qualitative research article writing

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31 Writing Up Qualitative Research

Jane F. Gilgun, School of Social Work, University of Minnesota, Twin Cities

• Published: 04 August 2014
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This chapter provides guidelines for writing journal articles based on qualitative approaches. The guidelines are part of the tradition of the Chicago School of Sociology and the author’s experience as a writer and reviewer. The guidelines include understanding experiences in context, immersion, interpretations grounded in accounts of informants’ lived experiences, and research as action-oriented. The chapter also covers writing articles that report findings based on ethnographies, autoethnographies, performances, poetry, and photography and other graphic media.

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• Published: 16 November 2020

Navigating the qualitative manuscript writing process: some tips for authors and reviewers

• Chris Roberts   ORCID: orcid.org/0000-0001-8613-682X 1 ,
• Koshila Kumar   ORCID: orcid.org/0000-0001-8504-1052 2 &
• Gabrielle Finn   ORCID: orcid.org/0000-0002-0419-694X 3  

BMC Medical Education volume  20 , Article number:  439 ( 2020 ) Cite this article

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An Editorial to this article was published on 04 August 2022

Qualitative research explores the ‘black box’ of how phenomena are constituted. Such research can provide rich and diverse insights about social practices and individual experiences across the continuum of undergraduate, postgraduate and continuing education, sectors and contexts. Qualitative research can yield unique data that can complement the numbers generated in quantitative research, [ 1 ] by answering “how” and “why” research questions. As you will notice in this paper, qualitative research is underpinned by specific philosophical assumptions, quality criteria and has a lexicon or a language specific to it.

A simple search of BMC Medical Education suggests that there are over 800 papers that employ qualitative methods either on their own or as part of a mixed methods study to evaluate various phenomena. This represents a considerable investment in time and effort for both researchers and reviewers. This paper is aimed at maximising this investment by helping early career researchers (ECRs) and reviewers new to the qualitative research field become familiar with quality criteria in qualitative research and how these can be applied in the qualitative manuscript writing process. Fortunately, there are numerous guidelines for both authors and for reviewers of qualitative research, including practical “how to” checklists [ 2 , 3 ]. These checklists can be valuable tools to confirm the essential elements of a qualitative study for early career researchers (ECRs). Our advice in this article is not intended to replace such “how to” guidance. Rather, the suggestions we make are intended to help ECRs increase their likelihood of getting published and reviewers to make informed decisions about the quality of qualitative research being submitted for publication in BMC Medical Education. Our advice is themed around long-established criteria for the quality of qualitative research developed by Lincoln and Guba [ 4 ]. (see Table  1 ) Each quality criterion outlined in Table 1 is further expanded in Table  2 in the form of several practical steps pertinent to the process of writing up qualitative research.

As a general starting point, the early career writer is advised to consult previously published qualitative papers in the journal to identify the genre (style) and relative emphasis of different components of the research paper. Patton [ 5 ] advises researchers to “FOCUS! FOCUS! FOCUS!” in deciding which components to include in the paper, highlighting the need to exclude side topics that add little to the narrative and reduce the cognitive load for readers and reviewers alike. Authors are also advised to do significant re-writing, rephrasing, re-ordering of initial drafts, to remove faulty grammar, and addresses stylistic and structural problems [ 6 ]. They should be mindful of “the golden thread,” that is their central argument that holds together the literature review, the theoretical and conceptual framework, the research questions, methodology, the analysis and organisation of the data and the conclusions. Getting a draft reviewed by someone outside of the research/writing team is one practical strategy to ensure the manuscript is well presented and relates to the plausibility element.

The introduction of a qualitative paper can be seen as beginning a conversation. Lingard advises that in this conversation, authors need to persuade the reader and reviewer of the strength, originality and contributions of their work [ 7 ]. In constructing a persuasive rationale, ECRs need to clearly distinguish between the qualitative research phenomenon (i.e. the broad research issue or concept under investigation) and the research context (i.e. the local setting or situation) [ 5 ]. The introduction section needs to culminate in a qualitative research question/s. It is important that ECRs are aware that qualitative research questions need to be fine-tuned from their original state to reflect gaps in the literature review, the researcher/s’ philosophical stance, the theory used, or unexpected findings [ 8 ]. This links to the elements of plausibility and consistency outlined in Table 1 .

Also, in the introduction of a qualitative paper, ECRs need to explain the multiple “lenses” through which they have considered complex social phenomena; including the underpinning research paradigm and theory. A research paradigm reveals the researcher/s’ values and assumptions about research and relates to axiology (what do you value?), ontology (what is out there to know?) epistemology (what and how can you know it?), and methodology (how do you go about acquiring that knowledge?) [ 9 ] ECRs are advised to explicitly state their research paradigm and its underpinning assumptions. For example, Ommering et al., state “We established our research within an interpretivist paradigm, emphasizing the subjective nature in understanding human experiences and creation of reality.” [ 10 ] Theory refers to a set of concepts or a conceptual framework that helps the writer to move beyond description to ‘explaining, predicting, or prescribing responses, events, situations, conditions, or relationships.’ [ 11 ] Theory can provide comprehensive understandings at multiple levels, including: the macro or grand level of how societies work, the mid-range level of how organisations operate; and the micro level of how people interact [ 12 ]. Qualitative studies can involve theory application or theory development [ 5 ]. ECRs are advised to briefly summarise their theoretical lens and identify what it means to consider the research phenomenon, process, or concept being studied with that specific lens. For example, Kumar and Greenhill explain how the lens of workplace affordances enabled their paper to draw “attention to the contextual, personal and interactional factors that impact on how clinical educators integrate their educational knowledge and skills into the practice setting, and undertake their educational role.” [ 13 ] Ensuring that the elements of theory and research paradigm are explicit and aligned, enhances plausibility, consistency and transparency of qualitative research. The use of theory can also add to the currency of research by enabling a new lens to be cast on a research phenomenon, process, or concept and reveal something previously unknown or surprising.

Moving to the methods, methodology is a general approach to studying a research topic and establishes how one will go about studying any phenomenon. In contrast, methods are specific research techniques and in qualitative research, data collection methods might include observation or interviewing, or photo elicitation methods, while data analysis methods may include content analysis, narrative analysis, or discourse analysis to mention a few [ 8 ]. ECRs will need to ensure the philosophical assumptions, methodology and methods follow from the introduction of a manuscript and the research question/s, [ 3 ] and this enhances the consistency and transparency elements. Moreover, triangulation or the combining of multiple observers, theories, methods, and data sources, is vital to overcome the limitation of singular methods, lone analysts, and single-perspective theories or models [ 8 ]. ECRs should report on not only what was triangulated but also how it was performed, thereby enhancing the elements of plausibility and consistency. For example, Touchie et al., describe using three researchers, three different focus groups, and representation of three different participant cohorts to ensure triangulation [ 14 ]. When it comes to the analysis of qualitative data, ECRs may claim they have used a specific methodological approach (e.g. interpretative phenomenological approach or a grounded theory approach) whereas the analytical steps are more congruent with a more generalist approach, such as thematic analysis [ 15 ]. ECRs are advised that such methodological approaches are founded on a number of philosophical considerations which need to inform the framing and conduct of a study, not just the analysis process. Alignment between the methodology and the methods informs the consistency, transparency and plausibility elements.

Comprehensively describing the research context in a way that is understandable to an international audience helps to illuminate the specific ‘laboratory’ for the research, and how the processes applied or insights generated in this ‘laboratory’ can be adapted or translated to other contexts. This addresses the relevancy element. To further enhance plausibility and relevance, ECRs should situate their work clearly on the evaluation–research continuum. Although not a strictly qualitative research consideration, evaluation focuses mostly on understanding how specific local practices may have resulted in specific outcomes for learners. While evaluation is vital for quality assurance and improvement, research has a broader and strategic focus and rates more highly against the currency and relevancy criteria. ECRs are more likely to undertake evaluation studies aimed at demonstrating the impact and outcomes of an educational intervention in their local setting, consistent with level one of Kirkpatrick’s criteria [ 16 ]. For example, Palmer and colleagues explain that they aimed to “develop and evaluate a continuing medical education (CME) course aimed at improving healthcare provider knowledge” [ 17 ]. To be competitive for publication, evaluation studies need to (measure and) report on at least level two and above of Kirkpatrick’s criteria. Learning how to problematise and frame the investigation of a problem arising from practice as research, provides ECRs with an opportunity to adopt a more critical and scholarly stance.

Also, in the methods, ECRs may provide detail about the study context and participants but little in the way of personal reflexive statements. Unlike quantitative research which claims that knowledge is objective and seeks to remove subjective influences, qualitative research recognises that subjectivity is inherent and that the researcher is directly involved in interpreting and constructing meanings [ 8 ]. For example, Bindels and colleagues provide a clear and concise description about their own backgrounds making their ‘lens’ explicit and enabling the reader to understand the multiple perspectives that have informed their research process [ 18 ]. Therefore, a clear description of the researcher/s position and relationship to the research phenomenon, context and participants, is vital for transparency, relevance and plausibility. We three are all experienced qualitative researchers, writers, reviewers and are associate editors for BMC Medical Education. We are situated in this research landscape as consumers, architects, and arbiters and we engage in these roles in collaboration with others. This provides a useful vantage point from which to provide commentary on key elements which can cause frustration for would-be authors and reviewers of qualitative research papers [ 19 ].

In the discussion of a qualitative paper, ECRs are encouraged to make detailed comments about the contributions of their research and whether these reinforce, extend, or challenge existing understandings based on an analysis that is theoretically or socially significant [ 20 ]. As an example, Barratt et al., found important data to inform the training of medical interns in the use of personal protective equipment during the COVID 19 pandemic [ 21 ]. ECRs are also expected to address the “so what” question which relates to the the consequence of findings for policy, practice and theory. Authors will need to explicitly outline the practical, theoretical or methodological implications of the study findings in a way that is actionable, thereby enhancing relevance and plausibility. For example, Burgess et al., presented their discussion according to four themes and outlined associated implications for individuals and institutions [ 22 ]. A balanced view of the research can be presented by ensuring there is congruence between the data and the claims made and searching the data and/or literature for evidence that disconfirms the findings. ECRs will also need to put forward the sources of uncertainty (rather than limitations) in their research and argue what these may mean for the interpretations made and how the contributions to knowledge could be adopted by others in different contexts [ 23 ]. This links to the plausibility and transparency elements.

In conclusion

Qualitative research is underpinned by specific philosophical assumptions, quality criteria and a lexicon, which ECRs and reviewers need to be mindful of as they navigate the qualitative manuscript writing and reviewing processes. We hope that the guidance provided here is helpful for ECRs in preparing submissions and for reviewers in making informed decisions and providing quality feedback.

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Writing conventions for qualitative research, sample size/sampling:.

• Integrating Qualitative Research into Systematic Reviews
• Publishing Qualitative Research
• Presenting Qualitative Research
• Qualitative & Libraries: a few gems
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Why is this information important?

• The conventions of good writing and research reporting are different for qualitative and quantitative research.
• Your article will be more likely to be published if you make sure you follow appropriate conventions in your writing.

On this page you will find the following helpful resources:

• Articles with information on what journal editors look for in qualitative research articles.
• Articles and books on the craft of collating qualitative data into a research article.

These articles provide tips on what journal editors look for when they read qualitative research papers for potential publication.  Also see Assessing Qualitative Research tab in this guide for additional information that may be helpful to authors.

Belgrave, L., D. Zablotsky and M.A. Guadagno.(2002). How do we talk to each other? Writing qualitative research for quantitative readers . Qualitative Health Research , 12(10),1427-1439.

Hunt, Brandon. (2011) Publishing Qualitative Research in Counseling Journals . Journal of Counseling and Development 89(3):296-300.

Fetters, Michael and Dawn Freshwater. (2015). Publishing a Methodological Mixed Methods Research Article. Journal of Mixed Methods Research 9(3): 203-213.

Koch, Lynn C., Tricia Niesz, and Henry McCarthy. (2014). Understanding and Reporting Qualitative Research: An Analytic Review and Recommendations for Submitting Authors. Rehabilitation Counseling Bulletin 57(3):131-143.

Morrow, Susan L. (2005) Quality and Trustworthiness in Qualitative Research in Counseling Psychology ; Journal of Counseling Psychology 52(2):250-260.

Oliver, Deborah P. (2011) "Rigor in Qualitative Research." Research on Aging 33(4): 359-360.

Sandelowski, M., & Leeman, J. (2012). Writing usable qualitative health research findings . Qual Health Res, 22(10), 1404-1413.

Schoenberg, Nancy E., Miller, Edward A., and Pruchno, Rachel. (2011) The qualitative portfolio at The Gerontologist : strong and getting stronger. Gerontologist 51(3): 281-284.

Weaver-Hightower, M. B. (2019). How to write qualitative research . [e-book]

Sidhu, Kalwant, Roger Jones, and Fiona Stevenson (2017). Publishing qualitative research in medical journals. Br J Gen Pract ; 67 (658): 229-230. DOI: 10.3399/bjgp17X690821 PMID: 28450340

• This article is based on a workshop on publishing qualitative studies held at the Society for Academic Primary Care Annual Conference, Dublin, July 2016.

Smith, Mary Lee.(1987) Publishing Qualitative Research. American Educational Research Journal 24(2): 173-183.

Tong, Allison, Sainsbury, Peter, Craig, Jonathan ; Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups , International Journal for Quality in Health Care , Volume 19, Issue 6, 1 December 2007, Pages 349–357, https://doi.org/10.1093/intqhc/mzm042 .

Tracy, Sarah. (2010) Qualitative Quality: Eight 'Big-Tent' Criteria for Excellent Qualitative Research. Qualitative Inquiry 16(10):837-51.

Because reviewers are not always familiar with qualitative methods, they may ask for explanation or justification of your methods when you submit an article. Because different disciplines,different qualitative methods, and different contexts may dictate different approaches to this issue, you may want to consult articles in your field and in target journals for publication.  Additionally, here are some articles that may be helpful in thinking about this issue. 

Bonde, Donna. (2013). Qualitative Interviews: When Enough is Enough . Research by Design.

Guest, Greg, Arwen Bunce, and Laura Johnson. (2006) How Many Interviews are Enough?: An Experiment with Data Saturation and Variability. Field Methods 18(1): 59-82.

Hennink, Monique and Bonnie N. Kaiser. (2022) Sample Sizes for Saturation in Qualitative Research: A Systematic Review of Empirical Tests . Social Science & Medicine 292:114523. doi: 10.1016/j.socscimed.2021.114523. Epub 2021 Nov 2. PMID: 34785096.

Morse, Janice M. (2015) "Data Were Saturated..." Qualitative Health Research 25(5): 587-88 . doi:10.1177/1049732315576699.

Nelson, J. (2016) "Using Conceptual Depth Criteria: Addressing the Challenge of Reaching Saturation in Qualitative Research." Qualitative Research, December. doi:10.1177/1468794116679873.

Patton, Michael Quinn. (2015) "Chapter 5: Designing Qualitative Studies, Module 30 Purposeful Sampling and Case Selection. In Qualitative Research & Evaluation Methods: Integrating Theory and Practice, Fourth edition, pp. 264-72. Thousand Oaks, California: SAGE Publications, Inc. ISBN: 978-1-4129-7212-3

Small, Mario Luis. (2009) 'How Many Cases Do I Need?': On Science and the Logic of Case-Based Selection in Field-Based Research. Ethnography 10(1): 538.

Search the UNC-CH catalog for books about qualitative writing . Selected general books from the catalog are listed below. If you are a researcher at another institution, ask your librarian for assistance locating similar books in your institution's catalog or ordering them via InterLibrary Loan.  

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• Morse, J. M. (1997). " Perfectly healthy, but dead": the myth of inter-rater reliability. DOI:10.1177/104973239700700401 Editorial
• Silberzahn, R., Uhlmann, E. L., Martin, D. P., Anselmi, P., Aust, F., Awtrey, E., ... & Carlsson, R. (2018). Many analysts, one data set: Making transparent how variations in analytic choices affect results. Advances in Methods and Practices in Psychologi
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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on September 5, 2024.

Qualitative research involves collecting and analyzing 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 analyzing 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, history, etc.

• 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 organization?
• 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, other interesting articles, 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 emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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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 analyzing 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 organize 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 categorize 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 analyzing qualitative data. Although these methods share similar processes, they emphasize 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.

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Researchers must consider practical and theoretical limitations in analyzing 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 analyzing 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 generalizability

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

• Labor-intensive

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

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.

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 organization 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 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 .

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Qualitative Research Writing

• First Online: 11 November 2020

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• Seyyed-Abdolhamid Mirhosseini 2  

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This chapter focuses on the presentation of qualitative studies in writing. Although not part of the technicalities of the process of inquiry itself, the quality of reporting the process and outcomes of research plays a crucial role in completing the research endeavor. Apart from sharing the research findings, research writing can serve two other purposes. The very attempt at preparing an account of a study to be read by outsiders can help researchers distance themselves from the details of the project and notice the possible shortcomings. Moreover, a transparent presentation of the details of the research process and illustrating the findings in qualitative writing can facilitate corroboration and contribute to the overall process of taking care of the quality of qualitative research. The chapter also briefly addresses publishing qualitative language education research and introduces some related journals.

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Mirhosseini, SA. (2020). Qualitative Research Writing. In: Doing Qualitative Research in Language Education. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-56492-6_10

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The SRQR guidelines for writing qualitative research articles

Use SRQR to confidently describe qualitative research so that others can find, understand, and use your work.

SRQR is endorsed by hundreds of journals and was developed by experienced researchers using a thorough process.

Full Title: Standards for Reporting Qualitative Research

Authors: Bridget O’Brien, Ilene Harris, Thomas Beckman, Darcy Reed, David Cook

DOI: 10.1234/equator/1010101    Version: 1.1

Translations: 🇫🇷 French

Recommendations to help describe your work clearly

Your research will be used by people from different disciplines and backgrounds for decades to come. Reporting guidelines list the information you should describe so that everyone can understand, replicate, and synthesise your work.

Reporting guidelines make writing research easier, and transparent research leads to better patient outcomes.

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How to use this guideline

• Read the full guidance below.
• Write your manuscript. Use a template if you like.
• Cite this guideline in your manuscript.
• Complete a checklist and include it with your journal submission.

Reporting guidelines do not prescribe order nor structure. You should include items in the article body whenever possible but some items can be reported in tables, figures, or supplementary materials if necessary (see FAQs ).

Additional resources:

Approx. 16 min read

Is this the right guideline for you?

Use this guideline for writing qualitative research articles . You can use it when describing all kinds of qualitative approaches, methods, and designs.

You can also use this guideline for:

• writing proposals or protocols (use the items within the Introduction and Method sections).
• reviewing the reporting of an article, but not for appraising its quality.

Do not use this guidance for:

• writing a qualitative evidence synthesis, use ENTREQ instead.
• appraising the quality of qualitative research, use an appraisal tool like CASP-Qual instead.

Related reporting guidelines:

• JARS Qual for writing qualitative, psychology manuscripts
• ENTREQ for writing qualitative evidence syntheses
• For writing studies involving interviews or focus groups, you can use this guideline or COREQ .

For appraising research consider:

Title & Abstract

Describe the nature and topic of the study.

Identify the study as qualitative or indicate the approach or data collection methods .

Why readers need this information

Training and resources.

This allows readers to quickly identify the type of study. Your title will be indexed by search tools so descriptive words will make it easier for others to discover .

Residents learning from a narrative experience with dying patients: a qualitative study.

Medical students’ perceptions of the factors influencing their academic performance: an exploratory interview study with high-achieving and re-sitting medical students.

Undergraduate rural medical education program development: focus group consultation with the NRHA Rural Medical Educators Group.

See this article for advice on writing titles that are interesting and descriptive.

The EQUATOR Network provides training for writing effective manuscript titles as part of their publication school .

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2. Abstract

Summarise key elements of the study including:

background about the problem or phenomenon of interest

description of the study purpose or research question

methods, including the approach or perspective (e.g., general inductive, grounded theory), context (setting, time period), sample (number and key characteristics of participants, events, documents), data collection strategies (e g., observation, interview, focus group) and data analysis techniques

description of main findings (e.g., themes or inferences) related to the study purpose and/or research question

study implications

Information presented in the abstract should be consistent with the information presented in the full text.

Use the format of your intended journal (see note ).

Use the format of your intended journal

A reader should be able to read the abstract independent of the manuscript and get a sense of the background, purpose, methods, main results and implications that will be described in greater detail in the manuscript.

Your abstract will be indexed by search tools so descriptive words will make it easier for others to discover .

Purpose : Although academic centers rely on assessments from medical trainees regarding the effectiveness of their faculty as teachers, little is known about how trainees conceptualize and approach their role as assessors of their clinical supervisors Method : In 2010, using a constructivist grounded theory approach , five focus group interviews were conducted with 19 residents from an internal medicine residency program. A constant comparative analysis of emergent themes was conducted. Results : Residents viewed clinical teaching assessment (CTA) as a time-consuming task with little reward. They reported struggling throughout the academic year to meet their CTA obligations and described several shortcut strategies they used to reduce their burden. Rather than conceptualizing their assessments as a conduit for both formative and summative feedback, residents perceived CTA as useful for the surveillance of clinical supervisors at the extremes of the spectrum of teaching effectiveness. They put the most effort, including the crafting of written comments, into the CTAs of these outliers. Trainees desired greater transparency in the CTA process and were sceptical regarding the anonymity and perceived validity of their faculty appraisals. Conclusions : Individual and system-based factors conspire to influence postgraduate medical trainees’ motivation for generating high-quality appraisals of clinical teaching. Academic centers need to address these factors if they want to maximize the usefulness of these assessments.

Some journals require abstracts to have subheadings, others don’t. In some cases the journal’s structured abstract format aligns more with positivist paradigms and quantitative approaches than with qualitative traditions, so translation may be necessary. For example, what might be labelled “Findings” in many qualitative research traditions could be reported as “Results” in the abstract. Similarly, “Design” might be labelled as “ Approach ” or “Methodology” for a qualitative study.

The EQUATOR Network provides training for writing effective manuscript abstracts as part of their publication school .

See this article from the London School of Economics for general abstract writing tips.

Introduction

3. problem formulation.

Describe the theoretical and/or practical issues or concerns that make the study necessary, including:

an overview of what is known about the problem

gaps in current knowledge (the problem statement)

the scope of the research problem or phenomena addressed in the study (what will and will not be included)

theoretical and/or empirical work directly relevant to the problem or phenomena studied

the need for a qualitative approach. 1

This information provides context for the research question or study purpose and situates the study in relation to other work in the field.

Regulatory focus theory may therefore offer insight into the variability in responses to feedback, but how well do these experimental findings translate to real clinical situations in which the reality of responsiveness to feedback seems frustratingly complex? …. In order to better elaborate a theory to account for this variability in learner response to feedback, the present study was undertaken. We aimed, in this study, to determine how readily clinical learning events could be classified as activating a promotion or a prevention focus, and to explore, through a careful analysis of doctors’ descriptions of their feedback experiences, the predictive value of regulatory focus theory in the context of real clinical learning situations.

4. Purpose or research question

Include a statement of study intent. This can be framed as one or more research questions, purposes, goals, or objectives. 2

By clearly stating the purpose of the study, authors set readers’ expectations for the methods, findings and discussion sections of the manuscript.

The purposes of this study were to investigate how medical students recognize, respond to and utilise feedback, and to determine whether there are maturational differences in understandings of the role of feedback across academic years in medical school.

See this article for advice on writing qualitative research questions.

5. Qualitative approach and research paradigm

Describe your qualitative approach , your guiding theory (if appropriate), and identify the research paradigm . 3

Explain why the selected approach is appropriate for the research question.

Provide references to theories or traditions that guide the use of the approach as needed.

If you don’t know what your approach or paradigm was, or you don’t think you had one, it’s OK to reflect on this after collecting data and you should still report it. Read this list to see what best describes your work.

Identifying the research paradigm helps readers understand whether the researcher assumes that there is a single, objective reality (positivist or post-positivist) and has thus designed the study to describe this reality or whether the researcher assumes multiple, subjective realities and designed the study to describe these multiple realities, with no attempt to merge or reconcile these realities (constructivist/interpretivist). The paradigm has implications for the study design, approach , methods, and techniques to ensure rigour and trustworthiness.

Since the research paradigm does not necessarily dictate particular approaches or methods, the approach should also be clearly defined. Stating the approach provides readers the opportunity to evaluate the fidelity of the research approach to the research question(s) and consider the rationale for modifications and deviations from the selected approach . Qualitative research also includes an array of methods that can be used across paradigms and approaches. (See also Item 10).

The study was performed from a constructivist point of view using an interpretative phenomenological epistemology. Based on the notion that social phenomena are constructed by the communal making of meaning about the underlying phenomena, we aimed to construct insightful accounts of lead consultants’ approaches to educational change, rather than to identify the ‘true’ nature of these approaches. Because the management of change by lead consultants is an under-researched area, we conducted an exploratory qualitative study…

Given the relative dearth of explanatory theories about factors affecting medical students’ emotional reactions, we chose to develop one by applying methods associated with grounded theory , specifically constant comparative analysis, to qualitative data obtained from learning logs and interviews. Our approach was constructivist, deliberately using researchers’ own experiences and acquired knowledge to enhance theoretical sensitivity and enrich theory development.

6. Researcher characteristics and reflexivity

Describe how roles and identities of research team members influence choice of research approach , data collection, and data analysis. 4

Describe the perspectives, assumptions, prior knowledge, preliminary hypotheses, and/or motives (the “stance”) of the members of the research team.

Describe the researchers’ relationships to participants in the study and what decisions were made in light of these relationships. 5

If your research was observational (e.g., ethnography), describe the role of the researcher along a spectrum from passive observer (no involvement in the activity studied) to participant-observer (ranging from some limited involvement in the activity to full involvement).

There is no expectation that the study could be precisely replicated; these characteristics and perspectives of the researcher should not be mentioned in the limitation section. (See also Item 14: Data Analysis )

In positivist and post-positivist paradigms, personal characteristics and perspectives of researchers might be viewed as biases that limit the credibility of study findings, while in constructivist or interpretivist paradigms the characteristics and perspectives of the researchers are important contextual factors that are an accepted part of the study design, data collection, and data analysis. These characteristics and perspectives may explain how the researcher(s) obtained access to the site or participants included in the study or may add valuable insight during data analysis.

Reflexivity was maintained by the research team through the analysis and writing by recording, discussing and challenging established assumptions. In addition both EH and SV kept reflexive diaries.

The first author conducted all interviews and discussion groups. Her own medical undergraduate training took place between 1995 and 2000. She was not known to the participants of this research prior to undertaking the study and deliberately did not undertake any clinical or teaching activities locally alongside this research. Whilst it was useful to ‘know’ (from her own background) what the students were talking about medically (and in terms of detecting items of significance), as a researcher she made conscious efforts not to accept potentially common assumptions at face value.

Describe the setting/site(s) in which the study was conducted, the reason(s) why the setting/site(s) was selected, and the salient cultural, political, historical, economic and/or other external factors that influence the study.

Additional context may be reported with findings (i.e., the Results section) to add evidence for interpretations and to enhance discussion of transferability.

This helps readers interpret the meaning and significance of the study findings by situating them in social, cultural, temporal and other relevant contexts.

We conducted the study among hospital-based clinical teachers of students in years 4 to 6 of a six-year undergraduate medical program at Maastricht University Medical School. Years 4 to 6 are devoted to clerkships in the academic hospital and affiliated regional hospitals. Rotations differ in duration depending on the type of rotation and the discipline, and the sequence of rotations differs among students. During rotations, students spend time in the wards, the outpatient clinics, and the accident and emergency department. Clerkships in years 4 and 5 last between 4 and 10 weeks (“regular clerkship”), whereas students in year 6 undertake an 18-week “senior clerkship” in a discipline of their choice.

8. Sampling strategy

Describe how and why research participants, sites, documents/artifacts, and/or events were selected for inclusion in (and, if appropriate, exclusion from) the study, along with a justification for this strategy.

Describe the sampling strategy rather than simply labeling it (e.g., “purposive” or “snowball”), since such labels do not have a universally accepted definition and, more importantly, procedures tend to be study- specific.

Describe how you established the final sample size:

If you used a flexible sampling strategy , then explain the criteria used to decide when no further sampling was necessary.

If data collection ended once saturation or sufficiency had been reached, then describe the specific criteria used to define saturation or sufficiency.

Describe procedures used to recruit participants, including:

who was involved in recruitment

what their relationship was to participants

how and when recruitment occurred

why these procedures were selected. (See also Item 6: Researcher characteristics and reflexivity )

This information helps readers understand the source of data / findings so they can consider the boundaries of the study and the relevance to their own context. It also gives readers insight into the researchers’ decisions, which can be important for critical appraisal.

As students’ perceptions were previously shown to be related to gender, age, prior experience and place of attachment,[REF] we purposely selected respondents with different backgrounds. This sampling strategy led to the diversity of gender, age, prior patient experience and place of attachment shown in Table 1.

Purposive sampling was directed towards achieving maximum variation in age and specialty, using a snowball approach (‘a non-probabilistic form of sampling in which persons initially chosen for the sample are used as informants to locate other persons having necessary characteristics making them eligible for the sample’).[REF ]

Potential participants were all medical students in Years 1 and 2 at the University of Toronto in 2004. Following research ethics board approval, recruitment was conducted via e-mail to class listservs. Participant responses were sent directly to the research assistant, who was unknown to participants, so that the principal investigators did not know who did or did not participate. This process was engaged to protect participants’ anonymity and to avoid any impression of coercion because the lead researcher (SG) was involved in the administration of the undergraduate curriculum at the time. Sample size was estimated to be sufficient based on the principle of theoretical saturation [REF] and our previous experience with this methodology (i.e., with a relatively homogeneous population, we expected to reach saturation with approximately 15 interviews per group). There were no exclusion criteria and we accepted the first 15 students from each class who volunteered.

9. Ethical issues pertaining to human subjects

Report approval for the study from an appropriate institutional review board for research associated with human subjects.

If you did not receive ethical approval, describe why.

Describe procedures used to protect participants, including:

data collection (e.g., recruitment and informed consent)

analysis (e.g., data security and integrity)

and reporting of findings (e.g., anonymization of excerpts).

If you provided compensation or offered incentives to facilitate participation, describe this too.

Journals will require an ethical approval statement.

Qualitative research often involves interaction between researchers and research participants. Correspondingly, researchers should ensure that participants are fully aware of their participation in a research study, the risks and benefits associated with the study, the steps and precautions the researchers will take to minimize risks, such as loss of privacy and confidentiality, and how the researchers plan to use the data.

Ethical approval was granted by the University of Otago and student participants were invited to attend each focus group discussion by the university representatives of New Zealand Medical Students Association (NZMSA). Usually, a key concern when collecting data from students is that students may feel vulnerable when sharing their experiences with academic staff during a focus group discussion. However, this potential harm was removed as each group discussion was facilitated by a fellow student, the discussions were transcribed by a professional transcribing service, and only the primary researchers [Names] had access to the raw data.

10. Data collection methods

Describe data collection methods and design in detail, and justify them in relation to the research question(s), paradigm, approach , and other methods. 6

If data collection and analysis was iterative:

describe the iterative process

if changes occurred during the research process, describe how and why study procedures changed in response to evolving study findings.

Identify the study period.

Describe important characteristics of the individuals conducting interviews, observations or focus groups, and methods used to train these individuals.

The study period helps readers place the study in temporal context and identify factors not mentioned by the authors that might affect findings, interpretation, and implications. (See Item 8 for ending data collection.)

Describing researcher characteristics clarifies the relationship between the individuals involved in data collection and the participants in the research and also explains what efforts were made to ensure consistency in the data collection process (See Items 6 and 15.)

Further, it was decided that group interviews, also known as focus group discussions would be the best means of data collection. This is a method of data collection that enables group members to feed off each other’s ideas and an effective moderator will maintain group focus whilst at the same time permitting flexibility in the direction those aspects of the discussion might take. [REF]

Adjustments to the interview protocol were made according to early experience and information participants had provided (i.e. redundant questions were eliminated; questions were reworded to improve flow and clarity; additional probes were included).

Faculty staff were then interviewed individually by a trained study investigator in a 15-minute, semi-structured interview. This sequence was repeated with other video encounters. Table 2 presents examples of interview questions. Each faculty member was interviewed by at least three interviewers over their various interviews. Interviewers were chosen based on their experience in interviewing. All were trained during a half-day meeting to interpret and deliver the interview guide in the same manner in order to elicit information of a consistent type.

11. Data collection instruments and technologies

Describe all data collection instruments , including their development, and if/how they changed over the course of the study . Cite relevant literatures, theories or conceptual frameworks as appropriate. Consider sharing the data collection instrument(s) or a detailed description of them in the article body, supplementary material, or published elsewhere .

Describe the use of equipment for audio or video recording, reproduction of paper documents or computer files, or other processes in data collection.

Describing instruments and equipment helps readers understand the full context in which data collection occurred and how this context might have affected data collection (e.g., the influence of recording devices on participants’ behaviors; the nature of inferences drawn from live vs. recorded events).

To facilitate the discussion and to maintain consistency over different sets of discussions, key trigger questions were devised prior to the discussion. The opening trigger question was: ‘Thinking back to some of your best clinical learning placements in 4th and 5th year. What was it about those clinical placements that provided good opportunities for learning?’

Interviews included discussion of the expectations, processes and consequences of AEE [authentic early experiences]. The interview schedule was derived following identification of questions that could not be fully answered in a systematic review of previous empirical or theoretical literature. It comprised a sequence of topic areas including experiences in action, and areas of frustration in Medical Education such as the learning of content knowledge, achieving functional knowledge, and transfer of knowledge.[REF]… Interested readers can request a copy of the schedules from the corresponding author. Interviews lasted between 20 and 90 min. and discussion groups between 60 and 90 min. All interviews and discussion groups were conducted in private rooms at the participant’s workplace—the medical school for students and faculty, and individual places of work for workplace supervisors (except for one who chose to be interviewed at the medical school). All data were audio-recorded, and transcribed verbatim.

12. Units of study

Describe the number of participants, documents, or events included in the study (the units of study).

Describe characteristics of the participants, documents or events that are relevant to the study purpose and research question(s). 7

Include the dates or timeframe for participation.

If the actual sample differs from the target sample, describe:

the difference,

why these differences may have occurred,

how this might affect the findings.

If the degree of participation varied among individuals, describe:

the different levels of participation,

the reasons for these differences (i.e., the researchers’ choice or the participants’ preferences),

and how these different levels of participation were taken into account in the analysis.

This information could appear in the Methods section as part of the description of the sample, or at the beginning of the Results section to provide context for the findings presented.

How does this item differ to Sampling (Item 8)?

The sampling item (Item 8) describes the target or ideal participants, documents, or events selected for the study. By contrast, this item focuses on description of the actual participants, documents or events included in the study.

This helps readers know whose experiences and perspective are and are not included.

Of the 70 Mindful Communication program participants, 46 met the eligibility requirements to participate in the in-depth interviews. We randomly chose and then contacted 22 participants, of whom 20 agreed to be interviewed within six months of completing the program: 15 in person and 5 by telephone. Two declined for lack of time. On reaching saturation after 20 interviews, no further attempts to contact the remaining 24 participants were made.

There were 31 nursing handovers covering 137 patients, and 21 resident handovers covering 101 patients included in this study.

13. Data processing

Describe the ways in which data are prepared for analysis and managed throughout the analysis process. These activities might include transcription, coding, data entry, and organization of data. (See footnote for audio or visual recordings 8 ).

Describe the processes used to organize, compile, and categorize data (e.g., field notes, transcripts, documents, photographs, artifacts) for analysis.

If you used transcripts, describe procedures used to check accuracy.

Describe procedures used to maintain data security and protect the privacy of participants, as specified in the human subjects protocols (see footnote on anonymisation 9 as an example).

This information helps readers know what decisions the researchers made and why so the reader can 1) consider the relevance to their context and the resonance with their own experience or observations (or lack of resonance and why that might be) and 2) evaluate or critically appraise the manuscript.

Interviews were anonymised and each participant was given a code number.

The interviewers and another member of the research team (H.B.) reviewed transcripts for accuracy.

We collected data throughout the admission process through direct observation, audio- recording, and chart extraction. We audio-recorded, transcribed, and anonymized both the overnight and morning case review discussions. We also observed the morning case review discussions in person and collected field notes. For each case review discussion, we copied the admission notes from the patient’s record and de-identified all data.

14. Data analysis

Describe your analytic process as transparently as possible. 10

If you used an approach that has a well-defined process for data analysis (e.g., grounded theory, discourse analysis, phenomenography):

cite the guiding literature

describe your processes in sufficient detail so readers can judge the extent to which your processes align with the guiding approach.

If you modified or deviated from the guiding approach, explain and justify these modifications.

Specify the unit of analysis. 11

Explain the rationale underlying different decisions made throughout the data analysis process to provide as much transparency as possible. 12

If observations that contrast or deviate from identified concepts or themes were important to your analysis, describe how these discrepancies were handled during the analysis.

If you drew upon a theoretical perspective or framework during analysis, describe theoretical or other influences on your analysis scheme or categories if they exist. If you identified a theoretical perspective or framework early in the conception of the study or after reviewing some or all of their data, consider referring to these as “sensitizing concepts” to acknowledge that the approach is inductive, but with influence from relevant theory, models, or organizational schemes. Alternatively, explain that themes were developed from the data with no external influences.

Describe which members of the research team are involved in data analysis and what perspective(s) they bring to the analysis.

If software was used to assist with data analysis 13 , describe how it was used. Simply stating that software was used is insufficient.

Techniques used for data analysis will depend on the paradigm, approach , and/or data collection methods selected by the researchers. Correspondingly, authors should be as transparent as possible about the analytic process so that readers can follow the logic of inquiry from the research question(s) to the analysis and findings.

…we brought sensitizing concepts to the analysis while we conducted an open, inductive analysis.[REF]In this case the sensitizing concepts arose, a priori to analysis, from a framework derived from the literature [REF] (as described above), in which participants’ motivations to act are based on principles of professionalism, internal affect, or potential implications of their actions.[REF]

Through an iterative process of listening, discussing, and relistening, the team identified and consensually validated emerging themes[REF] and appended segments of dialogue supporting the proposed themes. Recruitment stopped when saturation was reached (no new themes were identified). The team systematically reviewed the themes and sorted them into content domains. The team used an analytic matrix to identify patterns and connections amongst the domains. Two of us not involved in the qualitative coding process (R.E., M.K.) audited the analytic matrix, choice of quotes, and thematic analysis.

The analysis started after the first interview. All data were analyzed with the aid of the audio- coding facility of the NVivo 8: QSR International Pty Ltd, Doncaster, Vic, Australia programme. First, [name] and [name] coded independently from one another, making sure to stay semantically close to the participants’ wording. Then we discussed these open codes and defined axial codes.[REF] New insights about the impact of CST were written down in memos.

Videotapes were analysed using immersion/crystallisation methods of qualitative data analysis.[REF] With no pre-existing framework developed in advance for analysis, an inductive approach was used to discover patterns of NVB in the data. A team of six researchers met weekly for 18 months to view videos together. Using a consensus-building approach based on a combination of field notes, ‘opportunistic’ interviews with the participants, and repeated viewing of the same material, sometimes many months apart, we eventually achieved consensus on verbal, non-verbal, and physical themes and patterns observed in the data. Finally, as a test of ‘goodness-of-fit,’ we carefully reviewed the videotapes for any ‘deviant’ cases that did not fit the categories we had developed.

All transcripts were coded thematically by four of the five authors, who met regularly to identify areas of convergence until full agreement was reached. One of the interviewers (P.M.) maintained an audit trail to track the team’s developing thinking. A process of dialectical empiricism[REF] was used to categorise the emergent themes into more abstract concepts…

15. Techniques to enhance trustworthiness

Describe methods used to ensure trustworthiness and credibility throughout the data collection and analysis process. (See footnote on commonly used techniques 14 ).

Explain your choice of techniques and why these are appropriate for the particular study.

Training and resources

Member checking

Member checks [REF] with an external TBL expert (R.L.) supported the validity of these analyses.

Triangulation of data types and data sources

The interview data were triangulated with the data of 11 student and supervisor focus groups of a previous study, and more specifically, with those data that concern in particular the influence of CST [Communication Skills Training] on the development of patient-centredness…. Triangulation with the focus group data allowed us to broaden the in-depth information from the interviews in the analysis and to ‘share and compare’ this with information from students and doctors with varying levels of CST (no, limited, full programme) and from two universities (Universities of Antwerp and Ghent). Moreover, this enabled us to better explore the evolution over time, given that the focus groups included participants at different stages of their study: before clerkships (year 4, undergraduate), during clerkships (year 6, undergraduate), after clerkships (year 7, undergraduate) and postgraduate (general practice trainees, and supervising specialists and GPs; Table 1).

Finally, as a test of ‘goodness-of-fit’, we carefully reviewed the videotapes for any ‘deviant’ cases that did not fit the categories we had developed.

Triangulation of Researchers + Audit trail

To ensure rigor and increase authenticity in our methodology, we used two kinds of triangulation—investigator triangulation and data triangulation.[REF] We sought analytical rigor using an audit trail and multiple coders; our coding team included an experienced clinician (M.G.) as well as a nonclinician with expertise in medical communication and team dynamics (L.L.).

See Lincoln and Guba’s Evaluative Criteria for trustworthiness.

16. Synthesis and interpretation

Describe the main analytic findings . 15

In most cases, report a synthesis of the data along with specific quotes, examples, or illustrations derived from the data.

Consider describing frequency, variety, representativeness, counter-examples, concrete details, contextualization, conditions, and qualifications related to the findings.

Frequency counts play a limited role in qualitative research, and need not be reported unless they play a meaningful role in interpretation of the data.

If your findings include integration with prior literature or theory and/or the development of a theory, model or meta-narrative, consider using tables and figures to communicate these findings.

Items 16 and 18 can be reported in Results or Discussion sections. 16

We identified four patterns of NVB (non-verbal behavior) that relate to handover quality and have dubbed them: (1) joint focus of attention; (2) ‘the poker hand’; (3) parallel play; and (4) kerbside consultation. Each pattern constitutes a ‘transfix,’ or systematic way of participating non-verbally in the care transfer process. And, although there are variations in each pattern, we have been able to code virtually every handover we have observed in nursing, medicine and surgery into one of these four categories.

Because our participants came from similar educational backgrounds, had studied medicine as their tertiary course, were embedded in the culture of medicine, and were associated in meaningful ways with a single medical school, we approached their transcripts with the assumption that they belonged to a loosely formed discourse community. Although their graduation dates ranged over a period of 50 years and their collective sphere of practice included 10 different specialty areas, there were many similarities in their experiences of enculturation during and after medical school.

Their three major (often overlapping) areas of concern were epistemic (acquiring knowledge and skill), interpersonal (relating to patients, families, colleagues and administrators) and personal (achieving work–life balance). In each of these areas, medical enculturation was achieved by two overlapping processes, ‘absorption’ and ‘assimilation’, each of which may have distinct implications for postgraduate medical education.

17. Links to empirical data

Provide evidence (e.g., quotes, field notes, text excerpts, photographs) to substantiate the more general and abstract concepts or inferences they present as findings. 17

You could report this evidence in a table or figure, incorporated into a narrative description of findings, as a stand-alone narrative, or in text blocks embedded in the manuscript text. If you are constrained by word limits or media limitations (e.g.. video), consider sharing data via an appendix, supplemental material, or web-based repository.

See Frankel et al. for an excellent example of how to use photographs (or snapshots from video) to illustrate and provide supporting evidence for patterns of behavior identified in the analysis. http://qualitysafety.bmj.com/content/21/Suppl_1/i121 .

We identified five interruption types: (1) probing for further data, (2) prompting for expected sequence, (3) teaching around the case, (4) thinking out loud, and (5) providing direction (see Table 1). Several interruption types served both goals of the case review discussions—teaching and patient care. For example, when thinking out loud, supervisors reasoned through problems and taught the team: “So that’s the big question, did she have a mechanical fall, or did she have a medicine-related fall?” (Case 2). Supervisors prompted for expected sequence, preventing presenters from skipping over information while simultaneously allowing the supervisor to instruct the team on presentation style: “So now you can tell me what the rest of his test results are because I haven’t heard those” (Case 16).

18. Integration with prior work, implications, transferability, and contribution(s) to the field

Describe how the findings and conclusions connect to, support, elaborate on, or challenge previous findings, experiences, theory, or a guiding paradigm or approach . 18

Describe how the findings contribute to or advance the field.

Describe any implications of the work, such transferability or generalizability.

The short summary reminds readers of the main findings and may help them assess whether the subsequent interpretation and implications formulated by the authors are supported by the findings.

This study contributes to the understanding and discussion of the complexity of involving patients in healthcare education. It shows that integrating patient-led teaching into initiatives that are partly faculty-led influences the way in which students perceive learning from and with PIs. What is not known, however, is whether perceptions are also affected by type of health profession and the students’ different orientation towards logics of care and science, and issues of authority and power relations.

For complete examples of Discussions, see:

Henriksen & Ringsted, 2013

Westerman et al., 2013 .

19. Limitations

Describe problems or gaps in their efforts to ensure trustworthiness and the potential implications. 19

Describe how the chosen paradigm, approach, and methods will influence the situations to which the findings may reasonably apply. 20 (See also Item 18 .)

Describe how specific decisions or events in the conduct of the study strengthen or weaken the rigor of the findings.

All research has limitations. Discussing them will help readers consider the relevance to their context and the resonance with their own experience or observations (or lack of resonance and why that might be). If you don’t address limitations, editors and peer reviewers may ask you about them which will delay publication.

The study has several limitations. One is that the focus group interview method reveals students’ perceptions rather than their actual behaviors. Observations of the patient-led teaching encounter may have illuminated an understanding of the relationship between patient instructors and medical students. Another limitation is that the PI-led teaching is optional rather than mandatory, which may have influenced students’ attitudes in a positive direction. Moreover, students who are eager to take on extra-curricular activities may not be representative of the whole population. That only 23 out of 39 students signed up for this study might also have influenced results if the missing group of students represented other perceptions than those present in the focus groups. However the received data from the focus groups were rich in information and diverse perceptions were present. Another limitation is the overrepresentation of women over men in our sample. Even though women are also overrepresented in medical school this might potentially have influenced results, but gender differences in perceptions were nevertheless not identified in the data.

20. Conflicts of interest

Describe any real or potential conflicts of interest that might have influenced or could appear to have influenced the research.

how these conflicts were managed in the conduct of the study,

the potential impact on study findings and/or conclusions.

Some aspects may be mentioned as part of reflexivity (see Item 6 ).

“Many factors, including professional and personal relationships and activities, can influence the design, conduct, and reporting of the clinical science that informs health care decision. The potential for conflict of interest exists when these relationships and activities may bias judgment (1). Many stakeholders— editors, peer reviewers, clinicians, educators, policymakers, patients, and the public—rely on the disclosure of authors’ relationships and activities to inform their assessments. Trust in the transparency, consistency, and completeness of these disclosures is essential.” - ICMJE

21. Funding

Describe any sources of funding and other support for the study.

Describe the role of funders in data collection, data analysis, and reporting if applicable.

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How to cite

For attribution, please cite this guideline as:

You can use your reference manager to save citation information for this webpage, or copy the BibTeX below .

Who made this guideline?

Bridget O’Brien, PhD has been a faculty member in the Department of Medicine, Division of General Internal Medicine, since 2008. She is a professor of medicine and an education scientist in the Office of Medical Education’s Center for Faculty Educators. As co-director of the Teaching Scholars Program and the UCSF-University of Utrecht Health Professions Education doctoral program she teaches and mentors faculty and learners interested in education research and scholarship. At the San Francisco VA, she directs the Advanced Fellowship in Health Professions Education Evaluation and Research. In 2015 she was selected as one of five national Macy Faculty Scholars supported by the Josiah Macy Jr. Foundation and in 2021 she was selected as a KIPRIME Fellow at the Karolinska Instituet. She is a deputy editor for the journal Academic Medicine.

Dr. Ilene Harris, deceased, was professor and head, Department of Medical Education, University of Illinois at Chicago College of Medicine, Chicago, Illinois.

Dr. Thomas Beckman is professor of medicine and medical education, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Dr. Darcy Reed is associate professor of medicine and medical education, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Dr. David Cook is associate director, Mayo Clinic Online Learning, research chair, Mayo Multidisciplinary Simulation Center, and professor of medicine and medical education, Mayo Clinic College of Medicine, Rochester, Minnesota.

How was this guideline made?

The developers synthesised 40 sets of recommendations previously proposed by experts in qualitative methods. You can read about their development process here .

Does SRQR prescribe structure?

No. This reporting guideline does not prescribe a rigid format or standardized content. Consider each item and prioritize elements that are most relevant to your study, findings, context, and readers.

You may prefer to report an item in a different order, section, or in a table or figure. If you feel confident that an item is less important to your study, you could report it in an appendix or supplement. If you think an item is not applicable, state why. You don’t need to write your article in the order the items are presented.

What to do if asked to remove guideline related content

If a colleague or reviewer asks you to remove content that is related to this guideline, you can direct them to this guideline and the explanation for why that item is important. If they insist, consider moving the item to a supplement, table or figure.

Where can I get general writing training?

The EQUATOR Network provides in-person training for writing research articles .

AuthorAID have resources , an online course , and mentoring to help authors.

Research paradigm

The set of beliefs and assumptions that guide the research process. These commonly include positivist, post-positivist, constructivist or interpretivist, and critical theory. Qualitative research generally draws from a post-positivist or constructivist/interpretivist paradigm.”

Instruments

Sampling strategy.

Several sampling strategies are commonly used in qualitative research, although most fall under the umbrella of purposeful (or purposive ) sampling.

Purposeful sampling means that participants, documents, or events are selected for their relevance to the research question, based on guiding theory or experiences and assumptions of the researchers. Over the course of the research process, researchers may determine that additional or different participants, documents, or events should be included to address the research question.

Other sampling techniques, such as theoretical sampling (seeking examples of theoretical constructs), snowball sampling (using study participants to identify additional participants who meet study criteria), and convenience sampling (including any volunteers with no or minimal criteria for inclusion) may be appropriate depending on the question and approach, so long as the authors provide explanation and justification.

Data collection methods

Study period, ethnography.

The scientific description of peoples and cultures with their customs, habits, and mutual differences.

Grounded theory

A method consisting of a set of systematic, but flexible, guidelines for conducting inductive qualitative inquiry aimed toward theory construction. This method focuses squarely on the analytic phases of research, although both data collection and analysis inform and shape each other and are conducted in tandem.

Degree of participation

For example, if some participants were observed and interviewed and others only interviewed, or if some participants completed multiple interviews and others completed a single interview, these variations should be explained.

Unit of analysis

In qualitative research, the unit of analysis is not necessarily the same as the unit of sampling (e.g., individual participants or events). Instead, some approaches use specific events as the unit of analysis, such as mentions of a particular topic or experience, or observations of a particular behavior or phenomenon, while others use groups rather than individual group participants. This specification has implications for how the data are organized and analyzed as well as the inferences drawn from the data.

Reflexivity

Reflexivity refers to intentional, systematic consideration of the potential or actual effects of the researcher(s) on all aspects of the study process.

Transferability

The transferability of a research finding is the extent to which it can be applied in other contexts and studies. It is thus equivalent to or a replacement for the terms generalizability and external validity.

Generalizability

The appropriate scope for generalization of the findings beyond the study (e.g., to other settings, populations, time periods, circumstances)

Analytic findings

Analytic findings may include interpretations, inferences, narratives, themes, and models.

Frequency counts

The frequency of specific themes or codes.

Justifications for a qualitative approach include to elucidate poorly defined or previously unexplored constructs, to generate theories or to develop causal explanations connecting processes and outcomes, to understand phenomena as they naturally occur and the role of context, to explore problems involving high complexity, to gain insight into participants’ perspectives when such insight is lacking) ↩︎

Qualitative studies often explore “how” and “why” questions related to a social or human problems or phenomenon, and they are designed to enhance readers’ understanding of a problem or phenomenon. ↩︎

Qualitative research includes an array of approaches and methodologies, both general (e.g., qualitative content analysis, general inductive approach) and specific (e.g., ethnography, grounded theory, phenomenography). ↩︎

Relevant personal characteristics might include cultural background, occupation, experience, training, position/ power dynamics, gender, race/ethnicity, and sponsoring institution. ↩︎

For example, were any members of the research team part of the sample of potential participants in the study? Do any members of the team teach, supervise, or have any authority over participants in the study? If so, how do these characteristics influence choices about their roles in data collection and analysis? ↩︎

Researchers may choose to use information from multiple sources, contexts, and/or time points depending on their approach and research question(s). (See Item 11 for triangulation.) ↩︎

For participants, characteristics might include age, race, ethnicity, gender, profession, institution, year of training, or relationship to the researcher and/or other participants in the study. For documents, this might include the source, intended audience, date, or type of document. For events, this might include the location, date(s), length, characteristics of attendees or participants in the event, or mood or emotional climate. ↩︎

Details might include indication of verbatim transcription of dialogue, additional notes to capture non- verbal information (especially for group interviews or focus groups), and annotations to indicate vocal inflections and utterances, as appropriate for the analytic approach. ↩︎

If data are anonymized, the authors should explain how and at what point in the process this occurred. Authors may choose to use anonymous labels or identifiers to represent quotes or excerpts from unique participants, documents or events, in order to reflect the variety of sources from which such data were derived. ↩︎

E.g., characterize the processes and decisions made for initial classification or segmentation of data, pattern identification and description, and/or development of in-depth interpretations. ↩︎

In qualitative research, the unit of analysis is not necessarily the same as the unit of sampling (e.g., individual participants or events). Instead, some approaches use specific events as the unit of analysis, such as mentions of a particular topic or experience, or observations of a particular behavior or phenomenon, while others use groups rather than individual group participants. This specification has implications for how the data are organized and analyzed as well as the inferences drawn from the data. ↩︎

In some approaches researchers use memoing or bracketing to make their reflections, interpretations, and links among passages explicit and more transparent to others. ↩︎

e.g., used to apply codes after the final coding scheme was developed; to extract coded passages for further synthesis and identification of themes; or to identify passages with key words ↩︎

Techniques to enhance trustworthiness will depend on the paradigm, approach, and/or methods used. Commonly used techniques include: member checking; triangulation of data sources, methods, and/or researchers; creation of an explicit audit trail; and immersion in the site of data collection for an extended period of time (especially for research in which an observer’s presence is likely to disrupt the phenomenon under investigation). Member checking involves sharing findings, such as descriptions of key phenomena, themes, or an explanatory model, with participants and asking them to verify the accuracy or resonance with their perspectives. Triangulation involves using more than one data source, method, or researcher to add diverse perspectives on the findings of the study and, in some approaches, to test the transferability or generalizability of a model. An audit trail involves careful documentation of all decisions made throughout the study, from initial conceptualization to study design, sampling, analysis, and reporting, to provide transparency and to enable an external researcher to review all the steps involved in the study. ↩︎

The nature of these findings and how they are reported will depend on the approach and methodology selected and thus should be in alignment with the approach and methods. ↩︎

In qualitative research the distinction between results and discussion tends to blur because analysis often involves interpretation, inference, and synthesis. Although most journals require separate sections for Results and Discussion, many elements of Items 16 and 18 could reasonably be reported in either section. As such, we defer to authors and editors to determine where to report these essential elements. ↩︎

Evidence is typically de-identified to protect the privacy of study participants, settings, and/or institutions. ↩︎

The discussion provides authors an opportunity to elaborate on their findings in relation to their research question(s) and study purpose(s); connect their findings to prior empirical work, theories, and/or frameworks; and discuss implications. ↩︎

Whereas you should describe techniques used to ensure trustworthiness in the Methods section of the manuscript, this section is about the gaps that you didn’t or couldn’t cover. For example, if you intended to interview individuals with certain characteristics, or who might offer different perspectives, but were unsuccessful in recruiting any willing participants, explain this issue and describe possible consequences for transferability. (See also Item 18.) ↩︎

All research paradigms and approaches have strengths and weaknesses. ↩︎

To read this content please select one of the options below:

Please note you do not have access to teaching notes, a front-to-back guide to writing a qualitative research article.

Qualitative Market Research

ISSN : 1352-2752

Article publication date: 11 January 2016

This paper aims to offer junior scholars a front-to-back guide to writing an academic, theoretically positioned, qualitative research article in the social sciences.

Design/methodology/approach

The paper draws on formal (published) advice from books and articles as well as informal (word-of-mouth) advice from senior scholars.

Most qualitative research articles can be divided into four major parts: the frontend, the methods, the findings, and the backend. This paper offers step-by-step instructions for writing each of these four parts.

Originality/value

Much of the advice in this paper is taken-for-granted wisdom among senior scholars. This paper makes such wisdom available to junior scholars in a concise guide.

• Qualitative research
• Theoretical contribution
• Writing an article

Acknowledgements

The author thanks Andrew Smith, Bernardo Figueiredo, Daiane Scaraboto, Marie-Agnes Parmentier and Ryan Cruz for their feedback on prior versions of this article.

Gopaldas, A. (2016), "A front-to-back guide to writing a qualitative research article", Qualitative Market Research , Vol. 19 No. 1, pp. 115-121. https://doi.org/10.1108/QMR-08-2015-0074

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Dr Karen Lumsden

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Writing and Publishing a Qualitative Journal Article

Academic writing is an ‘intertwining of three equally important elements – the emotions of writing, a sense of self as a writer and writing know-how…’ (Cameron, Nairn and Higgins, 2009: 270)

How researchers write up results for journal publications depends upon the purposes of the research and the methodologies (Gilgun, 2014). There will be standard topics such as statements about methods and methodologies. However, there are also variations in how to represent other topics, i.e. related research and theory, reflexivity, and informants’ accounts:

For example, articles based on ethnographic research may be structured differently from articles in which we are writing up research whose purpose is theory development.

Most of the time journal editors and reviewers will be familiar with variations in write-ups. However, when they are not, they may ask for modifications that violate the methodological principles of the research (Gilgun, 2014). For example, in responses to qualitative articles:

‘A common reviewer request is for percentages, which has little meaning in almost all forms of qualitative research because the purpose of the research is to identify patterns of meanings and not distributions of variables.’ (Gilgun, 2014: 658)

Qualitative researchers face additional challenges when writing-up such as:

• Often working with a mass of data with no rules for the researcher to apply and little guidance as to how this data should be presented.
• No pre-defined categories, dimensions, etc.
• The language used by interviewees, etc. has multiple meanings and interpretations.
• Analysis is inherently subjective.

Therefore, when writing and publishing a qualitative article, it is important to revisit the principles of qualitative research and to address these principles in how we write up and present our qualitative data. We should review how others using the same qualitative methods as us, and working in similar disciplines, are presenting their qualitative data. What typical conventions do they follow?

Below, I offer steps to follow to help guide writers in their development, construction, writing and publication of qualitative research in journal articles.

Step 1: Review journals in your field The first step is to review other relevant journals in your field to help you decide which is the most appropriate for you to publish your work in. You should check which of these journals publish qualitative research and which journals are your colleagues and those working in your field regularly publishing in. There are high penalties for selecting the wrong journal – for example desk rejection and wasted time (Belcher, 2019). As you can only submit your article to one journal at a time, choosing the wrong journal will delay publication. One of the most frequent reasons a journal rejects an article is because it did not meet that journal’s requirements (Meyer et al. 2018).

You should also consider who your target audience are. For example, ‘think of your work more in terms of fit with specific journals and use this to help you write your paper for that journal.’ (Clark and Thompson, 2016: 2) This is especially important for qualitative articles because ‘framing, volume of methodological detail, and presentation of data differ across journals, based on word limits, style, and convention.’ (ibid)

Finally, consider what type of qualitative research and data they tend to publish. Do original articles tend to focus on conventional qualitative methods, i.e. qualitative interviews, focus groups, mixed methods? Do they publish ethnographic research, autoethnographies, narrative research and/or the use of creative methods? If they focus on the ‘conventional’ they may be less open to other qualitative methods and creative approaches. Articles which use ethnographic and/or autoethnographic approaches can look different from conventional reports (i.e. see journals such as Ethnography and Qualitative Inquiry)

Questions to ask:

• Which journals are colleagues publishing in?
• Who has done similar research to you and where do they publish?
• Where do scholars you regularly cite publish?
• Which of these journals regularly publishes qualitative research?
• Which are well cited and respected in your field?
• Is your institution/department concerned with journal metric? I.e. impact factor or SNIP?
• Do I need to consider Open Access requirements? i.e. see ‘Plan S.’ https://www.coalition-s.org/

Step 2: Select a journal Choose the journal you initially want to submit your journal article to (and possibly 2nd and 3rd options in case the first submission is rejected).

You should read similar papers in this journal and review them. I.e. break down the typical structure of a paper in this journal and any common factors in how articles are presented, the angle they take and how they present qualitative data. Read others’ writing not for content, ‘but for how the authors write, for how they present and progress their ideas and arguments’ (Cameron, Nairn and Higgins, 2009: 278) Which piece of academic writing do you particularly appreciate and why?

Also read the ‘instructions to authors’ and ‘submission guidelines’ to determine what you will need to do in preparing your manuscript and follow this when structuring and writing your article (i.e. word count etc.).

Step 3: Identify the type of journal article you will write Next, you need to identify the type of journal article you will write. For example:

Review of the field : This is a summary of research on a particular topic, and a perspective on the state of the field and where it is going. Has it been done before? What limitations or future areas of research are you proposing?

Methods : Are you setting out what your research adds to methodological debates in qualitative research or use of qualitative methods?

Original research / data based : Are you presenting original data? Are you expanding knowledge on a particular topic, issue, phenomenon in your research area?

Theoretical : Are you contributing to the development of theory in your area?

Step 4: Organise and plan your journal article Use the formatting and structure of the journal you are targeting to organise, plan and outline your argument. You should have a skeleton plan for your article before you start writing.

Step 5: Write your article Writing is an analytical task and is also the means through which we process and think about our qualitative data:

‘We have to approach it as an analytical task, in which the form of our reports and representations is as powerful and significant as their content. We also argue that writing and representing is a vital way of thinking about one’s data. Writing makes us think about data in new and different ways. Thinking about how to represent our data forces us to think about the meanings and understandings, voices and experiences present in the data. As such, writing actually deepens our level of analytic endeavor. Analytical ideas are developed and tried out in the process of writing and representing.’ (Coffey and Atkinson, 1996: 109)

Identify the unique contribution to knowledge you are making in your paper. Place this upfront in your abstract, Introduction and weave this through the paper to then expand in Discussion/Conclusion. This must be clear to your reader. Whatever type of article you are writing, you must nail your key message/s :

‘Too many messages, and the main points of the paper are lost—no clear messages, and reviewers are left wondering, ‘‘what’s the point?”’ (Clark and Thompson, 2016: 2)

Your article title can be a single message for conveying the ‘so what?’ of your paper

Review the current field of literature / theories : Make sure you review what is published currently in the journal you wish to publish in and CITE IT. These people might be your reviewers. If you cannot find similar work in the journal this is an indication that the journal may not be the correct fit.

Methods : Do not overlook this section. It is important that readers have information on background, context, research design, and ethics. They should be able to follow an audit trail of research design. Support these decisions and choices with reference to relevant methods literature.

‘ All good research requires reporting of methods in sufficient detail to provide a road map for readers regarding how the data were collected and analyzed. With a single, named method, such as narrative analysis, a brief orienting statement is needed to make explicit the specific authors and sources being employed. Bear in mind that even narrative analysis has variants and different schools of thought. Where multiple techniques drawn from different research methods are employed, a clear rationale for the use of each technique is needed. Clear, however, does not necessarily mean long.’ (Drisko, 2005: 291)

Select and present your data : What story do you want to tell? How much can you present and include in the paper? Presentation of themes – less is more. It is important to convey quality of the data on which the reports are based: ‘…skills of researchers in conveying the analysis concisely and with “grab” (Glaser, 1978), which means writing that is vivid and memorable (Gilgun, 2005b cited in Gilgun, 2014: 662).’

‘Grab brings findings to life. With grab, human experiences jump off the page.’ (Gilgun, 2014: 662)

You should give priority to the voices of your research participants. Moreover, strong articles have consistency between research traditions and the writing up of research (i.e. how ethnography is written up and how field notes are used / presented) (Gilgun, 2014).

Discussion and/or Conclusion : you must review what was covered in the article, restate your contribution to knowledge and link back to what this adds to the body of literature you reviewed in your field/discipline. You should also flag up any limitations of the study and suggest future areas of research, gaps that could be explored in later work.

I ntroduction, abstract and key words : write these last. Make sure you choose terms which are commonly used by those searching for similar work.

Step 6: Tidy up your manuscript Make sure that you edit, correctly format and proof-read your article:

• Revisit the requirements of the journal and check that you have adhered to these (i.e. word count, formatting, etc.).
• Make sure there are no spelling or grammatical errors.
• Double-check referencing. Use the same referencing style as the journal you are submitting to and follow their guidance closely.

Step 7: Peer review    Informal peer review of your work is important. Ask supervisors or colleagues to provide informal feedback on your paper.

Step 8: Submit the manuscript following ‘instructions for authors’ Make sure you include a cover letter and title page (if requested).

Suggest suitable reviewers if requested. These should be scholars who are supportive of your approach and working in the area (i.e. don’t choose a quantitative researcher to review a qualitative paper).

Step 9: Outcome Make a note of when you should hear back from the journal. Don’t be afraid to email editors to ask about review status if this goes beyond the stated number of weeks for review. But remember that it is currently difficult to find reviewers due to various circumstances so it might take longer than usual.

Possible outcomes include: accept with no changes (very rare), revise and resubmit with minor changes (again – rare), revise and resubmit with major changes, reject after review, desk rejection.

Good editors will edit and temper reviewer comments to remove anything which is overly negative or inappropriate.

If you have to revise and resubmit your article:

• Make any necessary changes as flagged up by the editors and reviewers
• Be fair in how you respond
• You can disagree with the reviewers, as long as you can justify why this is the case
• It is the Editor’s job to be balanced and fair in reviewing how you have opted to respond to reviewers
• When/if sent out for review again, it might be sent to different reviewers, not necessarily the original reviewers so don’t be surprised if you then receive additional comments.

Acceptance! Congratulations, you survived the arduous review and publication process! The editors will contact you with the good news and also provide a rough indication of when to expect your paper to be published online (and in print if relevant). Online first means speedier publication. Not all journals still do print publication. The publisher will be in touch with copyright forms for you to complete. Make sure you check open access requirements and if necessary submit a copy of your original paper in your institution’s repository.

Summary There are various steps to follow in developing, designing, writing and preparing your qualitative research journal article for publication. Adhering to the principles of qualitative research and demonstrating you have followed these principles in your article and your presentation of the data is vital. Some common conventions can be followed when drawing on more common forms of qualitative data (i.e. semi-structured interviews and focus groups) and those using other methods (i.e. narratives, ethnography, creative methods) should also familiarise themselves with the various ways in which previous qualitative researchers have written up and presented their data and material. Spending time reviewing the field and selecting an appropriate journal is also crucial so that you can be sure you are submitting your work to a journal and editors who are supportive of, and familiar with, qualitative methods and inquiry.

See our regular Qualitative Researcher courses on ‘Writing and Publishing Your Qualitative Journal Article’: www.qualitativetraining.com

References and further reading Belcher, W.L. (2019) Writing Your Journal Article in Twelve Weeks . Chicago: University of Chicago Press.

Cameron, K., Nairn, K. and Higgins, J. (2009) ‘Demystifying academic writing: Reflections on Emotions, Know-How and Academic Identity.’ Journal of Geography in Higher Education , 33(2): 269-284.

Clark, A.M. and Thompson, D.R. (2016) ‘Editorial. Five tips for writing qualitative research in high-impact journals: Moving from #BMJnoQual.’ International Journal of Qualitative Methods , p.1-3. DOI: 10.1177/1609406916641250

Coffey, A. and Atkinson, P. (1996) Making Sense of Qualitative Data: Complementary Research Strategies . London: Sage.

Drisko, J.W. (2005) ‘Writing up qualitative research.’ Families in Society , 86(4): 589-593.

Gilgun, J,F. (2014) ‘Writing up qualitative research.’ In: P. Leavy (ed.) The Oxford Handbook of Qualitative Research Methods (pp. 658-676). New York: Oxford University Press.

Meyer, H.S., Durning, S.J., Sklar, D. and Maggio, L.A. (2018) ‘Making the first cut: An analysis of academic medicine editors’ reasons for not sending manuscripts out for external peer review.’ Academic Medicine , 93(3): 464-470.

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Guidelines for Preparing Qualitative Manuscripts

Authors submitting qualitative manuscripts to Psychology of Religion and Spirituality ( PRS ) should familiarize themselves with the Journal Article Reporting Standards for Qualitative Primary Research (JARS-Qual) and seek to adhere to them as much as possible.

In particular, the following JARS-Qual standards are deemed especially important for authors to uphold in their submissions of qualitative research submitted to PRS .

• Download in PDF format (118KB)

Study Objectives/Aims/Research Goals

• State the purpose(s)/goal(s)/aim(s) of the study.
• Qualitative studies tend not to identify hypotheses, but research questions and goals.

Research Design Overview

• Summarize the research design (data-collection strategies, data-analytic strategies) and, if illuminating, approaches to inquiry (e.g., descriptive, interpretive, feminist, psychoanalytic, postpositivist, critical, postmodern or constructivist, pragmatic approaches).
• Provide the rationale for the design selected.

Researcher Description

• Describe the researchers' backgrounds in approaching the study, emphasizing their prior understandings of the phenomena under study. Prior understandings relevant to the analysis could include, but are not limited to, descriptions of researchers' demographic/cultural characteristics, credentials, experience with phenomena, training, values, or decisions in selecting archives or material to analyze.
• Describe how researchers' prior understandings of the phenomena under study were managed and/or influenced the research (e.g., enhancing, limiting, or structuring data collection and analysis).

Recruitment Process

• Describe the rationale for decision to halt data collection (e.g., saturation).
• Provide a rationale for the number of participants chosen.

Participant Selection

• Describe the participants/data sources selection process (e.g., purposive sampling methods such as maximum variation, diversity sampling, or convenience sampling methods such as snowball selection, theoretical sampling), inclusion/exclusion criteria.
• State the form of data collected (e.g., interviews, questionnaires, media, observation).
• Describe any alterations of data-collection strategy in response to the evolving findings or the study rationale.
• For interview and written studies, indicate the mean and range of the time duration in the data-collection process (e.g., "interviews were held for 75 to 110 min, with an average interview time of 90 min").
• Describe questions asked in data collection: Content of central questions, form of questions (e.g., open vs. closed).

Data-Analytic Strategies

• Describe the methods and procedures used and for what purpose/goal.
• Explicate in detail the process of analysis, including some discussion of the procedures (e.g., coding, thematic analysis, etc.) with a principle of transparency.
• Describe coders or analysts and their training, if not already described in the researcher description section (e.g., coder selection, collaboration groups).
• Identify whether coding categories emerged from the analyses or were developed a priori.
• Identify units of analysis (e.g., entire transcript, unit, text) and how units were formed, if applicable.
• Describe the process of arriving at an analytic scheme, if applicable (e.g., if one was developed before or during the analysis or was emergent throughout).
• Provide illustrations and descriptions of their development, if relevant.
• Indicate software, if used.

Methodological Integrity

The task force that developed JARS-Qual defines methodological integrity and its component processes as follows:

Methodological integrity can be evaluated through its two composite processes: fidelity to the subject matter and utility in achieving research goals. … Fidelity to the subject matter is the process by which researchers select procedures that develop and maintain allegiance to the phenomenon under study as it is conceived within their approach to inquiry (e.g., the phenomenon might be understood as a social construction). … The second composite process of methodological integrity, utility in achieving research goals is the process by which researchers select procedures that usefully answer their research questions and address their aims (e.g., raising critical consciousness, developing theory, deepening understanding, identifying social practices, forming conceptual frameworks, and developing local knowledge). (Levitt et al. [2018], Journal article reporting standards for qualitative primary, qualitative meta-analytic, and mixed methods research in psychology: The APA Publications and Communications Board Task Force report. American Psychologist, 73 (1), 26-46. P. 33).

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• Published: 13 September 2024

Physicians and nurses experiences of providing care to patients within a mobile care unit – a qualitative interview study

• Christofer Teske 1 , 2 ,
• Ghassan Mourad 1 &
• Micha Milovanovic 1 , 3  

BMC Health Services Research volume  24 , Article number:  1065 ( 2024 ) Cite this article

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Introduction

There is a growing need for alternative forms of care to address citizen demands and ensure a competent healthcare workforce across municipalities and regions. One of these forms of care is the use of mobile care units. The aim of the current study was to describe physicians and nurses experiences of providing care to patients within a mobile care unit in Sweden.

Data were collected between March 2022 and January 2023 through qualitative interviews with 14 physicians and nurses employed in various mobile care units in different regions in Sweden. These interviews were transcribed verbatim and subjected to content analysis, with the study adhering to the Standards for Reporting Qualitative Research (SRQR).

The analysis resulted in two main categories: “Unlocking the potential of mobile care”, and “The challenges of moving hospitals to patients’ homes”; and seven subcategories. The respondents viewed mobile care at home as highly advantageous, positively impacting both patients and caregivers. They believed their contributions enhanced patients’ well-being, fostering a welcoming atmosphere. They also noted receiving more quality time for each patient, enabling thorough assessments, and promoting a person-centered approach, which resulted in more gratifying mutual relationships. However, they experienced that mobile care also had challenges such as geographical limitations, limited opening hours and logistical complexity, which can lead to less equitable and efficient care.

Conclusions

Physicians and nurses in mobile care units emphasized positive outcomes, contributing to patient well-being through a person-centered approach. They highlighted increased quality time, comprehensive assessments, and overall satisfaction, praising the mobile care unit’s unique continuity for enhancing safety and fostering meaningful relationships in the patient’s home environment. In order for mobile care to develop and become a natural part of healthcare, challenges such as geographical limitations and logistics need to be addressed.

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Shifts in population demographics and the present structure of the healthcare system prompt inquiries about the optimal care for frail older people [ 1 , 2 , 3 , 4 ]. The multifaceted health conditions and diverse requirements of these individuals result in increased healthcare appointments and recurrent hospital stays, putting pressure on the current health infrastructure [ 5 , 6 ]. In Sweden, the state oversees general healthcare policy, with the Inspectorate for Health and Care supervising. While regions ensure that all citizens have access to quality care, municipalities look after long-term health and social care for the frail older people,. Primary care serves as the initial point of contact in the healthcare system, providing basic services either at facilities or at homes. They also guide patients to the appropriate level of care as required [ 7 ].

The transition towards accessible and qualitative healthcare is underway in municipalities and regions [ 8 ]. This transition is important because some individuals may experience problems accessing healthcare due to of distance, severe illness and immobility [ 9 , 10 , 11 ]. This change, however, demands long-term commitment and perseverance, not only from the regions and municipalities, but also from the government [ 12 ]. The goal is to develop person-centered, efficient, and purposeful methods that cater to patient needs. This also means that different healthcare stakeholders, specialties, and professions need to collaborate more effectively [ 6 ]. To respond to citizens’ demands for accessible care, there’s a need for alternative forms of care, for example, mobile care, that can offer prompt and appropriate care within the available resources [ 12 ].

The terminology, i.e. the meaning of mobile care varies from country to country, but the care provided is the same, as is its purpose, to provide highly specialized care, mainly by physicians and nurses, for conditions that normally require hospital admission [ 13 , 14 ]. Examples of mobile care are geriatric “Hospital at home” programs that offer treatments typically exclusive to hospitals right in the patient’s homes, including monitoring, drug administration, nursing, and rehabilitation processes [ 13 , 15 ]. Hospital at home is defined as “a service that provides active treatment, by health care professionals, in the patient’s home for a condition that otherwise would require acute hospital in-patient care, always for a limited time period” unlike home nursing care [ 13 , 16 ]. Patients are evaluated in various settings, including by their general practitioners or in emergency rooms, before being directed to these services. This model can also support those discharged early from hospital [ 17 , 18 ]. The target group for mobile care varies, but the mobile units in the current study focus on the frail older people. The National Board of Health and Welfare defines frail frail older people as people over 65 years of age with several chronic diseases and extensive needs for both outpatient and inpatient medical care [ 17 ].

Transitioning the care of patients from hospitals to their homes poses a formidable challenge, primarily due to concerns regarding patient safety and the constraints inherent to a patient’s home environment. Previous studies show that many patients are sent to hospitals instead of being assessed for mobile care due to various circumstances, e.g., for reasons of convenience [ 14 , 19 ]. In cases where the assessment is performed, the mobile care team often rejects the patient due to lack of time, logistical reasons or that the patient is unsuitable [ 13 , 14 , 20 ]. More knowledge is needed about physicians and nurses experiences of mobile care to provide an improved and developed perspective on how it can be incorporated into the healthcare system. The aim of the current study was to describe physicians and nurses experiences of providing care to patients within a mobile care unit in Sweden.

We employed a qualitative, inductive approach and used a content analysis methodology as outlined by Hsieh & Shannon [ 21 ]. In this approach, coding and theme development were driven by the shared meaning found within the data. The design’s primary objective was to discern, analyze, and interpret patterns within the qualitative data. The study adhered to the Standards for Reporting Qualitative Research (SRQR) [ 22 ]. The study was accepted by the Ethics Review Authority, Uppsala, Sweden (reg. number: 2020–06986).

Sampling and setting

The interviews were conducted between March 2022 and January 2023 in four Swedish cities in four different regions with populations varying between 61,000 and 160,000 inhabitants. All cities were equipped with mobile care units. Five units were found through an internet search, after which contact was made with the region management. Of these, four teams agreed to participate. These units specialize in mobile care as their primary field, delivering direct care to patients and offering indirect support to other physicians and nurses involved in providing such care. Mobile care units primarily offer home-based and inpatient care, with the number of patients receiving home care varying from 5 to 15. To be eligible for inclusion, participants had to meet the following criteria: active employment in a specialized field related to internal medicine or geriatric care, a minimum of 2 years of professional experience in the domain of the mobile care unit, and master the Swedish language. Invitation to participate in the study was issued by either the department head or a senior supervising physician within the healthcare facility. All physicians and nurses working in the included mobile care units who fulfilled the inclusion criteria were invited to participate, and all agreed to participate (Table  1 ).

Data collection

Due to the COVID-19 pandemic, interviews were performed using telephone ( n  = 11) and Microsoft Teams© (Microsoft Corporation, California, U.S.A) ( n  = 3). Participants were given the opportunity to propose a suitable time for the interview. The interview began with the participant introducing themselves and describing their experience with mobile care. The semi-structured interview guide was created by the authors with open-ended questions and was followed up by probing questions (See supplementary file). One pilot interview was conducted and did not result in any changes to the interview guide and was therefore included in the analysis. All interviews were performed by the first author (CT). CT is a registered nurse working within the field of emergency care and with previous experience in qualitative interviewing. CT had no prior care relationship with the study participants. Participants were encouraged to engage in open discussion, with occasional probing queries aimed at enhancing clarity, such as requests for further elaboration, explanations, and exploration of the how and why aspects. The interviews lasted between 25 and 55 min, were audio-recorded and then transcribed verbatim by CT. Before the study commenced, physicians and nurses were briefed on the study through both verbal and written communication. The participants were assured of confidentiality, and solely the researchers associated with the project could access the data, in line with The Swedish Research Council’s protocols [ 23 ].

Data analysis

The analysis of the transcribed interviews was conducted according to conventional content analysis based on Hsieh & Shannon [ 21 ]. All authors individually read four transcripts to gain both depth and breadth in understanding the material. Then, units of meaning in the text that were perceived to capture key thoughts or concepts were marked directly in the text. After this, notes were made in the margins describing the first impression, thereby conducting an initial analysis. To increase the trustworthiness of the study, all authors individually coded four transcripts and then mutually discussed the findings to employ a consistent coding scheme. Based on this coding scheme, CT coded the rest of the transcripts. The codes were then sorted into subcategories based on how the different codes were related and linked to each other. These subcategories were thereafter used to organize and group codes into meaningful clusters, which formed the basis for the emerging subcategories. Depending on how the subcategories were related to each other, they were afterwards divided into a smaller number of categories. These steps were mutually discussed by all authors. The findings of the research were strengthened and clarified by using specific quotations. These selected pieces, derived directly from the initial dataset, were eventually translated into English. Table  2 provides examples representing different stages of the analysis.

The results are derived from interviews with physicians and nurses, who were actively employed in specialized fields related to internal medicine or geriatric care. Each participant had at least two years of professional experience in the mobile care unit and was proficient in the Swedish language. Analysis of the interviews resulted in two main categories and seven subcategories according to Table  3 . The main categories were: Unlocking the potential of mobile care and The challenges of moving hospitals to patients’ homes.

Unlocking the potential of mobile care

Physicians and nurses described that mobile care promotes person-centered care based on mutual equality. Caring for the patient in their home increases transparency and safety for patients. Cooperation with different treatment units ensures comprehensive and safe care. It is a healthy work environment that gives professional pride.

Person-centered: the right way to care

Physicians and nurses described that it was rewarding to observe the patient in their natural environment. Physicians and nurses who had previously worked in a hospital setting experienced a shift in the balance of power when care had taken place in the patient’s home. The healthcare staff described that they felt that they were not in a position of power and called it “mutual equality”, and that this led to patients being more inclined to open up and share their opinions. This contributed to a more accurate assessment that aligned with a person-centered care approach. In an assessment of the patient in their living environment, physicians and nurses had been able to identify potential obstacles and complications more effectively. Such obstacles might have been, for example, thresholds in the dwelling that could potentially have been a fall risk. A significant distance between the toilet and bedroom might have resulted in the patient avoiding diuretics due to concerns about incontinence. Physicians and nursesdescribed that it is of central importance to not only identify existing shortcomings but also to anticipate potential vulnerabilities that might have arisen during the period when the patient was enrolled in the mobile care unit. Proactively working on prevention had been essential to ensure the patient’s overall well-being.

“I find it very rewarding to enter their home environment. You sort of get on the same wavelength , and it feels , what should I say , more human to sit with them at home. You get a sense of how this patient operates in their home environment , and it’s important information that we lack when the patient is in their hospital room” [ 7 ].

Safer care through increased patient activity

Physicians and nurses described that patients are satisfied with being cared for at home. The care can be planned collaboratively to a greater extent, ensuring continuous patient involvement. It facilitates conducting examinations and treatments at home rather than needing transportation. Physicians and nurses shared their experiences of safety of care and that a factor for increased safety of care was to enable a care plan with the patients. They expressed that this form of care offers a different type of continuity compared to hospital care where there is variability in the staff. Knowing the patient and their history increased the safety of care. According to physicians and nurses, communication was a key factor. It was essential to inform patients about the reason for the unit’s visit and the necessary treatments Additionally, informing relatives was highlighted as a aspect of care. Physicians and nurses described that relative need to be involved and aware of the plan for the patients, especially since this form of care might be new to some. Furthermore, it was important for physicians and nurses that they provide information to both relatives and the patient on how to contact healthcare if required as this leads to increased security for them.

“Sometimes , they may need an injection to reduce fluid retention for a week , and then the nurse will work together with the patient to develop a plan so that they feel confident in saying , ‘Yes , now we’re going to do it like this” [ 10 ].

Good care requires good collaboration

To ensure high-quality care, collaboration within different healthcare organizations was essential according to physicians and nurses. They conveyed that frequent interaction between various healthcare entities and professions enhanced the sense of security for physicians and nurses, which in turn positively affected the patients. When the mobile unit was aware that home care services assisted or that home healthcare was responsible for the patient at night, the unit felt an increased sense of security in providing care in the patient’s home.

“But the idea and the goal are that patients who do not require inpatient care should be able to stay with our assistance and in collaboration with home healthcare , as well as with , for example , occupational therapists and physiotherapists” [ 11 ].

The perceived benefit of collaborating with hospital specialists, who are not directly part of the mobile unit, was perceived to facilitate the unit’s care delivery. A contributing factor to effective collaboration was that the facility was a smaller hospital, and the mobile unit was stationed close to the hospital’s departments.

“We are a very small hospital , so we have the advantage of being close at hand. We have cooperation among all in.” [ 9 ].

Making a difference gives a sense of professional pride

Physicians and nurses experienced that they were doing something good for the frail older people. They provided good healthcare in a place where the patient wanted to be. Physicians and nurses believed that care in a patient’s home environment surpassed the care that was provided in hospitals. They felt that they had a meaningful profession and that they had a impact on the patients’ lives, but they also perceived that they contributed to the patient’s well-being. Physicians and nurses perceived that they contributed to the patient’s well-being. Physicians and nurses described that they had more time for each patient and did not have to move between patients as they did in the hospital. This led to less stress. It also allowed for a thorough assessment and promoted the establishment of a more rewarding mutual relationship.

“I believe that it’s necessary for us to fulfill a role and make a contribution for the elderly. I see that the unit is needed and that we serve a purpose” [ 3 ].

The challenges of moving hospitals to patients’ homes

Physicians and nurses describe that geographical differences and the limited operating hours of mobile care teams lead to unequal care. They face logistical challenges, such as transporting equipment and navigating different administrative systems, which need improvement. Additionally, maintaining good hygiene in less clean home environments can be difficult.

Mobile care availability varies among different populations

Physicians and nurses emphasized the limitations of a mobile care unit compared to traditional hospital care. They often used expressions such as: “compared to the hospital or the emergency room”.

Some of the physicians and nurses highlighted that this type of care is limited to geographical boundaries. Within a municipality, there is often a higher concentration of resources and opportunities compared to areas outside the central parts of the municipality. Physicians and nurses described that if the patients live within the area of the unit, they will be offered this type of care, otherwise not, leading to inequality in care. Furthermore, mobile care was perceived as insufficient as the number of scheduled visits must be reduced if the travel time becomes too long. At most, physicians and nurses need to travel up to 60 minutes for a visit.

“There are still quite significant differences in the care one receives when living inside the city as opposed to living outside the municipality.” [ 1 ]. “The furthest locations. It’s travel time and such. Considering that , we are not very efficient.” [ 3 ].

Limitations due to the unit size and working hours

According to physicians and nurses, the mobile unit usually consists of a fixed number of employees who are not replaced when illness occurs, making the unit fragile. The units’ operations include both scheduled and emergency visits, and emergency visits can be limited due to lack of necessary resources, e.g. due to illness in the unit members. In such situations, the common alternative is to call for ambulance transportation that brings the patient to nearest hospital for an emergency assessment.

Another aspect is that the mobile unit is only available during office hours. If the patient experiences an emergency with their health outside the office hours, they could speak to a healthcare professional who works in a hospital. Physicians and nurses perceived this opportunity as positive, that it provided an extra security for patients connected to mobile care, while others were more negative to the limited opening hours compared to the hospital.

“We work regular office hours , Monday to Friday. Then during other times , they can call us , and we leave a brochure. And if we don’t answer the phone , they are redirected to the department , so they can get in touch with the doctor. It has never really become a problem.” [ 8 ].

The importance of equipment and logistics

Physicians and nurses described that conducting home visits required extensive preparation, especially concerning the equipment that needed to be brought along. Technical complications can arise, which may be difficult to address in the patient’s home, underscoring the importance of reliable equipment. Another challenge highlighted by physicians and nurses was the incompatibility in record-keeping systems across different forms of care. Standardizing these systems could optimize the workflow. Moreover, physicians and nurses emphasized that some medical equipment cannot be easily implemented in the home environment. These were for example monitoring equipment, including the tracking of vital functions, and infusion systems that administer intravenous drugs safely.

“It requires quite a bit of logistics. You have to bring things with you. I realized it now when I was about to leave. It demands logistics , and you have to be organized.” [ 9 ].

Som physicians and nurses made it clear that not all patients are suitable for a specific treatment at home. In situations where the patient’s condition requires intravenous treatment, but the patient lacks supervision or municipal interventions, the unit need to make an assessment. If the unit can be present during the entire treatment period, then it is safe for the patient to receive the treatment at home, otherwise the alternative is to go to hospital.

Another issue was hygiene problems experienced by physicians and nurses. For example, in wound dressings, it is difficult to maintain cleanliness if the home is already dirty, which normally is not a problem in the hospital environment.

“First , it’s about how the home looks and what possibilities there are. If the home is in disarray , it’s impossible to keep it clean. I know , I was sewing today , and when I compare it to the healthcare center , it’s quite sterile in comparison to a bedroom” [ 2 ].

To our knowledge, this is the first study describing physicians and nurses’ experiences with providing care to patients within a mobile care unit in Sweden. The study contributes valuable knowledge and insights into how Physicians and nurses experience this type of highly specialized care in the patients’ homes, which differs from home care nursing which mainly offers basic medical treatment such as health monitoring, medication administration, wound dressing, and overall patient health support. Physicians and nurses considered that mobile care in the home environment offers advantages that have a positive impact on both the patient and physicians and nurses themselves. However, they also expressed some challenges connected with mobile care.

Physicians and nurses described mobile care as a person-centered approach, where caring for patients in their own home has several positive aspects that benefit not only the patient but also physicians and nurses. They perceived it as gratifying to witness patients in their natural surroundings and noted a power shift during home care, fostering mutual equality, which they felt was difficult to achieve when they worked in hospitals. Physicians and nurses described that patients experience satisfaction when they receive care at home. They emphasized that mobile care is characterized by collaborative planning, which ensures continuous patient participation. Although person-centered care emphasizes the importance of patient involvement in decision-making [ 24 ], earlier research has shown that not all patients prefer active participation. [ 25 , 26 ]. This is mainly due to health-related limitations, lack of support from physicians and nurses, or unfamiliarity with the possibility of participate actively. However, in cases where patients want to participate actively, they feel opposed by physicians and nurses. In those moments, they might feel like they don’t have much say or control, and it can make them feel less powerful and independent [ 27 , 28 ]. This suggests that physicians and nurses should pay attention to patients’ needs and wishes for participation in their care. It is also valuable to address non-active participation through targeted efforts such as patient education and empowerment initiatives to facilitate a smooth transition to acceptance of person-centered care in the home environment [ 26 ]. Through these efforts, we believe that it is possible to further promote and implement a person-centered approach in mobile care.

Physicians and nurses described that they received more quality time for each patient, enabling a more comprehensive assessment and fostering a more satisfying person-centered care. Specifically, they believed that their contributions had a substantial impact on the patient’s overall well-being and perceived a consistent sense of welcome, receiving affirmative responses regarding their endeavors. Physicians and nurses experience that the mobile care unit provides a unique continuity compared to hospital care, where staff turnover can introduce variability. Getting to know the patient and their medical history contributes to enhanced safety in care delivery. Previous research [ 11 , 12 , 13 ] has shown that building and maintaining relationships with the frail older people with physicians and nurses can be challenging due to the specialized and fragmented healthcare system. A limited number of staff meeting patients in their home environment usually means consistent contact that promotes the quality of care, affecting patients’ feelings of safety and comfort. However, other studies show that patients receiving medical care at home tend to report higher levels of satisfaction with their treating physician compared to patients receiving care in a traditional acute hospital environment [ 12 , 13 , 14 ]. Physicians and nurses in this study advocate for the mobile care unit, citing its unique continuity compared to hospitals. We therefore assume that consistent contact with a limited number of staff promotes relational continuity, positively impacting patient satisfaction.

Healthcare professional described that they provided good healthcare in a place where the patient wanted to be. They believed that care in a patients’ home environment surpassed the care that was provided in hospitals and had an impact on the patients’ lives. Physicians and nursesalso described having more time for each individual patient. This allowed for a thorough assessment and promoted the establishment of a more rewarding mutual relationship. This suggests that physicians and nurses appreciated the work environment in the mobile care team. Previous studies have shown a positive correlation between a healthy work environment and better patient experiences [ 29 , 30 ]. This implicates that a positive work environment in mobile care has far-reaching implications that extend beyond just the well-being of physicians and nurses. It also positively influences patient satisfaction, quality of care, staff engagement, and the overall efficiency of healthcare delivery in the mobile setting.

Physicians and nurses also described challenges in the work environment including unsanitary living conditions that can worsen a patient’s medical condition and make infection control more difficult. Previous studies confirm that there is an increased risk associated with certain types of treatment at home and that it is important to make a careful assessment of whether the patient and the environment are suitable for care [ 14 ]. On the other hand, being hospitalized, increases the risk ofnosocomial infections [ 31 , 32 , 33 ].

Physicians and nurses described that the mobile care units have limitations in terms of accessibility. This mostly concerns geographic accessibility, where patients in rural areas do not have the same opportunity for mobile care as in the cities. They also described that the units’ working hours and travelling distances was a limiting factor. The availability of mobile care, both geographically and in terms of restricted opening hours, is not in line with the Healthcare Act in Sweden [ 17 ], which stipulates that healthcare should be provided on equal terms for the entire population. Geographical accessibility can however be challenging to fulfill as Sweden is sparsely populated compared to many other European countries [ 34 ]. Proximity to patients in rural areas is a crucial factor affecting access to primary care [ 19 , 20 ]. To address this issue, the Ministry of Social Affairs has been tasked by the government to investigate and propose changes to increase access to healthcare in rural areas [ 21 ]. Global observations indicate a variety of essential approaches for enhancing accessibility to primary healthcare services in rural areas. These encompass reinforcing the healthcare financing system, enhancing the availability of medicines and supplies, collaborating with diverse partners and communities, implementing a robust evaluation system, and fostering dedicated leadership [ 35 , 36 , 37 ]. This indicates that follow-up healthcare appointments, digital solutions may become more relevant in the future to minimize transportation for the mobile care units.

Strengths and limitations

Mobile care is not yet widely adopted as a working method in Sweden. Consequently, a geographic spread could not be achieved, and the number of participants was limited. Nevertheless, the findings in this study are based on data collected from a relatively high number of physicians and nurses in Sweden with experiences of working in different mobile care units. According to Malterud [ 38 ], this indicates that the study has achieved sufficient information power, as all physicians and nurses working in the mobile care units participated in this study. They contributed with their unique experience and provided valuable knowledge to answer the aim of the study. Furthermore, the interviews yielded consistent data since no new information appeared in the last interviews, and this data was analyzed using an established analysis strategy by Hsieh & Shannon [ 21 ].

Eleven of the interviews were carried out via telephone and three via video using Microsoft Teams©. This might be considered as a limitation as telephone interviews may have impacted the richness of interview content compared with video interviews. However, research shows that the difference between telephone and video interviews is modest [ 39 , 40 ]. One strength is that the first author (CT) conducted all interviews, which may have influenced the quality of the interviews positively as the interviewer’s interview technique improved with each interview. Another strength is that all authors individually coded four transcripts and mutually discussed the findings to employ a consistent coding scheme, that CT used to code the rest of the transcripts afterwards. Furthermore, all authors participated in forming subcategories and categories to ensure credibility. Dependability was established by maintaining a comprehensive audit trail, ensuring consistent coding procedures, and involving multiple analysts to verify the stability and reliability of the findings, with every step of the research process thoroughly documented in the methods section.Variations were discussed among the authors during the meetings for the data analysis to enhance the confirmability of the study. The authors have different backgrounds and expertise, i.e. nursing, medicine and biomedicine and this can be seen as an “investigator triangulation” and thus a strength [ 41 ].

Although other mobile care units may work differently and have other experiences, our findings may demonstrate transferability to this context as care is delivered to patients in their homes, even though this could differ in content and delivery mode.

Physicians and nurses experience mobile care as a person-centered approach, promoting holistic care and collaborative planning. It emphasizes ongoing patient participation and eliminated transportation needs. On the other hand, mobile care poses challenges such as inequality of care if patients live outside the units’ areas, incompatible record-keeping, and difficulty implementing the use of certain medical devices. Despite this, mobile care is considered a a good alternative to traditional hospital care, where physicians and nurses felt they had a meaningful profession that positively affects the lives and well-being of the patients, and thus fostering rewarding mutual relationships. The challenge for the future is to engage at a national level with physicians, managers, and politicians to achieve improvements. Failing to come together to develop care pathways relevant to rural communities, for example, could be missing an opportunity to improve the nation’s health.

Data availability

The datasets used and/or analysed during the current study cannot be shared openly but are available on request from authors.

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We thank all the physicians and nurses for sharing their experiences in the interviews for this study.

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Christofer Teske, Ghassan Mourad & Micha Milovanovic

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CT collected and analyzed all data. Also contributed to writing - review and editing of the manuscript. GM contributed to study design, analysis of data via triangulation, reviewing and editing of the manuscript. MM contributed to discussion regarding all data of the study. Also contributed to writing - review and editing of the manuscript. All authors read and approved the final manuscript.

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Teske, C., Mourad, G. & Milovanovic, M. Physicians and nurses experiences of providing care to patients within a mobile care unit – a qualitative interview study. BMC Health Serv Res 24 , 1065 (2024). https://doi.org/10.1186/s12913-024-11517-8

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A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia

• Wolde Facha   ORCID: orcid.org/0000-0002-7463-524X 1 ,
• Takele Tadesse 1 ,
• Eskinder Wolka 1 &
• Ayalew Astatkie 2  

Scientific Reports volume  14 , Article number:  21440 ( 2024 ) Cite this article

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Loss to follow-up (LTFU) from Option B plus, a lifelong antiretroviral therapy (ART) for pregnant women living with human immunodeficiency virus (HIV), irrespective of their clinical stage and CD4 count, threatens the elimination of vertical transmission of the virus from mothers to their infants. However, evidence on reasons for LTFU and resumption after LTFU to Option B plus care among women has been limited in Ethiopia. Therefore, this study explored why women were LTFU from the service and what made them resume or refuse resumption after LTFU in Ethiopia. An exploratory, descriptive qualitative study using 46 in-depth interviews was employed among purposely selected women who were lost from Option B plus care or resumed care after LTFU, health care providers, and mother support group (MSG) members working in the prevention of mother-to-child transmission unit. A thematic analysis using an inductive approach was used to analyze the data and build subthemes and themes. Open Code Version 4.03 software assists in data management, from open coding to developing themes and sub-themes. We found that low socioeconomic status, poor relationship with husband and/or family, lack of support from partners, family members, or government, HIV-related stigma, and discrimination, lack of awareness on HIV treatment and perceived drug side effects, religious belief, shortage of drug supply, inadequate service access, and fear of confidentiality breach by healthcare workers were major reasons for LTFU. Healthcare workers' dedication to tracing lost women, partner encouragement, and feeling sick prompted women to resume care after LTFU. This study highlighted financial burdens, partner violence, and societal and health service-related factors discouraged compliance to retention among women in Option B plus care in Ethiopia. Women's empowerment and partner engagement were of vital importance to retain them in care and eliminate vertical transmission of the virus among infants born to HIV-positive women.

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Introduction.

Lost to follow-up is a major challenge in the prevention of mother-to-child transmission (PMTCT) of HIV among HIV-exposed infants (HEI). Globally, about 1.5 million children under 15 years old were living with HIV, and 130,000 acquired the virus in 2022 1 . In the African region, an estimated 1.3 million children aged 0–14 were living with HIV at the end of 2022, and 109,000 children were newly infected 2 . Five out of six paediatric HIV infections occurred in sub-Saharan Africa in 2022 3 . Most of these infections are due to mother-to-child transmission (MTCT), accounting for around 90% of all new infections 4 , 5 . Without any intervention, between 15 and 45 percent of infants born to HIV-positive mothers are likely to acquire the virus from their mothers, with half dying before their second birthday without treatment 3 . Almost 70% of new HIV infections were due to mothers not receiving ART or dropping off during pregnancy or breastfeeding 3 .

In Ethiopia, the burden of MTCT of HIV is high, with a pooled prevalence ranging from 5.6% to 11.4% 6 , 7 , 8 , 9 , 10 . Ethiopia adopted the 2013 World Health Organization’s Option B plus recommendations as the preferred strategy for the PMTCT of HIV in 2013 11 , 12 , 13 , 14 . Accordingly, a combination of triple antiretroviral (ARV) drugs was provided for all HIV-infected pregnant and/or breastfeeding women, irrespective of their CD4 count and World Health Organization (WHO) clinical staging 11 , 13 . Besides, the drug type was switched from an EFV-based to a DTG-based regimen to enhance maternal life quality and decrease LTFU from Option B plus care 11 , 15 . The Efavirenz-based regimen consists of Tenofovir (TDF), Lamivudine (3TC), and Efavirenz (EFV), while the DTG-based regimen consists of TDF, 3TC, and DTG 13 , 15 , 16 . The change in regimen was due to better tolerability and rapid viral suppression, thereby retaining women in care and achieving MTCT of HIV targets 17 , 18 .

The trend of women accessing ART for PMTCT services increases, and new HIV infections decrease over time 3 , 19 , 20 . However, the effectiveness of Option B plus depends not only on service coverage but also on drug adherence and retention in care 4 , 15 , 21 . In this regard, quantitative studies conducted in Ethiopia showed that the prevalence of LTFU from Option B plus ranged from 4.2% to 18.2% 22 , 23 , 24 . Besides, the overall incidence of LTFU ranged from 9 to 9.4 per 1000 person-months of observation 25 , 26 , which is a challenge for the success of the program.

Qualitative studies also revealed that the main reasons for LTFU among women were maternal educational status, drug side effects, lack of partner and family support, lack of HIV status disclosure, poverty, discordant HIV test results, religious belief, stigma, and discrimination, long distance to the health facility, and history of poor adherence to ART 27 , 28 , 29 , 30 , 31 , 32 . Reasons for resumption to care were a decline in health status, a desire to have an uninfected child, and support from others 30 , 33 . Unless the above risk factors for LTFU are managed, the national plan to eliminate the MTCT of HIV by 2025 will not be achieved 34 .

Currently, because of its fewer side effects and better tolerability, a Dolutegravir (DTG)-based regimen is given as a preferred first-line regimen to pregnant and/or breastfeeding women to reduce the risk of LTFU 13 , 16 . The goal is to reduce new HIV transmissions and achieve Sustainable Development Goal (SDG) 3.3 of ending Acquired Immunodeficiency Syndrome (AIDS) as a public health threat by 2030 35 , 36 , 37 . As mentioned above, there is rich information on the prevalence and risk factors of LTFU among women on Option B plus care before the DTG-based regimen was implemented. Besides, the previous qualitative studies addressed the reasons for LTFU from providers’ and/or women’s perspectives rather than including mother support group (MSG) members. However, there was a lack of evidence that explored the reasons for LTFU and resumption of care after LTFU from the perspectives of MSG members, lost women, and healthcare workers (HCWs) providing care to women. Therefore, this study aimed to explore the reasons why women LTFU and resumed Option B plus care after the implementation of a DTG-based regimen in Ethiopia.

Materials and methods

Study design and setting.

An exploratory, descriptive qualitative study 38 was conducted between June and October 2023. This study was conducted in two regions of Ethiopia: Central Ethiopia and South Ethiopia. These neighbouring regions were formed on August 19, 2023, after the disintegration of the Southern Nations, Nationalities, and Peoples' Region after a successful referendum 39 . The authors included these nearby regions to get an adequate sample size and cover a wider geographic area. In these regions, 140 health facilities (49 hospitals and 91 health centers) provided PMTCT and ART services to 28,885 patients at the time of the study, of whom 1,236 were pregnant or breastfeeding women (675 in South Ethiopia and 561 in Central Ethiopia).

Participants and data collection

Study participants were women who were lost from PMTCT care or resumed PMTCT care after LTFU, MSG members, and HCWs provided PMTCT care. Mother support group members were HIV-positive women working in the PMTCT unit to share experiences and provide counselling services on breastfeeding, retention, and adherence, and to trace women when they lost Option B plus care 11 , 40 . Healthcare workers were nurses or midwives working in the PMTCT unit to deliver services to women enrolled in Option B plus care.

Purposive criterion sampling was employed to select study participants from twenty-one facilities (nine health centers and twelve hospitals) providing PMTCT service. A total of 46 participants were included in the study. The interview included 15 women (eleven lost and four resumed care after LTFU), 14 providers, and 17 MSG members. Healthcare workers and MSG members were chosen based on the length of time they spent engaging with women on Option B plus care; the higher the work experience, the more they were selected to get adequate information about the study participants. Including the study participants in each group continued until data saturation.

The principal investigator, with the help of HCWs and MSG members, identified lost women from the PMTCT registration books and appointment cards. A woman's status was recorded as LTFU if she missed the last clinic appointment for at least 28 days without documented death or transfer out to another facility 15 . Providers contacted women based on their addresses recorded during enrolment in Option B plus care, either via phone (if functional) or by conducting home visits for those unable to be reached. Informed written consent was obtained, and the research assistants conducted in-depth interviews at women’s homes or health facilities based on their preferences. After an interview, eleven women who lost care were counselled to resume PMTCT care, but nine returned to care and two refused to resume care. Besides, the principal investigator, HCWs, and MSG members identified women who resumed care after LTFU, called them via phone to visit the health facility at their convenience, and conducted the interview after obtaining consent. The research team covered transportation costs and provided adherence counselling to women post-interview. A woman resumed care if she came back to PMTCT care on her own or healthcare workers’ efforts after LTFU.

One-on-one, in-depth interviews were conducted with eligible MSG members and HCWs at respective health facilities. A semi-structured interview guide translated into the local language (Amharic) was used to collect data. The guide comprises the following constructs: why women are lost to follow-up from PMTCT care, what made them resume caring after LTFU, and why they did not resume Option B plus care after LTFU with probing questions (Supplementary File 1 ). The interview was conducted for 18 to 37 min with each participant, and the duration was communicated to study participants before the interview. The interview was audio-taped, and field notes were taken during the interviews.

Data management and analysis

Thematic analysis was used to analyze the data. The research assistants transcribed the interviews verbatim within 48 h of data collection and translated them from the local language (Amharic) to English for analysis. The principal investigator read the translated document several times to get a general sense of the content. An inductive approach was applied to allow the conceptual clustering of ideas and patterns to emerge. The authors preferred an inductive approach to analyze data since there were no pre-determined categories. The core meaning of the phrases and sentences relevant to the research aim was searched. Codes were assigned to the phrases and sentences in the transcript, which were later used to develop themes and subthemes. The subthemes were substantiated by quotes from the interviews. The interviews developed two themes: reasons for LTFU and the reasons for resumption after LTFU. The findings were triangulated from healthcare workers, MSG members, and client responses. Open code software version 4.03 was used to assist in data management, from open coding to the development themes and sub-themes.

Background characteristics of the study participants

We successfully interviewed 46 participants (14 providers, 15 women, and 17 MSG members) until data saturation. The mean (± standard deviation [SD]) of age was 25.53 (± 0.99) years for women, 32.5 (± 1.05) years for MSG members, and 32.2 (± 1.05) years for care providers. Three out of fifteen women did not disclose their HIV status to their partner, and 5/15 women’s partners were discordant. The mean (± SD) service years in the PMTCT unit were 10.3 (± 1.3) for MSG members and 3.29 (± 0.42) for care providers (Supplementary File 2 ).

Reasons for LTFU

Women who started ART to prevent MTCT of HIV were lost from care due to different reasons. Societal and individual-related factors and health facility-related factors were the two main dimensions that made women LTFU. The societal and individual-related factors were socioeconomic status, relations with husbands or families, lack of support, HIV-related stigma and discrimination, lack of awareness and perceived antiretroviral (ARV) side effects, and religious belief. Health facility-related factors such as lack of confidentiality, drug supply shortages, and inadequate service access led to women's loss from Option B plus care (Supplementary File 3 ).

Societal and individual-related factors

Socioeconomic status.

Lack of money to buy food was a major identified problem for women’s LTFU. Women who did not have adequate food to eat became undernourished, which significantly increased the risk of LTFU. Besides, they did not want to swallow ARV drugs with an empty stomach and thus did not visit health facilities to collect their drugs.

“My life is miserable. I have nothing to eat at my home. How would I take the drug on an empty stomach? Let the disease kill me rather than die due to hunger. This is why I stopped to take the medicine and LTFU.” (W-02, 30-year-old woman, divorced, daily labourer)

Women also disappeared from PMTCT care due to a lack of money to cover transportation costs to reach health facilities.

I need a lot of money to pay for transportation that I can’t afford. Sometimes I came to the hospital borrowing money for transportation. It is challenging to attend a follow-up schedule regularly to collect ART medications.” (W-11, 26-year-old woman, married, housewife)

Relationships with husbands and/or families

Fear of violence and divorce by sexual partners were identified as major reasons for the LTFU of women from PMTCT care. Due to fear of partner violence and divorce, women did not want to be seen by their partners while visiting health facilities for Option B plus care and swallowing ARV drugs. As a result, they missed clinic appointments, did not swallow the drugs, and consequently lost care.

“Due to discordant test results, my husband divorced me. Then I went to my mother's home with my child. I haven’t returned to take the drug since then and have lost PMTCT care.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Women did not disclose their HIV status to their discordant sexual partners and family members due to fear of stigma and discrimination. As a result, they did not swallow drugs in front of others and were unable to collect the drugs from health facilities.

“I know a mother who picked up her drugs on market day as if she came to the market to buy goods. No one knows her status. She hides the drug and swallows it when her husband sleeps.” (P-05, 29-year-old provider, female, 3 years of experience in the PMTCT unit) “I don't want to be seen at the ART unit. I have no reason to convince the discordant husband to visit a health facility after delivery. My husband kills me if he knows that I am living with HIV. This is why I discontinued the care.” (W-12, 18-year-old woman, married, housewife)

Women who lack partner support in caring for children at home during visits to health facilities find it difficult to adhere to clinic visits. Besides, women who did not get financial and psychological support from their partners faced difficulties in retaining care.

“Taking care of children is not business for my husband. How could I leave my two children alone at home? Or can I bring them biting with my teeth?” (W-05, 24-year-old woman, divorced, daily labourer) “ I didn't get any financial or psychological support from my husband. This made me drop PMTCT care.” (W-15, 34-year-old woman, married, daily labourer) Lack of support

Women living with HIV also had complaints of lack of support from the government, non-governmental organizations (NGOs), and HIV-related associations in cash and in kind. As a result, they were disappointed to remain in care.

"Previously, we got financial and material support from NGOs. Besides, the government arranged places for material production and goods sale to improve our economic status. However, now we didn't get any support from anywhere. This made our lives hectic to retain PMTCT care.” (W-06, 29-year-old woman, married, daily labourer)

HIV-related stigma and discrimination

Fear of stigma and discrimination by sexual partners, family members, and the community were mentioned as reasons for LTFU. Gossip, isolation, and rejection from societal activities were the dominant stigma experiences the women encountered. As a result, they did not want to be seen by others who knew them while collecting ARV drugs from health facilities, and consequently, they were lost from care and treatment.

“Despite getting PMTCT service at the nearby facility, some women come to our hospital traveling long distances. They don't want to be seen by others while taking ARV drugs there due to fear of stigma and discrimination by the community.” (P-10, 34-year-old provider, female, 2 years of experience in the PMTCT unit) “I am a daily labourer and bake ‘injera’ (a favourite food in Ethiopia) at someone's house to run my life. If the owner knew my status, I am sure she would not allow me to continue the job. In that case, what would I give my child to eat?” (W-12, 18-year-old woman, married, housewife) “My family did not know that I was living with the virus. If they knew it, I am sure they would not allow me to contact them during any events. Thus, I am afraid of telling them that I had the virus in my blood.” (W-05, 24-year-old woman, divorced, daily labourer)

Lack of awareness and perceived ARV side effects

Sometimes women went to another area for different reasons without taking ARV drugs with them. As per the Ethiopian national treatment guidelines 13 , they could get the drugs temporarily from any nearby facility that delivers PMTCT service. However, those who did not know that they could get the drugs from other nearby PMTCT facilities lost their care until their return. Others were lost, considering that ARV drugs harm the health status of their babies.

“One mother refused to retain in care after the delivery of a congenitally malformed baby (no hands at birth). She said, 'This abnormal child was born due to the drug I was taking for HIV. I delivered two healthy children before taking this medication. I don't want to re-use the drug that made me give birth to a malformed baby." (P-14, 32-year-old provider, female, 4 years of experience in the PMTCT unit)

When they did not encounter any health problems, women were lost from care, considering that they had become healthy and not in need of ART. Some of them also believe that having HIV is a result of sin, not a disease. Besides, some women believed that it was not possible to have a discordant test result with their partner.

“I didn't commit any sexual practice other than with my husband. His test result is negative. So, from where did I get the virus? I don't want to take the drug again.” (W-02, 30-year-old woman, divorced, daily labourer)

Religious belief

Some study participants mentioned religious belief as a reason for LTFU and a barrier to resumption after LTFU. Women discontinued Option B plus care due to their religious faith and refused to resume care as they were cured by the Holy Water and prayer by religious leaders.

“I went to Holy Water and was there for two months. My health status resumed due to prayer by monks and priests there. Despite not taking the drugs during my stay, God cured me of this evil disease with Holy Water. Now I am healthy, and there is no need to take the medicine again.” (W-09, 25-year-old woman, married, daily labourer)

Some women believed that God cured them and made their children free of the virus despite not taking ART for themselves and not giving ARV prophylaxis for their infants.

“Don't raise this issue again (when MSG asked to resume PMTCT care). I don't want to use the medicine. I am cured of the disease by the word of God, and my child is too. My God did not lie in His word.” (MSG-16, 32-year-old MSG, married, 16 years of service experience “Don't come to my home again. I don't have the virus now. I have been praying for it, and God cured me.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Health facility-related factors

Shortage of drug supply.

Women were not provided with all HIV-related services free of charge and were required to pay for therapeutic and prophylactic drugs for themselves and their infants. Most facilities face a shortage of prophylactic drugs, primarily cotrimoxazole and nevirapine syrups, for infants and women, and other drugs used to treat opportunistic infections. As a result, women lost their PMTCT care when told to buy prophylactic syrups for infants and therapeutic drugs to treat opportunistic infections for themselves.

“Lack of cotrimoxazole syrup is one of the major reasons for women to miss PMTCT clinic visits. In our facility, it was out of stock for the last three months. Women can't afford its cost due to their economic problems.” (MSG-03, 34-year-old provider, married, 12 years of service experience)

Inadequate service access

Most women travelled long distances to reach health facilities to get PMTCT service due to the absence of a PMTCT site in their area. Due to a lack of transportation access and/or cost, they were forced to miss clinic visits for PMTCT care.

“In this district, there were only two PMTCT sites. Women travelled long distances to get the service. To reach our facility, they must travel half a day or pay more than three hundred Ethiopian birr for a motorbike that some cannot afford. Thus, women lost the service due to inadequate service access.” (P-06, 30-year-old provider, male, 2 years of experience in the PMTCT unit)

In almost all facilities, PMTCT service was not given on weekends and holidays, despite women's interest in being served at these times. When ARV drugs were stocked out at their homes, they did not get the drugs if facilities were not providing services on weekends and holidays. When appointment date was passed, they lost care due to fear of health workers’ reactions.

Lack of confidentiality

Despite maintaining ethical principles to retain women in care, breaches of confidentiality by HCWs were one of the reasons for LTFU by women. Women were afraid of meeting someone they knew or that their privacy would not be respected. As a result, they lost from PMTCT care.

“I don’t want to visit the facility. All my information was distributed to the community by a HCW who counselled me at the antenatal clinic.” (W-09, 25-year-old woman, married, daily labourer)

Reasons for resumption after LTFU

Healthcare workers' commitment to searching for lost women, partners’ encouragement, and women’s health status were key reasons for resuming women's Option B plus services after LTFU.

Healthcare workers’ commitment

The majority of lost women resumed Option B plus care after LTFU when healthcare workers called them via phone or conducted home visits for those who could not be reached by phone call.

“We went to a woman’s home, who started ART during delivery and lost for four months, travelling about 90 kilometers. She just cried when she saw us. She said, 'As long as you sacrificed your time traveling such a long distance to return me and save my life, I will never disappear from care today onward.' Then, she returned immediately and was linked to the ART unit after completing her PMTCT program.” (P-13, 32-year-old provider, male, 5 years of experience in the PMTCT unit) “We have an appointment date registry for every woman. We waited for them for seven days after they failed to arrive on the scheduled appointment date. From the 8th day onward, we called them via phone if it was available and functional. If we didn't find them via phone, we conducted home visits and returned them to care.” (P-02, 24-year-old provider, female, 3 years of experience in the PMTCT unit)

Partner encouragement

Women who got their partners' encouragement did not drop out of PMTCT care. Besides, most women returned to care and restarted their ARV drugs due to partner encouragement.

“I did not disclose my HIV status to my husband, which was diagnosed during the antenatal period. I lost my care after the delivery of a male baby. When my husband knew my status, rather than disagreeing, he encouraged me to resume the care to live healthily and to prevent the transmission of HIV to our baby. This was why I resumed care after LTFU.” (W-14, 28-year-old woman, divorced, daily labourer)

Women’s health status

Some women returned to Option B plus care on their own when they felt sick and wanted to stay healthy.

“When I felt healthy, I was away from care for about eight months. Later on, when I sought medical care for the illness, doctors gave me medicine and linked me to this unit (the PMTCT unit). I returned because of sickness.” (W-06, 29-year-old woman, married, daily labourer)

This qualitative study assessed the reasons why women left the service and why they resumed care after LTFU. The study aimed to enhance program implementation by providing insights into reasons for LTFU and facilitators for resumption from women's, health professionals', and MSG members' perspectives. We found that financial problems, partner violence, lack of support, HIV-related stigma and discrimination, lack of awareness, religious belief, shortage of drug supply, poor access to health services, and fear of confidentiality breaches by healthcare providers were major reasons for LTFU from PMTCT care. Healthcare workers’ commitment, partner encouragement, and feeling sick made women resume PMTCT care after LTFU.

In this study, fear of partner violence and divorce were identified as major reasons that made women discontinue the PMTCT service. Men are the primary decision-makers regarding healthcare service utilization, and the lack of male involvement in the continuity of PMTCT care decreases maternal health service utilization, including PMTCT services 41 , 42 . In addition, economic dependence on men threatened women not to adhere to clinic appointments without their partner’s willingness due to fear of violence and divorce 28 . Thus, strengthening couple counselling and testing 13 , male involvement in maternal health services, and women empowerment strategies like promoting education, property ownership, and authority sharing to reach decisions on health service utilization were crucial to retaining women in PMTCT care. Besides, legal authorities and community and religious leaders should be involved in preventing domestic violence and raising awareness about the negative effects of divorce on child health.

Financial constraints to cover daily expenses were major reasons expressed by women for LTFU from PMTCT care. Consistent with other studies, this study revealed that a lack of money to cover transportation costs resulted in poor adherence to ART and subsequent loss of PMTCT care 27 , 29 , 43 . As evidenced by other studies, lack of food resulting from financial problems was a major reason for LTFU in the study area 30 . As a result, women prefer death to living with hunger due to food scarcity, which led them to LTFU. Besides, women of poor economic status spent more time on jobs to get money to cover day-to-day expenses than thinking of appointment dates. Thus, governments and organizations working on HIV prevention programs should strengthen economic empowerment programs like arranging loans to start businesses and creating job opportunities for women living with HIV.

Despite continuous information dissemination via different media, fear of stigma and discrimination was a frequently reported reason for LTFU among women in PMTCT care. Consistent with other studies conducted in Ethiopia and other African countries, our study identified that fear of stigma and discrimination by partners, family, and community members are significant risk factors for LTFU 27 , 28 , 29 , 31 . As a result, women did not usually disclose their HIV status to their partners 28 , 32 so that they could not get financial and psychological support. This highlights the need to intensify interventions by different stakeholders to reduce HIV-related stigma and discrimination in the study area. Women's associations, community-based organizations, and religious, community, and political leaders should continuously work on advocacy and awareness creation to combat HIV-related stigma and discrimination.

Our study revealed that a lack of support for women made them discontinue life-saving ARV drugs. In developing countries like Ethiopia, most women living with HIV have low socio-economic status to run their lives, and thus they need support. However, as claimed by the majority of study participants, the government and organizations working on HIV programs were decreasing support from time to time. This was in line with qualitative studies such that lack of support by family members or partners 27 was identified as a barrier to adherence to and retention in PMTCT care 27 , 28 , 29 , 30 , 32 . Organizations working on HIV programs need to design strategies so that poor women get support from partners, family members, the community, religious leaders, and the government to stay in PMTCT care. Moreover, some women thought incentives and support must be given to retain them in Option B plus care. Thus, HCWs should inform women during counselling sessions that they should not link getting PMTCT care to incentives or support.

Women infected with HIV want to be healthy and have HIV-free infants, which could be achieved by proper utilization of recommended therapy as per the protocol 27 , 43 . However, women’s religious beliefs were found to interfere with adherence to the recommended treatment protocol, made them LTFU, and refused resumption after LTFU. Although religious belief did not oppose the use of ARV drugs at any time, women did not take the medicine when they went to Holy Water and prayer. As evidenced by previous studies, lost women perceived that they were cured of the disease with the help of God and refused to resume PMTCT care 27 , 30 . This finding suggests the need for sustained community sensitization about HIV and its treatment, engaging religious leaders. They need to inform women on ART that taking ARV drugs does not contradict religious preaching, and they should not discontinue the drug at any religious engagement.

Once on ART, women should not regress from care and treatment due to problems related to the facility. Unlike the study conducted in Malawi, which reported a shortage of drugs as not a cause of LTFU 29 , in the study area there was a shortage of drugs and supplies to give appropriate care to women and their infants and to retain them in care. They did not get all services related to HIV free of charge and were requested to pay for them, including the cotrimoxazole syrup given to their infants. The finding was consistent with the study conducted in Malawi, where the irregular availability of cotrimoxazole syrup was mentioned as a risk factor for LTFU 32 .

On some occasions, there may also be a shortage of ARV prophylaxis (Nevirapine and Zidovudine syrups) at some facilities for their infants that they couldn’t get from private pharmacies. Services related to PMTCT care were expected to be free of charge for mothers and their infants throughout the care. Ensuring an adequate supply of prophylactic and therapeutic drugs should be considered to prevent the MTCT of HIV and control the spread of the disease among communities via appropriate resource allocation. Facilities should have an adequate supply of ARV prophylaxis and should not request that women pay for diagnostic services. Besides, they always need to provide cotrimoxazole syrup free of charge for HIV-exposed infants.

Lack of awareness of a continuum of PMTCT care among women is a major challenge to retaining them in care. Women who experienced malpractice against standard care practice and had misconceptions about the disease were at higher risk for LTFU. Those women who forgot to take ARV drugs due to different reasons (maybe due to poor counselling) did not get the benefits of ART. Improved counselling and appropriate patient-provider interaction increase women’s engagement in care and reduce the risk of LTFU 28 , 44 . Thus, proper counselling on adherence, malpractice, and misconceptions should be strengthened by healthcare providers in PMTCT units to create optimal awareness for retention.

Maintaining clients’ confidentiality is the backbone of achieving HIV-related treatment goals. However, some women disappear from PMTCT care due to a lack of confidentiality by HCWs delivering the service. Although not large, women claimed a lack of privacy during counselling, and disclosing their HIV status in the community was practiced by some healthcare professionals. The finding was consistent with the study conducted in developing countries, including Ethiopia, where lack of privacy and fear regarding breaches of confidentiality by healthcare workers were identified as risk factors for LTFU 31 , 32 , 44 . Thus, HCWs should deliver appropriate counselling services and maintain clients’ confidentiality to develop trust among women.

The validity of the findings of this study was strengthened by the triangulating data collected from women, MSG members, and HCWs delivering PMTCT service. Besides, the study included women from the community who had already been lost from care during the study, which minimized the risk of recall bias. However, we recognized the following limitations. First, the study did not explore the husband’s perspective to validate the findings from women and HCWs. Second, the study may have different reasons for LTFU for women who were unreached or unwilling to participate compared to those who agreed to be interviewed. Thus, further studies are advised to include the husband’s perception to validate their concern and to address all women who have lost care.

Conclusions

Financial constraints to cover transportation costs, fear of partner divorce and violence, HIV-related stigma and discrimination, lack of psychological support, religious belief, shortage of drug supply, inadequate service access, and breach of confidentiality by HCWs were major reasons for women’s lost. Healthcare workers’ commitment to searching for lost women, partners’ encouragement to resume care, and women’s desire to live healthily were explored as reasons for resumption after LTFU. Women empowerment, partner engagement, involving community and religious leaders, awareness creation on the effect of HIV-related stigma and discrimination for the community, and service delivery as per the protocol were of vital importance to retain women on care and resume care after LTFU. Besides, HCWs should address false beliefs related to the disease during counseling sessions to retain women in care.

Data availability

All data generated or analysed during this study are included in this article and its Supplementary Information files.

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Acknowledgements

The authors acknowledge the staff of the South Ethiopia and Central Ethiopia Regional Health Bureaus for their technical and logistic support. Moreover, the authors sincerely thank the research assistants who translated and transcribed the interview. The authors would also like to thank the study participants who were involved in the study.

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W.F. was involved in the study's conception, design, execution, data acquisition, analysis, interpretation, and manuscript drafting. T.T., E.W., and A.A. were involved in the project concept, guidance, and critical review of the article. All the authors have reviewed and approved the final manuscript and agreed to publish it in scientific reports.

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Facha, W., Tadesse, T., Wolka, E. et al. A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia. Sci Rep 14 , 21440 (2024). https://doi.org/10.1038/s41598-024-71252-2

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Conducting and Writing Quantitative and Qualitative Research

Edward barroga.

1 Department of Medical Education, Showa University School of Medicine, Tokyo, Japan.

Glafera Janet Matanguihan

2 Department of Biological Sciences, Messiah University, Mechanicsburg, PA, USA.

Atsuko Furuta

Makiko arima, shizuma tsuchiya, chikako kawahara, yusuke takamiya.

Comprehensive knowledge of quantitative and qualitative research systematizes scholarly research and enhances the quality of research output. Scientific researchers must be familiar with them and skilled to conduct their investigation within the frames of their chosen research type. When conducting quantitative research, scientific researchers should describe an existing theory, generate a hypothesis from the theory, test their hypothesis in novel research, and re-evaluate the theory. Thereafter, they should take a deductive approach in writing the testing of the established theory based on experiments. When conducting qualitative research, scientific researchers raise a question, answer the question by performing a novel study, and propose a new theory to clarify and interpret the obtained results. After which, they should take an inductive approach to writing the formulation of concepts based on collected data. When scientific researchers combine the whole spectrum of inductive and deductive research approaches using both quantitative and qualitative research methodologies, they apply mixed-method research. Familiarity and proficiency with these research aspects facilitate the construction of novel hypotheses, development of theories, or refinement of concepts.

Graphical Abstract

INTRODUCTION

Novel research studies are conceptualized by scientific researchers first by asking excellent research questions and developing hypotheses, then answering these questions by testing their hypotheses in ethical research. 1 , 2 , 3 Before they conduct novel research studies, scientific researchers must possess considerable knowledge of both quantitative and qualitative research. 2

In quantitative research, researchers describe existing theories, generate and test a hypothesis in novel research, and re-evaluate existing theories deductively based on their experimental results. 1 , 4 , 5 In qualitative research, scientific researchers raise and answer research questions by performing a novel study, then propose new theories by clarifying their results inductively. 1 , 6

RATIONALE OF THIS ARTICLE

When researchers have a limited knowledge of both research types and how to conduct them, this can result in substandard investigation. Researchers must be familiar with both types of research and skilled to conduct their investigations within the frames of their chosen type of research. Thus, meticulous care is needed when planning quantitative and qualitative research studies to avoid unethical research and poor outcomes.

Understanding the methodological and writing assumptions 7 , 8 underpinning quantitative and qualitative research, especially by non-Anglophone researchers, is essential for their successful conduct. Scientific researchers, especially in the academe, face pressure to publish in international journals 9 where English is the language of scientific communication. 10 , 11 In particular, non-Anglophone researchers face challenges related to linguistic, stylistic, and discourse differences. 11 , 12 Knowing the assumptions of the different types of research will help clarify research questions and methodologies, easing the challenge and help.

SEARCH FOR RELEVANT ARTICLES

To identify articles relevant to this topic, we adhered to the search strategy recommended by Gasparyan et al. 7 We searched through PubMed, Scopus, Directory of Open Access Journals, and Google Scholar databases using the following keywords: quantitative research, qualitative research, mixed-method research, deductive reasoning, inductive reasoning, study design, descriptive research, correlational research, experimental research, causal-comparative research, quasi-experimental research, historical research, ethnographic research, meta-analysis, narrative research, grounded theory, phenomenology, case study, and field research.

AIMS OF THIS ARTICLE

This article aims to provide a comparative appraisal of qualitative and quantitative research for scientific researchers. At present, there is still a need to define the scope of qualitative research, especially its essential elements. 13 Consensus on the critical appraisal tools to assess the methodological quality of qualitative research remains lacking. 14 Framing and testing research questions can be challenging in qualitative research. 2 In the healthcare system, it is essential that research questions address increasingly complex situations. Therefore, research has to be driven by the kinds of questions asked and the corresponding methodologies to answer these questions. 15 The mixed-method approach also needs to be clarified as this would appear to arise from different philosophical underpinnings. 16

This article also aims to discuss how particular types of research should be conducted and how they should be written in adherence to international standards. In the US, Europe, and other countries, responsible research and innovation was conceptualized and promoted with six key action points: engagement, gender equality, science education, open access, ethics and governance. 17 , 18 International ethics standards in research 19 as well as academic integrity during doctoral trainings are now integral to the research process. 20

POTENTIAL BENEFITS FROM THIS ARTICLE

This article would be beneficial for researchers in further enhancing their understanding of the theoretical, methodological, and writing aspects of qualitative and quantitative research, and their combination.

Moreover, this article reviews the basic features of both research types and overviews the rationale for their conduct. It imparts information on the most common forms of quantitative and qualitative research, and how they are carried out. These aspects would be helpful for selecting the optimal methodology to use for research based on the researcher’s objectives and topic.

This article also provides information on the strengths and weaknesses of quantitative and qualitative research. Such information would help researchers appreciate the roles and applications of both research types and how to gain from each or their combination. As different research questions require different types of research and analyses, this article is anticipated to assist researchers better recognize the questions answered by quantitative and qualitative research.

Finally, this article would help researchers to have a balanced perspective of qualitative and quantitative research without considering one as superior to the other.

TYPES OF RESEARCH

Research can be classified into two general types, quantitative and qualitative. 21 Both types of research entail writing a research question and developing a hypothesis. 22 Quantitative research involves a deductive approach to prove or disprove the hypothesis that was developed, whereas qualitative research involves an inductive approach to create a hypothesis. 23 , 24 , 25 , 26

In quantitative research, the hypothesis is stated before testing. In qualitative research, the hypothesis is developed through inductive reasoning based on the data collected. 27 , 28 For types of data and their analysis, qualitative research usually includes data in the form of words instead of numbers more commonly used in quantitative research. 29

Quantitative research usually includes descriptive, correlational, causal-comparative / quasi-experimental, and experimental research. 21 On the other hand, qualitative research usually encompasses historical, ethnographic, meta-analysis, narrative, grounded theory, phenomenology, case study, and field research. 23 , 25 , 28 , 30 A summary of the features, writing approach, and examples of published articles for each type of qualitative and quantitative research is shown in Table 1 . 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43

QUANTITATIVE RESEARCH

Deductive approach.

The deductive approach is used to prove or disprove the hypothesis in quantitative research. 21 , 25 Using this approach, researchers 1) make observations about an unclear or new phenomenon, 2) investigate the current theory surrounding the phenomenon, and 3) hypothesize an explanation for the observations. Afterwards, researchers will 4) predict outcomes based on the hypotheses, 5) formulate a plan to test the prediction, and 6) collect and process the data (or revise the hypothesis if the original hypothesis was false). Finally, researchers will then 7) verify the results, 8) make the final conclusions, and 9) present and disseminate their findings ( Fig. 1A ).

Types of quantitative research

The common types of quantitative research include (a) descriptive, (b) correlational, c) experimental research, and (d) causal-comparative/quasi-experimental. 21

Descriptive research is conducted and written by describing the status of an identified variable to provide systematic information about a phenomenon. A hypothesis is developed and tested after data collection, analysis, and synthesis. This type of research attempts to factually present comparisons and interpretations of findings based on analyses of the characteristics, progression, or relationships of a certain phenomenon by manipulating the employed variables or controlling the involved conditions. 44 Here, the researcher examines, observes, and describes a situation, sample, or variable as it occurs without investigator interference. 31 , 45 To be meaningful, the systematic collection of information requires careful selection of study units by precise measurement of individual variables 21 often expressed as ranges, means, frequencies, and/or percentages. 31 , 45 Descriptive statistical analysis using ANOVA, Student’s t -test, or the Pearson coefficient method has been used to analyze descriptive research data. 46

Correlational research is performed by determining and interpreting the extent of a relationship between two or more variables using statistical data. This involves recognizing data trends and patterns without necessarily proving their causes. The researcher studies only the data, relationships, and distributions of variables in a natural setting, but does not manipulate them. 21 , 45 Afterwards, the researcher establishes reliability and validity, provides converging evidence, describes relationship, and makes predictions. 47

Experimental research is usually referred to as true experimentation. The researcher establishes the cause-effect relationship among a group of variables making up a study using the scientific method or process. This type of research attempts to identify the causal relationships between variables through experiments by arbitrarily controlling the conditions or manipulating the variables used. 44 The scientific manuscript would include an explanation of how the independent variable was manipulated to determine its effects on the dependent variables. The write-up would also describe the random assignments of subjects to experimental treatments. 21

Causal-comparative/quasi-experimental research closely resembles true experimentation but is conducted by establishing the cause-effect relationships among variables. It may also be conducted to establish the cause or consequences of differences that already exist between, or among groups of individuals. 48 This type of research compares outcomes between the intervention groups in which participants are not randomized to their respective interventions because of ethics- or feasibility-related reasons. 49 As in true experiments, the researcher identifies and measures the effects of the independent variable on the dependent variable. However, unlike true experiments, the researchers do not manipulate the independent variable.

In quasi-experimental research, naturally formed or pre-existing groups that are not randomly assigned are used, particularly when an ethical, randomized controlled trial is not feasible or logical. 50 The researcher identifies control groups as those which have been exposed to the treatment variable, and then compares these with the unexposed groups. The causes are determined and described after data analysis, after which conclusions are made. The known and unknown variables that could still affect the outcome are also included. 7

QUALITATIVE RESEARCH

Inductive approach.

Qualitative research involves an inductive approach to develop a hypothesis. 21 , 25 Using this approach, researchers answer research questions and develop new theories, but they do not test hypotheses or previous theories. The researcher seldom examines the effectiveness of an intervention, but rather explores the perceptions, actions, and feelings of participants using interviews, content analysis, observations, or focus groups. 25 , 45 , 51

Distinctive features of qualitative research

Qualitative research seeks to elucidate about the lives of people, including their lived experiences, behaviors, attitudes, beliefs, personality characteristics, emotions, and feelings. 27 , 30 It also explores societal, organizational, and cultural issues. 30 This type of research provides a good story mimicking an adventure which results in a “thick” description that puts readers in the research setting. 52

The qualitative research questions are open-ended, evolving, and non-directional. 26 The research design is usually flexible and iterative, commonly employing purposive sampling. The sample size depends on theoretical saturation, and data is collected using in-depth interviews, focus groups, and observations. 27

In various instances, excellent qualitative research may offer insights that quantitative research cannot. Moreover, qualitative research approaches can describe the ‘lived experience’ perspectives of patients, practitioners, and the public. 53 Interestingly, recent developments have looked into the use of technology in shaping qualitative research protocol development, data collection, and analysis phases. 54

Qualitative research employs various techniques, including conversational and discourse analysis, biographies, interviews, case-studies, oral history, surveys, documentary and archival research, audiovisual analysis, and participant observations. 26

Conducting qualitative research

To conduct qualitative research, investigators 1) identify a general research question, 2) choose the main methods, sites, and subjects, and 3) determine methods of data documentation access to subjects. Researchers also 4) decide on the various aspects for collecting data (e.g., questions, behaviors to observe, issues to look for in documents, how much (number of questions, interviews, or observations), 5) clarify researchers’ roles, and 6) evaluate the study’s ethical implications in terms of confidentiality and sensitivity. Afterwards, researchers 7) collect data until saturation, 8) interpret data by identifying concepts and theories, and 9) revise the research question if necessary and form hypotheses. In the final stages of the research, investigators 10) collect and verify data to address revisions, 11) complete the conceptual and theoretical framework to finalize their findings, and 12) present and disseminate findings ( Fig. 1B ).

Types of qualitative research

The different types of qualitative research include (a) historical research, (b) ethnographic research, (c) meta-analysis, (d) narrative research, (e) grounded theory, (f) phenomenology, (g) case study, and (h) field research. 23 , 25 , 28 , 30

Historical research is conducted by describing past events, problems, issues, and facts. The researcher gathers data from written or oral descriptions of past events and attempts to recreate the past without interpreting the events and their influence on the present. 6 Data is collected using documents, interviews, and surveys. 55 The researcher analyzes these data by describing the development of events and writes the research based on historical reports. 2

Ethnographic research is performed by observing everyday life details as they naturally unfold. 2 It can also be conducted by developing in-depth analytical descriptions of current systems, processes, and phenomena or by understanding the shared beliefs and practices of a particular group or culture. 21 The researcher collects extensive narrative non-numerical data based on many variables over an extended period, in a natural setting within a specific context. To do this, the researcher uses interviews, observations, and active participation. These data are analyzed by describing and interpreting them and developing themes. A detailed report of the interpreted data is then provided. 2 The researcher immerses himself/herself into the study population and describes the actions, behaviors, and events from the perspective of someone involved in the population. 23 As examples of its application, ethnographic research has helped to understand a cultural model of family and community nursing during the coronavirus disease 2019 outbreak. 56 It has also been used to observe the organization of people’s environment in relation to cardiovascular disease management in order to clarify people’s real expectations during follow-up consultations, possibly contributing to the development of innovative solutions in care practices. 57

Meta-analysis is carried out by accumulating experimental and correlational results across independent studies using a statistical method. 21 The report is written by specifying the topic and meta-analysis type. In the write-up, reporting guidelines are followed, which include description of inclusion criteria and key variables, explanation of the systematic search of databases, and details of data extraction. Meta-analysis offers in-depth data gathering and analysis to achieve deeper inner reflection and phenomenon examination. 58

Narrative research is performed by collecting stories for constructing a narrative about an individual’s experiences and the meanings attributed to them by the individual. 9 It aims to hear the voice of individuals through their account or experiences. 17 The researcher usually conducts interviews and analyzes data by storytelling, content review, and theme development. The report is written as an in-depth narration of events or situations focused on the participants. 2 , 59 Narrative research weaves together sequential events from one or two individuals to create a “thick” description of a cohesive story or narrative. 23 It facilitates understanding of individuals’ lives based on their own actions and interpretations. 60

Grounded theory is conducted by engaging in an inductive ground-up or bottom-up strategy of generating a theory from data. 24 The researcher incorporates deductive reasoning when using constant comparisons. Patterns are detected in observations and then a working hypothesis is created which directs the progression of inquiry. The researcher collects data using interviews and questionnaires. These data are analyzed by coding the data, categorizing themes, and describing implications. The research is written as a theory and theoretical models. 2 In the write-up, the researcher describes the data analysis procedure (i.e., theoretical coding used) for developing hypotheses based on what the participants say. 61 As an example, a qualitative approach has been used to understand the process of skill development of a nurse preceptor in clinical teaching. 62 A researcher can also develop a theory using the grounded theory approach to explain the phenomena of interest by observing a population. 23

Phenomenology is carried out by attempting to understand the subjects’ perspectives. This approach is pertinent in social work research where empathy and perspective are keys to success. 21 Phenomenology studies an individual’s lived experience in the world. 63 The researcher collects data by interviews, observations, and surveys. 16 These data are analyzed by describing experiences, examining meanings, and developing themes. The researcher writes the report by contextualizing and reporting the subjects’ experience. This research approach describes and explains an event or phenomenon from the perspective of those who have experienced it. 23 Phenomenology understands the participants’ experiences as conditioned by their worldviews. 52 It is suitable for a deeper understanding of non-measurable aspects related to the meanings and senses attributed by individuals’ lived experiences. 60

Case study is conducted by collecting data through interviews, observations, document content examination, and physical inspections. The researcher analyzes the data through a detailed identification of themes and the development of narratives. The report is written as an in-depth study of possible lessons learned from the case. 2

Field research is performed using a group of methodologies for undertaking qualitative inquiries. The researcher goes directly to the social phenomenon being studied and observes it extensively. In the write-up, the researcher describes the phenomenon under the natural environment over time with no implantation of controls or experimental conditions. 45

DIFFERENCES BETWEEN QUANTITATIVE AND QUALITATIVE RESEARCH

Scientific researchers must be aware of the differences between quantitative and qualitative research in terms of their working mechanisms to better understand their specific applications. This knowledge will be of significant benefit to researchers, especially during the planning process, to ensure that the appropriate type of research is undertaken to fulfill the research aims.

In terms of quantitative research data evaluation, four well-established criteria are used: internal validity, external validity, reliability, and objectivity. 23 The respective correlating concepts in qualitative research data evaluation are credibility, transferability, dependability, and confirmability. 30 Regarding write-up, quantitative research papers are usually shorter than their qualitative counterparts, which allows the latter to pursue a deeper understanding and thus producing the so-called “thick” description. 29

Interestingly, a major characteristic of qualitative research is that the research process is reversible and the research methods can be modified. This is in contrast to quantitative research in which hypothesis setting and testing take place unidirectionally. This means that in qualitative research, the research topic and question may change during literature analysis, and that the theoretical and analytical methods could be altered during data collection. 44

Quantitative research focuses on natural, quantitative, and objective phenomena, whereas qualitative research focuses on social, qualitative, and subjective phenomena. 26 Quantitative research answers the questions “what?” and “when?,” whereas qualitative research answers the questions “why?,” “how?,” and “how come?.” 64

Perhaps the most important distinction between quantitative and qualitative research lies in the nature of the data being investigated and analyzed. Quantitative research focuses on statistical, numerical, and quantitative aspects of phenomena, and employ the same data collection and analysis, whereas qualitative research focuses on the humanistic, descriptive, and qualitative aspects of phenomena. 26 , 28

Structured versus unstructured processes

The aims and types of inquiries determine the difference between quantitative and qualitative research. In quantitative research, statistical data and a structured process are usually employed by the researcher. Quantitative research usually suggests quantities (i.e., numbers). 65 On the other hand, researchers typically use opinions, reasons, verbal statements, and an unstructured process in qualitative research. 63 Qualitative research is more related to quality or kind. 65

In quantitative research, the researcher employs a structured process for collecting quantifiable data. Often, a close-ended questionnaire is used wherein the response categories for each question are designed in which values can be assigned and analyzed quantitatively using a common scale. 66 Quantitative research data is processed consecutively from data management, then data analysis, and finally to data interpretation. Data should be free from errors and missing values. In data management, variables are defined and coded. In data analysis, statistics (e.g., descriptive, inferential) as well as central tendency (i.e., mean, median, mode), spread (standard deviation), and parameter estimation (confidence intervals) measures are used. 67

In qualitative research, the researcher uses an unstructured process for collecting data. These non-statistical data may be in the form of statements, stories, or long explanations. Various responses according to respondents may not be easily quantified using a common scale. 66

Composing a qualitative research paper resembles writing a quantitative research paper. Both papers consist of a title, an abstract, an introduction, objectives, methods, findings, and discussion. However, a qualitative research paper is less regimented than a quantitative research paper. 27

Quantitative research as a deductive hypothesis-testing design

Quantitative research can be considered as a hypothesis-testing design as it involves quantification, statistics, and explanations. It flows from theory to data (i.e., deductive), focuses on objective data, and applies theories to address problems. 45 , 68 It collects numerical or statistical data; answers questions such as how many, how often, how much; uses questionnaires, structured interview schedules, or surveys 55 as data collection tools; analyzes quantitative data in terms of percentages, frequencies, statistical comparisons, graphs, and tables showing statistical values; and reports the final findings in the form of statistical information. 66 It uses variable-based models from individual cases and findings are stated in quantified sentences derived by deductive reasoning. 24

In quantitative research, a phenomenon is investigated in terms of the relationship between an independent variable and a dependent variable which are numerically measurable. The research objective is to statistically test whether the hypothesized relationship is true. 68 Here, the researcher studies what others have performed, examines current theories of the phenomenon being investigated, and then tests hypotheses that emerge from those theories. 4

Quantitative hypothesis-testing research has certain limitations. These limitations include (a) problems with selection of meaningful independent and dependent variables, (b) the inability to reflect subjective experiences as variables since variables are usually defined numerically, and (c) the need to state a hypothesis before the investigation starts. 61

Qualitative research as an inductive hypothesis-generating design

Qualitative research can be considered as a hypothesis-generating design since it involves understanding and descriptions in terms of context. It flows from data to theory (i.e., inductive), focuses on observation, and examines what happens in specific situations with the aim of developing new theories based on the situation. 45 , 68 This type of research (a) collects qualitative data (e.g., ideas, statements, reasons, characteristics, qualities), (b) answers questions such as what, why, and how, (c) uses interviews, observations, or focused-group discussions as data collection tools, (d) analyzes data by discovering patterns of changes, causal relationships, or themes in the data; and (e) reports the final findings as descriptive information. 61 Qualitative research favors case-based models from individual characteristics, and findings are stated using context-dependent existential sentences that are justifiable by inductive reasoning. 24

In qualitative research, texts and interviews are analyzed and interpreted to discover meaningful patterns characteristic of a particular phenomenon. 61 Here, the researcher starts with a set of observations and then moves from particular experiences to a more general set of propositions about those experiences. 4

Qualitative hypothesis-generating research involves collecting interview data from study participants regarding a phenomenon of interest, and then using what they say to develop hypotheses. It involves the process of questioning more than obtaining measurements; it generates hypotheses using theoretical coding. 61 When using large interview teams, the key to promoting high-level qualitative research and cohesion in large team methods and successful research outcomes is the balance between autonomy and collaboration. 69

Qualitative data may also include observed behavior, participant observation, media accounts, and cultural artifacts. 61 Focus group interviews are usually conducted, audiotaped or videotaped, and transcribed. Afterwards, the transcript is analyzed by several researchers.

Qualitative research also involves scientific narratives and the analysis and interpretation of textual or numerical data (or both), mostly from conversations and discussions. Such approach uncovers meaningful patterns that describe a particular phenomenon. 2 Thus, qualitative research requires skills in grasping and contextualizing data, as well as communicating data analysis and results in a scientific manner. The reflective process of the inquiry underscores the strengths of a qualitative research approach. 2

Combination of quantitative and qualitative research

When both quantitative and qualitative research methods are used in the same research, mixed-method research is applied. 25 This combination provides a complete view of the research problem and achieves triangulation to corroborate findings, complementarity to clarify results, expansion to extend the study’s breadth, and explanation to elucidate unexpected results. 29

Moreover, quantitative and qualitative findings are integrated to address the weakness of both research methods 29 , 66 and to have a more comprehensive understanding of the phenomenon spectrum. 66

For data analysis in mixed-method research, real non-quantitized qualitative data and quantitative data must both be analyzed. 70 The data obtained from quantitative analysis can be further expanded and deepened by qualitative analysis. 23

In terms of assessment criteria, Hammersley 71 opined that qualitative and quantitative findings should be judged using the same standards of validity and value-relevance. Both approaches can be mutually supportive. 52

Quantitative and qualitative research must be carefully studied and conducted by scientific researchers to avoid unethical research and inadequate outcomes. Quantitative research involves a deductive process wherein a research question is answered with a hypothesis that describes the relationship between independent and dependent variables, and the testing of the hypothesis. This investigation can be aptly termed as hypothesis-testing research involving the analysis of hypothesis-driven experimental studies resulting in a test of significance. Qualitative research involves an inductive process wherein a research question is explored to generate a hypothesis, which then leads to the development of a theory. This investigation can be aptly termed as hypothesis-generating research. When the whole spectrum of inductive and deductive research approaches is combined using both quantitative and qualitative research methodologies, mixed-method research is applied, and this can facilitate the construction of novel hypotheses, development of theories, or refinement of concepts.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

• Conceptualization: Barroga E, Matanguihan GJ.
• Data curation: Barroga E, Matanguihan GJ, Furuta A, Arima M, Tsuchiya S, Kawahara C, Takamiya Y, Izumi M.
• Formal analysis: Barroga E, Matanguihan GJ, Furuta A, Arima M, Tsuchiya S, Kawahara C.
• Investigation: Barroga E, Matanguihan GJ, Takamiya Y, Izumi M.
• Methodology: Barroga E, Matanguihan GJ, Furuta A, Arima M, Tsuchiya S, Kawahara C, Takamiya Y, Izumi M.
• Project administration: Barroga E, Matanguihan GJ.
• Resources: Barroga E, Matanguihan GJ, Furuta A, Arima M, Tsuchiya S, Kawahara C, Takamiya Y, Izumi M.
• Supervision: Barroga E.
• Validation: Barroga E, Matanguihan GJ, Furuta A, Arima M, Tsuchiya S, Kawahara C, Takamiya Y, Izumi M.
• Visualization: Barroga E, Matanguihan GJ.
• Writing - original draft: Barroga E, Matanguihan GJ.
• Writing - review & editing: Barroga E, Matanguihan GJ, Furuta A, Arima M, Tsuchiya S, Kawahara C, Takamiya Y, Izumi M.