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What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

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

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

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

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

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

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

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

Qualitative research approaches
Approach	What does it involve?
Grounded theory	Researchers collect rich data on a topic of interest and develop theories .
	Researchers immerse themselves in groups or organizations to understand their cultures.
Action research	Researchers and participants collaboratively link theory to practice to drive social change.
Phenomenological research	Researchers investigate a phenomenon or event by describing and interpreting participants’ lived experiences.
Narrative research	Researchers examine how stories are told to understand how participants perceive and make sense of their experiences.

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

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

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

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

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

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

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

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

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

Qualitative data analysis
Approach	When to use	Example
	To describe and categorize common words, phrases, and ideas in qualitative data.	A market researcher could perform content analysis to find out what kind of language is used in descriptions of therapeutic apps.
	To identify and interpret patterns and themes in qualitative data.	A psychologist could apply thematic analysis to travel blogs to explore how tourism shapes self-identity.
	To examine the content, structure, and design of texts.	A media researcher could use textual analysis to understand how news coverage of celebrities has changed in the past decade.
	To study communication and how language is used to achieve effects in specific contexts.	A political scientist could use discourse analysis to study how politicians generate trust in election campaigns.

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 analyzing and interpreting their data. Qualitative research suffers from:

Unreliability

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

Subjectivity

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

Limited generalizability

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

Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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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 intervening or introducing treatments just like in quantitative research, qualitative research helps generate hypothenar to 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 standalone study, purely relying on qualitative data, or part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and applications of qualitative research.

Qualitative research, at its core, asks 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, qualitative research design is often not linear like quantitative design. 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 complex to capture accurately and quantitatively. In contrast, a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a particular 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 essential 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 other, qualitative and quantitative work are neither necessarily opposites, nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites and 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 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.

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Disclosure: Steven Tenny declares no relevant financial relationships with ineligible companies.

Disclosure: Janelle Brannan declares no relevant financial relationships with ineligible companies.

Disclosure: Grace Brannan declares no relevant financial relationships with ineligible companies.

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Open access
Published: 27 May 2020

How to use and assess qualitative research methods

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

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

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

Availability of data and materials

Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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Loraine Busetto, Wolfgang Wick & Christoph Gumbinger

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Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z

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Published: 28 August 2024

Facilitators and barriers of midwife-led model of care at public health institutions of dire Dawa city, Eastern Ethiopia, 2022: a qualitative study

Mickiale Hailu 1 ,
Aminu Mohammed 1 ,
Daniel Tadesse 1 ,
Neil Abdurashid 1 ,
Legesse Abera 1 ,
Samrawit Ali 2 ,
Yesuneh Dejene 2 ,
Tadesse Weldeamaniel 1 ,
Meklit Girma 3 ,
Tekleberhan Hailemariam 1 ,
Netsanet Melkamu 1 ,
Tewodros Getnet 1 ,
Yibekal Manaye 1 ,
Tariku Derese 1 ,
Muluken Yigezu 1 ,
Natnael Dechasa 1 &
Anteneh Atle 1

BMC Health Services Research volume 24 , Article number: 998 ( 2024 ) Cite this article

Metrics details

The midwife-led model of care is woman-centered and based on the premise that pregnancy and childbirth are normal life events, and the midwife plays a fundamental role in coordinating care for women and linking with other health care professionals as required. Worldwide, this model of care has made a great contribution to the reduction of maternal and child mortality. For example, the global under-5 mortality rate fell from 42 deaths per 1,000 live births in 2015 to 39 in 2018. The neonatal mortality rate fell from 31 deaths per 1,000 live births in 2000 to 18 deaths per 1,000 in 2018. Even if this model of care has a pivotal role in the reduction of maternal and newborn mortality, in recent years it has faced many challenges.

To explore facilitators and barriers to a midwife-led model of care at a public health institution in Dire Dawa, Eastern Ethiopia, in 2021.

Methodology

: A qualitative approach was conducted at Dire Dawa public health institution from March 1–April 30, 2022. Data was collected using a semi-structured, in-depth interview tool guide, focused group discussions, and key informant interviews. A convenience sampling method was implemented to select study participants, and the data were analyzed thematically using computer-assisted qualitative data analysis software Atlas.ti7. The thematic analysis with an inductive approach goes through six steps: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up.

Two major themes were driven from facilitators of the midwife-led model of care (professional pride and good team spirit), and seven major themes were driven from barriers to the midwife-led model of care (lack of professional development, shortage of resources, unfair risk or hazard payment, limited organizational power of midwives, feeling of demoralization absence of recognition from superiors, lack of work-related security).

The midwifery-led model of care is facing considerable challenges, both pertaining to the management of the healthcare service locally and nationally. A multidisciplinary and collaborative effort is needed to solve those challenges.

Peer Review reports

Introduction

A midwife-led model of care is defined as care where “the midwife is the lead professional in the planning, organization, and delivery of care given to a woman from the initial booking to the postnatal period“ [ 1 ]. Within these models, midwives are, however, in partnership with the woman, the lead professional with responsibility for the assessment of her needs, planning her care, referring her to other professionals as appropriate, and ensuring the provision of maternity services. Most industrialized countries with the lowest mortality and morbidity rates of mothers and infants are those in which midwifery is a valued and integral pillar of the maternity care system [ 2 , 3 , 4 , 5 ].

Over the past 20 years, midwife-led model of care (MLC) has significantly lowered mother and infant mortality across the globe. In 2018, there were 39 deaths for every 1,000 live births worldwide, down from 42 in 2015. From 31 deaths per 1,000 live births in 2000 to 18 deaths per 1,000 in 2018, the neonatal mortality rate (NMR) decreased. The midwifery-led care approach is regarded as the gold standard of care for expectant women in many industrialized nations, including Canada, Australia, the United Kingdom, Sweden, the Netherlands, Norway, and Denmark. Evidence from those nations demonstrates that women and babies who get midwife-led care, as opposed to alternative types of care, experience favorable maternal outcomes, fewer interventions, and lower rates of fetal loss or neonatal death [ 6 , 7 , 8 ].

In Pakistan, the MLC was accompanied by many challenges. Some of the challenges were political threats, a lack of diversity (midwives had no opportunities for collaborating with other midwives outside their institutions), long duty hours and low remuneration, a lack of a career ladder, and a lack of socialization (the health centers are isolated from other parts of the country due to relative geographical inaccessibility, transportation issues, and a lack of infrastructure). Currently, in Pakistan, 276 women die for every 100,000 live births, and the infant mortality rate is 74/1000. But the majority of these deaths are preventable through the midwife-led care model [ 7 ].

The MLC in African countries has faced many challenges. Shortages of resources, work overload, low inter-professional collaboration between health facilities, lack of personal development, lack of a well-functioning referral system, societal challenges, family life troubles, low professional autonomy, and unmanageable workloads are the main challenges [ 8 ].

Due to the aforementioned challenges, Sub Saharan Africa (SSA) is currently experiencing the highest rate of infant mortality (1 in 13) and is responsible for 86% of all maternal fatalities worldwide. As a result, it is imperative to look at the MLC issues in low-income countries, which continue to be responsible for 99% of all maternal and newborn deaths worldwide [ 8 , 9 ].

Ethiopia’s has a Maternal mortality rate (MMR) and NMR of 412 per 100,000 live births and 33 per 1000 live births, respectively, remain high, making Ethiopia one of the largest contributors to the global burden of maternal and newborn deaths, placed 4th and 6th, although MLC could prevent a total of 83% of all neonatal and maternal fatalities in an environment that supports it. The MMR & infant mortality rate (IMR) in the research area were indistinguishable from that, at 150 per 100,000 live births and 67 fatalities per 1,000 live births, respectively [ 10 , 11 , 12 , 13 ].

Since the Federal Ministry of Health is currently viewing midwifery-led care as an essential tool in reducing the maternal mortality ratio and ending preventable deaths of newborns, exploring the facilitators and barriers of MLC may have a great contribution to make in reducing maternal and newborn mortality [ 14 ]. Since there has been no study done in Ethiopia or the study area regarding the facilitators and barriers of MLC, the aim of this research was to explore the facilitators and barriers of MLC in Dire Dawa City public health institutions.

In so doing, the research attempted to address the following research questions:

What were the facilitators for a midwife-led model of care at the Dire Dawa city public health institution?

What were the barriers to a midwife-led model of care at the Dire Dawa city public health institution?

Study setting and design

Institutional based qualitative study was conducted from March 01-April 30, 2022 in Dire Dawa city. Dire Dawa city is one of the federal city administrations in Ethiopia which is located at the distance of 515killo meters away from Addis Ababa (the capital city) to the east. The city administration has 9 urban and 38 rural kebeles (kebeles are the smallest administrative unit in Ethiopia). There are 2 government hospitals, 5 private hospitals, 15 health centers, and 33 health posts. The current metro area population of Dire Dawa city is 426,129.Of which 49.8% of them are males and 50.2% females. The total number of women in reproductive age group (15–49 years) is 52,673 which account 15.4% of the total population. It has hot temperature with a mean of 25 degree centigrade [ 15 ].

Study population and sampling procedure

The source population for this study included all midwives who worked at Dire Dawa City public health facilities as well as key informants from appropriate organizations (the focal person for the Ethiopian Midwives Association and maternal and child health (MCH) team leaders). The study encompassed basically 41 healthcare professionals who worked in Dire Dawa public health institutions in total, and the final sample size was decided based on the saturation of the data or information.

From the total 15 Health centers and 2 Governmental Hospitals found in Dire Dawa city administration, 8 Health centers and 2 Governmental Hospitals were selected by non-probability purposive sampling method. In addition to that a non-probability convenience sampling method was used to select midwives who were working in Dire Dawa city public health institutions and key informants from the relevant organization such as Ethiopian midwives association focal person and MCH team leaders. Midwives who were working for at least six months in the institution were taken as inclusion criteria while those who were working as a free service were excluded from the study.

Data collection tool and procedures

Focus groups, in-depth interviews, and key informant interviews were used in collecting data. A voice recorder, a keynote-keeping, and a semi-structured interview tool were all used to conduct the interviews. Voluntary informed written consent was obtained from the study participant’s before they participated in the study. Then an in-depth interview and focus group discussion were held with midwives chosen from various healthcare organizations. The MCH department heads and the Dire Dawa branch of the Ethiopian Midwife Association served as the key informants. In-depth interview (IDI) and key informant interviews (KII) with participants took place only once and lasted for roughly 50–60 min. In the midwives’ duty room, the interview was held. Six to eight people participated in focus group discussions (FGD), which lasted 90 to 100 min. Two midwives with experience in gathering qualitative data gathered the information.

Data quality control

The qualitative design is prone for bias but open-ended questions were used to avoid acquiescence and 2 day proper training was given for the data collector regarding taking keynotes and recording using a tape recorder. For consistency and possible modification, a pretest was done in one FGD and In-depth interviews at non selected health institutions of Dire Dawa city administrations. A detailed explanation was given for the study participants about the objectives of the study prior to the actual data collections. All (FGDs, key informant interview and In-depth interviews) were taken in a silent place.

Data analysis

Atlas.ti7, a qualitative data analysis program, was used for analyzing the data thematically. An inductive approach to thematic analysis involves six steps: familiarization, coding, generation of themes, review of themes, defining and naming of themes, and writing up. By listening to the taped interview again, the data was transcribed. The participants’ well-spoken verbatim was used to extract and describe the inductive meanings of the statements. The data was then coded after that. Each code describes the concept or emotion made clear in that passage of text. Then we look at the codes we’ve made, search for commonalities, and begin to develop themes. To ensure the data’s accuracy and representation, the generated themes were reviewed. Themes were defined and named, and then the analysis of the data was written up.

Trustworthiness of data

Meeting standards of trustworthiness by addressing credibility, conformability, and transferability ensures the quality of qualitative research. Data triangulation, data collection from various sites and study participants, the use of multiple data collection techniques (IDI, KII, and FGD), multiple peer reviews of the proposal, and the involvement of more than two researchers in the coding, analysis, and interpretation decisions are all instances of the methods that were used in order to fulfill the criteria for credibility. To increase its transferability to various contexts, the study gave details of the context, sample size and sampling method, eligibility criteria, and interview processes. To ensure conformability, the research paths were maintained throughout the study in accordance with the work plan [ 16 , 17 ].

Background characteristics of the study participants

In this study, a total of 41 health care providers who are working in Dire Dawa public health facilities participated in the three FGDs, six KIIs, and fifteen IDIs. The years of experience of study participants range from one year to 12 years. The participants represented a wide age range (30–39 years), and the educational status of the respondents ranged from diploma to master’s degree. (Table 1 )

As shown in Table 2 , from the qualitative analysis of the data, two major themes were driven from facilitators of MLC, and seven major themes were driven from barriers to MLC. (Table 2 ).

Facilitators of midwife-led model of care at a public health institution of Dire Dawa city, Eastern Ethiopia, in 2021

Professional pride.

This study found that saving the lives of mothers and newborns was a strong facilitator. Specifically, it was motivational to have skills within the midwifery domain, such as managing the full continuum of care during pregnancy and labour, supporting women in having normal physiologic births, being able to handle complications, and building relationships with the women and the community, as mentioned below by one of the IDI participants.

“I am so proud since I am a midwife; nothing is more satisfying than seeing a pregnant mother give birth almost without complications. I always see their smile and happiness on their faces , especially in the postpartum period , and they warmly thank me and say , “Here is your child; he or she is yours.” They bless me a lot. Even sometimes , when they sew me in the transport area , cafeteria , or other area , they thank me warmly , and some of them also want to invite me to something else. The sum total of those things motivates me to be in this profession or to provide midwifery care.“ IDI participants.

This finding is also supported by other participants in FGD.

“We have learned and promised to work as midwives. We are proud of our profession , to help women and children’s health. The greatest motivation is that we are midwives , we love the profession , and we are contributing a great role in decreasing maternal and child mortality….” FGD discussant.

Good teamwork

The research revealed that good midwifery teamwork and good social interaction within the staff have become facilitators of MLC. FGD participants share their experiences of working in a team.

“In our facility , all the midwives have good teamwork; we have good communication , and we share client information accurately and timely. In case a severe complication happens , we manage it as a team , and we try to cover the gap if some of our staff are absent. Further from that , we do have good social interactions in the case of weeding , funeral ceremonies , and other social activities. We do have good team spirit; we work as a team in the clinical area , and we also have good social relationships. “If some of our staff gets sick or if she or he has other social issues , the other free staff will cover her or his task.” FGD discussant.

Another participant from IDI also shared the same experience regarding their good teamwork and their social interactions.

“As a maternal and child health team , we do have a good team spirit , not only with midwives but also with other professions. We are not restricted by the ward that we assign. If there is a caseload in any unit , some midwives will volunteer to help the other team. Most of the time in the night , we admit more than 3 or 4 labouring mothers at the same time. Since in our health center only one midwife is assigned in the night , we always call nurses to help us. This is our routine experience.” IDI participants.

Barriers of midwife-led model of care at a public health institution of Dire Dawa city, Eastern Ethiopia, in 2021

Lack of professional development.

This study revealed that insufficient opportunities for further education and updated training were the main barriers for MLC. Even the few trainings and update courses that were actually arranged were unavailable to them, either because they did not meet the criteria seated or because the people who work in administration were selected. Even though opportunities are not arranged for them to upgrade themselves through self-sponsored. One of the participants from IDI narrates her opinion about opportunities for further education as follows:

“Training and updates are not sufficient; currently we are almost working with almost old science. For example , the new obstetrics management protocol for 2021 has been released from the ministry of health , and many things have changed there. But we did not receive any training or even announcements. Even the few trainings and update courses that were truly organized and turned in to us are unavailable since the selection criteria are not fair. As a result , we miss those trainings either because we did not meet the selection criteria or because those who work in administration are prioritized.” IDI participant.

FGD discussants also support this idea. She mentioned that even though opportunities are not arranged for them to upgrade themselves through self-sponsorship,

“There is almost no educational opportunity in our institution. Every year , one or two midwives may get institutional sponsorship. Midwives that will be selected for this opportunity are those who have served for more than five to ten years. Imagine that to get this chance , every midwife is expected to serve five or more years. Not only this , even if staff want to learn or upgrade at governmental or private colleges through self-sponsored programmes , whether at night or in an extension programme , they are not cooperative. Let me share with you my personal experience. Before two years , I personally started my MSc degree at Dire Dawa University in a weekend programme , and I have repeatedly asked the management bodies to let me free on weekends and to compensate me at night or any time from Monday to Friday. Since they refuse to accept my concern , I withdraw from the programme.“ FGD discussant.

Shortage of resource

The finding indicates that a shortage of equipment, staff, and rooms or wards was a challenge for MLC. Midwives claimed they were working with few staff, insufficient essential supplies, and advanced materials. This lack of equipment endangers both the midwives and their patients. One of the participants from IDI narrates her opinion about the shortage of resources as follows:

“Of course there is a shortage of resources in our hospital , like gloves and personal protective devices. Even the few types of medical equipment available , like the autoclave , forceps , vacuum delivery couch , and BP apparatus , are outdated , and some of them are unfunctional. If you see the Bp apparatus we used in ANC , it is digital but full of false positives. When I worked in the ANC , I did not trust it and always brought the analogue one from other wards. This is the routine experience of every staff member.“ IDI participants.

Another participant from IDI also shared the same experience regarding the crowdedness of rooms or wards.

“In our health center , there are no adequate wards or rooms. For example , the delivery ward and postnatal ward are almost in one room. Postnatal mothers and neonates did not get enough rest and sleep because of the sound of laboring mothers. Not only is this , but even the antenatal care and midwifery duty rooms are also very narrow.“ IDI participants.

The study also revealed midwifery staff were pressured to work long hours because they were understaffed, which in turn affected the quality of midwifery care. The experience of a certain midwife is shared as follows:

“I did not think that the management bodies understood the risk and stress that we midwives face. They did not want to consider the risk of midwives even equal to that of other disciplines but lower than the others. For example , in our health centre , during the night , only one midwife is assigned for the next 12 hours , but if you see in the nurse department , two or more nurses are assigned at night in the emergency ward.” IDI participants.

The discussion affirms the fact that being understaffed and not having an adequate allocation of midwife professionals on night shifts are affecting labouring mothers’ ability to get sufficient health midwifery care. The above narration is also supported by the FGD discussant.

“In our case , only one midwife is assigned to the labour ward during the night shift. I think this is the main challenge for midwives that needs attention. Let me share with you my experience that happened months before. While I was on night shift , two labouring mothers were fully dilated within three or four minutes. It was very difficult for me , to manage two labouring mothers at the same time. Immediately , I call one of my nurse friends from the emergency department to help me. If my friend was so busy , what could happen to the labouring mother and also to me? This is not only my experience but also the routine experience of other midwives.” FGD discussant.

Unfair risk or hazard payments

It is reported that the compensation amount paid for risk is lower than in other health professions. The health risks are not any less, but the remuneration system failed to capture the need to fairly compensate midwifery professionals. The narration from the FGD discussant regarding unfair payment is mentioned below.

“Only 470 ETB is paid for midwives as risk payments , which is incomparable with the risks that midwives are facing. But contrary to that , the risk payments for nurses (in emergencies) are about 1200 Ethiopian birr (ETB) , and Anesthesia is 1000 ETB. I did not want to compare my profession with other disciplines , but with the lowest cost , how the risk of midwifery cannot be equal to that of nursing and other professions. I did not know whose professionals made such types of unfair decisions and with what scientific background or base this calculation was done . ” FGD discussant.

The above finding is also supported by an IDI participant.

“………………………….Even though the midwifery profession is full of risks , with the current Ethiopian health care system , midwives are being paid the lowest risk payments compared to other disciplines…………….” IDI participants.

Limited organizational power of midwives

Midwives’ interviews reported that limited senior midwifery positions in the health system have become the challenge of midwifery care. This constrains the decision-making power and capability of midwives. This was compounded by limited opportunities for midwifery personnel to address their concerns to the responsible bodies, as stated by one of the key informants.

“Our staff has many concerns , especially professional-related concerns , which can contribute to the quality of midwifery care. Personally , as department head , I have tried to address those concerns in different management meetings at different times. But since the leadership positions are dominated by other disciplines , many of our staff concerns have not been solved yet. But let me tell you my personal prediction… If those concerns are not solved early and if this trend continues , the quality of midwifery care will be in danger.“ Participant from Key Informant.

The above finding is also supported by another IDI participant.

“In our hospital , at every hierarchal and structural level , midwives are not well represented. That is why all of our challenges or concerns have not been solved yet. For example , as a structure in the Dire Dawa Health Office (DDHO) , there is a team of management related to maternal and child health. But unfortunately , those professionals working there are not midwives. I was one of three midwives chosen to meet with Dr. X (former DDHO leader) to discuss this issue. At the time , we were reaching an agreement that two or three midwives would be represented on that team. But since a few months later the leader resigned , the issue has not gotten a solution yet.“ IDI participant.

Feeling of demoralization

One of the main concerns reported by the participants during the interviews was a feeling of demoralization induced by both their clients and their supervisors about barriers to midwifery care. They reported having been verbally abused by their patients, something that made them feel that their hard work was being undermined, as stated by an FGD participant.

“I don’t think there is any midwife who would be happy for anybody to lose their baby , or that there is any midwife who would want a woman to die. These things are accidents , but the patient and leaders will always blame the midwife.” FDG discussant.

A narration from an IDI participant also mentioned the following:

“……….If something happens , like a conflict with the patients or clients , the management is on the patient side. Not only that , the way in which they communicate with us is in an aggressive or disrespectful manner . ” IDI participant.

Absence of recognition or /motivation from superiors

This study revealed that midwives experience a loss of motivation at work due to limited support from their superiors. Their effort is used only for reporting purposes. A midwife from FGD shared her experience as follows.

“In our scenario , till the nearest time , the maternal and child health services are provided in a good way. But this was not easy; it is the cumulative effort of midwives. But unfortunately , only those in managerial positions are recognized. Nothing was done for us despite our efforts. To me , our efforts are used only for reporting purposes.” FGD discussant.

This finding was also supported by IDI participants.

“Even though we have good achievements in the MCH services , there is no motivation mechanism done to motivate midwives.” But if something or a minor mistake happens , they are on the front lines to intimidate us or write a warning letter. Generally , their concern is a report or a number issue. We are tired of such types of scenarios.” IDI participant.

Insufficient of work-related security

One of the main concerns reported by the participants during the interviews was the work related security, which has become a challenge for MLC. The midwives’ work environment was surrounded by insecurity, especially during night shifts, when midwives were facing verbal and even physical attack, as mentioned by participants.

“In the labour ward , especially at night , we face many security-related issues. The families of labouring mothers , especially those who are young , are very aggressive. Sometimes they even want to enter the delivery room. They did not hear what we told them to do , but if they hear any labour sounds from their family , they disturb the whole ward. This leads to verbal abuse , and sometimes we face physical abuse. There may be one or two security personnel at the main gate , but since the delivery ward is far from the main gate , they do not know what is happening in the delivery ward. When things become beyond our scope , we call security guards. Immediately after the security guards go back , similar things will continue. What makes it difficult to manage such situations is that only one midwife is assigned at night , and labouring mothers will not get quality midwifery care.” IDI participant.

FGD discussants also shared their experience that their working environment is full of insecurity.

“In case any complications occur , especially at night , it is very difficult to tell the labouring mother’s family or husband unless we call security personnel. It is not only swearing that we face but also that they intimidate us.” FDG discussant.

Discussions

The aim of this study was to explore facilitators’ and barriers to a midwifery-led model of care at Dire Dawa public health facilities. In this study, professional pride was the main facilitator of the midwifery-led model of care. Another qualitative study that examined the midwifery care challenges and factors that motivate them to remain in their workplace lends confirmation to this conclusion. It was found that a strong feeling of love for their work was the main facilitator’s midwifery-led model of care [ 9 ]. Having a good team spirit was also another facilitator’s midwifery-led model of care in our study. Another study’s findings confirmed this one, which emphasizes that building relationships with the midwives, women, and community was the driving force behind providing midwifery care [ 7 , 18 ].

The midwives in this study expressed a need for additional professional training, updates, and competence as part of their continuing professional development. Similar findings have been reported in the worldwide literature that midwives were struggling for survival due to a lack of limited in-service training opportunities to improve their knowledge and skills [ 19 ]. This phenomenon does not seem to differ between settings in high-, middle-, and low-income countries [ 7 , 9 , 18 ], in which midwives experienced difficult work situations due to a lack of professional development to autonomously manage work tasks, which made them feel frustrated, guilty, and inadequate. As such, this can contribute to distress and burnout, which in turn prevent midwives from being able to provide quality care and can eventually cause them to leave the profession [ 19 ].

Shortages of resources (shortage of staff, lack of physical space, and equipment) were the other reported barriers to midwifery care explored in this study. They reported that they are working in an environment with a shortage of resources, which leads to poor patient outcomes. This finding is supported by many other studies conducted around the globe [ 20 , 21 , 22 , 23 ]. Another qualitative finding, which likewise supports the aforementioned finding, which emphasizes that a shortage of resources was reported as a barrier to providing adequate midwifery care [ 19 ]. Delivery attended by skilled personnel with appropriate supplies and equipment has been found to be strongly associated with a reduction in child and maternal mortality [ 24 ].

The feeling of demoralization and lack of motivation from their superiors were other barriers to midwifery care explored in this study. This finding is concurrent with other studies conducted around the globe [ 19 , 25 , 26 , 28 ]. The above finding is also is in accord with another qualitative narration, which emphasizes that feelings of demoralization and a lack of motivation were the main challenges of midwifery care [ 22 ]. Positive support from supervisors has been demonstrated to be important for the quality of services that health workers are able to deliver. In the World Health Organization’s report on improving performance in healthcare, the WHO stresses that supportive supervision can contribute to the improved performance of health workers [ 27 ].

Unfair risk payment was the other challenge identified by the current study. Even though there is no difference in the risk they face among health professionals, the risk payment for midwives is very low compared to others. This finding was in conformity with another qualitative narration, which emphasizes that the lack of an equitable remuneration system was experienced by the DRC midwives, and it has also been confirmed to be highly problematic in other studies in low- and middle-income settings [ 7 , 8 , 22 , 28 ], leading to serious challenges. In settings where salaries are extremely low or unpredictable, proper remuneration is seen as crucial to worker motivation and the quality of midwifery care [ 29 , 30 ].

The limited organizational power of midwives was another identified challenge of MLC. This finding was in step with other studies that emphasize that limited senior midwifery positions in the health system constrain the decision-making power and capability of midwives. This was compounded by limited opportunities for midwifery personnel to address their concerns to the responsible bodies. Hence, midwives need to take control of their own situations. When midwives are included in customizing their work environments, it has proven to result in improved quality of care for women and newborns around the globe [ 8 , 15 ].

Lack of work-related security was another barrier to MLC explored in this study, in which the midwives’ work environment was surrounded by insecurity, especially during night shifts, when midwives are facing verbal and even physical attack, as mentioned by participants. This finding is supported by many other studies conducted around the globe [ 22 , 23 , 25 , 31 ]. The above finding is also in agreement with another qualitative narration, which emphasizes that the midwives’ work environment was surrounded by insecurity, especially during night shifts due to a lack of available security personnel; they often felt frightened on their way to and from work [ 7 ]. In order for midwives to provide quality care, it is crucial to create supportive work environments by ensuring sufficient pre-conditions, primarily security issues [ 31 ].

Conclusions

The study findings contribute to a better understanding of the facilitators’ and barriers of a midwifery-led model of care in the case of Dire Dawa public health facilities. Professional pride and having good team spirit were the main facilitators of midwifery-led model care. Contrary to that, insufficient professional development, shortage of resources, feeling of demoralization, lack of motivation, limited organizational power of midwives, unfair risk payment, and lack of work-related security were the main barriers to a midwifery-led model of care in the case of Dire Dawa public health facilities. Generally, midwifery care is facing considerable challenges, both pertaining to the management of the healthcare service locally and nationally.

Study implications

The findings of the study have implications for midwifery care practices in Eastern Ethiopia. Addressing these areas could potentially contribute to the reduction of IMR and MMR.

Strengths and limitations

The first strength of the study is that the participants represented different healthcare facilities, both urban and rural, thereby offering deeper and more varied experiences and reflections. A second strength is using a midwife as a moderator. She or he understood the midwives’ situation, thereby making the participants feel more comfortable and willing to share their stories. However, focusing solely on the perspective of the midwives is a limitation.

Recommendations

To overcome the barriers of midwifery care, based on the result of this study and in accordance with the 2020 Triad Statement made by the International Council of Nurses, the International Confederation of Midwives, and the World Health Organization, it is suggested that policymakers, Ethiopian federal ministry of health, Dire dawa health office, and regulators in Dire Dawa city and settings with similar conditions coordinate actions in the following:

To the Ethiopian federal ministry of health (FMOH)

Should strengthen regular and continuous educational opportunities, trainings, and updates for midwives, prioritizing and enforcing policies to include adequate and reasonable remuneration and hazard payment for midwives. Support midwifery leadership at all levels of the health system to contribute to health policy development and decision-making.

To dire Dawa health Bureau

Ensure decent working conditions and an enabling environment for midwives. This includes reasonable working hours, occupational safety, safe staffing levels, and merit-based opportunities for career progression. Special efforts must be made to ensure safe, respectful, and enabling workplaces for midwives operating on the night shift. Midwifery leaders should be involved in management bodies within an appropriate legal framework. Made regular mentorships on the functionality of different diagnostic instruments in respective health facilities.

To Dire Dawa public health facility’s

Create an arena for dialogue and implement a more supportive leadership style at the respective health facilities. Should address professional-related concerns of midwives early. Ensure midwives’ representation at the management bodies. Ensure the selection criteria for educational opportunities and different trainings are fair and inclusive. Ensure the safety and security of midwives, especially those who work night shifts. Should assign adequate staff (midwives and security guards) to the night shifts.

Ethiopian midwifery association

Should influence different stakeholders to solve midwife’s concerns like hazards payment and educational opportunity.

Data availability

All the datasets for this study are available from the corresponding author upon request.

Abbreviations

Focused group discussion

In-depth interview

Infant mortality rate

Key informant interview

Maternal and child health

Midwives led model of care

Neonatal mortality rate

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Acknowledgements

We are very grateful to Dire Dawa University for the financial support for this study and to the College of Medicine and Health for its monitoring ship. All study participants for their willingness to respond to our questionnaire.

this work has been funded by Dire Dawa University for data collection purposes. The Dire Dawa University College of Medicine and Health Sciences was involved in the project through monitoring and evaluation of the work from the beginning to the result submission. However, this organization was not involved in the design, analysis, critical review of its intellectual content, or manuscript preparation, and its budget did not include publication.

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Contributions

MH developed the study proposal, served as the primary lead for study implementation and data analysis/interpretation, and was a major contributor in writing and revising all drafts of the paper. AM, DT, NA, LA, and SA supported study implementation and data analysis, and contributed to writing the initial draft of the paper. YD, TW, MG, TH and, NM supported study recruitment and contributed to writing the final draft of the paper. TG, YM, TD, MY, ND and, AA conceptualized, acquired funding, and led protocol development for the study, co-led study implementation and data analysis/interpretation, and was a major contributor in writing and revising all drafts of the paper. All authors contributed to its content. All authors read and approved the final manuscript.

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Correspondence to Mickiale Hailu .

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All methods were followed in accordance with relevant guidelines and regulations. The institutional review board of Dire Dawa University has also examined and evaluated it for its methodological approach and ethical concerns. Ethical clearance was obtained from Dire Dawa University Institutional Review Board and an official letter from research affairs directorate office of Dire Dawa University was submitted to Dire Dawa health office and it was distributed to selected health institutions. Voluntary informed written consent was obtained from the study participant’s right after the objectives of the study were explained to the study participants and confidentiality of the study participants was assured throughout the study period. Participants were informed that they have the right to terminate the discussion (interview) or they can’t answer any questions they didn’t want to answer.

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Hailu, M., Mohammed, A., Tadesse, D. et al. Facilitators and barriers of midwife-led model of care at public health institutions of dire Dawa city, Eastern Ethiopia, 2022: a qualitative study. BMC Health Serv Res 24 , 998 (2024). https://doi.org/10.1186/s12913-024-11417-x

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Background: Simulation-based education (SBE) has been increasingly used to train healthcare workers in low-resource settings and has been endorsed by the World Health Organization (WHO). Consideration of the educational and cultural context is important to maximize the effectiveness of SBE. Despite its demonstrable benefits, there have been no studies of the general approach in the Pacific Islands. This study aimed to determine the factors that influence the uptake and success of SBE in the Pacific Islands. Methods: In this qualitative study, participants were recruited via professional networks to contribute to focus groups. Questions focused on participants' previous experiences and perspectives on SBE. Data were manually transcribed before thematic analysis. The reporting of the research was guided by the Standards for Reporting Qualitative Research (SRQR). Human Research Ethics Committee approval was obtained. Results: Two focus groups were conducted with 16 participants from six Pacific Island countries. Six themes and 15 subthemes were conceptualized from the data. Uptake of SBE is challenged by resource availability, clinical workloads and geographic remoteness. However, locally-driven solutions and positive attitudes towards SBE facilitate its success. Conclusion: This study reveals the complexity of factors affecting the uptake and success of SBE in the Pacific Islands. These findings can serve to optimize the impact of existing and future SBE programmes and may be considered by educators prior to programme implementation.

Original language	English
Number of pages	8
Journal
DOIs
Publication status	Accepted/In press - 2024

focus groups
global health
medical education
simulation-based education

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10.1111/ans.19156 Licence: CC BY-NC-ND

Qualitative Research in Healthcare: Necessity and Characteristics

1 Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

2 Ulsan Metropolitan City Public Health Policy’s Institute, Ulsan, Korea

3 Department of Nursing, Chung-Ang University, Seoul, Korea

Eun Young Choi

4 College of Nursing, Sungshin Women’s University, Seoul, Korea

Seung Gyeong Jang

5 Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Korea

Quantitative and qualitative research explore various social phenomena using different methods. However, there has been a tendency to treat quantitative studies using complicated statistical techniques as more scientific and superior, whereas relatively few qualitative studies have been conducted in the medical and healthcare fields. This review aimed to provide a proper understanding of qualitative research. This review examined the characteristics of quantitative and qualitative research to help researchers select the appropriate qualitative research methodology. Qualitative research is applicable in following cases: (1) when an exploratory approach is required on a topic that is not well known, (2) when something cannot be explained fully with quantitative research, (3) when it is necessary to newly present a specific view on a research topic that is difficult to explain with existing views, (4) when it is inappropriate to present the rationale or theoretical proposition for designing hypotheses, as in quantitative research, and (5) when conducting research that requires detailed descriptive writing with literary expressions. Qualitative research is conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants and data collection methods, (5) data analysis and description of findings, and (6) research validation. This review can contribute to the more active use of qualitative research in healthcare, and the findings are expected to instill a proper understanding of qualitative research in researchers who review qualitative research reports and papers.

Graphical abstract

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INTRODUCTION

The definition of research varies among studies and scholars, and it is difficult to devise a single definition. The Oxford English Dictionary defines research as “a careful study of a subject, especially in order to discover new facts or information about it” [ 1 ], while Webster’s Dictionary defines research as “studious inquiry or examination - especially: investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or laws in the light of new facts, or practical application of such new or revised theories or laws” [ 2 ]. Moreover, research is broadly defined as the process of solving unsolved problems to broaden human knowledge [ 3 ]. A more thorough understanding of research can be gained by examining its types and reasons for conducting it.

The reasons for conducting research may include practical goals, such as degree attainment, job promotion, and financial profit. Research may be based on one’s own academic curiosity or aspiration or guided by professors or other supervisors. Academic research aims can be further divided into the following: (1) accurately describing an object or phenomenon, (2) identifying general laws and establishing well-designed theories for understanding and explaining a certain phenomenon, (3) predicting future events based on laws and theories, and (4) manipulating causes and conditions to induce or prevent a phenomenon [ 3 ].

The appropriate type of research must be selected based on the purpose and topic. Basic research has the primary purpose of expanding the existing knowledge base through new discoveries, while applied research aims to solve a real problem. Descriptive research attempts to factually present comparisons and interpretations of findings based on analyses of the characteristics, progression, or relationships of a certain phenomenon by manipulating the variables or controlling the conditions. Experimental or analytical research attempts to identify causal relationships between variables through experiments by arbitrarily manipulating the variables or controlling the conditions [ 3 ]. In addition, research can be quantitative or qualitative, depending on the data collection and analytical methods. Quantitative research relies on statistical analyses of quantitative data obtained primarily through investigation and experiment, while qualitative research uses specific methodologies to analyze qualitative data obtained through participant observations and in-depth interviews. However, as these types of research are not polar opposites and the criteria for classifying research types are unclear, there is some degree of methodological overlap.

What is more important than differentiating types of research is identifying the appropriate type of research to gain a better understanding of specific questions and improve problems encountered by people in life. An appropriate research type or methodology is essential to apply findings reliably. However, quantitative research based on the philosophical ideas of empiricism and positivism has been the mainstay in the field of healthcare, with academic advancement achieved through the application of various statistical techniques to quantitative data [ 4 ]. In particular, there has been a tendency to treat complicated statistical techniques as more scientific and superior, with few qualitative studies in not only clinical medicine, but also primary care and social medicine, which are relatively strongly influenced by the social sciences [ 5 , 6 ].

Quantitative and qualitative research use different ways of exploring various social phenomena. Both research methodologies can be applied individually or in combination based on the research topic, with mixed quantitative and qualitative research methodologies becoming more widespread in recent years [ 7 ]. Applying these 2 methods through a virtuous cycle of integration from a complementary perspective can provide a more accurate understanding of human phenomena and solutions to real-world problems.

This review aimed to provide a proper understanding of qualitative research to assist researchers in selecting the appropriate research methodology. Specifically, this review examined the characteristics of quantitative and qualitative research, the applicability of qualitative research, and the data sources collected and analyzed in qualitative research.

COMPARISON OF QUALITATIVE AND QUANTITATIVE RESEARCH

A clearer understanding of qualitative research can be obtained by comparing qualitative and quantitative research, with which people are generally familiar [ 8 , 9 ]. Quantitative research focuses on testing the validity of hypotheses established by the researcher to identify the causal relationships of a specific phenomenon and discovering laws to predict that phenomenon ( Table 1 ). Therefore, it emphasizes controlling the influence of variables that may interfere with the process of identifying causality and laws. In contrast, qualitative research aims to discover and explore new hypotheses or theories based on a deep understanding of the meaning of a specific phenomenon. As such, qualitative research attempts to accept various environmental factors naturally. In quantitative research, importance is placed on the researcher acting as an outsider to take an objective view by keeping a certain distance from the research subject. In contrast, qualitative research encourages looking inside the research subjects to understand them deeply, while also emphasizing the need for researchers to take an intersubjective view that is formed and shared based on a mutual understanding with the research subjects.

Comparison of methodological characteristics between quantitative research and qualitative research

Characteristics	Quantitative research	Qualitative research
Research purpose	Test the validity of the hypotheses established by the researcher to identify the causal relationships and laws of the phenomenon and predict the phenomenon	Discover and explore new hypotheses or theories based on a deep understanding of the meaning of the phenomenon
Perspective on variables	View factors other than the variables of interest as factors to be controlled and minimize the influence of confounding factors	View factors as natural and accept assessments in a natural environment
Research view	Objective, outsider view	Intersubjective, insider view
Data used	Quantifiable, measurable data	Narrative data that can be expressed by words, images and so on
Data collection method	Primarily questionnaire surveys or tests	Primarily participant observation, in-depth interviews, and focus group discussions
Nature of data and depth of analysis	Focus on superficial aspects of the phenomenon by using reliable data obtained through repeated measurements	The aim is to identify the specific contents, dynamics, and processes inherent within the phenomenon and situation using deep and rich data
Strengths and weaknesses	High reliability and generalizability	High validity
Strengths and weaknesses	Difficulties with in-depth analysis of dynamic phenomena that cannot be expressed by numbers alone; difficulties in interpreting the results analyzed by numbers	Weak generalizability; interjection of subjectivity of the researcher is inevitable

The data used in quantitative research can be expressed as numerical values, and data accumulated through questionnaire surveys and tests are often used in analyses. In contrast, qualitative research uses narrative data with words and images collected through participant observations, in-depth interviews, and focus group discussions used in the analyses. Quantitative research data are measured repeatedly to enhance their reliability, while the analyses of such data focus on superficial aspects of the phenomenon of interest. Qualitative research instead focuses on obtaining deep and rich data and aims to identify the specific contents, dynamics, and processes inherent within the phenomenon and situation.

There are clear distinctions in the advantages, disadvantages, and goals of quantitative and qualitative research. On one hand, quantitative research has the advantages of reliability and generalizability of the findings, and advances in data collection and analysis methods have increased reliability and generalizability. However, quantitative research presents difficulties with an in-depth analysis of dynamic phenomena that cannot be expressed by numbers alone and interpreting the results analyzed in terms numbers. On the other hand, qualitative research has the advantage of validity, which refers to how accurately or appropriately a phenomenon was measured. However, qualitative research also has the disadvantage of weak generalizability, which determines whether an observed phenomenon applies to other cases.

APPLICATIONS OF QUALITATIVE RESEARCH AND ITS USEFULNESS IN THE HEALTHCARE FIELD

Qualitative research cannot be the solution to all problems. A specific methodology should not be applied to all situations. Therefore, researchers need to have a good understanding of the applicability of qualitative research. Generally, qualitative research is applicable in following cases: (1) when an exploratory approach is required on a topic that is not well known, (2) when something cannot be explained fully with quantitative research, (3) when it is necessary to newly present a specific view on a research topic that is difficult to explain with existing views, (4) when it is inappropriate to present the rationale or theoretical proposition for designing hypotheses, as in quantitative research, and (5) when conducting research that requires detailed descriptive writing with literary expressions [ 7 ]. In particular, qualitative research is useful for opening new fields of research, such as important topics that have not been previously examined or whose significance has not been recognized. Moreover, qualitative research is advantageous for examining known topics from a fresh perspective.

In the healthcare field, qualitative research is conducted on various topics considering its characteristics and strengths. Quantitative research, which focuses on hypothesis validation, such as the superiority of specific treatments or the effectiveness of specific policies, and the generalization of findings, has been the primary research methodology in the field of healthcare. Qualitative research has been mostly applied for studies such as subjective disease experiences and attitudes with respect to health-related patient quality of life [ 10 - 12 ], experiences and perceptions regarding the use of healthcare services [ 13 - 15 ], and assessments of the quality of care [ 16 , 17 ]. Moreover, qualitative research has focused on vulnerable populations, such as the elderly, children, disabled [ 18 - 20 ], minorities, and socially underprivileged with specific experiences [ 21 , 22 ].

For instance, patient safety is considered a pillar of quality of care, which is an aspect of healthcare with increasing international interest. The ultimate goal of patient safety research should be the improvement of patient safety, for which it is necessary to identify the root causes of potential errors and adverse events. In such cases, qualitative rather than quantitative research is often required. It is also important to identify whether there are any barriers when applying measures for enhancing patient safety to clinical practice. To identify such barriers, qualitative research is necessary to observe healthcare workers directly applying the solutions step-by-step during each process, determine whether there are difficulties in applying the solutions to relevant stakeholders, and ask how to improve the process if there are difficulties.

Patient safety is a very broad topic, and patient safety issues could be categorized into preventing, recognizing, and responding to patient safety issues based on related metrics [ 23 ]. Responding to issues that pertain to the handling of patient safety incidents that have already occurred has received relatively less interest than other categories of research on this topic, particularly in Korea. Until 2017, almost no research was conducted on the experiences of and difficulties faced by patients and healthcare workers who have been involved in patient safety incidents. This topic can be investigated using qualitative research.

A study in Korea investigated the physical and mental suffering experienced during the process of accepting disability and medical litigation by a patient who became disabled due to medical malpractice [ 21 ]. Another qualitative case study was conducted with participants who lost a family member due to a medical accident and identified psychological suffering due to the incident, as well as secondary psychological suffering during the medical litigation process, which increased the expandability of qualitative research findings [ 24 ]. A quantitative study based on these findings confirmed that people who experienced patient safety incidents had negative responses after the incidents and a high likelihood of sleep or eating disorders, depending on their responses [ 25 ].

A study that applied the grounded theory to examine the second victim phenomenon, referring to healthcare workers who have experienced patient safety incidents, and presented the response stages experienced by second victims demonstrated the strength of qualitative research [ 26 ]. Subsequently, other studies used questionnaire surveys on physicians and nurses to quantify the physical, mental, and work-related difficulties experienced by second victims [ 27 , 28 ]. As such, qualitative research alone can produce significant findings; however, combining quantitative and qualitative research produces a synergistic effect. In the healthcare field, which remains unfamiliar with qualitative research, combining these 2 methodologies could both enhance the validity of research findings and facilitate open discussions with other researchers [ 29 ].

In addition, qualitative research has been used for diverse sub-topics, including the experiences of patients and guardians with respect to various diseases (such as cancer, myocardial infarction, chronic obstructive pulmonary disease, depression, falls, and dementia), awareness of treatment for diabetes and hypertension, the experiences of physicians and nurses when they come in contact with medical staff, awareness of community health environments, experiences of medical service utilization by the general public in medically vulnerable areas, the general public’s awareness of vaccination policies, the health issues of people with special types of employment (such as delivery and call center workers), and the unmet healthcare needs of persons with vision or hearing impairment.

GENERAL WORKFLOW OF QUALITATIVE RESEARCH

Rather than focusing on deriving objective information, qualitative research aims to discern the quality of a specific phenomenon, obtaining answers to “why” and “how” questions. Qualitative research aims to collect data multi-dimensionally and provide in-depth explanations of the phenomenon being researched. Ultimately, the purpose of qualitative research is set to help researchers gain an understanding of the research topic and reveal the implications of the research findings. Therefore, qualitative research is generally conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants (or participation target) and data collection methods, (5) data analysis and description of findings, and (6) research validation ( Figure 1 ) [ 30 ]. However, unlike quantitative research, in which hypothesis setting and testing take place unidirectionally, a major characteristic of qualitative research is that the process is reversible and research methods can be modified. In other words, the research topic and question could change during the literature analysis process, and theoretical and analytical methods could change during the data collection process.

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General workflow of qualitative research.

Selection of a Research Topic and Question

As with any research, the first step in qualitative research is the selection of a research topic and question. Qualitative researchers can select a research topic based on their interests from daily life as a researcher, their interests in issues within the healthcare field, and ideas from the literature, such as academic journals. The research question represents a more specific aspect of the research topic. Before specifically starting to conduct research based on a research topic, the researcher should clarify what is being researched and determine what research would be desirable. When selecting a research topic and question, the research should ask: is the research executable, are the research topic and question worth researching, and is this a research question that a researcher would want to research?

Selection of Theoretical Framework and Methods

A theoretical framework refers to the thoughts or attitudes that a researcher has about the phenomenon being researched. Selecting the theoretical framework first could help qualitative researchers not only in selecting the research purpose and problem, but also in carrying out various processes, including an exploration of the precedent literature and research, selection of the data type to be collected, data analysis, and description of findings. In qualitative research, theoretical frameworks are based on philosophical ideas, which affect the selection of specific qualitative research methods. Representative qualitative research methods include the grounded theory, which is suitable for achieving the goal of developing a theory that can explain the processes involved in the phenomenon being researched; ethnographic study, which is suitable for research topics that attempt to identify and interpret the culture of a specific group; phenomenology, which is suitable for research topics that attempt to identify the nature of research participants’ experiences or the phenomenon being researched; case studies, which aim to gain an in-depth understanding of a case that has unique characteristics and can be differentiated from other cases; action research, which aims to find solutions to problems faced by research participants, with the researchers taking the same position as the participants; and narrative research, which is suitable for research topics that attempt to interpret the entire life or individual experiences contained within the stories of research participants. Other methodologies include photovoice research, consensual qualitative research, and auto-ethnographic research.

Literature Analysis

Literature analysis results can be helpful in specifically selecting the research problem, theoretical framework, and research methods. The literature analysis process compels qualitative researchers to contemplate the new knowledge that their research will add to the academic field. A comprehensive literature analysis is encouraged both in qualitative and quantitative research, and if the prior literature related to the subject to be studied is insufficient, it is sometimes evaluated as having low research potential or research value. Some have claimed that a formal literature review should not be performed before the collection of field data, as it could create bias, thereby interfering with the investigation. However, as the qualitative research process is cyclic rather than unidirectional, the majority believes that a literature review can be performed at any time. Moreover, an ethical review prior to starting the research is a requirement; therefore, the research protocol must be prepared and submitted for review and approval prior to conducting the research. To prepare research protocols, the existing literature must be analyzed at least to a certain degree. Nonetheless, qualitative researchers must keep in mind that their emotions, bias, and expectations may interject themselves during the literature review process and should strive to minimize any bias to ensure the validity of the research.

Selection of the Research Participants and Data Collection Methods

The subjects of qualitative research are not necessarily humans. It is more important to find the research subject(s) from which the most in-depth answers to the research problem can be obtained. However, the subjects in most qualitative studies are humans, as most research question focus on humans. Therefore, it is important to obtain research participants with sufficient knowledge, experience, and attitudes to provide the most appropriate answers to the research question. Quantitative research, which views generalizability as a key research goal, emphasizes the selection of research participants (i.e., the research sample that can represent the study’s population of interest), whereas qualitative research emphasizes finding research participants who can best describe and demonstrate the phenomenon of interest.

In qualitative research, the participant selection method is referred to as purposeful sampling (or purposive sampling), which can be divided into various types. Sampling methods have various advantages, disadvantages, and characteristics. For instance, unique sampling (extreme case sampling) has the advantage of being able to obtain interesting research findings by researching phenomena that have previously received little or no interest, and the disadvantage of deriving research findings that are interesting to only some readers if the research is conducted on an overly unique situation. Maximum variation sampling, also referred to as theoretical sampling, is commonly used in qualitative research based on the grounded theory. Selecting the appropriate participant sampling method that suits the purpose of research is crucial ( Table 2 ).

Sampling methods of selecting research participants in qualitative research

Sampling method	Explanation
Typical sampling	Selecting the most typical environment and people for the research topic
Unique sampling (extreme case sampling)	Selecting unique and uncommon situations or subjects who satisfy the research purpose
Maximum variation sampling	Selecting subjects showing maximum variation with a target population
Convenience sampling	Selecting subjects who can be sampled most conveniently considering practical limitations, such as funding, time, and location
Snowballing sampling	Selecting key research participants who satisfy the criteria established by the researcher and using their recommendations to recruit additional research participants

Once the researcher has decided how to select study participants, the data collection methods must be determined. Just as with participant sampling, various data collection methods are available, all of which have various advantages and disadvantages; therefore, the method must be selected based on the research question and circumstances. Unlike quantitative research, which usually uses a single data source and data collection method, the use of multiple data sources and data collection methods is encouraged in qualitative research [ 30 ]. Using a single data source and data collection method could cause data collection to be skewed by researcher bias; therefore, using multiple data sources and data collection methods is ideal. In qualitative research, the following data types are commonly used: (1) interview data obtained through one-on-one in-depth interviews and focus group discussions, (2) observational data from various observation levels, (3) documented data collected from personal or public documents, and (4) image data, such as photographs and videos.

Interview data are the most commonly used data source in qualitative research [ 31 ]. In qualitative research, an interview refers to communication that takes place based on a clear sense of purpose of acquiring certain information, unlike conversations that typically take place in daily life. The level of data acquired through interviews varies significantly depending on the researcher’s personal qualifications and abilities, as well as his or her level of interest and knowledge regarding the research topic. Therefore, interviewers must be trained to go beyond simply identifying the clearly expressed experiences of research participants to exploring their inner experiences and emotions [ 32 ]. Interview data can be classified based on the level of structuralization of the data collection method, sample size, and interview method. The characteristics of each type of interview are given in Table 3 .

Detailed types of interview methods according to the characteristics of in-depth interviews and focus group discussion

Classification	Specific method	Characteristics
Level of structuralization	Structured interview	Data are collected by asking closed questions in the order provided by highly specific interview guidelines
		Useful for asking questions without omitting any details that should be checked with each research participant
		Leaves little room for different interpretations of the participant’s responses or expressing original thoughts
	Semi-structured interview	Between a structured and unstructured interview; interview guidelines are developed in advance, but the questions are not strictly set and may vary
		The most widely used data collection method in qualitative research, as it allows interviews to be conducted flexibly depending on the characteristics and responses of the participants
		Researcher bias may influence the interview process
	Unstructured interview	The interview is conducted like a regular conversation, with extremely minimal prior information about the research topic and adherence to interview guidelines to exclude the intention for acquiring information needed for the research
		Can obtain rich and realistic meaning and experiences of the research participants
		The quality of information acquired and length (duration) of interview may vary depending on the competency of the interviewer, such as conversational skills and reasoning ability
Sample size	One-on-one in-depth interview	Excluding cases in which a guardian must accompany the research participant, such elderly or frail patients and children, a single participant discusses the research topic with one to two researchers during each interview session
		This data collection method is recommended for research topics that are difficult to discuss with others and suitable for obtaining in-depth opinions and experiences from individual participants
		The range of information that can be acquired may vary depending on the conversational skills and interview experience of the interviewer and requires a relatively large amount of effort to collect sufficient data
	Focus group discussion	At least 2 (generally 4–8) participants discuss the research topic during each interview session led by the researcher
		This method is effective when conducting interviews with participants who may be more willing to open up about themselves in a group setting than when alone, such as children and adolescents
		Richer experiences and opinions can be derived by promoting interaction within the group
		While it can be an effective data collection method, there may be some limitations in the depth of the interview; some participants may feel left out or not share their opinion if 1 or 2 participants dominate the discussion
Interview method	Face-to-face	The interviewer personally meets with the research participant to conduct the interview
		It is relatively easy to build rapport between the research participant and interviewer; can respond properly to the interview process by identifying non-verbal messages
		Cannot conduct interviews with research participants who are difficult to meet face-to-face
	Non-face-to-face	Interview between the interviewer and research participant is conducted through telephone, videoconferencing, or email
		Suitable data collection method for topics that deal with political or ethical matters or intimate personal issues; in particular, email interviews allow sufficient time for the research participant to think before responding
		It is not easy to generate interactions between the research participant and interviewer; in particular, it is difficult to obtain honest experiences through email interviews, and there is the possibility of misinterpreting the responses

Observations, which represent a key data collection method in anthropology, refer to a series of actions taken by the researcher in search of a deep understanding by systematically examining the appearances of research participants that take place in natural situations [ 33 ]. Observations can be categorized as participant and non-participant, insider and outsider, disguised and undisguised, short- and long-term, and structured and unstructured. However, a line cannot be drawn clearly to differentiate these categories, and the degree of each varies along a single spectrum. Therefore, it is necessary for a qualitative researcher to select the appropriate data collection method based on the circumstances and characteristics of the research topic.

Various types of document data can be used in qualitative research. Personal documents include diaries, letters, and autobiographies, while public documents include legal documents, public announcements, and civil documents. Online documents include emails and blog or bulletin board postings, while other documents include graffiti. All these document types may be used as data sources in qualitative research. In addition, image data acquired by the research participant or researcher, such as photographs and videos, serve as useful data sources in qualitative research. Such data sources are relatively objective and easily accessible, while they contain a significant amount of qualitative meaning despite the low acquisition cost. While some data may have been collected for research purposes, other data may not have been originally produced for research. Therefore, the researcher must not distort the original information contained in the data source and must verify the accuracy and authenticity of the data source in advance [ 30 ].

This review examined the characteristics of qualitative research to help researchers select the appropriate qualitative research methodology and identify situations suitable for qualitative research in the healthcare field. In addition, this paper analyzed the selection of the research topic and problem, selection of the theoretical framework and methods, literature analysis, and selection of the research participants and data collection methods. A forthcoming paper will discuss more specific details regarding other qualitative research methodologies, such as data analysis, description of findings, and research validation. This review can contribute to the more active use of qualitative research in the healthcare field, and the findings are expected to instill a proper understanding of qualitative research in researchers who review and judge qualitative research reports and papers.

Ethics Statement

Since this study used secondary data source, we did not seek approval from the institutional review board. We also did not have to ask for the consent of the participants.

Acknowledgments

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the material presented in this paper.

AUTHOR CONTRIBUTIONS

Conceptualization: Pyo J, Lee W, Choi EY, Jang SG, Ock M. Data curation: Pyo J, Ock M. Formal analysis: Pyo J, Ock M. Funding acquisition: None. Validation: Lee W, Choi EY, Jang SG. Writing - original draft: Pyo J, Ock M. Writing - review & editing: Pyo J, Lee W, Choi EY, Jang SG, Ock M.

Open access
Published: 25 August 2024

Navigating sexual minority identity in sport: a qualitative exploration of sexual minority student-athletes in China

Meng Xiang 1 , 2 ,
Kim Geok Soh 2 ,
Yingying Xu 3 ,
Seyedali Ahrari 4 &
Noor Syamilah Zakaria 5

BMC Public Health volume 24 , Article number: 2304 ( 2024 ) Cite this article

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Metrics details

Sexual minority student-athletes (SMSAs) face discrimination and identity conflicts in intercollegiate sport, impacting their participation and mental health. This study explores the perceptions of Chinese SMSAs regarding their sexual minority identities, aiming to fill the current gap in research related to non-Western countries.

A qualitative methodology was adopted, utilising the Interpretive Phenomenological Analysis (IPA) approach with self-categorization theory as the theoretical framework. Participants were recruited through purposive and snowball sampling, and data were collected via semi-structured interviews, documents, and field notes. Sixteen former and current Chinese SMSAs participated in this study.

The study reveals four themes: hidden truths, prioritisation of athlete identity, self-stereotyping, and attempt. The results revealed that while SMSAs were common in intercollegiate sport, their identities were often concealed and not openly discussed. The predominant focus on athlete identity in sport overshadowed their sexual minority identities. Additionally, SMSAs developed self-stereotypes that influenced their thoughts and behaviours. The non-heterosexual team atmosphere in women’s teams led to the development of intimate relationships among teammates.

Conclusions

The findings from this study could be incorporated into existing sport policies to ensure the safe participation of SMSAs in Chinese intercollegiate sports. This research offers valuable insights for the development and implementation of inclusive policies. Future research in China could investigate the attitudes of coaches and heterosexual student-athletes toward sexual minority identities to inform targeted interventions.

Peer Review reports

Collegiate sport serves as a conduit for hope, competition, learning, success, and enhanced well-being for students [ 1 , 2 ]. Within this context, situated at the intersection of student-athlete and sexual minority identities [ 3 ], sexual minority student-athletes (SMSAs) experience more challenges than their heterosexual counterparts. Sexual minority constitutes a group of individuals whose sexual and affectual orientation, romantic attraction, or sexual characteristics differ from that of heterosexuals. Sexual minority persons are inclusive of lesbian, gay, bi+, and asexual-identified individuals [ 4 ].

In an effort to enhance the support of SMSAs in sport, Team DC, the association of sexual minorities sport club, awarded seven SMSAs the 2023 Team DC College Scholarship [ 5 ]. Besides the Team DC scholarship, there are the Rambler Scholarship, US Lacrosse SMSAs Inclusion Scholarship, NCAA Women’s Athletics Scholarship and Ryan O’Callaghan Foundation [ 6 , 7 , 8 ]. These scholarships were set up to make sport a more welcoming and safer environment for SMSAs. In particular, the Sexual Minority Scholarship echoes the International Olympic Committee’s framework of equity, inclusion, and non-discrimination, which states that everyone has the right to participate in sport without discrimination and in a manner that respects their health, safety and dignity [ 9 , 10 ].

Despite efforts by educational and sport organisations to foster inclusivity, research shows that the sport environment remains hostile to sexual minority individuals [ 11 , 12 ]. In intercollegiate sport, empirical evidence points to persistent negative attitudes [ 13 , 14 , 15 , 16 , 17 ], which are expressed through marginalisation, exclusion, use of homophobic language, discrimination, and harassment [ 17 , 18 , 19 , 20 ]. SMSAs frequently confront the difficult choice of disclosing their identity, often opting for concealment. Denison et al. found that SMSAs who disclose their identity to their teams may face increased discrimination [ 21 ]. Pariera et al. also observed deep-rooted fears among SMSAs of being marginalised by their teams upon revealing their sexual orientation [ 22 ]. Consequently, the hostile environment led to lower participation rates among sexual minority youth compared to their heterosexual counterparts [ 23 ].

In China, there is a lack of clear public policies related to the sexual minority population [ 24 ]. Despite homosexuality being removed from the Chinese Classification of Mental Disorders-3 in 2001 [ 25 ]. China’s stance towards sexual minority issues remains ambiguous. Many scholars describe this attitude as “no approval, no disapproval, and no promotion” [ 26 , 27 , 28 , 29 ]. Due to the lack of legal protection, sexual minorities frequently encounter discrimination. A Chinese national survey revealed that only 5.1% of sexual minority individuals felt comfortable being open about their gender and sexual identity in China [ 30 ]. This discrimination is particularly severe among Chinese sexual minority youth, who are at higher risk of bullying in school and college [ 31 , 32 ]. These youths face childhood victimisation [ 33 , 34 , 35 ], which heightens their risk of mental and behavioural health issues [ 36 , 37 , 38 ], including non-medical use of prescription drugs [ 39 ], depression [ 40 , 41 ], and suicide [ 42 ].

While sports participation is crucial for the well-being of sexual minority individuals, research on the sports participation of sexual minority youth in China is limited. The literature highlights a significant gap in understanding the status and circumstances of SMSAs in China. Most existing studies focus on Western populations [ 43 , 44 , 45 ], overlooking the unique sociocultural interactions affecting SMSAs in non-Western contexts, making it challenging for China to apply these findings. Furthermore, the lack of reliable research on the interactions between sexual minorities and institutions in Chinese higher education hampers a comprehensive understanding of SMSAs’ situations. This research gap impedes the development of effective interventions to foster inclusivity. Persistent discrimination and inadequate protective policies underscore the urgent need for academic, policy, and practical advancements to support sexual minorities in China [ 46 ]. Therefore, the aim of this study was to explore SMSAs’ perceptions of their sexual minority identity in Chinese sports, providing insights to guide the creation of supportive educational and organisational strategies.

Homonegativity and discrimination in sport

Homonegativity refers to any prejudicial attitude or discriminatory behaviour directed towards an individual because of their homosexual orientation [ 47 ]. Compared to the more common term “homophobia,” [ 48 ] “homonegativity” more accurately describes negative attitudes towards homosexuality [ 49 ] because the fear is not irrational but is learned from parents, peers, teachers, coaches, and the daily interaction environment [ 50 ]. Sport context is an integral part of society, and an extensive body of research has consistently demonstrated the presence of homonegativity in sport [ 12 , 21 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ].

Homonegativity can manifest in forms such as verbal harassment, physical violence, or discriminatory behaviours. The “Out on the Fields” survey, conducted in 2015, represents the first large-scale international study focusing on homophobia in sports [ 60 ]. Participants were from six countries: Canada, Australia, Ireland, the United States, New Zealand, and the United Kingdom. It revealed extensive discrimination in sport, with a high percentage of gay men and lesbians experiencing verbal slander, bullying, threats, and physical assault. The OUTSPORT project, completed in 2019 and funded by the European Union, is the first comprehensive EU-wide study on homophobia and transphobia in sport. The project collected data from over 5500 sexual minority individuals across all 28 EU member countries [ 61 ]. The results revealed that a significant portion of participants faced adverse experiences in sport contexts related to their sexual orientation and gender identity, including verbal abuse, structural discrimination, physical boundary crossing, and violence. An overwhelming majority of respondents (92.9%) view homophobia and transphobia in sport as current issues. Additionally, 20% of respondents reported avoiding participation in sport due to concerns about their sexual orientation or gender identity, while 16% of active participants experienced at least one related negative incident in the past year. Notably, male student-athletes exhibited higher levels of homophobic attitudes compared to their female counterparts and non-physical education students [ 15 , 16 , 62 ]. Conversely, female athletes reported experiencing less fear of exclusion and a more inclusive team environment [ 22 , 63 , 64 ], highlighting significant gender disparities in homonegativity in sport.

Group and individual identity

The distinct team interaction inherent in sport may enhance or support expressions of homonegativity and discrimination, as Social Identity Theory posits that negative beliefs about certain groups may develop group identity [ 65 , 66 , 67 ]. This phenomenon is particularly noticeable in intercollegiate sport, where a strong emphasis on physical attributes and abilities often results in prejudices against those who deviate from established norms [ 16 ]. Such discrimination and mistreatment of SMSAs frequently stem from their teammates and coaches. Many SMSAs choose to conceal their sexual orientation due to fear of ostracism [ 60 ], with team members often identified as the primary perpetrators of discrimination [ 61 ].

Therefore, navigating sexual identity within intercollegiate sport is challenging for SMSAs, as their minority status becomes a focal point, impacting their overall experience [ 68 , 69 ]. They encounter a unique psychological and emotional burden, striving to reconcile societal norms and expectations with their true selves. This constant negotiation and management of their identity across different contexts further complicates their experiences, frequently leading to difficulties in maintaining authenticity [ 19 ]. Therefore, SMSAs in intercollegiate sport face intricate challenges in balancing their authentic identity with societal norms, significantly impacting their experience and sense of self.

Theoretical framework

Self-categorisation theory (SCT), an extension of Social Identity Theory, provides a valuable perspective for examining the perceptions of SMSAs in China, focusing on intragroup processes and individual navigation of personal and social identities [ 70 , 71 ]. Key principles of SCT, including self-categorisation, salience, depersonalisation, and individuality [ 67 ], are instrumental in understanding how SMSAs navigate their sexual identities within the confines of sport norms. Applying SCT, this study could explore the complex interplay of intragroup relations and identity processes among SMSAs in the Chinese sport context, underscoring how contextual factors distinctly shape their identity.

Purpose of the study

The purpose of this study is to explore SMSAs’ perceptions of their sexual minority identity within the Chinese sports context and understand how this identity influences their participation in sports. By illuminating the specific challenges and issues related to sexual minority identity in Chinese intercollegiate sports, this study provides a deeper understanding of the experiences of sexual minorities in this field.

Research design

This study was conducted with the interpretivist paradigm, which emphasises understanding the subjective experiences and meanings that individuals assign to their world. It posits that reality is not objective but is constructed through individual perceptions and social interactions [ 72 ]. Given the aim of exploring the perceptions of sexual minority identity in sport from SMSAs’ perspectives, a qualitative research approach is appropriate. In line with the purpose of the study, the Interpretative Phenomenological Analysis (IPA) was adopted in this study, an approach aimed at understanding people’s lived experiences and how they make sense of these experiences in the context of their personal and social worlds [ 73 ]. IPA research encompasses phenomenology, hermeneutics, and idiography and emphasises the personal significance of self-reflection among individuals with a shared experience in a specific context [ 74 ]. Additionally, IPA is particularly suitable for research focusing on identity and self-awareness [ 75 ]. The features and focus of IPA are consistent with the purpose of this study. Therefore, IPA was considered a suitable approach to explore the SMSAs’ perceptions of their sexual minority identity within the sport context in China.

Researcher characteristics and reflexivity

During the data collection phase of this study, the first researcher was a Ph.D. candidate and had obtained her Ph.D. by the time of this manuscript’s submission. Her doctoral committee continuously supervised the research. The first researcher’s doctoral committee members are proficient in qualitative research. The first researcher and the second coder have received systematic qualitative training, are skilled in qualitative analysis software (NVivo), and have published empirical studies using the IPA approach. Although none of the research team members were SMSAs, the first researcher and the second coder maintained long-term contact with SMSAs through their involvement in sport teams. The first researcher was a former student-athlete and is currently working as a coach. Given her background, she has had extensive time to interact with and understand SMSAs within student teams.

Participants and procedures

Purposive and snowball sampling methods were employed to recruit a homogeneous sample for this study, as recommended by Smith and Nizza [ 73 ]. Following approval from Universiti Putra Malaysia’s Human Research Review Committee, the researcher initially reached out to SMSAs within her network, subsequently expanding outreach through social media to reach a broader pool of potential participants. The participants were selected based on specific inclusion criteria (Table 1 ), ensuring relevance to the study’s focus. Of the 22 individuals contacted, 16 agreed to participate, while six individuals declined participation due to concerns regarding potential exposure. The sample included a diverse representation of sexual minority subgroups: one asexual man, four bisexual women, three gay men, and eight lesbians. Given the relatively low prevalence of asexual individuals [ 76 , 77 ], we only had one participant from this subgroup. Strict confidentiality measures were enforced, with participants assigned pseudonyms and their college affiliations omitted for anonymity. The demographic details of the participants are outlined in Table 2 .

In phenomenological research, the focus is on rich individual experiences rather than data saturation [ 78 ]. Similarly, IPA research aims to explore participants’ personal and social worlds through detailed, in-depth analysis [ 79 ]. Smith and Nizza [ 73 ] also highlighted that in IPA research, sample size is less crucial because of the emphasis on detailed analysis in small, homogeneous samples. Therefore, the richness of data and the depth of insight into each participant’s experience are more important than the number of participants or reaching data saturation. This study utilised IPA’s in-depth analytical approach with sixteen participants to provide detailed data. This methodological approach allows for a comprehensive exploration of individual experiences, aligning with the study’s objectives.

Data collection

Data for this study were collected through semi-structured interviews (Appendix A), allowing participants to choose the mode, time, and location, including face-to-face or online sessions on Chinese social networks. Each interview’s length is detailed in Table 2 , with an average duration of 63 min. Before each interview, participants signed informed consent forms following a detailed briefing on the study’s purpose and procedures. Given the sensitive nature of the research, the interviews were conducted solely between the researcher and the participant to ensure a safe and comfortable environment, fostering open and honest communication.

The methods of data collection exhibited some qualitative differences. In face-to-face interviews, participants were often cautious and hesitant to share personal experiences. Conversely, online interviews proved more effective, as participants felt more relaxed, leading to quicker rapport and greater openness. This difference likely stems from the reduced perceived risk of exposure in an online setting. Due to the clear objectives of the study and the structured interview guide, there were no differences between the data from current SMSAs and former SMSAs.

Notably, one participant provided data through written essays instead of a semi-structured interview due to concerns about exposure and discomfort. After discussing the matter, the participant agreed to respond to interview questions in written form. The first researcher sent the interview questions to the participant, who then provided written responses. Follow-up questions were asked based on these initial responses, resulting in four sets of essay responses. This approach, which aligns with the conventions of phenomenological research [ 80 ], allowed the participant to express their experiences comfortably. The essay data were analysed alongside the semi-structured interview data, with common themes identified across all responses.

Documents and field notes supplemented the data collection. Documents included photographs, videos, and diaries. With participant consent, these documents were analysed for relevance to the research purpose. Field notes captured contextual information during both face-to-face and online interviews, including keywords and participants’ pauses and intonations, with immediate elaboration post-interview to avoid biases [ 81 , 82 ]. These detailed notes contextualised data analysis [ 74 ] and contributed to the research’s credibility.

Data analysis

The data analysis in this study followed a seven-step process aligned with IPA research guidelines and contemporary IPA terminology. The data analysis procedure is depicted in Fig. 1 . The IPA analysis is iterative and inductive [ 83 ], involving the organisation of data into a structured format for easy tracking through various stages – from initial exploratory notes on transcripts to the development of empirical statements, theme clustering, and final group theme structure. The theoretical framework was incorporated at the final stage of empirical theme development.

To enhance the study’s validity, the first author invited another Ph.D. candidate to participate in the data analysis process. After the interview recordings were translated into transcripts using audio software, the first researcher listened to the recordings repeatedly to correct the transcripts. The second coder reviewed the recordings to ensure the transcriptions were accurate and verbatim. The first author employed NVivo software (released in March 2020) for coding, and the second coder utilised manual coding. All data were analysed in Chinese to maintain linguistic integrity and then translated into English for theme presentation.

Data Analysis Procedure. Adapted from Smith et al. ( 74 )

The procedures of this study adhered to the COREQ Checklist [ 84 ] (Appendix B) and the IPA Quality Evaluation Guide [ 85 ] to ensure rigour. The research met the good quality requirements for IPA studies as outlined by Smith [ 85 ] (Table 3 ). Throughout the research, emphasis was placed on internal validity, external validity, and reliability to maintain the study’s rigour and quality. The methods employed to address these aspects are summarised in Table 4 .

This study explored SMSAs’ perceptions of sexual minority identity within intercollegiate sport in China. From the perspective of SCT, the results uncovered four key themes from SMSA’s team-based interactive experiences. The research themes, along with their corresponding sub-themes and occurrences, are presented in Table 5 .

Hidden truths

The hidden truths refer to facts, scenarios, or knowledge that are not commonly known or readily available. In this study, the existence of SMSAs in intercollegiate sport was undeniable, yet it remained concealed due to the prevailing lack of transparency.

SMSAs are common in sport

This research uncovered the extensive existence of SMSAs in Chinese sport. Almost all participants acknowledged the ubiquity of sexual minorities in sport, with 12 out of the 16 participants specifically highlighting the presence of SMSAs in collegiate sport:

I think everyone is generally aware of sexual minorities; all people are aware of them to a greater or lesser extent. It is generally agreed that the existence of sexual minorities is a common phenomenon in modern society, and even more so in Sport, as anyone involved in sport knows that (Adam).

Participants frequently described the presence of SMSAs in intercollegiate sport, using terms like “widespread”, “common”, “normal”, and “quite many”. Several participants also provided specific details about the number of SMSAs in their respective teams. Jackie remarked, “At that time, half of my teammates were lesbians” (Jackie). Similarly, Zoe noted the significant presence of SMSAs in her team, “I think it (the number of SMSAs) was almost half of the team at that time. But I don’t know about the senior players; almost half of our junior players were SMSAs” (Zoe).

Silent identity

Participants noted the prevalence of SMSAs in sport but also emphasised the difficulty of openly discussing sexual minority identity in this context. They described the sport environment as reserved and lacking open conversations about SMSAs and their experiences.

The reticent nature of sport teams regarding sexual minority identity was evident in their attitudes. William observed, “I feel like most of my teammates just don’t take a stand. They don’t want to make a statement about SMSAs. Nor did they say they supported it or didn’t support it” (William). Similarly, Mia considered sexual minority identity as a personal issue, inappropriate for open discussion.

No one wants to ask or discuss this openly…we live in a very conservative environment all the time, and none of this content is something that teammates should be concerned about, and people would feel offended if you don’t handle it well (Mia).

Some SMSAs viewed avoiding discussions on sexual minorities in sport as respectful to teammates, aiming for a comfortable, stress-free environment. Joy said, “We came here to play, right? I don’t think any of the other players want to feel phased by who you are” (Joy). Mia echoed this sentiment:

…in team training, the game is the game, and I rarely bring other emotions into it…. In the company of most of our teammates, we don’t interact with each other in that way. It’s probably a default rule that respect is distance, I guess (Mia).

Charlotte, involved in volleyball and basketball, recounted a teammate’s public derogation due to her sexual minority identity, an incident not openly addressed by the team. She perceived sexual identity as a “taboo” topic. The narratives revealed a cautious approach among SMSAs towards expressing their sexual minority identity in sport. They felt compelled to carefully manage their sexual orientation, minimising its disclosure. This hesitancy likely stemmed from the existing reticence and limited acceptance of SMSAs in sport, fostering a sense of invisibility and concern over potential negative consequences.

Prioritisation of athlete identity

The theme of prioritisation of athlete identity suggests that for SMSAs, their identity as an athlete may play a more prominent or influential role in shaping their self-conception compared to their sexual minority identity.

Be an athlete

Several participants believed their primary role as student-athletes was to engage in sport, and they valued this aspect of their identity significantly. Joy expressed this sentiment, “I love volleyball very much … I don’t care much about relationships; I just love volleyball, and I think we are all here to do this, and nothing else matters. You don’t need to stress about it (sexual minority identity)” (Joy).

Emma echoed a similar perspective, noting, “I think my teammates are very professional; our program requires a high technical standard, and we spend most of our time training; other than that, things don’t seem that important” (Emma). When queried about the importance of sexual minority identity, she responded, “Yes, at least not concerning sport performance, or maybe it will have a bad effect” (Emma). Additionally, some participants felt that in the context of sport, sexual minority identity might be sidelined. Adam commented:

“We don’t share it (sexual minority identity) unless someone asks. We’re a team first, and then we’re individuals, and for me, I’m important personally, but in the team, we all probably need to sacrifice some of ourselves to make the team more united and stronger” (Adam).

Participants’ views as both student-athletes and sexual minorities highlighted contrasts in the intercollegiate sport environment. Their student-athlete identity was key in shaping self-perception and fostering a sense of community, while their sexual minority identity was often marginalised in aspects of interpersonal relations, team support, and self-identity development.

Sport performance first norms

In team sport, leaders are crucial in creating inclusive spaces for SMSAs and setting behavioural and attitudinal standards, including those towards SMSAs. In this study, some participants believed that coaches’ criteria for acceptance of sexual minority individuals or intra-team romantic relationships were based on athletic performance.

Some coaches firmly believe that team relationships negatively impact team performance and, therefore, strictly prohibit romantic relationships between teammates. Joy recalled,

She couldn’t accept that… she thinks being an athlete like that is ridiculous. It would make a mess; her team would be in a mess. She said you two are dating and that playing will affect your emotions, which means she meant to say there is no way I can treat another girl as a normal teammate… (Joy).

In contrast, some coaches adopt a more tolerant attitude. Jackie’s coach believes that if the team’s overall performance is not affected, issues such as sexual orientation or team relationships can be ignored. Jackie stated, “My coach is male and old, but he should know what’s going on, especially since our captain has dated several teammates and the coach pretends not to know. He would only care if we were winning games” (Jackie).

Whether it instructs prohibition or an indifferent attitude, both narratives reflect that the team’s norms for inclusivity are based on sport performance. These norms also influence how SMSAs assess their own sexual minority identity within the team, as Adam said:

As of now, I have someone in the team that I have a crush on and haven’t dated. Maybe if he and I argued over training or a game, it would affect the performance of the team and the relationship between teammates…. I don’t think I could let that happen (Adam).

The participants’ narratives emphasise how the “Sports Performance First” norms influence the attitudes and behaviours of coaches and SMSAs within the team. These norms not only shape the team culture but also profoundly affect how SMSAs navigate their identities and relationships in the team environment.

However, the excessive focus on sport performance highlights the athletic identity of student-athletes while neglecting their other identities, especially those of sexual minorities. This singular focus leads to the neglect of the personal needs and diverse identities of athletes. Although these measures may seem to ensure the overall performance of the team, they overlook the psychological health and holistic development needs of the individuals.

Self-stereotyping

Self-stereotyping denotes the tendency of SMSAs to describe themselves using stereotypical attributes in the sport context. These descriptions frequently align with stereotypical perceptions prevalent in the external environment. SMSAs tend to be perceived as having specific physical traits or behavioural tendencies.

Specific physical traits

Sophia provided an illustrative example of self-stereotyping through her personal experience. She commented:

In the beginning, I would think that if you are an SMSA, you must fit some characteristics. For example, at that time, I saw some lesbians in my team who had short hair or wore baggy t-shirts; I was a bit frustrated by my long hair and feminine appearance…and I felt that I might not quite fit those criteria. So, then I cut my hair and even wore a wrapping bra to the training ground (Sophia). Sophia’s narrative underscores how the pressure to conform to certain physical traits led her to change her appearance to fit the stereotypical image of an SMSA within the sport context.

Behavioural tendencies

In addition to physical traits, SMSAs also feel compelled to conform to certain behavioural tendencies that are stereotypically associated with SMSAs. Zoe explained, “Because of who I am (T), I felt I should have to perform stronger, so I put up with much training…. I felt I should be there to protect the other players; if I were vulnerable, I would look down on myself” (Zoe). This indicates a sense of obligation among some female SMSAs to embody strength, aligning with the stereotypical image of female SMSAs in sport. Conversely, male SMSAs in men’s teams often faced stereotypes of being fragile, weak, or exhibiting feminine traits. Royal noted that behaviours of some male SMSAs, like engaging in non-sport-related banter, led to gossip and negative perceptions within men’s sport. To avoid these stereotypes, Royal aimed to mimic the mannerisms of heterosexual athletes, as he explained:

I try to avoid being close to the team’s prominent male SMSAs and try to stay out of related conversations; I don’t want to be a standard gay; I want to have the same college life as the rest of the team (heterosexuality) (Royal).

Stereotypes in sport often forced SMSAs into roles incongruent with their authentic identities, significantly impacting their self-expression and identity. The pressure to conform to societal norms in sport settings created internal conflicts for SMSAs, challenging their ability to maintain their true sense of self.

This theme addresses situations where student-athletes engage in intra-team intimacy or mimic being SMSAs in sport. This attempt has two key elements: prolonged contact leading to intimacy and influence from sexual minority teammates.

Prolonged contact leading to intimacy

Participants noted that extensive training and competition schedules in sport fostered close bonds among team members. Lucas shared, “When we were preparing for the tournament, we trained together every morning and evening…the game spanned for almost a month, and after that, we felt as close as family to our teammates” (Lucas). Similarly, Ruby pointed out, “Back then, we were training every afternoon until late at night; it was quite hard (the training was very strenuous) … it lasted for six months” (Ruby). These prolonged interactions sometimes led to the development of more profound attractions among student-athletes.

“I think we had many moments of trust and intimacy together on the field that built up some heartfelt feelings. These feelings made me feel emotions beyond that of a teammate…. Then I realised that gender might not be so important because it’s hard to build that kind of relationship in a typical romance” (Savannah).

Influence from sexual minority teammates

Participants also described how interactions with sexual minority teammates led them to explore their own sexual identities, as illustrated by Ava’s recounting of her initial same-gender relationship experience:

That time we went out to a tournament, and I found that four of my teammates, three of them were lesbians…we didn’t have games at night, so they had been talking to their girlfriends every night on the phone, and I just felt as if that was not too bad. Probably influenced by them, I got a girlfriend at that tournament as well…. Even though we broke up when we returned, I could accept girls (Ava).

Mia described a similar experience:

There were some lesbians in my team, and then it just seemed natural that I got close to one of them…. Well, I was thinking about whether that relationship would affect the team. But then I found out that there were other couples on the team. So, I feel like I wasn’t doing anything wrong (Mia).

The phenomenon highlights the significant role of peer influence in team settings. When individuals are around many teammates in same-gender relationships, it fosters an environment that normalises such relationships. Notably, this influence is not coercive but stems from observing and interacting with teammates who are comfortable with their sexual orientations. This environment helps individuals feel accepted and more confident in exploring their identities and relationships.

This study explored the perceptions of SMSAs regarding their sexual identity within intercollegiate sport in China. Its importance lies in its contribution to understanding the complex realities of SMSAs in China, an area that has lacked depth in the literature. By reaffirming the necessity of examining these athletes’ experiences, this study reveals the intricate conflict between adhering to team norms and expressing personal characteristics within the context of the Chinese social and cultural background.

The results show that SMSAs are a recognised reality in Chinese intercollegiate sport, consistent with findings from Western countries. While precise figures of sexual minorities in sport may vary across countries, it is acknowledged that they are present at all competitive levels, from school and college sport to the professional sphere [ 22 , 86 , 87 , 88 , 89 , 90 , 91 ]. Although no national census on sexual minorities in China or in sports environments exists, related research indicates that many college and university students self-identify as sexual minorities. For instance, an online survey conducted across 26 colleges and universities in 10 Chinese provinces found that over 8% of students identify as sexual minorities [ 36 ]. Additionally, another national survey revealed that nearly a quarter of college students identify as non-heterosexual [ 92 ]. Recognising and addressing the unique challenges faced by sexual minority youth, who make up a notable percentage of the student population, is essential for sport and educational institutions.

Despite the apparent prevalence of SMSAs, the study confirms that their identities often remain hidden in the context of Chinese intercollegiate sport. This can be attributed to two main reasons: First is the concern about discrimination if exposed. Chinese sexual minorities frequently report experiencing abuse or discrimination in families, schools, and workplaces [ 93 ]. Additionally, conversion therapies and discriminatory counselling practices persist in mental health services [ 94 ], creating an environment where discrimination is a significant concern, thereby reducing the likelihood of SMSAs coming out in the sports environment. The second reason is the constraint of traditional Chinese culture. The dominant Confucian culture in China emphasises harmony, internalised homonegativity, and conformity [ 95 , 96 ], often at the expense of individual expression and identity development. This cultural backdrop influences how sexual minorities perceive their own identities [ 97 ] and creates an ideological constraint that leads to social rejection and resistance towards sexual minorities [ 98 ], thereby reducing the visibility of sexual orientation-related topics in the Chinese sport context.

Moreover, SMSAs in China often prioritise their athlete identity over their sexual minority identity, influenced by the attitudes of team leaders. This tendency is reinforced by coaches who primarily focus on the biological sex of athletes and lack training or understanding related to sexual minority issues [ 99 ]. Consequently, the Chinese coaches’ lack of knowledge about sex and sexual orientation exacerbates the silence surrounding sexual minority identities in the Chinese collegiate sport environment and intensifies the identity conflict for SMSAs. Emphasising athletic performance is central in sport but should not overshadow the holistic development of student-athletes. McCavanagh and Cadaret [ 100 ] noted that student-athletes might face challenges in reconciling various aspects of their identity in a heteronormative sport context. The suppression of sexual minority identity can lead to isolation from potential support systems that nurture positive sexual and gender identities. Prioritising athletic success over broader student development in sport departments limits growth opportunities for all students, including SMSAs. Chavez et al. [ 101 ] emphasised that student development requires recognising and valuing diversity, suggesting that a singular focus on athletic prowess can diminish the benefits of diversity among student-athletes. Embracing diversity is not only a personal journey but also one that can enhance the collective experience within sport settings.

In addition, self-stereotyping within SCT involves aligning one’s self-concept with the characteristics of valued social categories [ 102 ]. Latrofa [ 103 ] suggests that members of low-status groups, like SMSAs in sport, may self-stereotype to align more closely with their group, reflecting recognition of lower status and self-perception through peers. This study revealed SMSAs shape their self-identity based on the attitudes prevalent in their sport environment, with influences from peers and coaches being internalised as personal attitudes [ 104 ]. Such self-stereotyping supports maintaining a favourable social identity and adhering to group norms but can reinforce negative stereotypes and prejudices within sport.

Internalising stereotypes may lead SMSAs to develop prejudices against themselves and others, perpetuating discrimination. It can also hinder individual development, impacting self-esteem and confidence. For example, aligning with negative stereotypes could cause SMSAs to doubt their worth and capabilities, affecting emotional well-being and satisfaction. Liu and Song’s [ 105 ] survey of Chinese college students illustrated the direct impact of gender self-stereotypes on life satisfaction, highlighting the significant effects of self-stereotyping on individual well-being.

Furthermore, in the context of traditional and reserved Chinese culture, intercollegiate sport offers a relatively free and open space for sexual minority women. The results of this study suggest that the visibility of sexual minority women in teams and the long time spent together allow these athletes to explore and establish intimate relationships. These results are similar to findings in Spanish studies [ 103 ], which highlighted the protective and liberating role of sports teams in the sexual exploration of female sexual minority athletes. Research by Organista and Kossakowski on Polish female footballers [ 106 ] and Xiong and Guo [ 96 ] on Chinese women’s basketball teams also revealed a climate of non-heteronormativity in women’s sport. These climates provide a sanctuary from heterosexual pressures, allowing sexual minority athletes to engage in sport free from traditional constraints. Such environments help female sexual minority athletes navigate and subvert heteronormative norms by cultivating supportive subcultural networks within their teams.

This study addresses the lack of in-depth research on the experiences of SMSAs in Chinese intercollegiate sport. It fills the gap by exploring the complex realities of SMSAs, focusing on their identity conflicts and the influence of the Chinese social and cultural background. Specifically, this study provides valuable insights that align with SCT [ 71 ]. This study addresses a notable gap in the existing literature regarding sexual minority sport participation, as rarely have these perceptions been explored. Drawing from the lens of SCT, the results of this study revealed several valuable insights into how their sexual minority identity impacts their participation in sport. These findings not only enhance our understanding of how SCT applies to the sport experiences of sexual minority individuals but also contribute to the advancement of SCT in research on sexual minority sport participation. The themes uncovered in this study closely align with central SCT concepts such as identity salience, self-stereotyping, and depersonalisation, illuminating the ways SMSAs comprehend and express their sexual minority identity within the intercollegiate sport context. SCT, with its focus on both intragroup and intergroup relations within the multifaceted construct of the self, offers valuable insights into the complexities of SMSAs’ self-perceptions and the intricacies involved in developing and manifesting their identities in the realm of sport.

Based on the results, more effort needs to be put into understanding sexual minority identities in intercollegiate sport. By examining the perspectives and experiences of SMSAs, we can gain insights into the interactions and influences of sexual minority individuals in the sport context. The interplay between an individual’s self-perception and situational dynamics results in a self-identity that mirrors the collective. In addition, the prevalent pressures and normative prejudices inherent in the sport system significantly influence their self-identity. Therefore, valuing SMSAs’ understanding of their self-identity shows respect for each person’s differences and rights. We hope the findings will be incorporated into existing sport policies to promote inclusivity and ensure safe participation for sexual minority students. To encourage and support the full development of SMSAs, college athletics and related institutions should prioritise understanding and respecting their perceptions of their sexual minority identity. By doing so, institutions can create a more inclusive and supportive environment that acknowledges and addresses the unique challenges faced by SMSAs.

Nevertheless, caution should be exercised when generalizing the findings, especially for subgroups with low representation, such as asexual individuals. While the study provides valuable insights into SMSAs’ perceptions of their sexual minority identity within the Chinese sport context, the limited number of asexual participants means their unique perspectives may not be fully captured. Therefore, these findings may not fully represent all sexual minority subgroups.

Future research could focus on exploring the perceptions and experiences among various sexual minority subgroups within sport participation in China. Additionally, considering the cultural diversity across China’s vast geographic regions, it would be valuable to examine how SMSAs perceive their minority identity in different cultural contexts. Given the scarcity of related studies in China, it is also important to survey other stakeholders in the sport environment, such as coaches and heterosexual student-athletes, to gain a broader understanding of perceptions of sexual minority identities. These insights can inform the development of targeted interventions aimed at ensuring the safe and inclusive participation of SMSAs in intercollegiate sport.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to ethical considerations but are available from the corresponding author on reasonable request.

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Xiang, M., Soh, K.G., Xu, Y. et al. Navigating sexual minority identity in sport: a qualitative exploration of sexual minority student-athletes in China. BMC Public Health 24 , 2304 (2024). https://doi.org/10.1186/s12889-024-19824-9

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Understanding digital sweatshops: A qualitative investigation of workers’ perspectives

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Manoj Kumar Kamila ORCID: orcid.org/0000-0001-8456-5778 1 ,
Sahil Singh Jasrotia 2 &
Pooja Singh Kushwaha 1

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Digital sweatshops represent exploitative digital workplaces where individuals are compelled to work long hours under high demands for minimal compensation. This study employs in-depth, semi-structured interviews with digital workers to explore digital sweatshop operations’ challenges and adverse aspects, mainly focusing on ethical considerations. The collected data were transcribed and analyzed using grounded theory methodology. The findings highlight three key themes: conditions mitigating factors, organisational factors, and work environment factors, all of which contribute to the persistence of digital sweatshops. The study advocates for comprehensive labour laws, education and advocacy for digital employees, mental health support, transparency and accountability, skill development, career advancement, and ethical business practices. These recommendations are intended to help governments and organizations create a fair and ethical digital workplace, prioritizing workers’ rights and well-being.

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Digital Work Environment Rounds – Systematic Inspections of Usability Supported by the Legislation

Digitalisation of Work and Resistance

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Kamila, M.K., Jasrotia, S. . & Kushwaha, P.S. Understanding digital sweatshops: A qualitative investigation of workers’ perspectives. Asian J Bus Ethics (2024). https://doi.org/10.1007/s13520-024-00210-y

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Evaluating panel discussions in ESP classes: an exploration of international medical students’ and ESP instructors’ perspectives through qualitative research

Elham Nasiri ORCID: orcid.org/0000-0002-0644-1646 1 &
Laleh Khojasteh ORCID: orcid.org/0000-0002-6393-2759 1

BMC Medical Education volume 24 , Article number: 925 ( 2024 ) Cite this article

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This study investigates the effectiveness of panel discussions, a specific interactive teaching technique where a group of students leads a pre-planned, topic-focused discussion with audience participation, in English for Specific Purposes (ESP) courses for international medical students. This approach aims to simulate professional conference discussions, preparing students for future academic and clinical environments where such skills are crucial. While traditional group presentations foster critical thinking and communication, a gap exists in understanding how medical students perceive the complexities of preparing for and participating in panel discussions within an ESP setting. This qualitative study investigates the perceived advantages and disadvantages of these discussions from the perspectives of both panelists (medical students) and the audience (peers). Additionally, the study explores potential improvements based on insights from ESP instructors. Utilizing a two-phase design involving reflection papers and focus group discussions, data were collected from 46 medical students and three ESP instructors. Thematic analysis revealed that panel discussions offer unique benefits compared to traditional presentations, including enhanced engagement and more dynamic skill development for both panelists and the audience. Panelists reported gains in personal and professional development, including honing critical thinking, communication, and presentation skills. The audience perceived these discussions as engaging learning experiences that fostered critical analysis and information synthesis. However, challenges such as academic workload and concerns about discussion quality were also identified. The study concludes that panel discussions, when implemented effectively, can be a valuable tool for enhancing critical thinking, communication skills, and subject matter knowledge in ESP courses for medical students. These skills are transferable and can benefit students in various academic and professional settings, including future participation in medical conferences. This research provides valuable insights for ESP instructors seeking to integrate panel discussions into their curriculum, ultimately improving student learning outcomes and preparing them for future success in professional communication.

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Introduction

In the field of medical education, the acquisition and application of effective communication skills are crucial for medical students in today’s global healthcare environment [ 1 ]. This necessitates not only strong English language proficiency but also the ability to present complex medical information clearly and concisely to diverse audiences.

Language courses, especially English for Specific Purposes (ESP) courses for medical students, are highly relevant in today’s globalized healthcare environment [ 2 ]. In non-English speaking countries like Iran, these courses are particularly important as they go beyond mere language instruction to include the development of critical thinking, cultural competence, and professional communication skills [ 3 ]. Proficiency in English is crucial for accessing up-to-date research, participating in international conferences, and communicating with patients and colleagues from diverse backgrounds [ 4 ]. Additionally, ESP courses help medical students understand and use medical terminologies accurately, which is essential for reading technical articles, listening to audio presentations, and giving spoken presentations [ 5 ]. In countries where English is not the primary language, ESP courses ensure that medical professionals can stay current with global advancements and collaborate effectively on an international scale [ 6 ]. Furthermore, these courses support students who may seek to practice medicine abroad, enhancing their career opportunities and professional growth [ 7 ].

Moreover, ESP courses enable medical professionals to communicate effectively with international patients, which is crucial in multicultural societies and for medical tourism, ensuring that patient care is not compromised due to language barriers [ 8 ]. Many medical textbooks, journals, and online resources are available primarily in English, and ESP courses equip medical students with the necessary language skills to access and comprehend these resources, ensuring they are well-informed about the latest medical research and practices [ 9 ].

Additionally, many medical professionals from non-English speaking countries aim to take international certification exams, such as the USMLE or PLAB, which are conducted in English, and ESP courses prepare students for these exams by familiarizing them with the medical terminology and language used in these assessments [ 10 ]. ESP courses also contribute to the professional development of medical students by improving their ability to write research papers, case reports, and other academic documents in English, which is essential for publishing in international journals and contributing to global medical knowledge [ 11 ]. In the increasingly interdisciplinary field of healthcare, collaboration with professionals from other countries is common, and ESP courses facilitate effective communication and collaboration with international colleagues, fostering innovation and the exchange of ideas [ 12 ].

With the rise of telemedicine and online medical consultations, proficiency in English is essential for non-English speaking medical professionals to provide remote healthcare services to international patients, and ESP courses prepare students for these modern medical practices [ 13 ].

Finally, ESP courses often include training on cultural competence, which is crucial for understanding and respecting the cultural backgrounds of patients and colleagues, leading to more empathetic and effective patient care and professional interactions [ 14 ]. Many ESP programs for medical students incorporate group presentations as a vital component of their curriculum, recognizing the positive impact on developing these essential skills [ 15 ].

Group projects in language courses, particularly in ESP for medical students, are highly relevant for several reasons. They provide a collaborative environment that mimics real-world professional settings, where healthcare professionals often work in multidisciplinary teams [ 16 ]. These group activities foster not only language skills but also crucial soft skills such as teamwork, leadership, and interpersonal communication, which are essential in medical practice [ 17 ].

The benefits of group projects over individual projects in language learning are significant. Hartono, Mujiyanto [ 18 ] found that group presentation tasks in ESP courses led to higher self-efficacy development compared to individual tasks. Group projects encourage peer learning, where students can learn from each other’s strengths and compensate for individual weaknesses [ 19 ]. They also provide a supportive environment that can reduce anxiety and increase willingness to communicate in the target language [ 20 ]. However, it is important to note that group projects also come with challenges, such as social loafing and unequal contribution, which need to be managed effectively [ 21 ].

Traditional lecture-based teaching methods, while valuable for knowledge acquisition, may not effectively prepare medical students for the interactive and collaborative nature of real-world healthcare settings [ 22 ]. Panel discussions (hereafter PDs), an interactive teaching technique where a group of students leads a pre-planned, topic-focused discussion with audience participation, are particularly relevant in this context. They simulate professional conference discussions and interdisciplinary team meetings, preparing students for future academic and clinical environments where such skills are crucial [ 23 ].

PDs, also known as moderated discussions or moderated panels, are a specific type of interactive format where a group of experts or stakeholders engage in a facilitated conversation on a particular topic or issue [ 22 ]. In this format, a moderator guides the discussion, encourages active participation from all panelists, and fosters a collaborative environment that promotes constructive dialogue and critical thinking [ 24 ]. The goal is to encourage audience engagement and participation, which can be achieved through various strategies such as asking open-ended questions, encouraging counterpoints and counterarguments, and providing opportunities for audience members to pose questions or share their own experiences [ 25 ]. These discussions can take place in-person or online, and can be designed to accommodate diverse audiences and settings [ 26 ].

In this study, PD is considered a speaking activity where medical students are assigned specific roles to play during the simulation, such as a physician, quality improvement specialist, policymaker, or patient advocate. By taking on these roles, students can gain a better understanding of the diverse perspectives and considerations that come into play in real-world healthcare discussions [ 23 ]. Simulating PDs within ESP courses can be a powerful tool for enhancing medical students’ learning outcomes in multiple areas. This approach improves language proficiency, academic skills, and critical thinking abilities, while also enabling students to communicate effectively with diverse stakeholders in the medical field [ 27 , 28 ].

Theoretical framework

The panel discussions in our study are grounded in the concept of authentic assessment (outlined by Villarroel, Bloxham [ 29 ]), which involves designing tasks that mirror real-life situations and problems. In the context of medical education, this approach is particularly relevant as it prepares students for the complex, multidisciplinary nature of healthcare communication. Realism can be achieved through two means: providing a realistic context that describes and delivers a frame for the problem to be solved and creating tasks that are similar to those faced in real and/or professional life [ 30 ]. In our study, the PDs provide a realistic context by simulating scenarios where medical students are required to discuss and present complex medical topics in a professional setting, mirroring the types of interactions they will encounter in their future careers.

The task of participating in PDs also involves cognitive challenge, as students are required to think critically about complex medical topics, analyze information, and communicate their findings effectively. This type of task aims to generate processes of problem-solving, application of knowledge, and decision-making that correspond to the development of cognitive and metacognitive skills [ 23 ]. For medical students, these skills are crucial in developing clinical reasoning and effective patient communication. The PDs encourage students to go beyond the textual reproduction of fragmented and low-order content and move towards understanding, establishing relationships between new ideas and previous knowledge, linking theoretical concepts with everyday experience, deriving conclusions from the analysis of data, and examining both the logic of the arguments present in the theory and its practical scope [ 24 , 25 , 27 ].

Furthermore, the evaluative judgment aspect of our study is critical in helping students develop criteria and standards about what a good performance means in medical communication. This involves students judging their own performance and regulating their own learning [ 31 ]. In the context of panel discussions, students reflect on their own work, compare it with desired standards, and seek feedback from peers and instructors. By doing so, students can develop a sense of what constitutes good performance in medical communication and what areas need improvement [ 32 ]. Boud, Lawson and Thompson [ 33 ] argue that students need to build a precise judgment about the quality of their work and calibrate these judgments in the light of evidence. This skill is particularly important for future medical professionals who will need to continually assess and improve their communication skills throughout their careers.

The theoretical framework presented above highlights the importance of authentic learning experiences in medical education. By drawing on the benefits of group work and panel discussions, university instructor-researchers aimed to provide medical students with a unique opportunity to engage with complex cases and develop their communication and collaboration skills. As noted by Suryanarayana [ 34 ], authentic learning experiences can lead to deeper learning and improved retention. Considering the advantages of group work in promoting collaborative problem-solving and language development, the instructor-researchers designed a panel discussion task that simulates real-world scenarios, where students can work together to analyze complex cases, share knowledge, and present their findings to a simulated audience.

While previous studies have highlighted the benefits of interactive learning experiences and critical thinking skills in medical education, a research gap remains in understanding how medical students perceive the relevance of PDs in ESP courses. This study aims to address this gap by investigating medical students’ perceptions of PD tasks in ESP courses and how these perceptions relate to their language proficiency, critical thinking skills, and ability to communicate effectively with diverse stakeholders in the medical field. This understanding can inform best practices in medical education, contributing to the development of more effective communication skills for future healthcare professionals worldwide [ 23 ]. The research questions guiding this study are:

What are the perceived advantages of PDs from the perspectives of panelists and the audience?

What are the perceived disadvantages of PDs from the perspectives of panelists and the audience?

How can PDs be improved for panelists and the audience based on the insights of ESP instructors?

Methodology

Aim and design.

For this study, a two-phase qualitative design was employed to gain an understanding of the advantages and disadvantages of PDs from the perspectives of both student panelists and the audience (Phase 1) and to acquire an in-depth understanding of the suggested strategies provided by experts to enhance PPs for future students (Phase 2).

Participants and context of the study

This study was conducted in two phases (Fig. 1 ) at Shiraz University of Medical Sciences (SUMS), Shiraz, Iran.

Participants of the study in two phases

In the first phase, the student participants were 46 non-native speakers of English and international students who studied medicine at SUMS. Their demographic characteristics can be seen in Table 1 .

These students were purposefully selected because they were the only SUMS international students who had taken the ESP (English for Specific Purposes) course. The number of international students attending SUMS is indeed limited. Each year, a different batch of international students joins the university. They progress through a sequence of English courses, starting with General English 1 and 2, followed by the ESP course, and concluding with academic writing. At the time of data collection, the students included in the study were the only international students enrolled in the ESP course. This mandatory 3-unit course is designed to enhance their language and communication skills specifically tailored to their profession. As a part of the Medicine major curriculum, this course aims to improve their English language proficiency in areas relevant to medicine, such as understanding medical terminology, comprehending original medicine texts, discussing clinical cases, and communicating with patients, colleagues, and other healthcare professionals.

Throughout the course, students engage in various interactive activities, such as group discussions, role-playing exercises, and case studies, to develop their practical communication skills. In this course, medical students receive four marks out of 20 for their oral presentations, while the remaining marks are allocated to their written midterm and final exams. From the beginning of the course, they are briefed about PDs, and they are shown two YouTube-downloaded videos about PDs at medical conferences, a popular format for discussing and sharing knowledge, research findings, and expert opinions on various medical topics.

For the second phase of the study, a specific group of participants was purposefully selected. This group consisted of three faculty members from SUMS English department who had extensive experience attending numerous conferences at national and international levels, particularly in the medical field, as well as working as translators and interpreters in medical congresses. Over the course of ten years, they also gained considerable experience in PDs. They were invited to discuss strategies helpful for medical students with PDs.

Panel discussion activity design and implementation

When preparing for a PD session, medical students received comprehensive guidance on understanding the roles and responsibilities of each panel member. This guidance was aimed at ensuring that each participant was well-prepared and understood their specific role in the discussion.

Moderators should play a crucial role in steering the conversation. They are responsible for ensuring that all panelists have an opportunity to contribute and that the audience is engaged effectively. Specific tasks include preparing opening remarks, introducing panelists, and crafting transition questions to facilitate smooth topic transitions. The moderators should also manage the time to ensure balanced participation and encourage active audience involvement.

Panelists are expected to be subject matter experts who bring valuable insights and opinions to the discussion. They are advised to conduct thorough research on the topic and prepare concise talking points. Panelists are encouraged to draw from their medical knowledge and relevant experiences, share evidence-based information, and engage with other panelists’ points through active listening and thoughtful responses.

The audience plays an active role in the PDs. They are encouraged to participate by asking questions, sharing relevant experiences, and contributing to the dialogue. To facilitate this, students are advised to take notes during the discussion and think of questions or comments they can contribute during the Q&A segment.

For this special course, medical students were advised to choose topics either from their ESP textbook or consider current medical trends, emerging research, and pressing issues in their field. Examples included breast cancer, COVID-19, and controversies in gene therapy. The selection process involved brainstorming sessions and consultation with the course instructor to ensure relevance and appropriateness.

To accommodate the PD sessions within the course structure, students were allowed to start their PD sessions voluntarily from the second week. However, to maintain a balance between peer-led discussions and regular course content, only one PD was held weekly. This approach enabled the ESP lecturer to deliver comprehensive content while also allowing students to engage in these interactive sessions.

A basic time structure was suggested for each PD (Fig. 2 ):

Time allocation for panel discussion stages in minutes

To ensure the smooth running of the course and maintain momentum, students were informed that they could cancel their PD session only once. In such cases, they were required to notify the lecturer and other students via the class Telegram channel to facilitate rescheduling and minimize disruptions. This provision was essential in promoting a sense of community among students and maintaining the course’s continuity.

Research tools and data collection

The study utilized various tools to gather and analyze data from participants and experts, ensuring a comprehensive understanding of the research topic.

Reflection papers

In Phase 1 of the study, 46 medical students detailed their perceptions of the advantages and disadvantages of panel discussions from dual perspectives: as panelists (presenters) and as audience members (peers).

Participants were given clear instructions and a 45-minute time frame to complete the reflection task. With approximately 80% of the international language students being native English speakers and the rest fluent in English, the researchers deemed this time allocation reasonable. The questions and instructions were straightforward, facilitating quick comprehension. It was estimated that native English speakers would need about 30 min to complete the task, while non-native speakers might require an extra 15 min for clarity and expression. This time frame aimed to allow students to respond thoughtfully without feeling rushed. Additionally, students could request more time if needed.

Focus group discussion

In phase 2 of the study, a focus group discussion was conducted with three expert participants. The purpose of the focus group was to gather insights from expert participants, specifically ESP (English for Specific Purposes) instructors, on how presentation dynamics can be improved for both panelists and the audience.

According to Colton and Covert [ 35 ], focus groups are useful for obtaining detailed input from experts. The appropriate size of a focus group is determined by the study’s scope and available resources [ 36 ]. Morgan [ 37 ] suggests that small focus groups are suitable for complex topics where specialist participants might feel frustrated if not allowed to express themselves fully.

The choice of a focus group over individual interviews was based on several factors. First, the exploratory nature of the study made focus groups ideal for interactive discussions, generating new ideas and in-depth insights [ 36 ]. Second, while focus groups usually involve larger groups, they can effectively accommodate a limited number of experts with extensive knowledge [ 37 ]. Third, the focus group format fostered a more open environment for idea exchange, allowing participants to engage dynamically [ 36 ]. Lastly, conducting a focus group was more time- and resource-efficient than scheduling three separate interviews [ 36 ].

Data analysis

The first phase of the study involved a thorough examination of the data related to the research inquiries using thematic analysis. This method was chosen for its effectiveness in uncovering latent patterns from a bottom-up perspective, facilitating a comprehensive understanding of complex educational phenomena [ 38 ]. The researchers first familiarized themselves with the data by repeatedly reviewing the reflection papers written by the medical students. Next, an initial round of coding was independently conducted to identify significant data segments and generate preliminary codes that reflected the students’ perceptions of the advantages and disadvantages of presentation dynamics PDs from both the presenter and audience viewpoints [ 38 ].

The analysis of the reflection papers began with the two researchers coding a subset of five papers independently, adhering to a structured qualitative coding protocol [ 39 ]. They convened afterward to compare their initial codes and address any discrepancies. Through discussion, they reached an agreement on the codes, which were then analyzed, organized into categories and themes, and the frequency of each code was recorded [ 38 ].

After coding the initial five papers, the researchers continued to code the remaining 41 reflection paper transcripts in batches of ten, meeting after each batch to review their coding, resolve any inconsistencies, and refine the coding framework as needed. This iterative process, characterized by independent coding, joint reviews, and consensus-building, helped the researchers establish a robust and reliable coding approach consistently applied to the complete dataset [ 40 ]. Once all 46 reflection paper transcripts were coded, the researchers conducted a final review and discussion to ensure accurate analysis. They extracted relevant excerpts corresponding to the identified themes and sub-themes from the transcripts to provide detailed explanations and support for their findings [ 38 ]. This multi-step approach of separate initial coding, collaborative review, and frequency analysis enhanced the credibility and transparency of the qualitative data analysis.

To ensure the trustworthiness of the data collected in this study, the researchers adhered to the Guba and Lincoln standards of scientific accuracy in qualitative research, which encompass credibility, confirmability, dependability, and transferability [ 41 ] (Table 2 ).

The analysis of the focus group data obtained from experts followed the same rigorous procedure applied to the student participants’ data. Thematic analysis was employed to examine the experts’ perspectives, maintaining consistency in the analytical approach across both phases of the study. The researchers familiarized themselves with the focus group transcript, conducted independent preliminary coding, and then collaboratively refined the codes. These codes were subsequently organized into categories and themes, with the frequency of each code recorded. The researchers engaged in thorough discussions to ensure agreement on the final themes and sub-themes. Relevant excerpts from the focus group transcript were extracted to provide rich, detailed explanations of each theme, thereby ensuring a comprehensive and accurate analysis of the experts’ insights.

1. What are the advantages of PDs from the perspective of panelists and the audience?

The analysis of the advantages of PDs from the perspectives of both panelists and audience members revealed several key themes and categories. Tables 2 and 3 present the frequency and percentage of responses for each code within these categories.

From the panelists’ perspective (Table 3 ), the overarching theme was “Personal and Professional Development.” The most frequently reported advantage was knowledge sharing (93.5%), followed closely by increased confidence (91.3%) and the importance of interaction in presentations (91.3%).

Notably, all categories within this theme had at least one code mentioned by over 80% of participants, indicating a broad range of perceived benefits. The category of “Effective teamwork and communication” was particularly prominent, with collaboration (89.1%) and knowledge sharing (93.5%) being among the most frequently cited advantages. This suggests that PDs are perceived as valuable tools for fostering interpersonal skills and collective learning. In the “Language mastery” category, increased confidence (91.3%) and better retention of key concepts (87.0%) were highlighted, indicating that PDs are seen as effective for both language and content learning.

The audience perspective (Table 4 ), encapsulated under the theme “Enriching Learning Experience,” showed similarly high frequencies across all categories.

The most frequently mentioned advantage was exposure to diverse speakers (93.5%), closely followed by the range of topics covered (91.3%) and increased audience interest (91.3%). The “Broadening perspectives” category was particularly rich, with all codes mentioned by over 70% of participants. This suggests that audience members perceive PDs as valuable opportunities for expanding their knowledge and viewpoints. In the “Language practice” category, the opportunity to practice language skills (89.1%) was the most frequently cited advantage, indicating that even as audience members, students perceive significant language learning benefits.

Comparing the two perspectives reveals several interesting patterns:

High overall engagement: Both panelists and audience members reported high frequencies across all categories, suggesting that PDs are perceived as beneficial regardless of the role played.

Language benefits: While panelists emphasized increased confidence (91.3%) and better retention of concepts (87.0%), audience members highlighted opportunities for language practice (89.1%). This indicates that PDs offer complementary language learning benefits for both roles.

Interactive learning: The importance of interaction was highly rated by panelists (91.3%), while increased audience interest was similarly valued by the audience (91.3%). This suggests that PDs are perceived as an engaging, interactive learning method from both perspectives.

Professional development: Panelists uniquely emphasized professional growth aspects such as experiential learning (84.8%) and real-world application (80.4%). These were not directly mirrored in the audience perspective, suggesting that active participation in PDs may offer additional professional development benefits.

Broadening horizons: Both groups highly valued the diversity aspect of PDs. Panelists appreciated diversity and open-mindedness (80.4%), while audience members valued diverse speakers (93.5%) and a range of topics (91.3%).

2. What are the disadvantages of PDs from the perspective of panelists and the audience?

The analysis of the disadvantages of panel discussions (PDs) from the perspectives of both panelists and audience members revealed several key themes and categories. Tables 4 and 5 present the frequency and percentage of responses for each code within these categories.

From the panelists’ perspective (Table 5 ), the theme “Drawbacks of PDs” was divided into two main categories: “Academic Workload Challenges” and “Coordination Challenges.” The most frequently reported disadvantage was long preparation (87.0%), followed by significant practice needed (82.6%) and the time-consuming nature of PDs (80.4%). These findings suggest that the primary concern for panelists is the additional workload that PDs impose on their already demanding academic schedules. The “Coordination Challenges” category, while less prominent than workload issues, still presented significant concerns. Diverse panel skills (78.3%) and finding suitable panelists (73.9%) were the most frequently cited issues in this category, indicating that team dynamics and composition are notable challenges for panelists.

The audience perspective (Table 6 ), encapsulated under the theme “Drawbacks of PDs,” was divided into two main categories: “Time-related Issues” and “Interaction and Engagement Issues.” In the “Time-related Issues” category, the most frequently mentioned disadvantage was the inefficient use of time (65.2%), followed by the perception of PDs as too long and boring (60.9%). Notably, 56.5% of respondents found PDs stressful due to overwhelming workload from other studies, and 52.2% considered them not very useful during exam time. The “Interaction and Engagement Issues” category revealed more diverse concerns. The most frequently mentioned disadvantage was the repetitive format (82.6%), followed by limited engagement with the audience (78.3%) and the perception of PDs as boring (73.9%). The audience also noted issues related to the panelists’ preparation and coordination, such as “Not practiced and natural” (67.4%) and “Coordination and Interaction Issues” (71.7%), suggesting that the challenges faced by panelists directly impact the audience’s experience.

Workload concerns: Both panelists and audience members highlighted time-related issues. For panelists, this manifested as long preparation times (87.0%) and difficulty balancing with other studies (76.1%). For the audience, it appeared as perceptions of inefficient use of time (65.2%) and stress due to overwhelming workload from other studies (56.5%).

Engagement issues: While panelists focused on preparation and coordination challenges, the audience emphasized the quality of the discussion and engagement. This suggests a potential mismatch between the efforts of panelists and the expectations of the audience.

Boredom and repetition: The audience frequently mentioned boredom (73.9%) and repetitive format (82.6%) as issues, which weren’t directly mirrored in the panelists’ responses. This indicates that while panelists may be focused on content preparation, the audience is more concerned with the delivery and variety of the presentation format.

Coordination challenges: Both groups noted coordination issues, but from different perspectives. Panelists struggled with team dynamics and finding suitable co-presenters, while the audience observed these challenges manifesting as unnatural or unpracticed presentations.

Academic pressure: Both groups acknowledged the strain PDs put on their academic lives, with panelists viewing it as a burden (65.2%) and the audience finding it less useful during exam times (52.2%).

3. How can PDs be improved for panelists and the audience from the experts’ point of view?

The presentation of data for this research question differs from the previous two due to the unique nature of the information gathered. Unlike the quantifiable student responses in earlier questions, this data stems from expert opinions and a reflection discussion session, focusing on qualitative recommendations for improvement rather than frequency of responses (Braun & Clarke, 2006). The complexity and interconnectedness of expert suggestions, coupled with the integration of supporting literature, necessitate a more narrative approach (Creswell & Poth, 2018). This format allows for a richer exploration of the context behind each recommendation and its potential implications (Patton, 2015). Furthermore, the exploratory nature of this question, aimed at generating ideas for improvement rather than measuring prevalence of opinions, is better served by a detailed, descriptive presentation (Merriam & Tisdell, 2016). This approach enables a more nuanced understanding of how PDs can be enhanced, aligning closely with the “how” nature of the research question and providing valuable insights for potential implementation (Yin, 2018).

The experts provided several suggestions to address the challenges faced by students in panel discussions (PDs) and improve the experience for both panelists and the audience. Their recommendations focused on six key areas: time management and workload, preparation and skill development, engagement and interactivity, technological integration, collaboration and communication, and institutional support.

To address the issue of time management and heavy workload, one expert suggested teaching students to “ break down the task to tackle the time-consuming nature of panel discussions and balance it with other studies .” This approach aims to help students manage the extensive preparation time required for PDs without compromising their other academic responsibilities. Another expert emphasized “ enhancing medical students’ abilities to prioritize tasks , allocate resources efficiently , and optimize their workflow to achieve their goals effectively .” These skills were seen as crucial not only for PD preparation but also for overall academic success and future professional practice.

Recognizing the challenges of long preparation times and the perception of PDs being burdensome, an expert proposed “ the implementation of interactive training sessions for panelists .” These sessions were suggested to enhance coordination skills and improve the ability of group presenters to engage with the audience effectively. The expert emphasized that such training could help students view PDs as valuable learning experiences rather than additional burdens, potentially increasing their motivation and engagement in the process.

To combat issues of limited engagement and perceived boredom, experts recommended increasing engagement opportunities for the audience through interactive elements like audience participation and group discussions. They suggested that this could transform PDs from passive listening experiences to active learning opportunities. One expert suggested “ optimizing time management and restructuring the format of panel discussions ” to address inefficiency during sessions. This restructuring could involve shorter presentation segments interspersed with interactive elements to maintain audience attention and engagement.

An innovative solution proposed by one expert was “ using ChatGPT to prepare for PDs by streamlining scenario presentation preparation and role allocation. ” The experts collectively discussed the potential of AI to assist medical students in reducing their workload and saving time in preparing scenario presentations and allocating roles in panel discussions. They noted that AI could help generate initial content drafts, suggest role distributions based on individual strengths, and even provide practice questions for panelists, significantly reducing preparation time while maintaining quality.

Two experts emphasized the importance of enhancing collaboration and communication among panelists to address issues related to diverse panel skills and coordination challenges. They suggested establishing clear communication channels and guidelines to improve coordination and ensure a cohesive presentation. This could involve creating structured team roles, setting clear expectations for each panelist, and implementing regular check-ins during the preparation process to ensure all team members are aligned and progressing.

All experts were in agreement that improving PDs would not be possible “ if nothing is done by the university administration to reduce the ESP class size for international students .” They believed that large class sizes in ESP or EFL classes could negatively influence group oral presentations, hindering language development and leading to uneven participation. The experts suggested that smaller class sizes would allow for more individualized attention, increased speaking opportunities for each student, and more effective feedback mechanisms, all of which are crucial for developing strong presentation skills in a second language.

Research question 1: what are the advantages of PDs from the perspective of panelists and the audience?

The results of this study reveal significant advantages of PDs for both panelists and audience members in the context of medical education. These findings align with and expand upon previous research in the field of educational presentations and language learning.

Personal and professional development for panelists

The high frequency of reported benefits in the “Personal and Professional Development” theme for panelists aligns with several previous studies. The emphasis on language mastery, particularly increased confidence (91.3%) and better retention of key concepts (87.0%), supports the findings of Hartono, Mujiyanto [ 42 ], Gedamu and Gezahegn [ 15 ], Li [ 43 ], who all highlighted the importance of language practice in English oral presentations. However, our results show a more comprehensive range of benefits, including professional growth aspects like experiential learning (84.8%) and real-world application (80.4%), which were not as prominently featured in these earlier studies.

Interestingly, our findings partially contrast with Chou [ 44 ] study, which found that while group oral presentations had the greatest influence on improving students’ speaking ability, individual presentations led to more frequent use of metacognitive, retrieval, and rehearsal strategies. Our results suggest that PDs, despite being group activities, still provide significant benefits in these areas, possibly due to the collaborative nature of preparation and the individual responsibility each panelist bears. The high frequency of knowledge sharing (93.5%) and collaboration (89.1%) in our study supports Harris, Jones and Huffman [ 45 ] emphasis on the importance of group dynamics and varied perspectives in educational settings. However, our study provides more quantitative evidence for these benefits in the specific context of PDs.

Enriching learning experience for the audience

The audience perspective in our study reveals a rich learning experience, with high frequencies across all categories. This aligns with Agustina [ 46 ] findings in business English classes, where presentations led to improvements in all four language skills. However, our study extends these findings by demonstrating that even passive participation as an audience member can lead to significant perceived benefits in language practice (89.1%) and broadening perspectives (93.5% for diverse speakers). The high value placed on diverse speakers (93.5%) and range of topics (91.3%) by the audience supports the notion of PDs as a tool for expanding knowledge and viewpoints. This aligns with the concept of situated learning experiences leading to deeper understanding in EFL classes, as suggested by Li [ 43 ] and others [ 18 , 31 ]. However, our study provides more specific evidence for how this occurs in the context of PDs.

Interactive learning and engagement

Both panelists and audience members in our study highly valued the interactive aspects of PDs, with the importance of interaction rated at 91.3% by panelists and increased audience interest at 91.3% by the audience. This strong emphasis on interactivity aligns with Azizi and Farid Khafaga [ 19 ] study on the benefits of dynamic assessment and dialogic learning contexts. However, our study provides more detailed insights into how this interactivity is perceived and valued by both presenters and audience members in PDs.

Professional growth and real-world application

The emphasis on professional growth through PDs, particularly for panelists, supports Li’s [ 43 ] assertion about the power of oral presentations as situated learning experiences. Our findings provide more specific evidence for how PDs contribute to professional development, with high frequencies reported for experiential learning (84.8%) and real-world application (80.4%). This suggests that PDs may be particularly effective in bridging the gap between academic learning and professional practice in medical education.

Research question 2: what are the disadvantages of pds from the perspective of panelists and the audience?

Academic workload challenges for panelists.

The high frequency of reported challenges in the “Academic Workload Challenges” category for panelists aligns with several previous studies in medical education [ 47 , 48 , 49 ]. The emphasis on long preparation (87.0%), significant practice needed (82.6%), and the time-consuming nature of PDs (80.4%) supports the findings of Johnson et al. [ 24 ], who noted that while learners appreciate debate-style journal clubs in health professional education, they require additional time commitment. This is further corroborated by Nowak, Speed and Vuk [ 50 ], who found that intensive learning activities in medical education, while beneficial, can be time-consuming for students.

Perceived value of pds relative to time investment

While a significant portion of the audience (65.2%) perceived PDs as an inefficient use of time, the high frequency of engagement-related concerns (82.6% for repetitive format, 78.3% for limited engagement) suggests that the perceived lack of value may be more closely tied to the quality of the experience rather than just the time investment. This aligns with Dyhrberg O’Neill [ 27 ] findings on debate-based oral exams, where students perceived value despite the time-intensive nature of the activity. However, our results indicate a more pronounced concern about the return on time investment in PDs. This discrepancy might be addressed through innovative approaches to PD design and implementation, such as those proposed by Almazyad et al. [ 22 ], who suggested using AI tools to enhance expert panel discussions and potentially improve efficiency.

Coordination challenges for panelists

The challenges related to coordination in medical education, such as diverse panel skills (78.3%) and finding suitable panelists (73.9%), align with previous research on teamwork in higher education [ 21 ]. Our findings support the concept of the free-rider effect discussed by Hall and Buzwell [ 21 ], who explored reasons for non-contribution in group projects beyond social loafing. This is further elaborated by Mehmood, Memon and Ali [ 51 ], who proposed that individuals may not contribute their fair share due to various factors including poor communication skills or language barriers, which is particularly relevant in medical education where clear communication is crucial [ 52 ]. Comparing our results to other collaborative learning contexts in medical education, Rodríguez-Sedano, Conde and Fernández-Llamas [ 53 ] measured teamwork competence development in a multidisciplinary project-based learning environment. They found that while teamwork skills improved over time, initial coordination challenges were significant. This aligns with our findings on the difficulties of coordinating diverse panel skills and opinions in medical education settings.

Our results also resonate with Chou’s [ 44 ] study comparing group and individual oral presentations, which found that group presenters often had a limited understanding of the overall content. This is supported by Wilson, Ho and Brookes [ 54 ], who examined student perceptions of teamwork in undergraduate science degrees, highlighting the challenges and benefits of collaborative work, which are equally applicable in medical education [ 52 ].

Quality of discussions and perception for the audience

The audience perspective in our study reveals significant concerns about the quality and engagement of PDs in medical education. The high frequency of issues such as repetitive format (82.6%) and limited engagement with the audience (78.3%) aligns with Parmar and Bickmore [ 55 ] findings on the importance of addressing individual audience members and gathering feedback. This is further supported by Nurakhir et al. [ 25 ], who explored students’ views on classroom debates as a strategy to enhance critical thinking and oral communication skills in nursing education, which shares similarities with medical education. Comparing our results to other interactive learning methods in medical education, Jones et al. [ 26 ] reviewed the use of journal clubs and book clubs in pharmacy education. They found that while these methods enhanced engagement, they also faced challenges in maintaining student interest over time, similar to the boredom issues reported in our study of PDs in medical education. The perception of PDs as boring (73.9%) and not very useful during exam time (52.2%) supports previous research on the stress and pressure experienced by medical students [ 48 , 49 ]. Grieve et al. [ 20 ] specifically examined student fears of oral presentations and public speaking in higher education, which provides context for the anxiety and disengagement observed in our study of medical education. Interestingly, Bhuvaneshwari et al. [ 23 ] found positive impacts of panel discussions in educating medical students on specific modules. This contrasts with our findings and suggests that the effectiveness of PDs in medical education may vary depending on the specific context and implementation.

Comparative analysis and future directions

Our study provides a unique comparative analysis of the challenges faced by both panelists and audience members in medical education. The alignment of concerns around workload and time management between the two groups suggests that these are overarching issues in the implementation of PDs in medical curricula. This is consistent with the findings of Pasandín et al. [ 56 ], who examined cooperative oral presentations in higher education and their impact on both technical and soft skills, which are crucial in medical education [ 52 ]. The mismatch between panelist efforts and audience expectations revealed in our study is a novel finding that warrants further investigation in medical education. This disparity could be related to the self-efficacy beliefs of presenters, as explored by Gedamu and Gezahegn [ 15 ] in their study of TEFL trainees’ attitudes towards academic oral presentations, which may have parallels in medical education. Looking forward, innovative approaches could address some of the challenges identified in medical education. Almazyad et al. [ 22 ] proposed using AI tools like ChatGPT to enhance expert panel discussions in pediatric palliative care, which could potentially address some of the preparation and engagement issues identified in our study of medical education. Additionally, Ragupathi and Lee [ 57 ] discussed the role of rubrics in higher education, which could provide clearer expectations and feedback for both panelists and audience members in PDs within medical education.

Research question 3: how can PDs be improved for panelists and the audience from the experts’ point of view?

The expert suggestions for improving PDs address several key challenges identified in previous research on academic presentations and student workload management. These recommendations align with current trends in educational technology and pedagogical approaches, while also considering the unique needs of medical students.

The emphasis on time management and workload reduction strategies echoes findings from previous studies on medical student stress and academic performance. Nowak, Speed and Vuk [ 50 ] found that medical students often struggle with the fast-paced nature of their courses, which can lead to reduced motivation and superficial learning approaches. The experts’ suggestions for task breakdown and prioritization align with Rabbi and Islam [ 58 ] recommendations for reducing workload stress through effective assignment prioritization. Additionally, Popa et al. [ 59 ] highlight the importance of acceptance and planning in stress management for medical students, supporting the experts’ focus on these areas.

The proposed implementation of interactive training sessions for panelists addresses the need for enhanced presentation skills in professional contexts, a concern highlighted by several researchers [ 17 , 60 ]. This aligns with Grieve et al. [ 20 ] findings on student fears of oral presentations and public speaking in higher education, emphasizing the need for targeted training. The focus on interactive elements and audience engagement also reflects current trends in active learning pedagogies, as demonstrated by Pasandín et al. [ 56 ] in their study on cooperative oral presentations in engineering education.

The innovative suggestion to use AI tools like ChatGPT for PD preparation represents a novel approach to leveraging technology in education. This aligns with recent research on the potential of AI in scientific research, such as the study by Almazyad et al. [ 22 ], which highlighted the benefits of AI in supporting various educational tasks. However, it is important to consider potential ethical implications and ensure that AI use complements rather than replaces critical thinking and creativity.

The experts’ emphasis on enhancing collaboration and communication among panelists addresses issues identified in previous research on teamwork in higher education. Rodríguez-Sedano, Conde and Fernández-Llamas [ 53 ] noted the importance of measuring teamwork competence development in project-based learning environments. The suggested strategies for improving coordination align with best practices in collaborative learning, as demonstrated by Romero-Yesa et al. [ 61 ] in their qualitative assessment of challenge-based learning and teamwork in electronics programs.

The unanimous agreement on the need to reduce ESP class sizes for international students reflects ongoing concerns about the impact of large classes on language learning and student engagement. This aligns with research by Li [ 3 ] on issues in developing EFL learners’ oral English communication skills. Bosco et al. [ 62 ] further highlight the challenges of teaching and learning ESP in mixed classes, supporting the experts’ recommendation for smaller class sizes. Qiao, Xu and bin Ahmad [ 63 ] also emphasize the implementation challenges for ESP formative assessment in large classes, further justifying the need for reduced class sizes.

These expert recommendations provide a comprehensive approach to improving PDs, addressing not only the immediate challenges of preparation and delivery but also broader issues of student engagement, workload management, and institutional support. By implementing these suggestions, universities could potentially transform PDs from perceived burdens into valuable learning experiences that enhance both academic and professional skills. This aligns with Kho and Ting [ 64 ] systematic review on overcoming oral presentation anxiety among tertiary ESL/EFL students, which emphasizes the importance of addressing both challenges and strategies in improving presentation skills.

This study has shed light on the complex challenges associated with PDs in medical education, revealing a nuanced interplay between the experiences of panelists and audience members. The findings underscore the need for a holistic approach to implementing PDs that addresses both the academic workload concerns and the quality of engagement.

Our findings both support and extend previous research on the challenges of oral presentations and group work in medical education settings. The high frequencies of perceived challenges across multiple categories for both panelists and audience members suggest that while PDs may offer benefits, they also present significant obstacles that need to be addressed in medical education. These results highlight the need for careful consideration in the implementation of PDs in medical education, with particular attention to workload management, coordination strategies, and audience engagement techniques. Future research could focus on developing and testing interventions to mitigate these challenges while preserving the potential benefits of PDs in medical education.

Moving forward, medical educators should consider innovative approaches to mitigate these challenges. This may include:

Integrating time management and stress coping strategies into the PD preparation process [ 59 ].

Exploring the use of AI tools to streamline preparation and enhance engagement [ 22 ].

Developing clear rubrics and expectations for both panelists and audience members [ 57 ].

Incorporating interactive elements to maintain audience interest and participation [ 25 ].

Limitations and future research

One limitation of this study is that it focused on a specific population of medical students, which may limit the generalizability of the findings to other student populations. Additionally, the study relied on self-report data from panelists and audience members, which may introduce bias and affect the validity of the results. Future research could explore the effectiveness of PDs in different educational contexts and student populations to provide a more comprehensive understanding of the benefits and challenges of panel discussions.

Future research should focus on evaluating the effectiveness of these interventions and exploring how PDs can be tailored to the unique demands of medical education. By addressing the identified challenges, PDs have the potential to become a more valuable and engaging component of medical curricula, fostering both academic and professional development. Ultimately, the goal should be to transform PDs from perceived burdens into opportunities for meaningful learning and skill development, aligning with the evolving needs of medical education in the 21st century.

Future research could also examine the long-term impact of PDs on panelists’ language skills, teamwork, and communication abilities. Additionally, exploring the effectiveness of different training methods and tools, such as AI technology, in improving coordination skills and reducing workload stress for panelists could provide valuable insights for educators and administrators. Further research could also investigate the role of class size and audience engagement in enhancing the overall effectiveness of PDs in higher education settings. By addressing these gaps in the literature, future research can contribute to the ongoing development and improvement of PDs as a valuable learning tool for students in higher education.

However, it is important to note that implementing these changes may require significant institutional resources and a shift in pedagogical approaches. Future research could focus on piloting these recommendations and evaluating their effectiveness in improving student outcomes and experiences with PDs.

Data availability

We confirm that the data supporting the findings are available within this article. Raw data supporting this study’s findings are available from the corresponding author, upon request.

Abbreviations

Artificial Intelligence

English as a Foreign Language

English for Specific Purposes

Panel Discussion

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Nasiri, E., Khojasteh, L. Evaluating panel discussions in ESP classes: an exploration of international medical students’ and ESP instructors’ perspectives through qualitative research. BMC Med Educ 24 , 925 (2024). https://doi.org/10.1186/s12909-024-05911-3

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Published: 24 August 2024

Promoting gender equity in a home visits programme: a qualitative study in Northern Nigeria

Loubna Belaid 1 ,
Hadiza Mudi 2 ,
Khalid Omer 3 ,
Yagana Gidado 2 ,
Umaira Ansari 4 ,
Muhammad Rilwanu 5 ,
Neil Andersson 3 , 4 &
Anne Cockcroft 3 , 4

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Gender inequities remain critical determinants influencing maternal health. Harmful gender norms and gender-based violence adversely affect maternal health. Gendered division of labour, lack of access to and control of resources, and limited women’s decision-making autonomy impede women’s access to maternal healthcare services. We undertook a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in one local government area in Bauchi State, North-Eastern Nigeria. The trial demonstrated a significant improvement in maternal and child health outcomes and male knowledge, attitudes and behaviours. This paper qualitatively evaluates gender equity in the home visits programme.

The research team explored participants’ views about gender equity in the home visits programme. We conducted nine key informant interviews with policymakers and 14 gender and age-stratified focus group discussions with men and women from visited households, with women and men home visitors and supervisors, and with men and women community leaders. Analysis used an adapted conceptual framework exploring gender equity in mainstream health. A deductive thematic analysis of interviews and focus group reports looked for patterns and meanings.

All respondents considered the home visits programme to have a positive impact on gender equity, as they perceived gender equity. Visited women and men and home visitors reported increased male support for household chores, with men doing heavy work traditionally pre-assigned to women. Men increased their support for women’s maternal health by paying for healthcare and providing nutritious food. Households and community members confirmed that women no longer needed their spouses’ permission to use health services for their own healthcare. Households and home visitors reported an improvement in spousal communication. They perceived a significant reduction in domestic violence, which they attributed to the changing attitudes of both women and men due to the home visits. All stakeholder groups stressed the importance of engaging male spouses in the home visits programme.

The home visits programme, as implemented, contributed to gender equity.

Peer Review reports

Introduction

Maternal mortality remains a global health problem. Every day in 2020, almost 800 women died from preventable causes related to pregnancy and childbirth [ 1 ]. Nearly 95% of maternal deaths occur in economically limited resource settings [ 1 ]. Sub-Saharan Africa alone accounted for around 70% of maternal deaths [ 1 ].

Gender inequities are critical determinants influencing maternal health [ 2 , 3 , 4 , 5 ]. A 2021 study based on secondary analysis of country-level data from 54 African countries reported that gender inequities and the availability of skilled birth attendants were the most critical social determinants explaining variations in maternal mortality across Africa [ 6 ]. Harmful gender norms such as early marriage and pregnancy, genital mutilation, and gender-based violence adversely affect maternal health [ 7 , 8 ]. Gendered division of labour, lack of access and control of resources, limited women’s autonomy, and exclusion from decision-making impede women’s access to maternal healthcare services [ 2 , 9 ].

Since the 1990s, researchers have implemented interventions involving male partners to improve maternal and child health outcomes [ 10 ]. Systematic reviews reported positive impacts of these interventions in limited-economic resource settings [ 11 , 12 , 13 ]. Male involvement in these interventions was mainly focused on specific barriers, such as decision-making to use health services and male attendance at antenatal care visits [ 12 , 13 ]. Other interventions emphasized men’s role as gatekeepers for women’s health or engaged them as one target group under a broader strategy to increase community involvement in maternal and child health [ 11 ]. While these interventions improved some health-seeking behaviours and increased maternal and child health services uptake, they failed to address household inequitable gender norms and dynamics [ 14 ].

Male engagement interventions shifted from tackling specific barriers to being gender-transformative [ 10 ]. “Gender transformative interventions actively examine and promote the transformation of harmful gender norms and seek to reduce inequalities between men and women to achieve desired outcomes” (p125) [ 3 ].

There is evidence of the effectiveness of gender-transformative interventions in improving reproductive health outcomes and reducing gender violence [ 3 , 10 , 15 ]. However, qualitative evidence of the perceived impact of these interventions and details of the type of activities being implemented remain limited, particularly in African settings [ 3 , 4 , 16 ]. This paper describes the methods and findings of a qualitative evaluation of gender equity in a home visits programme aiming to improve maternal and early child health.

Bauchi State in North-Eastern Nigeria has a population of around five million, extrapolating from the 2006 census. The population is predominately Muslim with Hausa ethnicity. Some 63% of women in Bauchi have no education, compared with 35% nationally. Polygyny and large family size are common. In Bauchi, the fertility rate is 7.2 children per woman [ 17 ].

The maternal mortality ratio in Nigeria is among the highest in the World, with 1047 maternal deaths per 100,000 live births in 2020 [ 18 ]. The Maternal Mortality Ratio is even higher in the Northeastern region [ 19 ]. Women in Bauchi have poor access to maternal healthcare services. Only 20% give birth in a health facility, and only 46% of women receive antenatal care from a trained health worker [ 17 ]. Less than 20% participate independently or jointly in household decisions. Over 50% of ever-married women have experienced emotional, physical, or sexual violence committed by their current or most recent husband or partner [ 17 ].

Home visits intervention

Between 2015 and 2020, we conducted a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in eight wards (smallest administrative area) of Toro Local Government Area (LGA), Bauchi State, North-Eastern Nigeria [ 20 ].

Women home visitors visited all pregnant women every two months during their pregnancies and again after delivery, and men home visitors visited their husbands. Having women and men home visitors interact separately with the pregnant women and their male spouses followed faith-based cultural norms in Bauchi and was endorsed by religious leadership. The research team engaged with Muslim and Christian religious leaders and traditional leaders in each community, and these leaders supported the home visits programme.

The women’s home visitors visited every pregnant woman every two months during the pregnancy, and the men’s home visitors separately visited the male spouses of the pregnant women every two months. The women visitors visited every woman who gave birth within two months of the birth and again when the child was 12–18 months old.

The women and men visitors shared evidence about actionable risk factors for maternal and early child health from a recent survey in Bauchi State [ 21 ], separately from pregnant women and their spouses. The home visits significantly improved maternal and child health outcomes and male knowledge and attitudes [ 22 , 23 , 24 ]. Narratives of change helped to explore the experience of participants and possible mechanisms for the impact of the home visits [ 25 ].

The home visits programme deliberately aimed to increase men’s engagement in promoting maternal and child health. The risk factors for maternal health discussed in the home visits with pregnant women and their spouses included strongly gendered issues: women continuing heavy work during pregnancy, domestic violence, lack of spousal communication, and lack of knowledge (including among men) of danger signs during pregnancy and childbirth [ 13 ]. The men’s home visitors made specific arrangements to interact with the spouses of pregnant women; this often meant visiting in the evenings or at weekends when the men were home.

The programme recruited local women and men as home visitors, allowing them to earn an income and increase their social status. Women, in particular, reported earning an income as an important positive change in their lives from their involvement in the programme [ 26 ].

To support the sustainability of the home visits after the trial, the government agencies collaborating with the home visits programme at State, LGA and ward levels nominated women and men officers to work with the programme, including training to manage and monitor the home visits.

Focus group discussions and individual interviews

This qualitative study is based on focus group discussions and key informant interviews. The research team designed focus group discussions and individual interview guides (Appendix 1 ). The research team included female and male researchers from a Bauchi non-governmental organisation (NGO), representatives from the Bauchi State Primary Health Care Development Agency (BSPHCDA), and male and female international researchers with over ten years of experience in community-based research in Bauchi. Six people facilitated the focus groups and/or conducted key informant interviews: three men and three women. All but one were from Bauchi and affiliated with the local organisation implementing the home visits programme. Their qualifications ranged from a higher national diploma to a medical doctor. All had training and several years of experience facilitating Focus Group Discussions (FGD) and conducting KI key informant interviews. All of them were engaged in implementing the home visits programme and believed in its aims of improving maternal and child health by supporting households in taking action to reduce risk factors. They had no relationship with the participants before the study other than through their engagement in the home visits programme.

A technical working group from the research team drafted the instruments, and the project steering committee approved them. The team refined the guides using an iterative process. After each interview/focus group discussion, the team met to discuss how it went and refine questions to increase clarity if necessary. The guides covered how the visits addressed gender equity, perceptions of the programme, data monitoring about equitable coverage of the programme, capacity-building, challenges and opportunities in home visit implementation, and strengths and weaknesses of the programme. In this paper, we focus specifically on views about the gender equity aspects of the home visits programme.

Focus group discussions and individual interviews took place in August and September 2020.

The team used a purposive sampling strategy to recruit stakeholder participants [ 27 ]. The stakeholder groups were women and men from the households who received the home visits, community leaders involved in facilitating the programme in their communities, home visitors, supervisors of home visitors, and senior government officers.

The team liaised with the Toro Local Government Authority (LGA) coordinators and the ward focal persons to select stakeholders for the community focus groups. First, they selected three communities, one each from an urban, rural, and remote group of communities in the six wards. For each community, the team asked the ward focal person to invite women and their spouses who had received home visits during the project and were available and willing to spare time to participate. The focus group discussions took place in private and quiet spaces, often classrooms in primary schools.

Table 1 shows details of the focus groups and the number of participants in each group. Fourteen focus group discussions occurred in eight urban, six rural, and four rural-remote communities. They included ten gender and age-segregated groups of women (four) and men (six) from households that had received home visits, two groups of community leaders (male and female), and two groups of home visitors (male and female). The mean age was 49.3 years across the three older male groups, while the mean age across the three younger male groups was 27.7 years. The mean age was 39.7 years for the older women groups and 21.8 years for the younger women groups.

Two further focus groups covered supervisors from Toro LGA and the State level. Most of the supervisors at the LGA level were ward focal points (part-time government workers at this local level), while most of those at the State level were from the BSPHCDA.

Local facilitators (female and male) conducted the focus group discussions in the Hausa language. They are well-trained in qualitative research, have worked with the team on several projects, and understand the home visits programme well. A trained reporter took detailed notes during each meeting and sat with the facilitator after the meeting to produce a report in English. Facilitators did not audio-record the focus groups. Detailed notes by well-trained field workers are an effective approach to reporting focus group discussions [ 28 ].

The local skilled research team conducted nine interviews with senior government officers associated with the home visits programme. The interview guide covered government health priorities, the government’s role in designing and implementing the home visits programme, perceived equity in program coverage, data monitoring to support equity, capacity building, and gender equity. They telephoned to invite the officers to participate, and the interviews usually took place in their offices. The discussions were in English, and the interviewers took detailed notes and prepared a report after each interview.

One additional focus group included members of the local research team who implemented and managed the home visits programme. The discussion focused on their experience implementing the programme and their views on its perceived impact on gender equity. The first author (LB), external to the project, facilitated the discussion.

Only the researchers and the participants were present during the focus group discussions and the key informant interviews. The team encountered no participant refusals to join these discussions and interviews. We did not return the transcripts to the participants. Data saturation was achieved from the focus group discussions and key informant interviews. The interviews and focus groups ranged from one to two hours.

Analysis of focus group and interview reports and strategies for trustworthiness

The first author (a female of North African descent, external to the home visits project) and one female team member from Bauchi (HM), both experienced in qualitative research, conducted a deductive thematic analysis of the focus group and individual interview reports, following the steps proposed by Braun and Clarke [ 29 ]. They read all the texts, identified and clustered themes related to gender outcomes, and organized them into categories and subcategories to look for meanings and patterns.

In this paper, we understand gender as a multidimensional concept. It refers to “the characteristics of women, men, girls, and boys that are socially constructed. This includes norms, behaviours and roles associated with being a woman, man, girl or boy, as well as relationships with each other” [ 30 ]. We adapted a gender analysis framework [ 31 ], which captures gender dimensions and has been widely used in mainstream health [ 2 , 32 , 33 , 34 , 35 ]. We used this framework to explore how the home visits programme affected gender norms and dynamics. It included the following items: (i) division of labour, (ii) access to resources, (iii) decision-making, and (iv) values (social norms, ideologies, beliefs). In this paper, values were not analysed as an independent category but throughout the other categories. The framework positions gender as power relations negotiated about resource access, division of labour, social norms and decision-making [ 2 ] (Table 2 ). Appendix 2 describes the coding trees used to conduct the thematic analysis for each participant group (Appendix 2 : coding trees).

In addition to these dimensions from the gender analysis framework, we explored in the focus group and interview reports views about lack of spousal communication, heavy work in pregnancy and gender violence during pregnancy. These factors were identified as actionable factors associated with maternal morbidity in a survey in Bauchi conducted before the co-design and implementation of the home visits programme [ 21 ].

Several strategies increased trustworthiness [ 36 ]. We used validated methods for data collection (individual interviews, focus group discussions) and analysis (deductive thematic analysis). We triangulated findings by data sources (community members, community leaders, home visitors, supervisors, and senior government officers). We did not do a member-checking exercise with the participants; however, we discussed the findings with government officers in Bauchi.

To increase transferability, we describe the stakeholders and the study context. The researchers examined their biases, assumptions, beliefs, and suppositions that might affect their interpretation of findings to increase conformability. Some local research team members were involved in the home visit programmes. The team explained to the participants that the study’s objective is to understand their views on the home visit programmes and improve them if necessary. In reporting the study, we followed the 32-item COREQ checklist for reporting qualitative research (appendix 3).

We present the results according to the adapted conceptual framework. The results between the stakeholder groups converged.

Perceived gender equity effects of the programme

Policymakers appreciated that the programme engaged men and women and targeted husbands and wives in the home visits. They felt this created equitable maternal and child health awareness and maintained a gender-sensitive approach. By targeting husbands and wives, maternal health is no longer seen as a woman’s problem but rather a family issue in which husbands have a role to play. Previous maternal and child health programmes engaged only women leaving behind husbands. “Previously , the focus has been more on women alone , with a misunderstanding that health is a women’s issue (male , policymaker #9).

Division of labour: men’s participation in household work

Visited men and women and home visitors and supervisors believed the home visits led to more male support in household work. Groups described a cultural shift in gender division of labour. They described men doing heavy work traditionally pre-assigned to women, such as fetching and carrying water, collecting firewood, farming, and carrying harvest products. They noted that men had begun to participate in sweeping the house, washing clothes, and bathing children. “Yes , it provides changes; we even support them in sweeping , washing , and fetching water. Men do that due to the knowledge they receive from the home visitors. (FGD#10 , male youth , rural community).

In a particular community, participants raised a change in gender norms. In this community, male children used to not go to the market. With the home visits, male children go with their pregnant mothers to the market. This has changed the socialization of boys. " There is one of the settlements where male children are traditionally not sent to the market because they would be fathers of their households in the future. But with these home visits , this traditional belief has been abandoned. Male children are now supporting their pregnant mothers with heavy work and are being sent to the market” (FGD#4 , male home visitor) .

Groups reported that men were more involved in women’s healthcare. They go with their wives to the health facility for antenatal care and monitor the pregnancy’s progress. “ It helped us; some husbands are now escorting their pregnant wives to the clinic following the home visits interaction. We closely monitor the progress of the pregnancy with our wives and jointly take action (FGD#10 , male youth , rural community).

Female groups explained that women also got support from their co-wives and family during pregnancy. “Husbands and family members are really assisting women with heavy work during pregnancy” (FGD#6, female, rural/remote).

Access to resources: men increase financial support and assist women’s businesses

Groups considered men more willing to provide for their families after the visits. They paid medical bills and provided nutritious food. In Bauchi, gender norms are influenced by the Islamic faith, in which men are required to be the financial providers for their families. The home visits programme did not attempt to change this gender norm.

“The husbands , being the decision makers and financial providers , now give the women money to take care of their health needs and the health needs of their children”. (FGD#8 , young women , urban community)

Some groups pointed out that women who generate their own income sometimes pay medical bills, and their spouses reimburse them. Since the home visits, the husbands have been more willing to pay the medical bills. “Some of the women pay-out (med-bill) and later the husband pays them back when they get[money]” (FGD# 10 , young male , rural community) .

Home visit supervisors noted that the home visits led husbands to support their wives in their businesses: “The husbands have started empowering women financially by giving them money to start a business “( FGD#2 supervisors) .

Women’s participation in decision-making

Groups suggested that the home visits had increased women’s role as decision-makers for their own and their children’s health. They confirmed that, since the home visits, women do not need their spouses’ permission to use health services for themselves and their children.

They emphasized the importance of letting their spouses use health services early to prevent complications. “Husbands are now allowing pregnant women to visit the health facility for antenatal care. This was not the case before (FGD#7 , female , adult , urban community).

On the other hand, participants in some focus groups considered it important that the programme engaged men and their wives equally because men are the decision-makers in their households. They did not envisage a change in the role of women in decision-making. “Both men and women were involved; involving men is the biggest strength of the home visits program because men are the main decision-makers in their homes , so no one is left out.” (FGD#2 , supervisors) .

Spousal communication

After the home visits, groups highlighted improved spousal communication. Women could speak and express their needs freely, and they felt more confident. Men improved their capacity to listen to their spouses.

“The men are very supportive of their wives. They take time to listen to their problems and proffer solutions to the best of their ability” (FGD#5 , female , youth , rural community) .

“Women are more confident to talk to their spouses about pregnancy and child health issues. The home visits have enabled women and their husbands to make an informed decision on the best time to get pregnant or space their children” (FGD#5 , female , youth , rural community) .

Domestic violence during pregnancy

With no exception, all the groups perceived a significant reduction in domestic violence. Some male groups proposed average rates from 80 to 90% of domestic violence reduction in their communities. Some male groups labelled domestic violence as “an old-fashioned” way to do. Domestic violence is considered now as something shameful. They all attributed the reduction in domestic violence to the changing attitudes of both women and men due to the programme.

Many male groups felt that the programme made men more mature, taking their responsibilities more seriously toward their spouses and children. “Now men have stopped all kinds of “I don’t care” attitudes by providing basic needs to the house. They are now taking care of all their responsibilities. If you recall , before the home visits , a person who was always beating his wives was recognized as a warrior who did not tolerate the wrongs of women , but now it is considered taboo in this community. The attitude of men in the community has been changed as the members are no longer allowing anybody to do so [beat his wife] and go free” (FGD#12 , male , youth , urban community) .

Supervisors and visitors’ groups pointed out that the videos visitors showed during the home visits stimulated positive auto-reflections of men on their attitudes towards their spouses: “The videos have helped men realize their mistakes and change their attitudes. For instance , some men [in households] gave examples of themselves doing exactly what the man in the domestic violence video does to his wife. They said that the video portrays exactly what is happening in their homes and the communities” (FGD#2 supervisors) .

The programme had a positive ripple effect on co-wives’ relationships and the community. Women-visited groups attribute this change to the home visits. “There is no more fighting among co-wives and family members , and there are no more fights between neighbours. There is a great improvement in the people’s tolerance level in our community” (FGD#8 , visited female urban group).

The Bauchi programme’s impact on gender outcomes went beyond expectations. It has been transformative in several ways. The programme addressed key gender issues. In particular, focus groups of stakeholders stressed how the visits increased spousal communication, consistent with the growing evidence of the value of engaging men in maternal and child health. A 2018 systematic review found that interventions involving men increased couples’ communication about sexually transmitted diseases, family planning, and children’s health [ 11 ]. A cluster randomized controlled trial evaluating the effectiveness of a gender-transformative intervention on intimate partner violence and HIV prevention reported an increase in spousal communication on sexual health in Ethiopia [ 37 ]. The intervention consisted of 14 participatory and skills-building sessions led by same-sex facilitators to assist participants in identifying and transforming power imbalances within their relationships and building skills for healthy, nonviolent, and equitable relationships [ 37 ].

The home visits programme reduced heavy work during pregnancy, which confirms findings from several studies. A participatory community-based intervention in rural Andhra Pradesh observed increases in the proportion of men supporting their partners by completing housework during pregnancy. Compared with the baseline, significantly more women at the end-point reported reducing housework while pregnant (54% at baseline vs. 76% at the end-point) [ 38 ]. A 2018 cluster randomized controlled trial assessing the impact of a transformative gender intervention on promoting maternal and child health in Rwanda reported higher levels of men’s participation in childcare and household tasks (washing clothes, cooking, cleaning). A 2020 cluster randomized controlled trial evaluating a participatory, gender-transformative intimate partner violence and HIV prevention intervention improved household task-sharing in Ethiopia [ 37 ].

The Bauchi home visits contributed to reducing domestic violence, as previously reported as a quantitative finding [ 22 ] and supported by the conclusions of this qualitative study. This is in line with other recent reports. A 2023 systematic review of interventions based on social and psychological empowerment approaches reported a reduction in gender-based violence against women and girls in Sub-Saharan Africa [ 15 ]. The cluster randomized controlled trial in Rwanda found that women in the intervention group reported less past-year physical and sexual intimate partner violence [ 10 ].

The Bauchi home visits programme helped women have a say in decision-making regarding health issues, confirming findings from other studies. A qualitative study in rural Burkina Faso found free obstetric care meant women no longer needed to negotiate for money to pay for obstetric care, reducing delays in access to care. However, women did not report an increase in decision making about contraceptive use [ 39 ]. A study in Northern Uganda reported similar findings. While the intervention improved health-seeking behaviours, women still lacked control over financial and fertility decisions [ 40 ]. In these studies, the programmes did not address gender dynamics around finance or contraception; they did not involve male partners. The Bauchi home visits programme did not specifically intend to increase women’s decision-making power but rather to create a culturally safe environment for joint decisions and ultimately empower both spouses to tackle actionable risk factors for maternal and child health. This focus on joint decision-making is similar to that in the intervention in Rwanda, where the authors reported that “joint decision-making through skills-based activities and by creating spaces for couple communication, the intervention successfully targeted underlying, unequal gendered power dynamics” (p14) [ 10 ].

The participatory approach underlying the programme contributed to the positive changes reported. During the visits, home visitors discussed local risk factors, asking women and men in the households what could be done and what was being done in the home to reduce the risk factors rather than suggesting pre-determined actions. Home visits probably increased critical consciousness, an essential mechanism to target reproductive health outcomes successfully [ 4 ].

Gender norms also matter in delivering programmes. In the home visits programme, male home visitors perceived their involvement as a good way to engage spouses, and policymakers saw the recruitment of both women and men home visitors as increasing the programme’s acceptability, which aligns with the literature. A formative study on maternal nutrition in Burkina Faso reported that women preferred to receive visits from a female community health worker [ 41 ]. In Tanzania, a study assessed gender differentials in a home visits programme in maternal and child health and reported that men were more comfortable discussing sexual and reproductive concerns with male rather than female community health workers. Women were likely to disclose pregnancies earlier to female community health workers. Respondents also reported that having female and male community health workers helped address gender issues in community health workers’ acceptance [ 42 ]. Male community health workers were seen to be critical in reaching out to husbands [ 42 ]. An intervention in Rwanda paired female and male community health workers to make household visits to men and women in the community, motivated by cultural norms and concerns for women’s safety when travelling between communities [ 43 ].

Limitations

Translation from Hausa to English likely lost some nuances of meaning in the focus group discussion reports. We did not audio record the focus group discussions or interviews. We do not consider this is necessarily a limitation. We agree with Rutakumwa et al. [ 28 ] that notes from well-trained and experienced reporters can be at least as good as audio recording in capturing the key contents and contexts of focus group discussions and key informant interviews. In Bauchi, the research team carefully trained focus group facilitators and reporters. The role of the reporter is at least as important as that of the facilitator. After each focus group, the facilitator and reporter sat together to finalize the fair report of the session.

Using a deductive thematic analysis may constrain researchers from searching only for preconceived categories or themes, potentially overlooking important emergent patterns or nuances in the data. We acknowledge this limitation. This study examined how the home visits programme influenced gender norms and dynamics in Bauchi. We used a framework as a guideline to ensure we captured the key gender dimensions in mainstream health. The framework selected has been used in many studies focusing on maternal and child health in settings similar to that in Bauchi [ 2 , 32 , 33 , 34 ]. We recognize that our findings are context-specific and may not be transferable to other settings.

Conclusions

The qualitative evidence in this study suggests that the Bauchi home visits programme has been gender transformative. It addressed key gendered issues such as spousal communication and heavy work during pregnancy. The programme fostered critical examination of the harmful practice of gendered domestic violence and promoted more equitable gender norms related to the division of labour and, perhaps, to decision-making. The participatory approach underlying the programme increased critical consciousness, an essential mechanism to successfully target maternal health outcomes.

Data availability

The data sets are available from the corresponding author upon reasonable request.

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Acknowledgements

We thank the fieldworkers who collected the data and the women and men who generously shared their views on the programme.

The study was funded by the Réseau en Recherche de la Santé des populations of Québec (RRSPQ) under the programme : Soutien à des initiatives structurantes (IS) en santé mondiale conduites par des stagiaires postdoctoraux. The funding body had no role in the study’s design, the collection, analysis, and interpretation of data, or in writing the manuscript. We thank the Canadian Institutes of Health Research for supporting the costs of the article processing charge.

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Contributions

AC and NA designed the home visits programme and the cluster randomized controlled trial. AC, NA, YG, HM, MR, KO and UA and implemented the home visits programme. LB, AC, KO, YG, UA, and HM designed the qualitative evaluation study. LB and AC drafted the manuscript. KO, UA, YG, and HM collected the data and supervised the community focus group discussions. HM, KO, YG and UA contributed to reporting the data. LB, HM, and AC analyzed the qualitative data. LB, NA, AC, KO, YG, UA, HM, and MR participated in intellectual content analysis. All authors read and approved the final manuscript.

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Correspondence to Loubna Belaid .

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The Bauchi State Ministry of Health gave ethical approval for the study (NREC/12/05/2013/2017/21). The McGill University Faculty of Medicine IRB gave ethical approval (A09-B60-17B). The participants gave oral informed consent. Both ethical committees approved the use of oral informed consent, agreeing that the study was minimal risk and recognizing the low adult literacy in the study area.

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Belaid, L., Mudi, H., Omer, K. et al. Promoting gender equity in a home visits programme: a qualitative study in Northern Nigeria. BMC Women's Health 24 , 469 (2024). https://doi.org/10.1186/s12905-024-03293-8

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DOI : https://doi.org/10.1186/s12905-024-03293-8

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Abstract. This guide explains the focus, rigor, and relevance of qualitative research, highlighting its role in dissecting complex social phenomena and providing in-depth, human-centered insights. The guide also examines the rationale for employing qualitative methods, underscoring their critical importance. An exploration of the methodology ...
Criteria for Good Qualitative Research: A Comprehensive Review
This article synthesizes a published set of evaluative criteria for good qualitative research based on different paradigmatic standpoints. It also offers some prospects and recommendations to improve the quality of qualitative research in various disciplines.
How to use and assess qualitative research methods
Abstract. This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions ...
Qualitative Psychology
The mission of the journal Qualitative Psychology® is to provide a forum for innovative methodological, theoretical, and empirical work that advances qualitative inquiry in psychology. The journal publishes articles that underscore the distinctive contributions that qualitative research can make to the advancement of psychological knowledge.
Qualitative Research Journal
Yumi Kimura. 20 March 2024. Browse open Calls for Papers. Read the latest articles of Qualitative Research Journal at ScienceDirect.com, Elsevier's leading platform of peer-reviewed scholarly literature.
What is Qualitative in Research
In this text we respond and elaborate on the four comments addressing our original article. In that piece 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." In light of the comments, we identify three positions in ...
Full article: A practical guide to reflexivity in qualitative research
Abstract. Qualitative research relies on nuanced judgements that require researcher reflexivity, yet reflexivity is often addressed superficially or overlooked completely during the research process. In this AMEE Guide, we define reflexivity as a set of continuous, collaborative, and multifaceted practices through which researchers self ...
Qualitative Research
Table of contents for Qualitative Research, 24, 4, Aug 01, 2024. Abstract This paper delves into the creative methodology adopted whilst engaging in a research study with five families whose young children (aged between 8 and 10 years old) were excluded from school due to social, emotional and mental health difficulties.
What Is Qualitative Research?
Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research. Qualitative research is the opposite of quantitative research, which involves collecting and ...
Qualitative Study
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 standalone study, purely relying on qualitative data, or part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers ...
How to use and assess qualitative research methods
Abstract. This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions ...
Qualitative Methods in Health Care Research
Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and ...
(PDF) Exploring Thematic Analysis in Qualitative Research
Description: Qualitative research is a systematic approach used to understand and interpret phenomena in their natural settings. Unlike quantitative research, which focuses on numerical data and ...
Qualitative Psychology Sample articles
Recommendations for Designing and Reviewing Qualitative Research in Psychology: Promoting Methodological Integrity (PDF, 166KB) February 2017 by Heidi M. Levitt, Sue L. Motulsky, Fredrick J. Wertz, Susan L. Morrow, and Joseph G. Ponterotto; Racial Microaggression Experiences and Coping Strategies of Black Women in Corporate Leadership (PDF, 132KB)
Facilitators and barriers of midwife-led model of care at public health
Background The midwife-led model of care is woman-centered and based on the premise that pregnancy and childbirth are normal life events, and the midwife plays a fundamental role in coordinating care for women and linking with other health care professionals as required. Worldwide, this model of care has made a great contribution to the reduction of maternal and child mortality. For example ...
International Journal of Qualitative Methods: Sage Journals
The International Journal of Qualitative Methods is the peer-reviewed interdisciplinary open access journal of the International Institute for Qualitative Methodology (IIQM) at the University of Alberta, Canada. The journal, established in 2002, is an eclectic international forum for insights, innovations and advances in methods and study designs using qualitative or mixed methods research.
What is Qualitative in Qualitative Research
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 ...
"I've yet to meet anyone who's not keen for simulation"
The reporting of the research was guided by the Standards for Reporting Qualitative Research (SRQR). Human Research Ethics Committee approval was obtained. Results: Two focus groups were conducted with 16 participants from six Pacific Island countries. Six themes and 15 subthemes were conceptualized from the data.
Qualitative Research in Healthcare: Necessity and Characteristics
Qualitative research is conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants and data collection methods, (5) data analysis and description of findings, and (6) research validation.
Navigating sexual minority identity in sport: a qualitative exploration
Sexual minority student-athletes (SMSAs) face discrimination and identity conflicts in intercollegiate sport, impacting their participation and mental health. This study explores the perceptions of Chinese SMSAs regarding their sexual minority identities, aiming to fill the current gap in research related to non-Western countries. A qualitative methodology was adopted, utilising the ...
Understanding digital sweatshops: A qualitative investigation of
Through qualitative research, the current study seeks to promote global employee ethics and ultimately help to eliminate sweatshop labour practices. Background literature. Sweatshops originated during the era of industrialization, which was marked by the extensive use of factory-based manufacturing techniques.
Qualitative Research
Qualitative Research: Create email alert. Also from Sage. CQ Library Elevating debate opens in new tab; Sage Data Uncovering insight opens in new tab; Sage Business Cases Shaping futures opens in new tab; Sage Campus Unleashing potential opens in new tab; Sage Knowledge Multimedia learning resources opens in new tab;
Evaluating panel discussions in ESP classes: an exploration of
Aim and design. For this study, a two-phase qualitative design was employed to gain an understanding of the advantages and disadvantages of PDs from the perspectives of both student panelists and the audience (Phase 1) and to acquire an in-depth understanding of the suggested strategies provided by experts to enhance PPs for future students (Phase 2).
Promoting gender equity in a home visits programme: a qualitative study
Some local research team members were involved in the home visit programmes. The team explained to the participants that the study's objective is to understand their views on the home visit programmes and improve them if necessary. In reporting the study, we followed the 32-item COREQ checklist for reporting qualitative research (appendix 3).
Learning to Do Qualitative Data Analysis: A Starting Point
This question is particularly relevant to researchers new to the field and practice of qualitative research and instructors and mentors who regularly introduce students to qualitative research practices. In this article, we seek to offer what we view as a useful starting point for learning how to do qualitative analysis. We begin by discussing ...

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How to use and assess qualitative research methods

What is qualitative research?

Why conduct qualitative research?

How to conduct qualitative research?

Data collection

Document study

Observations

Semi-structured interviews

Focus groups

Choosing the “right” method

Data analysis

How to report qualitative research?

How to combine qualitative with quantitative research?

How to assess qualitative research?

Reflexivity

Sampling and saturation

Member checking

Stakeholder involvement

How not to assess qualitative research

Protocol adherence

Sample size

Randomisation

Interrater reliability, variability and other “objectivity checks”

Not being quantitative research

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

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Facilitators and barriers of midwife-led model of care at public health institutions of dire Dawa city, Eastern Ethiopia, 2022: a qualitative study

Methodology

Introduction

Study setting and design

Study population and sampling procedure

Data collection tool and procedures

Data quality control

Data analysis

Trustworthiness of data

Background characteristics of the study participants

Facilitators of midwife-led model of care at a public health institution of Dire Dawa city, Eastern Ethiopia, in 2021

Good teamwork

Barriers of midwife-led model of care at a public health institution of Dire Dawa city, Eastern Ethiopia, in 2021

Shortage of resource

Unfair risk or hazard payments

Limited organizational power of midwives

Feeling of demoralization

Absence of recognition or /motivation from superiors

Insufficient of work-related security

Discussions

Conclusions

Study implications

Strengths and limitations

Recommendations

To the Ethiopian federal ministry of health (FMOH)

To dire Dawa health Bureau

To Dire Dawa public health facility’s