for students support in clinical settings to acquire EmONC competencies for enhanced practice. For quality midwifery education, adequate resources and regulatory/policy directives are needed in midwifery faculty staffing and development. A continuous professional development specific for educators is needed for effective student teaching and learning of a competency-based pre-service curriculum.

Peer Review reports

Approximately one third of all maternal and neonatal deaths are due to poor quality maternal and newborn care [ 1 ]. Midwifery delivered interventions including skilled attendance at birth, provision of emergency obstetric and newborn care (EmONC) and family planning are central to averting the preventable maternal deaths, newborn deaths and stillbirths [ 2 ]. However, midwifery education and training in low- and middle-income countries is substandard leading to suboptimal quality of care [ 3 ]. The World Health Organization (WHO) recommends that midwifery educators should possess competencies to support theoretical learning, learning in the clinical areas, assessment and evaluation of students and midwifery practice [ 4 ]. The International Confederation of Midwives (ICM) defines assessment as a systematic process for collecting qualitative and quantitative data to measure, evaluate or appraise performance against specified outcomes or competencies. On the other hand, it defines evaluation as the systematic process for collecting qualitative and quantitative data to measure or evaluate the overall provision of and outcomes of a course of studies [ 5 ]. Evidence suggests that midwifery educators are insufficiently prepared for their teaching role [ 4 , 6 ]. The ICM recommends that at least 50% of the midwifery curriculum to be practical-based with opportunities for clinical and community experience [ 5 ]. In many countries, this does not occur. The inadequately prepared midwifery faculty compounded with a deficient curriculum compared to international standards and limited practical clinical experience for students affect the quality of midwifery graduates and subsequent quality of care [ 7 , 8 , 9 , 10 , 11 ]. As a result, midwifery educators are expected to structure their curriculum and develop learning activities that enable midwifery graduates to learn the knowledge and develop skills and behaviours essential for midwifery practice. The acquired competencies promote the role of the midwife to assess, diagnose, act, intervene, consult and refer as necessary, including providing emergency interventions [ 12 ].

The WHO, United Nations Population Fund (UNFPA), United Nations International Children’s Emergency Fund (UNICEF) and ICM recommend that skilled health personnel (includes midwives) as part of a team should be competent to perform all the signal functions of EmONC, to optimize the health and well-being of women and newborns [ 13 ]. Competency as defined in the Global Standards for Midwifery Education by ICM refers to the combined utilisation of personal abilities and attributes, skills and knowledge to effectively perform a job, role, function, task, or duty [ 5 ]. However, evidence shows that midwifery graduates are inadequately prepared with limited support and lack requisite competencies needed to function adequately as skilled health personnel after graduation [ 7 , 8 , 9 , 14 , 15 ]. Thus, midwifery graduates should achieve essential clinical competence – defined as a combination of knowledge, skill, attitude, judgment and ability needed for providing safe and effective care without any need for supervision [ 16 ]. Key barriers leading to suboptimal clinical competence include a deficient and largely didactic curriculum, educators/faculty who are less confident with clinical teaching compared to theoretical classroom teaching, inadequate teaching resources/equipment, insufficient clinical exposure of students for practice, absence of clinical supervisors and mentors and poor relationship with qualified hospital/clinical staff [ 3 , 7 , 8 , 9 , 14 , 15 , 17 , 18 , 19 ].

Emergency obstetric and newborn care training helps improve the knowledge and skills of skilled health personnel, change in clinical practice and improved maternal and newborn health outcomes [ 20 ]. The Kenya national Ministry of Health (MoH) included EmONC training for skilled health personnel in the National Health Policy 2014–2030 and Health Sector Strategic Plan 2018–2023 as a priority to improve the quality of maternity care and subsequent maternal and newborn health outcomes [ 21 , 22 ]. Introducing the training at pre-service with a supporting curriculum has the potential for greater returns on midwifery investments [ 23 ]. Funded by Foreign, Commonwealth and Development Office, Liverpool School of Tropical Medicine supported the Kenya MoH through the Nursing Council of Kenya and Kenya Medical Training College to conduct a detailed review of their national training syllabi and curriculum respectively. Curriculum content integrating EmONC and teaching methods were updated [ 24 ] aligned to the WHO and ICM competencies for midwifery practitioners and educators. This approach was designed to shift from the largely theoretical training to a competency-based skills training for graduates. This was followed by a bundle of interventions to build/strengthen the capacity of the training institutions and midwifery educators. The programme equipped the training colleges’ skills laboratories with EmONC training equipment. Blended (virtual and face-to-face) learning workshops for educators focusing on teaching (theory and practical/clinical EmONC skills), students’ assessments and giving effective feedback were conducted to improve their capacity to deliver the updated EmONC-enhanced curriculum. Supportive follow-up mentoring of midwifery educators in sampled colleges was implemented to build their professional skills in teaching, assessments and effective feedback. This bundle of interventions was evaluated and demonstrated improved educators’ knowledge, skills and confidence in teaching and EmONC skills [ 24 , 25 ]. Consequently, midwifery students’ knowledge and skills in EmONC improved before graduation [ 26 ]. Although the investments were promising, understanding experiences of educators and students is critical for a successful and sustainable implementation of the pre-service competency-based curriculum, scale up and uptake of the bundle of interventions.

Previous studies largely evaluated the changes in knowledge, skills and confidence of educators and students after programme training interventions [ 24 , 25 , 27 , 28 ]. However, studies focusing on experiences of the target group (either the educators or student group only) after midwifery educator capacity strengthening interventions are limited [ 29 , 30 , 31 , 32 ]. Experiences of students and educators enable midwifery educators to improve the design of the courses and support systems in place for effective teaching and learning [ 18 , 33 ]. Exploring students’ experiences is critical in determining what students find important and promoting their learning process [ 32 , 34 ]. This is relevant in designing training programmes that facilitate students’ learning and application of acquired competencies into practice.

This was a nested qualitative study within the broader cluster randomised controlled trial that assessed the effectiveness of a pre-service EmONC-enhanced midwifery curriculum delivered by trained and mentored midwifery educators in Kenya [ 35 ]. The objectives of this study were to explore the experiences, barriers and understand the perspectives of educators, students, and external mentors for educators to successfully implement an updated EmONC-enhanced curriculum during pre-service training. Findings are relevant to improve the design, delivery, uptake and scale-up of the pre-service midwifery programme for competent midwifery graduates as part of accelerating progress towards achieving maternal and newborn health sustainable development goals and universal health coverage.

Study design

This was a qualitative descriptive study using focussed group discussions (FGDs) and field notes nested within a cluster randomised controlled trial reported in a separate paper [ 35 ]. Qualitative descriptive studies generate data that describe the ‘who, what, and where of events or experiences’ from a subjective perspective [ 36 ]. Qualitative studies in trials are important in interpretation of trial findings and enhances the understanding of how contextual barriers and facilitators may influence outcomes [ 37 , 38 ]. Insights from qualitative studies can also inform implementation if the intervention is successful. This is because they can help trialists ‘to be sensitive to the human beings who participate in trials’ [ 38 ]. The objective was to understand the experiences of educators, students and mentors, challenges encountered and opportunities for improving the delivery and implementation of the updated EmONC-enhanced midwifery curriculum in Kenya.

The Kirkpatrick model is an effective tool with four levels for evaluating training programmes [ 39 ]. Level 1 (Participants’ reaction to the programme experience) helps to understand how satisfying, engaging and relevant participants find the experience. Level 2 (Learning) measures the changes in knowledge, skills and confidence after training. Level 3 (Behaviour) measures the degree to which participants apply what they learned during training when they are back on job or impact of training to their practice. This level is critical as it can also reveal where participants might need help to successfully implement what was learned. Level 4 (Results) measures the degree to which targeted outcomes occur because of training. The findings from this study are further analysed using the Kirkpatrick model at level 1 (experiences of educators and students) and level 3 (application of what was learned and areas for further support and investment) to improve the quality of pre-service midwifery education and training.

The focus group discussions explored the experiences of educators with the updated content, clinical teaching and skills demonstration, peer teaching and support, clinical supervision and mentoring of students, and effective feedback. Also, institutional challenges/bottlenecks and support required to implementing the updated curriculum. Students feedback on the teaching of the updated curriculum, clinical placements, clinical support supervision and mentoring during placements was documented. Mentors’ experiences and perspectives on the uptake of mentorship intervention by educators were explored. Additional components from mentors included strengths observed during the mentorship intervention (educators and institutional); bottlenecks experienced in the mentoring intervention and opportunities for support and improvement. The study is reported in accordance with the COnsolidated criteria for REporting Qualitative research (COREQ) (Supplementary Material) [ 40 ].

Study setting

This study was conducted in 20 (12 intervention arm and 8 control arm colleges) of the 52 KMTCs randomly selected in Kenya offering the integrated nursing and midwifery training programme in Kenya (Kenya Registered Community Health Nursing – KRCHN programme). This is the predominant direct entry programme offered at diploma level for nursing and midwifery workforce in the country. Each KMTC has two intakes of 50 students each per year (March and September), thus approximately 50 final year nursing and midwifery students are expected to graduate per intake. The duration of the diploma programme is three years with no internship period after graduation. Midwifery content and clinical placements are distributed across the three years of training. Students are posted to the respective hospitals (offering comprehensive EmONC services) attached to the training colleges for their clinical placements for practice and clinical experience. This is critical to reinforce theoretical learning, develop their clinical skills and attitudes for practice. A common curriculum by KMTC approved by the Nursing Council of Kenya is used for midwifery education in all colleges.

Intervention

Liverpool School of Tropical Medicine supported the review and update of the predominant nursing and midwifery training curriculum for training of nurse midwives at diploma level in Kenya in 2020/2021. The curriculum review and update were conducted by selected midwifery educators and practitioners. The output was a pre-service curriculum with EmONC content. Following the review, midwifery educators from both study arms (intervention and control) received training on the new content to strengthen their capacity to deliver the EmONC-enhanced curriculum. Training used Liverpool School of Tropical Medicine’s adapted Emergency Obstetric Care and Newborn Care Skilled Health Personnel training package [ 41 ]. This package has been used by LSTM in collaboration with MoH in over 15 low- and middle- income countries to strengthen the capacity of maternity care providers for quality EmONC service delivery [ 42 ]. Educators in the intervention study arm received additional mentoring and peer support on teaching and EmONC skills every three months for 12 months.

Mentoring support intervention

This was conducted every three months after the training for 12 months in the intervention colleges. A group of eight experienced EmONC faculty consisting of midwifery educators and obstetricians were recruited and trained as mentors. Educators were from university or midwifery training colleges not included in the study and they did not form part of the master trainers. They received a virtual one-day mentorship training facilitated by the corresponding author and an LSTM – UK senior MNH specialist experienced in EmONC capacity strengthening and pedagogy. Training focused on introduction to mentoring, building effective working relationships, giving effective feedback, handling difficult situations during mentorship, and teaching methods. The training used interactive lectures, discussions, and case studies. Mentorship sessions were a full day intervention per college for educators and focused on teaching skills, EmONC skills and drills and giving effective feedback to promote learning among students especially on performance of critical lifesaving EmONC skills or scenarios.

Structured participant observation of teaching sessions (theoretical or practical) and support by mentors for midwifery educators were also conducted in the intervention study arm at 3, 9 and 12 months after the training. Key elements of good quality teaching and learning were observed including: [ 1 ] teaching style, [ 2 ] use of visual aids, [ 3 ] teaching environment and [ 4 ] student involvement using a standardized observation checklist [ 43 ].

LSTM’s lead researcher (corresponding author) based in Nairobi Kenya conducted quality assurance visits to some of the mentoring sessions for all mentors. At the end of the mentoring visit, debrief sessions were held by the mentor, mentees, and the campus administration as necessary. The debrief provided feedback and areas that needed institutional support to promote quality teaching and learning. On occasions where the lead researcher was not present at the mentoring visit, the mentor recorded and shared field notes on key strengths observed, areas for further support and the action points proposed by the mentees for development.

Participants

A convenience sampling approach was used to select participants that were already enrolled in the trial to take part in the FGDs. Twelve [ 12 ] intervention arm educators, eight [ 8 ] control arm educators and eight [ 8 ] mentors participated in the FGDs. Each training college was represented by one midwifery educator.

A total sample of 146 final year nursing-midwifery students (KRCHN March 2020 class), the first group to be taught the updated EmONC-enhanced curriculum participated in the study. Due to the variability in the number of students per college, 20 clusters of 6–9 students, selected through stratified systematic sampling who participated in the knowledge and skills assessments participated in the debrief sessions.

Data collection

Three virtual FGDs were conducted at six months of the implementation (February 2022) with the intervention and control colleges’ educators and mentors by the corresponding author using semi-structured interview guides. The adapted interview topic guides were piloted and validated in a previous study [ 28 ]. These guides were also reviewed by study team members with experience in qualitative research. Each FGD lasted between 60 and 90 min. Respondent/member validation/check was routinely applied during the interview discussions to ensure that participants’ responses were accurately interpreted [ 44 ]. The FGDs were audio-recorded with permission from participants and transcribed verbatim in English. New emerging data from educators and mentors was routinely collected during the study implementation period. This strategy was employed due to the information power from a sample of participants but with rich relevant information for the study in qualitative research [ 45 ]. Although the corresponding author was not a faculty member with the KMTC, his status was known to the participants.

Two debriefing sessions moderated by the corresponding author and two independent assessors per college were held with students immediately after completing the knowledge and skills assessments between December 2022 and March 2023. The independent assessors were midwives and obstetricians working as midwifery educators in public or private training institutions and/or in clinicals and experienced EmONC faculty. They worked in pairs per college and were blinded to the intervention implemented and study arms. Details on the assessments are reported in a different paper [ 35 ]. In the first debrief, lasting between 30 and 60 min, were conducted immediately after the assessments by the corresponding author and the two assessors with the students for every college. These were confidential and not recorded to allow students express themselves freely on their experiences with the completed assessments, curriculum content covered, clinical placements and support received during maternity clinical placements. The second debrief lasted between 15 and 30 min and included the available institutional midwifery faculty/administration, students and the research team. Field notes were taken during the students debrief sessions by the corresponding author. Due to the potentially sensitive nature of the students’ feedback in the first debrief, general findings were shared with the college midwifery faculty and administration during the second debrief. Areas of strengths, opportunities and weak sections that needed additional support for improvement were highlighted.

Data management and analysis

Preparation for data analysis involved a rigorous process of transcription of recorded FGDs. Data analysis was led by the lead researcher, but the other authors contributed by reviewing the transcripts and quality checks. Collaborative thematic framework analysis by Braun and Clarke (2006) was used as it provides clear steps to follow, is flexible and uses a very structured process and enables transparency and team working [ 44 ]. Due to the small number of transcripts, computer assisted coding in Microsoft Word using the margin and comments tool was applied for the FGD transcripts and manual coding of text for the field notes. The six steps by Braun and Clarke in thematic analysis were conducted: (i) familiarising oneself with the data – the lead researcher listened to all of the audio recordings while reviewing the transcripts, looking for recurring issues/inconsistencies and, identifying possible categories and sub-categories of data; (ii) generating initial codes – both deductive (using topic guides/research questions) and inductive coding (recurrent views, phrases, patterns from the data) were conducted to derive the codes and enhance transparency of the study. The lead researcher generated a comprehensive list of codes. A second author with expertise in qualitative research separately analysed a selection of transcripts and then compared codes, agreed codes and broad themes; (iii) searching for themes by collating initial codes into potential sub-themes/themes; each transcript was reviewed to refine sub-themes/themes and an exhaustive list of sub-themes/themes was generated (iv) reviewing themes by generating a thematic map (code book) of the analysis; data were mapped to identify prevalence (new and old) of themes; again, two authors compared and validated the interpretations using one transcript (v) defining and naming themes through repeated, systematic and collaborative analysis of transcripts (ongoing analysis to refine the specifics of each sub-theme/theme, and the overall story the analysis tells); and (vi) writing findings/producing a report – findings were written up as descriptive accounts with illustrative quotes from the transcripts. Trustworthiness was achieved by (i) respondent validation/check during the interviews for accurate data interpretation; (ii) using a criterion for thematic analysis; (iii) returning to the data repeatedly to check for accuracy in interpretation; (iv) quality checks and discussions with the study team with expertise in mixed methods research [ 44 , 46 ].

Reflexivity

Due to the sensitive nature of the feedback from educators, students and mentors, the lead researcher had good awareness of who and where to address the emerging concerns from the study. These concerns together with programme achievements, challenges and best practices were disseminated to the KMTC management during the joint LSTM – MoH programme knowledge, management and learning dissemination events and policy forums. There was real benefit in the lead researcher being a near-peer to the participants as he was a male midwife educated and trained in Kenya and Uganda and an Associate Fellow of the Higher Education Academy, United Kingdom. He could relate to certain aspects of the educators and students’ experience of skills teaching and clinical placement as he had previous experience both as a midwifery student and adjunct faculty in the two countries. This also helped him to ask for points of clarification about certain aspects of the midwifery academic experience, educator and student experience, particularly around clinical skills teaching, organisation of clinical placements and midwifery support during the clinical placements. In addition, this allowed him sufficient distance to ask questions and not take the discussion contents personally. Use of multiple methods of data collection (knowledge surveys, direct observations through objective structured clinical evaluation of skills and debriefing after students assessments/field notes) enhanced triangulation of findings to give detailed descriptions and broad perspectives important in understanding the implementation of the updated EmONC-enhanced curriculum [ 46 ].

Eight of the 14 research team members who participated designing the study, data collection and data analysis were midwifery and obstetric faculty staff, with only two being from KMTC. They reflected that they found some comments about the educators and students experiences with clinical teaching and support supervision troubling as they held teaching roles in their respective training institutions.

Demographic characteristics of participants

All 20 midwifery educators were nurse-midwives by profession with majority ( n  = 12, 60%) being holders of a bachelor’s degree and aged 40–49 years ( n  = 9, 45%) and half of the midwifery educators being male ( n  = 10, 50%). Majority of mentors were males ( n  = 7, 87.5%), holders of master’s degrees ( n  = 5, 62.5%) and aged 40–49 years ( n  = 4, 50%). Equal number of mentors were either obstetricians ( n  = 4, 50%) or midwives ( n  = 4, 50%) (Table  1 ).

Experiences of educators, mentors and students on the implementation of the updated curriculum

The experiences from educators, external mentors and students are presented and organized into four broad themes: (1) relevancy of updated EmONC-enhanced curriculum to enhance practice, (2) continuous professional development opportunities for midwifery educators, (3) effective teaching and learning strategies and, (4) effective collaboration between school and hospital staff for effective training.

Relevancy of the updated EmONC-enhanced curriculum to enhance practice

Experiences on the EmONC content in the curriculum revealed three major sub-themes: (i) positive reactions to the EmONC content, (ii) demand for EmONC training and, (iii) approaches and time constraints in delivery of the content.

Positive reaction to EmONC content

Integrating EmONC within the pre-service midwifery curriculum was acknowledged as important and relevant to potentially improve the quality of midwifery care. Educators found the content useful and integrated it within their classroom and clinical teaching. Educators also reinforced the importance to introduce students to the EmONC-enhanced curriculum so that when they complete their training programme, they have the know-how and confidence to deal with obstetric emergencies.

“During the clinicals they have been able to apply the skills they have been taught. The EmONC has been of great help, they don’t panic when they see an emergency. They are able to attend to clients with confidence, even when they are alone. When the other qualified staff is not available or maybe they have a shortage, they are able to support care and not just be spectators.” Educator, intervention colleges FGD.

Mentors recounted that students loved to participate actively in skills demonstrations as it helped in mastery of skills and application of learned theory. Students recollected that skills demonstrations were conducted in the classroom/skills lab before their clinical placements. This was useful as they could link theory to practice and apply the learned skill when in the clinical placements. They found the EmONC content relevant in the maternity ward placements when they experienced complicated maternal cases that required specific EmONC care. The classroom knowledge and skills demonstrations in EmONC built their confidence in anticipating, detecting and handling obstetric emergencies.

“And my students are appreciating it. It is very important for these people to have this knowledge and they usually tell me they have not gotten any experience as good as the one that is being introduced by the EmONC” Educator, control colleges FGD. “They were feedback reports of students in clinical placement in various areas…. One of the students was able to use one of the skills of manual removal of a placenta. I did not believe that with the training they would have such confidence.” Mentor, FGD.

Demand for pre-service EmONC training

Reports from both intervention and control colleges showed that there was demand for EmONC training from students in upper classes who had completed the midwifery theory and clinical placements without the practical EmONC skills training. This was to build their skills and confidence in handling emergency obstetric cases before exiting the training programmes.

“And we were able to go through it, it was really intense. We were able to go through it with the teachers themselves, the lecturers and then with the students. And I think after that the word went around, the students started demanding that they also be taken through the skills” Educator, intervention colleges FGD.

Approaches and time constraints to deliver EmONC skills

Major approaches used to deliver EmONC within the updated curriculum were either as a blocked 5-day training during an ‘EmONC week’ (only by two colleges, one from each study arm) or specific skills taught within the topic lesson plans in the classroom/skills lab. Although EmONC content was taught in classroom/skills labs, time was cited by educators from both study arms as a key challenge in delivering the content effectively. This was largely due to the reduced time from the initial 3.5 year-nursing and midwifery curriculum to 3 years. As a result, each college had to design their teaching activities to accommodate the EmONC skills within the available limited curriculum time – either as a blocked course for five days or specific skills demonstrated within the topics taught. In addition, staffing levels within institutions in both study arms was a critical factor in the adopted approach to deliver the EmONC content.

“The curriculum is very comprehensive in terms of the EmONC training. But at the same time, we have reduced the number of years in that the curriculum is currently three years, instead of the three and a half. That time is too little to teach the theory sessions and then have the practical skills demonstrations, but we try to combine it during the teaching sessions. I find that it is a bit inadequate.” Educator, control colleges FGD.

Team teaching was identified as a potential solution used in two institutions to deliver blocked EmONC training during the EmONC weeks. The team-teaching included faculty from nursing and midwifery, clinical medicine (reproductive health) and integrated with a few hospital staff.

Students identified that skills demonstrations were often provided in the classroom/skills lab but they had limited opportunities for repeated return demonstrations. This they claimed was due to the inadequate time for the skills demonstrations in the classroom. Hence, practical learning was expected to take place during their clinical placements or at their own time in the skills labs. During the OSCE assessments, gaps were identified in student’s ability to identify, set up or use the right equipment for skills practice.

Continuous professional development opportunities for midwifery educators

Educators from both study arms acknowledged the training on EmONC and teaching techniques as a capacity strengthening and professional development opportunity. They found the training important as it built/strengthened their skills and confidence in applying different interactive teaching techniques for theory and skills to promote learning and helped educators in lesson planning.

“I feel more confident teaching alongside my colleague in terms of teaching midwifery skills through the demonstrations and both in the skills lab and follow up in the clinical area.” Educator, control colleges FGD.

There were initial fears and anxiety on the role and conduct of mentorship intervention among educators. Mentors reported that some educators initially were reluctant of the initiative as they thought it was a supervisory, assessment or audit visit for fault finding.

“They (educators) thought that it (mentorship) was more of supervision than support. They thought it was an assessment” Mentor, FGD.

Despite the initial anxiety and fears about the role of mentorship intervention, the mentoring support in the intervention colleges was greatly accepted and welcomed after understanding the goals and the implementation strategy by the mentors. Educators and mentors also acknowledged the administrative and logistical support received from the institutional managers to participate in the mentorship programme. Educators were enthusiastic and reported the mentoring intervention as supportive, encouraging and was greatly appraised for building the confidence of the educators particularly in EmONC skills teaching/demonstrations to students.

“And us as the lecturers it has really boosted our confidence in terms of our skills lab sessions…We had not been very confident in our skills lab sessions.” Educator, intervention colleges FGD.

Educators and students liked the use of external mentors drawn from other institutions with different expertise and experiences in midwifery and obstetrics during the lessons. Intervention stimulated and encouraged consultations and updates for capacity strengthening in midwifery, obstetrics and gynecology through the interactive mentoring sessions. Mentors complemented the educators during the teaching sessions of the updated curriculum in both theory and skills demonstrations. Students were also encouraged and actively participated in the teaching sessions as they could ask questions and receive feedback on topical concerns. Improved teaching techniques were effective in promoting confidence and learning among both educators and students.

“We have been able to learn a lot. It is through that mentor support that we have been updated about the resuscitation of the newborn, the current practices, .… shoulder dystocia, the best way to teach the skills….mentor demonstrated and updated us on the content like magnesium sulphate use and management of eclampsia and pre-eclampsia. We were able to be updated and shown how to train the student on the same.” Educator, intervention colleges FGD.

Although educators were flexible in planning and scheduling the mentoring visits, mentors expressed challenges with time constraints in some colleges in scheduling and completing the mentoring activities. This was largely due to the shortage of faculty and competing school activities involving examinations, students’ follow-up, and other administrative/management responsibilities.

Mentors identified that educators were more knowledgeable in theory compared to skills teaching and thus the need for regular hands-on refresher trainings to improve their skills teaching capacity. To promote the mentoring programme, the mentors and educators formed a WhatsApp community of practice group where resources including current guidelines, policies, updates, relevant literature and books could be shared. This platform promoted peer to peer support and sharing of best practices.

Effective teaching strategies

Participants mentioned effective strategies which aided their teaching and learning experiences presented as sub themes below.

Peer teaching and support/team teaching effective for learning

Peer teaching and support emerged as a key solution to complement the strengths and weaknesses of the educators and students. This included teacher – teacher, teacher – hospital staff, or student – student as below.

Teacher peer teaching and support

Educators highlighted the value in peer teaching and support although this was practiced in a few colleges. This included teacher-to-teacher or teacher-to-hospital midwife for theoretical or clinical skills teaching. Occasionally, midwifery educators collaborated and conducted team teaching of skills with the clinical medicine faculty. It improved interaction and mentoring for colleagues. This was largely in the skills teaching although was also observed and applied in some theoretical sessions. For those who had an opportunity to practice, they commended the approach as an opportunity for them to complement their strengths and weaknesses in skills teaching. In addition, this provided an avenue for them to receive supportive feedback from colleagues to improve their teaching skills.

“And us as the lecturers it has really boosted our confidence… It really built our confidence and now when we go through our peer-to-peer teaching, if one of us is not confident in a particular skill we even go through it ourselves first, we correct each other, we improve each other, and I think that is something unique and we appreciate.” Educator, intervention colleges FGD. “I was very impressed when I found that they had called in one midwife staff from the labour ward, to come and help them demonstrate (EmONC skill). We agree it was a resource that they could tap on… they need to do that practice with the staff and other competent people in the clinical area before teaching.” Mentor, FGD.

Educators reported that they consulted with one another on emerging updates on specific topics before teaching. Where resources allowed, educators combined with hospital staff to jointly deliver specific EmONC skills to students. This promoted peer support and was beneficial in ensuring that the classroom teaching resonated with the clinical practice.

Student facilitators for peer teaching and support

Educators in a few colleges used students to facilitate teaching to their fellow students particularly in EmONC skills. Those identified as student facilitators were either (i) those pursuing advanced diploma qualification in midwifery (ii) senior students in a similar nursing and midwifery programme or (iii) more competent student peers from the same class. Coaching of student facilitators by educators was also acknowledged to strengthen their confidence and competence. Student facilitators also provided personalised support for their peers with specific weaknesses in skills during/after practical teaching sessions. Educators found this approach beneficial as it encouraged active interaction and engagement between learners and promoted learning. Educators observed that students learnt faster from their colleagues as it also motivated the weaker students to strive to achieve similar competencies as their peers. In one of the intervention colleges, student facilitators were integrated in the hospital team to participate by facilitating some EmONC skills sessions to the qualified maternity staff during their weekly continuous professional development activities in the hospital.

“The students are divided into groups with each lecturer so that the lecturer demonstrates, and the students give the return demonstrations, and we ensure that everyone is hands-on. And as we are with the students, we pick those good students who have managed to master the skills very well and encourage them to mentor the other students.” Educator, intervention colleges FGD. “You see, for the students, they will learn better from one another, rather than me. I think that is proven. When you learn from someone who is almost a peer, you are able to understand better. Sometimes a lecturer will be using a language, they may see as if a language is difficult for them. But when they extend the content among one another, they are able to understand it better.” Educator, control colleges FGD. “On this peer teaching, when we have an EmONC demonstration, when we have one lecturer doing a demonstration, we invite others (lecturers) to participate. Normally we use the senior students who have done that content and have already been assessed. We request them to help the other students and mentor them and supervise.” Educator, control colleges FGD.

Participatory teaching methods

Educators and students commended the use of active and participatory teaching techniques to enhance learning. Consequently, mentors observed that mentorship improved the teaching practices of the educators including use of audio-visuals in teaching to promote learning. These included skills demonstrations with return demonstrations, use of small groups discussions for assignments and skills teaching and overall engagement/interaction with learners during teaching sessions. Educators expressed increased confidence and competence in leading EmONC skills teaching. They also integrated videos in the teaching of EmONC skills. However, mentors reported that use of scenarios and facilitating clinical teaching for students was irregularly practiced by the educators. Low confidence of educators in select skills was highlighted as a barrier contributing to low uptake of some of the effective interactive teaching techniques.

“After we taught (classroom), we went to the skills lab where we demonstrated with the students where I think we got the feedback from the students and they really appreciated those sessions.” Educator, intervention colleges FGD.

It was also observed by mentors that in some colleges, educators trained in EmONC only participated in theoretical teaching but not practical skills teaching. This was because some specific courses/lessons, for instance, obstetric emergencies, were assigned to a specific educator. Others recounted that the training received was short/inadequate and needed more refresher trainings to build more confidence.

“The biggest gap there is the fact that the lecturers trained are not teaching the practical part of it. Some were trained but they were not teaching. And there was only one teaching abnormal delivery, who was given all the tasks of demonstrating the skills. And I found that to be a challenge to keep up with the curriculum” Mentor, FGD.

Although there was remarkable improvement in skills teaching, mentors observed that the large number of students was a barrier to effective skills teaching with return demonstrations.

Feedback for effective learning

Effective feedback in teaching and learning was also highlighted. Educators from both study arms reported that feedback after clinical skills assessments was provided to improve the students. Observations during the students’ feedback sessions provided strong sentiments both critical of and appreciating the quality of the teachings and support students receive from their teachers. Some students acknowledged the constructive feedback received from educators with clear corrective measures to promote learning. However, some expressed fears that some educators provided feedback that was inappropriate, untimely and ineffective for learning and development. For some, they felt the feedback received was demeaning, disrespectful and discouraging for learning and received in an inappropriate environment.

“For the effective feedback to the students, we usually give the feedback as they demonstrate as we support them. We also have OSCE of the clinical areas and after that assessment we give marks, then we are also able to give the feedback to the students and the shortcomings of the students” Educator, control colleges FGD.

Educators integrated online platforms for receiving anonymous feedback on teaching sessions. However, this was sparsely used by educators from both study arms.

“… we have frequent interaction with the students, generally, in all lessons, they give feedback online, because now we have the Google platform where we can quickly get surveys and get feedback from the students.” Educator, intervention colleges FGD.

Effective collaboration between school and hospital staffs for effective training

Collaboration between colleges and hospitals emerged as an important theme that promoted effective learning. This included collaboration between educators and hospital midwives to jointly support and mentor students in their clinical placements and co-facilitating EmONC skills teaching (due to faculty shortage, deficiencies in some skills and to align theoretical classroom teaching with clinical teaching and practice). Other collaborations included support with hospital equipment for skills training where appropriate and co-assessment of students in their clinical placements. Educators emphasized the need for strong collaborations between the training institutions and hospitals for the benefit of the students.

“When we are doing the skills lab, for our students, during the skills lab time, sometimes we invite the midwives from the clinical area to help us demonstrate the skills. And we feel this is important for the students to have a contact with the clinical midwives so that when they get to the clinical area, they are already familiar with each other, and this improves on their confidence, and they appreciate.” Educator, intervention colleges FGD. “At the clinical area, there is also a day that we go through the EmONC skills together using mannequins.…We usually involve everyone – the midwives, the medical officers, the clinical officers and also to appreciate the teamwork in managing the mothers and the neonates….” Educator, intervention colleges FGD. “I was very impressed when I found that they had called in one midwife staff from the labour ward, to come and help them demonstrate (EmONC skill). We agree it was a resource that they could tap on… they need to do that practice with the staff and other competent people in the clinical area before teaching.” Mentor, FGD.

Challenges in implementing the updated pre-service midwifery curriculum

Challenges in implementing the EmONC-enhanced curriculum in pre-service institutions are presented in four themes below: (1) midwifery faculty shortage and workload, (2) infrastructure gaps in simulation teaching, (3) inadequate clinical support for students and, (4) limited resources to support effective learning.

Midwifery faculty shortage and workload

The ICM defines a midwifery faculty as a group of qualified individuals who teach students in a midwifery programme. This includes the following: midwife teachers; experts from other disciplines; and clinical preceptors/teachers [ 5 ]. Midwifery educators from both study arms reported an acute shortage of qualified nursing and midwifery educators to support the midwifery training programme. This shortage was attributed to the large number of nursing and midwifery students in the programme, heavy nursing and midwifery content to be covered, multiple academic activities including teaching, support supervision/mentoring of students, conducting theoretical and clinical assessments and other non-academic administrative roles. Due to the heavy workload, educators indicated that participating in effective teaching for skills and supervision/mentoring of students in the clinical areas during their clinical placements for experience and learning was a challenge. Shortage of midwifery faculty was also highlighted as a key challenge in the uptake of peer teaching and support among educators due to competing priorities and workload. To mitigate the shortage of qualified midwifery educators, institutions relied on hospital nurses and midwives to provide support to students during their clinical placements.

“Having only four lecturers from KMTC is a really big challenge. Out of those four lecturers, one is the head of department and the other is a deputy principal….So we manage to do only one students’ follow-up in a placement of maternity” Educator, intervention colleges FGD. “Now when we come to the EmONC skills demonstrations, it has been mandatory that we must take the students to the skills lab and include it as well in teaching. But unfortunately, with demonstrations, we cannot do a complete full EMOC because of the shortage of the staff trained to do the same.” Educator, control colleges FGD.

Mentors also emphasized the need for professional development for all midwifery faculty in the institutions. This was attributed to the fact that fewer educators were confident to conduct EmONC skills teaching effectively and no clinical mentors/preceptors specifically assigned to support clinical teaching and learning of students while in their clinical placements. For institutions that offer advanced diploma training for midwives, educators reported that students pursuing the advanced diploma midwifery programmes were requested to support with clinical skills teaching and demonstrations.

Due to the shortage of educators and competing institutional activities, mentors observed that occasionally, it was difficult to have a whole group of midwifery educators participating in the mentorship programme on the intervention day within the institution. Mentors and educators also reflected that the acute shortage of midwifery faculty negatively influenced the quality of training and education including teaching, support in clinical placements for skills acquisition and assessments.

“And also we are few, it is overwhelming when we have to do the EmONC activities and the other teaching activities and the other college activities.” Educator, control colleges FGD.

Infrastructure gaps in simulation teaching

All colleges reported availability of EmONC training equipment although some could benefit from replenishment or repairs. For most colleges, they reported effective collaboration with the hospitals’ staff for support in skills teaching when required. However, there were challenges with the availability of skills labs/classrooms, inadequate space in the skills lab for skills teaching/demonstrations and storage of equipment, worn out equipment that needed replenishment/repairs or lack of consumables. There were also gaps in skills lab equipment inventory with sporadic/infrequent monitoring of equipment availability and functionality through dedicated audits. To mitigate against the inadequate/lack of skills labs, some colleges modified teaching classrooms to act as skills labs for skills demonstrations during teaching sessions while others modified the multi-purpose halls for skills demonstrations with students.

A common feature across all the colleges was that the skills labs were not freely accessible to students for skills practice because of (i) lack of dedicated skills lab technicians (ii) overwhelmed educators participating in teaching, assessments, students’ follow-up during clinical placements and other administrative roles, (iii) inadequate time for skills teaching and practice and (iii) security of the equipment in the skills lab.

“The challenge we have is infrastructure. We have a small skills lab…We organise our classes where we teach, we organise the sessions there and the equipment and we are able to teach them well” Educator, intervention college FGD. “At the same time, when you are teaching this skill, the time is so limited. The students cannot practice enough, and you can’t leave the students in the skills lab on their own, because of the security and safety of our equipment. So they need somebody to be there all the time maybe to demonstrate and do a return demonstration…Because you have other activities to attend to. Maybe you have another class or you need to be somewhere else. So it becomes a challenge because these students want to engage and you are involved in other activities” Educator, control colleges FGD.

Skills lab personnel for safe keeping and maintenance of training equipment, support skills lab functionality and students for skills demonstrations were sparsely available across the study colleges. Although the skills labs were almost adequately equipped with training equipment in all colleges, mentors also identified that educators were often unfamiliar with how to utilise some equipment in the skills labs. This was highlighted to contribute to low skills lab utilisation for skills teaching and demonstrations.

“The lecturer is there though they do not visit the skills lab frequently. Some of the lecturers don’t know what is in the skills lab such as the EmONC kit and where to find it and how to use them (equipment).” Mentor, FGD.

Inadequate clinical support for students

Across the two study arms, students experienced inadequate support during their clinical placements. Most times, students reported that they largely participated by observing provision of emergency obstetric care services and rarely were they involved in the care. Educators confirmed that feedback from students showed that there was a variation or conflicting information from the classroom teaching and the hospital practices in some health facilities. Four main sub-themes under the theme were: (i) inadequate hospitals for clinical experience, (ii) hospital staff trained on EmONC, (iii) ineffective supervision and mentoring support for students and (iv) no clinical mentors to support clinical teaching and learning.

Inadequate comprehensive EmONC hospitals for clinical experience

High numbers of students and training schools (nursing/medical and clinical medicine programmes) vs. inadequate high volume/comprehensive EmONC health facilities for clinical experience and learning was highlighted as a major challenge. As a result, alternative options of hospitals away from the training region or lower level/basic EmONC health facilities were integrated and formed part of the clinical placement sites for students. Congestion of different cadre of students in clinical placements was a key factor that inhibited effective learning. At the basic EmONC health facilities, students commented that most of the time, they completed their placements without experiencing and/or participating in the management of some obstetric cases like obstructed labour, shoulder dystocia, breech presentation and newborn resuscitation in birth asphyxia. It was also observed that some students completed their clinical placements without having clinical placements and participating in care of obstetric emergencies in a comprehensive EmONC hospital.

Untrained hospital staff in EmONC

In some hospitals, educators enthused about the availability of EmONC-trained midwives who supported students while in their clinical placements. This promoted harmony between the classroom teaching and clinical practice which enhanced positive student learning and experience.

“In fact, when we go for clinical supervision, we find that they are being taken through the skills, they speak in one language which is a real advantage to us and I think the challenge comes when we start taking our students out of this hospital then the supervision becomes challenging.” Educator, intervention colleges FGD. “Clinical supervision, we are lucky, all the midwives in labour ward are trained in EmONC and help to train our students. Our students are giving us positive feedback when it comes to EmONC” Educator, control colleges FGD.

However, outdated clinical practices were also observed and learned by students in clinical placements in some training hospitals they were attached to. This was attributed to lack of/irregular training or professional development opportunities on EmONC for healthcare workers working in maternity.

“When the students have given us feedback about the clinical area, they have been giving us very negative feedback about the clinical practices which are going on…We had realised the staff had not been updated about the EmONC, all of them and the county nurse was notified and she has given me a feedback that they are planning to put a nurse there who has done the training, the on-job training. Also, they are planning in the next financial year to include the EmONC training to at least update the midwives working in the maternity area.” Educator, intervention colleges FGD.

Ineffective supervision and mentoring support for students

Feedback from educators and students revealed sporadic supervision visits by educators with no standard schedule for students support in most colleges, inefficient/lack of mentoring support in clinical placements by educators and hospital staff, untrained hospital staff providing clinical support. Students revealed that most visits by educators were only conducted towards the end of the clinical placement to prepare students for their clinical placement assessments. Locally developed institutional specific monitoring forms/tools for supervisory visits to be completed by the students and the visiting educator were available in only two of the 20 participating colleges. Most times, students were pessimistic about clinical teaching and learning as they expressed that their educators only visited and enquired about their general welfare including accommodation and upkeep while out of college for their clinical placements. Also, students rarely had opportunities to express challenges they experienced in their clinical placements including clinical teaching. Surprise findings included educators not involved in teaching midwifery also participating in the supervisory visits. The FGDs revealed that some ineligible and clinically inexperienced educators participated in the clinical supervisory visits for financial gains. Some educators also acknowledged that they lacked the clinical experience to provide mentoring support to the students.

“So, as I say the specific mentoring within the clinical placement might not be very much applicable in our setups because of the workload. So, we rely on the staff that are within the hospital to do the mentoring, us what we do is basically clinical supervision and mentoring, but it will not be as comprehensive as it would be if we had a specific mentor within the hospital centre.” Intervention college FGD. “Okay the only challenge I would say is when it comes to the clinical supervision outside the (college training hospital). I don’t know why people are seeing money instead of teaching. You find that people are not qualified or trained in EmONC in midwifery teaching, but they want to make a follow-up.” Intervention college FGD.

No clinical mentors to support clinical teaching and learning

Availability/lack of clinical mentors to support students during their clinical placements was highlighted by both educators and students. There were no dedicated clinical mentors employed by the colleges to support students while on clinical placements. Instead, colleges relied on hospital staff who had other primary duties in the clinical departments to provide mentoring support to students. Students and educators reiterated that for cases where they had a hospital staff assigned as a mentor, this was a secondary role that depended on the ward/unit activities.

“We have a big challenge when it comes to mentoring because we don’t have full-fledged mentors who are specifically handling students. What we have is somebody in the hospital, but that person has some other duties or some other roles.” Intervention college FGD. “It would have been better if we had mentors within the clinical placements who could be staying with the students for quite some time compared to lecturers having to go back to the clinical placement and mentor the students.” Intervention college FGD. “With clinical supervision and mentoring, we are still working on it so much, though we still have these bottleneck issues in term of the mentors in the hospital. We do not have them specifically to support students.” Control college FGD.

Limited resources to support effective learning

Although some colleges received some administrative support to engage hospital staff to support during EmONC skills teaching and mentoring of students, financial constraints emerged as a key challenge for institutionalizing and sustaining the initiatives. Educators reported limited resources by institutions to support academic functions to promote learning among students. Key areas affected were (i) clinical support supervision visits by educators for students during their clinical placements, (ii) recruitment of additional dedicated educators, clinical mentors and skills lab technicians to support clinical teaching and mentoring, (iii) refresher training for educators to update their knowledge and skills (iv) facilitating hospital staff and clinical mentors to effectively support institutional educators with skills/clinical teaching and mentoring of students, (v) expand skills lab infrastructure and replenishment of skills training equipment and consumables, (vi) motivation/support for student facilitators during their dedicated mentoring of colleagues and (vii) facilitated coffee/lunch breaks for students to fully participate in scheduled EmONC trainings.

“On clinical supervision, we have been going to the other clinical placement sites that they have been giving us. When the students are rotating within the college training hospital, we are able to do two or more supervisions but there is a challenge when we take our students far away because we cannot be facilitated to do supervisions more than twice in one place.” Intervention college FGD.

Mentors’ perspective on the future of mentorship

Mentors strongly recommended the institutionalizing of the mentoring intervention within the training institutions as part of the continuous professional development for educators. Mentors from the KMTC emphasized the need to institutionalize intervention in respective regions and establish regional hubs for refresher trainings for educators to strengthen their knowledge, skills and confidence. To consolidate learning, mentors expressed the need for blocked time for EmONC training – preferably for final year students before their exit into service delivery; encourage team/peer teaching and skills demonstrations for midwifery and clinical medicine students; develop a critical mass of student facilitators to support fellow students at free time and ensure access to the skills labs for skills practice. Appropriate recognition of the student facilitators and highly competent educators who supported mentoring of their colleagues was recommended as motivation for the selfless support of the passionate faculty. Importantly, it was emphasized that updates and guidelines should be jointly disseminated to the pre-service and in-service midwifery workforce to promote seamless classroom teaching and clinical practice.

Main findings

Our study explored experiences of educators, students and mentors (Kirkpatrick level 1) and application of what was learned into practice (Kirkpatrick level 3) in the implementation of an EmONC-enhanced curriculum. Challenges and areas for further support and investment to improve the quality of pre-service midwifery education and training were also identified. Key experiences include: (i) educators and students reacted positively to the EmONC content, (ii) the capacity strengthening training and mentoring of educators improved their knowledge, skills and confidence in teaching the EmONC-enhanced curriculum (iii) students applied the acquired EmONC knowledge and skills in their clinical practice during their clinical placements. Key interventions and improvements reported include: (i) educators improved their teaching skills by integrating participatory teaching methods (ii) educators adopted peer teaching and team teaching in their practice and (iii) improved feedback mechanisms between educators and students. Despite the positive reaction to the updated curriculum and capacity strengthening initiatives, key challenges with (i) midwifery faculty shortages (ii) high number of students in the programme (iii) inadequate time for delivery of the updated curriculum and (iv) inadequate clinical support for students in the clinical placements were identified. Strong collaborations between the training institutions and hospital staff were critical for strengthening the quality of pre-service education. However, resources including teaching infrastructure, supporting faculty and equipment replenishment were identified as key to the successful implementation of a competency-based curriculum.

Interpretation of our findings

Our findings are important as they are aligned and respond to WHO’s 7-step action plan to improving the quality of midwifery education [ 17 ], ICM’s global standards for midwifery education [ 5 ] and the global strategic directions for nursing and midwifery 2021–2025 [ 47 ].

This study demonstrated that a mentorship intervention improved educators’ knowledge, skills and confidence in skills teaching and integration of feedback mechanisms during teaching sessions. The mentorship intervention provided a much valued and needed opportunity for continuous professional development to update/improve their competencies for effective teaching. Joint specific programmes involving clinical midwives who participate in mentoring students during their clinical placements are important for enhanced learning and optimal clinical practice. Mentoring has been shown to improve skills acquisition, understanding of the professional role, personal and professional development. Mentoring relationships for student to student (peer), midwife to student, and midwife to new graduate midwife have been evaluated [ 48 , 49 , 50 , 51 ]. However, studies evaluating the role of mentorship for midwifery educators are limited.

Our findings are similar to other studies that showed that midwifery educators were not competent enough in their professional teaching roles particularly skills teaching [ 7 , 9 , 18 , 52 ]. Challenges identified include an overwhelmed faculty compared with the high numbers of students in the programme. This is a barrier to effective theory and practical skills teaching, clinical mentoring and support, assessments and providing effective feedback for learning and improvement. In addition, teaching infrastructure (skills labs and equipment) and hospital placement sites are inadequate and overstretched. This finding is similar to other studies conducted in LMICs [ 10 , 15 , 18 , 53 , 54 , 55 ] and may impact the uptake and scale-up of the mentorship programme in the future. Overstretched hospital placement sites and inadequate teaching infrastructure have been shown to have a direct negative impact on the quality of education and midwifery graduates produced for service delivery [ 3 , 17 ]. In competency-based education, active learner participation and accountability must be encouraged [ 56 ]. Training programmes are expected to integrate simulation skills training in their curricula before the clinical placements for clinical practical experience. Evidence shows that simulation and skills training make the students feel prepared and confident before clinical practice [ 31 ]. Although ICM recommends institutions to consider students vs. teacher ratios for effective training and education, the actual ratios are not prescribed. Therefore, training schools should design curriculum and programmes with a balanced context-specific teacher-student ratio, including clinical preceptors-student ratio, appropriate teaching and evaluation methods to promote learning and available resources for effective education as recommended by the ICM [ 5 ].

Our study findings compare to other studies where there is weak, ineffective or lack of supervisory follow-up support during the clinical placements for clinical experiences [ 18 , 19 , 32 , 52 , 53 , 55 , 57 ]. Curriculum implementation in the clinical area is a critical component to effective pre-service midwifery education and quality of midwifery graduates [ 7 ]. Clinical placements are essential for quality pre-service training and education and development of clinical competence [ 58 ]. During the clinical placements, students are exposed to the real practical settings and expected to apply the knowledge and skills acquired from classroom teaching under supervision. This experience helps students to develop mastery and right attitudes for practice. The International Association for Health Professions Education emphasizes that direct supervision and mentorship of students positively affects student development and patient outcome. For impact, supervision should be structured with regular scheduled meetings, provide essential constructive feedback regularly and should be aligned to students’ learning outcomes in the clinical placement [ 59 ]. In addition, effective supervisors/clinical teachers should have good interpersonal skills, good teaching skills and be clinically competent and knowledgeable [ 59 , 60 ]. Competent and updated educators and clinical midwives in training hospitals are critical for effective support of learning for midwifery students through supervision and mentoring in the clinical settings. Evidence shows that learning opportunities for students during clinical placements increase when there is joint support from academics/faculty and recognized, motivated preceptors in the clinical environment [ 29 , 61 , 62 , 63 ]. The collective team of qualified individuals who teach students in a midwifery programme (midwife teachers; experts from other disciplines; and clinical preceptors/teachers) are important faculty to prepare competent midwifery workforce [ 5 ].

Our findings showed that peer education was an approach practiced by both educators and students in theory and clinical skills teaching. Evidence suggests that peer education creates a safe supportive learning environment, learners view near-peer teachers as effective role models and increases confidence among learners and teachers [ 64 ]. Peer education as a complementary method in teaching along with the didactic approach have been found appropriate and effective [ 65 ]. Peer teaching increase student’s confidence and performance in clinical practice and improve learning in the psychomotor and cognitive domains [ 65 , 66 ]. When effectively used, students can share skills, experiences, and knowledge as equals. Also, it encourages feedback between students and saves time for the educators/preceptors [ 67 ]. Although the use of students’ peer teaching is associated with positive outcomes, students should be provided with adequate supervision and coaching by faculty and clinical mentors. Peer teaching approach can be ineffective with poor student learning due to incompatible students’ personalities and learning styles [ 66 ]. Therefore, careful consideration and support is required for this approach in midwifery education and training.

A one-off training in EmONC for final year midwifery students before graduation can consolidate the knowledge and skills learned over the years through classroom and clinical experience. However, learning opportunities on patients can be limited. Therefore, simulation-based education can facilitate learning hands-on clinical examination and procedural skills, using mannequins and realistic part-task and high-fidelity simulators prior to approaching patients [ 68 ]. Evidence has shown that simulation trainings improve knowledge, skills, self-efficacy, and satisfaction in learning. Additionally, they can reduce anxiety among learners before exit into the workforce [ 69 , 70 , 71 ]. However, resources (human, financial and infrastructure – space, equipment, and consumables) are essential to support the initiative across all the colleges. Sustainability should be considered, and midwifery education managers must therefore plan and allocate resources to implement the EmONC updated midwifery curriculum for optimal impact.

Strengths and limitations

To the best of our knowledge, this was the first study that explored experiences of educators, their mentors and students on the implementation of an EmONC-enhanced midwifery curriculum in Kenya. The study was conducted in KMTC, the largest trainer of the nursing and midwifery workforce in Kenya. Findings led to the 2024 KMTC nursing and midwifery curriculum review and allocation of 40-hours of EmONC specific content implemented in all the public mid-level training colleges in Kenya. This is to allow each institution to teach/facilitate EmONC training for final year midwifery students as a blocked standardised training to consolidate the knowledge/skills learned during the programme. The FGDs were considered adequate due to their information power for qualitative research (indicating that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed) [ 45 , 72 ]. Qualitative data was collected from multiple groups (educators in both study groups, mentors and students) and this enhanced data triangulation and improved the credibility of the findings [ 73 ]. Use of both inductive and deductive coding demonstrated rigor and helped uncover new themes/patterns in data, was more objective, reliable, flexible and adaptable to new information [ 44 , 74 ]. The study was conducted in sampled public mid-level nursing and midwifery training colleges and may affect the generalizability of the findings. As such, it may not be representative of the experiences of all the nursing and midwifery educators and students in Kenya.

Implications

Our findings showed the value of training and mentorship interventions improved educators’ knowledge and skills. For effective education, curricula reviews should be followed with specific capacity strengthening of educators to deliver the updated curricula. To achieve this, sustainable, specific, and relevant skills-based professional development programmes should be designed and targeted to ensure that midwifery faculty are competent to provide quality education. To strengthen practical skills training, midwifery educators should keep their own clinical skills up to date in clinical practice on a regular basis – annually to demonstrate evidence and complement professional development. Relevant policy and opportunities for clinical experience by educators to improve their supervisory roles in the clinical areas for midwifery students should be considered.

Training programmes should ensure that students have sufficient midwifery practice experience in facility-based and community settings to attain the current ICM Essential Competencies for Midwifery Practice. For adequate preparation of competent midwifery graduates, support in skills acquisition through simulation training and supervision and mentoring during clinical placements for practice should be strengthened. Educators and clinical mentors should be regularly updated to deliver a harmonised competency-based curriculum. Opportunities for structured constructive feedback should be provided to enhance student learning of key clinical skills.

Future research on return on investments is needed. The impact of an updated EmONC-enhanced curriculum delivered within the pre-service education and strengthened midwifery faculty on maternal and newborn health outcomes is needed.

Midwifery faculty and students reacted positively to the updated competency-based curriculum as relevant for practice. Training and mentoring intervention improved educators’ competencies to deliver the updated EmONC-enhanced curriculum. The study reveals an overwhelmed midwifery faculty and an urgent demand for students support in clinical settings to acquire the international ICM competencies for practice. There are regulatory challenges: high number of students verses faculty, lack of clinical practice for the midwifery academic faculty and lack of mandatory regular professional development opportunities for specific clinical and teaching skills competencies for educators. Ineffective clinical supervision and mentoring of students during clinical placements due to low numbers of competent faculty hinders effective student learning. Although the bundle of interventions was effective in improving institutional capacity, a policy for regular professional development of midwifery educators is needed for sustainability. Midwifery training institutions should refocus resources towards educator recruitment, skills training equipment, training and deployment midwifery educator and clinical mentors for optimal return on investments.

Data availability

The transcripts/datasets generated and/or analysed during the current study are not publicly available due to the confidentiality of the data but are available from the corresponding author on request.

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Acknowledgements

The study was made possible through the financial support of the FCDO for the four-year Reducing Maternal and Newborn Deaths Programme in Kenya (2019 – 2023). Special acknowledgement to the KMTC headquarters and campuses’ management, midwifery educators and students who participated in the study. Also, we specially appreciate the experts who participated in the review of the curriculum, training and mentoring of educators and assessment of students. Gratitude to Dr. Paul Nyongesa and Dr. Fiona Dickinson for support with study ethics processes. Lastly, the authors would like to acknowledge the special technical and logistical support provided by the LSTM – Kenya team during the curriculum reviews, capacity strengthening interventions and data collection (David Ndakalu, Roselynne Githinji, Diana Bitta, Esther Wasike, Onesmus Maina, Martin Eyinda, Veneranda Kamanu and Evans Koitaba).

The study was funded by the Foreign, Commonwealth and Development Office (FCDO) as part of the four-year “Reducing Maternal and Newborn Deaths Programme in Kenya.” The FCDO were not involved in the research – study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

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Duncan N. Shikuku, Alice Norah Ladur, Helen Allott, Carol Bedwell & Charles Ameh

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Contributions

DNS and CA conceptualised and designed the study protocol; designed the mentoring intervention and data collection tools. DNS, PN and AU conducted the FGDs and student debrief sessions. DNS coded and analysed the data and interpreted the results, drafted the primary manuscript, reviewed, and prepared it for publication. ANL provided qualitative expertise on methods, analysis, interpretation of findings and substantively reviewed the draft manuscript. SBZ, HA, CM, ET, EN, LW, LN, IB and CB participated in the design of the study procedures and substantively reviewed the drafts and final manuscript. CA obtained funding for the study, provided oversight in investigation, analysis, interpretation and substantially reviewed the manuscript drafts. All the authors read and approved the final manuscript.

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Correspondence to Duncan N. Shikuku .

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Ethics approval and consent to participate.

The study was approved by Liverpool School of Tropical Medicine’s Research and Ethics Committee (REC 20–050), Moi University/Moi Teaching and Referral Hospital Institutional Research and Ethics Committee (IREC) (IREC FAN: 0003764), Kenya Medical Training College (KMTC/ADM/74/Vol VI) and National Commission for Science, Technology, and Innovation (License No: NACOSTI/P/21/8931). Study participants received an electronic detailed study information booklet containing all information about the study. Written informed consent was obtained from participants. Participation was voluntary with an option to withdraw at any time with no consequences. Transcripts were anonymized with pseudonyms used to maintain confidentiality. Assessments and debrief meetings were conducted in a designated private space within the colleges for privacy.

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Shikuku, D.N., Bar-Zeev, S., Ladur, A. et al. Experiences, barriers and perspectives of midwifery educators, mentors and students implementing the updated emergency obstetric and newborn care-enhanced pre-service midwifery curriculum in Kenya: a nested qualitative study. BMC Med Educ 24 , 950 (2024). https://doi.org/10.1186/s12909-024-05872-7

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• Volume 14, Issue 8
• Exploring the perceptions of senior medical students on gender and pain: a qualitative study of the interplay between formal and hidden curricula
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• http://orcid.org/0000-0002-9334-0922 Megan E L Brown 1 ,
• Cristina Costache 2 ,
• Stephanie Bull Parker 3 ,
• http://orcid.org/0000-0003-0219-4956 Ravi Parekh 3 ,
• William Laughey 4 , 5 ,
• Sonia Kumar 6
• 1 School of Medicine , Newcastle University , Newcastle upon Tyne , UK
• 2 School of Medical Sciences , The University of Manchester , Manchester , UK
• 3 Medical Education Innovation & Research Centre, School of Public Health , Imperial College London , London , UK
• 4 Health Professions Education Unit , Hull York Medical School , York , UK
• 5 Reckitt Benckiser Plc , Slough , UK
• 6 University of Leeds , Leeds , UK
• Correspondence to Dr Megan E L Brown; megan.brown{at}newcastle.ac.uk

Objective Explore the perceptions of senior medical students on the relationship between gender and pain and examine how formal and hidden curricula in medical education shape their experiences.

Design We conducted a cross-sectional qualitative interview study, using individual semistructured interviews and adhering to interpretative description methodology. We used Braun and Clarke’s reflexive approach to thematic analysis to analyse our data.

Setting Six medical schools across the UK. Data collection occurred between the autumn of 2022 and the spring of 2023.

Participants 14 senior (penultimate or final year) medical students.

Results We created three themes, which describe key educational forces shaping students’ experiences of the relationship between gender and pain. These are (1) the sociocultural influencer, (2) the pedagogical influencer and (3) the professorial influencer. Our findings highlight the influence of both wider societal norms and students’ own identities on their experiences. Further, we explore the nature and detrimental role of formal curricular gaps, and negative role modelling as a key mechanism by which a hidden curriculum relating to gender and pain exerts its influence.

Conclusions These findings have several educational implications, including the need for a more holistic, person-centred approach to pain management within medical school curricula. Additionally, we recommend the creation of reflective spaces to engage students in critical thinking around bias and advocacy from the early stages of their training. We present actionable insights for medical educators to address issues of gender bias and pain management.

• MEDICAL EDUCATION & TRAINING
• QUALITATIVE RESEARCH
• PAIN MANAGEMENT
• Chronic Pain

Data availability statement

No data are available. As ethical approval was not obtained to make data sharing possible outside of the listed research team, no additional data are available.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-080420

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STRENGTHS AND LIMITATIONS OF THIS STUDY

By examining the hidden curricula of gender and pain within medical education, our research builds on previous studies noting insufficient formal education by highlighting the nuanced ways in which such gaps may be perpetuated or mitigated through everyday clinical interactions and informal learning experiences.

The in-depth, qualitative approach of this study has generated rich data and allowed for the consideration of important social and cultural nuances, captured particularly by our first theme: the sociocultural influencer.

The interview questions were codeveloped with a patient community group to shape and clarify our interview focus and language.

Though students were prompted to reflect on their experiences throughout medical school, this is a cross-sectional study, so students’ perceptions may have changed on recall.

Convenience sampling may mean that bias awareness appears more prevalent among medical students than it is within the wider medical student population.

Introduction

Gender bias in healthcare kills. This bias, which can be defined as ‘prejudiced actions or thoughts based on the gender-based perception that women are not equal to men’, 1 leads to increased mortality for girls and women. 2 For example, in countries with high levels of gender inequality, girls under the age of 5 are more likely to die than boys. 3 In the UK, women often receive poor medical treatment for gynaecological conditions, 4 and poorer care in relation to men for dementia 5 and cardiovascular disease. 6

Pain—its diagnosis and its management—is an area of healthcare practice where gendered stereotyping leads to poor outcomes for patients. Research indicates that the pain of Black women, for example, is not taken seriously by healthcare professionals, leading to increased morbidity and mortality. 7 Healthcare staff routinely underestimate women’s pain, leading to undertreatment and the suggestion of psychological rather than analgesic treatment. 8 Where women are scored with low rates of perceived ‘trustworthiness’, healthcare professionals are more likely to believe that they are exaggerating their pain. 9 Not only gender, but ethnicity, age, perceived attractiveness, likeability, manner and the presence or absence of medical diagnoses influence healthcare professionals’ perceptions of pain. 9

Though we know that gender bias exists in how healthcare professionals respond to and manage, pain (eg, women are perceived as more emotional than men), what is less clear are the reasons underlying such biases. 10 One potential explanation for how doctors develop biases is that they do so through the hidden curriculum. Doctors acquire many of their perspectives and professional values during medical school 11 where students are exposed to and experience such gender biases in the clinical workplace and the curriculum. This often happens via the mechanism of the hidden curriculum—‘…the attitudes and values conveyed, most often in an implicit and tacit fashion, sometimes unintentionally, via the educational structures, practices and culture of an educational institution’. 12 Influences operating within the hidden curriculum of medicine include clinical experiences, contact with role models, the attitudes of staff and patients, as well as external influences such as family/friends, the media and personal experiences. 11 Experiences within the hidden curriculum shape medical students’ views and carry into their future practice as a practising clinician.

While there is a growing clinical body of literature on gender and pain, relatively little attention has been paid to how medical education shapes students’ perceptions of gender and pain, and how these perceptions may affect their clinical practice as they become doctors. There is some literature on the presence or absence of pain assessment and management teaching within medical school curricula—one study, 13 for example, reports that pain education in US medical schools is fragmentary, limited and fails to cover key pain topics identified by the International Association for the Study of Pain. 13 While important, this study did not explore teaching on both gender bias and pain.

Another recent international study 14 has focused on gender and chronic pain within the curricula of the 10-top global ranked medical schools (as per the QS World University Rankings 2022). This study’s search revealed that the curricula of most medical schools lack comprehensive coverage of gender bias and chronic pain. 14 Our study aims to build on these findings by examining how medical education influences students’ attitudes and beliefs about gender and pain. While we know medical education on gender and chronic pain is insufficient, we do not have a detailed picture of UK medical education (only one UK institution was included in the study’s sample), we do not have intelligence on pain education beyond chronic pain, and we do not know whether and how that education influences students’ beliefs and attitudes towards gender and pain. Developing this understanding could help us reveal the implications of these educational practices. If medical students are not adequately trained to consider gender differences in pain perception and management, they may carry these biases into their professional practice, potentially leading to disparities in patient care and outcomes.

Henceforth, in this study, we explore the perceptions of senior medical students (penultimate or final year) in the UK on gender and pain, using a qualitative approach to examine how these perceptions relate to their experiences of formal and hidden curricula in medical education. To date, and to our best knowledge, no research exists regarding how the hidden curriculum of medical education relates to perceptions of gender and pain. Exploring this has cast light on the subtle, often unspoken, lessons regarding gender and pain that medical students experience alongside their formal education. By examining these hidden curricula, our research builds on previous studies noting insufficient formal education on gender bias and pain by highlighting the nuanced ways in which such gaps may be perpetuated or mitigated through everyday clinical interactions and informal learning experiences. This approach allows us to contribute to existing literature by capturing the full spectrum of medical student experiences relating to gender and pain.

Research questions

How do senior medical students perceive the relationship between gender and pain?

How do medical students experience the formal and hidden curricula of medical education in relation to gender and pain?

What elements of formal and hidden curricula within students’ longitudinal experience of medical education have influenced the development of their views on gender and pain?

Research approach

This is a constructivist, 15 cross-sectional qualitative study. We view reality as subjective, and knowledge as constructed uniquely by each individual in response to their interactions in social settings. 16 17 This is appropriate for our study, as we are interested in exploring, through qualitative interviews, students’ individual perceptions of pain and gender bias, and the ways in which they make sense and build their understanding of social experiences during medical school.

Methodology

The study methodology is interpretative description. The focus of this methodology is a rich description of participant experiences through the lens of the study research questions. It is aligned with a constructivist approach to qualitative research. 18 To support conclusions regarding the quality of this study, we consider how we designed Lincoln and Guba’s qualitative research evaluative criteria throughout, namely: credibility, dependability, transferability and confirmability. 19 20

Patient and public involvement

We piloted our interview questions in collaboration with the charity BME (Black and Minority Ethnic) Health Forum. Through the forum, we met with a focus group of four women to shape our interview focus and clarify our interview language. Members of the forum were compensated for their time in line with National Institute of Health and Care Research (NIHR) guidance. 21 This collaboration helped to ensure that our questions were culturally sensitive and accurately captured the experiences of diverse participants, enhancing the credibility of our data collection.

Data collection

We invited senior medical students (students in their penultimate or final year of study) based at any UK medical school to participate in an individual, in-depth semistructured, virtual interview over Microsoft Teams. We employed convenience sampling based on participant interest in the study and availability, given that the medical student population can be difficult to access due to study demands. Pragmatically, we sampled until we reached 14 participants. We selected this figure based on available funding, capacity and our experience as qualitative researchers.

We recruited using social media and local email recruitment at two UK institutions. CC, SBP and MELB completed all interviews with consented volunteers, using the interview questions developed with BME Health Forum as prompts to structure the discussion. The interview schedule is available ( online supplemental material ). We conducted 1-hour interviews with 14 participants online from 6 UK medical schools. Each participant was offered a £20 food voucher as thanks for their time. The interview audio was transcribed verbatim by a professional transcription company, then anonymised for analysis.

Supplemental material

Data analysis.

We used Braun and Clarke’s reflexive approach to thematic analysis to analyse our data. 22 The six steps of the method were used as a framework for coding, sorting, classifying and describing our data. We worked with the coding software Dedoose (V.9.0) to organise our data. We maintained an audit trail of our data collection and analytical processes, including decisions made and changes implemented, to enhance the confirmability of our findings. The steps of analysis, and what we did within each, are detailed in table 1 . By following a structured and well-documented approach to thematic analysis, we ensured that our analytic procedures were systematic and transparent, which supports the dependability of our findings. Further, in providing rich, detailed descriptions of our themes and using participants' own words where possible, we aimed to offer insights that others might be able to apply to similar contexts, supporting the transferability of our findings.

• View inline

The process of reflexive thematic analysis followed in this study

Reflexivity

The authors met regularly to discuss their own positions and perspectives as researchers involved in the analysis of this study’s data. This is a critical component of Braun and Clarke’s method, 22 which recognises the active role researchers play in interpretation, how this can add depth to study findings, and the importance of reflecting transparently on these perspectives. Reflexivity statements for each member of the research team are provided in table 2 . These statements formalise some of the reflections we shared throughout this project and attuned us to our strengths as a diverse team, and areas where we may have less insight and so need to challenge ourselves to think more deeply. It is important to note that none of the research team had pre-existing educational or personal relationships with any of the study participants.

Team reflexivity statements

We interviewed 14 senior medical students and gave each participant the opportunity to select a pseudonym. Where a participant did not wish to select a pseudonym, we selected one for them from a pregenerated list of gender-neutral and non-identifiable names. The list was created to be culturally diverse—where participants disclosed their cultural background, we selected a name culturally associated with their background, given the importance of culture in discussions of pain.

The pseudonyms in use for all participants are listed in table 3 . Quotes from participants are indicated in the below discussion of themes using italic text.

Participant pseudonyms

We created three themes which capture medical students’ perceptions of gender and pain, and experiences of the hidden curriculum. We name three key educational influences students experience, and engage with, in relation to gender and pain: ‘the sociocultural influencer’; ‘the pedagogical influence’ and ‘the professorial influencer’. The sociocultural influencer is an educational force relating to societal and cultural norms; the pedagogical influencer is formed of formal educational experiences; and, finally, the professorial influencer relates to the influence of academic and clinical teachers.

Our broad themes have several analytical subthemes, which constitute subheadings within the results narrative. Our themes and subthemes are:

The sociocultural influencer: conceptualisations of the relationship between gender and pain are shaped by sociocultural norms.

Understandings of pain and gender are shaped by the replication of gendered stereotypes.

Understandings of pain and gender are shaped by students’ personal identities.

The pedagogical influencer: formal pain curricula are experienced as deficient.

Students experience tension between the clinical diagnosis and management of pain, and holistic understandings of pain.

Students are motivated to engage in learning about the relationship between gender and pain, and their role in addressing key challenges.

The professorial influencer: senior role models, particularly within clinical environments, help create a hidden curriculum of gender bias in relation to pain.

Understandings of pain and gender are shaped by the hidden curriculum’s communication of gendered stereotypes.

Senior clinicians often role model biased understandings of pain.

The sociocultural influencer: conceptualisations of the relationship between gender and pain are shaped by sociocultural norms

We asked students to define pain and elaborate on their understanding of its nature, and the relationship between gender and pain. This theme describes senior medical students’ responses to these prompts, or their thoughts and opinions regarding the relationship between gender and pain. Interestingly, students explored the sociocultural dimensions of their understanding—namely their knowledge and the impact of societal norms (such as gendered stereotypes) and the influence of their own backgrounds.

These constitute two subthemes within this theme. Taken together, they help to cast light on how sociocultural gender biases are both perpetuated and challenged by medical students when conceptualising the relationship between gender and pain. In sum, this theme provides insight into part of a complex web of sociocultural factors that seem to be influencing learners’ perceptions of pain and gender.

We present this theme first to provide a foundation for our exploration of formal and hidden medical school curricula. The thoughts and understandings voiced by students in this theme relate to their experiences of the sociocultural contexts and norms they navigate. This theme sets the stage for a deeper analysis of how formal and hidden curricula interact with broader sociocultural influences regarding pain and gender.

Understandings of pain and gender are shaped by the replication of gendered stereotypes broadly and in clinical practice

This subtheme illuminates the influence of stereotypes, assumptions and biases in this context. During data collection and analysis, it became evident that students’ perceptions were multifaceted and shaped by various factors, including societal and clinical norms, medical school teaching and personal experiences. We explore these influences in greater depth in later themes.

Personal identities shape students’ understanding of the relationship between gender and pain

In this subtheme, we explore how students’ personal experiences, backgrounds and identities play an important role in shaping their understanding of the relationship between gender and pain.

Students noted that where they shared experiences with patients in pain (either experiences of pain personally, or via family and friends’ experiences) they could better empathise with patients. M, for example, describes women in their family being dismissed when in pain–seeing the distress this causes on a personal level, has meant M aspires to take patients’ pain seriously: ‘ I’m always like, ‘oh my God no aunty, I swear I’ll take you seriously’…if [a patient] has said, ‘so and so’ and they’re visibly distressed because of it, yes, I think I take that a bit more seriously because I don’t want to be another dismissive doctor’ (M ). Students highlighted that their personal experiences of pain management influenced the recommendations they made to patients: ‘ That’s affected my suggestions for management… I’m often much more inclined to suggest physio, having been through that experience where… [I was] offered painkillers and nothing else’ (Krishna ).

Some women noted that being a woman in pain made it easier to sincerely empathise with other women experiencing pain. Andrea, for example, comments on their personal experiences of gynaecological services and pain as a source of empathy for patients with similar pain, interacting with similar services: ‘ Every single month I’m so much pain that I pass out and being like, oh my god. I’m so sorry to hear that, I’m not reading off a script and just writing, here is your mefenamic acid or whatever they give to them. So, I feel like that impacted myself in a professional way but also in a personal way, because it’s like, wow, gynaecological services across the board are bad. Whether you’re a medical student or you’re a patient yourself’ (Andrea ).

Similarly, where students shared a particular characteristic with patients, for example, ethnicity, they were more attuned to the intersectional nature of bias in relation to pain and the needs of patients who were like them for example, patients’ cultural norms and how this might influence pain presentation and management. M describes advocating for patients where language barriers are an issue, based on their own experience of this barrier within their family:

I think for anyone who cannot speak English to some degree, probably because I sometimes have to advocate for my own parents and stuff like that, that I feel like I always take what they’re saying seriously… everyone has a bit of unconscious bias when they think, “oh she’s being dramatic or he’s being dramatic”, well that’s not right. And it’s very easy to get into that mindset, but as soon as they can’t speak English I feel like I’m a bit more serious about it, because I feel like I have to be, because I don’t think anyone else is going to give them that benefit of the doubt (M).

The pedagogical influencer: formal pain curricula are experienced as deficient

Students spoke at length about gaps in their formal medical school curricula in relation to gender, pain and the relationship between them. In this theme, we discuss how gaps in medical school curricula in relation to pain and gender are experienced by medical students.

There were many gaps and curricula needs identified. Common to the suggestions made were the desire for enhanced learning about the relationship between pain and bias across all years of medical school (‘ it makes up so much of clinical practice, but so little of our teaching time’ (Jiva )), but with a particular focus on discussing bias early at medical school (‘ Bias needs to be introduced really early. We need to learn to accept it. We need to normalise talking about it. And we need to appreciate just because you had a biased action, that doesn’t make you evil. It makes you human. And you just need to try and do better next time’ (Peter )).

Students experience tension between the clinical diagnosis and management of pain, and holistic understandings of pain

Students saw existing curricula as focusing only on the pharmacological management of pain: ‘ at all stages it’s generally been focused on the [World Health Organisation] pain ladder’ (Krishna ).

This sends a hidden message to students and clinicians—that the focus of clinical practice should be the medical management of pain. This, coupled with a relative lack of holistic teaching on pain management and bias (‘ Medicine, at least the way medicine is taught at my university is very much like, if it’s not objective, it’s too difficult to try to make you conceptualise, so we’ll try to avoid that topic’ (Jiva )) leads to an uneasy tension where medical students understand pain both to be objective and physiological, but also to be subjectively experienced by each patient. This causes conflict in clinical practice (‘ we have ways of assessing patients’ pain by looking at them, by the way they move, how they act. And we quite often hear people say, ‘oh, they can’t be in that much pain because they’re doing this’… I generally try to look at pain as whatever the patient tells you it is’ (Rory )) and is implicated in previously described views regarding catching patients out who aren’t ‘actually’ in pain (‘ I’ve certainly spoken to patients and gone… They’ve said their pain is a nine out of ten. And I’ve gone, I don’t believe you. Obviously, not to the patient. But I’ve walked out the room and gone, I don’t believe you’ (Rory )).

Further, this hidden message contributes to the focus of clinicians (identified by the students) on treating the underlying cause of pain, rather than managing pain itself (‘ Doctors prioritise the particular condition or treatment over exploring the pain’ (Aarya )). This can also be connected to the unease students perceived clinicians as feeling when dealing with chronic pain (where an underlying cause may be illusive) (‘ It seems people come in for a recurrent pain and they’re just giving you medication and don’t really discuss the impact or the hows and the whys or the self-help’ (Michelle )), pain of psychological origin (‘ I think that if someone is in pain and physicians perceive that there isn’t a visible or diagnosable related physical experience that would cause them that level of pain, I don’t think that there is much sympathy for patients’ (Alex)), and subsequent poor management of such patients.

Relatedly, students recognised the need for an enhanced focus on the lived experiences of people who are/have experienced pain. They saw opportunities for an increased focus on patient perspectives (in relation to pain and gender) in case studies, as both a developing strand within spiral curricula models, and through engagement with the arts and humanities: ‘ I think it’s best to hear it from and have talked with patients themselves to name their experience. But I think the next best thing would be reading patient accounts, reading poems, reading narratives about what it’s actually like to experience these different kinds of pain’ (Alex ).

Students are motivated to engage in learning about the relationship between gender and pain, and their role in addressing key challenges

Many students who were well-informed about gender bias and pain had engaged in significant self-directed learning in their own time, without opportunity to discuss their learning formally with their peers or tutors: ‘ All those things I’ve just picked up from external sources, whether it’s on Twitter, or I read a paper on it, it’s never been formally taught to me’ (M ).

Students are motivated to learn about pain and gender in a more holistic way and expressed a desire to be part of a conversation regarding the manifestations of gender bias in relation to pain (‘ The most important thing is getting people aware of it… making young medics willing to talk about it. Because we’re all educated people. We’re all bright. We’re all, hopefully, kind and compassionate. And if we just would talk about it, we could probably get a decent way to fixing it without massive intervention’ (Peter)); and part of action to challenge identified inequalities (‘ The other thing that really is important to me, personally, is what we can do about it…. it gets quite repetitive and quite infuriating… I get the whole point of raising awareness and that it’s important that we know. But what is the point of me…going into clinical practice, knowing that women are generally discriminated against… if I can’t do anything about it?’ (Rory )).

The professorial influencer: senior role models, particularly within clinical environments, help create a hidden curriculum of gender bias in relation to pain

Students learnt about pain not only from their formal medical school teaching (which, as above, they see as limited) but also from the hidden curriculum. The hidden curriculum in relation to pain and gender bias manifests in several ways. Prominent in our data is the way in which the hidden curriculum of clinical environments communicates gendered stereotypes, and the significant influence of senior clinicians’ role modelling.

Understandings of pain and gender are shaped by the hidden curriculum’s communication of gendered stereotypes

Gendered stereotypes were present in students’ understanding of pain and were described by students as communicated through the hidden curriculum. Overall, women were perceived as ‘more anxious’ (Lucy ) than men, and more likely to ‘ moan’ about pain —‘Even the way I’ve just said it, moaning about pain, because that’s what’s ingrained to us’ (Jiva ).

Students perceived that women’s pain was more likely to be dismissed clinically: ‘ Patients are dismissed based off their pains’ (Aarya ); attributed erroneously to gynaecological causes: ‘ The amount of times I’ve had to go, ‘are you sure it’s not your period pain?’ I’m pretty sure the 30-year-old who’s been having 18 years, 12 periods a month, 18 years, she’s had over 200 of these things now. I’m pretty sure she knows it isn’t that. Why are we asking?’ (Peter ); and psychological origin: ‘ … it really saddens me that so many more women are likely to be misdiagnosed with anxiety (Krishna ). Where pain was discussed as psychological, it was sometimes associated with women ‘ over exaggerating’ (Jiva ) pain—as Akira puts it ‘ in the ward you learn how to distract the patients away from their pain… how you could divert their attention. It reveals them as well… a patient came in… they were in agony… distract them and then you can tell it’s not too bad’ .

The intersectionality of other characteristics, such as race, socioeconomic status, weight and disability status, also played a role in the students' perceptions of pain. Most students appreciated that bias was intersectional, and that individuals affected by many different types of bias would be most negatively affected in relation to diagnosis, treatment and management of pain: ‘ I think working class women of colour are probably the most affected when it comes to pain [management]’ (Jiva); ‘People of lower socioeconomic class, [there’s] a higher assumption they’re drug seeking’ (Peter ). Students were often aware of harmful bias relating to race, ethnicity and socioeconomic status and saw this manifest in their teaching and clinical experiences: ‘ We’re taught outdated science, like, oh, Black people have a higher tolerance for pain. That’s just frankly a lie that came from no science ever. But it’s still propagated and people still believe’ (Peter ).

It is important to note that not all students believed they had encountered gendered stereotypes in relation to pain in clinical practice, or in their university education: ‘ I haven’t picked up on patients being treated differently because of gender… the patient’s experiencing pain… you need to give them something to relieve that… their gender or any other specific characteristic isn’t important in that’ (Vanya ). Others recognised their lack of familiarity with gender bias may be due to their own limited awareness: ‘ Nothing I’ve seen myself… but often you read about things or hear about things other people have seen’ (Kaivalya ).

Senior clinicians often role model biased understandings of pain

Senior clinicians’ opinions and actions were greatly influential and are an aspect of the hidden curriculum that impacts student perceptions of gender and pain. Through these opinions and behaviours, students are exposed to negative stereotypes and biases regarding pain and its management in the clinical environment. Students reported witnessing a lack of empathy from clinicians that they suspected was a result of taught (‘ Medical school teaches you to dissociate, pain-wise’ (Jiva )) and necessary (‘ It’s either detach or let it affect you too much’ (Jiva )) detachment, dismissive attitudes regarding patient pain (‘ It has to be very, very severe before anyone takes it seriously’ (Shubhi )). There were many reports of instances where patient pain was inadequately managed, which students suspected to be as a result of bias—Michelle, for example, describes the following:

A young Black woman with sickle cell anaemia came in with the crises… she had a PCA [Patient Controlled Analgesia] set up… and was asking nurses again and again throughout the night and saying that she was pushing the button, she wasn’t getting pain relief… the nurses had been very dismissive and they came in the next morning and they found that the PCA wasn’t connected to the driver, so she’d been pushing this button again and again and obviously it hadn’t done anything at all…that really just shocked me, actually, that a ward that’s so pro… when given a young Black woman with a known terrible disease that needs adequate pain relief, they seemed to be just disbelieving her (Michelle).

Some students discussed bias in pain relating to disability status and weight and noted negative assumptions among senior clinicians, for example, if someone can mobilise, they are not in pain; if someone is fat, they could be doing more to improve their lifestyle and manage their pain. Akira comments on the management of pain in primary care: ‘ … they’re like, I can walk with a walking stick, and so maybe they [the General Practitioner] perceive their chronic pain less of a major thing’; whilst Alex notes bias regarding patients’ weight and doctors’ perceptions of lifestyle changes ‘ …. that culture of, well, if you hadn’t let yourself get like this then you wouldn’t be in pain’ .

For some students, witnessing the negative role modelling from their seniors motivated them to behave differently: ‘ My whole experience on that placement made me feel like I would never do that to my patients. I would never, even if I’m so busy and I’m running an hour late in my clinic, I’m never going to rush through a speculum exam. Because it can be traumatic’ (Andrea ). However, this was not echoed in all student accounts.

In this study, we set out to explore senior medical students’ perceptions of gender and pain using a qualitative approach, particularly in reference to how these perceptions relate to participants’ experiences of formal and hidden curricula within medical education. Our research identifies three key educational forces, which students experience of the relationship between gender and pain as they progress through medical education: the sociocultural influencer, the pedagogical influencer and the professorial influencer.

Our data reinforce existing literature to demonstrate the impact of social norms and diverse identities on perceptions of gender and pain; and significant gaps in formal curricula. Our data build on existing literature by revealing a nuanced hidden curriculum that sends biased messages to students regarding gender and pain. Students perceived the origin of many of these messages to be clinical environments, and the senior clinicians involved in their instruction. The output of these influencers is gendered stereotyping and a lack of focus on the holistic management of women’s pain. In this discussion, we explore in greater depth how our findings relate to wider literature and make recommendations for educators which we hope will positively influence educational strategies.

The sociocultural influencer

Our findings show that many medical students are aware of, and actively perceive, gender bias in relation to the diagnosis and management of pain. Assumptions relating to gender were influenced by social norms and learners’ own backgrounds. Interestingly, the likelihood that a student would report witnessing gender bias in patient care appeared to increase when students’ personal identities corresponded with those of the patients they were treating. This awareness is consistent with the literature on increased empathy where students and patients share experiences, 23 and literature on bias within healthcare practice more broadly 24 and adds further weight to the need for a diverse clinical workforce. 25 The creation of reflective spaces in which all students can explore their clinical experiences for instances of bias, and develop cultural competence, would be beneficial. This need aligns with a critical consciousness approach to medical education, where students are engaged in open dialogue to encourage critical thinking about personal and societal beliefs. 26

The pedagogical influencer

Our participants reported several gaps in their formal medical school curricula in relation to gender bias and pain. These gaps represent more than missing content, as curricula gaps inadvertently convey messages to students about the relative unimportance of the content that is missing— 27 for example, the importance of holistic pain management, chronic pain, the significance of patient perspectives regarding pain and the role of bias. This is an important way in which the hidden curriculum manifests in relation to gender bias and pain education. This suggestion has been reported previously in relation to chronic pain, 28 but not beyond this. Interestingly, many students noted a tension these various gaps established—between viewing pain as something which was objective (which they felt the formal curriculum emphasised through its focus on pharmacology, the assigning of numbers to rate the severity of pain and regarding treating underlying causes of pain) and viewing pain as subjectively experienced by each patient (which they had witnessed as important through personal and clinical experiences, given the patient perspective gap in their formal curricula). This tension led to confusion and conflict. To address this, we suggest formal curricula and assessments which emphasise holistic approaches to pain management and explore patients’ experiences of pain (eg, through the arts and humanities, 29 and the inclusion of patients (eg, those with chronic pain) in curricula design) 30 would be beneficial. Our data suggest that exploring bias and advocacy in relation to pain is also important and would be valued by students at an early stage of their training. Critically, the students in our study were motivated to learn about bias in relation to pain, many conducting their own self-study. It may also be useful to involve students in the cocreation of formal curricula to ensure educational material meets their learning needs.

The professorial influencer

Another impactful way in which the hidden curriculum manifested in our data was in relation to role modelling. Medical education literature documents the harmful impact of negative role modelling, 31 which our data supports in relation to perceptions of, and behaviours relating to, pain within clinical practice. Negative role modelling can be a result of poor awareness of bias, but also of system-level constraints such as a lack of time or resources. 12 Our data highlight a lack of opportunities for students to reflect on their experiences, consider their own biases and consider both possible reasons for, and how they might act when they witness poor experiences of pain management in practice. Reflection plays a critical role in student sensemaking and subsequent awareness of how to advocate for patients. 32 There is a pressing need to either create these reflective spaces (again, here, a critical consciousness approach would be beneficial), or integrate discussion regarding students’ experiences of role modelling and their own perceptions in relation to pain within existing reflective spaces. Critically, educators and practising clinicians represent a key target audience for faculty development relating to gender bias and pain, to increase awareness of the perception of their actions and develop strategies for discussing pain and bias with students, including discussing the impact of resource shortages. Perceptions and practice relating to gender bias and pain across the continuum of medical education careers is an important direction for future research.

Across our findings, we have summarised our recommendations for educational practice ( table 4 ).

Suggestions for educators and organisations based on these findings

Limitations

Though we recruited widely, our convenience sampling approach means that we are likely to have attracted students interested in the topics of gender bias and pain and so there is a risk that our findings overemphasise student awareness of bias. The comments regarding desired developments for formal medical school curricula are based on student perceptions of what is covered by their medical school curricula presently, rather than our own analysis of medical school curricula coverage and, as such, there may be disparities between these reports and actual coverage. Despite this, we believe students’ perceptions of their curricula here are important as such perceptions influence engagement and can be inferred to represent students’ take-home understandings of teaching. Some students declined to select a pseudonym, meaning that in some instances, selected pseudonyms are researcher generated. This risks some loss of participant voice in our findings, though it does not negate the value of the experiences reported.

Additionally, this cross-sectional research offers a particular, time-bound perspective on students’ experiences. Given the participants’ descriptions of how early experiences are important, and education on gender and pain is particularly lacking at early stages, future research could longitudinally explore medical students’ experiences and perceptions from an early stage of their education.

We have explored the ways in which senior medical students perceive the relationship between gender and pain, exploring their experiences of their formal medical school curricula, and the hidden curricula they are exposed to by way of their presence within university and clinical environments. As the first study, to our knowledge, to explore how the hidden curriculum of medical education shapes students’ experiences of care in relation to gender and pain, this paper offers important insight for educators and researchers regarding the varied ability of students to identify gender bias in action, the powerful messaging of curricula gaps and impact of negative role modelling. We suggest further integration of curricular content focused on bias and advocacy, patient perspectives, holistic pain management and reflective spaces which encourage critical consciousness development at early stages of medical school curricula might go some way to addressing the gender bias present in many healthcare systems globally.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and we received ethical approval following the Imperial College London Education Ethics Review Process (EERP) (approval number: 2223-013). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors affiliated with Imperial College London would like to acknowledge the support of the Applied Health Research (ARC) programme for North West London.

• ↵ European institute of gender inequality . 2023 . Available : https://eige.europa.eu/thesaurus/terms/1155 [Accessed 03 Feb 2023 ].
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X @Megan_EL_Brown, @Imperial_Medic

Contributors MELB and WL were responsible for conception of the research and MELB, WL, RP, SK were responsible for design. MELB, SBP and CC collected all study data. MELB, CC and SBP analysed all study data. MELB prepared the first draft of this paper and all other authors (CC, SBP, RP, SK and WL) revised the work. RP is the guarantor.

Funding This independent research was supported by a research grant from Reckitt. The views expressed in this publication are those of the author(s) and not necessarily those of Reckitt. Grant number: N/A.

Disclaimer The views expressed in this publication are those of those author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Competing interests WL is a senior medical scientist at Reckitt, the funder of this research. This research is not focused on any of Reckitt’s products, and WL participated in his capacity as an independently qualified medical education researcher.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Published: 30 August 2024

A qualitative investigation of financial decision-making and enabling factors among ethnic minority young adults in Hong Kong

• Esther Yin-Nei Cho 1  

Humanities and Social Sciences Communications volume  11 , Article number:  1113 ( 2024 ) Cite this article

Metrics details

Current understanding of financial decision-making among racial/ethnic minority young adults is limited: day-to-day financial decisions of racial/ethnic minorities are underexamined, younger racial/ethnic minorities receive limited attention, studies on racial/ethnic minorities are mainly conducted in Western societies, and research on financial literacy and decision-making is predominantly quantitative in nature. Against this backdrop, this study utilized a qualitative approach to examine a range of financial decision-making among ethnic minority young adults in Hong Kong, including personal budgeting, spending, financial planning, the use of financial products, debt management, and the detection of financial fraud. Individual interviews were conducted with 53 Pakistani, Indian, Nepalese, and Filipino participants aged 18 to 29 who employed various budgeting strategies and faced challenges. Their spending was modest, and they espoused various spending philosophies. Many saved approximately one-third of their income using saving tactics and setting financial goals, and investing in both Hong Kong and their home countries. Informal borrowing was common, though some sought alternative loans. One-third used credit cards, with accompanying occasional risks. Despite employing protective tactics, they still fell victim to scams. Factors facilitating their financial decision-making include family social capital, intrapersonal characteristics, social dynamics factors, command of knowledge, and facilitative contextual circumstances. This study addresses knowledge gaps by providing an in-depth understanding of financial decision-making among ethnic minority young adults in a non-Western context. It has significant implications for timely and tailored financial literacy education for minority societal members.

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Introduction.

Extensive attention has been given to studying and promoting financial literacy, as shown by the burgeoning literature on the subject (e.g., Angrisani et al., 2021 ; Atkinson and Messy, 2012 ; Kempson, 2009 ; Lusardi and Mitchell, 2007 ), financial literacy incorporated as a national priority (OECD, 2015a ), and the proliferation of financial education programs worldwide (Kaiser and Menkhoff, 2020 ). The primary reason for this attention and effort lies in the growing awareness of the generally low levels of financial literacy across the world (e.g., Lusardi, 2019 ; Lusardi and Mitchell, 2011a ) and its impact on financial well-being, which, in turn, influences overall individual and societal well-being (Grohmann et al., 2018 ).

There is no universal definition of financial literacy, but the definitions used in the literature are essentially similar (e.g., Atkinson and Messy, 2012 ; Hung et al., 2009 ; OECD, 2015b ). For instance, financial literacy is defined as the “knowledge of basic economic and financial concepts, as well as the ability to use that knowledge and other financial skills to manage financial resources effectively for a lifetime of financial well-being” (Hung et al., 2009 , p.12) or “a combination of awareness, knowledge, skill, attitude, and behavior necessary to make sound financial decisions and ultimately achieve individual financial well-being” (Atkinson and Messy, 2012 , p.14). The terms “financial literacy” and “financial capability” are often used interchangeably (e.g., Muir et al., 2017 ; Xiao et al., 2014 ), referring to the ability to apply appropriate financial knowledge and engage in financial behaviors to achieve financial well-being (Xiao et al., 2014 ), though it may also include access to financial resources (Johnson and Sherraden, 2007 ).

These slightly different definitions converge around three interrelated ideas. First, financial literacy consists of basic elements, such as knowledge, attitudes, skills, and behavior, necessary for making financial decisions. Second, it involves the ability to apply these elements for sound financial decision-making. Third, financial literacy ultimately affects financial well-being through improved financial decision-making. Therefore, the extent of individuals’ financial literacy is not merely determined by their knowledge but also by how well they apply knowledge in their decision-making, which requires practice and judgement (Worthington, 2006 ). To fully understand people’s financial literacy, it is also necessary to examine their financial decisions in terms of both their practice and perceptions.

Disparities in financial literacy among different population groups have been documented based on characteristics such as age, gender, education, race/ethnicity, income level, and marital status (e.g., Brown and Graf, 2013 ; Lusardi et al., 2010 ; Lusardi and Mitchell, 2011a , 2011b ). Racial/ethnic minorities comprise one of the most vulnerable groups (Al-Bahrani et al., 2019 ; Angrisani et al., 2021 ; Brown and Graf, 2013 ; Lusardi and Mitchell, 2011b ). For example, Black and Hispanic individuals in the USA tend to score lower on financial literacy questions than Whites (Lusardi and Mitchell, 2011b ). While it is recognized that racial/ethnic minorities have lower levels of financial knowledge, a more comprehensive understanding of their financial literacy is still needed.

First, racial/ethnic minorities’ financial decision-making has not been sufficiently examined. Existing studies focus on banking accounts (Barcellos and Zamarro, 2021 ; Kim et al., 2016 ; Lusardi, 2005 ), credit use and debts (Ekanem, 2013 ; Gaur et al., 2020 ; Goodstein et al., 2021 ; Yao et al., 2011 ), asset holding (Lusardi, 2005 ), and retirement planning (Kim et al., 2021 ). Other important day-to-day financial decisions are less understood, such as budgeting, savings, using other financial products, and detecting financial fraud.

Second, younger members of racial/ethnic minorities, who face double challenges, have received limited attention. As racial/ethnic minorities, they already have low levels of financial literacy. As younger adults, they are more financially vulnerable than their older counterparts. Not only do they have lower levels of financial knowledge, such as inflation, compound interest, and risk diversification (Lusardi et al., 2010 ; Lusardi and Mitchell, 2011a ), but they also face more financial challenges due to longer life spans, more financial decisions to make, and greater financial risks in an increasingly complex global financial environment.

Third, most studies on racial/ethnic minorities have been conducted in Western societies, particularly the USA, with more limited research conducted in other contexts, such as Asian societies.

Fourth, research on financial literacy is predominantly quantitative (Goyal and Kumar, 2021 ; Kelley et al., 2021 ). Qualitative studies are few, particularly regarding racial/ethnic minorities (Ekanem, 2013 ; Gaur et al., 2020 ). While quantitative studies provide a broad perspective on the subject matter, qualitative studies offer an in-depth understanding of how individuals perceive and make meaning of their financial decisions. This information is valuable for informing financial literacy education and thus improving financial decision-making.

This study examined a range of financial decisions made by ethnic minority young adults in Hong Kong using qualitative inquiry to address these limitations. By adopting a qualitative approach, the study focuses on generating themes that may not be captured in quantitative studies relying on statistical figures. It extends the literature by providing a deeper understanding of the financial decisions made by younger ethnic minority individuals within a non-Western context. The findings also reveal factors facilitating sound financial decision-making among ethnic minority younger people, particularly in Hong Kong. These findings have important implications for tailoring “just-in-time” financial literacy education to meet their specific needs, as opposed to a “one-size-fits-all” approach (Goyal and Kumar, 2021 ).

In the following, after briefly highlighting the relevant literature on financial literacy and financial decisions, the findings on ethnic minority young adults regarding different areas of financial decision-making will be presented. Factors facilitating their financial decision-making will be identified, and implications for financial literacy education and further research discussed.

A brief overview of financial literacy and financial decisions

Patterns of financial literacy.

Financial literacy levels are associated with various socioeconomic factors, including age, gender, education, parental education, employment status, marital status, area of residence, and race and ethnicity. Financial literacy exhibits a bell curve distribution with age. It is lower among young and old individuals than those in the middle of the life cycle (Atkinson and Messy, 2012 ; Brown and Graf, 2013 ). For instance, less than one-third of young adults possess basic concepts about inflation, risk diversification, and compound interest (Lusardi et al., 2010 ; Lusardi and Mitchell, 2011a ). Regarding gender, women tend to have lower levels of financial literacy than men. They have less financial knowledge about debt, inflation, risk diversification, and compound interest (Brown and Graf, 2013 ; Lusardi and Mitchell, 2011a ; Lusardi and Tufano, 2015 ) and are less likely to plan for retirement (Herd et al., 2012 ). Educational attainment is positively related to financial literacy (Herd et al., 2012 ; Klapper et al., 2012 ; Lusardi and Mitchell, 2007 , 2011a ). Less well-educated people are less likely to answer financial literacy questions correctly and tend to indicate not knowing the answer (Lusardi and Mitchell, 2011a ). Individuals without a college degree are less likely to understand concepts about inflation, risk diversification, and simple interest calculations (Herd et al., 2012 ). More educated people tend to have positive attitudes towards retirement planning (van Rooij et al., 2011a ) and possess a bank account (Klapper et al., 2012 ). Parental education, particularly mothers’ education, and parents’ possession of stock or retirement accounts are positively related to financial literacy (Lusardi et al., 2010 ). Fathers’ education is positively associated with their daughters’ financial literacy (Mahdavi and Horton, 2014 ). In terms of employment status, employed individuals have substantially higher levels of financial literacy than those who are unemployed or retired (Brown and Graf, 2013 ; Bucher-Koenen and Lusardi, 2011 ). Marital status is also related to financial literacy levels, with married people tending to have higher levels than single individuals (Brown and Graf, 2013 ). In terms of area of residence, those who live in a city score better in financial knowledge than their rural counterparts (Klapper and Panos, 2011 ). As for race and ethnicity, individuals belonging to the racial majority or being native-born have higher financial literacy levels (Brown and Graf, 2013 ; Lusardi and Mitchell, 2007 , 2011b ). For example, African Americans and Hispanics in the USA have lower financial literacy than Whites (Al-Bahrani et al., 2019 ; Lusardi and Mitchell, 2007 , 2011b ). In Switzerland, foreign citizens, especially immigrants with a non-German native language, exhibit lower financial literacy than native-born individuals (Brown and Graf, 2013 ). Students from an immigrant background also have lower financial literacy than other students (OECD, 2014 ).

The association between financial literacy and financial decision-making

Financial literacy is crucial for making sound financial decisions and avoiding costly mistakes. Empirical findings show that financial literacy is associated with various outcomes of financial decision-making, including day-to-day financial management, financial planning, using financial products, debt management, and detecting financial scams.

First, financial literacy can lead to better day-to-day financial management, such as responsible family budgeting, timely bill payments, and avoiding impulsive purchases (Akben-Selcuk, 2015 ; Atkinson and Messy, 2012 ; Hilgert et al., 2003 ; Perry and Morris, 2005 ). For example, a study of college students shows that those with higher financial literacy are more likely to pay bills on time and have a budget in place (Akben-Selcuk, 2015 ). Second, financial literacy is associated with better financial planning. Financially literate individuals are more likely to engage in savvy and active saving behavior (Akben-Selcuk, 2015 ; de Bassa Scheresberg, 2013 ; Deuflhard et al., 2019 ; Klapper et al., 2012 ). They are more likely to plan for retirement and save for emergencies (de Bassa Scheresberg, 2013 ). Third, financial literacy is related to better debt management. Individuals with better debt literacy will avoid high-cost borrowing, high transaction costs, and higher fees (Lusardi and Tufano, 2015 ; de Bassa Scheresberg, 2013 ). They also adopt better credit card behavior, which minimizes fees and interest charges resulting from late payments, cash advances, and paying only the minimum amount due (Lusardi and Tufano, 2015 ; Mottola, 2013 ). Fourth, financial literacy influences the use of financial products. Individuals with higher levels of financial literacy are less likely to be unbanked and use alternative financial services, such as payday loans (Kim and Lee, 2018 ). It is also associated with greater participation in investment and savvy investment decisions. Financially literate people tend to evaluate financial products carefully (Atkinson and Messy, 2012 ) and be more involved in the stock market (Almenberg and Dreber, 2015 ; van Rooij et al., 2011b ). Finally, financial literacy can increase the ability to detect financial fraud. Findings show that a one standard deviation increase in financial knowledge increases the probability of fraud detection by three percentage points (Engels et al., 2020 ).

Financial decisions of racial/ethnic minorities

Research on financial decisions made by racial/ethnic minorities has mostly focused on using financial products, debt management and credit use, and retirement planning.

Regarding financial products, African Americans and Hispanics in the USA are less likely to have a bank account and hold asset investments, such as stocks, than Whites (Kim et al., 2016 ; Lusardi, 2005 ; Shanbhag, 2022 ). Another study examined community development credit unions providing affordable financial services, such as mortgages, to help African Americans save money and build assets (Nembhard, 2013 ). Newly arrived immigrants in Australia demonstrated low utilization of financial products and services, such as ATM cards, bank savings accounts, and credit cards (Zuhair et al., 2015 ).

As for debt, around 80% of Chinese American respondents in a study on debt ownership held some type of debt, such as credit cards, mortgages, and instalment loans (Yao et al., 2011 ). Age, the presence of children under 18, health, income, and amount of financial or non-financial assets are associated with the probability of borrowing. Other studies have explored the attitudes of Black and other minority ethnic entrepreneurs experiencing bankruptcy in England (Ekanem, 2013 ) or Pacific Island adults in New Zealand towards debt, money, or bankruptcy (Gaur et al., 2020 ). Significant racial/ethnic differences in credit use have also been reported. Approximately 75% of White, 80% of Asian, 50% of Hispanic, and 45% of Black households use bank credit, in terms of a credit card or a personal loan or line of credit from a bank. However, nonbank credit, such as payday loans, is more predominant among Black and Hispanic households (Goodstein et al., 2021 ).

Studies on retirement planning show that ethnic minorities have less savings for retirement than Whites (Gough and Adami, 2013 ) and are also less motivated to hold retirement savings even after controlling for different socio-economic characteristics (Kim et al., 2021 ).

Ethnic minorities in Hong Kong

Despite growing efforts to promote financial literacy among people in Hong Kong in recent years, such as establishing the Investor and Financial Education Council as a public organization to promote financial education in Hong Kong, ethnic minority younger adults are still largely overlooked. In terms of research, the financial literacy of ethnic minority young adults or even ethnic minority communities is underexplored. Existing survey findings only show disparities in financial literacy between younger and older adults in the general population, with the former performing poorly, particularly in timely bill payments, making ends meet without borrowing, and keeping up with their financial affairs (Investor Education Centre, 2018 ). Financial education programs targeting ethnic minorities are also limited. Only 0.6% of the 661 financial education initiatives conducted between 2011 and 2015 were intended for the ethnic minority population (Investor Education Centre, 2015 ).

Ethnic minorities in Hong Kong refer to the non-Chinese population, which makes up 8.4% of the total population (Census and Statistics Department, 2022 ). Most are Filipino and Indonesian, constituting 32.5% and 22.9%, respectively, and most (more than 90%) of these are foreign domestic helpers living in their employers’ homes. South Asians, including Pakistanis, Indians, and Nepalese, make up 16.5% of the ethnic minority population. The rest are mostly White people and other Asians, such as Korean and Japanese, who often enjoy a higher social and economic status in the city and are not the focus of this study. After excluding the Filipina and Indonesian domestic helpers, Pakistanis, Indians, Nepalese, and Filipinos represent the largest proportion of the ethnic minority population in Hong Kong and are the focus of this study. These individuals may have migrated to Hong Kong with their families or were born in Hong Kong. Some of them may have acquired a certain level of English and Cantonese, the local language, especially if they have received education in Hong Kong.

In Hong Kong, ethnic minority younger adults are likely to perform less well in financial literacy and financial decisions than the general population, which is largely made up of ethnic Chinese. This is because they generally fare poorly in terms of education and employment. For example, school attendance rates for ethnic minorities in the age groups 3–5, 12–17, and 18–24 years were 90.7%, 96.2%, and 29.2%, respectively, compared to 92.5%, 97.8%, and 51.8% for the whole population in 2016 (Census and Statistics Department, 2017 ). As regards occupation, 35% of Nepalese, 35% of Pakistani, and 25% of Indian individuals were engaged in elementary jobs, such as cleaners, laborers, and food preparation assistants, compared to 21% of the general population (Census and Statistics Department, 2017 ).

Drawing on the literature, this study examined the financial decision-making of ethnic minority young adults in Hong Kong and posed the following research questions:

What are the experiences of ethnic minority young adults, in terms of practice or strategies and perceptions, in different areas of financial decision-making, including day-to-day financial management (personal budgeting and spending), financial planning, using financial products, debt management, and detecting financial fraud?

What factors enable ethnic minority young adults to make sound financial decisions?

This study employed a qualitative approach, using individual in-depth interviews, to examine the financial decision-making of ethnic minority young adults in their daily lives. The rich data gathered from qualitative inquiry can provide a nuanced understanding of human behavior, which involves practice and judgement. Semi-structured interviews allow participants to express their thoughts in their own words, which is particularly beneficial for delving into a poorly understood topic.

Participants and data collection

In this study, Pakistani, Indian, Nepalese, and Filipino participants were recruited through NGOs that provided services for ethnic minority young adults and international offices of universities using purposive sampling. In addition to ethnicities, young adults who were 18 to 29 years old, permanent residents of Hong Kong, and students or employed were recruited. Table 1 summarizes the participants’ background characteristics. Fifty-three ethnic minority young adults aged between 18 and 29 years were recruited: 16 Pakistani, 13 Indian, 13 Nepalese, and 11 Filipino. Thirty-five were aged 18–23, and 18 were aged 24–29. There were 30 males and 23 females. Thirty-two were employed at the time of the interview, and 21 were students. The occupations of those in employment included elementary jobs (e.g., security guards), service workers (e.g., customer service), associate professionals (e.g., program workers in NGOs), and professionals (e.g., software developers). Many ethnic minority students had part-time jobs ( n  = 12), such as cashiers, tutors, football coaches, and delivery workers. Other students depended on their parents for financial support ( n  = 9). Most participants were pursuing or had attained at least a bachelor’s degree ( n  = 30). Sub-degree education being pursued or attained included associate degrees, higher diplomas, or foundation diplomas ( n  = 11). The education level of the remaining participants ranged from Secondary 3 to 6 ( n  = 12). Students’ monthly earnings ranged from US$90 to $2500; more than half received US$1250 or less ( n  = 18). Working participants’ monthly earnings ranged from US$625 to $3560, most receiving between US$1250 and $2500 ( n  = 16).

The Research Ethics Committee of the university to which the author was affiliated provided ethical approval before the study commenced. Before interviewing, participants’ informed consent was obtained after explaining the study’s objectives and principles of confidentiality and voluntary participation. Each interview took place in an NGO or university and generally lasted between 60 and 75 min.

Interview questions

The interview questions were developed to gather information on a range of financial decisions based on the literature on financial literacy and financial decisions, including day-to-day financial management (personal budgeting and spending), financial planning, using financial products, debt management, and detecting financial fraud. Participants were asked about their practices or strategies and perceptions of each area of financial decision-making. The interviews were conducted in English.

The audio recordings of individual interviews were transcribed verbatim. Following Braun and Clarke ( 2006 ), thematic analysis was employed to identify, analyze, and report major themes within the data. The researchers first familiarized themselves with the data through repeated readings. They then developed initial codes to capture the meaningful aspects of the data. These codes were further organized into potential themes, and the relevant data associated with each code were collated within the potential themes. The potential themes were refined through careful review to ensure the coherence of data within each of them and that they were distinct. Once the refinements were finalized, the themes were named to accurately reflect their essence.

The following findings present the practices, strategies and perceptions of various financial decisions. Table 2 summarizes the major themes., which also align with particular components of financial literacy, including financial knowledge, attitudes, and behavior (Atkinson and Messy, 2012 ).

Personal budgeting

Spending- or saving-centric approach in practice.

Most participants had developed habits of monthly budgeting, using saving- or spending-centric approaches. The former involves setting a savings amount and then spending the remainder, whereas the latter involves setting a spending limit and then saving the remainder. For example, one participant was more conscious of his savings:

I set in mind that every month I have a certain percentage to be saved and not to be touched. The rest is like spendable expenses, so I don’t have to go crazy saving mode. (18Indian, M/26 y, W, Degree) Footnote 1

Digital tools, parental monitoring, and mental bucketing as strategies

Participants employed various strategies in practice, including digital tools, parental monitoring, and mental bucketing. The digital tools they utilized included budgeting apps, Excel spreadsheets, online banking, and calendar or note taking apps in their phone. Some examples of budgeting apps to keep track of budgets were Zoho Expense, Ahorro, Mobills, Money Manager, Spendee, and Savings Planner.

I have this app Mobills …I just type all my expenses in where I spent the money so it helps me track if I have exceeded the monthly limit. (27Nepalese, M/20 y, S, Degree)

Some participants relied on online banking, e-statements, or Excel spreadsheets to keep track of their budgets. One participant primarily used credit cards for spending: “I check my monthly statement and like …oh, this month I spent more on food. I should cut it down a bit.” (18Indian, M, WA, 26 y, Degree) Another participant updated his budget sheet almost daily, “I make sure I don’t cross the budget for daily food expenditures, so I separate expenditures of breakfast, lunch, and dinner. (35Filipino, M/28 y, W, S7)

Parental monitoring in budgeting was common, where parents set spending limits or kept the money to prevent their children from overspending. Participants were positive about parental monitoring:

I gave all my earnings to my mom and she’ll help save for me. After deducting the savings, she’ll allocate some for my spending. (11Pakistani, M/20 y, S, S6)

They won’t let me spend my own money so that they can keep track of what I do. …I’ll always show my mom what I bought. …I can say it is ‘control’ …but it’s good to have monitoring. (1Indian, F/23 y, S, Master’s)

However, some participants simply allocated money into different categories mentally. One said, “I don’t like keeping notes. Everything is in my mind.” (47Indian, M/18 y, W, S4), while another responded, “I just keep them in my mind, divided by categories.” (40Nepalese, F/21 y, W, SD)

Parental influence and experiential learning

Participants indicated that they acquired budgeting ideas through observing their parents and learning by doing, especially after earning their first income.

I’m learning from him [father], like how to save up money, how to spend it wisely, and how to spend it on only the important things and not to waste the money. (2Pakistani, M/22 y, S, SD)

It was around my university years when I was doing a part-time job and earning some money …my own concept of saving started to form. (18Indian, M/26 y, W, Degree)

Perceptions of budgeting

Most participants perceived budgeting positively, agreeing that it could provide a sense of control against overspending, as one said, “If you don’t have a budget, it’s really easy to overspend on stuff and you can’t control your money.” (47Indian, M/18 y, W, S4). Budgeting was also seen as a form of psychological restraint, evoking a sense of guilt when budget limits were exceeded, and fostering discipline for conscious spending:

It makes me feel guilty …kind of a warning …a yellow light that you’re spending more than you’re supposed to. … It’s psychological when I see a big number in the amount of expenses. (29Filipino, F/22 y, S, Degree)

However, many expressed the difficulty of maintaining a budgeting habit due to economic and personal challenges. Limited funds and high living costs posed economic challenges as there was not a lot of money to go around, as expressed by one participant, “I don’t really have a lot of money. …I don’t know how I can track it.” (4Indian, M/21 y, S, Degree) Another said, “It’s very difficult because nowadays all the things are pricey, but you just have a limited amount of money.” (28Filipino, F/19 y, S, S6)

Personal challenges relate to feelings that budgeting is demanding, requires much self-discipline, and causes stress. Some participants found it demanding as it was time-consuming and involved excessive work.

It sounds, you know, ridiculous to me …somewhat a waste of time. There’s a lot of data. (15Pakistani, F/25 y, S, Degree)

It’s tedious and it takes time to write down all the details. …The effort needed to keep track of things demotivates me. (34Indian, M/30 y, W, Degree)

Others found it difficult because they struggled with self-control. One said, “I want to buy many things like this and that. …It’s hard for me as I could not control myself.” (42Nepalese, F/25 y, W, SD) Others were reluctant to budget because it induced too much stress:

I think budgeting gives me a lot of stress. I just want to focus on making money, so I don’t have to worry about it. (31Filipino, M/22 y, S, Degree)

Constantly checking is kind of torturing me. …If I check it too much, I’ll get sad about my expenditure. (18Indian, M/26 y, W, Degree)

Nevertheless, a smaller proportion of participants who showed qualities such as determination and mathematical competence did not find budgeting as hard.

It’s just the willpower of a person. I don’t think there’s too much difficulty for me. (32Indian, M/29 y, W, Degree)

I have a strong mathematical background since I studied math a lot, so I don’t think numbers are a problem for me. (17Nepalese, M/18 y, S, Degree)

Spending decisions

Modest spending.

Many participants appeared to spend modestly and consciously. They generally allocated a higher portion of their budgets to basic needs. As many lived with their parents, they mostly spent money on food and transportation. Other major expenses included tuition fees, financial support for their families, rent, and personal entertainment.

I’d say 50% goes toward my food. …Insurance and everything, I’d say 20%. (38Indian, M/23 y, W, SD)

Half of my money goes to food and transportation, and the other half I’m saving for school fees and all that. (2Pakistani, M/22 y, S, SD)

Deferred purchase, bargain shopping, and one-time payment as strategies

Strategies in spending decisions included deferred purchases, bargain shopping, and one-time payments. One strategy employed was to re-evaluate spending decisions by deferring purchases:

When I shop, I double-think. … I’ll buy it a day or two later …to think about if I truly need it or not. (22Pakistani, F/25 y, W, S6)

Another common strategy was bargain shopping. Participants described how they bargain-hunted or waited for sales to get the best value for money.

If I go to buy a pair of shoes, then I like to go through the whole mall and see, you know, which one is really worth the money. (4Indian, M/21 y, S, Degree)

I’ll try my best to use as little money as I can. …I’ll check where I can get it the cheapest. (51Pakistani, M/25 y, W, Degree)

When making purchases, most preferred a one-time lump sum payment to avoid interest charges. One participant talked about the extra charges:

I used to buy in instalments with credit cards and I spent a lot, and I couldn’t pay some of the bills….Now I pay in lump sum, I find this very clear to your mind. …Nobody is calling you to pay for the minimum. (43Nepalese, M/28 y, W, Degree)

However, some paid in instalments, incurring interest on expensive products or when the budget was tight. Generally, an item costing more than HK$1000 (approximately US$125) was considered expensive.

If it’s around HK$500–$1000 (US$63–$125), I’ll spend a lump sum. But if it’s HK$5000 or HK$6,000 (US$625 or $750) like that, I’ll usually spend it on instalment. …When making it 12 months, I only need to pay HK$500. (51Pakistani, M/25 y, W, Degree)

Spending philosophies

Participants shared their perceptions about spending, revealing various spending philosophies such as differentiating between needs and wants, viewing spending as a work incentive, and embracing YOLO (You Only Live Once) spending. Conscious spenders distinguished between must-haves and nice-to-haves, ensuring they spent on what was necessary rather than what was desired.

When you buy something …you have to ask yourself whether you need it or want it, like you just think it’s cute. (25Pakistani, F/19 y, S, Master’s)

I often question whether I really need it …especially when it comes to luxury items like clothes and shoes. But for food, I do not compromise; for health, I do not compromise. (17Nepalese, M/18 y, S, Degree)

Some participants showed that spending was a motivation to work hard, as one said: “I base how much I work on my expenses. If I have many expenses coming up, I’ll try to work more.” (3Indian, M/21 y, S, Degree). Others embraced YOLO spending as a means of seeking happiness:

I didn’t want to decide how I was going to spend it. …You should never restrict yourself. Of course, you have savings. But for your spending, you should just go with whatever makes you happier. (18Indian, M/26 y, W, Degree)

You only live once! … It’s good to spend a little bit on something expensive. …With the money I earned …I deserve at least some to use on myself. (32Indian, M/29 y, W, Degree)

Financial planning

Savings habits and setting savings goals.

Many participants established a habit of saving. More than half said they allocated at least 30% of their monthly salary or pocket money to savings. Some started to save in childhood, but many did so after their first employment while their earnings served as resources for hands-on learning. One participant said, “When I started to earn my own money, I didn’t want to spend all of it. I want to save and learn about investments.” (29Filipino, F/22 y, S, Degree)

Depending on their life stage, those who saved set various saving goals. In addition to saving for education, some saved to buy property, start a family, build a business in their home country, or for retirement. Some described the goals:

I’ve always wanted to start a piggery business. …In the Philippines, …a full roasted pig we call it Lechon. It’s in every celebration. …There’s a market for that. …I want to start one because my uncle, sisters, and brothers are good at that. (29Filipino, F/22 y, S, Degree)

For the very long term, like for retirement, I’m setting aside 20% of my salary to invest in stocks and bonds. (34Indian, M/30 y, W, Degree)

Gaining financial autonomy was also mentioned as a goal, as recounted by one participant:

I’m never going to focus too much on my future husband. I’m not going to be financially dependent on another person. …I always thought …I’d get educated and then earn money. I’d not be together [with someone] and be scared of splitting just because of money. (10Nepalese, F/21 y, S, Degree)

External restraints and personal tricks as strategies

Participants employed various savings strategies. In addition to saving money in bank accounts, they used external assistance or restraints as strategies by having their parents or boyfriend save it for them:

My parents don’t want me to be spoiled with so much money. We often see that people who start earning money do some bad stuff, like getting into drugs, gaming, or going out with friends a lot. …I’m not doing all these. …But still, they keep my money. (49Filipino, M/19 y, W, S6)

I’ll give half of it [salary] to my boyfriend so I won’t be able to touch it. The remaining is for my spending. …He has a better concept of saving than me …and he helps me save. (16Indian, F/27 y, W, Degree)

Participants reported using various personal hacks, such as opening separate bank accounts for specified uses:

I have two different bank accounts. One is strictly for saving money. …The other one is for paying bills and spending on things like necessities. (35Filipino, M/28 y, W, S7)

When I started my job, I only had a Hang Seng bank account. Then I specifically opened an HSBC account to keep my education savings there. …If you see a large amount of money, it makes you less intelligent about your expenditure because it projects an illusion that you have a lot of money. (48Indian, M/24 y, W, Degree)

Another example was a four-wallet strategy to divide money into smaller portions for designated purposes:

One wallet is for saving money. …If I buy something and I get some money left, I put it in the second wallet. The third wallet is for putting money that I couldn’t touch, like paying for my violin lessons and the dentist. …The fourth wallet is for transportation. (30Filipino, F/21 y, W, SD)

Another strategy was simply stashing cash away under the mattress or in other hidden places to reduce its accessibility:

I have like HK$10,000 (US$1250) under my mattress. Every month I have HK$1000 (US$12.5) …a hundred of $10 s …put inside my mattress, and I would sleep on it. My goal is …to the point if I can’t sleep properly, I have enough money. …Some people have their piggy bank I have my mattress. (31Filipino, M/22 y, S, Degree)

Sometimes I took all the money out and put it in a more hidden place like I can literally forget about it. (28Filipino, F/19 y, S, S6)

Perceptions of financial planning

Most participants agreed that financial planning and saving were important. Some thought of it as a grown-up responsibility. As adults, they were responsible for making financial plans and avoiding irresponsible purchases:

I already feel ashamed that I’ve been asking for pocket money from my parents. …I think it’s because we’re Asian, …we depend a lot on our parents. I don’t really want to live like that. …I want to be able to stand up on my feet. (10Nepalese, F/21 y, S, Degree)

I feel like after turning 18, …it’s important to budget your money, save it, invest it, and not make stupid and foolish purchases. (19Indian, M/19 y, S, Degree)

Financial planning was seen as a safeguard against financial shocks, offering a sense of emotional wellness or peace of mind as they knew they had backup resources. This was particularly important after they experienced the COVID-19 pandemic and became motivated to be well-prepared:

It taught me that no job is stable …even pilots get laid off. …Your income is not always there. You always have to be prepared for it. (41Nepalese, M/22 y, W, Degree)

You can have a fire break out in your house, you can have your stuff get stolen, you can get hit by cancer, and even this pandemic. So financial planning is extremely important. (21Pakistani, F/23 y, W, Degree)

It’s like a comfort …in case anything goes wrong in your life. It’s always good to have a backup plan …and you always have something to protect you. (35Filipino, M/28 y, W, S7)

Nevertheless, not all participants were positive about financial planning; some valued income generation over saving money:

Saving isn’t super important to me because I feel I should be earning more than I should be able to save. …If I am earning more, I don’t have to worry about saving. (31Filipino, M/22 y, S, Degree)

Some also felt they were not good at saving because of inadequate self-discipline and limited money: “The reality …is that my income is really not a lot at all. And I recognize there’s a limit on how much I can stretch, even if I really want to stretch it.” (36Filipino, M/26 y, W, Degree)

The use of financial products

A diverse range of financial products.

Participants reported using various financial products or investments. Insurance was most frequently mentioned, followed by stocks, and other choices, including cryptocurrency, index funds, and forex trading. Buying property or gold in their home country as conventional investments was popular, as the older generations have done.

Different types of insurance, including life, medical, accident, and critical illness, were purchased and considered safe and flexible:

My insurance is three years old. …If something bad happens, I can use it. If I don’t use it after 20 years, it’s my money, so it’s like a saving. (43Nepalese, M/28 y, W, Degree)

All of them are index funds because the management cost is low and it’s simple to set up. It’s set and forget, no need to actively manage. (34Indian, M/30 y, W, Degree)

Buying property or gold in the home country was popular. Like their parents, they made or were planning to make these investments as they believed their value would steadily increase:

Dad bought properties in Pakistan and the values increase every year as it’s on the main side of the road. …The more convenient the properties, the higher the price it is. …Three are under my name, others under my siblings’ name. (22Pakistani, F/25 y, W, S6)

Buying property is safer compared to stocks. …Buying it overseas is a lot safer …because the property in Hong Kong is a lot more expensive. (31Filipino, M/22 y, S, Degree)

I can use this gold in my wedding … it’s kind of holding money because I don’t think the gold price will drop. It’s a good investment. (53Nepalese, F/25 y, W, Degree)

Parental support, peer mentoring, and self-education as strategies

Participants employed various means of obtaining information and experiencing financial products, including parental support, peer assistance, and self-education with online resources. Some parents were supportive by providing funds for hands-on learning in stock investment or opportunities for joint investment:

My dad gave me a small amount of money just to learn. …Because the only way you can learn is you do it yourself. …He helped me set up my account and everything and then I started. (19Indian, M/19 y, S, Degree)

I invested with the help of my mom. …She invested and got a return and she gave me the interests. (10Nepalese, F/21 y, S, Degree)

Assistance from financially savvy friends was also a way to enhance their knowledge and gain experience in stocks, insurance, or setting up a business:

I have a group of friends and we all invest in stocks. We like to give each other tips like, “I’m going to invest in this …maybe you should take a look at this.” Or sometimes before they invest, they ask “What do you think about this company?” And then I do my research …like we help each other. (19Indian, M/19 y, S, Degree)

My friends are in Pakistan …their family has been investing in property and stocks. …They bought their own shisha lounge recently. …I discussed with them: What was the cost? How much should I save for starting up this kind of stuff? (22Pakistani, F/25 y, W, S6)

Another strategy was self-education, by reading news, studying company information, and surfing the internet and YouTube for tutorials and knowledge:

I see the performance of their company around 5 or 10 years. Then I see the future analysis …how the company will perform in the future. (13Pakistani, M/23 y, W, Degree)

There are a lot of tutorials online or on YouTube. … There are also a lot of good pages that talk about investing. … It’s easily obtainable. (10Nepalese, F/21 y, S, Degree)

Perceptions of using financial products

Participants expressed different views about using financial products. The favorable view held that financial products acted as a passive form of income and could help protect against inflation, as one participant expressed, “It’s good to buy stocks because it’s like passive income. You can do your job when it also generates income.” (43Nepalese, M/28 y, W, Degree)

However, some viewed it unfavorably as they thought investment carried substantial risk. In particular, stock investment was akin to gambling, which involved taking chances and the possibility of losing hard-earned money:

You are literally gambling …the price of shares would rise or fall suddenly. …Just in days, you could lose so much. That’s why my aim is to look for a professional job so that I don’t have to depend on unexpected business. (17Nepalese, M/18 y, S, Degree)

Some others held unfavorable views due to their own or their families’ and friends’ negative experiences resulting from poor understanding of financial products:

I bought stock and I sold it. …If I had kept it a bit longer, I could have gotten a much higher return. …I just sold it based on rumors that the stock won’t go up. (27Nepalese, M/20 y, S, Degree)

My uncle didn’t know how to play it. He just went to the bank and was told to invest this and that without any explanation. …In the end, he lost a lot of money. (26Nepalese, F/21 y, S, Degree)

Sometimes, the lack of understanding of financial products could result from language barriers. One participant referred to the Mandatory Provident Fund (MPF), a compulsory pension fund in Hong Kong, as an example:

If you go to work, your employer won’t tell you what’s this or that. They just give you the MPF paper. …People don’t know what’s written there. They just sign it. Which product is better? They don’t know. (2Pakistani, M/22 y, S, SD)

Debt management

Borrowing money as a common practice.

It was quite common for participants to take out loans from different sources, including family, friends, the government, and financial institutions. Some borrowed money from their parents or siblings. Due to close family ties and strong support, paying back the loan was not always expected. Some would also borrow from friends despite feeling uneasy about it:

I had zero income and my wife is jobless. …I felt it was a shame to borrow from my parents. …I asked my brother who is in Qatar. …It’s like a brother thing. He just sent it to me and …no need to return it. (14Pakistani, M/28 y, W, Degree)

To be broke on the 25th of the month but your salary only comes on the 31st. …Those few days you have to live …so I have to borrow from my friend. (38Indian, M/23 y, W, SD)

Some participants who were or had been students took out government student loans for educational expenses:

Hong Kong is so expensive, and so are school fees. I can’t pay it all at once so I had to borrow from the government. (23Filipino, F/23 y, W, Degree)

Some participants borrowed money from banks to buy an apartment. Others borrowed from lending institutions charging high interest rates to pay for tuition fees, buy iPads, or pay off credit card debts. They described their own or their friends’ experiences:

I have a period of time without a job. I have to pay with a credit card every month. I’ve skipped one month …and they started to call me and I was irritated. …Then I realized …why I wouldn’t start to do research tracking the annual rate, and at last, I decided to go to this loan company. (26Nepalese, F/21 y, S, Degree)

My friend found it hard to pay back because the interest rate was high. …She graduated last year and she has only worked for a few months. …She has to pay for the loan and to pay for her credit cards. (22Pakistani, F/25 y, W, S6)

Mostly safe credit card usage with some risks

Approximately one-third of participants owned a credit card. Occasionally, some used their parents’, siblings’, or friends’ credit cards, with approval, when they could not get their own, as illustrated by one participant:

My friend doesn’t use her credit card much. …I just took hers, bought things, and on the same spot transferred money to her account. (22Pakistani, F/25 y, W, S6)

Most credit card users could settle their bills on time, like one who said, “Unlike others who may pay it last minute. I pay it immediately after receiving the statements.” (48Indian, M/24 y, W, Degree)

However, some participants only paid the minimum due on credit cards, especially due to ignorance about interest charges. One did not know the consequences of doing so:

I was studying for an associate degree and I wanted to get as high marks as possible. I thought that if I got into the university then I could pay for them all afterwards, so there’s no pressure if I give minimum payment every month. …I didn’t realize about the interest. I swiped a lot. (26Nepalese, F/21 y, S, Degree)

Perceptions of debt management

Participants considered borrowing money was shameful and could hurt their social relationships. Borrowing money was associated with shame and guilt, especially for people capable of working, instead of borrowing money from others:

We have everything to earn money. … We’re healthy. We have all the physical and mental ability to work. …So we don’t have to depend on other people. (5Indian, M/22 y, S, Degree)

The shame is that …if God has given me a healthy body and I have my hands fine, if I can walk, if I can work, then why go ask someone for anything? (14Pakistani, M/28 y, W, Degree)

Others thought that borrowing money could create tensions with friends or relatives, especially if money was not returned:

Some friends of mine have taken money from me …but they don’t return it. … They’ll say, “I still don’t have money.” …What the bank does is good …charge the interest from them. (52Indian, F/29 y, W, Master’s)

You lend money to relatives or friends …but they might not return it to you. They might not pick up your phones. They might go away from the city. …That’s what I’ve heard….I don’t think they call the police …at the end they are family. (17Nepalese, M/18 y, S, Degree)

Participants considered credit cards to be convenient, and they enjoyed the reward systems. One said, “It’s like an Octopus card Footnote 2 but is more widely used, especially for online shopping. And it’s convenient …you can accumulate points for more savings.” (35Filipino, M/28 y, W, S7) However, many were also aware that credit card use could lead to uncontrollable spending because they could easily overlook how much they had spent:

If I had one, I would go non-stop shopping because I have pressure at work. Who wouldn’t go shopping after work? (38Indian, M/23 y, W, SD)

When you take out your money, you know your limit. Like if your wallet has $5,000 and you’re using it, you’ll notice how much money you’ve left. But credit cards …you’ll keep using it. (8Pakistani, M/23 y, W, SD)

Detecting fraud

Fraud victimization experiences.

Participants were vulnerable to fraud; some shared stories about falling or almost falling for scams or had heard about friends being scammed, relating to possible charity scams, unnecessary lab tests, online gaming, investment fraud, and money lent but not returned. One participant believed he had been scammed when he was asked for a donation on the street:

I’ve been scammed once on the street by a man who’s requesting money for their own institution from their own country. It involves children who are sick. …Because I was young and naive, I didn’t ask them for validation. Although he wanted to scam more money at the time, I didn’t carry too much. (35Filipino, M/28 y, W, S7)

There were unnecessary medical lab tests:

They said they got funding from the government. They did 10 different cancer tests on me for $4000. My mom was very angry about why I did it. She said it’s a scam because I’m so young. I won’t have any cancer right now. (1Indian, F/23 y, S, Master’s)

Money was lost due to an online scam:

There was once an email …saying if you put $10,000 on this account, we’ll give you $20,000 …that kind of scam …but I didn’t do it. …The second time when I bought a computer game online, they just asked me to send some money in advance. …They totally scammed me and then blocked me. (44Nepalese, M/20 y, W, S6)

Friends had also experienced investment fraud:

I have a friend who invested in …some sort of software soccer game. …He saw an advertisement online in a newspaper. He invested and then the money was just gone. …He lost HK$5000. (6Pakistani, M/25 y, W, S6)

They called and encouraged my friend to put in money and said, “…This is very good. You can earn a lot. You can be a rich person. You can do whatever you want to do.” She put a little bit to see. After six months, they kept calling and saying she was doing well, she could do better. And they got everything on that scam and they never called back. (43Nepalese, M/28 y, W, Degree)

Strategies and perceptions for detecting fraud

Participants reported that the flood of suspicious calls and messages they received, and uncertainty about whether they were genuine or not, exposed them to potential scams.

I don’t know if it’s a scam. …I got calls for buying currencies from them. They told me the whole plan, and I’d even go into a discussion and I was close to paying them. I’ve been near that. (49Filipino, M/19 y, W, S6)

Once I borrowed money and after that many financial companies have my number. …They ask what my name is and ask for my information. …I didn’t give them because I know they might want to get my bank information … it’s not safe. (8Pakistani, M/23 y, W, SD)

They also talked about how to avoid scams by understanding their psychology as emotional manipulation to induce feelings of guilt:

They try to confuse you with a lot of situations to guilt trip you. They make you feel bad about other people. They try to trick you into thinking that your life is a lot better than theirs. …They can make you feel good about giving money. … They’re mentally threatening you not in a bad way. …If you have a strong personality, you can fight back easily. But if you’re naive, it can be quite difficult. (35Filipino, M/28 y, W, S7)

Participants reported pretending they did not understand Cantonese (the local spoken language in Hong Kong) or simply ignoring dubious calls or messages as tactics to tackle potential scams:

I think it’s funny because I can speak okay Cantonese. Whenever I get calls from banks or something, I always ask, “Can you speak in English?” and then they just disconnect. (22Pakistani, F/25 y, W, S6)

Some unknown WhatsApp messages are frequent. But I’d ignore them as I know they are dangerous. (30Filipino, F/21 y, W, SD)

This study has various implications. It contributes to conceptual or theoretical understanding, provides insights into practical strategies, and offers directions for further research.

Knowledge or theoretical contributions

Financial decision-making experiences.

This study has contributed knowledge to addressing the research gap by revealing the financial decision-making experiences of younger ethnic minorities in a non-Western context. We examined their behaviors, strategies, and perceptions across a range of financial decisions, including personal budgeting, spending, financial planning, the use of financial products, debt management, and detecting fraud. Many ethnic minority young adults practiced budgeting, using digital tools, parental monitoring, and mental bucketing. They learned about budgeting by observing their parents and gaining hands-on experience with their own earnings. Budgeting was challenging due to limited funds, high living expenses, time demands, stress, and self-control issues. Most were modest spenders, prioritizing basic needs like food and transportation and employing strategies like deferred purchases, bargain shopping, and lump-sum payments. Some opted for instalment payments for expensive items, and when their budget was tight. When spending, they differentiated between needs and wants, sought value for money, worked to meet their spending needs, and purchased for happiness. Saving at least one-third of their monthly income, they utilized external assistance and personal tricks. Their long-term saving goals encompassed education, housing, family, business, retirement, and female autonomy. Financial planning was perceived as an adult responsibility, a safeguard against emergencies, and ensuring peace of mind. They invested in insurance, stocks, cryptocurrency, index funds, forex trading, property, and gold. Parental support, peer mentoring, and self-learning influenced their investment decisions. Lack of knowledge and language barriers may contribute to negative perceptions or experiences of financial products. Informal borrowing from family and friends was commonplace, while others resorted to government or lending institution loans. Around one-third owned a credit card. Most used them safely, but risks exist when using someone else’s card, or they are ignorant about interest charges. They were aware of financial scams and employed preventive strategies like understanding the psychology of scams and ignoring scammers, although they occasionally fell victim to fraud.

Enabling factors to financial decision-making

Factors affecting financial literacy are widely understood in the literature, but less has been examined regarding the factors affecting financial decision-making. Based on the financial decision-making experiences, we further identified various factors or conditions that facilitated ethnic minority young adults’ financial decision-making and enabled them to make better financial decisions. While some other factors acted as barriers, awareness of these barriers and taking action to address them can transform them into enabling factors. The enabling factors include family social capital, intrapersonal characteristics, social dynamics factors, command of knowledge, and facilitative contextual circumstances. These insights can help devise financial literacy education for ethnic minority young adults.

Family social capital. Family social capital enables families to leverage both material and symbolic resources to benefit their members (Furstenberg and Kaplan, 2004 ). In this study family social capital played a crucial role in participants’ financial decision-making, as shown by the resources and support derived from the family relationships, including the passing down of money-related attitudes, norms, and behavior from one generation to another and between siblings. Both intergenerational support and sibling support are key components of this family social capital. In the study, intergenerational support was demonstrated through parental role modeling and involvement. While participants did not mention direct teaching of financial education by parents, parents served as role models from whom their children observed and learned financial attitudes and behaviors. This was how participants acquired their ideas of budgeting. Parents also actively coached financial decision-making by monitoring budgeting, setting spending limits, supervising saving, providing funds to help set up stock accounts, offering joint investment opportunities, and providing financial assistance. Sibling support refers to the emotional and practical support provided by siblings. Study participants sought help from their siblings or provided financial assistance to one another during financial difficulties, as shown by their lending money to each other to avoid unnecessary interest charges that may arise from resorting to other sources. Strong family social capital can be attributed to cultural values emphasizing family relationships, filial piety, and respect for parents.

Intrapersonal characteristics. Intrapersonal characteristics, which comprise personal attributes and life perspectives, are evident in facilitating ethnic minority young adults’ financial decision-making. Personal attributes such as self-motivation, self-discipline, and other competencies play a role. Self-motivation is an inner force that compels behavior (Waitley, 2010 ) and gives people energy to initiate actions and persist in efforts to attain a goal (Robbins and Judge, 2022 ). This study revealed self-motivation to be important in financial decision-making, such as budgeting, as it is difficult for those with lower motivation to sustain a budgeting habit when they consider budgeting as demanding, time consuming, and excessive in work. Self-discipline involves being able to control one’s impulses and desires in favor of long-term goals (American Psychological Association, 2023 ). Participants expressed the importance of self-discipline in successful budgeting, saving, and spending. Math competencies ease financial decisions. Those with numeracy skills tend to feel it easy to engage in budgeting.

Life perspectives are about people’s overall views of life, which include personal philosophies and future orientation and facilitate ethnic minority young adults’ financial decisions. Personal philosophies, which are values and attitudes that can be shaped by personal experiences and family and cultural influences, guide people’s decisions. Spending philosophies can be part of an expression of personal philosophies. Study participants exhibited various personal philosophies, such as simplicity-based, enjoyment-based, and work-to-spend philosophies, reflected in their spending philosophies. Simplicity-based living philosophy emphasizes a minimalist lifestyle over material possessions, as evident in the differentiation between needs and wants in spending philosophy. Enjoyment-based living philosophy values pleasures and living in the present moment, as reflected in the YOLO style of spending philosophy. A work-to-spend philosophy underscores the importance of working hard to support desired spending levels and is shown by the work-as-incentive spending philosophy.

Future orientation is the ability to anticipate future events, give them personal meaning, and operate with them mentally (Nurmi, 1991 ). It is associated with future-oriented behaviors, such as planning and delayed gratification (Strathman et al., 1994 ). This study suggests that individuals with saving goals tend to have a stronger future orientation as they plan for long-term objectives such as education, starting a family, property investments, and retirement. Those who practice delayed gratification by deferring purchases also show future-oriented tendencies.

Social dynamics factors. Social dynamics factors include peer support and vigilance within ethnic communities. Peer support involves ethnic minority young adults helping each other to make financial decisions through monitoring, mentoring, and collaborating to keep track of each other’s financial behaviors towards goals, offer practical advice in planning decisions, and share tips and efforts in decision-making, respectively. For example, peer monitoring serves as a social restraint to help those who struggle with saving. Peer advice is sought concerning investments in their home countries. Collaboration facilitates joint decision-making on buying stocks. Peers, along with parents, also serve as financial socialization agents.

Vigilance in ethnic minority communities is needed to prevent exploitation, as trust is often presumed within these communities. In the study, trust was demonstrated in the common practice of informal borrowing. Although informal loans can be enforced by social or community ties, they are not without risk. Without legal loan agreements, the possibility of bad debts or scams can arise, and did occur within participants’ communities.

Knowledge proficiency. Knowledge proficiency refers to the command of knowledge essential for making informed financial decisions. There are two types of knowledge. The first applies to a range of financial concepts required to navigate choices in everyday financial situations, such as knowledge of effective saving strategies, information on different financial products, and interest charges for instalment plans, loans, and minimum payments on credit cards. It is important, as the study revealed possible risks and negative experiences among participants stemming from a lack of caution or knowledge, like stashing cash away and ignorance of high interest rates when repaying minimum amounts on credit card debts or loans from lending companies. This type of knowledge is also important considering the potential issue of misinformation. Many participants were interested in using financial products such as insurance policies and stocks in Hong Kong and property investment in their home countries. However, their reliance on self-learning through online resources, such as YouTube’s KOL, or listening to peers exposed them to the risks of misinformation. For instance, one participant regretted making a poor decision to sell stocks based on hearsay, lacking proper knowledge of how stocks work.

The second type of knowledge involves protection against fraud. While participants tried to avoid suspicious messages and calls, some fell victim to various scams, accentuating the importance of being equipped with proactive measures, as the ones used, simply ignoring them, appear passive. Familiarizing oneself with common forms of fraud, exercising caution with offers that seem too good to be true, accessing scam alert information, knowing how to report scams, and understanding one’s legal rights when encountering scams would be good anti-fraud measures to learn.

Facilitative contextual circumstances. Various contextual circumstances, including leverage of real-life lessons, access to technology, and language accessibility, can be influential in ethnic minority young adults’ financial decisions. This study shows that the employment and pandemic experiences have been translated into real-life lessons to acquire financial knowledge and attitudes. The first earnings from employment nurtured the ideas of budgeting and financial planning, and provided opportunities for acquiring relevant skills. This suggests that promoting financial planning strategies and saving habits earlier, at least before starting employment, is beneficial. Individuals can avoid making unnecessary mistakes and enter smoothly the world of work that requires many financial decisions. Due to the pandemic, some participants experienced a positive change in their financial attitudes. They realized the importance of preparing for economic uncertainty and were eager to improve their financial planning.

Technology not only provides easy access to online financial materials, but can also facilitate financial decision-making using digital tools, which are particularly useful for following budgeting and tracking expenses. As many participants considered budgeting to be arduous, it can be made easier by adopting technological aids.

Finally, language accessibility can affect the acquisition of financial literacy. Participants’ negative experiences with financial products, such as bank products or MPF, for instance, largely stemmed from a lack of understanding that can also be compounded by a language barrier.

Enriched understanding of financial socialization

Family social capital as an enabling factor of financial decisions aligns with the theory of financial socialization, referring to the process of developing values, attitudes, standards, norms, knowledge, and behaviors promoting financial viability and individual well-being (Danes, 1994 ). Research shows that parents are important socialization agents influencing financial attitudes, such as credit attitudes (Norvilitis et al., 2006 ). Despite arguments suggesting that parental importance declines as children get older (Danes, 1994 ) and peers take on greater influence (John, 1999 ), this study shows that ethnic minority young adults continue to rely heavily on their parents for financial guidance. The findings of this study extend the understanding of financial socialization processes by recognizing the persistent and exceptionally influential roles of ethnic minority parents. Other research also supports that ethnic minority young adults seek parental advice on important education and employment decisions (Chan et al., 2020 ).

Practical implications

The findings on enabling factors and various behaviors shed light on practical suggestions for enhancing financial literacy education, which, in turn, improves the financial decision-making of ethnic minority young adults.

First, in relation to family social capital, if parental influence remains strong in young adulthood, it may be strategically beneficial to involve ethnic minority parents, either as target participants or partners, in tailored financial literacy education.

Second, to promote holistic financial literacy education for ethnic minority young adults, it is necessary to address their specific personal attributes and life perspectives as attitude components, in addition to increasing general financial knowledge and skills. Self-discipline, self-motivation, spending philosophies, and future orientation could be positively fostered by taking into account the unique challenges they face in financial literacy education.

Third, in response to social dynamic factors, while ensuring the accuracy of shared financial information, peer influence can be capitalized on for effective financial literacy education by utilizing collaboration as a learning approach and developing peer mentoring to optimize mutual learning experiences. Also, addressing vigilance in community trust and the potential risks associated with informal loans are important topics to be included in financial literacy education.

Fourth, concerning knowledge proficiency, financial literacy education should incorporate the two essential types of knowledge required for making financial decisions. This includes knowledge about everyday financial situations—such as the use of various financial products, the consequences of different credit card payment options, and the interest rate information associated with formal debts—as well as knowledge about proactive anti-fraud strategies.

Fifth, in response to facilitative contextual circumstances, the current post-pandemic period is an opportune time to offer ethnic minority young adults financial literacy education to capitalize on their increased motivation to learn and improve their financial decisions. Also, as smartphone use is indispensable among young people, including ethnic minorities, user-friendly budgeting apps that fit well their financial situations can help make budgeting efficient, stress-free, and engaging. Moreover, it is important to provide financial literacy education that takes into consideration language needs to ensure a thorough grasp of financial concepts. For instance, interpretation support can ease language barriers. However, in the long run, policy interventions in the educational system, such as remedial language support and learning Chinese at a young age, are necessary.

Last, various financial behaviors prone to mental accounting bias should be addressed in financial literacy education to equip ethnic minority young adults with the skills to make optimal decisions. Mental accounting refers to the cognitive operations to organize, create mental labels, and keep track of money or financial activities (Thaler, 1985 ). An important concept in this theory is that money is fungible or interchangeable, regardless of its source or purpose. However, people often violate this principle and see money differently, resulting in suboptimal decisions. For instance, some participants might treat credit cards as different mental accounts. They were willing to spend more on credit cards compared to cash, as there seems to be no loss at the time of purchase and the payment can be deferred. This could lead to overspending. Also, in saving, some might stash cash away under the mattress, ignoring the interest earnings from a savings account. Other possible behaviors could be funding a low-interest savings account while carrying high-interest debt.

Research implications

Further research can address several issues or limitations. First, since ethnic Chinese young adults did not participate in this study, their inclusion in future research would facilitate a more comprehensive investigation. As young adults, they likely share similarities, such as spending philosophies, self-learning about financial information, and exposure to potential scams. However, differences may also exist in certain areas. The use of external restraint and personal hacks in financial matters, such as strong roles of parents and boyfriends in monitoring spending, and stashing cash away was less commonly observed among Chinese young adults. Informal borrowing and property investment in their home country were also unique characteristics of ethnic minority young adults. Further research can confirm these possibilities.

Second, this study may not fully reflect the situation of ethnic minority young adults with a lower socio-economic status. This is because the sample was generally well educated, as half of the participants had an undergraduate degree, and almost one-fifth educated to secondary education. In addition, the interviews were conducted in English, indicating a good command of the language among the participants. Future research may include those who are less socioeconomically advantaged as they may have different mechanisms surrounding financial decision-making.

Third, the relative influence of parents and peers across life stages, as well as differences in intrapersonal characteristics as facilitating factors between ethnic minority and non-ethnic minority young people, can be investigated to offer insights into tailored financial literacy education.

Moreover, we acknowledge the limitation of small sample size in a qualitative study, which aims to reveal themes for the financial literacy of ethnic minority young adults, an underexamined group. A future quantitative study for a larger population will be needed to allow for a broader generalization.

This study examined financial decision-making among ethnic minority young adults in Hong Kong and identified major enabling factors for their financial decision-making. Ethnic minority young adults employed strategies for budgeting, but they also found budgeting challenging. They had various spending philosophies, while basic needs were mostly a priority. Saving at least one-third of their income was common, and they had long-term financial planning goals. They used financial products both in Hong Kong and their home countries. Informal borrowing was common, despite some turning to other sources of loans. One-third used credit cards, incurring occasional risks. They were aware of scams and employed protective tactics, but still fell victim to scams.

Enabling factors to financial decisions included family social capital, intrapersonal characteristics, social dynamics factors, knowledge proficiency, and facilitative contextual circumstances. To enhance financial decision-making among ethnic minority young adults, the following can be considered. First, leveraging parental influence by involving them in financial education efforts. Second, fostering positive financial attitudes alongside increasing financial knowledge for a holistic financial education. Third, optimizing peer influence through collaborative learning and peer mentoring and raising awareness about community trust and potential issues with informal borrowing. Fourth, covering financial concepts for everyday financial decision-making and mental accounting bias, as well as practical knowledge for fraud prevention. Fifth, capitalizing on pre-employment and post-pandemic periods for timely financial education. Sixth, developing tailored digital tools and language support for specific ethnic communities. Finally, conducting further research is necessary. This includes the inclusion of ethnic Chinese and ethnic minority young people from various socioeconomic backgrounds and investigating the relative importance of parental and peer influence across different age groups. Moreover, comparing the intrapersonal characteristics as facilitating factors between ethnic minority and non-ethnic minority young people and expanding studies to include a larger population to enable generalization are also important.

Data availability

The data analysed during this study are not publicly available to protect research participant privacy but are available from the corresponding author upon reasonable request.

Information in parentheses denotes participant ID with ethnicity, gender and age, status as studying or working (S or W), and educational level, respectively. Education level may refer to the level of secondary school (e.g., S6), sub-degree (SD), Bachelor’s degree (Degree), or Master’s degree (Master’s).

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Acknowledgements

The research project was funded by the Investor and Financial Education Council in Hong Kong while the author was working at Hong Kong Baptist University. The research was conducted at that time. This paper was supported by the Children and Youth Research Centre and an Institutional Development Grant of Saint Francis University, Hong Kong, following the author’s transition to the new position at that university.

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Cho, E.YN. A qualitative investigation of financial decision-making and enabling factors among ethnic minority young adults in Hong Kong. Humanit Soc Sci Commun 11 , 1113 (2024). https://doi.org/10.1057/s41599-024-03605-1

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Use of kidney trajectory charts as an adjunct to chronic kidney disease guidelines- a qualitative study of general practitioners

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia, School of Rural Medicine, University of New England, Armidale, Australia

Roles Data curation, Formal analysis, Project administration, Writing – review & editing

Affiliation School of Rural Medicine, University of New England, Armidale, Australia

Roles Conceptualization, Formal analysis, Methodology, Supervision, Writing – review & editing

Affiliation Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

Affiliation Australian Women and Girls Health Research (AWaGHR) Centre, School of Public Health, Faculty of Medicine, The University of Queensland, Queensland, Australia

• Michelle Guppy, 
• Esther Joy Bowles, 
• Paul Glasziou, 
• Jenny Doust

• Published: August 29, 2024
• https://doi.org/10.1371/journal.pone.0305605
• Reader Comments

Chronic kidney disease (CKD) affects up to 11% of the population. General practice is at the forefront of the identification of patients with declining kidney function, and appropriate monitoring and management of patients with CKD. An individualized and patient-centred approach is currently recommended in guidelines, but would be enhanced by more detailed guidance on how this should be applied to different age groups, such as use of a kidney trajectory chart. We explored the opinion of general practitioners (GPs) about the potential utility of kidney trajectory charts.

Qualitative study interviewing 27 Australian GPs about their management of chronic kidney disease. GPs were presented with charts that plotted percentiles of kidney function (eGFR) with age and discussed how they would use the charts manage to patients with declining kidney function. GPs’ opinion was sought as to how useful these charts might be in clinical practice.

Most GPs were positive about the use of kidney trajectory charts to assist them with recognition and management of declining kidney function in general practice: e.g, comments included a “ valuable tool ”, “ a bit of an eye opener” , ” will help me explain to the patients” , “ I’ll stick it on my wall . ” . GPs responded that the charts could help monitor patients, trigger early recognition of a younger patient at risk, and assist with older patients to determine when treatment may not be warranted. GPs also thought that charts could also be useful to motivate patients and help them monitor their own condition.

Conclusions

Use of percentile charts in conjunction with the current CKD guidelines help support a patient-centred model of care. Kidney trajectory charts can help patients to understand their risk of further kidney damage or decline. Research on the use of these charts in clinical practice should be undertaken to further develop their use.

Citation: Guppy M, Bowles EJ, Glasziou P, Doust J (2024) Use of kidney trajectory charts as an adjunct to chronic kidney disease guidelines- a qualitative study of general practitioners. PLoS ONE 19(8): e0305605. https://doi.org/10.1371/journal.pone.0305605

Editor: Ahsan Saleem, Bolton Clarke Research Institute, AUSTRALIA

Received: May 3, 2024; Accepted: June 3, 2024; Published: August 29, 2024

Copyright: © 2024 Guppy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The GP interview questions and kidney trajectory charts are included in the supplementary information. The data used in this study are anonymous participant questionnaire responses and de-identified interview transcripts. Due to the potentially sensitive nature of the information, the data are not available publicly, in accordance with the Bond University Human Research Ethics Committee guidelines. Data are available upon reasonable request to Bond University Research Services at [email protected] .

Funding: This work was supported by a research grant from The Royal Australian College of General Practitioners Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests- Paul Glasziou and Jenny Doust report grants from the Australian National Health and Medical Research Council during the period of this study. Michelle Guppy, Paul Glasziou, and Jenny Doust received a grant from the Royal Australian College of General Practitioners Foundation to undertake this research. Joy Bowles was paid as a research assistant through this grant. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction

Chronic kidney disease (CKD) is a prevalent condition affecting between 2.5–11.2% of the adult populations of Australia, Europe, Asia and North America [ 1 ]. It is associated with common lifestyle diseases such as obesity, hypertension and diabetes [ 1 ]. General practice and primary care is at the forefront of the identification of patients with declining kidney function, and appropriate monitoring and management of patients with CKD [ 2 ]. Guidelines for the identification and management of CKD have been available for 20 years [ 3 ]. International guidelines have been recently updated, and feature special consideration for specific populations including older patients [ 4 ]. Different age groups are associated with differences in risks and long-term outcomes from renal impairment. For older patients the guidelines recommend a personalized approach that takes into account multimorbidity, frailty, cognitive function, polypharmacy and end-of-life care [ 4 ]. This patient-centred approach would be enhanced by more detailed guidance on how this should be applied to different age groups. It is not always clear how to apply shared-decision making with patients, as the outcome of a patient’s lower kidney function is not always apparent. For this reason GPs and primary care physicians need clearer guidance on the likely trajectory of a patient’s kidney function.

For younger patients, identification of those at risk can be more difficult. Younger patients with an estimated glomerular filtration rate (eGFR) above the abnormal range (≥60 mL/min/1.73m 2 ) and without protein in the urine are not currently identified by the guidelines as being at risk. However, modestly reduced eGFR in young people is associated with adverse outcomes, including cardiovascular disease and death [ 5 ].

The current fixed threshold of an eGFR of 60 mL/min/1.73m 2 to define chronic kidney disease may lead to missed diagnosis of kidney problems in younger patients, and overdiagnosis of declining kidney function in older patients [ 6 ]. Using an additional calculation that includes the percentiles of eGFR values with age, or means and standard deviations per age category, has been proposed as a method that might help prevent underdiagnosis and overdiagnosis of CKD [ 6 ]. A ‘kidney trajectory chart’ that plots eGFR percentiles with age could be a useful tool to show the normal distribution of kidney function with age, and its likely future trajectory. It could also help to monitor patients, allowing clinicians to re-evaluate the patient’s condition if they are dropping across percentiles [ 6 , 7 ]. Our previous research showed that GPs using a kidney trajectory chart in two randomised case vignettes- an older patient and a younger patient- led to more appropriate recognition of the patients’ kidney function status and more appropriate management recommendations for both patients [ 8 , 9 ]. In the present study we sought to determine GPs’ opinions of a kidney trajectory chart, and the acceptability of its use in clinical practice. We wanted to understand whether GPs thought this could be a useful tool and how it might be used as an adjunct to the kidney guidelines.

This study was a nested qualitative component of a larger mixed-methods study. Participants were Australian GPs who had firstly participated in an online survey. GPs were initially recruited via email through an organisation called AMPCo. After participating in an online survey about CKD management, and a clinical vignette study, GPs could indicate whether they were willing to participate in a further interview about their management of CKD. GPs who responded were then purposively sampled and invited to do an hour-long interview about how they managed CKD in their clinical practice. Recruitment of GPs occurred between the 8 th August 2018 and 13 th November 2018, and the GPs were subsequently interviewed from May to June 2019. In the final component of the interview, the clinical vignettes and kidney trajectory charts that the GPs had originally seen in the online study were presented to them again. The GPs and the interviewer (MG- an academic GP) discussed these clinical cases and how they might apply the charts to their management decisions. GPs were asked a general question about the utility of the charts, and how they might use these charts on their real patients in clinical practice. The case vignettes, kidney trajectory charts and interview schedule can be seen in the supplementary files ( S1 and S2 Files).

Ethics approval was obtained through the Bond University Human Research Ethics Committee. Prior to interview, GPs were sent a participant information statement with information about the research and interviewer. Written informed consent was obtained prior to the interviews taking place. Interviews were done using videoconferencing software, and were transcribed verbatim. Interview transcripts were emailed to the GPs for them to make any comments or corrections. Transcripts underwent thematic analysis by two researchers (MG and EJB) according to the method described in Braun and Clark [ 10 ]. Interviews continued until saturation of themes was reached. NVivo version 12 was used to assist in the coding and analysis process.

An email was sent to 9500 Australian GPs, and 469 responded. Of those, 399 completed an online survey, and 373 completed a clinical vignette study. Eighty-three GPs indicated that they would be available to be interviewed. Twenty-seven GPs were chosen purposively to be interviewed to ensure a balance of gender, age, and distribution of practice in Australia (urban, regional, rural, and spread across all Australian states and territories). There were no dropouts. Sixty percent of the GP respondents were female, with an age range from 31 to 70 years. Thirty-seven percent of respondents practiced in a remote location, 22% regional, and 44% urban.

Most of the GPs (89%, n = 24/27) responded positively to the kidney trajectory charts and said they would be useful in their clinical practice. Three GPs were neutral about them, and wanted more information on the chart to explain its use. None of the GPs were negative about the charts.

Most GPs made comments that the charts would be helpful: a “ valuable tool ” [GP2], “ it all makes sense… it would be a fantastic addition ” [GP38], “ it’s fairly straightforward ” [GP51], “ it’s quite user friendly , it’s quite easy to use ” [GP66]. With the three GPs who were neutral about the charts, they wanted some more information about using the chart: “ how to interpret the chart- that would be useful ” [GP19]. Another three GPs wanted to start using the charts in their clinical practice immediately “ I might even print it off and use it . Am I allowed to do that ?” [GP10] “ I think it would be quite useful to have this upper most in one’s mind or available as a resource . I’ll stick it on my wall . ” [GP27]

A common response to the chart was that it was a very useful tool for monitoring a patient over time, and giving some clear direction on indicating when further decline in kidney function was problematic.

“ I think it gives a bit more clarity into how to assess and monitor the kidney disease in the older age groups, that we were mentioning before in the guidelines it wasn’t necessarily, not that specific. That’s helpful. You could obviously plot that over time presumably for patients and it would be nice to have that even in your health record, because you could have a quick look at that and it would very quickly tell you where they were at and their rate of change .” [GP1] “ As a GP , I would definitely like to chart every patient on this and would like to see where they fall into that percentile and this would give me a very good idea of we had to be more vigilant and more proactive in management of risk factors and medications , managing their lifestyle and prescribing ACE inhibitors and all that , controlling risk factors .” [GP35]

GPs also commented that the charts made it very clear when a younger patient was at higher risk, even if their eGFR was currently in the ‘normal’ range.

“ I think it helps very much with younger people…, but I think it’s extremely useful to highlight how abnormal a low eGFR is in a younger person.” [GP36] “ I think it’s a bit of an eye opener to look , we sort of have this impression of GFR and what it should be and doesn’t look absolutely dreadful , but when you plot it all out on this chart , it’s quite sobering and you realise that relative to people of his own (age) … it’s either reassuring or concerning . It gives you a better perspective on what these people’s GFRs actually are .” [GP27]

Reflecting on their older patients, several GPs responded that it might alter their management in an older patient.

“I think it would be useful to be maybe—to modify your approach when people are a lot older, yeah. So I think they’d be really good, they’d be super good for us, actually, because this is such bread and butter for us. ” [GP10] “ Having looked at the chart beforehand , look I would probably , in a 76-year-old , I’d probably treat them with a small amount of ACE , but looking at the kidney trajectory chart , possibly I wouldn’t bother .” [GP62]

However, one GP felt the chart wouldn’t change their management of older patients.

“ I’m not sure if it helps much with older people, just because I’m so hesitant to stop the things that they’re already on, or like I still feel the need to—I’m undecided, I’m ambivalent about starting things in older people .” [GP36]

GPs also described the chart as being a useful tool for patient motivation, or for patients to monitor their own condition.

“ I can show people something and I think if people see something, it means more. ” [GP18] “ Also it will help me explain to the patients as well that considering your kidney health , falls into this percentile , so it will also make them more involved in their care as well .” [GP35] “ For the patients , you know , to try and spur people into taking action to control their own lives … you need something that means something to them . ” [GP62]

There were a few components of the charts where GPs felt there was room for improvement. The first issue was around which population the chart was relevant for. Several GPs wondered whether this chart applied to Australian First Nations patients. Some GPs wanted further information about how to interpret the chart, such as a clinical decision aid. Two GPs commented on wanting further information on the chart, for example an indication of stages 3a and 3b CKD delineated on the chart. They also felt the age categories were a little hard to understand, and that either breaking into years of age, or smaller age gaps would be easier to determine. GPs gave varying views as to whether an electronic or paper format for the chart would be easier. A couple of GPs wanted to print the charts out and have them on their desk, or in a format they could give to patients. One GP described a paper-free office, and said the chart would be best integrated into their medical software, or on a website. Several GPs suggested that the chart should be integrated into pathology test reporting and automatically charted so that GPs could see the trajectory when reviewing patients’ pathology results.

Summary of findings

The majority of GPs in our study were positive about the use of kidney trajectory charts to assist them with recognition of declining kidney function and management of CKD in general practice. Charts could help monitor patients, trigger early recognition of a patient at risk, and assist in determining when aggressive treatment may not be warranted in older patients. Charts could also be useful to motivate patients and help them monitor their own condition. Suggestions for different formats and charts for different ethnicities were discussed.

Comparison with the literature

The concept of kidney age or using percentiles of function is not new, and has been proposed internationally [ 6 , 11 – 13 ]. The normal rate of decline of kidney function with age has been regarded as 1 mL/min/1.73m 2 per year, and occurs in healthy older people, not just those with disease risk factors [ 7 ]. The median eGFR in healthy younger adults is 106 mL/min/1.73m 2 , and begins to decline after age 40 [ 14 ]. Kidney function declines to <60 mL/min/1.73m 2 in 40% older adults over 70 years [ 15 ]. Currently guidelines state that an eGFR of <60 mL/min/1.73m 2 is common in older people but is nevertheless predictive of significantly increased risks of adverse clinical outcomes and should not be considered physiological or age-related [ 4 ]. Most older patients will never go on to have end stage kidney disease [ 16 ]. There are similar mortality risks for people with only mild reduction in kidney function (stage 3a CKD) and a normal urine ACR compared to those with normal kidney function [ 6 , 16 ]. GFR performs similarly to other cardiovascular risk predictors, with urine ACR being the stronger risk predictor for cardiovascular mortality [ 17 ]. GPs in our study indicated that having a chart that made explicit this normal rate of decline of kidney function in visual form would be helpful for them to monitor their patients’ kidney function, be able to discuss risks with patients and make better decisions about when to monitor and when to intervene with their older patients. The trajectory charts presented here may form a useful adjunct to the well-validated Kidney Failure Risk Equation (KFRE) [ 18 ]. The KFRE equation predicts kidney failure risk in the subsequent 2 and 5 years, which can help to inform clinical decisions. Clinicians may, however, be concerned about an individual’s lifetime risk of advanced kidney disease, and comparing patients’ renal function trajectory with the age-matched general population is expected to assist in this assessment.

There is currently a gap in the guidelines relating to younger patients who might have a declining kidney function that is still above the reference range of 60 mL/min/1.73m 2 , but who are not identified as having CKD. A recent study found that 17% of young adults have a modestly reduced eGFR that is outside current guidelines for CKD threshold, putting them at risk for early cardiovascular disease and adverse outcomes [ 5 ]. Other recent studies highlight age related disparities for young people with moderate kidney function loss who aren’t classified appropriately in current guidelines [ 7 ]. If these young people are recognised early, their poor health outcomes may be prevented. As an adjunct to the guidelines, using percentiles of function according to age could aid in the appropriate classification of younger patients at risk [ 6 , 7 , 19 ]. GPs in our study indicated that the chart made a big difference in their ability to recognise risk in a younger patient with lower kidney function, and that it would be useful to have this as an adjunct to the guidelines to assist their assessment of risk. Fig 1 describes how these charts might be used in clinical practice.

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GPs are very familiar with the concept of percentile charts, and regularly use paediatric growth charts, which are a similar concept. GPs already receive pathology data that they can track graphically over time, for example HbA1c in diabetic patients. Further research on the use of a kidney trajectory chart as an adjunct to the chronic kidney disease guidelines should be undertaken to see how GPs use these charts in the clinical environment. A trial of automated plotting of eGFR graphically by pathology companies would be a useful step to see how these might support the monitoring of patients with declining kidney function.

https://doi.org/10.1371/journal.pone.0305605.g001

Limitations

One strength of this study is that it was conducted amongst GPs with a diversity of age, gender, and distribution of practice throughout Australia. The results of this study represent the views of the GPs who self- selected to participate in the interviews. This may not be representative of the broader GP community. However we continued to sample GPs until themes reached saturation in the interviews. Another limitation is the applicability to some groups of patients. Several GPs in our study questioned the relevance of the kidney trajectory charts to Australian First Nations patients and one GP asked whether they were relevant to Asian populations. The development of these charts has been previously described, and creatinine data was taken from the AusDiab study [ 8 , 20 ]. The AusDiab study was a population based cross-sectional study of 11,249 community dwelling Australians conducted in 1999–2000 [ 20 ]. The Ausdiab sample underrepresented First Nations people, with 0.8% of the sample being First Nations, compared to ~2% of the Australian population [ 20 ]. The results of the Ausdiab study may not be generalisable to the First Nations or rural population of Australia, and may not be applicable to populations in other countries. Charts may need to be developed from different ethnic groups to reflect differences in kidney function between ethnic groups, for example the normal values of creatinine in a South-Asian population are different from the Western population [ 21 ]. However, there are also problems using averages from ethnic groups that may reflect socio-economic disadvantage rather than biological or genetic differences, and charts derived from these groups may perpetuate these disadvantages [ 22 ]. We only discussed two different patient clinical vignettes with GPs in this study. This may limit the responses of GPs, who may have considered the charts differently with a wider range of clinical scenarios. Further research needs to be done to test the charts with a broader range of clinical scenarios.

A few GPs described the need for more information on the charts to aid understanding. In our original study we deliberately did not indicate stage 3a and 3b CKD on the charts, as we were trying to determine GPs’ decision making without this information. We also did not provide detailed information on how to interpret the charts as we wanted to gain a clear understanding of how intuitive the charts were without a detailed decision aid. For use in clinical practice, charts would need to have clearer indications of how to interpret them to ensure consistency of use by clinicians. The charts do not include urinary albumin:creatinine ratio, which is an important part of the diagnostic criteria for CKD [ 4 ] and an important marker for cardiovascular risk [ 17 ]. Therefore these charts are not intended for use on their own, but as an adjunct to the clinical guidelines. There are inherent limitations in the estimation of eGFR, being based on serum creatinine levels, which need to be considered in any clinical decision making based on this measurement [ 23 ].

Use of percentile charts in conjunction with the current CKD guidelines help support an individualized and patient-centred model of care. Kidney trajectory charts can help patients to understand their risk of further kidney decline or damage and should be done in conjunction with measurement of urinary albumin: creatinine, and an absolute cardiovascular risk approach. Further research on the use of these charts in everyday clinical practice should be undertaken to further refine their presentation and use.

Supporting information

S1 file. gp interview questions..

https://doi.org/10.1371/journal.pone.0305605.s001

S2 File. Kidney trajectory charts.

https://doi.org/10.1371/journal.pone.0305605.s002

Acknowledgments

We wish to thank the GPs who participated in this study for their invaluable insights.

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Article Contents

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Trustworthiness

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

Credibility

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

Applicability

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

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

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

Consistency

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

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

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

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

The authors have no conflicts of interest to declare.

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• Published: 27 May 2020

How to use and assess qualitative research methods

• Loraine Busetto   ORCID: orcid.org/0000-0002-9228-7875 1 ,
• Wolfgang Wick 1 , 2 &
• Christoph Gumbinger 1  

Neurological Research and Practice volume  2 , Article number:  14 ( 2020 ) Cite this article

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This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 , 8 , 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

From data collection to data analysis

Attributions for icons: see Fig. 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 , 32 , 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

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Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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What Is Qualitative Research? | Methods & Examples

Published on 4 April 2022 by Pritha Bhandari . Revised on 30 January 2023.

Qualitative research involves collecting and analysing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analysing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, and history.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organisation?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography, action research, phenomenological research, and narrative research. They share some similarities, but emphasise different aims and perspectives.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves ‘instruments’ in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analysing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organise your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorise your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analysing qualitative data. Although these methods share similar processes, they emphasise different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Researchers must consider practical and theoretical limitations in analysing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analysing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalisability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalisable conclusions because the data may be biased and unrepresentative of the wider population .

• Labour-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to test a hypothesis by systematically collecting and analysing data, while qualitative methods allow you to explore ideas and experiences in depth.

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organisation to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organisations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organise your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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Criteria for Good Qualitative Research: A Comprehensive Review

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Good Qualitative Research: Opening up the Debate

Beyond qualitative/quantitative structuralism: the positivist qualitative research and the paradigmatic disclaimer.

What is Qualitative in Research

Avoid common mistakes on your manuscript.

Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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9.1 Qualitative research: What is it and when should it be used?

Learning objectives.

• Define qualitative research
• Explain the differences between qualitative and quantitative research
• Identify the benefits and challenges of qualitative research

Qualitative versus quantitative research methods refers to data-oriented considerations about the type of data to collected and how they are analyzed. Qualitative research relies mostly on non-numeric data, such as interviews and observations to understand their meaning, in contrast to quantitative research which employs numeric data such as scores and metrics. Hence, qualitative research is not amenable to statistical procedures, but is coded using techniques like content analysis. Sometimes, coded qualitative data are tabulated quantitatively as frequencies of codes, but this data is not statistically analyzed.  Qualitative research has its roots in anthropology, sociology, psychology, linguistics, and semiotics, and has been available since the early 19th century, long before quantitative statistical techniques were employed.

Distinctions from Quantitative Research

In qualitative research, the role of the researcher receives critical attention.  In some methods such as ethnography, action research, and participant observation, the researcher is considered part of the social phenomenon, and her specific role and involvement in the research process must be made clear during data analysis. In other methods, such as case research, the researcher must take a “neutral” or unbiased stance during the data collection and analysis processes, and ensure that her personal biases or preconceptions does not taint the nature of subjective inferences derived from qualitative research.

Analysis in qualitative research is holistic and contextual, rather than being reductionist and isolationist. Qualitative interpretations tend to focus on language, signs, and meanings from the perspective of the participants involved in the social phenomenon, in contrast to statistical techniques that are employed heavily in positivist research. Rigor in qualitative research is viewed in terms of systematic and transparent approaches for data collection and analysis rather than statistical benchmarks for construct validity or significance testing.

Lastly, data collection and analysis can proceed simultaneously and iteratively in qualitative research. For instance, the researcher may conduct an interview and code it before proceeding to the next interview. Simultaneous analysis helps the researcher correct potential flaws in the interview protocol or adjust it to capture the phenomenon of interest better. The researcher may even change her original research question if she realizes that her original research questions are unlikely to generate new or useful insights. This is a valuable but often understated benefit of qualitative research, and is not available in quantitative research, where the research project cannot be modified or changed once the data collection has started without redoing the entire project from the start.

Benefits and Challenges of Qualitative Research

Qualitative research has several unique advantages. First, it is well-suited for exploring hidden reasons behind complex, interrelated, or multifaceted social processes, such as inter-firm relationships or inter-office politics, where quantitative evidence may be biased, inaccurate, or otherwise difficult to obtain. Second, it is often helpful for theory construction in areas with no or insufficient pre-existing theory. Third, qualitative research is also appropriate for studying context-specific, unique, or idiosyncratic events or processes. Fourth, it can help uncover interesting and relevant research questions and issues for follow-up research.

At the same time, qualitative research also has its own set of challenges. First, this type of research tends to be more time and resource intensive than quantitative research in data collection and analytic efforts. Too little data can lead to false or premature assumptions, while too much data may not be effectively processed by the researcher. Second, qualitative research requires well-trained researchers who are capable of seeing and interpreting complex social phenomenon from the perspectives of the embedded participants and reconciling the diverse perspectives of these participants, without injecting their personal biases or preconceptions into their inferences. Third, all participants or data sources may not be equally credible, unbiased, or knowledgeable about the phenomenon of interest, or may have undisclosed political agendas, which may lead to misleading or false impressions. Inadequate trust between participants and researcher may hinder full and honest self-representation by participants, and such trust building takes time. It is the job of the qualitative researcher to “see through the smoke” (hidden or biased agendas) and understand the true nature of the problem. Finally, given the heavily contextualized nature of inferences drawn from qualitative research, such inferences do not lend themselves well to replicability or generalizability.

Key Takeaways

• Qualitative research examines words and other non-numeric media
• Analysis in qualitative research is holistic and contextual
• Qualitative research offers unique benefits, while facing challenges to generalizability and replicability
• Qualitative methods – examine words or other media to understand their meaning

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Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

Qualitative research is a type of research methodology that focuses on exploring and understanding people’s beliefs, attitudes, behaviors, and experiences through the collection and analysis of non-numerical data. It seeks to answer research questions through the examination of subjective data, such as interviews, focus groups, observations, and textual analysis.

Qualitative research aims to uncover the meaning and significance of social phenomena, and it typically involves a more flexible and iterative approach to data collection and analysis compared to quantitative research. Qualitative research is often used in fields such as sociology, anthropology, psychology, and education.

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

This method involves conducting an interview with a single participant to gain a detailed understanding of their experiences, attitudes, and beliefs. One-to-one interviews can be conducted in-person, over the phone, or through video conferencing. The interviewer typically uses open-ended questions to encourage the participant to share their thoughts and feelings. One-to-one interviews are useful for gaining detailed insights into individual experiences.

Focus Groups

This method involves bringing together a group of people to discuss a specific topic in a structured setting. The focus group is led by a moderator who guides the discussion and encourages participants to share their thoughts and opinions. Focus groups are useful for generating ideas and insights, exploring social norms and attitudes, and understanding group dynamics.

Ethnographic Studies

This method involves immersing oneself in a culture or community to gain a deep understanding of its norms, beliefs, and practices. Ethnographic studies typically involve long-term fieldwork and observation, as well as interviews and document analysis. Ethnographic studies are useful for understanding the cultural context of social phenomena and for gaining a holistic understanding of complex social processes.

Text Analysis

This method involves analyzing written or spoken language to identify patterns and themes. Text analysis can be quantitative or qualitative. Qualitative text analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Text analysis is useful for understanding media messages, public discourse, and cultural trends.

This method involves an in-depth examination of a single person, group, or event to gain an understanding of complex phenomena. Case studies typically involve a combination of data collection methods, such as interviews, observations, and document analysis, to provide a comprehensive understanding of the case. Case studies are useful for exploring unique or rare cases, and for generating hypotheses for further research.

Process of Observation

This method involves systematically observing and recording behaviors and interactions in natural settings. The observer may take notes, use audio or video recordings, or use other methods to document what they see. Process of observation is useful for understanding social interactions, cultural practices, and the context in which behaviors occur.

Record Keeping

This method involves keeping detailed records of observations, interviews, and other data collected during the research process. Record keeping is essential for ensuring the accuracy and reliability of the data, and for providing a basis for analysis and interpretation.

This method involves collecting data from a large sample of participants through a structured questionnaire. Surveys can be conducted in person, over the phone, through mail, or online. Surveys are useful for collecting data on attitudes, beliefs, and behaviors, and for identifying patterns and trends in a population.

Qualitative data analysis is a process of turning unstructured data into meaningful insights. It involves extracting and organizing information from sources like interviews, focus groups, and surveys. The goal is to understand people’s attitudes, behaviors, and motivations

Qualitative Research Analysis Methods

Qualitative Research analysis methods involve a systematic approach to interpreting and making sense of the data collected in qualitative research. Here are some common qualitative data analysis methods:

Thematic Analysis

This method involves identifying patterns or themes in the data that are relevant to the research question. The researcher reviews the data, identifies keywords or phrases, and groups them into categories or themes. Thematic analysis is useful for identifying patterns across multiple data sources and for generating new insights into the research topic.

Content Analysis

This method involves analyzing the content of written or spoken language to identify key themes or concepts. Content analysis can be quantitative or qualitative. Qualitative content analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Content analysis is useful for identifying patterns in media messages, public discourse, and cultural trends.

Discourse Analysis

This method involves analyzing language to understand how it constructs meaning and shapes social interactions. Discourse analysis can involve a variety of methods, such as conversation analysis, critical discourse analysis, and narrative analysis. Discourse analysis is useful for understanding how language shapes social interactions, cultural norms, and power relationships.

Grounded Theory Analysis

This method involves developing a theory or explanation based on the data collected. Grounded theory analysis starts with the data and uses an iterative process of coding and analysis to identify patterns and themes in the data. The theory or explanation that emerges is grounded in the data, rather than preconceived hypotheses. Grounded theory analysis is useful for understanding complex social phenomena and for generating new theoretical insights.

Narrative Analysis

This method involves analyzing the stories or narratives that participants share to gain insights into their experiences, attitudes, and beliefs. Narrative analysis can involve a variety of methods, such as structural analysis, thematic analysis, and discourse analysis. Narrative analysis is useful for understanding how individuals construct their identities, make sense of their experiences, and communicate their values and beliefs.

Phenomenological Analysis

This method involves analyzing how individuals make sense of their experiences and the meanings they attach to them. Phenomenological analysis typically involves in-depth interviews with participants to explore their experiences in detail. Phenomenological analysis is useful for understanding subjective experiences and for developing a rich understanding of human consciousness.

Comparative Analysis

This method involves comparing and contrasting data across different cases or groups to identify similarities and differences. Comparative analysis can be used to identify patterns or themes that are common across multiple cases, as well as to identify unique or distinctive features of individual cases. Comparative analysis is useful for understanding how social phenomena vary across different contexts and groups.

Applications of Qualitative Research

Qualitative research has many applications across different fields and industries. Here are some examples of how qualitative research is used:

• Market Research: Qualitative research is often used in market research to understand consumer attitudes, behaviors, and preferences. Researchers conduct focus groups and one-on-one interviews with consumers to gather insights into their experiences and perceptions of products and services.
• Health Care: Qualitative research is used in health care to explore patient experiences and perspectives on health and illness. Researchers conduct in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education: Qualitative research is used in education to understand student experiences and to develop effective teaching strategies. Researchers conduct classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work : Qualitative research is used in social work to explore social problems and to develop interventions to address them. Researchers conduct in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : Qualitative research is used in anthropology to understand different cultures and societies. Researchers conduct ethnographic studies and observe and interview members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : Qualitative research is used in psychology to understand human behavior and mental processes. Researchers conduct in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy : Qualitative research is used in public policy to explore public attitudes and to inform policy decisions. Researchers conduct focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

• Identify your research question: Qualitative research starts with a research question or set of questions that you want to explore. This question should be focused and specific, but also broad enough to allow for exploration and discovery.
• Select your research design: There are different types of qualitative research designs, including ethnography, case study, grounded theory, and phenomenology. You should select a design that aligns with your research question and that will allow you to gather the data you need to answer your research question.
• Recruit participants: Once you have your research question and design, you need to recruit participants. The number of participants you need will depend on your research design and the scope of your research. You can recruit participants through advertisements, social media, or through personal networks.
• Collect data: There are different methods for collecting qualitative data, including interviews, focus groups, observation, and document analysis. You should select the method or methods that align with your research design and that will allow you to gather the data you need to answer your research question.
• Analyze data: Once you have collected your data, you need to analyze it. This involves reviewing your data, identifying patterns and themes, and developing codes to organize your data. You can use different software programs to help you analyze your data, or you can do it manually.
• Interpret data: Once you have analyzed your data, you need to interpret it. This involves making sense of the patterns and themes you have identified, and developing insights and conclusions that answer your research question. You should be guided by your research question and use your data to support your conclusions.
• Communicate results: Once you have interpreted your data, you need to communicate your results. This can be done through academic papers, presentations, or reports. You should be clear and concise in your communication, and use examples and quotes from your data to support your findings.

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

• Customer Feedback: A company may conduct qualitative research to understand the feedback and experiences of its customers. This may involve conducting focus groups or one-on-one interviews with customers to gather insights into their attitudes, behaviors, and preferences.
• Healthcare : A healthcare provider may conduct qualitative research to explore patient experiences and perspectives on health and illness. This may involve conducting in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education : An educational institution may conduct qualitative research to understand student experiences and to develop effective teaching strategies. This may involve conducting classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work: A social worker may conduct qualitative research to explore social problems and to develop interventions to address them. This may involve conducting in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : An anthropologist may conduct qualitative research to understand different cultures and societies. This may involve conducting ethnographic studies and observing and interviewing members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : A psychologist may conduct qualitative research to understand human behavior and mental processes. This may involve conducting in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy: A government agency or non-profit organization may conduct qualitative research to explore public attitudes and to inform policy decisions. This may involve conducting focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

Purpose of Qualitative Research

The purpose of qualitative research is to explore and understand the subjective experiences, behaviors, and perspectives of individuals or groups in a particular context. Unlike quantitative research, which focuses on numerical data and statistical analysis, qualitative research aims to provide in-depth, descriptive information that can help researchers develop insights and theories about complex social phenomena.

Qualitative research can serve multiple purposes, including:

• Exploring new or emerging phenomena : Qualitative research can be useful for exploring new or emerging phenomena, such as new technologies or social trends. This type of research can help researchers develop a deeper understanding of these phenomena and identify potential areas for further study.
• Understanding complex social phenomena : Qualitative research can be useful for exploring complex social phenomena, such as cultural beliefs, social norms, or political processes. This type of research can help researchers develop a more nuanced understanding of these phenomena and identify factors that may influence them.
• Generating new theories or hypotheses: Qualitative research can be useful for generating new theories or hypotheses about social phenomena. By gathering rich, detailed data about individuals’ experiences and perspectives, researchers can develop insights that may challenge existing theories or lead to new lines of inquiry.
• Providing context for quantitative data: Qualitative research can be useful for providing context for quantitative data. By gathering qualitative data alongside quantitative data, researchers can develop a more complete understanding of complex social phenomena and identify potential explanations for quantitative findings.

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

• Exploring a new area: If little is known about a particular topic, qualitative research can help to identify key issues, generate hypotheses, and develop new theories.
• Understanding complex phenomena: Qualitative research can be used to investigate complex social, cultural, or organizational phenomena that are difficult to measure quantitatively.
• Investigating subjective experiences: Qualitative research is particularly useful for investigating the subjective experiences of individuals or groups, such as their attitudes, beliefs, values, or emotions.
• Conducting formative research: Qualitative research can be used in the early stages of a research project to develop research questions, identify potential research participants, and refine research methods.
• Evaluating interventions or programs: Qualitative research can be used to evaluate the effectiveness of interventions or programs by collecting data on participants’ experiences, attitudes, and behaviors.

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

• Focus on subjective experience: Qualitative research is concerned with understanding the subjective experiences, beliefs, and perspectives of individuals or groups in a particular context. Researchers aim to explore the meanings that people attach to their experiences and to understand the social and cultural factors that shape these meanings.
• Use of open-ended questions: Qualitative research relies on open-ended questions that allow participants to provide detailed, in-depth responses. Researchers seek to elicit rich, descriptive data that can provide insights into participants’ experiences and perspectives.
• Sampling-based on purpose and diversity: Qualitative research often involves purposive sampling, in which participants are selected based on specific criteria related to the research question. Researchers may also seek to include participants with diverse experiences and perspectives to capture a range of viewpoints.
• Data collection through multiple methods: Qualitative research typically involves the use of multiple data collection methods, such as in-depth interviews, focus groups, and observation. This allows researchers to gather rich, detailed data from multiple sources, which can provide a more complete picture of participants’ experiences and perspectives.
• Inductive data analysis: Qualitative research relies on inductive data analysis, in which researchers develop theories and insights based on the data rather than testing pre-existing hypotheses. Researchers use coding and thematic analysis to identify patterns and themes in the data and to develop theories and explanations based on these patterns.
• Emphasis on researcher reflexivity: Qualitative research recognizes the importance of the researcher’s role in shaping the research process and outcomes. Researchers are encouraged to reflect on their own biases and assumptions and to be transparent about their role in the research process.

Advantages of Qualitative Research

Qualitative research offers several advantages over other research methods, including:

• Depth and detail: Qualitative research allows researchers to gather rich, detailed data that provides a deeper understanding of complex social phenomena. Through in-depth interviews, focus groups, and observation, researchers can gather detailed information about participants’ experiences and perspectives that may be missed by other research methods.
• Flexibility : Qualitative research is a flexible approach that allows researchers to adapt their methods to the research question and context. Researchers can adjust their research methods in real-time to gather more information or explore unexpected findings.
• Contextual understanding: Qualitative research is well-suited to exploring the social and cultural context in which individuals or groups are situated. Researchers can gather information about cultural norms, social structures, and historical events that may influence participants’ experiences and perspectives.
• Participant perspective : Qualitative research prioritizes the perspective of participants, allowing researchers to explore subjective experiences and understand the meanings that participants attach to their experiences.
• Theory development: Qualitative research can contribute to the development of new theories and insights about complex social phenomena. By gathering rich, detailed data and using inductive data analysis, researchers can develop new theories and explanations that may challenge existing understandings.
• Validity : Qualitative research can offer high validity by using multiple data collection methods, purposive and diverse sampling, and researcher reflexivity. This can help ensure that findings are credible and trustworthy.

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

• Subjectivity : Qualitative research relies on the subjective interpretation of researchers, which can introduce bias into the research process. The researcher’s perspective, beliefs, and experiences can influence the way data is collected, analyzed, and interpreted.
• Limited generalizability: Qualitative research typically involves small, purposive samples that may not be representative of larger populations. This limits the generalizability of findings to other contexts or populations.
• Time-consuming: Qualitative research can be a time-consuming process, requiring significant resources for data collection, analysis, and interpretation.
• Resource-intensive: Qualitative research may require more resources than other research methods, including specialized training for researchers, specialized software for data analysis, and transcription services.
• Limited reliability: Qualitative research may be less reliable than quantitative research, as it relies on the subjective interpretation of researchers. This can make it difficult to replicate findings or compare results across different studies.
• Ethics and confidentiality: Qualitative research involves collecting sensitive information from participants, which raises ethical concerns about confidentiality and informed consent. Researchers must take care to protect the privacy and confidentiality of participants and obtain informed consent.

Also see Research Methods

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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How to use and assess qualitative research methods

Affiliations.

• 1 Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
• 2 Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany.
• PMID: 33324920
• PMCID: PMC7650082
• DOI: 10.1186/s42466-020-00059-z

This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

Keywords: Mixed methods; Qualitative research; Quality assessment.

© The Author(s) 2020.

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Conflict of interest statement

Competing interestsThe authors declare no competing interests.

Iterative research process

Possible combination of data collection…

Possible combination of data collection methods

From data collection to data…

From data collection to data analysis

Three common mixed methods designs

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• Qualitative vs. Quantitative Research | Differences, Examples & Methods

Qualitative vs. Quantitative Research | Differences, Examples & Methods

Published on April 12, 2019 by Raimo Streefkerk . Revised on June 22, 2023.

When collecting and analyzing data, quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings. Both are important for gaining different kinds of knowledge.

Common quantitative methods include experiments, observations recorded as numbers, and surveys with closed-ended questions.

Quantitative research is at risk for research biases including information bias , omitted variable bias , sampling bias , or selection bias . Qualitative research Qualitative research is expressed in words . It is used to understand concepts, thoughts or experiences. This type of research enables you to gather in-depth insights on topics that are not well understood.

Common qualitative methods include interviews with open-ended questions, observations described in words, and literature reviews that explore concepts and theories.

Table of contents

The differences between quantitative and qualitative research, data collection methods, when to use qualitative vs. quantitative research, how to analyze qualitative and quantitative data, other interesting articles, frequently asked questions about qualitative and quantitative research.

Quantitative and qualitative research use different research methods to collect and analyze data, and they allow you to answer different kinds of research questions.

Quantitative and qualitative data can be collected using various methods. It is important to use a data collection method that will help answer your research question(s).

Many data collection methods can be either qualitative or quantitative. For example, in surveys, observational studies or case studies , your data can be represented as numbers (e.g., using rating scales or counting frequencies) or as words (e.g., with open-ended questions or descriptions of what you observe).

However, some methods are more commonly used in one type or the other.

Quantitative data collection methods

• Surveys :  List of closed or multiple choice questions that is distributed to a sample (online, in person, or over the phone).
• Experiments : Situation in which different types of variables are controlled and manipulated to establish cause-and-effect relationships.
• Observations : Observing subjects in a natural environment where variables can’t be controlled.

Qualitative data collection methods

• Interviews : Asking open-ended questions verbally to respondents.
• Focus groups : Discussion among a group of people about a topic to gather opinions that can be used for further research.
• Ethnography : Participating in a community or organization for an extended period of time to closely observe culture and behavior.
• Literature review : Survey of published works by other authors.

A rule of thumb for deciding whether to use qualitative or quantitative data is:

• Use quantitative research if you want to confirm or test something (a theory or hypothesis )
• Use qualitative research if you want to understand something (concepts, thoughts, experiences)

For most research topics you can choose a qualitative, quantitative or mixed methods approach . Which type you choose depends on, among other things, whether you’re taking an inductive vs. deductive research approach ; your research question(s) ; whether you’re doing experimental , correlational , or descriptive research ; and practical considerations such as time, money, availability of data, and access to respondents.

Quantitative research approach

You survey 300 students at your university and ask them questions such as: “on a scale from 1-5, how satisfied are your with your professors?”

You can perform statistical analysis on the data and draw conclusions such as: “on average students rated their professors 4.4”.

Qualitative research approach

You conduct in-depth interviews with 15 students and ask them open-ended questions such as: “How satisfied are you with your studies?”, “What is the most positive aspect of your study program?” and “What can be done to improve the study program?”

Based on the answers you get you can ask follow-up questions to clarify things. You transcribe all interviews using transcription software and try to find commonalities and patterns.

Mixed methods approach

You conduct interviews to find out how satisfied students are with their studies. Through open-ended questions you learn things you never thought about before and gain new insights. Later, you use a survey to test these insights on a larger scale.

It’s also possible to start with a survey to find out the overall trends, followed by interviews to better understand the reasons behind the trends.

Qualitative or quantitative data by itself can’t prove or demonstrate anything, but has to be analyzed to show its meaning in relation to the research questions. The method of analysis differs for each type of data.

Analyzing quantitative data

Quantitative data is based on numbers. Simple math or more advanced statistical analysis is used to discover commonalities or patterns in the data. The results are often reported in graphs and tables.

Applications such as Excel, SPSS, or R can be used to calculate things like:

• Average scores ( means )
• The number of times a particular answer was given
• The correlation or causation between two or more variables
• The reliability and validity of the results

Analyzing qualitative data

Qualitative data is more difficult to analyze than quantitative data. It consists of text, images or videos instead of numbers.

Some common approaches to analyzing qualitative data include:

• Qualitative content analysis : Tracking the occurrence, position and meaning of words or phrases
• Thematic analysis : Closely examining the data to identify the main themes and patterns
• Discourse analysis : Studying how communication works in social contexts

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

In mixed methods research , you use both qualitative and quantitative data collection and analysis methods to answer your research question .

The research methods you use depend on the type of data you need to answer your research question .

• If you want to measure something or test a hypothesis , use quantitative methods . If you want to explore ideas, thoughts and meanings, use qualitative methods .
• If you want to analyze a large amount of readily-available data, use secondary data. If you want data specific to your purposes with control over how it is generated, collect primary data.
• If you want to establish cause-and-effect relationships between variables , use experimental methods. If you want to understand the characteristics of a research subject, use descriptive methods.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

A research project is an academic, scientific, or professional undertaking to answer a research question . Research projects can take many forms, such as qualitative or quantitative , descriptive , longitudinal , experimental , or correlational . What kind of research approach you choose will depend on your topic.

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Qualitative Research: Characteristics, Design, Methods & Examples

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Qualitative research is a type of research methodology that focuses on gathering and analyzing non-numerical data to gain a deeper understanding of human behavior, experiences, and perspectives.

It aims to explore the “why” and “how” of a phenomenon rather than the “what,” “where,” and “when” typically addressed by quantitative research.

Unlike quantitative research, which focuses on gathering and analyzing numerical data for statistical analysis, qualitative research involves researchers interpreting data to identify themes, patterns, and meanings.

Qualitative research can be used to:

• Gain deep contextual understandings of the subjective social reality of individuals
• To answer questions about experience and meaning from the participant’s perspective
• To design hypotheses, theory must be researched using qualitative methods to determine what is important before research can begin. 

Examples of qualitative research questions include: 

• How does stress influence young adults’ behavior?
• What factors influence students’ school attendance rates in developed countries?
• How do adults interpret binge drinking in the UK?
• What are the psychological impacts of cervical cancer screening in women?
• How can mental health lessons be integrated into the school curriculum? 

Characteristics 

Naturalistic setting.

Individuals are studied in their natural setting to gain a deeper understanding of how people experience the world. This enables the researcher to understand a phenomenon close to how participants experience it. 

Naturalistic settings provide valuable contextual information to help researchers better understand and interpret the data they collect.

The environment, social interactions, and cultural factors can all influence behavior and experiences, and these elements are more easily observed in real-world settings.

Reality is socially constructed

Qualitative research aims to understand how participants make meaning of their experiences – individually or in social contexts. It assumes there is no objective reality and that the social world is interpreted (Yilmaz, 2013). 

The primacy of subject matter 

The primary aim of qualitative research is to understand the perspectives, experiences, and beliefs of individuals who have experienced the phenomenon selected for research rather than the average experiences of groups of people (Minichiello, 1990).

An in-depth understanding is attained since qualitative techniques allow participants to freely disclose their experiences, thoughts, and feelings without constraint (Tenny et al., 2022). 

Variables are complex, interwoven, and difficult to measure

Factors such as experiences, behaviors, and attitudes are complex and interwoven, so they cannot be reduced to isolated variables , making them difficult to measure quantitatively.

However, a qualitative approach enables participants to describe what, why, or how they were thinking/ feeling during a phenomenon being studied (Yilmaz, 2013). 

Emic (insider’s point of view)

The phenomenon being studied is centered on the participants’ point of view (Minichiello, 1990).

Emic is used to describe how participants interact, communicate, and behave in the research setting (Scarduzio, 2017).

Interpretive analysis

In qualitative research, interpretive analysis is crucial in making sense of the collected data.

This process involves examining the raw data, such as interview transcripts, field notes, or documents, and identifying the underlying themes, patterns, and meanings that emerge from the participants’ experiences and perspectives.

Collecting Qualitative Data

There are four main research design methods used to collect qualitative data: observations, interviews,  focus groups, and ethnography.

Observations

This method involves watching and recording phenomena as they occur in nature. Observation can be divided into two types: participant and non-participant observation.

In participant observation, the researcher actively participates in the situation/events being observed.

In non-participant observation, the researcher is not an active part of the observation and tries not to influence the behaviors they are observing (Busetto et al., 2020). 

Observations can be covert (participants are unaware that a researcher is observing them) or overt (participants are aware of the researcher’s presence and know they are being observed).

However, awareness of an observer’s presence may influence participants’ behavior. 

Interviews give researchers a window into the world of a participant by seeking their account of an event, situation, or phenomenon. They are usually conducted on a one-to-one basis and can be distinguished according to the level at which they are structured (Punch, 2013). 

Structured interviews involve predetermined questions and sequences to ensure replicability and comparability. However, they are unable to explore emerging issues.

Informal interviews consist of spontaneous, casual conversations which are closer to the truth of a phenomenon. However, information is gathered using quick notes made by the researcher and is therefore subject to recall bias. 

Semi-structured interviews have a flexible structure, phrasing, and placement so emerging issues can be explored (Denny & Weckesser, 2022).

The use of probing questions and clarification can lead to a detailed understanding, but semi-structured interviews can be time-consuming and subject to interviewer bias. 

Focus groups 

Similar to interviews, focus groups elicit a rich and detailed account of an experience. However, focus groups are more dynamic since participants with shared characteristics construct this account together (Denny & Weckesser, 2022).

A shared narrative is built between participants to capture a group experience shaped by a shared context. 

The researcher takes on the role of a moderator, who will establish ground rules and guide the discussion by following a topic guide to focus the group discussions.

Typically, focus groups have 4-10 participants as a discussion can be difficult to facilitate with more than this, and this number allows everyone the time to speak.

Ethnography

Ethnography is a methodology used to study a group of people’s behaviors and social interactions in their environment (Reeves et al., 2008).

Data are collected using methods such as observations, field notes, or structured/ unstructured interviews.

The aim of ethnography is to provide detailed, holistic insights into people’s behavior and perspectives within their natural setting. In order to achieve this, researchers immerse themselves in a community or organization. 

Due to the flexibility and real-world focus of ethnography, researchers are able to gather an in-depth, nuanced understanding of people’s experiences, knowledge and perspectives that are influenced by culture and society.

In order to develop a representative picture of a particular culture/ context, researchers must conduct extensive field work. 

This can be time-consuming as researchers may need to immerse themselves into a community/ culture for a few days, or possibly a few years.

Qualitative Data Analysis Methods

Different methods can be used for analyzing qualitative data. The researcher chooses based on the objectives of their study. 

The researcher plays a key role in the interpretation of data, making decisions about the coding, theming, decontextualizing, and recontextualizing of data (Starks & Trinidad, 2007). 

Grounded theory

Grounded theory is a qualitative method specifically designed to inductively generate theory from data. It was developed by Glaser and Strauss in 1967 (Glaser & Strauss, 2017).

This methodology aims to develop theories (rather than test hypotheses) that explain a social process, action, or interaction (Petty et al., 2012). To inform the developing theory, data collection and analysis run simultaneously. 

There are three key types of coding used in grounded theory: initial (open), intermediate (axial), and advanced (selective) coding. 

Throughout the analysis, memos should be created to document methodological and theoretical ideas about the data. Data should be collected and analyzed until data saturation is reached and a theory is developed. 

Content analysis

Content analysis was first used in the early twentieth century to analyze textual materials such as newspapers and political speeches.

Content analysis is a research method used to identify and analyze the presence and patterns of themes, concepts, or words in data (Vaismoradi et al., 2013). 

This research method can be used to analyze data in different formats, which can be written, oral, or visual. 

The goal of content analysis is to develop themes that capture the underlying meanings of data (Schreier, 2012). 

Qualitative content analysis can be used to validate existing theories, support the development of new models and theories, and provide in-depth descriptions of particular settings or experiences.

The following six steps provide a guideline for how to conduct qualitative content analysis.

• Define a Research Question : To start content analysis, a clear research question should be developed.
• Identify and Collect Data : Establish the inclusion criteria for your data. Find the relevant sources to analyze.
• Define the Unit or Theme of Analysis : Categorize the content into themes. Themes can be a word, phrase, or sentence.
• Develop Rules for Coding your Data : Define a set of coding rules to ensure that all data are coded consistently.
• Code the Data : Follow the coding rules to categorize data into themes.
• Analyze the Results and Draw Conclusions : Examine the data to identify patterns and draw conclusions in relation to your research question.

Discourse analysis

Discourse analysis is a research method used to study written/ spoken language in relation to its social context (Wood & Kroger, 2000).

In discourse analysis, the researcher interprets details of language materials and the context in which it is situated.

Discourse analysis aims to understand the functions of language (how language is used in real life) and how meaning is conveyed by language in different contexts. Researchers use discourse analysis to investigate social groups and how language is used to achieve specific communication goals.

Different methods of discourse analysis can be used depending on the aims and objectives of a study. However, the following steps provide a guideline on how to conduct discourse analysis.

• Define the Research Question : Develop a relevant research question to frame the analysis.
• Gather Data and Establish the Context : Collect research materials (e.g., interview transcripts, documents). Gather factual details and review the literature to construct a theory about the social and historical context of your study.
• Analyze the Content : Closely examine various components of the text, such as the vocabulary, sentences, paragraphs, and structure of the text. Identify patterns relevant to the research question to create codes, then group these into themes.
• Review the Results : Reflect on the findings to examine the function of the language, and the meaning and context of the discourse. 

Thematic analysis

Thematic analysis is a method used to identify, interpret, and report patterns in data, such as commonalities or contrasts. 

Although the origin of thematic analysis can be traced back to the early twentieth century, understanding and clarity of thematic analysis is attributed to Braun and Clarke (2006).

Thematic analysis aims to develop themes (patterns of meaning) across a dataset to address a research question. 

In thematic analysis, qualitative data is gathered using techniques such as interviews, focus groups, and questionnaires. Audio recordings are transcribed. The dataset is then explored and interpreted by a researcher to identify patterns. 

This occurs through the rigorous process of data familiarisation, coding, theme development, and revision. These identified patterns provide a summary of the dataset and can be used to address a research question.

Themes are developed by exploring the implicit and explicit meanings within the data. Two different approaches are used to generate themes: inductive and deductive. 

An inductive approach allows themes to emerge from the data. In contrast, a deductive approach uses existing theories or knowledge to apply preconceived ideas to the data.

Phases of Thematic Analysis

Braun and Clarke (2006) provide a guide of the six phases of thematic analysis. These phases can be applied flexibly to fit research questions and data. 

Template analysis

Template analysis refers to a specific method of thematic analysis which uses hierarchical coding (Brooks et al., 2014).

Template analysis is used to analyze textual data, for example, interview transcripts or open-ended responses on a written questionnaire.

To conduct template analysis, a coding template must be developed (usually from a subset of the data) and subsequently revised and refined. This template represents the themes identified by researchers as important in the dataset. 

Codes are ordered hierarchically within the template, with the highest-level codes demonstrating overarching themes in the data and lower-level codes representing constituent themes with a narrower focus.

A guideline for the main procedural steps for conducting template analysis is outlined below.

• Familiarization with the Data : Read (and reread) the dataset in full. Engage, reflect, and take notes on data that may be relevant to the research question.
• Preliminary Coding : Identify initial codes using guidance from the a priori codes, identified before the analysis as likely to be beneficial and relevant to the analysis.
• Organize Themes : Organize themes into meaningful clusters. Consider the relationships between the themes both within and between clusters.
• Produce an Initial Template : Develop an initial template. This may be based on a subset of the data.
• Apply and Develop the Template : Apply the initial template to further data and make any necessary modifications. Refinements of the template may include adding themes, removing themes, or changing the scope/title of themes. 
• Finalize Template : Finalize the template, then apply it to the entire dataset. 

Frame analysis

Frame analysis is a comparative form of thematic analysis which systematically analyzes data using a matrix output.

Ritchie and Spencer (1994) developed this set of techniques to analyze qualitative data in applied policy research. Frame analysis aims to generate theory from data.

Frame analysis encourages researchers to organize and manage their data using summarization.

This results in a flexible and unique matrix output, in which individual participants (or cases) are represented by rows and themes are represented by columns. 

Each intersecting cell is used to summarize findings relating to the corresponding participant and theme.

Frame analysis has five distinct phases which are interrelated, forming a methodical and rigorous framework.

• Familiarization with the Data : Familiarize yourself with all the transcripts. Immerse yourself in the details of each transcript and start to note recurring themes.
• Develop a Theoretical Framework : Identify recurrent/ important themes and add them to a chart. Provide a framework/ structure for the analysis.
• Indexing : Apply the framework systematically to the entire study data.
• Summarize Data in Analytical Framework : Reduce the data into brief summaries of participants’ accounts.
• Mapping and Interpretation : Compare themes and subthemes and check against the original transcripts. Group the data into categories and provide an explanation for them.

Preventing Bias in Qualitative Research

To evaluate qualitative studies, the CASP (Critical Appraisal Skills Programme) checklist for qualitative studies can be used to ensure all aspects of a study have been considered (CASP, 2018).

The quality of research can be enhanced and assessed using criteria such as checklists, reflexivity, co-coding, and member-checking. 

Co-coding 

Relying on only one researcher to interpret rich and complex data may risk key insights and alternative viewpoints being missed. Therefore, coding is often performed by multiple researchers.

A common strategy must be defined at the beginning of the coding process  (Busetto et al., 2020). This includes establishing a useful coding list and finding a common definition of individual codes.

Transcripts are initially coded independently by researchers and then compared and consolidated to minimize error or bias and to bring confirmation of findings. 

Member checking

Member checking (or respondent validation) involves checking back with participants to see if the research resonates with their experiences (Russell & Gregory, 2003).

Data can be returned to participants after data collection or when results are first available. For example, participants may be provided with their interview transcript and asked to verify whether this is a complete and accurate representation of their views.

Participants may then clarify or elaborate on their responses to ensure they align with their views (Shenton, 2004).

This feedback becomes part of data collection and ensures accurate descriptions/ interpretations of phenomena (Mays & Pope, 2000). 

Reflexivity in qualitative research

Reflexivity typically involves examining your own judgments, practices, and belief systems during data collection and analysis. It aims to identify any personal beliefs which may affect the research. 

Reflexivity is essential in qualitative research to ensure methodological transparency and complete reporting. This enables readers to understand how the interaction between the researcher and participant shapes the data.

Depending on the research question and population being researched, factors that need to be considered include the experience of the researcher, how the contact was established and maintained, age, gender, and ethnicity.

These details are important because, in qualitative research, the researcher is a dynamic part of the research process and actively influences the outcome of the research (Boeije, 2014). 

Reflexivity Example

Who you are and your characteristics influence how you collect and analyze data. Here is an example of a reflexivity statement for research on smoking. I am a 30-year-old white female from a middle-class background. I live in the southwest of England and have been educated to master’s level. I have been involved in two research projects on oral health. I have never smoked, but I have witnessed how smoking can cause ill health from my volunteering in a smoking cessation clinic. My research aspirations are to help to develop interventions to help smokers quit.

Establishing Trustworthiness in Qualitative Research

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability.

1. Credibility in Qualitative Research

Credibility refers to how accurately the results represent the reality and viewpoints of the participants.

To establish credibility in research, participants’ views and the researcher’s representation of their views need to align (Tobin & Begley, 2004).

To increase the credibility of findings, researchers may use data source triangulation, investigator triangulation, peer debriefing, or member checking (Lincoln & Guba, 1985). 

2. Transferability in Qualitative Research

Transferability refers to how generalizable the findings are: whether the findings may be applied to another context, setting, or group (Tobin & Begley, 2004).

Transferability can be enhanced by giving thorough and in-depth descriptions of the research setting, sample, and methods (Nowell et al., 2017). 

3. Dependability in Qualitative Research

Dependability is the extent to which the study could be replicated under similar conditions and the findings would be consistent.

Researchers can establish dependability using methods such as audit trails so readers can see the research process is logical and traceable (Koch, 1994).

4. Confirmability in Qualitative Research

Confirmability is concerned with establishing that there is a clear link between the researcher’s interpretations/ findings and the data.

Researchers can achieve confirmability by demonstrating how conclusions and interpretations were arrived at (Nowell et al., 2017).

This enables readers to understand the reasoning behind the decisions made. 

Audit Trails in Qualitative Research

An audit trail provides evidence of the decisions made by the researcher regarding theory, research design, and data collection, as well as the steps they have chosen to manage, analyze, and report data. 

The researcher must provide a clear rationale to demonstrate how conclusions were reached in their study.

A clear description of the research path must be provided to enable readers to trace through the researcher’s logic (Halpren, 1983).

Researchers should maintain records of the raw data, field notes, transcripts, and a reflective journal in order to provide a clear audit trail. 

Discovery of unexpected data

Open-ended questions in qualitative research mean the researcher can probe an interview topic and enable the participant to elaborate on responses in an unrestricted manner.

This allows unexpected data to emerge, which can lead to further research into that topic. 

The exploratory nature of qualitative research helps generate hypotheses that can be tested quantitatively (Busetto et al., 2020).

Flexibility

Data collection and analysis can be modified and adapted to take the research in a different direction if new ideas or patterns emerge in the data.

This enables researchers to investigate new opportunities while firmly maintaining their research goals. 

Naturalistic settings

The behaviors of participants are recorded in real-world settings. Studies that use real-world settings have high ecological validity since participants behave more authentically. 

Limitations

Time-consuming .

Qualitative research results in large amounts of data which often need to be transcribed and analyzed manually.

Even when software is used, transcription can be inaccurate, and using software for analysis can result in many codes which need to be condensed into themes. 

Subjectivity 

The researcher has an integral role in collecting and interpreting qualitative data. Therefore, the conclusions reached are from their perspective and experience.

Consequently, interpretations of data from another researcher may vary greatly. 

Limited generalizability

The aim of qualitative research is to provide a detailed, contextualized understanding of an aspect of the human experience from a relatively small sample size.

Despite rigorous analysis procedures, conclusions drawn cannot be generalized to the wider population since data may be biased or unrepresentative.

Therefore, results are only applicable to a small group of the population. 

While individual qualitative studies are often limited in their generalizability due to factors such as sample size and context, metasynthesis enables researchers to synthesize findings from multiple studies, potentially leading to more generalizable conclusions.

By integrating findings from studies conducted in diverse settings and with different populations, metasynthesis can provide broader insights into the phenomenon of interest.

Extraneous variables

Qualitative research is often conducted in real-world settings. This may cause results to be unreliable since extraneous variables may affect the data, for example:

• Situational variables : different environmental conditions may influence participants’ behavior in a study. The random variation in factors (such as noise or lighting) may be difficult to control in real-world settings.
• Participant characteristics : this includes any characteristics that may influence how a participant answers/ behaves in a study. This may include a participant’s mood, gender, age, ethnicity, sexual identity, IQ, etc.
• Experimenter effect : experimenter effect refers to how a researcher’s unintentional influence can change the outcome of a study. This occurs when (i) their interactions with participants unintentionally change participants’ behaviors or (ii) due to errors in observation, interpretation, or analysis. 

What sample size should qualitative research be?

The sample size for qualitative studies has been recommended to include a minimum of 12 participants to reach data saturation (Braun, 2013).

Are surveys qualitative or quantitative?

Surveys can be used to gather information from a sample qualitatively or quantitatively. Qualitative surveys use open-ended questions to gather detailed information from a large sample using free text responses.

The use of open-ended questions allows for unrestricted responses where participants use their own words, enabling the collection of more in-depth information than closed-ended questions.

In contrast, quantitative surveys consist of closed-ended questions with multiple-choice answer options. Quantitative surveys are ideal to gather a statistical representation of a population.

What are the ethical considerations of qualitative research?

Before conducting a study, you must think about any risks that could occur and take steps to prevent them. Participant Protection : Researchers must protect participants from physical and mental harm. This means you must not embarrass, frighten, offend, or harm participants. Transparency : Researchers are obligated to clearly communicate how they will collect, store, analyze, use, and share the data. Confidentiality : You need to consider how to maintain the confidentiality and anonymity of participants’ data.

What is triangulation in qualitative research?

Triangulation refers to the use of several approaches in a study to comprehensively understand phenomena. This method helps to increase the validity and credibility of research findings. 

Types of triangulation include method triangulation (using multiple methods to gather data); investigator triangulation (multiple researchers for collecting/ analyzing data), theory triangulation (comparing several theoretical perspectives to explain a phenomenon), and data source triangulation (using data from various times, locations, and people; Carter et al., 2014).

Why is qualitative research important?

Qualitative research allows researchers to describe and explain the social world. The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively.

In qualitative research, participants are able to express their thoughts, experiences, and feelings without constraint.

Additionally, researchers are able to follow up on participants’ answers in real-time, generating valuable discussion around a topic. This enables researchers to gain a nuanced understanding of phenomena which is difficult to attain using quantitative methods.

What is coding data in qualitative research?

Coding data is a qualitative data analysis strategy in which a section of text is assigned with a label that describes its content.

These labels may be words or phrases which represent important (and recurring) patterns in the data.

This process enables researchers to identify related content across the dataset. Codes can then be used to group similar types of data to generate themes.

What is the difference between qualitative and quantitative research?

Qualitative research involves the collection and analysis of non-numerical data in order to understand experiences and meanings from the participant’s perspective.

This can provide rich, in-depth insights on complicated phenomena. Qualitative data may be collected using interviews, focus groups, or observations.

In contrast, quantitative research involves the collection and analysis of numerical data to measure the frequency, magnitude, or relationships of variables. This can provide objective and reliable evidence that can be generalized to the wider population.

Quantitative data may be collected using closed-ended questionnaires or experiments.

What is trustworthiness in qualitative research?

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability. 

Credibility refers to how accurately the results represent the reality and viewpoints of the participants. Transferability refers to whether the findings may be applied to another context, setting, or group.

Dependability is the extent to which the findings are consistent and reliable. Confirmability refers to the objectivity of findings (not influenced by the bias or assumptions of researchers).

What is data saturation in qualitative research?

Data saturation is a methodological principle used to guide the sample size of a qualitative research study.

Data saturation is proposed as a necessary methodological component in qualitative research (Saunders et al., 2018) as it is a vital criterion for discontinuing data collection and/or analysis. 

The intention of data saturation is to find “no new data, no new themes, no new coding, and ability to replicate the study” (Guest et al., 2006). Therefore, enough data has been gathered to make conclusions.

Why is sampling in qualitative research important?

In quantitative research, large sample sizes are used to provide statistically significant quantitative estimates.

This is because quantitative research aims to provide generalizable conclusions that represent populations.

However, the aim of sampling in qualitative research is to gather data that will help the researcher understand the depth, complexity, variation, or context of a phenomenon. The small sample sizes in qualitative studies support the depth of case-oriented analysis.

What is narrative analysis?

Narrative analysis is a qualitative research method used to understand how individuals create stories from their personal experiences.

There is an emphasis on understanding the context in which a narrative is constructed, recognizing the influence of historical, cultural, and social factors on storytelling.

Researchers can use different methods together to explore a research question.

Some narrative researchers focus on the content of what is said, using thematic narrative analysis, while others focus on the structure, such as holistic-form or categorical-form structural narrative analysis. Others focus on how the narrative is produced and performed.

Boeije, H. (2014). Analysis in qualitative research. Sage.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology , 3 (2), 77-101. https://doi.org/10.1191/1478088706qp063oa

Brooks, J., McCluskey, S., Turley, E., & King, N. (2014). The utility of template analysis in qualitative psychology research. Qualitative Research in Psychology , 12 (2), 202–222. https://doi.org/10.1080/14780887.2014.955224

Busetto, L., Wick, W., & Gumbinger, C. (2020). How to use and assess qualitative research methods. Neurological research and practice , 2 (1), 14-14. https://doi.org/10.1186/s42466-020-00059-z 

Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of triangulation in qualitative research. Oncology nursing forum , 41 (5), 545–547. https://doi.org/10.1188/14.ONF.545-547

Critical Appraisal Skills Programme. (2018). CASP Checklist: 10 questions to help you make sense of a Qualitative research. https://casp-uk.net/images/checklist/documents/CASP-Qualitative-Studies-Checklist/CASP-Qualitative-Checklist-2018_fillable_form.pdf Accessed: March 15 2023

Clarke, V., & Braun, V. (2013). Successful qualitative research: A practical guide for beginners. Successful Qualitative Research , 1-400.

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Qualitative vs Quantitative Research: Which to Use?

• Survey Tips

Regardless of the subject of your study, you have just two types of research to choose from: qualitative and quantitative.

Your knowledge of your research area and respondents will determine the right type of research for you. Most people will need a combination of the two to get the most accurate data.

When and How to Use Qualitative Research

Qualitative research is by definition exploratory. We use it when we don’t know what to expect. It helps define the problem or develop an approach to the problem.

We also use it to go deeper into issues of interest and explore nuances related to the problem at hand. Common data collection methods used in qualitative research are:

• Focus groups
• In-depth interviews
• Uninterrupted observation
• Bulletin boards
• Ethnographic participation/observation.

The Best Times for Quantitative Research

Quantitative research is conclusive in its purpose. It tries to quantify a problem and understand how prevalent it is. It looks for projectable results to a larger population.

For this type of study we collect data through:

• Surveys (online, phone, paper)
• Points of purchase (purchase transactions)
• Click-streams.

Guidelines For Using Both Types of Research

Ideally, if the budget allows, we should use both qualitative and quantitative research. They provide different perspectives and usually complement each other.

Advanced survey software should give you the option to integrate video and chat sessions with your surveys. This can provide you with the best of both quantitative and qualitative research.

This methodological approach is a cost-effective alternative to the combination of in-person focus groups and a separate quantitative study.

It allows us to save on facility rental, recruitment costs, incentives, and travel usually associated with focus groups. Clients can still monitor the sessions remotely from the convenience of their desktops. They can also ask questions to respondents through the moderator.

If you still want to go with traditional methods, and if you can only afford one or the other, make sure you select the approach that best fits the research objectives. Be aware of its caveats as well.

Never assume that conducting additional focus groups can replace quantitative research. Also, don’t assume that a lengthy survey will provide all the nuanced information obtainable through qualitative research methods.

For a more detailed guide on the best way to ask quantitative questions, check out our article on New Ways to Ask Quantitative Research Questions .

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Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis

Albine moser.

a Faculty of Health Care, Research Centre Autonomy and Participation of Chronically Ill People , Zuyd University of Applied Sciences , Heerlen, The Netherlands

b Faculty of Health, Medicine and Life Sciences, Department of Family Medicine , Maastricht University , Maastricht, The Netherlands

Irene Korstjens

c Faculty of Health Care, Research Centre for Midwifery Science , Zuyd University of Applied Sciences , Maastricht, The Netherlands

In the course of our supervisory work over the years, we have noticed that qualitative research tends to evoke a lot of questions and worries, so-called frequently asked questions (FAQs). This series of four articles intends to provide novice researchers with practical guidance for conducting high-quality qualitative research in primary care. By ‘novice’ we mean Master’s students and junior researchers, as well as experienced quantitative researchers who are engaging in qualitative research for the first time. This series addresses their questions and provides researchers, readers, reviewers and editors with references to criteria and tools for judging the quality of qualitative research papers. The second article focused on context, research questions and designs, and referred to publications for further reading. This third article addresses FAQs about sampling, data collection and analysis. The data collection plan needs to be broadly defined and open at first, and become flexible during data collection. Sampling strategies should be chosen in such a way that they yield rich information and are consistent with the methodological approach used. Data saturation determines sample size and will be different for each study. The most commonly used data collection methods are participant observation, face-to-face in-depth interviews and focus group discussions. Analyses in ethnographic, phenomenological, grounded theory, and content analysis studies yield different narrative findings: a detailed description of a culture, the essence of the lived experience, a theory, and a descriptive summary, respectively. The fourth and final article will focus on trustworthiness and publishing qualitative research.

Key points on sampling, data collection and analysis

• The data collection plan needs to be broadly defined and open during data collection.
• Sampling strategies should be chosen in such a way that they yield rich information and are consistent with the methodological approach used.
• Data saturation determines sample size and is different for each study.
• The most commonly used data collection methods are participant observation, face-to-face in-depth interviews and focus group discussions.
• Analyses of ethnographic, phenomenological, grounded theory, and content analysis studies yield different narrative findings: a detailed description of a culture, the essence of the lived experience, a theory or a descriptive summary, respectively.

Introduction

This article is the third paper in a series of four articles aiming to provide practical guidance to qualitative research. In an introductory paper, we have described the objective, nature and outline of the Series [ 1 ]. Part 2 of the series focused on context, research questions and design of qualitative research [ 2 ]. In this paper, Part 3, we address frequently asked questions (FAQs) about sampling, data collection and analysis.

What is a sampling plan?

A sampling plan is a formal plan specifying a sampling method, a sample size, and procedure for recruiting participants ( Box 1 ) [ 3 ]. A qualitative sampling plan describes how many observations, interviews, focus-group discussions or cases are needed to ensure that the findings will contribute rich data. In quantitative studies, the sampling plan, including sample size, is determined in detail in beforehand but qualitative research projects start with a broadly defined sampling plan. This plan enables you to include a variety of settings and situations and a variety of participants, including negative cases or extreme cases to obtain rich data. The key features of a qualitative sampling plan are as follows. First, participants are always sampled deliberately. Second, sample size differs for each study and is small. Third, the sample will emerge during the study: based on further questions raised in the process of data collection and analysis, inclusion and exclusion criteria might be altered, or the sampling sites might be changed. Finally, the sample is determined by conceptual requirements and not primarily by representativeness. You, therefore, need to provide a description of and rationale for your choices in the sampling plan. The sampling plan is appropriate when the selected participants and settings are sufficient to provide the information needed for a full understanding of the phenomenon under study.

Sampling strategies in qualitative research. Based on Polit & Beck [ 3 ].

Some practicalities: a critical first step is to select settings and situations where you have access to potential participants. Subsequently, the best strategy to apply is to recruit participants who can provide the richest information. Such participants have to be knowledgeable on the phenomenon and can articulate and reflect, and are motivated to communicate at length and in depth with you. Finally, you should review the sampling plan regularly and adapt when necessary.

What sampling strategies can I use?

Sampling is the process of selecting or searching for situations, context and/or participants who provide rich data of the phenomenon of interest [ 3 ]. In qualitative research, you sample deliberately, not at random. The most commonly used deliberate sampling strategies are purposive sampling, criterion sampling, theoretical sampling, convenience sampling and snowball sampling. Occasionally, the ‘maximum variation,’ ‘typical cases’ and ‘confirming and disconfirming’ sampling strategies are used. Key informants need to be carefully chosen. Key informants hold special and expert knowledge about the phenomenon to be studied and are willing to share information and insights with you as the researcher [ 3 ]. They also help to gain access to participants, especially when groups are studied. In addition, as researcher, you can validate your ideas and perceptions with those of the key informants.

What is the connection between sampling types and qualitative designs?

The ‘big three’ approaches of ethnography, phenomenology, and grounded theory use different types of sampling.

In ethnography, the main strategy is purposive sampling of a variety of key informants, who are most knowledgeable about a culture and are able and willing to act as representatives in revealing and interpreting the culture. For example, an ethnographic study on the cultural influences of communication in maternity care will recruit key informants from among a variety of parents-to-be, midwives and obstetricians in midwifery care practices and hospitals.

Phenomenology uses criterion sampling, in which participants meet predefined criteria. The most prominent criterion is the participant’s experience with the phenomenon under study. The researchers look for participants who have shared an experience, but vary in characteristics and in their individual experiences. For example, a phenomenological study on the lived experiences of pregnant women with psychosocial support from primary care midwives will recruit pregnant women varying in age, parity and educational level in primary midwifery practices.

Grounded theory usually starts with purposive sampling and later uses theoretical sampling to select participants who can best contribute to the developing theory. As theory construction takes place concurrently with data collection and analyses, the theoretical sampling of new participants also occurs along with the emerging theoretical concepts. For example, one grounded theory study tested several theoretical constructs to build a theory on autonomy in diabetes patients [ 4 ]. In developing the theory, the researchers started by purposefully sampling participants with diabetes differing in age, onset of diabetes and social roles, for example, employees, housewives, and retired people. After the first analysis, researchers continued with theoretically sampling, for example, participants who differed in the treatment they received, with different degrees of care dependency, and participants who receive care from a general practitioner (GP), at a hospital or from a specialist nurse, etc.

In addition to the ‘big three’ approaches, content analysis is frequently applied in primary care research, and very often uses purposive, convenience, or snowball sampling. For instance, a study on peoples’ choice of a hospital for elective orthopaedic surgery used snowball sampling [ 5 ]. One elderly person in the private network of one researcher personally approached potential respondents in her social network by means of personal invitations (including letters). In turn, respondents were asked to pass on the invitation to other eligible candidates.

Sampling is also dependent on the characteristics of the setting, e.g., access, time, vulnerability of participants, and different types of stakeholders. The setting, where sampling is carried out, is described in detail to provide thick description of the context, thereby, enabling the reader to make a transferability judgement (see Part 3: transferability). Sampling also affects the data analysis, where you continue decision-making about whom or what situations to sample next. This is based on what you consider as still missing to get the necessary information for rich findings (see Part 1: emergent design). Another point of attention is the sampling of ‘invisible groups’ or vulnerable people. Sampling of these participants would require applying multiple sampling strategies, and more time calculated in the project planning stage for sampling and recruitment [ 6 ].

How do sample size and data saturation interact?

A guiding principle in qualitative research is to sample only until data saturation has been achieved. Data saturation means the collection of qualitative data to the point where a sense of closure is attained because new data yield redundant information [ 3 ].

Data saturation is reached when no new analytical information arises anymore, and the study provides maximum information on the phenomenon. In quantitative research, by contrast, the sample size is determined by a power calculation. The usually small sample size in qualitative research depends on the information richness of the data, the variety of participants (or other units), the broadness of the research question and the phenomenon, the data collection method (e.g., individual or group interviews) and the type of sampling strategy. Mostly, you and your research team will jointly decide when data saturation has been reached, and hence whether the sampling can be ended and the sample size is sufficient. The most important criterion is the availability of enough in-depth data showing the patterns, categories and variety of the phenomenon under study. You review the analysis, findings, and the quality of the participant quotes you have collected, and then decide whether sampling might be ended because of data saturation. In many cases, you will choose to carry out two or three more observations or interviews or an additional focus group discussion to confirm that data saturation has been reached.

When designing a qualitative sampling plan, we (the authors) work with estimates. We estimate that ethnographic research should require 25–50 interviews and observations, including about four-to-six focus group discussions, while phenomenological studies require fewer than 10 interviews, grounded theory studies 20–30 interviews and content analysis 15–20 interviews or three-to-four focus group discussions. However, these numbers are very tentative and should be very carefully considered before using them. Furthermore, qualitative designs do not always mean small sample numbers. Bigger sample sizes might occur, for example, in content analysis, employing rapid qualitative approaches, and in large or longitudinal qualitative studies.

Data collection

What methods of data collection are appropriate.

The most frequently used data collection methods are participant observation, interviews, and focus group discussions. Participant observation is a method of data collection through the participation in and observation of a group or individuals over an extended period of time [ 3 ]. Interviews are another data collection method in which an interviewer asks the respondents questions [ 6 ], face-to-face, by telephone or online. The qualitative research interview seeks to describe the meanings of central themes in the life world of the participants. The main task in interviewing is to understand the meaning of what participants say [ 5 ]. Focus group discussions are a data collection method with a small group of people to discuss a given topic, usually guided by a moderator using a questioning-route [ 8 ]. It is common in qualitative research to combine more than one data collection method in one study. You should always choose your data collection method wisely. Data collection in qualitative research is unstructured and flexible. You often make decisions on data collection while engaging in fieldwork, the guiding questions being with whom, what, when, where and how. The most basic or ‘light’ version of qualitative data collection is that of open questions in surveys. Box 2 provides an overview of the ‘big three’ qualitative approaches and their most commonly used data collection methods.

Qualitative data collection methods.

What role should I adopt when conducting participant observations?

What is important is to immerse yourself in the research setting, to enable you to study it from the inside. There are four types of researcher involvement in observations, and in your qualitative study, you may apply all four. In the first type, as ‘complete participant’, you become part of the setting and play an insider role, just as you do in your own work setting. This role might be appropriate when studying persons who are difficult to access. The second type is ‘active participation’. You have gained access to a particular setting and observed the group under study. You can move around at will and can observe in detail and depth and in different situations. The third role is ‘moderate participation’. You do not actually work in the setting you wish to study but are located there as a researcher. You might adopt this role when you are not affiliated to the care setting you wish to study. The fourth role is that of the ‘complete observer’, in which you merely observe (bystander role) and do not participate in the setting at all. However, you cannot perform any observations without access to the care setting. Such access might be easily obtained when you collect data by observations in your own primary care setting. In some cases, you might observe other care settings, which are relevant to primary care, for instance observing the discharge procedure for vulnerable elderly people from hospital to primary care.

How do I perform observations?

It is important to decide what to focus on in each individual observation. The focus of observations is important because you can never observe everything, and you can only observe each situation once. Your focus might differ between observations. Each observation should provide you with answers regarding ‘Who do you observe?’, ‘What do you observe’, ‘Where does the observation take place?’, ‘When does it take place?’, ‘How does it happen?’, and ‘Why does it happen as it happens?’ Observations are not static but proceed in three stages: descriptive, focused, and selective. Descriptive means that you observe, on the basis of general questions, everything that goes on in the setting. Focused observation means that you observe certain situations for some time, with some areas becoming more prominent. Selective means that you observe highly specific issues only. For example, if you want to observe the discharge procedure for vulnerable elderly people from hospitals to general practice, you might begin with broad observations to get to know the general procedure. This might involve observing several different patient situations. You might find that the involvement of primary care nurses deserves special attention, so you might then focus on the roles of hospital staff and primary care nurses, and their interactions. Finally, you might want to observe only the specific situations where hospital staff and primary care nurses exchange information. You take field notes from all these observations and add your own reflections on the situations you observed. You jot down words, whole sentences or parts of situations, and your reflections on a piece of paper. After the observations, the field notes need to be worked out and transcribed immediately to be able to include detailed descriptions.

Further reading on interviews and focus group discussion.

Qualitative data analysis.

What are the general features of an interview?

Interviews involve interactions between the interviewer(s) and the respondent(s) based on interview questions. Individual, or face-to-face, interviews should be distinguished from focus group discussions. The interview questions are written down in an interview guide [ 7 ] for individual interviews or a questioning route [ 8 ] for focus group discussions, with questions focusing on the phenomenon under study. The sequence of the questions is pre-determined. In individual interviews, the sequence depends on the respondents and how the interviews unfold. During the interview, as the conversation evolves, you go back and forth through the sequence of questions. It should be a dialogue, not a strict question–answer interview. In a focus group discussion, the sequence is intended to facilitate the interaction between the participants, and you might adapt the sequence depending on how their discussion evolves. Working with an interview guide or questioning route enables you to collect information on specific topics from all participants. You are in control in the sense that you give direction to the interview, while the participants are in control of their answers. However, you need to be open-minded to recognize that some relevant topics for participants may not have been covered in your interview guide or questioning route, and need to be added. During the data collection process, you develop the interview guide or questioning route further and revise it based on the analysis.

The interview guide and questioning route might include open and general as well as subordinate or detailed questions, probes and prompts. Probes are exploratory questions, for example, ‘Can you tell me more about this?’ or ‘Then what happened?’ Prompts are words and signs to encourage participants to tell more. Examples of stimulating prompts are eye contact, leaning forward and open body language.

Further reading on qualitative analysis.

What is a face-to-face interview?

A face-to-face interview is an individual interview, that is, a conversation between participant and interviewer. Interviews can focus on past or present situations, and on personal issues. Most qualitative studies start with open interviews to get a broad ‘picture’ of what is going on. You should not provide a great deal of guidance and avoid influencing the answers to fit ‘your’ point of view, as you want to obtain the participant’s own experiences, perceptions, thoughts, and feelings. You should encourage the participants to speak freely. As the interview evolves, your subsequent major and subordinate questions become more focused. A face-to-face or individual interview might last between 30 and 90 min.

Most interviews are semi-structured [ 3 ]. To prepare an interview guide to enhance that a set of topics will be covered by every participant, you might use a framework for constructing a semi-structured interview guide [ 10 ]: (1) identify the prerequisites to use a semi-structured interview and evaluate if a semi-structured interview is the appropriate data collection method; (2) retrieve and utilize previous knowledge to gain a comprehensive and adequate understanding of the phenomenon under study; (3) formulate a preliminary interview guide by operationalizing the previous knowledge; (4) pilot-test the preliminary interview guide to confirm the coverage and relevance of the content and to identify the need for reformulation of questions; (5) complete the interview guide to collect rich data with a clear and logical guide.

The first few minutes of an interview are decisive. The participant wants to feel at ease before sharing his or her experiences. In a semi-structured interview, you would start with open questions related to the topic, which invite the participant to talk freely. The questions aim to encourage participants to tell their personal experiences, including feelings and emotions and often focus on a particular experience or specific events. As you want to get as much detail as possible, you also ask follow-up questions or encourage telling more details by using probes and prompts or keeping a short period of silence [ 6 ]. You first ask what and why questions and then how questions.

You need to be prepared for handling problems you might encounter, such as gaining access, dealing with multiple formal and informal gatekeepers, negotiating space and privacy for recording data, socially desirable answers from participants, reluctance of participants to tell their story, deciding on the appropriate role (emotional involvement), and exiting from fieldwork prematurely.

What is a focus group discussion and when can I use it?

A focus group discussion is a way to gather together people to discuss a specific topic of interest. The people participating in the focus group discussion share certain characteristics, e.g., professional background, or share similar experiences, e.g., having diabetes. You use their interaction to collect the information you need on a particular topic. To what depth of information the discussion goes depends on the extent to which focus group participants can stimulate each other in discussing and sharing their views and experiences. Focus group participants respond to you and to each other. Focus group discussions are often used to explore patients’ experiences of their condition and interactions with health professionals, to evaluate programmes and treatment, to gain an understanding of health professionals’ roles and identities, to examine the perception of professional education, or to obtain perspectives on primary care issues. A focus group discussion usually lasts 90–120 mins.

You might use guidelines for developing a questioning route [ 9 ]: (1) brainstorm about possible topics you want to cover; (2) sequence the questioning: arrange general questions first, and then, more specific questions, and ask positive questions before negative questions; (3) phrase the questions: use open-ended questions, ask participants to think back and reflect on their personal experiences, avoid asking ‘why’ questions, keep questions simple and make your questions sound conversational, be careful about giving examples; (4) estimate the time for each question and consider: the complexity of the question, the category of the question, level of participant’s expertise, the size of the focus group discussion, and the amount of discussion you want related to the question; (5) obtain feedback from others (peers); (6) revise the questions based on the feedback; and (7) test the questions by doing a mock focus group discussion. All questions need to provide an answer to the phenomenon under study.

You need to be prepared to manage difficulties as they arise, for example, dominant participants during the discussion, little or no interaction and discussion between participants, participants who have difficulties sharing their real feelings about sensitive topics with others, and participants who behave differently when they are observed.

How should I compose a focus group and how many participants are needed?

The purpose of the focus group discussion determines the composition. Smaller groups might be more suitable for complex (and sometimes controversial) topics. Also, smaller focus groups give the participants more time to voice their views and provide more detailed information, while participants in larger focus groups might generate greater variety of information. In composing a smaller or larger focus group, you need to ensure that the participants are likely to have different viewpoints that stimulate the discussion. For example, if you want to discuss the management of obesity in a primary care district, you might want to have a group composed of professionals who work with these patients but also have a variety of backgrounds, e.g. GPs, community nurses, practice nurses in general practice, school nurses, midwives or dieticians.

Focus groups generally consist of 6–12 participants. Careful time management is important, since you have to determine how much time you want to devote to answering each question, and how much time is available for each individual participant. For example, if you have planned a focus group discussion lasting 90 min. with eight participants, you might need 15 min. for the introduction and the concluding summary. This means you have 75 min. for asking questions, and if you have four questions, this allows a total of 18 min. of speaking time for each question. If all eight respondents participate in the discussion, this boils down to about two minutes of speaking time per respondent per question.

How can I use new media to collect qualitative data?

New media are increasingly used for collecting qualitative data, for example, through online observations, online interviews and focus group discussions, and in analysis of online sources. Data can be collected synchronously or asynchronously, with text messaging, video conferences, video calls or immersive virtual worlds or games, etcetera. Qualitative research moves from ‘virtual’ to ‘digital’. Virtual means those approaches that import traditional data collection methods into the online environment and digital means those approaches take advantage of the unique characteristics and capabilities of the Internet for research [ 10 ]. New media can also be applied. See Box 3 for further reading on interview and focus group discussion.

Can I wait with my analysis until all data have been collected?

You cannot wait with the analysis, because an iterative approach and emerging design are at the heart of qualitative research. This involves a process whereby you move back and forth between sampling, data collection and data analysis to accumulate rich data and interesting findings. The principle is that what emerges from data analysis will shape subsequent sampling decisions. Immediately after the very first observation, interview or focus group discussion, you have to start the analysis and prepare your field notes.

Why is a good transcript so important?

First, transcripts of audiotaped interviews and focus group discussions and your field notes constitute your major data sources. Trained and well-instructed transcribers preferably make transcripts. Usually, e.g., in ethnography, phenomenology, grounded theory, and content analysis, data are transcribed verbatim, which means that recordings are fully typed out, and the transcripts are accurate and reflect the interview or focus group discussion experience. Most important aspects of transcribing are the focus on the participants’ words, transcribing all parts of the audiotape, and carefully revisiting the tape and rereading the transcript. In conversation analysis non-verbal actions such as coughing, the lengths of pausing and emphasizing, tone of voice need to be described in detail using a formal transcription system (best known are G. Jefferson’s symbols).

To facilitate analysis, it is essential that you ensure and check that transcripts are accurate and reflect the totality of the interview, including pauses, punctuation and non-verbal data. To be able to make sense of qualitative data, you need to immerse yourself in the data and ‘live’ the data. In this process of incubation, you search the transcripts for meaning and essential patterns, and you try to collect legitimate and insightful findings. You familiarize yourself with the data by reading and rereading transcripts carefully and conscientiously, in search for deeper understanding.

Are there differences between the analyses in ethnography, phenomenology, grounded theory, and content analysis?

Ethnography, phenomenology, and grounded theory each have different analytical approaches, and you should be aware that each of these approaches has different schools of thought, which may also have integrated the analytical methods from other schools ( Box 4 ). When you opt for a particular approach, it is best to use a handbook describing its analytical methods, as it is better to use one approach consistently than to ‘mix up’ different schools.

In general, qualitative analysis begins with organizing data. Large amounts of data need to be stored in smaller and manageable units, which can be retrieved and reviewed easily. To obtain a sense of the whole, analysis starts with reading and rereading the data, looking at themes, emotions and the unexpected, taking into account the overall picture. You immerse yourself in the data. The most widely used procedure is to develop an inductive coding scheme based on actual data [ 11 ]. This is a process of open coding, creating categories and abstraction. In most cases, you do not start with a predefined coding scheme. You describe what is going on in the data. You ask yourself, what is this? What does it stand for? What else is like this? What is this distinct from? Based on this close examination of what emerges from the data you make as many labels as needed. Then, you make a coding sheet, in which you collect the labels and, based on your interpretation, cluster them in preliminary categories. The next step is to order similar or dissimilar categories into broader higher order categories. Each category is named using content-characteristic words. Then, you use abstraction by formulating a general description of the phenomenon under study: subcategories with similar events and information are grouped together as categories and categories are grouped as main categories. During the analysis process, you identify ‘missing analytical information’ and you continue data collection. You reread, recode, re-analyse and re-collect data until your findings provide breadth and depth.

Throughout the qualitative study, you reflect on what you see or do not see in the data. It is common to write ‘analytic memos’ [ 3 ], write-ups or mini-analyses about what you think you are learning during the course of your study, from designing to publishing. They can be a few sentences or pages, whatever is needed to reflect upon: open codes, categories, concepts, and patterns that might be emerging in the data. Memos can contain summaries of major findings and comments and reflections on particular aspects.

In ethnography, analysis begins from the moment that the researcher sets foot in the field. The analysis involves continually looking for patterns in the behaviours and thoughts of the participants in everyday life, in order to obtain an understanding of the culture under study. When comparing one pattern with another and analysing many patterns simultaneously, you may use maps, flow charts, organizational charts and matrices to illustrate the comparisons graphically. The outcome of an ethnographic study is a narrative description of a culture.

In phenomenology, analysis aims to describe and interpret the meaning of an experience, often by identifying essential subordinate and major themes. You search for common themes featuring within an interview and across interviews, sometimes involving the study participants or other experts in the analysis process. The outcome of a phenomenological study is a detailed description of themes that capture the essential meaning of a ‘lived’ experience.

Grounded theory generates a theory that explains how a basic social problem that emerged from the data is processed in a social setting. Grounded theory uses the ‘constant comparison’ method, which involves comparing elements that are present in one data source (e.g., an interview) with elements in another source, to identify commonalities. The steps in the analysis are known as open, axial and selective coding. Throughout the analysis, you document your ideas about the data in methodological and theoretical memos. The outcome of a grounded theory study is a theory.

Descriptive generic qualitative research is defined as research designed to produce a low inference description of a phenomenon [ 12 ]. Although Sandelowski maintains that all research involves interpretation, she has also suggested that qualitative description attempts to minimize inferences made in order to remain ‘closer’ to the original data [ 12 ]. Descriptive generic qualitative research often applies content analysis. Descriptive content analysis studies are not based on a specific qualitative tradition and are varied in their methods of analysis. The analysis of the content aims to identify themes, and patterns within and among these themes. An inductive content analysis [ 11 ] involves breaking down the data into smaller units, coding and naming the units according to the content they present, and grouping the coded material based on shared concepts. They can be represented by clustering in treelike diagrams. A deductive content analysis [ 11 ] uses a theory, theoretical framework or conceptual model to analyse the data by operationalizing them in a coding matrix. An inductive content analysis might use several techniques from grounded theory, such as open and axial coding and constant comparison. However, note that your findings are merely a summary of categories, not a grounded theory.

Analysis software can support you to manage your data, for example by helping to store, annotate and retrieve texts, to locate words, phrases and segments of data, to name and label, to sort and organize, to identify data units, to prepare diagrams and to extract quotes. Still, as a researcher you would do the analytical work by looking at what is in the data, and making decisions about assigning codes, and identifying categories, concepts and patterns. The computer assisted qualitative data analysis (CAQDAS) website provides support to make informed choices between analytical software and courses: http://www.surrey.ac.uk/sociology/research/researchcentres/caqdas/support/choosing . See Box 5 for further reading on qualitative analysis.

The next and final article in this series, Part 4, will focus on trustworthiness and publishing qualitative research [ 13 ].

Acknowledgements

The authors thank the following junior researchers who have been participating for the last few years in the so-called ‘Think tank on qualitative research’ project, a collaborative project between Zuyd University of Applied Sciences and Maastricht University, for their pertinent questions: Erica Baarends, Jerome van Dongen, Jolanda Friesen-Storms, Steffy Lenzen, Ankie Hoefnagels, Barbara Piskur, Claudia van Putten-Gamel, Wilma Savelberg, Steffy Stans, and Anita Stevens. The authors are grateful to Isabel van Helmond, Joyce Molenaar and Darcy Ummels for proofreading our manuscripts and providing valuable feedback from the ‘novice perspective’.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.