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Qualitative Research – Methods, Analysis Types and Guide

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Qualitative Research

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

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

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

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

Focus Groups

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

Ethnographic Studies

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

Text Analysis

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

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

Process of Observation

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

Record Keeping

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

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

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

Qualitative Research Analysis Methods

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

Thematic Analysis

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

Content Analysis

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

Discourse Analysis

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

Grounded Theory Analysis

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

Narrative Analysis

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

Phenomenological Analysis

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

Comparative Analysis

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

Applications of Qualitative Research

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

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

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

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

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

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

Purpose of Qualitative Research

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

Qualitative research can serve multiple purposes, including:

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

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

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

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

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

Advantages of Qualitative Research

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

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

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

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

Also see Research Methods

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalisability

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

• Labour-intensive

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Qualitative Research : Definition

Qualitative research is the naturalistic study of social meanings and processes, using interviews, observations, and the analysis of texts and images.  In contrast to quantitative researchers, whose statistical methods enable broad generalizations about populations (for example, comparisons of the percentages of U.S. demographic groups who vote in particular ways), qualitative researchers use in-depth studies of the social world to analyze how and why groups think and act in particular ways (for instance, case studies of the experiences that shape political views).   

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Qualitative Research

What is qualitative research.

Qualitative research is the methodology researchers use to gain deep contextual understandings of users via non-numerical means and direct observations. Researchers focus on smaller user samples—e.g., in interviews—to reveal data such as user attitudes, behaviors and hidden factors: insights which guide better designs.

“ There are also unknown unknowns, things we don’t know we don’t know.” — Donald Rumsfeld, Former U.S. Secretary of Defense

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See how you can use qualitative research to expose hidden truths about users and iteratively shape better products.

Qualitative Research Focuses on the “Why”

Qualitative research is a subset of user experience (UX) research and user research . By doing qualitative research, you aim to gain narrowly focused but rich information about why users feel and think the ways they do. Unlike its more statistics-oriented “counterpart”, quantitative research , qualitative research can help expose hidden truths about your users’ motivations, hopes, needs, pain points and more to help you keep your project’s focus on track throughout development. UX design professionals do qualitative research typically from early on in projects because—since the insights they reveal can alter product development dramatically—they can prevent costly design errors from arising later. Compare and contrast qualitative with quantitative research here:

Qualitative research

Quantitative Research

You Aim to Determine

The “why” – to get behind how users approach their problems in their world

The “what”, “where” & “when” of the users’ needs & problems – to help keep your project’s focus on track during development

Loosely structured (e.g., contextual inquiries) – to learn why users behave how they do & explore their opinions

Highly structured (e.g., surveys) – to gather data about what users do & find patterns in large user groups

Number of Representative Users

Often around 5

Ideally 30+

Level of Contact with Users

More direct & less remote (e.g., usability testing to examine users’ stress levels when they use your design)

Less direct & more remote (e.g., analytics)

Statistically

You need to take great care with handling non-numerical data (e.g., opinions), as your own opinions might influence findings

Reliable – given enough test users

Regarding care with opinions, it’s easy to be subjective about qualitative data, which isn’t as comprehensively analyzable as quantitative data. That’s why design teams also apply quantitative research methods, to reinforce the “why” with the “what”.

Qualitative Research Methods You Can Use to Get Behind Your Users

You have a choice of many methods to help gain the clearest insights into your users’ world – which you might want to complement with quantitative research methods. In iterative processes such as user-centered design , you/your design team would use quantitative research to spot design problems, discover the reasons for these with qualitative research, make changes and then test your improved design on users again. The best method/s to pick will depend on the stage of your project and your objectives. Here are some:

Diary studies – You ask users to document their activities, interactions, etc. over a defined period. This empowers users to deliver context-rich information. Although such studies can be subjective—since users will inevitably be influenced by in-the-moment human issues and their emotions—they’re helpful tools to access generally authentic information.

Structured – You ask users specific questions and analyze their responses with other users’.

Semi-structured – You have a more free-flowing conversation with users, but still follow a prepared script loosely.

Ethnographic – You interview users in their own environment to appreciate how they perform tasks and view aspects of tasks.

Usability testing

Moderated – In-person testing in, e.g., a lab.

Unmoderated – Users complete tests remotely: e.g., through a video call.

Guerrilla – “Down-the-hall”/“down-and-dirty” testing on a small group of random users or colleagues.

User observation – You watch users get to grips with your design and note their actions, words and reactions as they attempt to perform tasks.

Qualitative research can be more or less structured depending on the method.

Qualitative Research – How to Get Reliable Results

Some helpful points to remember are:

Participants – Select a number of test users carefully (typically around 5). Observe the finer points such as body language. Remember the difference between what they do and what they say they do.

Moderated vs. unmoderated – You can obtain the richest data from moderated studies, but these can involve considerable time and practice. You can usually conduct unmoderated studies more quickly and cheaply, but you should plan these carefully to ensure instructions are clear, etc.

Types of questions – You’ll learn far more by asking open-ended questions. Avoid leading users’ answers – ask about their experience during, say, the “search for deals” process rather than how easy it was. Try to frame questions so users respond honestly: i.e., so they don’t withhold grievances about their experience because they don’t want to seem impolite. Distorted feedback may also arise in guerrilla testing, as test users may be reluctant to sound negative or to discuss fine details if they lack time.

Location – Think how where users are might affect their performance and responses. If, for example, users’ tasks involve running or traveling on a train, select the appropriate method (e.g., diary studies for them to record aspects of their experience in the environment of a train carriage and the many factors impacting it).

Overall, no single research method can help you answer all your questions. Nevertheless, The Nielsen Norman Group advise that if you only conduct one kind of user research, you should pick qualitative usability testing, since a small sample size can yield many cost- and project-saving insights. Always treat users and their data ethically. Finally, remember the importance of complementing qualitative methods with quantitative ones: You gain insights from the former; you test those using the latter.

Learn More about Qualitative Research

Take our course on User Research to see how to get the most from qualitative research.

Read about the numerous considerations for qualitative research in this in-depth piece.

This blog discusses the importance of qualitative research , with tips.

Explore additional insights into qualitative research here .

Literature on Qualitative Research

Here’s the entire UX literature on Qualitative Research by the Interaction Design Foundation, collated in one place:

Learn more about Qualitative Research

Take a deep dive into Qualitative Research with our course User Research – Methods and Best Practices .

How do you plan to design a product or service that your users will love , if you don't know what they want in the first place? As a user experience designer, you shouldn't leave it to chance to design something outstanding; you should make the effort to understand your users and build on that knowledge from the outset. User research is the way to do this, and it can therefore be thought of as the largest part of user experience design .

In fact, user research is often the first step of a UX design process—after all, you cannot begin to design a product or service without first understanding what your users want! As you gain the skills required, and learn about the best practices in user research, you’ll get first-hand knowledge of your users and be able to design the optimal product—one that’s truly relevant for your users and, subsequently, outperforms your competitors’ .

This course will give you insights into the most essential qualitative research methods around and will teach you how to put them into practice in your design work. You’ll also have the opportunity to embark on three practical projects where you can apply what you’ve learned to carry out user research in the real world . You’ll learn details about how to plan user research projects and fit them into your own work processes in a way that maximizes the impact your research can have on your designs. On top of that, you’ll gain practice with different methods that will help you analyze the results of your research and communicate your findings to your clients and stakeholders—workshops, user journeys and personas, just to name a few!

By the end of the course, you’ll have not only a Course Certificate but also three case studies to add to your portfolio. And remember, a portfolio with engaging case studies is invaluable if you are looking to break into a career in UX design or user research!

We believe you should learn from the best, so we’ve gathered a team of experts to help teach this course alongside our own course instructors. That means you’ll meet a new instructor in each of the lessons on research methods who is an expert in their field—we hope you enjoy what they have in store for you!

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Quantitative and Qualitative Research

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What is qualitative research?

Qualitative research is a process of naturalistic inquiry that seeks an in-depth understanding of social phenomena within their natural setting. It focuses on the "why" rather than the "what" of social phenomena and relies on the direct experiences of human beings as meaning-making agents in their every day lives. Rather than by logical and statistical procedures, qualitative researchers use multiple systems of inquiry for the study of human phenomena including biography, case study, historical analysis, discourse analysis, ethnography, grounded theory, and phenomenology.

University of Utah College of Nursing, (n.d.). What is qualitative research? [Guide] Retrieved from  https://nursing.utah.edu/research/qualitative-research/what-is-qualitative-research.php#what 

The following video will explain the fundamentals of qualitative research.

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Home Market Research

Qualitative Research Methods: Types, Analysis + Examples

Qualitative research is based on the disciplines of social sciences like psychology, sociology, and anthropology. Therefore, the qualitative research methods allow for in-depth and further probing and questioning of respondents based on their responses. The interviewer/researcher also tries to understand their motivation and feelings. Understanding how your audience makes decisions can help derive conclusions in market research.

What is qualitative research?

Qualitative research is defined as a market research method that focuses on obtaining data through open-ended and conversational communication .

This method is about “what” people think and “why” they think so. For example, consider a convenience store looking to improve its patronage. A systematic observation concludes that more men are visiting this store. One good method to determine why women were not visiting the store is conducting an in-depth interview method with potential customers.

For example, after successfully interviewing female customers and visiting nearby stores and malls, the researchers selected participants through random sampling . As a result, it was discovered that the store didn’t have enough items for women.

So fewer women were visiting the store, which was understood only by personally interacting with them and understanding why they didn’t visit the store because there were more male products than female ones.

Gather research insights

Types of qualitative research methods with examples

Qualitative research methods are designed in a manner that helps reveal the behavior and perception of a target audience with reference to a particular topic. There are different types of qualitative research methods, such as in-depth interviews, focus groups, ethnographic research, content analysis, and case study research that are usually used.

The results of qualitative methods are more descriptive, and the inferences can be drawn quite easily from the obtained data .

Qualitative research methods originated in the social and behavioral research sciences. Today, our world is more complicated, and it is difficult to understand what people think and perceive. Online research methods make it easier to understand that as it is a more communicative and descriptive analysis .

The following are the qualitative research methods that are frequently used. Also, read about qualitative research examples :

1. One-on-one interview

Conducting in-depth interviews is one of the most common qualitative research methods. It is a personal interview that is carried out with one respondent at a time. This is purely a conversational method and invites opportunities to get details in depth from the respondent.

One of the advantages of this method is that it provides a great opportunity to gather precise data about what people believe and their motivations . If the researcher is well experienced, asking the right questions can help him/her collect meaningful data. If they should need more information, the researchers should ask such follow-up questions that will help them collect more information.

These interviews can be performed face-to-face or on the phone and usually can last between half an hour to two hours or even more. When the in-depth interview is conducted face to face, it gives a better opportunity to read the respondents’ body language and match the responses.

2. Focus groups

A focus group is also a commonly used qualitative research method used in data collection. A focus group usually includes a limited number of respondents (6-10) from within your target market.

The main aim of the focus group is to find answers to the “why, ” “what,” and “how” questions. One advantage of focus groups is you don’t necessarily need to interact with the group in person. Nowadays, focus groups can be sent an online survey on various devices, and responses can be collected at the click of a button.

Focus groups are an expensive method as compared to other online qualitative research methods. Typically, they are used to explain complex processes. This method is very useful for market research on new products and testing new concepts.

3. Ethnographic research

Ethnographic research is the most in-depth observational research method that studies people in their naturally occurring environment.

This method requires the researchers to adapt to the target audiences’ environments, which could be anywhere from an organization to a city or any remote location. Here, geographical constraints can be an issue while collecting data.

This research design aims to understand the cultures, challenges, motivations, and settings that occur. Instead of relying on interviews and discussions, you experience the natural settings firsthand.

This type of research method can last from a few days to a few years, as it involves in-depth observation and collecting data on those grounds. It’s a challenging and time-consuming method and solely depends on the researcher’s expertise to analyze, observe, and infer the data.

4. Case study research

T he case study method has evolved over the past few years and developed into a valuable quality research method. As the name suggests, it is used for explaining an organization or an entity.

This type of research method is used within a number of areas like education, social sciences, and similar. This method may look difficult to operate; however , it is one of the simplest ways of conducting research as it involves a deep dive and thorough understanding of the data collection methods and inferring the data.

5. Record keeping

This method makes use of the already existing reliable documents and similar sources of information as the data source. This data can be used in new research. This is similar to going to a library. There, one can go over books and other reference material to collect relevant data that can likely be used in the research.

6. Process of observation

Qualitative Observation is a process of research that uses subjective methodologies to gather systematic information or data. Since the focus on qualitative observation is the research process of using subjective methodologies to gather information or data. Qualitative observation is primarily used to equate quality differences.

Qualitative observation deals with the 5 major sensory organs and their functioning – sight, smell, touch, taste, and hearing. This doesn’t involve measurements or numbers but instead characteristics.

Explore Insightfully Contextual Inquiry in Qualitative Research

Qualitative research: data collection and analysis

A. qualitative data collection.

Qualitative data collection allows collecting data that is non-numeric and helps us to explore how decisions are made and provide us with detailed insight. For reaching such conclusions the data that is collected should be holistic, rich, and nuanced and findings to emerge through careful analysis.

• Whatever method a researcher chooses for collecting qualitative data, one aspect is very clear the process will generate a large amount of data. In addition to the variety of methods available, there are also different methods of collecting and recording the data.

For example, if the qualitative data is collected through a focus group or one-to-one discussion, there will be handwritten notes or video recorded tapes. If there are recording they should be transcribed and before the process of data analysis can begin.

• As a rough guide, it can take a seasoned researcher 8-10 hours to transcribe the recordings of an interview, which can generate roughly 20-30 pages of dialogues. Many researchers also like to maintain separate folders to maintain the recording collected from the different focus group. This helps them compartmentalize the data collected.
• In case there are running notes taken, which are also known as field notes, they are helpful in maintaining comments, environmental contexts, environmental analysis , nonverbal cues etc. These filed notes are helpful and can be compared while transcribing audio recorded data. Such notes are usually informal but should be secured in a similar manner as the video recordings or the audio tapes.

B. Qualitative data analysis

Qualitative data analysis such as notes, videos, audio recordings images, and text documents. One of the most used methods for qualitative data analysis is text analysis.

Text analysis is a  data analysis method that is distinctly different from all other qualitative research methods, where researchers analyze the social life of the participants in the research study and decode the words, actions, etc. 

There are images also that are used in this research study and the researchers analyze the context in which the images are used and draw inferences from them. In the last decade, text analysis through what is shared on social media platforms has gained supreme popularity.

Characteristics of qualitative research methods

• Qualitative research methods usually collect data at the sight, where the participants are experiencing issues or research problems . These are real-time data and rarely bring the participants out of the geographic locations to collect information.
• Qualitative researchers typically gather multiple forms of data, such as interviews, observations, and documents, rather than rely on a single data source .
• This type of research method works towards solving complex issues by breaking down into meaningful inferences, that is easily readable and understood by all.
• Since it’s a more communicative method, people can build their trust on the researcher and the information thus obtained is raw and unadulterated.

Qualitative research method case study

Let’s take the example of a bookstore owner who is looking for ways to improve their sales and customer outreach. An online community of members who were loyal patrons of the bookstore were interviewed and related questions were asked and the questions were answered by them.

At the end of the interview, it was realized that most of the books in the stores were suitable for adults and there were not enough options for children or teenagers.

By conducting this qualitative research the bookstore owner realized what the shortcomings were and what were the feelings of the readers. Through this research now the bookstore owner can now keep books for different age categories and can improve his sales and customer outreach.

Such qualitative research method examples can serve as the basis to indulge in further quantitative research , which provides remedies.

When to use qualitative research

Researchers make use of qualitative research techniques when they need to capture accurate, in-depth insights. It is very useful to capture “factual data”. Here are some examples of when to use qualitative research.

• Developing a new product or generating an idea.
• Studying your product/brand or service to strengthen your marketing strategy.
• To understand your strengths and weaknesses.
• Understanding purchase behavior.
• To study the reactions of your audience to marketing campaigns and other communications.
• Exploring market demographics, segments, and customer care groups.
• Gathering perception data of a brand, company, or product.

LEARN ABOUT: Steps in Qualitative Research

Qualitative research methods vs quantitative research methods

The basic differences between qualitative research methods and quantitative research methods are simple and straightforward. They differ in:

• Their analytical objectives
• Types of questions asked
• Types of data collection instruments
• Forms of data they produce
• Degree of flexibility

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Qualitative Study

Affiliations.

• 1 University of Nebraska Medical Center
• 2 GDB Research and Statistical Consulting
• 3 GDB Research and Statistical Consulting/McLaren Macomb Hospital
• PMID: 29262162
• Bookshelf ID: NBK470395

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. Instead of collecting numerical data points or intervene or introduce treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and application of qualitative research.

Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’. Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is. One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify and it is important to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Examples of Qualitative Research Approaches

Ethnography

Ethnography as a research design has its origins in social and cultural anthropology, and involves the researcher being directly immersed in the participant’s environment. Through this immersion, the ethnographer can use a variety of data collection techniques with the aim of being able to produce a comprehensive account of the social phenomena that occurred during the research period. That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc. through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded Theory

Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.” As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences. In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is defined as the “study of the meaning of phenomena or the study of the particular”. At first glance, it might seem that Grounded Theory and Phenomenology are quite similar, but upon careful examination, the differences can be seen. At its core, phenomenology looks to investigate experiences from the perspective of the individual. Phenomenology is essentially looking into the ‘lived experiences’ of the participants and aims to examine how and why participants behaved a certain way, from their perspective . Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources whereas Phenomenology focuses on describing and explaining an event or phenomena from the perspective of those who have experienced it.

Narrative Research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called ‘thick’ or ‘rich’ description and is a strength of qualitative research. Narrative research is rife with the possibilities of ‘thick’ description as this approach weaves together a sequence of events, usually from just one or two individuals, in the hopes of creating a cohesive story, or narrative. While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be “opportunities for innovation”.

Research Paradigm

Research paradigms are the assumptions, norms, and standards that underpin different approaches to research. Essentially, research paradigms are the ‘worldview’ that inform research. It is valuable for researchers, both qualitative and quantitative, to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontology and epistemologies . Ontology is defined as the "assumptions about the nature of reality” whereas epistemology is defined as the “assumptions about the nature of knowledge” that inform the work researchers do. It is important to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a full understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, it is crucial that researchers understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist vs Postpositivist

To further understand qualitative research, we need to discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social as well as natural sciences. Essentially, positivist thinking insists that the social sciences should use natural science methods in its research which stems from positivist ontology that there is an objective reality that exists that is fully independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained but it could be approximated. Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world” and therefore postpositivist philosophy is often associated with qualitative research. An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are constructivist as well, meaning they think there is no objective external reality that exists but rather that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. “Constructivism contends that individuals’ views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality”. Essentially, Constructivist thought focuses on how ‘reality’ is not a fixed certainty and experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike in positivist views, that there is not necessarily an ‘objective’ reality we all experience. This is the ‘relativist’ ontological view that reality and the world we live in are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.”

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have and can even change the role of the researcher themselves. For example, is the researcher an ‘objective’ observer such as in positivist quantitative work? Or is the researcher an active participant in the research itself, as in postpositivist qualitative work? Understanding the philosophical base of the research undertaken allows researchers to fully understand the implications of their work and their role within the research, as well as reflect on their own positionality and bias as it pertains to the research they are conducting.

Data Sampling

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors at play. The following are examples of participant sampling and selection:

Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

Snowball sampling- the selection is by referral from other participants or people who know potential participants.

Extreme case sampling- targeted selection of rare cases.

Typical case sampling-selection based on regular or average participants.

Data Collection and Analysis

Qualitative research uses several techniques including interviews, focus groups, and observation. [1] [2] [3] Interviews may be unstructured, with open-ended questions on a topic and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one on one and is appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be a participant-observer to share the experiences of the subject or a non-participant or detached observer.

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo.

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. Results also could be in the form of themes and theory or model development.

Dissemination

To standardize and facilitate the dissemination of qualitative research outcomes, the healthcare team can use two reporting standards. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research.

Examples of Application

Many times a research question will start with qualitative research. The qualitative research will help generate the research hypothesis which can be tested with quantitative methods. After the data is collected and analyzed with quantitative methods, a set of qualitative methods can be used to dive deeper into the data for a better understanding of what the numbers truly mean and their implications. The qualitative methods can then help clarify the quantitative data and also help refine the hypothesis for future research. Furthermore, with qualitative research researchers can explore subjects that are poorly studied with quantitative methods. These include opinions, individual's actions, and social science research.

A good qualitative study design starts with a goal or objective. This should be clearly defined or stated. The target population needs to be specified. A method for obtaining information from the study population must be carefully detailed to ensure there are no omissions of part of the target population. A proper collection method should be selected which will help obtain the desired information without overly limiting the collected data because many times, the information sought is not well compartmentalized or obtained. Finally, the design should ensure adequate methods for analyzing the data. An example may help better clarify some of the various aspects of qualitative research.

A researcher wants to decrease the number of teenagers who smoke in their community. The researcher could begin by asking current teen smokers why they started smoking through structured or unstructured interviews (qualitative research). The researcher can also get together a group of current teenage smokers and conduct a focus group to help brainstorm factors that may have prevented them from starting to smoke (qualitative research).

In this example, the researcher has used qualitative research methods (interviews and focus groups) to generate a list of ideas of both why teens start to smoke as well as factors that may have prevented them from starting to smoke. Next, the researcher compiles this data. The research found that, hypothetically, peer pressure, health issues, cost, being considered “cool,” and rebellious behavior all might increase or decrease the likelihood of teens starting to smoke.

The researcher creates a survey asking teen participants to rank how important each of the above factors is in either starting smoking (for current smokers) or not smoking (for current non-smokers). This survey provides specific numbers (ranked importance of each factor) and is thus a quantitative research tool.

The researcher can use the results of the survey to focus efforts on the one or two highest-ranked factors. Let us say the researcher found that health was the major factor that keeps teens from starting to smoke, and peer pressure was the major factor that contributed to teens to start smoking. The researcher can go back to qualitative research methods to dive deeper into each of these for more information. The researcher wants to focus on how to keep teens from starting to smoke, so they focus on the peer pressure aspect.

The researcher can conduct interviews and/or focus groups (qualitative research) about what types and forms of peer pressure are commonly encountered, where the peer pressure comes from, and where smoking first starts. The researcher hypothetically finds that peer pressure often occurs after school at the local teen hangouts, mostly the local park. The researcher also hypothetically finds that peer pressure comes from older, current smokers who provide the cigarettes.

The researcher could further explore this observation made at the local teen hangouts (qualitative research) and take notes regarding who is smoking, who is not, and what observable factors are at play for peer pressure of smoking. The researcher finds a local park where many local teenagers hang out and see that a shady, overgrown area of the park is where the smokers tend to hang out. The researcher notes the smoking teenagers buy their cigarettes from a local convenience store adjacent to the park where the clerk does not check identification before selling cigarettes. These observations fall under qualitative research.

If the researcher returns to the park and counts how many individuals smoke in each region of the park, this numerical data would be quantitative research. Based on the researcher's efforts thus far, they conclude that local teen smoking and teenagers who start to smoke may decrease if there are fewer overgrown areas of the park and the local convenience store does not sell cigarettes to underage individuals.

The researcher could try to have the parks department reassess the shady areas to make them less conducive to the smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk population their perceptions of the changes, what factors are still at play, as well as quantitative research that includes teen smoking rates in the community, the incidence of new teen smokers, among others.

Copyright © 2024, StatPearls Publishing LLC.

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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

You have full access to this article via your institution.

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Professionalism in dentistry: deconstructing common terminology

A review of technical and quality assessment considerations of audio-visual and web-conferencing focus groups in qualitative health research, introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Chapter 12. Focus Groups

Introduction.

Focus groups are a particular and special form of interviewing in which the interview asks focused questions of a group of persons, optimally between five and eight. This group can be close friends, family members, or complete strangers. They can have a lot in common or nothing in common. Unlike one-on-one interviews, which can probe deeply, focus group questions are narrowly tailored (“focused”) to a particular topic and issue and, with notable exceptions, operate at the shallow end of inquiry. For example, market researchers use focus groups to find out why groups of people choose one brand of product over another. Because focus groups are often used for commercial purposes, they sometimes have a bit of a stigma among researchers. This is unfortunate, as the focus group is a helpful addition to the qualitative researcher’s toolkit. Focus groups explicitly use group interaction to assist in the data collection. They are particularly useful as supplements to one-on-one interviews or in data triangulation. They are sometimes used to initiate areas of inquiry for later data collection methods. This chapter describes the main forms of focus groups, lays out some key differences among those forms, and provides guidance on how to manage focus group interviews.

Focus Groups: What Are They and When to Use Them

As interviews, focus groups can be helpfully distinguished from one-on-one interviews. The purpose of conducting a focus group is not to expand the number of people one interviews: the focus group is a different entity entirely. The focus is on the group and its interactions and evaluations rather than on the individuals in that group. If you want to know how individuals understand their lives and their individual experiences, it is best to ask them individually. If you want to find out how a group forms a collective opinion about something (whether a product or an event or an experience), then conducting a focus group is preferable. The power of focus groups resides in their being both focused and oriented to the group . They are best used when you are interested in the shared meanings of a group or how people discuss a topic publicly or when you want to observe the social formation of evaluations. The interaction of the group members is an asset in this method of data collection. If your questions would not benefit from group interaction, this is a good indicator that you should probably use individual interviews (chapter 11). Avoid using focus groups when you are interested in personal information or strive to uncover deeply buried beliefs or personal narratives. In general, you want to avoid using focus groups when the subject matter is polarizing, as people are less likely to be honest in a group setting. There are a few exceptions, such as when you are conducting focus groups with people who are not strangers and/or you are attempting to probe deeply into group beliefs and evaluations. But caution is warranted in these cases. [1]

As with interviewing in general, there are many forms of focus groups. Focus groups are widely used by nonresearchers, so it is important to distinguish these uses from the research focus group. Businesses routinely employ marketing focus groups to test out products or campaigns. Jury consultants employ “mock” jury focus groups, testing out legal case strategies in advance of actual trials. Organizations of various kinds use focus group interviews for program evaluation (e.g., to gauge the effectiveness of a diversity training workshop). The research focus group has many similarities with all these uses but is specifically tailored to a research (rather than applied) interest. The line between application and research use can be blurry, however. To take the case of evaluating the effectiveness of a diversity training workshop, the same interviewer may be conducting focus group interviews both to provide specific actionable feedback for the workshop leaders (this is the application aspect) and to learn more about how people respond to diversity training (an interesting research question with theoretically generalizable results).

When forming a focus group, there are two different strategies for inclusion. Diversity focus groups include people with diverse perspectives and experiences. This helps the researcher identify commonalities across this diversity and/or note interactions across differences. What kind of diversity to capture depends on the research question, but care should be taken to ensure that those participating are not set up for attack from other participants. This is why many warn against diversity focus groups, especially around politically sensitive topics. The other strategy is to build a convergence focus group , which includes people with similar perspectives and experiences. These are particularly helpful for identifying shared patterns and group consensus. The important thing is to closely consider who will be invited to participate and what the composition of the group will be in advance. Some review of sampling techniques (see chapter 5) may be helpful here.

Moderating a focus group can be a challenge (more on this below). For this reason, confining your group to no more than eight participants is recommended. You probably want at least four persons to capture group interaction. Fewer than four participants can also make it more difficult for participants to remain (relatively) anonymous—there is less of a group in which to hide. There are exceptions to these recommendations. You might want to conduct a focus group with a naturally occurring group, as in the case of a family of three, a social club of ten, or a program of fifteen. When the persons know one another, the problems of too few for anonymity don’t apply, and although ten to fifteen can be unwieldy to manage, there are strategies to make this possible. If you really are interested in this group’s dynamic (not just a set of random strangers’ dynamic), then you will want to include all its members or as many as are willing and able to participate.

There are many benefits to conducting focus groups, the first of which is their interactivity. Participants can make comparisons, can elaborate on what has been voiced by another, and can even check one another, leading to real-time reevaluations. This last benefit is one reason they are sometimes employed specifically for consciousness raising or building group cohesion. This form of data collection has an activist application when done carefully and appropriately. It can be fun, especially for the participants. Additionally, what does not come up in a focus group, especially when expected by the researcher, can be very illuminating.

Many of these benefits do incur costs, however. The multiplicity of voices in a good focus group interview can be overwhelming both to moderate and later to transcribe. Because of the focused nature, deep probing is not possible (or desirable). You might only get superficial thinking or what people are willing to put out there publicly. If that is what you are interested in, good. If you want deeper insight, you probably will not get that here. Relatedly, extreme views are often suppressed, and marginal viewpoints are unspoken or, if spoken, derided. You will get the majority group consensus and very little of minority viewpoints. Because people will be engaged with one another, there is the possibility of cut-off sentences, making it even more likely to hear broad brush themes and not detailed specifics. There really is very little opportunity for specific follow-up questions to individuals. Reading over a transcript, you may be frustrated by avenues of inquiry that were foreclosed early.

Some people expect that conducting focus groups is an efficient form of data collection. After all, you get to hear from eight people instead of just one in the same amount of time! But this is a serious misunderstanding. What you hear in a focus group is one single group interview or discussion. It is not the same thing at all as conducting eight single one-hour interviews. Each focus group counts as “one.” Most likely, you will need to conduct several focus groups, and you can design these as comparisons to one another. For example, the American Sociological Association (ASA) Task Force on First-Generation and Working-Class Persons in Sociology began its study of the impact of class in sociology by conducting five separate focus groups with different groups of sociologists: graduate students, faculty (in general), community college faculty, faculty of color, and a racially diverse group of students and faculty. Even though the total number of participants was close to forty, the “number” of cases was five. It is highly recommended that when employing focus groups, you plan on composing more than one and at least three. This allows you to take note of and potentially discount findings from a group with idiosyncratic dynamics, such as where a particularly dominant personality silences all other voices. In other words, putting all your eggs into a single focus group basket is not a good idea.

How to Conduct a Focus Group Interview/Discussion

Advance preparations.

Once you have selected your focus groups and set a date and time, there are a few things you will want to plan out before meeting.

As with interviews, you begin by creating an interview (or discussion) guide. Where a good one-on-one interview guide should include ten to twelve main topics with possible prompts and follow-ups (see the example provided in chapter 11), the focus group guide should be more narrowly tailored to a single focus or topic area. For example, a focus might be “How students coped with online learning during the pandemic,” and a series of possible questions would be drafted that would help prod participants to think about and discuss this topic. These questions or discussion prompts can be creative and may include stimulus materials (watching a video or hearing a story) or posing hypotheticals. For example, Cech ( 2021 ) has a great hypothetical, asking what a fictional character should do: keep his boring job in computers or follow his passion and open a restaurant. You can ask a focus group this question and see what results—how the group comes to define a “good job,” what questions they ask about the hypothetical (How boring is his job really? Does he hate getting up in the morning, or is it more of an everyday tedium? What kind of financial support will he have if he quits? Does he even know how to run a restaurant?), and how they reach a consensus or create clear patterns of disagreement are all interesting findings that can be generated through this technique.

As with the above example (“What should Joe do?”), it is best to keep the questions you ask simple and easily understood by everyone. Thinking about the sequence of the questions/prompts is important, just as it is in conducting any interviews.

Avoid embarrassing questions. Always leave an out for the “I have a friend who X” response rather than pushing people to divulge personal information. Asking “How do you think students coped?” is better than “How did you cope?” Chances are, some participants will begin talking about themselves without you directly asking them to do so, but allowing impersonal responses here is good. The group itself will determine how deep and how personal it wants to go. This is not the time or place to push anyone out of their comfort zone!

Of course, people have different levels of comfort talking publicly about certain topics. You will have provided detailed information to your focus group participants beforehand and secured consent. But even so, the conversation may take a turn that makes someone uncomfortable. Be on the lookout for this, and remind everyone of their ability to opt out—to stay silent or to leave if necessary. Rather than call attention to anyone in this way, you also want to let everyone know they are free to walk around—to get up and get coffee (more on this below) or use the restroom or just step out of the room to take a call. Of course, you don’t really want anyone to do any of these things, and chances are everyone will stay seated during the hour, but you should leave this “out” for those who need it.

Have copies of consent forms and any supplemental questionnaire (e.g., demographic information) you are using prepared in advance. Ask a friend or colleague to assist you on the day of the focus group. They can be responsible for making sure the recording equipment is functioning and may even take some notes on body language while you are moderating the discussion. Order food (coffee or snacks) for the group. This is important! Having refreshments will be appreciated by your participants and really damps down the anxiety level. Bring name tags and pens. Find a quiet welcoming space to convene. Often this is a classroom where you move chairs into a circle, but public libraries often have meeting rooms that are ideal places for community members to meet. Be sure that the space allows for food.

Researcher Note

When I was designing my research plan for studying activist groups, I consulted one of the best qualitative researchers I knew, my late friend Raphael Ezekiel, author of The Racist Mind . He looked at my plan to hand people demographic surveys at the end of the meetings I planned to observe and said, “This methodology is missing one crucial thing.” “What?” I asked breathlessly, anticipating some technical insider tip. “Chocolate!” he answered. “They’ll be tired, ready to leave when you ask them to fill something out. Offer an incentive, and they will stick around.” It worked! As the meetings began to wind down, I would whip some bags of chocolate candies out of my bag. Everyone would stare, and I’d say they were my thank-you gift to anyone who filled out my survey. Once I learned to include some sugar-free candies for diabetics, my typical response rate was 100 percent. (And it gave me an additional class-culture data point by noticing who chose which brand; sure enough, Lindt balls went faster at majority professional-middle-class groups, and Hershey’s minibars went faster at majority working-class groups.)

—Betsy Leondar-Wright, author of Missing Class , coauthor of The Color of Wealth , associate professor of sociology at Lasell University, and coordinator of staffing at the Mission Project for Class Action

During the Focus Group

As people arrive, greet them warmly, and make sure you get a signed consent form (if not in advance). If you are using name tags, ask them to fill one out and wear it. Let them get food and find a seat and do a little chatting, as they might wish. Once seated, many focus group moderators begin with a relevant icebreaker. This could be simple introductions that have some meaning or connection to the focus. In the case of the ASA task force focus groups discussed above, we asked people to introduce themselves and where they were working/studying (“Hi, I’m Allison, and I am a professor at Oregon State University”). You will also want to introduce yourself and the study in simple terms. They’ve already read the consent form, but you would be surprised at how many people ignore the details there or don’t remember them. Briefly talking about the study and then letting people ask any follow-up questions lays a good foundation for a successful discussion, as it reminds everyone what the point of the event is.

Focus groups should convene for between forty-five and ninety minutes. Of course, you must tell the participants the time you have chosen in advance, and you must promptly end at the time allotted. Do not make anyone nervous by extending the time. Let them know at the outset that you will adhere to this timeline. This should reduce the nervous checking of phones and watches and wall clocks as the end time draws near.

Set ground rules and expectations for the group discussion. My preference is to begin with a general question and let whoever wants to answer it do so, but other moderators expect each person to answer most questions. Explain how much cross-talk you will permit (or encourage). Again, my preference is to allow the group to pick up the ball and run with it, so I will sometimes keep my head purposefully down so that they engage with one another rather than me, but I have seen other moderators take a much more engaged position. Just be clear at the outset about what your expectations are. You may or may not want to explain how the group should deal with those who would dominate the conversation. Sometimes, simply stating at the outset that all voices should be heard is enough to create a more egalitarian discourse. Other times, you will have to actively step in to manage (moderate) the exchange to allow more voices to be heard. Finally, let people know they are free to get up to get more coffee or leave the room as they need (if you are OK with this). You may ask people to refrain from using their phones during the duration of the discussion. That is up to you too.

Either before or after the introductions (your call), begin recording the discussion with their collective permission and knowledge . If you have brought a friend or colleague to assist you (as you should), have them attend to the recording. Explain the role of your colleague to the group (e.g., they will monitor the recording and will take short notes throughout to help you when you read the transcript later; they will be a silent observer).

Once the focus group gets going, it may be difficult to keep up. You will need to make a lot of quick decisions during the discussion about whether to intervene or let it go unguided. Only you really care about the research question or topic, so only you will really know when the discussion is truly off topic. However you handle this, keep your “participation” to a minimum. According to Lune and Berg ( 2018:95 ), the moderator’s voice should show up in the transcript no more than 10 percent of the time. By the way, you should also ask your research assistant to take special note of the “intensity” of the conversation, as this may be lost in a transcript. If there are people looking overly excited or tapping their feet with impatience or nodding their heads in unison, you want some record of this for future analysis.

I’m not sure why this stuck with me, but I thought it would be interesting to share. When I was reviewing my plan for conducting focus groups with one of my committee members, he suggested that I give the participants their gift cards first. The incentive for participating in the study was a gift card of their choice, and typical processes dictate that participants must complete the study in order to receive their gift card. However, my committee member (who is Native himself) suggested I give it at the beginning. As a qualitative researcher, you build trust with the people you engage with. You are asking them to share their stories with you, their intimate moments, their vulnerabilities, their time. Not to mention that Native people are familiar with being academia’s subjects of interest with little to no benefit to be returned to them. To show my appreciation, one of the things I could do was to give their gifts at the beginning, regardless of whether or not they completed participating.

—Susanna Y. Park, PhD, mixed-methods researcher in public health and author of “How Native Women Seek Support as Survivors of Intimate Partner Violence: A Mixed-Methods Study”

After the Focus Group

Your “data” will be either fieldnotes taken during the focus group or, more desirably, transcripts of the recorded exchange. If you do not have permission to record the focus group discussion, make sure you take very clear notes during the exchange and then spend a few hours afterward filling them in as much as possible, creating a rich memo to yourself about what you saw and heard and experienced, including any notes about body language and interactions. Ideally, however, you will have recorded the discussion. It is still a good idea to spend some time immediately after the conclusion of the discussion to write a memo to yourself with all the things that may not make it into the written record (e.g., body language and interactions). This is also a good time to journal about or create a memo with your initial researcher reactions to what you saw, noting anything of particular interest that you want to come back to later on (e.g., “It was interesting that no one thought Joe should quit his job, but in the other focus group, half of the group did. I wonder if this has something to do with the fact that all the participants were first-generation college students. I should pay attention to class background here.”).

Please thank each of your participants in a follow-up email or text. Let them know you appreciated their time and invite follow-up questions or comments.

One of the difficult things about focus group transcripts is keeping speakers distinct. Eventually, you are going to be using pseudonyms for any publication, but for now, you probably want to know who said what. You can assign speaker numbers (“Speaker 1,” “Speaker 2”) and connect those identifications with particular demographic information in a separate document. Remember to clearly separate actual identifications (as with consent forms) to prevent breaches of anonymity. If you cannot identify a speaker when transcribing, you can write, “Unidentified Speaker.” Once you have your transcript(s) and memos and fieldnotes, you can begin analyzing the data (chapters 18 and 19).

Advanced: Focus Groups on Sensitive Topics

Throughout this chapter, I have recommended against raising sensitive topics in focus group discussions. As an introvert myself, I find the idea of discussing personal topics in a group disturbing, and I tend to avoid conducting these kinds of focus groups. And yet I have actually participated in focus groups that do discuss personal information and consequently have been of great value to me as a participant (and researcher) because of this. There are even some researchers who believe this is the best use of focus groups ( de Oliveira 2011 ). For example, Jordan et al. ( 2007 ) argue that focus groups should be considered most useful for illuminating locally sanctioned ways of talking about sensitive issues. So although I do not recommend the beginning qualitative researcher dive into deep waters before they can swim, this section will provide some guidelines for conducting focus groups on sensitive topics. To my mind, these are a minimum set of guidelines to follow when dealing with sensitive topics.

First, be transparent about the place of sensitive topics in your focus group. If the whole point of your focus group is to discuss something sensitive, such as how women gain support after traumatic sexual assault events, make this abundantly clear in your consent form and recruiting materials. It is never appropriate to blindside participants with sensitive or threatening topics .

Second, create a confidentiality form (figure 12.2) for each participant to sign. These forms carry no legal weight, but they do create an expectation of confidentiality for group members.

In order to respect the privacy of all participants in [insert name of study here], all parties are asked to read and sign the statement below. If you have any reason not to sign, please discuss this with [insert your name], the researcher of this study, I, ________________________, agree to maintain the confidentiality of the information discussed by all participants and researchers during the focus group discussion.

Signature: _____________________________ Date: _____________________

Researcher’s Signature:___________________ Date:______________________

Figure 12.2 Confidentiality Agreement of Focus Group Participants

Third, provide abundant space for opting out of the discussion. Participants are, of course, always permitted to refrain from answering a question or to ask for the recording to be stopped. It is important that focus group members know they have these rights during the group discussion as well. And if you see a person who is looking uncomfortable or like they want to hide, you need to step in affirmatively and remind everyone of these rights.

Finally, if things go “off the rails,” permit yourself the ability to end the focus group. Debrief with each member as necessary.

Further Readings

Barbour, Rosaline. 2018. Doing Focus Groups . 2nd ed. Thousand Oaks, CA: SAGE. Written by a medical sociologist based in the UK, this is a good how-to guide for conducting focus groups.

Gibson, Faith. 2007. “Conducting Focus Groups with Children and Young People: Strategies for Success.” Journal of Research in Nursing 12(5):473–483. As the title suggests, this article discusses both methodological and practical concerns when conducting focus groups with children and young people and offers some tips and strategies for doing so effectively.

Hopkins, Peter E. 2007. “Thinking Critically and Creatively about Focus Groups.” Area 39(4):528–535. Written from the perspective of critical/human geography, Hopkins draws on examples from his own work conducting focus groups with Muslim men. Useful for thinking about positionality.

Jordan, Joanne, Una Lynch, Marianne Moutray, Marie-Therese O’Hagan, Jean Orr, Sandra Peake, and John Power. 2007. “Using Focus Groups to Research Sensitive Issues: Insights from Group Interviews on Nursing in the Northern Ireland ‘Troubles.’” International Journal of Qualitative Methods 6(4), 1–19. A great example of using focus groups productively around emotional or sensitive topics. The authors suggest that focus groups should be considered most useful for illuminating locally sanctioned ways of talking about sensitive issues.

Merton, Robert K., Marjorie Fiske, and Patricia L. Kendall. 1956. The Focused Interview: A Manual of Problems and Procedures . New York: Free Press. This is one of the first classic texts on conducting interviews, including an entire chapter devoted to the “group interview” (chapter 6).

Morgan, David L. 1986. “Focus Groups.” Annual Review of Sociology 22:129–152. An excellent sociological review of the use of focus groups, comparing and contrasting to both surveys and interviews, with some suggestions for improving their use and developing greater rigor when utilizing them.

de Oliveira, Dorca Lucia. 2011. “The Use of Focus Groups to Investigate Sensitive Topics: An Example Taken from Research on Adolescent Girls’ Perceptions about Sexual Risks.” Cien Saude Colet 16(7):3093–3102. Another example of discussing sensitive topics in focus groups. Here, the author explores using focus groups with teenage girls to discuss AIDS, risk, and sexuality as a matter of public health interest.

Peek, Lori, and Alice Fothergill. 2009. “Using Focus Groups: Lessons from Studying Daycare Centers, 9/11, and Hurricane Katrina.” Qualitative Research 9(1):31–59. An examination of the efficacy and value of focus groups by comparing three separate projects: a study of teachers, parents, and children at two urban daycare centers; a study of the responses of second-generation Muslim Americans to the events of September 11; and a collaborative project on the experiences of children and youth following Hurricane Katrina. Throughout, the authors stress the strength of focus groups with marginalized, stigmatized, or vulnerable individuals.

Wilson, Valerie. 1997. “Focus Groups: A Useful Qualitative Method for Educational Research?” British Educational Research Journal 23(2):209–224. A basic description of how focus groups work using an example from a study intended to inform initiatives in health education and promotion in Scotland.

• Note that I have included a few examples of conducting focus groups with sensitive issues in the “ Further Readings ” section and have included an “ Advanced: Focus Groups on Sensitive Topics ” section on this area. ↵

A focus group interview is an interview with a small group of people on a specific topic.  “The power of focus groups resides in their being focused” (Patton 2002:388).  These are sometimes framed as “discussions” rather than interviews, with a discussion “moderator.”  Alternatively, the focus group is “a form of data collection whereby the researcher convenes a small group of people having similar attributes, experiences, or ‘focus’ and leads the group in a nondirective manner.  The objective is to surface the perspectives of the people in the group with as minimal influence by the researcher as possible” (Yin 2016:336).  See also diversity focus group and convergence focus group.

A form of focus group construction in which people with diverse perspectives and experiences are chosen for inclusion.  This helps the researcher identify commonalities across this diversity and/or note interactions across differences.  Contrast with a convergence focus group

A form of focus group construction in which people with similar perspectives and experiences are included.  These are particularly helpful for identifying shared patterns and group consensus.  Contrast with a diversity focus group .

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

• Open access
• Published: 27 April 2024

Exploring health care providers’ engagement in prevention and management of multidrug resistant Tuberculosis and its factors in Hadiya Zone health care facilities: qualitative study

• Bereket Aberham Lajore 1   na1   nAff5 ,
• Yitagesu Habtu Aweke 2   na1   nAff6 ,
• Samuel Yohannes Ayanto 3   na1   nAff7 &
• Menen Ayele 4   nAff5  

BMC Health Services Research volume  24 , Article number:  542 ( 2024 ) Cite this article

Metrics details

Engagement of healthcare providers is one of the World Health Organization strategies devised for prevention and provision of patient centered care for multidrug resistant tuberculosis. The need for current research question rose because of the gaps in evidence on health professional’s engagement and its factors in multidrug resistant tuberculosis service delivery as per the protocol in the prevention and management of multidrug resistant tuberculosis.

The purpose of this study was to explore the level of health care providers’ engagement in multidrug resistant tuberculosis prevention and management and influencing factors in Hadiya Zone health facilities, Southern Ethiopia.

Descriptive phenomenological qualitative study design was employed between 02 May and 09 May, 2019. We conducted a key informant interview and focus group discussions using purposely selected healthcare experts working as directly observed treatment short course providers in multidrug resistant tuberculosis treatment initiation centers, program managers, and focal persons. Verbatim transcripts were translated to English and exported to open code 4.02 for line-by-line coding and categorization of meanings into same emergent themes. Thematic analysis was conducted based on predefined themes for multidrug resistant tuberculosis prevention and management and core findings under each theme were supported by domain summaries in our final interpretation of the results. To maintain the rigors, Lincoln and Guba’s parallel quality criteria of trustworthiness was used particularly, credibility, dependability, transferability, confirmability and reflexivity.

Total of 26 service providers, program managers, and focal persons were participated through four focus group discussion and five key informant interviews. The study explored factors for engagement of health care providers in the prevention and management of multidrug resistant tuberculosis in five emergent themes such as patients’ causes, perceived susceptibility, seeking support, professional incompetence and poor linkage of the health care facilities. Our findings also suggest that service providers require additional training, particularly in programmatic management of drug-resistant tuberculosis.

The study explored five emergent themes: patient’s underlying causes, seeking support, perceived susceptibility, professionals’ incompetence and health facilities poor linkage. Community awareness creation to avoid fear of discrimination through provision of support for those with multidrug resistant tuberculosis is expected from health care providers using social behavioral change communication strategies. Furthermore, program managers need to follow the recommendations of World Health Organization for engaging healthcare professionals in the prevention and management of multidrug resistant tuberculosis and cascade trainings in clinical programmatic management of the disease for healthcare professionals.

Peer Review reports

Introduction

Mycobacterium tuberculosis, the infectious agent that causes multi-drug resistant tuberculosis (MDR-TB), is resistant to at least rifampicin and isoniazid. Direct infection can cause the disease to spread, or it can develop secondary to improper management of tuberculosis among drug susceptible tuberculosis cases and associated poor adherence [ 1 ].

Multidrug-resistant strains of mycobacterium tuberculosis have recently emerged, which makes achieving “End TB Strategy” more difficult [ 2 ]. Multi drug resistant tuberculosis (MDR-TB) has been found to increasingly pose a serious threat to global and Ethiopian public health sector. Despite the fact that a number of risk factors for MDR-TB have been identified through various research designs, the epidemiology of this disease is complex, contextual, and multifaceted [ 1 ]. Quantitative studies demonstrate that prior treatment history [ 3 , 4 , 5 , 6 , 7 ], interrupted drug supply [ 8 ], inappropriate treatments and poor patient compliance [ 3 , 7 , 9 ], poor quality directly observed treatment short course (DOTS), poor treatment adherence [ 10 ], age [ 5 ], and malnutrition [ 11 ] were factors associated with multi drug resistant TB.

Globally, an estimated 20% of previously treated cases and 3.3% of new cases are thought to have MDR-TB; these levels have essentially not changed in recent years. Globally, 160,684 cases of multidrug-resistant TB and rifampicin-resistant TB (MDR/RR-TB) were notified in 2017, and 139,114 cases were enrolled into treatment in 2017 [ 12 ]. A systematic review in Ethiopia reported 2% prevalence of MDR-TB [ 3 ] that is higher than what is observed in Sub-Saharan Africa, 1.5% [ 13 ]. The prevalence of MDR-TB, according to the national drug-resistant tuberculosis (DR-TB) sentinel report, was 2.3% among newly diagnosed cases of TB and 17.8% among cases of TB who had already received treatment,. This suggests a rising trend in the prevalence of TB drug resistance compared to the results of the initial drug-resistant TB survey carried out in Ethiopia from 2003 to 2005 [ 14 ].

Ethiopia has placed strategies into place that emphasize political commitment, case finding, appropriate treatment, a continuous supply of second-line anti-TB medications of high quality, and a recording system. Due to other competing health priorities, the nation is having difficulty accelerating the scale-up of the detection, enrollment and treatment of drug-resistant TB patients [ 15 , 16 ]. To address these issues, the nation switched from a hospital-based to a clinic-based ambulatory model of care, which has allowed MDR-TB services to quickly decentralize and become more accessible. Accordingly, the nation has set up health facilities to act as either treatment initiating centers (TIC) or treatment follow-up centers (TFC) or both for improved referral and communication methods [ 15 ].

One of the key components of the “End TB strategy” is engagement of health care professionals in the prevention and management of multidrug resistant tuberculosis [ 17 ]. Inadequate engagement of healthcare providers is one aspect of the healthcare system that negatively influences MDR-TB prevention and control efforts [ 17 ]. This may be manifested in a number of ways, including inadequate understanding of drug-resistant tuberculosis, improper case identification, failure to initiate treatment again, placement of the wrong regimens, improper management of side effects and poor infection prevention [ 1 ]. These contributing factors are currently being observed in Ethiopia [ 18 ], Nigeria [ 7 , 19 , 20 ] and other countries [ 21 , 22 ]. According to a study conducted in Ethiopia, MDR-TB was linked to drug side effects from first-line treatments, being not directly observed, stopping treatment for at least a day, and retreating with a category II regimen [ 17 ].

This may be the result of a synergy between previously investigated and other contextual factors that have not yet been fully explored, such as professional engagement, beliefs, and poor preventive practices. The engagement of health professionals in MDR-TB prevention and control is assessed using a number of composite indicators. Health professionals may interact primarily inside the healthcare facilities. Typically, they play a significant role in connecting healthcare services with neighborhood-based activities [ 17 ]. One of the main research areas that have not sufficiently addressed is evidence indicating the status of healthcare professionals’ engagement and contextual factors in MDR-TB prevention and management.

It is increasingly urgent to identify additional and existing factors operating in a particular context that contribute to the development of the disease in light of the epidemic of drug resistance, including multi-drug resistance (MDR-TB) and extensively drug resistant TB (XDR-TB) in both new and previously treated cases of the disease [ 23 ]. In order to develop and implement control measures, it is therefore essential to operationally identify a number of contextual factors operating at the individual, community, and health system level.

Therefore, the overall purpose of this study was to explore the level of engagement of health care providers and contextual factors hindering/enabling the prevention and provision of patient-centered care for MDR-TB in health facilities, DOTS services centers and MDR-TB treatment initiation center [TIC], in Hadiya Zone, Southern Ethiopia.

Qualitative approach and research paradigm

Descriptive phenomenological qualitative study design was employed to explore factors influencing engagement of health professionals in MDR-TB prevention and management and thematic technique was employed for the analysis of the data.

Researchers’ characteristics and reflexivity

Three Principal investigators conducted this study. Two of them had Masters of public health in Epidemiology and Reproductive health and PhD candidates and the third one had Bachelor’s degree in public health with clinical experience in the area of Tuberculosis prevention and management and MPH in Biostatistics. The principal investigators have research experience with published articles in different reputable journals. There were no prior contacts between researchers and participants before the study whereas researchers have built positive rapport with study participants during data collection to foster open communication and trust and had no any assumptions and presuppositions about the research topic and result.

Context/ study setting and period

The study was conducted between 2 and 9 May, 2019 in Hadiya Zone with more than 1.7 million people residing in the Zone. There are 300 health posts, 63 health centers, 3 functional primary hospitals and 1 comprehensive specialized hospital in the Zone. Also, there are more than 350 private clinics and 1 private hospital in the Zone. All of the public health facilities and some private health facilities provide directly observed short course treatment (DOTS) service for tuberculosis patients. There are more than eight treatment initiation centers (TICs) for MDR-TB patients in Hadiya Zone. MDR-TB (Multidrug-resistant tuberculosis) treatment initiation centers are specialized facilities that provide comprehensive care, diagnosis and treatment initiation, psychosocial support, and follow up services to individuals with MDR-TB. The linkage between MDR-TB treatment initiation centers and other healthcare facilities lies in the coordination of care, referral pathways, and collaboration to ensure comprehensive and integrated care for individuals with MDR-TB. Overall, healthcare providers play a crucial role in the management of MDR-TB by providing specialized care, ensuring treatment adherence, monitoring progress and outcomes, and supporting individuals in achieving successful treatment outcomes and improved health.

Units of study and sampling strategy

Our study participants were health care professionals working in MDR-TB TICs in both private and public health facilities, and providing DOTS services, MDR-TB program leaders in treatment initiation centers, as well as TB focal persons, disease prevention and health promotion focal person, and project partners from district health offices. The study involved four focus group discussion (FGDs) and five key informants’ interview (KII) with a total of 26 participants to gather the necessary information. Expert purposive sampling technique was employed and sample size was determined based on the saturation of idea required during data collection process.

Data collection methods and instruments

Focus group discussion and face to face key informants’ interviews were employed to collect the data. We conducted a total of four FGD and five key informants’ interviews with participants chosen from DOTS providing health facilities and MDR-TB program leaders in treatment initiation centers, as well as TB focal persons and project partners from district health offices and disease prevention and health promotion focal person. One of the FGDs was conducted among health professionals from the public MDR-TB treatment initiation centers. Three FGDs were conducted among disease prevention and health promotion focal persons, TB focal persons and DOTS providers in public health facilities (health centers).

An observation checklist was developed to assess the general infection prevention and control measures used by specific healthcare facilities in the study area. We used unstructured FGD guide, key informant interview guide, observation checklist and audio recorders to collect primary data and it was collected using local language called Amharic. Prior to data collection, three people who are not among principal investigators with at least a master’s degree in public health and prior experience with qualitative research were trained by principal investigators. Three of them acts as a tape recorder, a moderator, and as a note taker alternatively. The length of FGD ranged from 58 to 82 min and that of key informants’ interview lasted from 38 to 56 min.

Data processing and data analysis

Memos were written immediately after interviews followed by initial analysis. Transcription of audio records was performed by principal investigators. The audio recordings and notes were refined, cleaned and matched at the end of each data collection day to check for inconsistencies, correct errors, and modify the procedures in response to evolving study findings for subsequent data collection. Transcribed interviews, memos, and notes from investigator’s observation were translated to English and imported to Open Code 4.02 [ 2 ] for line by line coding of data, and categorizing important codes (sub theming). The pre-defined themes for MDR-TB prevention and control engagement were used to thematize the line-by-line codes, categories, and meanings using thematic analysis. Finally, the phenomenon being studied was explained by emerging categories and themes. Explanations in themes were substantiated by participants’ direct quotations when necessary.

Trustworthiness

Phone calls and face to face briefing were requested from study participants when some expressions in the audio seems confusing while transcripts were performed. To ensure the credibility of the study, prolonged engagement was conducted, including peer debriefing with colleagues of similar status during data analysis and inviting available study participants to review findings to ensure as it is in line with their view or not. Memos of interviews and observation were crosschecked while investigator was transcribing to ensure credibility of data as well as to triangulate investigator’s categorizing and theming procedures. For transferability, clear outlines of research design and processes were provided, along with a detailed study context for reader judgment. Dependability was ensured through careful recording and transcription of verbal and non-verbal data, and to minimize personal bias, scientific procedures were followed in all research stages. Conformability was maintained by conducting data transcription, translation, and interpretation using scientific methods. Researchers did all the best to show a range of realities, fairly and faithfully. Finally, an expert was invited to put sample of codes and categories to emerged corresponding categories and themes respectively.

Demographic characteristics of study participants

Four focus group discussions and five key informants’ interviews were conducted successfully. There were 26 participants in four focus group discussions, and key informants’ interview. Ages of participants ranges from 20 to 50 years with an average age of 33.4  ±  6.24 SD years. Participants have five to ten years of professional experience with DOTS services (Table  1 ).

Emergent themes and subthemes

The study explored how health care providers’ engagement in MDR-TB prevention and management was influenced. The investigation uncovered five major themes. These themes were the patient’s underlying causes, seeking support, perceived susceptibility, healthcare providers’ incompetence, and poor linkage between health facilities. Weak community TB prevention, health system support, and support from colleagues were identified subthemes in the search for help by health professionals whereas socioeconomic constraints, lack of awareness, and fear of discrimination were subthemes under patients underlying factors (Fig.  1 ).

Themes and subthemes emerged from the analysis of health professionals’ engagement in MDR-TB prevention and management study in Hadiya zone’s health facilities, 2019

The patient’s underlying causes

This revealed why TB/MDR-TB treatment providers believe health professionals are unable to provide standard MDR-TB services. The subthemes include TB/MDR-TB awareness, fear of discrimination, and patients’ socioeconomic constraints.

Socioeconomic constraints

According to our research, the majority of healthcare professionals who provided directly observed short-course treatment services mentioned socioeconomic constraints as barriers to engage per standard and provide MDR-TB prevention and management service. More than half of the participants stated that patients’ primary reasons include lack of money for house rental close to the treatment centers, inability to afford food and other expenses, and financial constraints to cover transportation costs.

In addition to this, patients might have additional responsibilities to provide food and cover other costs for their families’ need. The majority of health care professionals thought that these restrictions led to their poor engagement in MDR-TB prevention and management. One of the focus groups’ discussants provided description of the scenario in the following way:

“…. I have many conversations with my TB/MDR-TB patients. They fail to complete DOTS or treatment intensive care primarily as a result of the requirement of prolonged family separation. They might provide most of the family needs, including food and other expenses” (FGD-P01).

Lack of awareness about MDR-TB

This subtheme explains how MDR-TB patients’ knowledge of the illness can make it more difficult for health professionals to provide DOTS or TICs services. The majority of DOTS providers stated that few TB or MDR-TB patients were aware of how MDR-TB spreads, how it is treated, and how much medication is required. Additionally, despite the fact that they had been educated for the disease, majority of patients did not want to stop contact with their families or caregivers. A health care provider stated,

“…. I provided health education for MDR-TB patients on how the disease is transmitted and how they should care for their family members. They don’t care; however, give a damn about their families .” (FGD-P05).

Some healthcare professionals reported that some patients thought that MDR-TB could not be cured by modern medication. One medical professional described the circumstance as follows:

“…. I noticed an MDR-TB patient who was unwilling to be screened. He concluded that modern medication is not effective and he went to spiritual and traditional healers” (FGD-P02).

As a result, almost all participants agreed on the extent to which patient knowledge of TB and MDR-TB can influence a provider’s engagement to MDR-TB services. The majority suggested that in order to improve treatment outcomes and preventive measures, the media, community leaders, health development armies, one-to-five networks, non-governmental organizations, treatment supporters, and other bodies with access to information need to put a lot of efforts.

Fear of discrimination

According to our research, about a quarter of healthcare professionals recognized that patients’ fear of discrimination prevents them from offering MDR-TB patients the DOTS services they need, including counseling index cases and tracing contact histories.

HEWs, HDAs, and 1-to-5 network members allegedly failed to monitor and counsel the index cases after their immediate return to their homes, according to the opinions from eight out of twenty-six healthcare professionals. The patients began to engage in routine social and political activities with neighbors while hiding their disease status. A healthcare professional described this situation as follows:

“…. I understood from my MDR-TB patient’s words that he kept to himself and avoided social interaction. He made this decision as a result of stigmatization by locals, including health extension workers. As a result, the patient can’t attend social gatherings. …. In addition, medical professionals exclude MDR-TB patients due to fear of exposures. As a result, patients are unwilling to undergo early screening” (FGD-P04).

Professionals’ perceived risk of occupational exposure

This theme highlights the anxiety that healthcare workers experience because of MDR-TB exposure when providing patient care. Our research shows that the majority of health professionals viewed participation as “taking coupons of death.” They believed that regardless of how and where they engaged in most healthcare facilities, the risk of exposure would remain the same. According to our discussion and interview, lack of health facility’s readiness takes paramount shares for the providers’ risk of exposures and their susceptibility.

According to the opinion from the majority of FGD discussants and in-depth interviewees, participants’ self-judgment score and our observation, the majority of healthcare facilities that offer DOTS for DS-TB and MDR-TB did not create or uphold standards in infection prevention in the way that could promote better engagement. These include poor maintenance of care facilities, lack of personal protective equipment, unsuitable facility design for service provision, lack of patient knowledge regarding the method of MDR-TB transmission, and lack of dedication on the part of health care staff.

As one of our key informant interviewees [District Disease Prevention Head], described health professionals’ low engagement has been due to fear of perceived susceptibility. He shared with us what he learned from a community forum he moderated.

Community forum participant stated that “… There was a moment a health professional run-away from the TB unit when MDR-TB patient arrived. At least they must provide the necessary service, even though they are not willing to demonstrate respectful, compassionate, or caring attitude to MDR-TB patients” (KII-P01). Besides , one of the FGD discussants described the circumstance as follows:

“…. Emm…. Because most health facilities or MDR-TB TIC are not standardized, I am concerned about the risk of transmission. They are crammed together and poor ventilation is evident as well as their configuration is improper. Other medical services are causing the TICs to become overcrowded. Most patients and some medical professionals are unconcerned with disease prevention ” (FGD-P19).

Participants’ general fear of susceptibility may be a normal psychological reaction and may serve as a motivation for taking preventative actions. However, almost all participants were concerned that the main reasons for their fear were brought up by the improper application of programmatic management and MDR-TB treatment standards and infection prevention protocols in healthcare facilities.

Health care providers’ incompetence

This theme illustrates how professionalism and dedication impact participation in MDR-TB prevention and management. The use of DS-TB prevention and management by health professionals was also taken into account because it is a major factor in the development of MDR-TB. This theme includes the participants’ perspectives towards other healthcare workers involved in and connected to MDR-TB.

Nearly all of the participants were aware of the causes and danger signs of MDR-TB. The majority of the defined participants fit to the current guidelines. However, participants in focus groups and key informant interviews have brought up shortcomings in MDR-TB service delivery practice and attitude. We looked at gaps among healthcare professionals’ knowledge, how they use the national recommendations for programmatic management and prevention of MDR-TB, prevent infections, take part in community MDR-TB screenings, and collaborate with other healthcare professionals for better engagement.

More than half of the participants voiced concerns about their attitudes and skill sets when using MDR-TB prevention and management guideline. When asked about his prior experiences, one of the focus group participants said:

“…. Ok, let me tell you my experience, I was new before I attended a training on MDR-TB. I was unfamiliar with the MDR-TB definition given in the recommendations. When I was hired, the health center’s director assigned me in the TB unit. I faced difficulties until I received training” (FGD-P24). Furthermore , one of the key informant interview participants shared a story: “…. In my experience, the majority of newly graduated health professionals lack the required skill. I propose that pre-service education curricula to include TB/MDR-TB prevention and management guideline trainings” (KII-P01).

The majority of participants mentioned the skill gap that was seen among health extension workers and laboratory technicians in the majority of healthcare facilities. Some of the participants in the in-depth interviews and FGD described the gaps as follows:

“…. According to repeated quality assurance feedbacks, there are many discordant cases in our [ District TB Focal Person ] case. Laboratory technicians who received a discrepant result (KII-P01) are not given training which is augmented by shared story from FGD discussants, “According to the quality assurance system, laboratory technicians lack skill and inconsistent results are typical necessitating training for newly joining laboratory technicians” (FGD-P20).

Through our discussions, we explored the level of DOTS providers’ adherence to the current TB/MDR-TB guideline. As a result, the majority of participants pointed out ineffective anti-TB management and follow-up care. One of the participants remembered her practical experience as follows:

“…. In my experience, the majority of health professionals fail to inform patients about the drug’s side effects, follow-up procedures, and other techniques for managing the burden of treatment. Only the anti-TB drug is provided, and the patient is left alone. The national treatment recommendation is not properly implemented by them” (FGD-P04).

Many barriers have been cited as reasons that might have hindered competencies for better engagement of health professionals. Training shortage is one of the major reasons mentioned by many of the study participants. One of discussants from private health facility described the problem as

“…. We are incompetent, in my opinion. Considering that we don’t attend update trainings. Many patients who were diagnosed negative at private medical facilities turned out to be positive, and vice versa which would be risky for drug resistance” (FGD-P14) which was supported by idea from a participant in our in-depth interview: “…. We [Program managers] are running short of training for our health care providers at different health centers and revealed that four out of every five healthcare professionals who work in various health centers are unaware of the TB/MDR-TB new guideline” (KII-P02).

Seeking support

This theme focuses on the significance and effects of workplace support in the engagement of MDR-TB prevention and control. This also explains the enabling and impeding elements in the engagement condition of health professionals. Three elements make up the theme: coworkers (other health professionals) in the workplace, support from community TB prevention actors, and a healthcare system.

Support from community TB prevention actors

This subtheme includes the assistance provided to study participants by important parties such as community leaders, the health development army, and other stakeholders who were involved in a community-based TB case notification, treatment adherence, and improved patient outcomes.

Many of the study participants reported that health extension workers have been poorly participating in MDR-TB and TB-related community-based activities like contact tracing, defaulter tracing, community forums, health promotion, and treatment support. One study participant described their gap as follows:

“…. I understood that people in the community were unaware of MDR-TB. The majority of health extension workers do not prioritize raising community awareness of MDR-TB” (FGD-P13). This was supported by idea from a district disease prevention head and stated as: “…. There is no active system for contacts tracing. Health educators send us information if they find suspected cases. However, some patients might not show up as expected. We have data on three family members who tested positive for MDR-TB” (KII-P3).

Support from a health system

The prime focus of this subtheme is on the enabling elements that DOTS providers require assistance from the current healthcare system for better engagement. All study participants expressed at least two needs to be met from the health system in order for them to effectively participate in MDR-TB prevention, treatment, and management. All study participants agreed that issues with the health system had a negative impact on their engagement in the prevention, treatment, diagnosis, and management of MDR-TB in almost all healthcare facilities. Poor conditions in infrastructure, resources (supplies, equipment, guidelines, and other logistics), capacity building (training), supportive supervision, establishment of public-private partnerships, and assignment of motivated and trained health professionals are some of the barriers that needs to be worked out in order to make them engage better. One of the participants pronounces supplies and logistics problems as:

“…. The health center I worked in is listed as a DOTS provider. However, it lacks constant electricity, a working microscope, lab supplies, medications, etc, and we refer suspected cases to nearby health centers or district hospitals for AFB-examination and, “Sometimes we use a single kit for many patients and wait for the medication supply for three or more weeks and patients stops a course of therapy that might induce drug resistance” (FGD-PI04) which was augmented by statement from FGD participant who works at a treatment initiation center: “…. We faced critical shortage of supplies and hospital administrators don’t care about funding essential supplies for patient care. For instance, this hospital (the hospital in which this FGD was conducted) can easily handle N-95 masks. Why then they (hospital administrators working in some TIC) can’t do it?” (FGD-P18).”

Regarding in-service training on MDR-TB, almost all participants pointed out shortage of on-job training mechanisms. One of our FGD participants said:

“…. I missed the new training on MDRTB programmatic management guidelines. I’ve heard that new updates are available. I still work using the old standard” (FGD-PI05). A health professional working in private clinic heightens the severity of training shortage as: “…. We have not participated in TB/MDR-TB guidelines training. You know, most of for-profit healthcare facilities do not provide any training for their staff. I’m not sure if I’m following the (TB/MDR-TB) guideline” (FGD-P14). One of our key informant interview participants; MDR-TB center focal person suggested the need for training as: “…. I’ve received training on the MDR-TB services and public-private partnership strategy. It was crucial in my opinion for better engagement. It is provided for our staff [MDRTB center focal person]. However, this has not yet been expanded to other health facilities” (KII-P04).

Concerning infrastructures, transportation problem was one of the frequently mentioned obstacles by many participants that hinder engagement in MDR-TB/TB service. This factor had a negative impact to both sides (health professionals and patients). One of discussants said:

“…. I face obstacles such as transport cost to perform effective TB/MDR-TB outreach activities like health education, tracing family contacts and defaulters and community mobilization. Rural kebeles are far apart from each other. How can I support 6 rural Kebeles?” (FGD-P01). One of the participants; MDR-TB treatment centers supervisor/program partner seconded the above idea as: “…. I suggest government must establish a system to support health professionals working in remote health care facilities in addition to MDR-TB centers. I guess there are more than 30 government health centers and additional private clinics. We can’t reach them all due to transportation challenges” (KII-P05). One of the participants , a district disease prevention head added: “…. Our laboratory technicians take sample from MDR-TB suspects to the post office and then, the post office sends to MDR-TB site. Sometimes, feedback may not reach timely. There is no any system to cover transportation cost. That would make case detection challenging” (FGD-P02).

Support from colleagues

Study participants stated the importance of having coworker with whom they could interconnect. However, eight participants reported that they were discriminated by their workmates for various reasons, such as their perceived fear of exposure to infection and their perception as if health professionals working in TB/MDR-TB unit get more training opportunities and other incentives. One of the focus group discussants said:

“…. My colleagues [health professional working out of MDR-TB TICs] stigmatize us only due to our work assignment in MDR-TB clinic. I remember that one of my friends who borrowed my headscarf preferred to throw it through a window than handing-over it back safely. Look, how much other health professionals are scared of working in MDR-TB unit. This makes me very upset. I am asking myself that why have I received such training on MDR-TB?” (FGD-P04).

Some of the participants also perceived that, health professionals working in MDR-TB/TB unit are the only responsible experts regarding MDR-TB care and treatment. Because, other health professionals consider training as if it is an incentive to work in such units. One of the FGD discussants described:

“… Health professionals who work in other service units are not volunteer to provide DOTS if TB focal person/previously trained staffs are not available. Patients wait for longer time” (FGD-P11).

Health facilities’ poor linkage

This theme demonstrates how various healthcare facilities, including private and public healthcare facilities such as, health posts, health care centers and hospitals, and healthcare professionals working at various levels of the healthcare system in relation to TB/MDR-TB service, are inter-linked or communicating with one another.

Many study participants noted a lack of coordination between higher referral hospitals, TB clinics, health posts, and health centers. Additionally, the majority of the assigned healthcare professionals had trouble communicating with patients and their coworkers. A focus group discussant also supported this idea as

“…. There is a lack of communication between us [DOTS providers at treatment initiation centers] and health posts, health centers, and private clinics. We are expected to support about 30 public health facilities. It’s of too much number, you know. They are out of our reach. We only took action when a problem arose” (FGD-P16).

Significant number of participants had raised the problem of poor communication between health facilities and treatment initiation centers. One of the interviewees [program manager] said:

“…. I see that one of our challenges is the weak referral connections between treatment initiation centers and health centers. As a result, improper sample transfer to Gene- Xpert sites and irregular postal delivery are frequent” . “Our; DOTS staff at the MDR-TB center, DOTS staff at the health center, and health extension workers are not well connected to one another. Many patients I encountered came to this center [MDR-TB center] after bypassing both health post and health center. Poor linkage and communication, in my opinion, could be one of the causes. The same holds true for medical facilities that are both public and private ” (KII-P02).

Engagement of individual healthcare providers is one of the peculiar interventions to achieve the goal of universal access to drug resistance tuberculosis care and services [ 17 ]. Healthcare providers engagement in detecting cases, treating and caring for multidrug resistant tuberculosis (MDR-TB) may be influenced by various intrinsic (individual provider factors) and extrinsic (peer, health system, political and other factors) [ 15 ]. Our study explored engagement of individual DOTS providers and factors that influence their engagement in MDR-TB prevention and management service. This is addressed through five emergent themes and subthemes as clearly specified in our results section.

The findings showed patients’ socioeconomic constraints were important challenges that influence health professionals’ engagement, and provision of MDR-TB prevention and management services. Although approaches differ, studies in Ethiopia [ 24 ], South Africa [ 25 ] and India [ 26 , 27 ] documented that such factors influence health providers’ engagement in the prevention and management of multi drug resistant tuberculosis. Again, the alleviation of these factors demands the effort from patients, stakeholders working on TB, others sectors, and the healthcare system so that healthcare providers can deliver the service more effectively in their day-to-day activities and will be more receptive to the other key factors.

We explored participants’ experiences on how patients’ awareness about drug sensitive or multi drug resistant tuberculosis influenced their engagement. Accordingly, participants encountered numerous gaps that restricted their interactions with TB/MDR-TB patients. In fact, our study design and purposes vary, studies [ 28 , 29 , 30 ] indicated that patients awareness influenced providers decision in relation to MDR-TB services and patients’ awareness status is among factors influencing healthcare providers’ decision making about the care the MDR-TB patient receives. As to our knowledge, patients’ perceived fear of discrimination was not documented whether it had direct negative impact on reducing providers’ engagement. Therefore, patients’ awareness creation is an important responsibility that needs to be addressed by the community health development army, health extension workers, all other healthcare providers and stakeholder for better MDR-TB services and patient outcomes.

Our study indicates that healthcare providers perceived that they would be exposed to MDR-TB while they are engaged. Some of the participants were more concerned about the disadvantages of engagement in providing care to MDR-TB patients which were predominantly psychological and physical pressure. In this context, the participants emphasized that engagement in MDR-TB patient care is “always being at risk” and expressed a negative attitude. This finding is similar to what has been demonstrated in a cross-sectional study conducted in South Africa in which majority of healthcare providers believed their engagement in MDR-TB services would risk their health [ 21 ].

However, majority of the healthcare providers demonstrated perceived fear of exposures mainly due to poor infection prevention practices and substandard organization of work environment in most TB/MDR-TB units. This is essentially reasonable fear, and needs urgent intervention to protect healthcare providers from worsening/reducing their effective engagement in MDR-TB patient care. On the other side of the coin, perceived risk of occupational exposure to infection could be source for taking care of oneself to combat the spread of the infection.

In our study, healthcare provider’s capability (competence) also had an impact on their ability to engage in prevention and management of MDR-TB. Here, participants had frequently raised their and other healthcare providers’ experience regarding skill gaps, negative attitude towards the service unit they were working in, ineffective use of MDR-TB guideline, poor infection prevention practices and commitment. In addition, many health professionals report serious problems regarding case identification and screening, drug administration, and side effect management. These findings were supported by other studies in Ethiopia [ 7 ] and in Nigeria [ 19 , 20 ]. This implies an urgent need for training of health care worker on how to engage in prevention and management of multidrug resistant TB.

Moreover, our findings provide insights into the role of community TB prevention actors, currently functioning health system, and colleagues and other stakeholders’ regarding healthcare providers’ engagement. Participants emphasized that support from community TB prevention actors is a key motivation to effectively engage on management and prevention roles towards MDR-TB. Evidence shows that community TB prevention is one of the prominent interventions that study participants would expect in DOTS provision as community is the closest source of information regarding the patients [ 31 , 32 ].

Similarly, all participants had pointed out the importance of support from a health system directly or indirectly influence their engagement in the prevention, diagnosis, treatment, and management of MDR-TB. Researches indicated that health system supports are enabling factors for healthcare providers in decision making regarding TB/MDR-TB prevention and treatment [ 33 ]. This problem is documented by the study done in Ethiopia [ 22 ]. In addition, support from colleagues and other stakeholders was also a felt need to engage in MDR-TB which was supported by the World Health Organization guideline which put engagement in preventing MDR-TB and providing patients centered care needs collaborative endeavor among healthcare providers, patients, and other stakeholders [ 17 ].

Participants showed that there were poor linkage among/within DOTS providers working in health post (extension workers), health centers, hospitals and MDRTB treatment initiation centers. Our finding is consistent with a research in South Africa which shows poor health care attitude is linked to poor treatment adherence [ 34 ]. Our study implies the need for further familiarization especially on clinical programmatic management of drug resistant tuberculosis. Moreover, program managers need to follow health professionals’ engagement approaches recommended by the World Health Organization: End TB strategy [ 17 ].

Limitations of the study

There are some limitations that must be explicitly acknowledged. First, participants from private health facilities were very few, which might have restricted the acquisition and incorporation of perspectives from health care providers from private health care facilities. Second, healthcare providers’ engagement was not measured from patient side given that factors for engagement may differ from what has been said by the healthcare provides. Third, power relationships especially among focus group discussant in MDR-TB treatment initiation centers might have influenced open disclosures of some sensitive issues.

The study showed how healthcare provider’s engagement in MDR-TB management and prevention was influenced. Accordingly, patient’s underlying causes, seeking support, perceived occupational exposure, healthcare provider’s incompetence and health facilities poor linkage were identified from the analysis. Weak community TB prevention efforts, poor health system support and support from colleagues, health care providers’ incompetence and health facilities poor linkage were among identified factors influencing engagement in MDR – TB prevention and management. Therefore, measures need to be in place that avert the observed obstacles to health professionals’ engagement including further quantitative studies to determine the effects of the identified reasons and potential factors in their engagement status.

Furthermore, our findings pointed out the need for additional training of service providers, particularly in clinical programmatic management of drug-resistant tuberculosis. Besides, program managers must adhere to the World Health Organization’s recommendations for health professional engagement. Higher officials in the health sector needs to strengthen the linkage between health facilities and service providers at different levels. Community awareness creation to avoid fear of discrimination including provision of support for those with MDR-TB is expected from health experts through implementation of social behavioral change communication activities.

Abbreviations

Directly observed treatment short-course

Drug susceptible tuberculosis

Millennium development goals

Multidrug resistant tuberculosis

Sustainable development goals

Tuberculosis

Treatment initiation center

World Health Organization

Extensively drug resistant TB

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Acknowledgements

We would like to acknowledge Hosanna College of Health Sciences Research and community service directorate for providing us the opportunity and necessary fund to conduct this research. Our appreciation also goes to heads of various health centers, hospitals, district health and Hadiya Zone Health office for unreserved cooperation throughout data collection.

The authors declare that this study received funding from Hosanna College of Health Sciences. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

Author information

Bereket Aberham Lajore & Menen Ayele

Present address: Hossana College of Health Sciences, Hosanna, SNNPR, Ethiopia

Yitagesu Habtu Aweke

Present address: College of Health Sciences, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia

Samuel Yohannes Ayanto

Present address: College of Health Sciences, Institute of Public Health, Department of -Population and Family Health, Jimma University, Jimma, Ethiopia

Bereket Aberham Lajore, Yitagesu Habtu Aweke and Samuel Yohannes Ayanto contributed equally to this work.

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Department of Family Health, Hossana College of health sciences, Hossana, Ethiopia

Bereket Aberham Lajore

Department of Health informatics, Hossana College of Health Sciences, Hossana, Ethiopia

Department of Midwifery, Hossana College of Health Sciences, Hossana, Ethiopia

Department of Clinical Nursing, Hossana College of Health Sciences, Hossana, Ethiopia

Menen Ayele

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Bereket Aberham Lajore, Yitagesu Habtu Aweke, and Samuel Yohannes Ayanto conceived the idea and wrote the proposal, participated in data management, analyzed the data and drafted the paper and revised the analysis and subsequent draft of the paper. Menen Ayele revised and approved the proposal, revised the analysis and subsequent draft of the paper. Yitagesu Habtu and Bereket Aberham Lajore wrote the main manuscript text and prepared all tables. All authors reviewed and approved the final manuscript.

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Ethical approval was obtained from Institutional review board [IRB] of Hossana College of health sciences after reviewing the protocol for ethical issues and provided a formal letter of permission to concerned bodies in the health system. Accordingly, permission to conduct this study was granted by respective health facilities in Hadiya zone. Confidentiality of the information was assured and participants’ autonomy not to participate or to opt-out at any stage of the interview were addressed. Finally, informed consent was obtained from the study participants after detailed information.

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Lajore, B.A., Aweke, Y.H., Ayanto, S.Y. et al. Exploring health care providers’ engagement in prevention and management of multidrug resistant Tuberculosis and its factors in Hadiya Zone health care facilities: qualitative study. BMC Health Serv Res 24 , 542 (2024). https://doi.org/10.1186/s12913-024-10911-6

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Hope as experienced by people with acquired brain injury in a rehabilitationor recovery process: A qualitative systematic review and thematic synthesis Provisionally Accepted

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Background: There has been an increasing interest in the concept of hope within the field of brain injury rehabilitation. Existing reviews have nevertheless focused on stroke, leaving out the broad populationgroup of people with acquired brain injury (ABI). Furthermore a just as majority of the included studies in those reviews excluded the subgroup of people with communication difficulties, thus primarily giving voice to a select group of people with ABI. Methods: A qualitative systematic review was conducted with the purpose of systematically reviewing and thematically synthesise findings about hope as experienced by adultspeople with ABI in a rehabilitation or recovery process. The search strategy included peer-reviewed qualitative studies published after 2000 in English or Scandinavian languages. Searches of EBSCO databases incorporating CINAHL, MEDLINE, and PsycINFO were conducted together with SocINDEX, Social Work Abstracts, Eric and Web of Science. Ten qualitative studies were included, and the Critical Appraisal Skills Program (CASP) was used for assessing the quality and relevance of the ten studies. Qualitative findings were synthesized using Thomas and Harden's methodology. data were analysed based on methods for thematic synthesis by Thomas and Harden. Results: Through a thematic synthesis eleven subthemes were identifiedemerged relating to experiences of hope. These were grouped into four analytical themes: (1) Hope a two folded phenomenon; (2) Time and temporality; (3) Progress, goals and visibility and (4) The alliance. Conclusion: This review has shown that even though hope has both a positive and negative side to it, it is necessary as a driving force for people with ABI in terms of supporting them to keep going and not give up. Rehabilitation professionals are advised to embrace the ambiguity of hope, customizing the support of hope to each person with ABI. Attention is needed on how to make progress visible for persons with ABI during their rehabilitation process just as rehabilitation professionals should acknowledge the alliance with the person with ABI as a core component of rehabilitation. This requires a focus on professionals' communication skills if hope promoting relationships between professionals and persons with ABI are to be achieved.

Keywords: hope, acquired brain injury, Rehabilitation, Recovery, literature review, qualitative studies, thematic synthesis

Received: 26 Jan 2024; Accepted: 26 Apr 2024.

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

* Correspondence: PhD. Camilla Højgaard Nejst, Aalborg University, Aalborg, Denmark

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What is Qualitative in Qualitative Research

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What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

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What is Qualitative in Research

Unsettling definitions of qualitative research, what is “qualitative” in qualitative research why the answer does not matter but the question is important.

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If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

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Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

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Aspers, P., Corte, U. What is Qualitative in Qualitative Research. Qual Sociol 42 , 139–160 (2019). https://doi.org/10.1007/s11133-019-9413-7

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What It Means To Be Asian in America

The lived experiences and perspectives of asian americans in their own words.

Asians are the fastest growing racial and ethnic group in the United States. More than 24 million Americans in the U.S. trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent.

The majority of Asian Americans are immigrants, coming to understand what they left behind and building their lives in the United States. At the same time, there is a fast growing, U.S.-born generation of Asian Americans who are navigating their own connections to familial heritage and their own experiences growing up in the U.S.

In a new Pew Research Center analysis based on dozens of focus groups, Asian American participants described the challenges of navigating their own identity in a nation where the label “Asian” brings expectations about their origins, behavior and physical self. Read on to see, in their own words, what it means to be Asian in America.

• Introduction

Table of Contents

This is how i view my identity, this is how others see and treat me, this is what it means to be home in america, about this project, methodological note, acknowledgments.

No single experience defines what it means to be Asian in the United States today. Instead, Asian Americans’ lived experiences are in part shaped by where they were born, how connected they are to their family’s ethnic origins, and how others – both Asians and non-Asians – see and engage with them in their daily lives. Yet despite diverse experiences, backgrounds and origins, shared experiences and common themes emerged when we asked: “What does it mean to be Asian in America?”

In the fall of 2021, Pew Research Center undertook the largest focus group study it had ever conducted – 66 focus groups with 264 total participants – to hear Asian Americans talk about their lived experiences in America. The focus groups were organized into 18 distinct Asian ethnic origin groups, fielded in 18 languages and moderated by members of their own ethnic groups. Because of the pandemic, the focus groups were conducted virtually, allowing us to recruit participants from all parts of the United States. This approach allowed us to hear a diverse set of voices – especially from less populous Asian ethnic groups whose views, attitudes and opinions are seldom presented in traditional polling. The approach also allowed us to explore the reasons behind people’s opinions and choices about what it means to belong in America, beyond the preset response options of a traditional survey.

The terms “Asian,” “Asians living in the United States” and “Asian American” are used interchangeably throughout this essay to refer to U.S. adults who self-identify as Asian, either alone or in combination with other races or Hispanic identity.

“The United States” and “the U.S.” are used interchangeably with “America” for variations in the writing.

Multiracial participants are those who indicate they are of two or more racial backgrounds (one of which is Asian). Multiethnic participants are those who indicate they are of two or more ethnicities, including those identified as Asian with Hispanic background.

U.S. born refers to people born in the 50 U.S. states or the District of Columbia, Puerto Rico, or other U.S. territories.

Immigrant refers to people who were not U.S. citizens at birth – in other words, those born outside the U.S., Puerto Rico or other U.S. territories to parents who were not U.S. citizens. The terms “immigrant,” “first generation” and “foreign born” are used interchangeably in this report.  

Second generation refers to people born in the 50 states or the District of Columbia with at least one first-generation, or immigrant, parent.

The pan-ethnic term “Asian American” describes the population of about 22 million people living in the United States who trace their roots to more than 20 countries in East and Southeast Asia and the Indian subcontinent. The term was popularized by U.S. student activists in the 1960s and was eventually adopted by the U.S. Census Bureau. However, the “Asian” label masks the diverse demographics and wide economic disparities across the largest national origin groups (such as Chinese, Indian, Filipino) and the less populous ones (such as Bhutanese, Hmong and Nepalese) living in America. It also hides the varied circumstances of groups immigrated to the U.S. and how they started their lives there. The population’s diversity often presents challenges . Conventional survey methods typically reflect the voices of larger groups without fully capturing the broad range of views, attitudes, life starting points and perspectives experienced by Asian Americans. They can also limit understanding of the shared experiences across this diverse population.

Across all focus groups, some common findings emerged. Participants highlighted how the pan-ethnic “Asian” label used in the U.S. represented only one part of how they think of themselves. For example, recently arrived Asian immigrant participants told us they are drawn more to their ethnic identity than to the more general, U.S.-created pan-ethnic Asian American identity. Meanwhile, U.S.-born Asian participants shared how they identified, at times, as Asian but also, at other times, by their ethnic origin and as Americans.

Another common finding among focus group participants is the disconnect they noted between how they see themselves and how others view them. Sometimes this led to maltreatment of them or their families, especially at heightened moments in American history such as during Japanese incarceration during World War II, the aftermath of 9/11 and, more recently, the COVID-19 pandemic. Beyond these specific moments, many in the focus groups offered their own experiences that had revealed other people’s assumptions or misconceptions about their identity.

Another shared finding is the multiple ways in which participants take and express pride in their cultural and ethnic backgrounds while also feeling at home in America, celebrating and blending their unique cultural traditions and practices with those of other Americans.

This focus group project is part of a broader research agenda about Asians living in the United States. The findings presented here offer a small glimpse of what participants told us, in their own words, about how they identify themselves, how others see and treat them, and more generally, what it means to be Asian in America.

Illustrations by Jing Li

Publications from the Being Asian in America project

• Read the data essay: What It Means to Be Asian in America
• Watch the documentary: Being Asian in America
• Explore the interactive: In Their Own Words: The Diverse Perspectives of Being Asian in America
• View expanded interviews: Extended Interviews: Being Asian in America
• About this research project: More on the Being Asian in America project
• Q&A: Why and how Pew Research Center conducted 66 focus groups with Asian Americans

One of the topics covered in each focus group was how participants viewed their own racial or ethnic identity. Moderators asked them how they viewed themselves, and what experiences informed their views about their identity. These discussions not only highlighted differences in how participants thought about their own racial or ethnic background, but they also revealed how different settings can influence how they would choose to identify themselves. Across all focus groups, the general theme emerged that being Asian was only one part of how participants viewed themselves.

The pan-ethnic label ‘Asian’ is often used more in formal settings

“I think when I think of the Asian Americans, I think that we’re all unique and different. We come from different cultures and backgrounds. We come from unique stories, not just as a group, but just as individual humans.” Mali , documentary participant

Many participants described a complicated relationship with the pan-ethnic labels “Asian” or “Asian American.” For some, using the term was less of an active choice and more of an imposed one, with participants discussing the disconnect between how they would like to identify themselves and the available choices often found in formal settings. For example, an immigrant Pakistani woman remarked how she typically sees “Asian American” on forms, but not more specific options. Similarly, an immigrant Burmese woman described her experience of applying for jobs and having to identify as “Asian,” as opposed to identifying by her ethnic background, because no other options were available. These experiences highlight the challenges organizations like government agencies and employers have in developing surveys or forms that ask respondents about their identity. A common sentiment is one like this:

“I guess … I feel like I just kind of check off ‘Asian’ [for] an application or the test forms. That’s the only time I would identify as Asian. But Asian is too broad. Asia is a big continent. Yeah, I feel like it’s just too broad. To specify things, you’re Taiwanese American, that’s exactly where you came from.”

–U.S.-born woman of Taiwanese origin in early 20s

Smaller ethnic groups default to ‘Asian’ since their groups are less recognizable

Other participants shared how their experiences in explaining the geographic location and culture of their origin country led them to prefer “Asian” when talking about themselves with others. This theme was especially prominent among those belonging to smaller origin groups such as Bangladeshis and Bhutanese. A Lao participant remarked she would initially say “Asian American” because people might not be familiar with “Lao.”

“​​[When I fill out] forms, I select ‘Asian American,’ and that’s why I consider myself as an Asian American. [It is difficult to identify as] Nepali American [since] there are no such options in forms. That’s why, Asian American is fine to me.”

–Immigrant woman of Nepalese origin in late 20s

“Coming to a big country like [the United States], when people ask where we are from … there are some people who have no idea about Bhutan, so we end up introducing ourselves as being Asian.”

–Immigrant woman of Bhutanese origin in late 40s

But for many, ‘Asian’ as a label or identity just doesn’t fit

Many participants felt that neither “Asian” nor “Asian American” truly captures how they view themselves and their identity. They argue that these labels are too broad or too ambiguous, as there are so many different groups included within these labels. For example, a U.S.-born Pakistani man remarked on how “Asian” lumps many groups together – that the term is not limited to South Asian groups such as Indian and Pakistani, but also includes East Asian groups. Similarly, an immigrant Nepalese man described how “Asian” often means Chinese for many Americans. A Filipino woman summed it up this way:

“Now I consider myself to be both Filipino and Asian American, but growing up in [Southern California] … I didn’t start to identify as Asian American until college because in [the Los Angeles suburb where I lived], it’s a big mix of everything – Black, Latino, Pacific Islander and Asian … when I would go into spaces where there were a lot of other Asians, especially East Asians, I didn’t feel like I belonged. … In media, right, like people still associate Asian with being East Asian.”

–U.S.-born woman of Filipino origin in mid-20s

Participants also noted they have encountered confusion or the tendency for others to view Asian Americans as people from mostly East Asian countries, such as China, Japan and Korea. For some, this confusion even extends to interactions with other Asian American groups. A Pakistani man remarked on how he rarely finds Pakistani or Indian brands when he visits Asian stores. Instead, he recalled mostly finding Vietnamese, Korean and Chinese items.

Among participants of South Asian descent, some identified with the label “South Asian” more than just “Asian.” There were other nuances, too, when it comes to the labels people choose. Some Indian participants, for example, said people sometimes group them with Native Americans who are also referred to as Indians in the United States. This Indian woman shared her experience at school:

“I love South Asian or ‘Desi’ only because up until recently … it’s fairly new to say South Asian. I’ve always said ‘Desi’ because growing up … I’ve had to say I’m the red dot Indian, not the feather Indian. So annoying, you know? … Always a distinction that I’ve had to make.”

–U.S.-born woman of Indian origin in late 20s

Participants with multiethnic or multiracial backgrounds described their own unique experiences with their identity. Rather than choosing one racial or ethnic group over the other, some participants described identifying with both groups, since this more accurately describes how they see themselves. In some cases, this choice reflected the history of the Asian diaspora. For example, an immigrant Cambodian man described being both Khmer/Cambodian and Chinese, since his grandparents came from China. Some other participants recalled going through an “identity crisis” as they navigated between multiple identities. As one woman explained:

“I would say I went through an identity crisis. … It’s because of being multicultural. … There’s also French in the mix within my family, too. Because I don’t identify, speak or understand the language, I really can’t connect to the French roots … I’m in between like Cambodian and Thai, and then Chinese and then French … I finally lumped it up. I’m just an Asian American and proud of all my roots.”

–U.S.-born woman of Cambodian origin in mid-30s

In other cases, the choice reflected U.S. patterns of intermarriage. Asian newlyweds have the highest intermarriage rate of any racial or ethnic group in the country. One Japanese-origin man with Hispanic roots noted:

“So I would like to see myself as a Hispanic Asian American. I want to say Hispanic first because I have more of my mom’s culture in me than my dad’s culture. In fact, I actually have more American culture than my dad’s culture for what I do normally. So I guess, Hispanic American Asian.”

–U.S.-born man of Hispanic and Japanese origin in early 40s

Other identities beyond race or ethnicity are also important

Focus group participants also talked about their identity beyond the racial or ethnic dimension. For example, one Chinese woman noted that the best term to describe her would be “immigrant.” Faith and religious ties were also important to some. One immigrant participant talked about his love of Pakistani values and how religion is intermingled into Pakistani culture. Another woman explained:

“[Japanese language and culture] are very important to me and ingrained in me because they were always part of my life, and I felt them when I was growing up. Even the word itadakimasu reflects Japanese culture or the tradition. Shinto religion is a part of the culture. They are part of my identity, and they are very important to me.”

–Immigrant woman of Japanese origin in mid-30s

For some, gender is another important aspect of identity. One Korean participant emphasized that being a woman is an important part of her identity. For others, sexual orientation is an essential part of their overall identity. One U.S.-born Filipino participant described herself as “queer Asian American.” Another participant put it this way:

“I belong to the [LGBTQ] community … before, what we only know is gay and lesbian. We don’t know about being queer, nonbinary. [Here], my horizon of knowing what genders and gender roles is also expanded … in the Philippines, if you’ll be with same sex, you’re considered gay or lesbian. But here … what’s happening is so broad, on how you identify yourself.”

–Immigrant woman of Filipino origin in early 20s

Immigrant identity is tied to their ethnic heritage

Participants born outside the United States tended to link their identity with their ethnic heritage. Some felt strongly connected with their ethnic ties due to their citizenship status. For others, the lack of permanent residency or citizenship meant they have stronger ties to their ethnicity and birthplace. And in some cases, participants said they held on to their ethnic identity even after they became U.S. citizens. One woman emphasized that she will always be Taiwanese because she was born there, despite now living in the U.S.

For other participants, family origin played a central role in their identity, regardless of their status in the U.S. According to some of them, this attitude was heavily influenced by their memories and experiences in early childhood when they were still living in their countries of origin. These influences are so profound that even after decades of living in the U.S., some still feel the strong connection to their ethnic roots. And those with U.S.-born children talked about sending their kids to special educational programs in the U.S. to learn about their ethnic heritage.

“Yes, as for me, I hold that I am Khmer because our nationality cannot be deleted, our identity is Khmer as I hold that I am Khmer … so I try, even [with] my children today, I try to learn Khmer through Zoom through the so-called Khmer Parent Association.”

–Immigrant man of Cambodian origin in late 50s

Navigating life in America is an adjustment

Many participants pointed to cultural differences they have noticed between their ethnic culture and U.S. culture. One of the most distinct differences is in food. For some participants, their strong attachment to the unique dishes of their families and their countries of origin helps them maintain strong ties to their ethnic identity. One Sri Lankan participant shared that her roots are still in Sri Lanka, since she still follows Sri Lankan traditions in the U.S. such as preparing kiribath (rice with coconut milk) and celebrating Ramadan.

For other participants, interactions in social settings with those outside their own ethnic group circles highlighted cultural differences. One Bangladeshi woman talked about how Bengalis share personal stories and challenges with each other, while others in the U.S. like to have “small talk” about TV series or clothes.

Many immigrants in the focus groups have found it is easier to socialize when they are around others belonging to their ethnicity. When interacting with others who don’t share the same ethnicity, participants noted they must be more self-aware about cultural differences to avoid making mistakes in social interactions. Here, participants described the importance of learning to “fit in,” to avoid feeling left out or excluded. One Korean woman said:

“Every time I go to a party, I feel unwelcome. … In Korea, when I invite guests to my house and one person sits without talking, I come over and talk and treat them as a host. But in the United States, I have to go and mingle. I hate mingling so much. I have to talk and keep going through unimportant stories. In Korea, I am assigned to a dinner or gathering. I have a party with a sense of security. In America, I have nowhere to sit, and I don’t know where to go and who to talk to.”

–Immigrant woman of Korean origin in mid-40s

And a Bhutanese immigrant explained:

“In my case, I am not an American. I consider myself a Bhutanese. … I am a Bhutanese because I do not know American culture to consider myself as an American. It is very difficult to understand the sense of humor in America. So, we are pure Bhutanese in America.”

–Immigrant man of Bhutanese origin in early 40s

Language was also a key aspect of identity for the participants. Many immigrants in the focus groups said they speak a language other than English at home and in their daily lives. One Vietnamese man considered himself Vietnamese since his Vietnamese is better than his English. Others emphasized their English skills. A Bangladeshi participant felt that she was more accepted in the workplace when she does more “American” things and speaks fluent English, rather than sharing things from Bangladeshi culture. She felt that others in her workplace correlate her English fluency with her ability to do her job. For others born in the U.S., the language they speak at home influences their connection to their ethnic roots.

“Now if I go to my work and do show my Bengali culture and Asian culture, they are not going to take anything out of it. So, basically, I have to show something that they are interested in. I have to show that I am American, [that] I can speak English fluently. I can do whatever you give me as a responsibility. So, in those cases I can’t show anything about my culture.”

–Immigrant woman of Bangladeshi origin in late 20s

“Being bi-ethnic and tri-cultural creates so many unique dynamics, and … one of the dynamics has to do with … what it is to be Americanized. … One of the things that played a role into how I associate the identity is language. Now, my father never spoke Spanish to me … because he wanted me to develop a fluency in English, because for him, he struggled with English. What happened was three out of the four people that raised me were Khmer … they spoke to me in Khmer. We’d eat breakfast, lunch and dinner speaking Khmer. We’d go to the temple in Khmer with the language and we’d also watch videos and movies in Khmer. … Looking into why I strongly identify with the heritage, one of the reasons is [that] speaking that language connects to the home I used to have [as my families have passed away].”

–U.S.-born man of Cambodian origin in early 30s

Balancing between individualistic and collective thinking

For some immigrant participants, the main differences between themselves and others who are seen as “truly American” were less about cultural differences, or how people behave, and more about differences in “mindset,” or how people think . Those who identified strongly with their ethnicity discussed how their way of thinking is different from a “typical American.” To some, the “American mentality” is more individualistic, with less judgment on what one should do or how they should act . One immigrant Japanese man, for example, talked about how other Japanese-origin co-workers in the U.S. would work without taking breaks because it’s culturally inconsiderate to take a break while others continued working. However, he would speak up for himself and other workers when they are not taking any work breaks. He attributed this to his “American” way of thinking, which encourages people to stand up for themselves.

Some U.S.-born participants who grew up in an immigrant family described the cultural clashes that happened between themselves and their immigrant parents. Participants talked about how the second generation (children of immigrant parents) struggles to pursue their own dreams while still living up to the traditional expectations of their immigrant parents.

“I feel like one of the biggest things I’ve seen, just like [my] Asian American friends overall, is the kind of family-individualistic clash … like wanting to do your own thing is like, is kind of instilled in you as an American, like go and … follow your dream. But then you just grow up with such a sense of like also wanting to be there for your family and to live up to those expectations, and I feel like that’s something that’s very pronounced in Asian cultures.”

–U.S.-born man of Indian origin in mid-20s

Discussions also highlighted differences about gender roles between growing up in America compared with elsewhere.

“As a woman or being a girl, because of your gender, you have to keep your mouth shut [and] wait so that they call on you for you to speak up. … I do respect our elders and I do respect hearing their guidance but I also want them to learn to hear from the younger person … because we have things to share that they might not know and that [are] important … so I like to challenge gender roles or traditional roles because it is something that [because] I was born and raised here [in America], I learn that we all have the equal rights to be able to speak and share our thoughts and ideas.”

U.S. born have mixed ties to their family’s heritage

“I think being Hmong is somewhat of being free, but being free of others’ perceptions of you or of others’ attempts to assimilate you or attempts to put pressure on you. I feel like being Hmong is to resist, really.” Pa Houa , documentary participant

How U.S.-born participants identify themselves depends on their familiarity with their own heritage, whom they are talking with, where they are when asked about their identity and what the answer is used for. Some mentioned that they have stronger ethnic ties because they are very familiar with their family’s ethnic heritage. Others talked about how their eating habits and preferred dishes made them feel closer to their ethnic identity. For example, one Korean participant shared his journey of getting closer to his Korean heritage because of Korean food and customs. When some participants shared their reasons for feeling closer to their ethnic identity, they also expressed a strong sense of pride with their unique cultural and ethnic heritage.

“I definitely consider myself Japanese American. I mean I’m Japanese and American. Really, ever since I’ve grown up, I’ve really admired Japanese culture. I grew up watching a lot of anime and Japanese black and white films. Just learning about [it], I would hear about Japanese stuff from my grandparents … myself, and my family having blended Japanese culture and American culture together.”

–U.S.-born man of Japanese origin in late 20s

Meanwhile, participants who were not familiar with their family’s heritage showed less connection with their ethnic ties. One U.S.-born woman said she has a hard time calling herself Cambodian, as she is “not close to the Cambodian community.” Participants with stronger ethnic ties talked about relating to their specific ethnic group more than the broader Asian group. Another woman noted that being Vietnamese is “more specific and unique than just being Asian” and said that she didn’t feel she belonged with other Asians. Some participants also disliked being seen as or called “Asian,” in part because they want to distinguish themselves from other Asian groups. For example, one Taiwanese woman introduces herself as Taiwanese when she can, because she had frequently been seen as Chinese.

Some in the focus groups described how their views of their own identities shifted as they grew older. For example, some U.S.-born and immigrant participants who came to the U.S. at younger ages described how their experiences in high school and the need to “fit in” were important in shaping their own identities. A Chinese woman put it this way:

“So basically, all I know is that I was born in the United States. Again, when I came back, I didn’t feel any barrier with my other friends who are White or Black. … Then I got a little confused in high school when I had trouble self-identifying if I am Asian, Chinese American, like who am I. … Should I completely immerse myself in the American culture? Should I also keep my Chinese identity and stuff like that? So yeah, that was like the middle of that mist. Now, I’m pretty clear about myself. I think I am Chinese American, Asian American, whatever people want.”

–U.S.-born woman of Chinese origin in early 20s

Identity is influenced by birthplace

“I identified myself first and foremost as American. Even on the forms that you fill out that says, you know, ‘Asian’ or ‘Chinese’ or ‘other,’ I would check the ‘other’ box, and I would put ‘American Chinese’ instead of ‘Chinese American.’” Brent , documentary participant

When talking about what it means to be “American,” participants offered their own definitions. For some, “American” is associated with acquiring a distinct identity alongside their ethnic or racial backgrounds, rather than replacing them. One Indian participant put it this way:

“I would also say [that I am] Indian American just because I find myself always bouncing between the two … it’s not even like dual identity, it just is one whole identity for me, like there’s not this separation. … I’m doing [both] Indian things [and] American things. … They use that term like ABCD … ‘American Born Confused Desi’ … I don’t feel that way anymore, although there are those moments … but I would say [that I am] Indian American for sure.”

–U.S.-born woman of Indian origin in early 30s

Meanwhile, some U.S.-born participants view being American as central to their identity while also valuing the culture of their family’s heritage.

Many immigrant participants associated the term “American” with immigration status or citizenship. One Taiwanese woman said she can’t call herself American since she doesn’t have a U.S. passport. Notably, U.S. citizenship is an important milestone for many immigrant participants, giving them a stronger sense of belonging and ultimately calling themselves American. A Bangladeshi participant shared that she hasn’t received U.S. citizenship yet, and she would call herself American after she receives her U.S. passport.

Other participants gave an even narrower definition, saying only those born and raised in the United States are truly American. One Taiwanese woman mentioned that her son would be American since he was born, raised and educated in the U.S. She added that while she has U.S. citizenship, she didn’t consider herself American since she didn’t grow up in the U.S. This narrower definition has implications for belonging. Some immigrants in the groups said they could never become truly American since the way they express themselves is so different from those who were born and raised in the U.S. A Japanese woman pointed out that Japanese people “are still very intimidated by authorities,” while those born and raised in America give their opinions without hesitation.

“As soon as I arrived, I called myself a Burmese immigrant. I had a green card, but I still wasn’t an American citizen. … Now I have become a U.S. citizen, so now I am a Burmese American.”

–Immigrant man of Burmese origin in mid-30s

“Since I was born … and raised here, I kind of always view myself as American first who just happened to be Asian or Chinese. So I actually don’t like the term Chinese American or Asian American. I’m American Asian or American Chinese. I view myself as American first.”

–U.S.-born man of Chinese origin in early 60s

“[I used to think of myself as] Filipino, but recently I started saying ‘Filipino American’ because I got [U.S.] citizenship. And it just sounds weird to say Filipino American, but I’m trying to … I want to accept it. I feel like it’s now marry-able to my identity.”

–Immigrant woman of Filipino origin in early 30s

For others, American identity is about the process of ‘becoming’ culturally American

Immigrant participants also emphasized how their experiences and time living in America inform their views of being an “American.” As a result, some started to see themselves as Americans after spending more than a decade in the U.S. One Taiwanese man considered himself an American since he knows more about the U.S. than Taiwan after living in the U.S. for over 52 years.

But for other immigrant participants, the process of “becoming” American is not about how long they have lived in the U.S., but rather how familiar they are with American culture and their ability to speak English with little to no accent. This is especially true for those whose first language is not English, as learning and speaking it without an accent can be a big challenge for some. One Bangladeshi participant shared that his pronunciation of “hot water” was very different from American English, resulting in confusions in communication. By contrast, those who were more confident in their English skills felt they can better understand American culture and values as a result, leading them to a stronger connection with an American identity.

“[My friends and family tease me for being Americanized when I go back to Japan.] I think I seem a little different to people who live in Japan. I don’t think they mean anything bad, and they [were] just joking, because I already know that I seem a little different to people who live in Japan.”

–Immigrant man of Japanese origin in mid-40s

“I value my Hmong culture, and language, and ethnicity, but I also do acknowledge, again, that I was born here in America and I’m grateful that I was born here, and I was given opportunities that my parents weren’t given opportunities for.”

–U.S.-born woman of Hmong origin in early 30s

During the focus group discussions about identity, a recurring theme emerged about the difference between how participants saw themselves and how others see them. When asked to elaborate on their experiences and their points of view, some participants shared experiences they had with people misidentifying their race or ethnicity. Others talked about their frustration with being labeled the “model minority.” In all these discussions, participants shed light on the negative impacts that mistaken assumptions and labels had on their lives.

All people see is ‘Asian’

For many, interactions with others (non-Asians and Asians alike) often required explaining their backgrounds, reacting to stereotypes, and for those from smaller origin groups in particular, correcting the misconception that being “Asian” means you come from one of the larger Asian ethnic groups. Several participants remarked that in their own experiences, when others think about Asians, they tend to think of someone who is Chinese. As one immigrant Filipino woman put it, “Interacting with [non-Asians in the U.S.], it’s hard. … Well, first, I look Spanish. I mean, I don’t look Asian, so would you guess – it’s like they have a vision of what an Asian [should] look like.” Similarly, an immigrant Indonesian man remarked how Americans tended to see Asians primarily through their physical features, which not all Asian groups share.

Several participants also described how the tendency to view Asians as a monolithic group can be even more common in the wake of the COVID-19 pandemic.

“The first [thing people think of me as] is just Chinese. ‘You guys are just Chinese.’ I’m not the only one who felt [this] after the COVID-19 outbreak. ‘Whether you’re Japanese, Korean, or Southeast Asian, you’re just Chinese [to Americans]. I should avoid you.’ I’ve felt this way before, but I think I’ve felt it a bit more after the COVID-19 outbreak.”

–Immigrant woman of Korean origin in early 30s

At the same time, other participants described their own experiences trying to convince others that they are Asian or Asian American. This was a common experience among Southeast Asian participants.

“I have to convince people I’m Asian, not Middle Eastern. … If you type in Asian or you say Asian, most people associate it with Chinese food, Japanese food, karate, and like all these things but then they don’t associate it with you.”

–U.S.-born man of Pakistani origin in early 30s

The model minority myth and its impact

“I’ve never really done the best academically, compared to all my other Asian peers too. I never really excelled. I wasn’t in honors. … Those stereotypes, I think really [have] taken a toll on my self-esteem.” Diane , documentary participant

Across focus groups, immigrant and U.S.-born participants described the challenges of the seemingly positive stereotypes of Asians as intelligent, gifted in technical roles and hardworking. Participants often referred to this as the “model minority myth.”

The label “model minority” was coined in the 1960s and has been used to characterize Asian Americans as financially and educationally successful and hardworking when compared with other groups. However, for many Asians living in the United States, these characterizations do not align with their lived experiences or reflect their socioeconomic backgrounds. Indeed, among Asian origin groups in the U.S., there are wide differences in economic and social experiences. 

Academic research on the model minority myth has pointed to its impact beyond Asian Americans and towards other racial and ethnic groups, especially Black Americans, in the U.S. Some argue that the model minority myth has been used to justify policies that overlook the historical circumstances and impacts of colonialism, slavery, discrimination and segregation on other non-White racial and ethnic groups.

Many participants noted ways in which the model minority myth has been harmful. For some, expectations based on the myth didn’t match their own experiences of coming from impoverished communities. Some also recalled experiences at school when they struggled to meet their teachers’ expectations in math and science.

“As an Asian person, I feel like there’s that stereotype that Asian students are high achievers academically. They’re good at math and science. … I was a pretty mediocre student, and math and science were actually my weakest subjects, so I feel like it’s either way you lose. Teachers expect you to fit a certain stereotype and if you’re not, then you’re a disappointment, but at the same time, even if you are good at math and science, that just means that you’re fitting a stereotype. It’s [actually] your own achievement, but your teachers might think, ‘Oh, it’s because they’re Asian,’ and that diminishes your achievement.”

–U.S.-born woman of Korean origin in late 20s

Some participants felt that even when being Asian worked in their favor in the job market, they encountered stereotypes that “Asians can do quality work with less compensation” or that “Asians would not complain about anything at work.”

“There is a joke from foreigners and even Asian Americans that says, ‘No matter what you do, Asians always do the best.’ You need to get A, not just B-plus. Otherwise, you’ll be a disgrace to the family. … Even Silicon Valley hires Asian because [an] Asian’s wage is cheaper but [they] can work better. When [work] visa overflow happens, they hire Asians like Chinese and Indian to work in IT fields because we are good at this and do not complain about anything.”

–Immigrant man of Thai origin in early 40s

Others expressed frustration that people were placing them in the model minority box. One Indian woman put it this way:

“Indian people and Asian people, like … our parents or grandparents are the ones who immigrated here … against all odds. … A lot of Indian and Asian people have succeeded and have done really well for themselves because they’ve worked themselves to the bone. So now the expectations [of] the newer generations who were born here are incredibly unrealistic and high. And you get that not only from your family and the Indian community, but you’re also getting it from all of the American people around you, expecting you to be … insanely good at math, play an instrument, you know how to do this, you know how to do that, but it’s not true. And it’s just living with those expectations, it’s difficult.”

–U.S.-born woman of Indian origin in early 20s

Whether U.S. born or immigrants, Asians are often seen by others as foreigners

“Being only not quite 10 years old, it was kind of exciting to ride on a bus to go someplace. But when we went to Pomona, the assembly center, we were stuck in one of the stalls they used for the animals.” Tokiko , documentary participant

Across all focus groups, participants highlighted a common question they are asked in America when meeting people for the first time: “Where are you really from?” For participants, this question implied that people think they are “foreigners,” even though they may be longtime residents or citizens of the United States or were born in the country. One man of Vietnamese origin shared his experience with strangers who assumed that he and his friends are North Korean. Perhaps even more hurtful, participants mentioned that this meant people had a preconceived notion of what an “American” is supposed to look like, sound like or act like. One Chinese woman said that White Americans treated people like herself as outsiders based on her skin color and appearance, even though she was raised in the U.S.

Many focus group participants also acknowledged the common stereotype of treating Asians as “forever foreigners.” Some immigrant participants said they felt exhausted from constantly being asked this question by people even when they speak perfect English with no accent. During the discussion, a Korean immigrant man recalled that someone had said to him, “You speak English well, but where are you from?” One Filipino participant shared her experience during the first six months in the U.S.:

“You know, I spoke English fine. But there were certain things that, you know, people constantly questioning you like, oh, where are you from? When did you come here? You know, just asking about your experience to the point where … you become fed up with it after a while.”

–Immigrant woman of Filipino origin in mid-30s

U.S.-born participants also talked about experiences when others asked where they are from. Many shared that they would not talk about their ethnic origin right away when answering such a question because it often led to misunderstandings and assumptions that they are immigrants.

“I always get that question of, you know, ‘Where are you from?’ and I’m like, ‘I’m from America.’ And then they’re like, ‘No. Where are you from-from ?’ and I’m like, ‘Yeah, my family is from Pakistan,’ so it’s like I always had like that dual identity even though it’s never attached to me because I am like, of Pakistani descent.”

–U.S.-born man of Pakistani origin in early 20s

One Korean woman born in the U.S. said that once people know she is Korean, they ask even more offensive questions such as “Are you from North or South Korea?” or “Do you still eat dogs?”

In a similar situation, this U.S.-born Indian woman shared her responses:

“I find that there’s a, ‘So but where are you from?’ Like even in professional settings when they feel comfortable enough to ask you. ‘So – so where are you from?’ ‘Oh, I was born in [names city], Colorado. Like at [the hospital], down the street.’ ‘No, but like where are you from?’ ‘My mother’s womb?’”

–U.S.-born woman of Indian origin in early 40s

Ignorance and misinformation about Asian identity can lead to contentious encounters

“I have dealt with kids who just gave up on their Sikh identity, cut their hair and groomed their beard and everything. They just wanted to fit in and not have to deal with it, especially [those] who are victim or bullied in any incident.” Surinder , documentary participant

In some cases, ignorance and misinformation about Asians in the U.S. lead to inappropriate comments or questions and uncomfortable or dangerous situations. Participants shared their frustration when others asked about their country of origin, and they then had to explain their identity or correct misunderstandings or stereotypes about their background. At other times, some participants faced ignorant comments about their ethnicity, which sometimes led to more contentious encounters. For example, some Indian or Pakistani participants talked about the attacks or verbal abuse they experienced from others blaming them for the 9/11 terrorist attacks. Others discussed the racial slurs directed toward them since the COVID-19 pandemic in 2020. Some Japanese participants recalled their families losing everything and being incarcerated during World War II and the long-term effect it had on their lives.

“I think like right now with the coronavirus, I think we’re just Chinese, Chinese American, well, just Asian American or Asians in general, you’re just going through the same struggles right now. Like everyone is just blaming whoever looks Asian about the virus. You don’t feel safe.”

–U.S.-born man of Chinese origin in early 30s

“At the beginning of the pandemic, a friend and I went to celebrate her birthday at a club and like these guys just kept calling us COVID.”

–U.S.-born woman of Korean origin in early 20s

“There [were] a lot of instances after 9/11. One day, somebody put a poster about 9/11 [in front of] my business. He was wearing a gun. … On the poster, it was written ‘you Arabs, go back to your country.’ And then someone came inside. He pointed his gun at me and said ‘Go back to your country.’”

–Immigrant man of Pakistani origin in mid-60s

“[My parents went through the] internment camps during World War II. And my dad, he was in high school, so he was – they were building the camps and then he was put into the Santa Anita horse track place, the stables there. And then they were sent – all the Japanese Americans were sent to different camps, right, during World War II and – in California. Yeah, and they lost everything, yeah.”

–U.S.-born woman of Japanese origin in mid-60s

As focus group participants contemplated their identity during the discussions, many talked about their sense of belonging in America. Although some felt frustrated with people misunderstanding their ethnic heritage, they didn’t take a negative view of life in America. Instead, many participants – both immigrant and U.S. born – took pride in their unique cultural and ethnic backgrounds. In these discussions, people gave their own definitions of America as a place with a diverse set of cultures, with their ethnic heritage being a part of it.

Taking pride in their unique cultures

“Being a Pakistani American, I’m proud. … Because I work hard, and I make true my dreams from here.” Shahid , documentary participant

Despite the challenges of adapting to life in America for immigrant participants or of navigating their dual cultural identity for U.S.-born ones, focus group participants called America their home. And while participants talked about their identities in different ways – ethnic identity, racial (Asian) identity, and being American – they take pride in their unique cultures. Many also expressed a strong sense of responsibility to give back or support their community, sharing their cultural heritage with others on their own terms.

“Right now it has been a little difficult. I think it has been for all Asians because of the COVID issue … but I’m glad that we’re all here [in America]. I think we should be proud to be here. I’m glad that our families have traveled here, and we can help make life better for communities, our families and ourselves. I think that’s really a wonderful thing. We can be those role models for a lot of the future, the younger folks. I hope that something I did in the last years will have impacted either my family, friends or students that I taught in other community things that I’ve done. So you hope that it helps someplace along the line.”

“I am very proud of my culture. … There is not a single Bengali at my workplace, but people know the name of my country. Maybe many years [later] – educated people know all about the country. So, I don’t have to explain that there is a small country next to India and Nepal. It’s beyond saying. People after all know Bangladesh. And there are so many Bengali present here as well. So, I am very proud to be a Bangladeshi.”

Where home is

When asked about the definition of home, some immigrant participants said home is where their families are located. Immigrants in the focus groups came to the United States by various paths, whether through work opportunities, reuniting with family or seeking a safe haven as refugees. Along their journey, some received support from family members, their local community or other individuals, while others overcame challenges by themselves. Either way, they take pride in establishing their home in America and can feel hurt when someone tells them to “go back to your country.” In response, one Laotian woman in her mid-40s said, “This is my home. My country. Go away.”

“If you ask me personally, I view my home as my house … then I would say my house is with my family because wherever I go, I cannot marry if I do not have my family so that is how I would answer.”

–Immigrant man of Hmong origin in late 30s

“[If somebody yelled at me ‘go back to your country’] I’d feel angry because this is my country! I live here. America is my country. I grew up here and worked here … I’d say, ‘This is my country! You go back to your country! … I will not go anywhere. This is my home. I will live here.’ That’s what I’d say.”

–Immigrant woman of Laotian origin in early 50s

‘American’ means to blend their unique cultural and ethnic heritage with that in the U.S.

“I want to teach my children two traditions – one American and one Vietnamese – so they can compare and choose for themselves the best route in life.” Helen , documentary participant (translated from Vietnamese)

Both U.S.-born and immigrant participants in the focus groups shared their experiences of navigating a dual cultural environment between their ethnic heritage and American culture. A common thread that emerged was that being Asian in America is a process of blending two or more identities as one.

“Yeah, I want to say that’s how I feel – because like thinking about it, I would call my dad Lao but I would call myself Laotian American because I think I’m a little more integrated in the American society and I’ve also been a little more Americanized, compared to my dad. So that’s how I would see it.”

–U.S.-born man of Laotian origin in late 20s

“I mean, Bangladeshi Americans who are here, we are carrying Bangladeshi culture, religion, food. I am also trying to be Americanized like the Americans. Regarding language, eating habits.”

–Immigrant man of Bangladeshi origin in mid-50s

“Just like there is Chinese American, Mexican American, Japanese American, Italian American, so there is Indian American. I don’t want to give up Indianness. I am American by nationality, but I am Indian by birth. So whenever I talk, I try to show both the flags as well, both Indian and American flags. Just because you make new relatives but don’t forget the old relatives.”

–Immigrant man of Indian origin in late 40s

Pew Research Center designed these focus groups to better understand how members of an ethnically diverse Asian population think about their place in America and life here. By including participants of different languages, immigration or refugee experiences, educational backgrounds, and income levels, this focus group study aimed to capture in people’s own words what it means to be Asian in America. The discussions in these groups may or may not resonate with all Asians living in the United States. Browse excerpts from our focus groups with the interactive quote sorter below, view a video documentary focused on the topics discussed in the focus groups, or tell us your story of belonging in America via social media. The focus group project is part of a broader research project studying the diverse experiences of Asians living in the U.S.

Read sortable quotes from our focus groups

Browse excerpts in the interactive quote sorter from focus group participants in response to the question “What does it mean to be [Vietnamese, Thai, Sri Lankan, Hmong, etc.] like yourself in America?” This interactive allows you to sort quotes from focus group participants by ethnic origin, nativity (U.S. born or born in another country), gender and age.

Video documentary

Videos throughout the data essay illustrate what focus group participants discussed. Those recorded in these videos did not participate in the focus groups but were sampled to have similar demographic characteristics and thematically relevant stories.

Watch the full video documentary and watch additional shorter video clips related to the themes of this data essay.

Share the story of your family and your identity

Did the voices in this data essay resonate? Share your story of what it means to be Asian in America with @pewresearch. Tell us your story by using the hashtag #BeingAsianInAmerica and @pewidentity on Twitter, as well as #BeingAsianInAmerica and @pewresearch on Instagram.

This cross-ethnic, comparative qualitative research project explores the identity, economic mobility, representation, and experiences of immigration and discrimination among the Asian population in the United States. The analysis is based on 66 focus groups we conducted virtually in the fall of 2021 and included 264 participants from across the U.S. More information about the groups and analysis can be found in this appendix .

Pew Research Center is a subsidiary of The Pew Charitable Trusts, its primary funder. This data essay was funded by The Pew Charitable Trusts, with generous support from the Chan Zuckerberg Initiative DAF, an advised fund of the Silicon Valley Community Foundation; the Robert Wood Johnson Foundation; the Henry Luce Foundation; The Wallace H. Coulter Foundation; The Dirk and Charlene Kabcenell Foundation; The Long Family Foundation; Lu-Hebert Fund; Gee Family Foundation; Joseph Cotchett; the Julian Abdey and Sabrina Moyle Charitable Fund; and Nanci Nishimura.

The accompanying video clips and video documentary were made possible by The Pew Charitable Trusts, with generous support from The Sobrato Family Foundation and The Long Family Foundation.

We would also like to thank the Leaders Forum for its thought leadership and valuable assistance in helping make this study possible. This is a collaborative effort based on the input and analysis of a number of individuals and experts at Pew Research Center and outside experts.

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This paper is in the following e-collection/theme issue:

Published on 25.4.2024 in Vol 8 (2024)

Developing Social Enhancements for a Web-Based, Positive Emotion Intervention for Alzheimer Disease Caregivers: Qualitative Focus Group and Interview Study

Authors of this article:

Original Paper

• Ian Kwok 1 , PhD   ; 
• Emily Gardiner Lattie 1 , PhD   ; 
• Dershung Yang 2 , PhD   ; 
• Amanda Summers 1 , MA   ; 
• Paul Cotten 3 , BA   ; 
• Caroline Alina Leong 1 , BA   ; 
• Judith Tedlie Moskowitz 1 , MPH, PhD  

1 Feinberg School of Medicine, Northwestern University, Chicago, IL, United States

2 BrightOutcome, Buffalo Grove, IL, United States

3 University of California San Francisco, San Francisco, CA, United States

Corresponding Author:

Ian Kwok, PhD

Feinberg School of Medicine

Northwestern University

420 E Superior St

Chicago, IL, 60611

United States

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Background: Alzheimer disease is a degenerative neurological condition that requires long-term care. The cost of these responsibilities is often borne by informal caregivers, who experience an elevated risk of negative physical and psychological outcomes. Previously, we designed a positive emotion regulation intervention that was shown to improve well-being among dementia caregivers when delivered through one-on-one videoconferencing lessons with a trained facilitator. However, the format required significant resources in terms of logistics and facilitator time. To broaden the reach of the intervention, we aimed to develop the Social Augmentation of Self-Guided Electronic Delivery of the Life Enhancing Activities for Family Caregivers (SAGE LEAF) program, an iteration of the intervention in a self-guided, web-based format with enhanced opportunities for social connection.

Objective: The aim of this study was to gather feedback to inform the design of social features for the SAGE LEAF intervention. In the absence of a facilitator, our goal with the self-guided SAGE LEAF intervention was to integrate various social features (eg, discussion board, automated support, and profiles) to maximize engagement among participants.

Methods: Qualitative data were collected from 26 individuals through (1) interviews with participants who completed a previous version of the intervention via videoconferencing with a facilitator, (2) focus groups with dementia caregivers who had not previously experienced the intervention, and (3) focus groups with Alzheimer disease clinical care providers. We conducted a qualitative thematic analysis to identify which social features would be the most helpful and how they could be implemented in a way that would be best received by caregivers.

Results: Interview and focus group feedback indicated that participants generally liked the potential features suggested, including the discussion boards, multimedia content, and informational support. They had valuable suggestions for optimal implementation. For example, participants liked the idea of a buddy system where they would be matched up with another caregiver for the duration of the study. However, they expressed concern about differing expectations among caregivers and the possibility of matched caregivers not getting along. Participants also expressed interest in giving caregivers access to a podcast on the skills, which would allow them to review additional content when they wished.

Conclusions: Taken together, the discussions with caregivers and providers offered unique insights into the types of social features that may be integrated into the SAGE LEAF intervention, as well as implementation suggestions to improve the acceptability of the features among caregivers. These insights will allow us to design social features for the intervention that are optimally engaging and helpful for caregivers.

Introduction

The impact of Alzheimer disease (AD) continues to broaden as the global average life expectancy grows [ 1 , 2 ]. Consequently, the number of individuals who will assume the role of a primary caregiver of a friend or family member with AD is expected to rise, with estimates indicating that informal care accounts for 40% of the total cost of care [ 3 ]. In the United States alone, this amounts to an estimated annual total of 18.6 billion hours of unpaid care [ 4 ].

At the individual level, the protracted nature of AD results in an extended caregiving role that intensifies as the care recipient’s health gradually declines [ 5 ]. For example, initial caregiving responsibilities may include assisting with activities of daily living such as providing transportation, preparing meals, and helping with chores [ 6 ]. However, in more advanced stages of the disease, caregivers often have to cope with agitation, aggression, and wandering [ 7 ] while shouldering an increasing logistical and financial burden of coordinating care [ 8 , 9 ].

The weight of these responsibilities comes at a cost to caregivers, who experience adverse mental health outcomes such as increased depression, anxiety, and suicidality [ 10 - 13 ] as well as negative consequences for physical health, demonstrated by increased sleep disturbance, fatigue, and undernutrition [ 14 , 15 ]. This, in turn, may lead to a decline in the quality of care and, subsequently, poorer outcomes for the care recipient [ 5 ].

In light of the growing recognition of the stress of AD caregiving, researchers are developing targeted interventions that offer a combination of psychoeducation, social support, and psychological support for caregivers [ 16 , 17 ]. Of note, researchers are increasingly using eHealth technologies that leverage electronic information and communication (eg, telehealth, mobile apps, and web-based applications) to broaden the dissemination of these resources [ 18 , 19 ]. After the onset of the COVID-19 pandemic, eHealth technologies found renewed significance when in-person AD support services were suspended, necessitating a rapid shift to telehealth offerings [ 20 ].

This study was the first step in the adaptation of an existing caregiver intervention into a socially enhanced web-based intervention—Social Augmentation of Self-Guided Electronic Delivery of the Life Enhancing Activities for Family Caregivers (SAGE LEAF). SAGE LEAF will comprise a positive emotion regulation curriculum that has been shown to be helpful for individuals experiencing significant life stress, including those with type 2 diabetes, metastatic breast cancer, HIV, and depression [ 21 - 24 ]. In a previous study, the intervention was also tailored specifically for dementia caregivers and delivered through videoconferencing by trained facilitators [ 25 ]. The intervention was effective at reducing symptoms of depression while improving self-reported physical health and positive emotion outcomes. However, the one-on-one facilitation that was provided for participants required a significant commitment of resources in terms of recruiting and training facilitators as well as an estimated 6 to 8 individual contact hours per participant over the course of 6 weeks. Hence, our goal was to tailor the self-guided, web-based version of the intervention for caregivers while incorporating unique social features that may help foster engagement among participants.

Specifically, our aim was to enhance social presence , defined by computer-human interaction researchers as the perception of others in a virtual environment [ 26 - 28 ]. The construct has been shown to be associated with enhanced perceived learning and satisfaction in e-learning environments [ 29 ]. However, to identify potential social features that may be helpful for AD caregivers, it is also necessary to first understand how they currently use social technologies to support their caregiving activities and emotional well-being. For example, caregivers may use discussion boards hosted by the Alzheimer’s Association [ 30 ] or on social platforms such as Facebook or Reddit [ 31 ]. Furthermore, in the context of the COVID-19 pandemic, caregivers are now increasingly reliant on these social technologies with the rapid shift from in-person to virtual support resources, which include videoconferencing support groups for caregivers [ 32 ].

Hence, to examine the preferences and requirements of AD caregivers, this study aimed to solicit feedback on a set of potential social features for the SAGE LEAF intervention. These were identified from a review that we conducted on social features that were being implemented on research-focused and commercial eHealth applications (I Kwok, unpublished data, May 2021) in consultation with study team members and developers who were involved in the design of previous versions of the intervention ( Textbox 1 ).

We collected feedback through (1) individual interviews with caregivers who completed the previous version of the intervention [ 25 ], (2) focus groups with dementia caregivers who had not yet been exposed to the intervention, and (3) focus groups with clinical providers of people with AD. The findings will inform the types of social features to be included in the SAGE LEAF intervention and how they can be implemented in a way that is most beneficial for caregivers.

Social feature and description

• Peer groups or cohort: enrolling caregivers in groups so that they have a “cohort” of peers that progress together in the program. This allows group participation to occur synchronously in a “live” virtual setting or asynchronously in a manner that allows participants to engage with the intervention at their own pace in the context of an assigned cohort [ 33 - 35 ].
• Profiles: a profile page that may be shared with others. Examples of profile content include being able to choose an avatar and answering some questions about themselves. Such features involve varying levels of self-disclosure, data management, and personalization that may enhance the sense of the presence of others in the intervention [ 36 - 38 ].
• Private messaging: participants are able to send each other private messages. Some examples include messaging through SMS text messages [ 39 , 40 ] or commercially available applications such as Facebook and WhatsApp [ 41 ] or built into the eHealth intervention [ 42 , 43 ].
• Buddy system or matching: pairing participants who are going through the intervention at the same time. Some examples include matching participants who are going through the intervention at the same time or with someone who has previously completed the program as a “peer mentor” for each other or enrolling a partner whom the participant has an existing relationship with [ 44 - 46 ].
• Videoconferencing group: a facilitated group with participants through videoconference. Similar formats include support group and education or training videoconferencing sessions [ 47 , 48 ].
• Discussion board: a web-based discussion board on the content of the lessons. Possible discussion board enhancements include notifications for when other users like or comment on their posts [ 49 - 51 ].
• Automated support: this may include reminders or notifications for participants who are not logging in or feedback collected at the end of lessons. Such features have been shown to enhance adherence in eHealth interventions [ 52 , 53 ].
• Multimedia, videos, or podcasts: these forms of multimedia are commonly used to disseminate educational material in a way that engages participants, thereby promoting literacy and enhancing health-related outcomes [ 54 ]. This might include testimonials and quotes from previous participants or messages from the study team.
• Informational support: frequently asked questions or other information about how to connect with caregiver organizations, online support groups, and mental health care providers. Such resources may enhance a participant’s sense of perceived support and information competence [ 55 ].

A combination of focus groups and interviews was conducted to solicit feedback on the short list of potential social features for the SAGE LEAF intervention. Subsequently, a qualitative analysis was conducted on the transcripts to identify and gather feedback on each feature.

Sample and Sampling

Three groups of participants were recruited ( Tables 1 and 2 ):

• Individual interviews: dementia caregivers who participated in a previous version of the intervention [ 56 ]. We emailed individuals who had previously provided consent for recontact and provided them with information about the interviews. If they wished to participate, they completed a screener survey to determine whether they met the following eligibility criteria: (1) currently identifying as the primary family caregiver of a person with dementia, (2) ability to speak and read English, (3) access to high-speed internet, and (4) access to a webcam for videoconferencing. The interviews were conducted by the lead author (IK), who adhered to a semistructured interview protocol to guide the discussions. They lasted approximately 45 to 60 minutes, and topics included (1) the types of social connection technologies that participants use in their everyday life, (2) reactions to potential social features that may be implemented for SAGE LEAF (eg, private messaging, discussion board, and virtual profiles), and (3) solicitation of suggestions for other social features not previously mentioned.
• Caregiver focus groups: dementia caregivers from Northwestern Memorial Hospital’s Cognitive Neurology and Alzheimer’s Disease Center (CNADC) were recruited for 2 focus groups comprising 5 caregivers each (n=10). We emailed caregivers who had previously provided consent to be contacted for research purposes through the CNADC and provided them with information about the focus groups. If they wished to participate, they were asked to complete a web-based screener survey to determine whether they met the following eligibility criteria: (1) currently identifying as the primary family caregiver of a person with dementia, (2) ability to speak and read English, (3) access to high-speed internet, and (4) access to a webcam for videoconferencing. The focus groups lasted approximately 90 to 120 minutes and were similar in content to the interviews.
• Clinician focus groups: we contacted clinicians who provided care for people with AD or their family or informal caregivers (eg, physicians, nurses, and social workers) from the CNADC and the University of California, San Francisco’s Memory and Aging Center via email. Both are comprehensive research and care centers that treat AD; hence, clinicians are involved in a broad range of AD programs that integrate patient care, training, and research. Interested clinicians completed a screener survey where they could indicate their professional experience to determine whether they met the following eligibility criteria: (1) current employment as a clinician for patients with AD and their caregivers (eg, physicians, nurses, and social workers), (2) access to high-speed internet, and (3) access to a webcam for videoconferencing. One focus group was conducted for AD care providers (n=6).

a AD: Alzheimer disease.

Data Extraction Procedure

We conducted a qualitative thematic analysis to identify (1) positive and negative feedback and implementation suggestions for each of the potential social features and (2) additional social features suggested by participants.

The interview and focus group recordings were transcribed and uploaded to the Dedoose qualitative and mixed methods research application (SocioCultural Research Consultants) in preparation for thematic analysis. Because the interviews and focus groups followed a similar structure, with questions asked about the same set of features, all transcripts were collated and analyzed together. In total, 2 independent coders performed the coding (IK and CL). First, they conducted open-ended coding of a test transcript to extract a preliminary list of codes. The coders met to discuss their observations, resolve differences in these observations, and refine the list of codes. An additional study team member (JM) was involved in reviewing the list to ensure that it captured the potential range of feedback. Next, to ensure a high level of agreement, the coders performed an interrater reliability test on 3 transcripts. While there is debate about the applicability of interrater reliability in interpretive qualitative research, its measurement allows for greater transparency and motivates adherence to the established coding guidelines [ 57 ]. During the test, a Cohen κ of 0.68 was achieved, which is regarded as a substantial level of agreement [ 58 ]. Subsequently, the coders met to resolve the discrepancies highlighted by the test and refined the codebook once again.

Next, the coders proceeded with a first round of independent coding that comprised 5 transcripts. They randomly selected one of the transcripts to be double coded and met to discuss any discrepancies in their coding. Finally, they proceeded with a second round of independent coding of the 5 remaining transcripts.

The codes were organized based on the type of social feature that they referenced. For each social feature, subcodes were created for positive feedback, negative feedback or barriers, and implementation suggestions. Additional codes were created for other social technologies mentioned (eg, WhatsApp and Facebook), web-based resources, and additional ideas suggested by participants. In the Results section, the results are categorized by social feature type. Quotes from participants are presented with the following identifiers: (1) “PX” to denote participants who completed a previous version of the intervention, (2) “CR” to denote caregivers who participated in the focus groups, and (3) “PR” to denote providers who participated in the focus groups. Due to the personal nature of the interviews and focus groups, the full transcripts are not publicly available.

Ethical Considerations

The protocol for this study was approved by Northwestern University’s institutional review board (STU00215548) before conducting the study. Eligible participants were sent an electronic consent form via email delineating the risks and benefits of participation, at which point they could confirm their preference to participate or decline participation in the study. Data collected from REDCap (Research Electronic Data Capture; Vanderbilt University) surveys were stored on a secure, Health Insurance Portability and Accountability Act–compliant, and password-protected server at the university. The data were deidentified, with no identifying information linked to their feedback. Participants were paid US $25 for attending the virtual focus groups and interviews. Providers were not reimbursed for their participation.

Peer Groups or Cohort

Participants generally liked the idea of being in a peer group, and caregivers drew comparisons to their previous participation in caregiving support groups. However, they expressed concern as to how they would be matched into groups:

I think if you want to have peers, you do need to match them up closely. By the progression of disease maybe. [CR2]

I think that you have to be careful as to who’s in the peer group...I’ve been in other support groups where [caregivers were caring for] somebody had dementia, somebody with Alzheimer’s, and [another caregiver was caring for someone with] PPA (primary progressive aphasia). And they’ve got similarities, but they’re so drastically different. [CR3]

Furthermore, participants had varying opinions on how caregivers should be grouped together. Some suggestions included grouping by age, relationship to the care recipient, or type of dementia. One participant also suggested that it may be helpful to group individuals based on their recreational interests instead of their caregiving status:

I think it’s also good to have in a peer group...And I don’t think gender or anything like that matters whatsoever, it’s more about where they are and what they’re doing at the time, with the same type of diagnosis. [CR1]

Well, I think that general background is so important...You know, educational—the number of degrees you get isn’t as important as interests. Are you interested in art? Are you interested in gardening?...It’s one way that certainly people get together. [PX1]

Hence, type of dementia or progression of the disease were the most preferred methods of grouping individuals. Participants in the focus groups and interviews were able to readily articulate their grouping preferences by tapping into their own experience of caregiving and their specific needs based on their care recipient’s diagnosis. This underscores the utility of segmenting future participants by type of dementia diagnosis.

There is a high degree of variability in how user profiles are used in eHealth platforms, ranging from toggling basic settings to more extensive social features such as managing invites, notifications, and social groups. Our proposed enhanced user profiles would allow participants to customize the way in which they present themselves in the virtual space and would help lay the groundwork for future social interaction on the SAGE LEAF platform. Such user profiles might include the ability to select an avatar or allow participants to display their name and other personal information if they choose to do so.

Similar to the feedback on the peer groups, focus group and interview participants were primarily interested in the caregiving-related characteristics of other users, such as the relationship between the caregiver and care recipient and type of dementia diagnosis:

Family relationship. If they’re the adult child or spouse/partner. I’ve also—if it’s the younger onset versus later onset. [PR1]

I think people would be interested in knowing the diagnosis of the person the other caregivers are caring for. So, if someone is an adult child caring for their parent with Alzheimer’s, I feel like they would be interested in meeting other people in similar situations. [PR3]

I think age is a big factor. I’ve had a lot of people who are younger, like maybe family caregivers, who are more interested in talking with somebody their own age. Or around—near their own age. [PR4]

Taken together, this feedback suggests that the information that is shared in the profiles may be similar to the variables by which participants might be grouped together. This emphasizes the synergy between these features and how they may foster a sense of shared identity among participants.

Private Messaging

A private messaging function would allow participants to contact each other individually on their own and would function similarly to social networking platforms such as Facebook and Instagram that allow for direct messaging. Overall, feedback was positive, but one clinician articulated their concerns about privacy and security:

...in my support group there are people who request, you know, to be connected to each other. And I think I always try to make sure that I ask both parties before I connect them...So maybe the option to stay private or to be public. [PR5]

Contrary to our expectations that caregivers may share similar concerns about security and privacy regarding being contacted, the feedback suggests that caregivers were open to the idea of being able to send and receive messages and expressed minimal hesitation toward the private messaging feature:

Oh, I think that would be fine. You know, I see nothing wrong with that. I think, you know, friendships could be formed out of that. And private support and like-minded thinking people...I see absolutely nothing wrong with that. [PX10]

I think that’s fine. I think that would be good because you’re going to have to find a way to build trust, and then it’s also somebody who is in a similar circumstance than yourself. So, yeah, so that’s how I would look at it. [PX12]

Hence, feedback was generally positive on the ability to connect with other caregivers through a private messaging feature. Participants emphasized that their potential willingness to use this feature was based on the assumption that other participants would be in a similar caregiving situation to theirs. For instance, participants indicated that the similarity of the diagnosis of their care recipient or whether they were also spousal or other family caregivers were important attributes that might influence their use of this feature.

Buddy System or Matching

To maximize the sense of social presence that future participants might experience, we initially proposed a buddy system where participants would be paired up with a peer or “buddy”—either with someone who was going through the program at the same time as them or with participants who had previously completed the intervention. This social feature would complement the peer groups in that participants would be able to feel like they were part of a group while being able to connect individually with other participants. Alternatively, this could be deployed as a stand-alone feature in the event that there were not enough participants to form a cohort. Overall, we received mixed feedback from caregivers and clinicians on the concept of a buddy system.

In their feedback, caregivers expressed interest in this idea because it would provide accountability for progressing through the program to their potential buddies and enhance their motivation to engage with the content:

Oh, it totally would [be helpful]. Because I would be more concerned about disappointing the other person. “Oh, they need me! I have to check my email,” or “I have to check that text. I don’t want to disappoint them.” [CR3]

I think it’s a great idea. You know, it would have been nice, if I had had one, but I was just flying by the skin of my teeth and sometimes I crash landed. [PX7]

In contrast, clinicians expressed significant concerns about the implementation of a buddy system. They described past experiences with similar efforts where the matching was unsuccessful or burdensome and led to a disappointing experience for the caregivers involved:

I’ve tried connecting caregivers that I work with, and unless they really hit it off naturally in most cases it doesn’t work out. [PR5]

I think there can be a problem in the two caregivers having really different expectations about what the relationship is going to be...I think it would add a level of burden to caregivers too... [PR2]

Hence, while caregivers expressed enthusiasm for this idea, clinicians spoke from their own past experiences and were strongly against the idea of matching because they found it challenging to establish shared expectations and to anticipate whether caregivers who were matched would get along well. Therefore, it is unclear whether the benefits of the buddy system may be outweighed by potential complications that arise from these unanticipated social dynamics.

Videoconferencing Group

At present, support groups form a crucial resource for AD caregivers, as demonstrated by the wide range of group programing in both virtual and in-person formats [ 17 , 59 ]. Hence, another possible feature was a videoconferencing group where participants would be able to log in at a given time during the week to connect with other caregivers with the specific focus on discussing the skills being taught in the program.

The onset of the COVID-19 pandemic hastened the transition of in-person support groups to web-based videoconferencing groups. This transition was demonstrated in the readiness that caregivers expressed in adopting these videoconferencing technologies. It should be noted that all the interviews and focus groups took place at the start of the pandemic:

I have been surprised that the Zoom meetings—I’ve gone to many of them...I should point out I’m 83 years old, okay?...via online, that sort of thing, would be very good for a person like me. [PX1]

In terms of implementation suggestions, one participant highlighted that these videoconferencing groups would be a good addition to the program as long as participation was optional. This underscores the importance of building flexibility into the social features being offered as caregivers have competing demands or may simply prefer different features:

I think if you could make it as an offering but not a requirement...But I think you have to be understanding of the fact that not everybody’s going to be able to do that at the same time...it’s hard for me to commit weekly to a certain time. [PX10]

One concern that was expressed by both caregivers and clinicians was the importance of making sure that the videoconferencing group discussions stayed on topic. Caregivers articulated various past experiences where their time was not spent efficiently because other participants deviated from the focus of the discussions:

...I would go and check out other groups, and that was always a real disappointment. And I would not go back to those when, you know, somebody would just insist on eating up the entire hour with their issues. And so that's a problem... [PX11]

I would gravitate toward anything where there was some real-time moderation or facilitation, just to help keep the learning on track. [CR5a]

The feedback suggests that videoconferencing groups can be helpful for caregivers. However, there was concern about the efficiency of these meetings, which could be addressed by having a facilitator who is able to moderate and guide the discussions. A facilitated group would allow participants to discuss the topics freely while ensuring that the time is directed toward the topics and skills taught in the program. Participants also liked the idea of having a portion of the videoconferencing group sessions be not necessarily related to caregiving or the positive emotion skills taught in the program, with several participants expressing interest in an informal happy hour where they could connect with each other casually.

Discussion Group

Caregivers often seek information about their care recipient’s diagnosis, behaviors, and symptoms through the internet. Hence, many already participate in AD-specific discussion groups that are associated with the Alzheimer’s Association or informal groups that proliferate on social media platforms such as Facebook and Reddit. In line with our expectations, participants were generally open to the idea of using a discussion board. One clinician suggested that there may be some overlap with these existing platforms, which could present a barrier to participants using the discussion board:

...some of the feedback we get from caregivers is that, “You’re asking me to do something I already have a mechanism for doing that. So, I already have a way to share photos with people that I’m close to, it’s called Facebook or whatever. But you’re asking me to sort of do it in this different venue.” So that’s been a negative when you’re asking somebody to do something, that they already have a way to do that. [PR2]

Furthermore, both participants and providers emphasized that the use of the discussion board would be contingent on how the benefits of engaging with it were conveyed to participants. Some of their suggestions included highlighting how the discussion board could amplify their practice of the skills or allow them to feel more connected with other participants in the study:

I think there are some advantages, and that if you really say the discussion board is to really talk about the skills or share examples of where you use the skills...And if you framed it so that—I could even see it as being a way to amplify the skills. [PR3]

...to encourage people and say, “Hey, look at, you know, it’s normal for you to feel isolated and trying to get questions answered. It’s worth it to try and work with these tools.” [PX12]

This feedback suggests that caregivers may be open to using the discussion boards, yet there were concerns about how these discussion boards might duplicate existing resources. Thus, it is essential to highlight the benefits of engaging with the discussion board associated with the positive emotion skills program to encourage its use. This may be in the form of prompts or reminders to participants about these benefits.

Automated Support

As described in Textbox 1 , automated support would comprise notifications or reminders that are sent out based on certain triggers, for example, if a participant does not log on to the platform for a certain number of days or if they endorse poor mood for an extended period. With automated support, the intention is to provide caregivers with a sense that their participation is valued and that we would be responsive to their level of engagement. Similar to the feedback collected in previous versions of the intervention, participants found the concept of reminders helpful but expressed the need for these messages to be framed in a way that was supportive and encouraging:

I guess that’s where I would give them points, and like, more like entice them rather than nag them. [PR5]

Because when you first said it [automated support], it was totally irritating to me. I thought, “I’m doing this to take care of myself, and now you’re making me accountable?! I don’t have time today!” And then after you talked a little more, then I felt better about it...I think it’s how you frame it. Or how I frame it for myself. [CR3]

You could try to be really empathetic and kind of understand why they didn’t get to it, versus the risk that if someone got an automated message that might just add to their sense of everything negative about why they haven’t done the skills. [PR2]

Across the board, providers and caregivers reiterated the importance of supportive and encouraging messaging when implementing the automated support features. This underscores the importance of emphasizing the rewarding aspects of participation—instead of reprimanding or penalizing caregivers for not using the various features. Furthermore, it may be helpful for this supportive language to be integrated not only into the automated support features but throughout the intervention as well—for example, using the registration emails, videos, and podcasts as opportunities for cheerleading and supporting participants.

Multimedia, Videos, or Podcasts

Multimedia content such as videos and podcasts may help enhance the perception that there are study staff members behind the program and other caregivers who are involved in the study. In previous versions of the intervention, caregivers worked one-on-one with a facilitator to learn the skills. To compensate for a lack of face time in this self-guided format, we proposed the addition of multimedia content to make the skill-building lessons more engaging by hearing directly from the team members involved in the development of the intervention. In their feedback, participants unanimously liked the idea of including this multimedia content:

I think that would be good. I mean, again, it takes the program out of being a program and puts it into a dialogue with someone. And I think it’s always good to see the face of the people who are running the program. [PX1]

It might be encouraging for them to hear and see that they’re not alone, that others have gone through it and have come out on the other side. [PX14]

Some participants suggested the idea of including a podcast as part of the program. This would allow caregivers to review the material at a time that is most convenient for them. This is consistent with feedback on other social features, in which participants suggested that flexibility may be helpful for caregivers who are busy:

And I like the idea of the podcast, so that you can do it on your time and when it’s convenient for you...ten, less than ten minutes here and there throughout the week... [CR1]

I participate in a 30-day class right now...It is a five-minute podcast that she sends, along with a list of daily activities and a curriculum has been provided in advance. So, you know that the five-minute podcast is five minutes out of your day, and you can do that, it’s pretty easy to find five minutes. [CR4]

The overwhelmingly positive feedback on the proposed multimedia social features demonstrates that participants are interested in the sharing of insights from the study team as well as from previous participants. In the absence of live communication, their feedback suggests that such multimedia features may be central to developing a sense of social presence.

Informational Support

Caregivers often use web-based resources to seek information about providing care for their loved ones with dementia. While participants felt that informational support could be helpful, their feedback suggests that it was important for it to be targeted and provide specific information that was useful for caregivers:

But be real specific...the specific information is way more helpful. [PX6]

...my husband’s diagnosis is not specifically Alzheimer’s...a lot of the things that have to do with the Alzheimer's Association don't apply to him... [PX10]

...the referral...You know, a piece of paper with 20 different organizations on it were not helpful. [CR5a]

Their feedback also suggests that many caregivers are discerning about such resources and sophisticated in their information search methods. Hence, the informational support provided by the intervention should be thorough and specific for it to be meaningful for participants. For example, participants indicated that it would be helpful if such resources were organized by geographic location or if they could be sorted in a way that would make it easy for participants to find the resources that are most helpful to them. Another approach would be to provide additional resources that relate specifically to the skills that are being taught.

Other Social Features

We also collected feedback on other social features that might be helpful for caregivers. One participant suggested that the study team solicit participants’ input throughout the program to foster a sense of involvement. This has some similarities to the brief survey that we will provide at the end of each lesson asking participants to rate how they felt about the lesson on a scale from 1 to 5 stars. While this feature was not previously considered a social feature, the act of soliciting feedback provides participants with an opportunity to express their thoughts about the program and reinforces the sense that there is a study team who is collecting the feedback and trying to improve the intervention for the benefit of caregivers:

I think asking for opinions...getting involved in just what you’re doing and asking what I think. “Okay, what do you think of the program?” It’s certainly one way to get involved, as long as it’s done in such a way that it’s meaningful. [PX1]

Participants also mentioned how the use of other platforms such as Instagram or Facebook may complement the intervention. The feedback suggests that creating a parallel dialogue on these already used platforms could foster an enhanced sense of social connection. One benefit to using these platforms is that participants would be able to connect with each other regarding the positive emotion skills across multiple platforms, which may enhance their learning. Participants also mentioned how the COVID-19 pandemic heightened their sense of social isolation; hence, the integration of these popular social networking platforms may help caregivers feel more connected as they complete the study:

I think if you had something that allowed people to respond to one another, whether it was a chat room...they create a Facebook group that is specific to that course...And that those people during that course can talk to each other, and every now and then the instructor chimes in if she feels that there’s something that she can add to it or some guidance. But I think something where people could connect would be nice. [PX10]

I was thinking along the same lines of connecting on a specific theme, you mentioned gardening or cooking, I think those are the kinds of things that people do on Instagram or Facebook. But the WhatsApp group can be more private, so it can be formed just with the people who meet each other, and then they can share... [PR5]

Principal Findings

In this study, we collected feedback on social features that may be implemented for a web-based positive emotion skills intervention for AD and other dementia caregivers. Through (1) individual interviews with participants who completed a previous version of the intervention, (2) focus groups with dementia caregivers, and (3) focus groups with AD clinicians, we collected information about the specific needs and preferences of caregivers in the implementation of these social features. Participants provided a number of insights into how to implement these features in a way that may be best received by caregivers.

Overall, participants provided extensive feedback on the proposed features and how they could be best implemented. However, they had fewer suggestions for additional features that might enhance a sense of social connection. This may be because we asked participants open-ended questions about additional features toward the end of the interviews and focus groups, at which point they may have exhausted their ideas or there may have been overlap with our proposed features. Nonetheless, participants were engaged throughout the discussions and provided unique insights into how we could refine our feature set.

Participants generally liked the proposed social features and provided valuable suggestions for how they could be improved. One such example is the multimedia content proposed for the intervention, for which participants suggested a podcast format to allow caregivers to review this additional material at their convenience. This is similar to other exploratory eHealth interventions that have used this delivery format to enhance health literacy [ 60 ], weight loss [ 61 ], and self-compassion [ 62 ].

Other feedback related to the automated support features, in which participants emphasized the importance of providing encouragement to caregivers instead of shaming them for nonadherence. In a study of a physical activity intervention for older adults, it was found that, when the messaging was positively framed (ie, described in terms of the rewards and benefits of exercise as opposed to the costs of inactivity), participants’ pedometer readings indicated that they had walked more compared to those who received negative or neutral messaging [ 63 ]. Therefore, we could incorporate this positive framing, for example, if participants have not logged into the website for several days, and send personalized email messages letting them know that their participation is missed, while recognizing that caregivers have busy schedules, and reminding them that they might receive a boost in positive emotion by spending just a couple of minutes completing the home practice activities.

There were certain instances in which caregivers and clinicians differed in their feedback. For example, caregiver participants were generally open to the idea of being paired up with a buddy in the program. However, clinicians who had implemented similar programs were able to speak from their own experiences with attempts to match participants that were not successful based on differences in life experiences and expectations for engaging with a buddy program. Thus, although caregivers thought that they would enjoy a buddy feature, clinicians noted significant barriers to the implementation of this feature. Another example of disagreement between caregivers and clinicians was the private messaging feature, where one clinician highlighted concerns about privacy and security that caregivers did not report. Across eHealth interventions, researchers have far more information about how these platforms work and the accompanying benefits and risks compared to their participants [ 64 ]. Hence, researchers have an ethical responsibility to convey this information to participants. Recognizing these differing perspectives underscores the importance of integrating feedback from both caregivers and clinicians in refining these social features.

Participants were asked for additional suggestions for features that would enhance social connection or a sense of social presence. Their suggestions included soliciting feedback from caregivers as they progress through the program and using existing social media platforms to foster a sense of social connection beyond the SAGE LEAF intervention.

Further Research and Implications

The feedback collected from the focus groups and interviews will be used to inform the development of the social features for the SAGE LEAF intervention. This will include developing a list of “trigger events” for the automated support features and wording the notifications or reminders in a way that would be supportive to participants. We will also include enhanced user profiles where participants can toggle how they would like to receive notifications and share more detailed information about their caregiving status to other users if they wish to. We will also include videos and podcasts where study team members will introduce each positive emotion skill and suggest methods for mastering it.

The feedback from the focus groups and interviews also helped clarify which social features may be potentially challenging to implement, such as the buddy system. In future versions of the intervention, a study team member could facilitate a matching process among participants. However, this may require additional resources to implement.

The feedback made clear that informational resources were extremely helpful for caregivers. However, it was apparent that caregivers already seek these resources through web-based groups or informational websites hosted by caregiver organizations. Furthermore, it appeared that this information is most helpful when it is specific and tailored for the caregiver and care recipient. Recognizing that the primary aim of the intervention was to deliver the positive emotion skills and not more general caregiving skills per se and acknowledging that it would take significant resources to successfully implement these informational support features, this feature is less likely to be prioritized for inclusion in future iterations of SAGE LEAF.

While this study focused on all the potential social feature enhancements (ie, discussion boards, podcasts, and automated notifications) intended for SAGE LEAF, future versions of the intervention could explore which enhancements are most effective by using a factorial design where participants are randomly assigned to different combinations of the features to determine which can be most helpful or may best enhance a sense of social connection. In a randomized controlled trial of a previous version of the intervention designed for individuals with depressive symptoms [ 50 ], we randomly assigned participants to different combinations of enhancements and found that facilitator contact in combination with virtual badges yielded the highest participant engagement. Given that SAGE LEAF will be entirely self-guided, future research should explore which features, individually and in combination, lead to the biggest impact on caregiver engagement and well-being. For example, user profiles may help caregivers disclose more information about themselves and their caregiving circumstances, which may then enhance the quality of the interactions that take place on the discussion boards. Additional research may also involve measuring the extent to which these combinations of features lead to measurable increases in social presence —which is hypothesized to mediate the relationship between the application of these social features and desired intervention outcomes.

Strengths and Limitations

The feedback collected from caregivers and providers offered valuable perspectives not only on features that may be helpful and engaging but also on ways in which they may be implemented to best benefit caregivers. In addition, the combination of interview and focus group formats allowed for both individual feedback and group discussions to aid in the generation of ideas.

However, the semistructured format of the interviews and focus groups potentially limited the range of feedback collected. With our questions focusing primarily on the proposed features, this may have constrained the participants’ ability to provide novel ideas for new social features.

Another limitation to our study is the lack of ethnic diversity in our caregiver sample, which consisted of primarily White participants. To achieve a more diverse sample and perspectives in future studies, future research should oversample for underrepresented ethnic groups if needed.

Conclusions

This study involved a qualitative analysis of focus groups and interviews with caregivers and clinicians to determine which social features might be most helpful in tailoring a self-guided positive emotion intervention for AD caregivers. The feedback collected suggests that the participants were mostly open and receptive to the innovative social features we proposed. However, their lived and professional experiences provided unique insights into how best to implement these features in a way that would be helpful and engaging for caregivers participating in future versions of SAGE LEAF.

Acknowledgments

The authors would like to express their gratitude to the Mesulam Center for Cognitive Neurology and Alzheimer’s Disease for their collaboration in this research. This study was supported in part by a Small Business Innovation Research grant (R43AG065080) from the National Institute on Aging to BrightOutcome. In addition, this study was supported in part by an Alzheimer’s Disease Core Center grant (P30 AG013854) from the National Institute on Aging to Northwestern University, Chicago, Illinois. The authors gratefully acknowledge the assistance of the Clinical Core and its participants. Generative artificial intelligence was not used in the writing of this manuscript.

Data Availability

The data collected in the coding process may be obtained by contacting the first author (IK).

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 23.06.23; peer-reviewed by A AL Sawafi; comments to author 06.02.24; revised version received 26.02.24; accepted 06.03.24; published 25.04.24.

©Ian Kwok, Emily Gardiner Lattie, Dershung Yang, Amanda Summers, Paul Cotten, Caroline Alina Leong, Judith Tedlie Moskowitz. Originally published in JMIR Formative Research (https://formative.jmir.org), 25.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

This paper is in the following e-collection/theme issue:

Published on 26.4.2024 in Vol 26 (2024)

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study

Authors of this article:

Natalie Benda   1 , PhD ;   Sydney Woode   2 , BSc ;   Stephanie Niño de Rivera   1 , BS ;   Robin B Kalish   3 , MD ;   Laura E Riley   3 , MD ;   Alison Hermann   4 , MD ;   Ruth Masterson Creber   1 , MSc, PhD, RN ;   Eric Costa Pimentel   5 , MS ;   Jessica S Ancker   6 , MPH, PhD

1 School of Nursing, Columbia University, New York, NY, United States

2 Department of Radiology, Early Lung and Cardiac Action Program, The Mount Sinai Health System, New York, NY, United States

3 Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, United States

4 Department of Psychiatry, Weill Cornell Medicine, New York, NY, United States

5 Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States

6 Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States

Corresponding Author:

• Natalie Benda , PhD
• School of Nursing
• Columbia University
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Zooming into Focus Groups: Strategies for Qualitative Research in the Era of Social Distancing

Lekshmi santhosh.

1 Department of Medicine, University of California-San Francisco, San Francisco, California

Juan C. Rojas

2 Department of Medicine, University of Chicago, Chicago, Illinois

Patrick G. Lyons

3 Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri; and

4 Healthcare Innovation Laboratory, BJC HealthCare, St. Louis, Missouri

Associated Data

Qualitative research methods are important and have become increasingly prominent in medical education and research. The reason is simple: many pressing questions in these fields require qualitative approaches to elicit nuanced insights and additional meaning beyond standard quantitative measurements in surveys or observatons. Among the most common qualitative data collection methods are structured or semistructured in-person interviews and focus groups, in which participants describe their experiences relevant to the research question at hand. In the era of physical and social distancing because of the novel coronavirus disease (COVID-19) pandemic, little guidance exists for strategies for conducting focus groups or semistructured interviews. Here we describe our experience with, and recommendations for, conducting remote focus groups and/or interviews in the era of social distancing. Specifically, we discuss best practice recommendations for researchers using video teleconferencing programs to continue qualitative research during the COVID-19 pandemic.

Qualitative research focuses on exploring individuals’ perspectives related to specific research questions, issues, or activities ( 1 ). Frequently, structured interviews or focus groups are tools employed for data collection for qualitative research. In-person interviews are ideal, although phone and digital alternatives may be considered ( 2 , 3 ). However, little guidance exists for strategies for conducting focus groups or semistructured interviews in the era of physical and social distancing with the coronavirus disease (COVID-19) pandemic. In this article, we describe some strategies for conducting focus groups or structured interviews with the use of video conferencing platforms ( Figure 1 ). Video conferencing may provide researchers and research participants with a convenient and safe alternative to in-person qualitative research, albeit with some important limitations and considerations.

Key strategies to ensure successful remote focus groups and interviews. IRB = institutional review board.

Throughout 2019, we collaborated on a series of stakeholder focus groups to explore clinician experiences with patient handoffs between the intensive care unit and the wards. These focus groups, conducted in-person at our respective academic medical centers, helped us delineate key strengths and “pain points” of our handoff processes and identify facilitators and barriers to the user-centered design and implementation of a new process ( 4 ). We had scheduled subsequent in-person focus groups for this iterative design and testing process to take place in Spring 2020. However, we were forced to recalibrate our plans based on the rapidly changing COVID-19 situation and the situations of our intended participants (internal medicine residents). This article provides some practical guidance and reflections based on our experiences conducting semistructured focus groups using a videoconference platform with internal medicine residents at three academic medical centers. We outline our recommendations by describing the process of these remote focus groups, from planning and recruitment to the execution and technical troubleshooting of the videoconference.

Setting the Stage

More than ever, healthcare professionals are overtaxed because of increased clinical responsibilities; new or altered clinical environments and workflows; and increased burdens of administrative, educational, and investigatory work conducted by phone, e-mail, and video conference ( 5 – 7 ). Because of the school and childcare facility closures, many healthcare professionals may be engaged in nonclinical work while simultaneously caring for their children or supervising remote learning ( 8 ). With this in mind, we recommend that researchers carefully consider the timing of planned focus groups or interviews to maximize participation and minimize the strain on potential participants. Whenever possible, researchers should seek input on optimal timing and duration from potential participants.

The flexibility of video conferencing may potentially allow researchers to recruit participants by eliminating transportation and transit time barriers and allows for increased flexibility to consider scheduling focus groups or interviews at nontraditional times to accommodate the participants’ schedules.

Overall, we recommend that focus groups are conducted over video rather than audio if unable to be done in-person. Audio-only experiences are inherently more challenging than remote video sessions; it is difficult to tell when participants are speaking but muted, to identify an individual speaker among many participants, and to interpret tone and body language. In addition, audio-only encounters often limit crosstalk, which can enhance the depth of responses. We acknowledge that video is less private than audio, but it may be more private than in-person (e.g., a participant may decline to enroll in an in-person interview or group around a sensitive topic if they do not wish to be seen physically entering or exiting a known research room). Consent must specify whether audio alone is being recorded, or whether video and audio are both recorded.

Most importantly, before recruitment and consent, researchers should identify which video teleconferencing platform (e.g., Zoom, Google Meet, or Microsoft Teams) is best suited for the project ( Table 1 ); because these platforms share many of the same capabilities (e.g., screencasting/sharing and audio recording), this decision may be based on institutional adoption or availability.

Overview of several common videoconferencing platforms

Definition of abbreviation : HIPAA = Health Insurance Portability and Accountability Act.

Recruitment and Consent

Although some local institutional review board (IRB) procedures may have changed in response to COVID-19, qualitative research projects with human participants still require IRB review for determination of exempt status or formal approval. Researchers should obtain IRB approval to record the audio from the focus group or structured interview if a recording is desired.

Recruitment is likely to be predominantly virtual, in the form of e-mail “blasts” describing the study and providing the information needed for informed consent. After completing recruitment and selecting a video conferencing platform for the proposed research, we recommend providing attendees a password-protected electronic invitation to ensure the privacy of the session. In addition, it is helpful when this invitation includes an attached electronic calendar “event,” which can allow potential participants to quickly cross reference their electronic calendars, which are increasingly full of virtual meetings. Gray and colleagues found that participants wanted to synchronize these invitations with their electronic calendars and preferred the interview be limited to 1 hour at most, to avoid fatigue and schedule disruption ( 9 ). Zoom and other similar platforms offer a straightforward option for participants to add the session to their personal electronic calendars automatically. We recommend this method of invitation to increase convenience for participants who are increasingly accustomed to daily schedules of virtual meetings.

As with in-person focus groups, there is likely to be a “U-shaped” relationship between the number of participants and the volume and depth of insights gained within a session; too few participants may prevent dialogue and limit progress toward thematic saturation or uncovering new insights, whereas too many participants will preclude opportunities for deeper follow-up and will limit the amount of time that any single participant may contribute. Most commonly available videoconference platforms permit audience sizes of 50 or more, which far exceeds the number of participants a typical focus group would contain.

Presession Technical Preparation

It is crucial that researchers familiarize themselves with the interface and options of their chosen videoconference platform, both to maximize the effectiveness of their session facilitation and to improve their ability to solve common technical difficulties that may arise. This preparation should take place on the computing device that the researcher intends to use for research sessions to ensure that video, audio volume, and internet speed are adequate to host a successful video conference meeting. We recommend recording a practice session to become familiar with recording logistics and file storage locations, and to ensure the device’s microphone records clearly enough for participants’ hearing and transcription. Beyond the opportunity to troubleshoot the virtual platform, this practice session may also serve the second purpose of familiarizing the facilitator with the discussion questions.

Of note, researchers should evaluate the adequacy of their devices’ storage capabilities, given the large file sizes required to record audio and video. Many universities provide network storage solutions to members of their academic community, which may help facilitate storing large files. Importantly, if the research participants are patients, any recorded data (i.e., audio, video, and transcripts) are considered protected health information. These data require additional privacy considerations, especially around storage and electronic transfer. Because commercial video chat platforms may host or store files on their servers, the research team should ensure, ahead of time, that any commercial video chat platform used for research meets both the Health Insurance Portability and Accountability Act and institutional standards for secure data storage.

After successful completion of the trial run as a host, we recommend contacting the study participants before the session to ensure that any technical questions or concerns are addressed.

Introducing the Session

Initializing a virtual meeting is, in many ways, similar to initializing an in-person meeting. Like physical meetings, attendees may “trickle in” late because of preceding scheduled events or technical difficulties. We recommend allowing 1–5 minutes at the session’s beginning to account for late arrivals and to address technical issues if any are apparent. Once individuals are in the meeting, the facilitator can “lock” the session so uninvited attendees do not “Zoom-bomb.” In addition, researchers can further protect their meeting by using a Waiting Room, if available. Videoconference waiting rooms are virtual staging areas, which prevents attendees from joining a meeting until permitted, either individually or in a group, to enter. The facilitator should introduce the focus group or structured interviews just as they would an in-person session, including assurances regarding confidentiality, an overview of the session’s objectives, and an explicit statement of the session’s ground rules. The facilitator should obtain permission to record the focus group or structured interview and provide attendees the opportunity to leave the meeting if they do not consent to the recording. Finally, we recommend that researchers consider using a visual cue on a shared slide to remind them to initiate recording before beginning the session’s questions. Ideally, having two individuals record the meeting helps ensure redundancy so that if one individual has recording issues, the copy is preserved.

Depending on the size of the focus group or structured interview, the facilitator may wish to describe, at the meeting’s beginning, how attendee opinions will be solicited. For example, focus group participants can “unmute” themselves to speak or use the “raise hand” function on the meeting service. We recommend discouraging the use of the “chat” function because chat box contents are not recorded unless explicitly read aloud. If attendees do type in the chat box during the session, we recommend that the facilitator read the chat box contents aloud to capture these insights in the recording and transcript. Last, consider asking attendees to share their video feeds so participants and leaders can view attendee facial expressions and identify visual cues when individuals are about to speak (or are speaking, but are inadvertently muted). However, we recognize that this recommendation could limit participation by attendees without video-capable devices and/or put undue stress or burden on attendees who may be simultaneously parenting or multitasking. Above all, researchers should encourage attendees to make choices that will maximize their comfort with the session, and thus, maximize their contributions to the discussion.

During the Session

In general, remote qualitative inquiry sessions should follow a structure similar to that of face-to-face sessions. The facilitator should use effective moderation techniques online just as they would in-person. We have found that having an additional research team member serve as a scribe and timekeeper is helpful, if available. This teammate could also serve as a backup host if the primary host has unresolvable technical issues. Facilitators guiding semistructured interviews should ask follow-up probing questions and avoid sharing their own opinion, asking closed or leading questions, and other missteps that contribute to bias.

Within these general guidelines, however, the research team should be cognizant of the ways in which remote interactions differ from a live discussion. For instance, participants may be either more (e.g., because of additional perceived anonymity) or less (e.g., because of multitasking) likely to interact on videoconference, which may require proactive facilitation (e.g., direction questions or probes to individual participants). Similarly, a proactive facilitator may wish to be particularly attentive for openings to ask probing or follow-up questions, as some data suggest that online qualitative inquiry provides less opportunity for probing and follow-up ( 10 ). Furthermore, microphone technology is likely to preclude the degree of crosstalk seen in many face-to-face focus groups, which could limit the depth and quality of dialogue elicited. This lack of crosstalk may inhibit the ability to develop social norms, which are often a key factor distinguishing focus groups from individual structured interviews. It is not known whether facilitator behaviors or factors like focus group size can modify these limitations, although certain characteristics of focus group questions (e.g., open-ended) appear to yield richer discussion and data ( 10 ). Finally, if an audio-only focus group is the only option, we suggest using a visual model (e.g., a map or list of participants) to remind the facilitator of focus group participants, so notes can be transcribed visually under each participant.

Researchers should consider the need to maintain the privacy and potential anonymity of all participants, as outlined in the project’s IRB protocol. This consideration should also include any potential protected health information if the participants are patients. If strict anonymity is required, avoid stating participants’ names during the recording. If deidentification during transcription or review is appropriate, using the names of participants may increase the connection between the facilitator and the respondent, allowing for greater psychological safety.

After the Session

Concluding a virtual interview or focus group is similar to concluding an in-person session of the same type. The researchers should thank participants for their time, particularly given the stressors of the pandemic. In addition, we recommend discussing criteria for possible follow-up discussions. After ending the recording, ensure the file is saved to a secure location. Use professional transcription software to transcribe the audio recording from the focus group. Analyze the data with the qualitative framework outlined in the study design stage.

Because qualitative analysis of remote interviews and focus groups is typically conducted on transcribed audio, the decision to use a video platform often has little impact on data analysis. However, in some situations, the recorded video may prove advantageous. For example, the inclusion of video might facilitate the differentiation of speakers or clarification of unclear words during transcription or transcript reviews. Similarly, video might provide context around pauses, hand gestures, or facial expressions. Whether remote sessions have the same Hawthorne-esque effect on participants (i.e., do they behave in a particular way because of their awareness of being observed) is unknown. For instance, it is possible that participants behave differently when observed on video as compared with an audio-only (e.g., telephone) experience, or as compared with an in person session. One implication of this possibility could involve the perceived acceptability of multitasking or split attention; not infrequently, video participants elect not to share their individual video feeds.

Common Pitfalls and Strategies for Success

Qualitative interviews and focus groups, regardless of the setting, are subject to certain pitfalls along with a project’s progression from research question to analysis and dissemination. For instance, suboptimal recruitment practices (e.g., lack of advertisement) may limit enrollment, whereas incomplete or rushed interview scripts may not elicit complete or nuanced insights from participants. For remote interviews or focus groups, distance and technology may present additional obstacles (or interact with known risks), which can threaten a project’s success ( Table 2 ). Overall, the virtual qualitative experience offers a tradeoff between participant availability and an increased number of potential distractions. Whether these potential threats to qualitative insight are worth access to participants who might be unable to attend face-to-face sessions is likely to vary across research questions and teams of investigators. In general, these pitfalls can be avoided or mitigated with careful preplanning, practice sessions, and deliberate attention to areas of risk.

Potential remote focus group pitfalls and related strategies for success

Definition of abbreviation s: IRB = institutional review board; HIPAA = Health Insurance Portability and Accountability Act.

Conclusions

We hope that these practical tips can help with conducting rigorous qualitative inquiry through remote focus groups or structured interviews in the era of physical and social distancing.

Supplementary Material

Supported by an APCCMPD, CHEST, and ATS Education Research Award (L.S.).

Author Contributions : Conception and design: P.G.L. Drafting of the article: L.S., J.C.R., and P.G.L. Critical revision of the article for important intellectual content: L.S., J.C.R., and P.G.L. Final approval of the article: L.S., J.C.R., and P.G.L. Administrative, technical, or logistic support: P.G.L.

Author disclosures are available with the text of this article at www.atsjournals.org .