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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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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: 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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Criteria for Good Qualitative Research: A Comprehensive Review

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Published: 18 September 2021
Volume 31 , pages 679–689, ( 2022 )

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

Good Qualitative Research: Opening up the Debate

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

What is Qualitative in Research

Avoid common mistakes on your manuscript.

Introduction

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

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

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

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

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

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

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

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

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

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

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

Qualitative Research: Interpretive Paradigms

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

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

Improving Quality: Strategies

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

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

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

Essential elements of a conceptual framework

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

How to Assess the Quality of the Research Findings?

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

Quality Checklists: Tools for Assessing the Quality

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

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

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

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

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

Conclusions, Future Directions, and Outlook

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

Prospects : A Road Ahead for Qualitative Research

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

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

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

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

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

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

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

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

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

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Am J Pharm Educ
v.74(8); 2010 Oct 11

Presenting and Evaluating Qualitative Research

The purpose of this paper is to help authors to think about ways to present qualitative research papers in the American Journal of Pharmaceutical Education . It also discusses methods for reviewers to assess the rigour, quality, and usefulness of qualitative research. Examples of different ways to present data from interviews, observations, and focus groups are included. The paper concludes with guidance for publishing qualitative research and a checklist for authors and reviewers.

INTRODUCTION

Policy and practice decisions, including those in education, increasingly are informed by findings from qualitative as well as quantitative research. Qualitative research is useful to policymakers because it often describes the settings in which policies will be implemented. Qualitative research is also useful to both pharmacy practitioners and pharmacy academics who are involved in researching educational issues in both universities and practice and in developing teaching and learning.

Qualitative research involves the collection, analysis, and interpretation of data that are not easily reduced to numbers. These data relate to the social world and the concepts and behaviors of people within it. Qualitative research can be found in all social sciences and in the applied fields that derive from them, for example, research in health services, nursing, and pharmacy. 1 It looks at X in terms of how X varies in different circumstances rather than how big is X or how many Xs are there? 2 Textbooks often subdivide research into qualitative and quantitative approaches, furthering the common assumption that there are fundamental differences between the 2 approaches. With pharmacy educators who have been trained in the natural and clinical sciences, there is often a tendency to embrace quantitative research, perhaps due to familiarity. A growing consensus is emerging that sees both qualitative and quantitative approaches as useful to answering research questions and understanding the world. Increasingly mixed methods research is being carried out where the researcher explicitly combines the quantitative and qualitative aspects of the study. 3 , 4

Like healthcare, education involves complex human interactions that can rarely be studied or explained in simple terms. Complex educational situations demand complex understanding; thus, the scope of educational research can be extended by the use of qualitative methods. Qualitative research can sometimes provide a better understanding of the nature of educational problems and thus add to insights into teaching and learning in a number of contexts. For example, at the University of Nottingham, we conducted in-depth interviews with pharmacists to determine their perceptions of continuing professional development and who had influenced their learning. We also have used a case study approach using observation of practice and in-depth interviews to explore physiotherapists' views of influences on their leaning in practice. We have conducted in-depth interviews with a variety of stakeholders in Malawi, Africa, to explore the issues surrounding pharmacy academic capacity building. A colleague has interviewed and conducted focus groups with students to explore cultural issues as part of a joint Nottingham-Malaysia pharmacy degree program. Another colleague has interviewed pharmacists and patients regarding their expectations before and after clinic appointments and then observed pharmacist-patient communication in clinics and assessed it using the Calgary Cambridge model in order to develop recommendations for communication skills training. 5 We have also performed documentary analysis on curriculum data to compare pharmacist and nurse supplementary prescribing courses in the United Kingdom.

It is important to choose the most appropriate methods for what is being investigated. Qualitative research is not appropriate to answer every research question and researchers need to think carefully about their objectives. Do they wish to study a particular phenomenon in depth (eg, students' perceptions of studying in a different culture)? Or are they more interested in making standardized comparisons and accounting for variance (eg, examining differences in examination grades after changing the way the content of a module is taught). Clearly a quantitative approach would be more appropriate in the last example. As with any research project, a clear research objective has to be identified to know which methods should be applied.

Types of qualitative data include:

Audio recordings and transcripts from in-depth or semi-structured interviews
Structured interview questionnaires containing substantial open comments including a substantial number of responses to open comment items.
Audio recordings and transcripts from focus group sessions.
Field notes (notes taken by the researcher while in the field [setting] being studied)
Video recordings (eg, lecture delivery, class assignments, laboratory performance)
Case study notes
Documents (reports, meeting minutes, e-mails)
Diaries, video diaries
Observation notes
Press clippings
Photographs

RIGOUR IN QUALITATIVE RESEARCH

Qualitative research is often criticized as biased, small scale, anecdotal, and/or lacking rigor; however, when it is carried out properly it is unbiased, in depth, valid, reliable, credible and rigorous. In qualitative research, there needs to be a way of assessing the “extent to which claims are supported by convincing evidence.” 1 Although the terms reliability and validity traditionally have been associated with quantitative research, increasingly they are being seen as important concepts in qualitative research as well. Examining the data for reliability and validity assesses both the objectivity and credibility of the research. Validity relates to the honesty and genuineness of the research data, while reliability relates to the reproducibility and stability of the data.

The validity of research findings refers to the extent to which the findings are an accurate representation of the phenomena they are intended to represent. The reliability of a study refers to the reproducibility of the findings. Validity can be substantiated by a number of techniques including triangulation use of contradictory evidence, respondent validation, and constant comparison. Triangulation is using 2 or more methods to study the same phenomenon. Contradictory evidence, often known as deviant cases, must be sought out, examined, and accounted for in the analysis to ensure that researcher bias does not interfere with or alter their perception of the data and any insights offered. Respondent validation, which is allowing participants to read through the data and analyses and provide feedback on the researchers' interpretations of their responses, provides researchers with a method of checking for inconsistencies, challenges the researchers' assumptions, and provides them with an opportunity to re-analyze their data. The use of constant comparison means that one piece of data (for example, an interview) is compared with previous data and not considered on its own, enabling researchers to treat the data as a whole rather than fragmenting it. Constant comparison also enables the researcher to identify emerging/unanticipated themes within the research project.

STRENGTHS AND LIMITATIONS OF QUALITATIVE RESEARCH

Qualitative researchers have been criticized for overusing interviews and focus groups at the expense of other methods such as ethnography, observation, documentary analysis, case studies, and conversational analysis. Qualitative research has numerous strengths when properly conducted.

Strengths of Qualitative Research

Issues can be examined in detail and in depth.
Interviews are not restricted to specific questions and can be guided/redirected by the researcher in real time.
The research framework and direction can be quickly revised as new information emerges.
The data based on human experience that is obtained is powerful and sometimes more compelling than quantitative data.
Subtleties and complexities about the research subjects and/or topic are discovered that are often missed by more positivistic enquiries.
Data usually are collected from a few cases or individuals so findings cannot be generalized to a larger population. Findings can however be transferable to another setting.

Limitations of Qualitative Research

Research quality is heavily dependent on the individual skills of the researcher and more easily influenced by the researcher's personal biases and idiosyncrasies.
Rigor is more difficult to maintain, assess, and demonstrate.
The volume of data makes analysis and interpretation time consuming.
It is sometimes not as well understood and accepted as quantitative research within the scientific community
The researcher's presence during data gathering, which is often unavoidable in qualitative research, can affect the subjects' responses.
Issues of anonymity and confidentiality can present problems when presenting findings
Findings can be more difficult and time consuming to characterize in a visual way.

PRESENTATION OF QUALITATIVE RESEARCH FINDINGS

The following extracts are examples of how qualitative data might be presented:

Data From an Interview.

The following is an example of how to present and discuss a quote from an interview.

The researcher should select quotes that are poignant and/or most representative of the research findings. Including large portions of an interview in a research paper is not necessary and often tedious for the reader. The setting and speakers should be established in the text at the end of the quote.

The student describes how he had used deep learning in a dispensing module. He was able to draw on learning from a previous module, “I found that while using the e learning programme I was able to apply the knowledge and skills that I had gained in last year's diseases and goals of treatment module.” (interviewee 22, male)

This is an excerpt from an article on curriculum reform that used interviews 5 :

The first question was, “Without the accreditation mandate, how much of this curriculum reform would have been attempted?” According to respondents, accreditation played a significant role in prompting the broad-based curricular change, and their comments revealed a nuanced view. Most indicated that the change would likely have occurred even without the mandate from the accreditation process: “It reflects where the profession wants to be … training a professional who wants to take on more responsibility.” However, they also commented that “if it were not mandated, it could have been a very difficult road.” Or it “would have happened, but much later.” The change would more likely have been incremental, “evolutionary,” or far more limited in its scope. “Accreditation tipped the balance” was the way one person phrased it. “Nobody got serious until the accrediting body said it would no longer accredit programs that did not change.”

Data From Observations

The following example is some data taken from observation of pharmacist patient consultations using the Calgary Cambridge guide. 6 , 7 The data are first presented and a discussion follows:

Pharmacist: We will soon be starting a stop smoking clinic. Patient: Is the interview over now? Pharmacist: No this is part of it. (Laughs) You can't tell me to bog off (sic) yet. (pause) We will be starting a stop smoking service here, Patient: Yes. Pharmacist: with one-to-one and we will be able to help you or try to help you. If you want it. In this example, the pharmacist has picked up from the patient's reaction to the stop smoking clinic that she is not receptive to advice about giving up smoking at this time; in fact she would rather end the consultation. The pharmacist draws on his prior relationship with the patient and makes use of a joke to lighten the tone. He feels his message is important enough to persevere but he presents the information in a succinct and non-pressurised way. His final comment of “If you want it” is important as this makes it clear that he is not putting any pressure on the patient to take up this offer. This extract shows that some patient cues were picked up, and appropriately dealt with, but this was not the case in all examples.

Data From Focus Groups

This excerpt from a study involving 11 focus groups illustrates how findings are presented using representative quotes from focus group participants. 8

Those pharmacists who were initially familiar with CPD endorsed the model for their peers, and suggested it had made a meaningful difference in the way they viewed their own practice. In virtually all focus groups sessions, pharmacists familiar with and supportive of the CPD paradigm had worked in collaborative practice environments such as hospital pharmacy practice. For these pharmacists, the major advantage of CPD was the linking of workplace learning with continuous education. One pharmacist stated, “It's amazing how much I have to learn every day, when I work as a pharmacist. With [the learning portfolio] it helps to show how much learning we all do, every day. It's kind of satisfying to look it over and see how much you accomplish.” Within many of the learning portfolio-sharing sessions, debates emerged regarding the true value of traditional continuing education and its outcome in changing an individual's practice. While participants appreciated the opportunity for social and professional networking inherent in some forms of traditional CE, most eventually conceded that the academic value of most CE programming was limited by the lack of a systematic process for following-up and implementing new learning in the workplace. “Well it's nice to go to these [continuing education] events, but really, I don't know how useful they are. You go, you sit, you listen, but then, well I at least forget.”

The following is an extract from a focus group (conducted by the author) with first-year pharmacy students about community placements. It illustrates how focus groups provide a chance for participants to discuss issues on which they might disagree.

Interviewer: So you are saying that you would prefer health related placements? Student 1: Not exactly so long as I could be developing my communication skill. Student 2: Yes but I still think the more health related the placement is the more I'll gain from it. Student 3: I disagree because other people related skills are useful and you may learn those from taking part in a community project like building a garden. Interviewer: So would you prefer a mixture of health and non health related community placements?

GUIDANCE FOR PUBLISHING QUALITATIVE RESEARCH

Qualitative research is becoming increasingly accepted and published in pharmacy and medical journals. Some journals and publishers have guidelines for presenting qualitative research, for example, the British Medical Journal 9 and Biomedcentral . 10 Medical Education published a useful series of articles on qualitative research. 11 Some of the important issues that should be considered by authors, reviewers and editors when publishing qualitative research are discussed below.

Introduction.

A good introduction provides a brief overview of the manuscript, including the research question and a statement justifying the research question and the reasons for using qualitative research methods. This section also should provide background information, including relevant literature from pharmacy, medicine, and other health professions, as well as literature from the field of education that addresses similar issues. Any specific educational or research terminology used in the manuscript should be defined in the introduction.

The methods section should clearly state and justify why the particular method, for example, face to face semistructured interviews, was chosen. The method should be outlined and illustrated with examples such as the interview questions, focusing exercises, observation criteria, etc. The criteria for selecting the study participants should then be explained and justified. The way in which the participants were recruited and by whom also must be stated. A brief explanation/description should be included of those who were invited to participate but chose not to. It is important to consider “fair dealing,” ie, whether the research design explicitly incorporates a wide range of different perspectives so that the viewpoint of 1 group is never presented as if it represents the sole truth about any situation. The process by which ethical and or research/institutional governance approval was obtained should be described and cited.

The study sample and the research setting should be described. Sampling differs between qualitative and quantitative studies. In quantitative survey studies, it is important to select probability samples so that statistics can be used to provide generalizations to the population from which the sample was drawn. Qualitative research necessitates having a small sample because of the detailed and intensive work required for the study. So sample sizes are not calculated using mathematical rules and probability statistics are not applied. Instead qualitative researchers should describe their sample in terms of characteristics and relevance to the wider population. Purposive sampling is common in qualitative research. Particular individuals are chosen with characteristics relevant to the study who are thought will be most informative. Purposive sampling also may be used to produce maximum variation within a sample. Participants being chosen based for example, on year of study, gender, place of work, etc. Representative samples also may be used, for example, 20 students from each of 6 schools of pharmacy. Convenience samples involve the researcher choosing those who are either most accessible or most willing to take part. This may be fine for exploratory studies; however, this form of sampling may be biased and unrepresentative of the population in question. Theoretical sampling uses insights gained from previous research to inform sample selection for a new study. The method for gaining informed consent from the participants should be described, as well as how anonymity and confidentiality of subjects were guaranteed. The method of recording, eg, audio or video recording, should be noted, along with procedures used for transcribing the data.

Data Analysis.

A description of how the data were analyzed also should be included. Was computer-aided qualitative data analysis software such as NVivo (QSR International, Cambridge, MA) used? Arrival at “data saturation” or the end of data collection should then be described and justified. A good rule when considering how much information to include is that readers should have been given enough information to be able to carry out similar research themselves.

One of the strengths of qualitative research is the recognition that data must always be understood in relation to the context of their production. 1 The analytical approach taken should be described in detail and theoretically justified in light of the research question. If the analysis was repeated by more than 1 researcher to ensure reliability or trustworthiness, this should be stated and methods of resolving any disagreements clearly described. Some researchers ask participants to check the data. If this was done, it should be fully discussed in the paper.

An adequate account of how the findings were produced should be included A description of how the themes and concepts were derived from the data also should be included. Was an inductive or deductive process used? The analysis should not be limited to just those issues that the researcher thinks are important, anticipated themes, but also consider issues that participants raised, ie, emergent themes. Qualitative researchers must be open regarding the data analysis and provide evidence of their thinking, for example, were alternative explanations for the data considered and dismissed, and if so, why were they dismissed? It also is important to present outlying or negative/deviant cases that did not fit with the central interpretation.

The interpretation should usually be grounded in interviewees or respondents' contributions and may be semi-quantified, if this is possible or appropriate, for example, “Half of the respondents said …” “The majority said …” “Three said…” Readers should be presented with data that enable them to “see what the researcher is talking about.” 1 Sufficient data should be presented to allow the reader to clearly see the relationship between the data and the interpretation of the data. Qualitative data conventionally are presented by using illustrative quotes. Quotes are “raw data” and should be compiled and analyzed, not just listed. There should be an explanation of how the quotes were chosen and how they are labeled. For example, have pseudonyms been given to each respondent or are the respondents identified using codes, and if so, how? It is important for the reader to be able to see that a range of participants have contributed to the data and that not all the quotes are drawn from 1 or 2 individuals. There is a tendency for authors to overuse quotes and for papers to be dominated by a series of long quotes with little analysis or discussion. This should be avoided.

Participants do not always state the truth and may say what they think the interviewer wishes to hear. A good qualitative researcher should not only examine what people say but also consider how they structured their responses and how they talked about the subject being discussed, for example, the person's emotions, tone, nonverbal communication, etc. If the research was triangulated with other qualitative or quantitative data, this should be discussed.

Discussion.

The findings should be presented in the context of any similar previous research and or theories. A discussion of the existing literature and how this present research contributes to the area should be included. A consideration must also be made about how transferrable the research would be to other settings. Any particular strengths and limitations of the research also should be discussed. It is common practice to include some discussion within the results section of qualitative research and follow with a concluding discussion.

The author also should reflect on their own influence on the data, including a consideration of how the researcher(s) may have introduced bias to the results. The researcher should critically examine their own influence on the design and development of the research, as well as on data collection and interpretation of the data, eg, were they an experienced teacher who researched teaching methods? If so, they should discuss how this might have influenced their interpretation of the results.

Conclusion.

The conclusion should summarize the main findings from the study and emphasize what the study adds to knowledge in the area being studied. Mays and Pope suggest the researcher ask the following 3 questions to determine whether the conclusions of a qualitative study are valid 12 : How well does this analysis explain why people behave in the way they do? How comprehensible would this explanation be to a thoughtful participant in the setting? How well does the explanation cohere with what we already know?

CHECKLIST FOR QUALITATIVE PAPERS

This paper establishes criteria for judging the quality of qualitative research. It provides guidance for authors and reviewers to prepare and review qualitative research papers for the American Journal of Pharmaceutical Education . A checklist is provided in Appendix 1 to assist both authors and reviewers of qualitative data.

ACKNOWLEDGEMENTS

Thank you to the 3 reviewers whose ideas helped me to shape this paper.

Appendix 1. Checklist for authors and reviewers of qualitative research.

Introduction

□ Research question is clearly stated.
□ Research question is justified and related to the existing knowledge base (empirical research, theory, policy).
□ Any specific research or educational terminology used later in manuscript is defined.
□ The process by which ethical and or research/institutional governance approval was obtained is described and cited.
□ Reason for choosing particular research method is stated.
□ Criteria for selecting study participants are explained and justified.
□ Recruitment methods are explicitly stated.
□ Details of who chose not to participate and why are given.
□ Study sample and research setting used are described.
□ Method for gaining informed consent from the participants is described.
□ Maintenance/Preservation of subject anonymity and confidentiality is described.
□ Method of recording data (eg, audio or video recording) and procedures for transcribing data are described.
□ Methods are outlined and examples given (eg, interview guide).
□ Decision to stop data collection is described and justified.
□ Data analysis and verification are described, including by whom they were performed.
□ Methods for identifying/extrapolating themes and concepts from the data are discussed.
□ Sufficient data are presented to allow a reader to assess whether or not the interpretation is supported by the data.
□ Outlying or negative/deviant cases that do not fit with the central interpretation are presented.
□ Transferability of research findings to other settings is discussed.
□ Findings are presented in the context of any similar previous research and social theories.
□ Discussion often is incorporated into the results in qualitative papers.
□ A discussion of the existing literature and how this present research contributes to the area is included.
□ Any particular strengths and limitations of the research are discussed.
□ Reflection of the influence of the researcher(s) on the data, including a consideration of how the researcher(s) may have introduced bias to the results is included.

Conclusions

□ The conclusion states the main finings of the study and emphasizes what the study adds to knowledge in the subject area.

Open access
Published: 28 August 2024

Pre-implementation planning for a sepsis intervention in a large learning health system: a qualitative study

Tara A. Eaton 1 ,
Marc Kowalkowski 1 , 2 ,
Ryan Burns 3 ,
Hazel Tapp 4 ,
Katherine O’Hare 5 &
Stephanie P. Taylor 6

BMC Health Services Research volume 24 , Article number: 996 ( 2024 ) Cite this article

Metrics details

Sepsis survivors experience high morbidity and mortality. Though recommended best practices have been established to address the transition and early post hospital needs and promote recovery for sepsis survivors, few patients receive recommended post-sepsis care. Our team developed the Sepsis Transition and Recovery (STAR) program, a multicomponent transition intervention that leverages virtually-connected nurses to coordinate the application of evidence-based recommendations for post-sepsis care with additional clinical support from hospitalist and primary care physicians. In this paper, we present findings from a qualitative pre-implementation study, guided by the Consolidated Framework for Implementation Research (CFIR), of factors to inform successful STAR implementation at a large learning health system prior to effectiveness testing as part of a Type I Hybrid trial.

We conducted semi-structured qualitative interviews ( n = 16) with 8 administrative leaders and 8 clinicians. Interviews were transcribed and analyzed in ATLAS.ti using a combination deductive/inductive strategy based on CFIR domains and constructs and the Constant Comparison Method.

Six facilitators and five implementation barriers were identified spanning all five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals and Process). Facilitators of STAR included alignment with health system goals, fostering stakeholder engagement, sharing STAR outcomes data, good communication between STAR navigators and patient care teams/PCPs, clinician promotion of STAR with patients, and good rapport and effective communication between STAR navigators and patients, caregivers, and family members. Barriers of STAR included competing demands for staff time and resources, insufficient communication and education of STAR’s value and effectiveness, underlying informational and technology gaps among patients, lack of patient access to community resources, and patient distrust of the program and/or health care.

Conclusions

CFIR proved to be a robust framework for examining facilitators and barriers for pre-implementation planning of post-sepsis care programs within diverse hospital and community settings in a large LHS. Conducting a structured pre-implementation evaluation helps researchers design with implementation in mind prior to effectiveness studies and should be considered a key component of Type I hybrid trials when feasible.

Trial registration

Clinicaltrials.gov, NCT04495946 . Registered August 3, 2020.

Peer Review reports

Contributions to literature

This qualitative pre-implementation study of a telehealth nurse navigator-led sepsis transition and recovery (STAR) program demonstrates the Consolidated Framework for Implementation Research (CFIR) is useful to explore contextual conditions of healthcare settings as part of rigorous pre-implementation planning efforts.

This analysis identified actionable facilitators and barriers spanning all five CFIR domains (e.g., inner setting, outer setting) to inform and enhance initial implementation strategies of STAR.

These findings help to close recognized gaps in the literature on post-sepsis survivorship, including how to plan implementation of evidenced-based practices to address transition and early post hospital needs of sepsis survivors and promote recovery.

Sepsis, a common and life-threatening dysregulated response to infection, remains a major cause of morbidity, mortality, and healthcare costs [ 1 , 2 , 3 ]. Although hospital survival has improved in recent years, the increasing number of sepsis survivors are vulnerable to additional health problems [ 4 , 5 , 6 ]. Fewer than one-half of sepsis survivors return to their pre-sepsis health status and many experience new or worsening physical, cognitive, and psychological impairments, along with high rates of rehospitalization and excess mortality for years after sepsis hospitalization [ 7 , 8 , 9 ]. Given increasing recognition of the substantial long-term sequelae and social determinants of health-related needs after sepsis [ 10 ], recommended best practices have been established to address the transition and early post hospital needs and promote recovery for sepsis survivors [ 11 , 12 , 13 ]. However, like the majority of other evidence-based practices (EBPs) that have yet to be successfully adopted into routine practice, few patients receive recommended post-sepsis care [ 14 , 15 ].

To address the transition and early post hospital needs for sepsis survivors, our team developed the Sepsis Transition and Recovery (STAR) program, a multicomponent transition intervention that leverages centrally-located, virtually-connected nurses to coordinate the application of evidence-based recommendations for post-sepsis care with additional clinical support from hospitalist and primary care physicians [ 16 ]. The STAR program, based on the chronic care model [ 17 ], empowers patients and clinicians, via targeted education and coordinated care approaches, and was found to improve mortality and readmission outcomes among sepsis survivors [ 18 ]. There are complex barriers to translation of research findings into real-world post-sepsis care which we sought to identify and mitigate prior to effectiveness testing as part of a Type I Hybrid trial [ 19 ].

Before initiating a large-scale, pragmatic effectiveness evaluation of the STAR program (NCT04495946), we conducted a qualitative pre-implementation study with the aim to identify actionable facilitators and barriers to inform and enhance initial implementation strategies of the program across diverse hospital and community settings in a large Learning Health System (LHS). Qualitative methods are considered an integral component of implementation research and are well-known for being rigorous and efficient in the study of the hows and whys of implementation [ 20 ]. Conducting a robust pre-implementation evaluation was an intentional design choice for the overall project given the critical role of this step in the implementation process [ 21 ]. Through our qualitative investigation, we explored variations in stakeholder perspectives of the program by interviewing both administrators and clinicians.

We guided our study with the Consolidated Framework for Implementation Research (CFIR), due to its breadth, widespread use [ 22 , 23 ], and expert-recommended mapping from CFIR-identified barriers to defined implementation strategies [ 24 ]. As a framework, the CFIR offers a systematic approach well-known for planning, evaluating, and supporting behavioral change for a diverse array of studies [ 25 ], using a consistent language of 39 constructs organized across five domains—Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals and Process [ 22 ]. It can be used to build implementation knowledge to describe determinants of implementation [ 23 ], as well as tailor pre-implementation strategies to promote intervention success [ 26 , 27 ].

For this pre-implementation study, we conducted a qualitative investigation to identify facilitators and barriers to implementing the STAR program in hospital transition care, and to elaborate and compare key stakeholder perspectives. Instrument development, data collection, analysis, and interpretation of study results were guided by the CFIR. A PhD-level trained qualitative health services researcher (TE) on the study team with experience conducting qualitative research for program evaluations and intervention development led the process of interview instrument design, data collection, and analysis. She was not known to participants of the research prior to undertaking the study. Our study team followed the Standards for Reporting Qualitative Research in the reporting of this work [ 28 ].

Study design

The pre-implementation study was conducted from March through July of 2020 in preparation for the planned implementation of the STAR program intervention in July 2020 at a large LHS. Headquartered in Charlotte, North Carolina, Atrium Health provides not-for-profit healthcare supporting over 14 million patient encounters annually across 40 hospitals and over 1,000 care locations in North Carolina, Georgia, and Alabama. We identified all stakeholders involved with post-sepsis care in this health system according to a framework for stakeholder mapping in health research [ 29 ]. With sepsis survivors and caregivers at the center of our focus for STAR, we identified stakeholder categories relevant to them to determine our recruitment approach for the pre-implementation interviews. By employing an iterative process of delineation between key individuals and groups involved in post-sepsis care at the LHS, we identified key stakeholders.

These stakeholders comprised two main groups: administrative leaders and clinicians. Administrative leaders were chief medical and nursing officers. We selected administrators due to their understanding of outer and inner setting factors and influence on organizational policy. Clinicians were hospitalists and ambulatory care providers representing diverse practice settings. We selected clinicians as representative intervention users with knowledge of intervention characteristics, outer setting, inner setting, characteristics of individuals, and process factors. We purposively sampled potential participants to reflect these organizational roles and responsibilities at the planned intervention sites. We aimed to recruit individuals to sufficiently capture a range of beliefs about post-sepsis care in these practice settings, while limiting redundancy in our data collection.

The final sample included 8 administrators (Chief Medical Officers, Nursing Executives, and a Departmental Chair; representing 7 study hospitals and leadership over post-hospital continuing care and primary care services) and 8 clinicians (with specialty areas in one or more of the following: Hospital Medicine, Internal Medicine, Infectious Disease, Family Medicine and Critical Care; representing individuals with care privileges at 6 study hospitals and primary care responsibilities in the communities served by these hospitals). See Table 1 : Participant Characteristics.

Data collection

We conducted semi-structured qualitative interviews with 16 stakeholders from diverse hospitals and care settings to explore organizational support, culture, workflow processes, needs, and recommendations for STAR’s implementation. Separate and original interview guides were developed for administrator and clinician groups (See Additional file 1: Administrator Interview Guide and Additional file 2: Clinician Interview Guide) in this study, however, both guides included questions about stakeholder roles and work environments, the fit of the STAR program for their facilities which was facilitated using a printed intervention workflow diagram (See Fig. 1 : Patient Trajectory through the STAR Program), and questions about the implementation of STAR. Interview guides intentionally included questions representative of all 5 of the CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals and Process) and were initially scripted by adapting questions from the CFIR Interview Guide Tool available at the CFIR website, www.cfguide.org [ 30 ]. Some of the sample questions from the guides are included below:

Patient trajectory through the STAR program

Do you think effectiveness data about the sepsis transition program would be needed to get team buy-in in your facility? (Intervention Characteristics)

How well, would you say, are new ideas (e.g., work processes, new interventions, QI projects, research) embraced and used to make improvements in your facility? (Inner Setting)

What, if any, barriers do you think patients will face to participate in the intervention? (Outer Setting)

What is your role within the organization? (Characteristics of Individuals)

Who would you recommend are the key individuals to speak with to make sure new interventions are successful in your practice or department? (Process)

We pilot tested (field tested) the interview guides in three rounds prior to their administration and iteratively refined the guides based on participant feedback and research team members’ perceptions of the usefulness of the data collection instruments for eliciting information we intended to capture for each stakeholder group (See Fig. 2 : Diagram of Interview Guide Development at Pre-Implementation). Field testing is an established technique in qualitative research for developing interview guides as it provides researchers with the opportunity to practice asking the interview questions and identify weaknesses in the wording and order of questions when spoken aloud [ 31 ]. We then used the refined data collection instruments for the interviews reported here.

Diagram of interview guide development at pre-implementation

Prior to each interview, participants received standardized background information about the study topic and verbal informed consent was obtained. As an adaptation due to research restrictions during the COVID-19 pandemic, interviews were conducted telephonically. Interviews were on average 30 min in duration, which was expected given the number of questions asked of participants (13 questions for the administrators and 15 questions for the clinicians) and what was seen during the pilot testing of the interview guides prior to data collection. Participants were offered a $25 gift card for their participation. Ethical approval for this study was granted by the Advarra IRB Committee.

Data analysis

Interview recordings were transcribed and entered into ATLAS.ti X8 as text documents for thematic coding and analysis. One team member with extensive experience in qualitative research methods (TE) led the analysis of the data set using a combination deductive/inductive strategy based on CFIR domains and constructs and the Constant Comparison Method. The Constant Comparison Method is an inductive approach for developing code structure through the iterative comparison of newly coded text with previously coded text of the same theme until final thematic refinement is achieved [ 32 ]. We referred to the cfirguide.org website’s CFIR Codebook Template [ 33 ], containing domain and construct definitions and guidance for coding qualitative data with the framework and inclusion and exclusion criteria for most constructs, in our application of the framework to our codebook development and analysis. This process included creating a codebook (a complete list of codes and definitions for each code), coding the data set among team members, comparing identified codes, and merging codes when it was necessary based on analytical discussion. Each code was labeled using the following convention: 1) if it was an implementation facilitator or barrier code, 2) a simplified title indicating what the code was, and 3) and a tag of the CFIR domains and constructs that corresponded to the code. E.g., ImplFacilitator_Family support for PT: OUTSET-PT Needs & Res. Throughout the process of analyzing the qualitative interview data, our study team met bi-weekly to discuss the results and engaged with the larger stakeholder group monthly to discuss ideas for overcoming identified barriers.

To promote the reliability of the analysis and prevent interpretive bias, two study team members (TE and RB) completed inter-rater reliability (IRR) coding for 50% of the administrator interviews (n = 4). Three team members (TE, KO, and HT) completed IRR for 50% of the clinician interviews ( n = 4). IRR was conducted by having additional coders (RB, KO, and HT) apart from the principal analyst (TE) apply the codebook to the data set to determine whether they agreed with the original coding of selected interview transcripts. Instances of disagreement were discussed thoroughly and, at times, resulted in the application of additional codes for selected quotations. All identified conflicts in coding were fully resolved, resulting in a final agreement of 100% between coders.

Using a combination deductive/inductive coding strategy, we found 77 codes related to STAR implementation facilitators ( n = 38) and barriers ( n = 39) and labeled those codes with applicable CFIR domains and constructs as appropriate. The STAR implementation facilitators and barriers codes were then aggregated into 11 themes consisting of 6 facilitators (See Table 2 ) and 5 implementation barriers (See Table 3 ). STAR implementation facilitators and barriers, together, spanned all five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals and Process). Administrators and clinicians reported no other sepsis-specific transition programs in their facilities at the time of data collection and indicated the STAR program would be important to address sepsis survivor needs.

Facilitators influencing the implementation of STAR

Our analysis identified six themes pertaining to implementation facilitators. See Table 2 : CFIR-Guided Facilitators of STAR Implementation.

Alignment between STAR and health system goals

Participants reported that STAR’s alignment with other telehealth programs at the LHS, such as virtual hospital care, amidst surge of telehealth care during the COVID-19 pandemic would promote implementation of STAR as indicated in the administrator’s response below:

“I also think it [STAR] would be well received based on the information regarding virtual hospital and what we have been able to achieve with that. And, again with just looking for the bright spots in COVID, there have been a lot of transitions that have taken place in the last couple of months that I think you would have a much easier time implementing this in the new world of healthcare.” (A7)

Beyond virtual care, participants also described other existing infrastructure within the LHS that would align with the STAR program objectives, including sepsis work groups and sepsis champions from physicians, nurses, pharmacy, and case management. These inner setting facilitators combined demonstrate how STAR’s alignment with the implementation climate (compatibility) and structural characteristics of the LHS would influence its adoption.

Fostering engagement with stakeholders

Participants stated that fostering engagement to promote buy-in with stakeholders, including administrators, care teams, patients and caregivers, would facilitate the implementation of STAR. They recommended stakeholders be educated about what STAR is, its benefits, and for organizational stakeholders, how best to integrate STAR into their facility. See the clinician’s response below:

“I think just education [about STAR]. Just tons of education to everyone in the hospital that touches a patient. The nurses. The critical care physicians. The Hospitalists…But I think just educating the patient [about STAR] at the time of admission, just start that process. You know, this is our sepsis program, and let them know that this is going to happen at the time of discharge. And then also provide education to the providers.” (C1)

Participants also emphasized the importance of leaders heading communication about STAR with care teams and STAR navigators establishing a good rapport with clinicians who have patients enrolled in the program. See the clinician’s response below:

“Well, definitely share the information [about STAR] with their [health system leaders] teams. We have a normal leadership structure that provides the mechanism for things like this to be communicated in top down. And for sure, expecting the leaders to disseminate it from Level 2 to Level 3, Level 3 to Level 4 and on down. You know, that would be a minimum expectation…I think they should welcome you all [the STAR study team] at the meetings and give you time on the agenda to share your initiatives, at a minimum.” (C3)

These responses illustrate the relevance of the CFIR outer setting, process, and characteristics of individuals domains for the implementation of STAR, where prioritizing patient needs, attracting and involving appropriate individuals, and individual attitudes about the intervention would be facilitators of its adoption.

Share positive STAR outcomes data

Participants reported sharing positive results or impacts from the program would be helpful. They recommended using STAR performance metrics as motivation for continued buy-in and that leaders share effectiveness data. See the clinician responses below:

“I think readmission data [would be good to provide], like at 90 days, because if you are trying to get people to buy in for 90 days, cause that’s a long time, that’s about three months, I think you need to prove that it is worthwhile. If you’re trying to cut back on that 90-day readmission, because that’s what Medicare looks at, I think that would maybe entice some people to participate.” (C7)

“But, if you want to implement it as a standard process then we are going to have to see some sort of data on it before we say “yep, let’s do it”. Because there are many things that are competing for the resources that we have. So we have to on the basis on which our decisions on where the money goes, where those resources get diverted to is based on how efficiently they affect patient care, rates of readmission, and patient mortality. So we need the data to make an informed decision.” (C2)

Responses pertaining to this theme point to the significance of the CFIR intervention characteristics, inner setting and process domains in STAR’s implementation. Participants’ remarks regarding STAR’s evidence, strength and quality, shared receptivity to STAR within the LHS, and the recommendation to provide quantitative and qualitative feedback for reflecting and evaluating STAR’s quality would be facilitators of its implementation.

Good communication between STAR navigators and patient care teams/PCPs

Participants stated that good communication and recommendation-sharing between the STAR navigator and the patient’s care team and PCP will make STAR’s implementation successful. See the clinician’s response below:

“So, I think, effectively communicating with one another [the STAR navigator and clinician] what is beneficial and helping us ultimately provide for the patient from our end would be helpful. It will be a learning process, but you know, I think once we both communicate what we need from the other to be able to do our jobs, then I think that would be fine if that makes sense.” (C5)

These intervention characteristics and inner setting facilitators demonstrate the importance of intervention design, including how well STAR is bundled, presented and assembled to stakeholders, and navigator-led communication in its implementation.

Clinician promotion of STAR with patients

Our study participants emphasized the importance of clinician promotion of STAR with enrolled patients for implementation success. Specifically, our participants recommended that the LHS show patients their primary care providers and STAR navigators are in alignment to engender patient trust in the program. See the administrator’s response below:

“It always helps if they [patients] feel like it’s their own physicians or their own team that is a part of this. I think it would be important for it not to look like it was some external program that their clinicians were not involved in. So, I think, you know, trust always is important if you feel like people that you trust are endorsing something or believing it’s going to be useful.” (A8)

Similarly, one clinician said:

“I think trust, you know, would be a factor. A lot of times if patients view resources as being disconnected from their Primary Care, they may not be very accepting of them. So, if they view them as being part of “my team”, I think patients are much more likely to participate.” (C3)

Participant responses within this theme underscore the multi-domain influence of outer setting, inner setting and the process of implementation in the success of STAR, where the LHS’s prioritization of patient needs, LHS members’ and structures’ characteristics and behaviors, and the engagement of individuals with STAR would be facilitators of its implementation.

Good rapport and effective communication between STAR navigators and patients, caregivers, and family members

Participants reported that good rapport and effective communication between STAR navigators and enrolled patients and their caregivers/families would be important for implementing STAR. They emphasized the need for STAR navigators to foster a good connection with patients and their caregivers or family members. They also spoke to the integral role caregivers and family members play in patients’ post-sepsis recovery as additional points of contact who are familiar with the program if the patient does not recall what STAR is or if the patient is too ill to speak for themselves. See the clinicians’ responses below:

“I think patients get called a lot about a lot of things and they don’t always know who the person on the phone is. So, I think having that established and really something that the patient is okay with is important. And engaging, if possible, family or support members. I think that reduces barriers if they have support people available.” (C6)

“I think obviously reaching out to the family and support staff and things like that may be helpful. Some of our patients, in general, even at their baseline and at their best day aren’t going to be able to provide you the information that you need, or may not be able to provide an adequate history, or have an appropriate follow-up, and things like that, in place to be able to give you the information you need to help them as well as you would like.” (C5)

Responses within this facilitator theme highlight the importance of intervention characteristics, such as the perceived quality of STAR, and outer setting domains and constructs (patient needs and resources) in STAR navigator communication with patients and their caregivers and family members. Results show how effective navigator communication when presenting STAR to patients and their caregivers/family members, consideration of patient needs and barriers to participation, and the involvement of caregivers or family members would be facilitators of STAR’s implementation.

Barriers influencing the implementation of STAR

Our analysis identified five themes pertaining to implementation barriers. See Table 3 : CFIR-Guided Barriers to STAR Implementation.

Competing demands for staff time and resources

Participants reported that competing demands for staff time and resources, including the busy state of the LHS’ facilities at the time, COVID priorities, other concurrent program implementations, and a lack of time among clinicians to engage with STAR could be barriers to its implementation. See the administrator’s response below:

“So, I think barriers would be too many implementations going on at the same time. It would fail. The other is, right now in COVID time, it’s unlikely to muster enough support or enough interest to do it. I think we need to look at what else is going on, so that there is not information overload for the front-end teammates. And the other thing we look at is, most of these programs become paper intensive or computer intensive. That means, you are just putting things there, and then, if you ask people to do too much, yes, they do too much, but they don’t really do the thing…So just be mindful of that, what you expect them to spend time on.” (A3)

Similarly, one clinician commented:

“Now, from a willingness standpoint, not that people would necessarily disagree with the overall goals and the process of your program, it’s just that if you’re in my field, and in some of my partners, if we are being pulled in ten different directions at one time, you have to prioritize what you can do in a day. So, not willingness from the standpoint of people not wanting to participate, but sometimes people not being able to weight or value that as high as something else that needs to be done.” (C5)

Participants responses pertaining to this barrier theme illustrate the role that the LHS’s inner setting, specifically its implementation climate of decreased organizational capacity to absorb change and a lack of resources dedicated for STAR, would play in hindering the implementation of the program.

Insufficient communication and education of program value and effectiveness

Participants reported that insufficient communication and education of STAR’s value and effectiveness to other clinicians could be barriers to its implementation. See the administrator’s response below:

“To me, it’s always a matter of communication. If there was, if communication didn’t work, people didn’t see it had value, they didn’t want to put any effort into it, you know, those would really be obviously the big things.” (A8)

“So, if it’s not marketed like correctly or appropriately. If we really as attending or residents don’t see the benefit. You know, is this just another checky box, or is this really going to impact our patients in the long term? Will this make a difference in their survival? Or getting them back to a base line or improvements on a base line? I think that’s probably what’s going to help make it successful or not.” (C8)

Responses related to this barrier theme show that the LHS’s inner setting and characteristics of individuals (clinicians) are important implementation domains in the adoption of STAR. Participants identified poor quality communication, and a lack of clinician knowledge and positive beliefs about STAR’s value, would be barriers to the implementation of the program.

Underlying informational and technology gaps among patients

Participants reported several patient-facing factors related to information and technology gaps among patients that could be barriers to implementing STAR. This included a patient’s health literacy or understanding of STAR, a patient’s digital literacy, and a patient’s lack of access to technology when communicating with the STAR telehealth navigator. See the clinician responses below:

“Well, I think a lot of our patients don’t have secure housing. I think our patients’ baseline social determinants of health, like consistent phone numbers, housing, health literacy around that, I think that’s a barrier that a patient would experience [to participate in the intervention].” (C6)

“I think the only barrier is that they [patients] may not understand what is going on. But that’s okay [as if not a big deal], as long as they are receptive to someone talking to them. And like I said, I want to be respectful of our patients, but some of them just do not have the medical literacy or the insight to understand….So, I think a barrier might be that the patient may not understand why you are calling and why you are asking those questions.” (C1)

“Definitely patients have to be capable of doing it uh participating with the Telehealth. At least from the perspective of a lot of my patients and during the Coronavirus pandemic, it has been difficult to get some buy in with Telehealth linkages to care. We have a very rural population and there is some adherence issues with trying to initiate, you know, telephonic or video visits that we have kind of noticed over the last several months. So, patient participation I think in some settings would be challenging.” (C4)

Participant responses within this barrier theme highlight the importance of the outer setting (external to the LHS) in the challenge of implementing STAR, where literacy and technology gaps among patients could be barriers to program enrollees’ participating in the telehealth-based intervention.

Lack of access to community resources for patients

Finally, participants reported that a patient’s lack of access to community resources, including limited primary care, paramedicine, home physical therapy, speech therapy and mental health resources in certain communities (e.g., rural communities), could pose a barrier to the implementation of the STAR program. See the clinicians’ responses below:

“I think that the idea is a good idea [pauses], but it’s just where it would work best based upon the resources of the area. I think that is going to be the major challenge.” (C7)

“Just getting plugged into community resources that can assist with their psycho-social needs as well as their comorbidities” [would be a barrier to patient participation]. (A1)

Participant responses within this theme demonstrate the relevance of intervention characteristics and the outer setting when implementing EBPs for post-sepsis care for patients who lack access to community resources. The extent to which STAR cannot adapt and meet patients’ local needs, especially those of patients who live in areas where there are insufficient resources, will be a barrier to its implementation.

Patient distrust of the program and/or healthcare

Both administrators and clinicians interviewed stated that patient distrust of the program and/or healthcare could be a potential barrier to STAR’s implementation. These reasons included patients being slow to trust a new provider, discomfort when talking with a navigator, feeling skeptical of providers who seem unaffiliated with their primary care, and general distrust of the healthcare system, particularly for patients in rural communities or impoverished areas. See the administrator and clinician responses below:

“You know, people are always a little wary of people they do not know, especially in small and rural communities.” (A1)

“Yeah, I think most of the barriers that are already well known that go with socio economic status or poverty. Trust in the healthcare system. I think those are all going to be barriers.” (C4)

Responses within this theme point to the significance of outer setting factors and the extent to which a patient’s need to trust their provider is accurately known and prioritized by the STAR navigator. Data suggests patient distrust of the STAR program or other providers would be a barrier to implementing EBPs for post-sepsis care.

A foundation of implementation science is that intervention delivery should be tailored to local context to maximize uptake and impact [ 34 , 35 ]. Formative, or pre-implementation, evaluations facilitate initial assessment of the local context and the potential determinants for implementation success within that context. Multiple theoretical frameworks have been applied to pre-implementation evaluations; the Consolidated Framework for Implementation Science (CFIR) is one of the most widely used due to its ability to comprehensively identify implementation facilitators and barriers [ 36 ]. In this study, we utilized qualitative pre-implementation interviews to identify actionable facilitators and barriers to inform and enhance initial implementation strategies of the STAR program across diverse hospital and community settings in a large LHS. From this work, our study offers several contributions to the literature on post-sepsis care.

First, our study successfully leveraged the CFIR to inform and enhance initial implementation strategies of the STAR program across diverse hospital and community settings in a large LHS. This is in line with other studies that similarly applied the CFIR during pre-implementation and found implementation determinants like ours, such as stakeholder involvement being necessary to promote buy-in and the relevance of intervention fit within the organization’s inner setting [ 26 , 37 ]. While some have applied CFIR in the pre-implementation planning of a sepsis management intervention at a single site [ 38 ], to our knowledge, our team is the first to apply the CFIR at pre-implementation to inform the design and dissemination of a sepsis transition and recovery intervention for patients within a large LHS. We decided to guide our interview instrument development and subsequent analysis using the CFIR because we were interested, fundamentally, in the organizational change that will be needed to successfully implement the STAR program. By incorporating the CFIR domains and constructs into our interview instruments and intervention planning, our study was able to identify implementation partners and collect stakeholder input on the potential facilitators and barriers to the STAR program at a large LHS. One benefit of using the CFIR for pre-implementation work is the potential for direct translation to implementation strategies selection using the Expert Recommendations for Implementing Change (ERIC) mapping.

Second, study findings revealed the importance of stakeholder buy-in like other CFIR-guided pre-implementation studies [ 26 , 39 ] across diverse groups, including administrators, care teams, patients, and caregivers. Implementation facilitators related to buy-in that were identified included active engagement with stakeholders, education about STAR, the sharing of positive outcomes data from STAR with clinicians, and promotion of the program’s value throughout implementation. Participants also emphasized the criticality of demonstrating alignment between clinicians and the STAR program. This included the recommendation for clinician support and promotion of STAR with patients to engender patient trust in the program. Conversely, our study found implementation barriers pertaining to lack of stakeholder buy-in as well. These included that a lack of engagement and education about the post-sepsis care program’s value and effectiveness, possible patient distrust of STAR and/or of health care, and patients’ lack of access to community resources could be potential barriers to its implementation. Together these findings point to the necessity of stakeholder buy-in for overcoming inner and outer setting barriers to implementation. They also suggest successful championing of STAR should extend beyond navigator efforts alone and include system and care team participation as well.

Third, our study found the STAR program’s fit with the LHS’s inner setting to be informative for our planning. Participants reported STAR’s compatibility with the structural characteristics and implementation climate of the LHS to likely be important considerations for implementation. At the time of this study, virtual hospital care and other telehealth programs were highly active within the LHS, in part related to the need for such programs during the surge of the COVID-19 pandemic. Additionally, STAR’s alignment with other sepsis-focused work groups and sepsis champions across the LHS was identified as another possible facilitator for implementation success. We found implementation barriers pertaining to the implementation climate of the LHS’s inner setting as well. Despite acknowledging that the program would likely align with current health system goals, participants cautioned STAR would have to compete with demands for staff time and resources. Decreased organizational capacity for a new program was another potential implementation barrier identified. Participants recommended engaging clinicians about the value and effectiveness of the program to promote support and assuage concerns. These facilitators and barriers suggest health system priorities and routine healthcare practice in the inner setting should be identified and considered carefully when making post-sepsis care program implementation decisions. They also underscore how the inner setting is not simply a background of implementation but can rather serve as an important context in implementation success.

Finally, our study findings highlighted the importance of good communication between the STAR navigator and other stakeholders, including clinicians, patients, caregivers, and family members, for successful implementation. Participants recommended clear and reciprocal communication between STAR navigators and clinicians. Similarly, they advised that navigators attempt to establish good rapport with patients, caregivers, and family members by using effective communication. Several potential implementation barriers related to communication were also reported. Participants discussed underlying patient-facing information and technology gaps that could be potential barriers to communicating with STAR navigators related to digital literacy, health literacy, or a lack of access to technology to participate in STAR. These suggest further study may be recommended to identify other patient-facing environmental conditions, such as social determinants of health, affecting sepsis recovery, as proposed in other’s work [ 10 ]. These points underscore the necessity of both effective communication and communication technology to support telehealth-based sepsis transition and recovery intervention implementation.

Study limitations

A limitation of the present research is that it is based on interviews with a small sample of employees at one, albeit large, health system. Although we carefully sampled stakeholders based on their awareness, organizational authority, and involvement in activities related to implementation of a post-sepsis care intervention at study facilities, these perspectives may not necessarily reflect the experience of all facilities within the same LHS or outside of the LHS. A second limitation is that patients were not included as participants at pre-implementation, despite later finding several facilitators and barriers related to patient needs. Third, we deliberately used the CFIR, and included all domains, to inform our approach to data collection and analysis due to its comprehensive assessment of implementation determinants and well-described associations with implementation strategies. However, using CFIR alone may have limited collection of other relevant contextual factors not represented by CFIR or specifically incorporated in our data collection. Our analysis strategy that combined inductive and deductive methods did allow for capture of themes outside of CFIR, if new information emerged from participant responses. Finally, our analysis strategy focused specifically on identifying key individual determinants; thus, additional empirical analyses examining the causal pathways or combinations of contextual factors may be helpful to advance evidence and guide decision making regarding effective implementation strategies tailored to complex determinants.

Our findings demonstrate effective use of the CFIR as a robust framework to examine facilitators and barriers for pre-implementation planning of post-sepsis care programs within diverse hospital and community settings in a large LHS. The comprehensive structure of the framework enabled researchers to identify key implementation determinants across external-, internal-, and program-level domains, plan for organizational change associated with implementation, and engage with relevant stakeholders. Conducting a structured pre-implementation evaluation helps researchers design with implementation in mind prior to effectiveness studies and should be considered a key component of Type I hybrid trials when feasible.

Availability of data and materials

The datasets generated and analyzed during the study are not available due to participant privacy and ethics restrictions, but the codebook and data collection tools may be available from the corresponding author on reasonable request.

Abbreviations

Sepsis transition and recovery

Learning health system

Consolidated framework for implementation research

Evidence-based practices

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Acknowledgements

The authors would like to thank all of the study participants for sharing their time and insights.

Research reported in this publication was supported by the National Institute Of Nursing Research of the National Institutes of Health under Award Number R01NR018434. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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TE, ST, MK, and HT contributed to the design of the study. TE, ST, MK, RB and KO contributed to the acquisition of study data. TE, RB, KO, and HT analyzed the data. TE, ST, and MK contributed to the interpretation of the data. TE, ST, MK, RB, and HT drafted the manuscript. All authors critically revised the intellectual content of the manuscript. All authors approved the final manuscript.

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Eaton, T.A., Kowalkowski, M., Burns, R. et al. Pre-implementation planning for a sepsis intervention in a large learning health system: a qualitative study. BMC Health Serv Res 24 , 996 (2024). https://doi.org/10.1186/s12913-024-11344-x

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Qualitative Research Questionnaire – Types & Examples

Published by Alvin Nicolas at August 19th, 2024 , Revised On August 20, 2024

Before you start your research, the first thing you need to identify is the research method . Depending on different factors, you will either choose a quantitative or qualitative study.

Qualitative research is a great tool that helps understand the depth and richness of human opinions and experiences. Unlike quantitative research, which focuses on numerical data , qualitative research allows exploring and interpreting the experiences of the subject. Questionnaires, although mostly associated with quantitative research, can also be a valuable instrument in qualitative studies. Let’s explore what qualitative research questionnaires are and how you can create one.

What Is A Qualitative Research Questionnaire

Qualitative research questionnaires are a structured or semi-structured set of questions designed to gather detailed, open-ended participant responses. It allows you to uncover underlying reasons and opinions and provides insights into a particular phenomenon.

While quantitative questionnaires often have closed-ended questions and numerical responses, a qualitative questionnaire encourages participants to express themselves freely. Before you design your questionnaire, you should know exactly what you need so you can keep your questions specific enough for the participants to understand.

For example:

Describe your experience using our product.
How has technology impacted your work-life balance?

Types of Qualitative Research Questions With Examples

Now that you are familiar with what qualitative research questions are, let’s look at the different types of questions you can use in your survey .

Descriptive Questions

These are used to explore and describe a phenomenon in detail. It helps answer the “what” part of the research, and the questions are mostly foundational.

Example: How do students experience online learning?

Comparative Questions

This type allows you to compare and contrast different groups or situations. You can explore the differences and similarities to highlight the impact of specific variables.

Example: How do the study habits of first-year and fourth-year university students differ?

Interpretive Questions

These questions help you understand the meanings people attach to experiences or phenomena by answering the “how” and “why”.

Example: What does “success” mean to entrepreneurs?

Evaluative Questions

You can use these to assess the quality or value of something. These allow you to understand the outcomes of various situations.

Example: How effective is the new customer service training program?

Process-Oriented Questions

To understand how something happens or develops over time, researchers often use process-oriented questions.

Example: How do individuals develop their career goals?

Exploratory Questions

These allow you to discover new perspectives on a topic. However, you have to be careful that there must be no preconceived notions or research biases to it.

Example: What are the emerging trends in the mobile gaming industry?

How To Write Qualitative Research Questions?

For your study to be successful, it is important to consider designing a questionnaire for qualitative research critically, as it will shape your research and data collection. Here is an easy guide to writing your qualitative research questions perfectly.

Tip 1: Understand Your Research Goals

Many students start their research without clear goals, and they have to make substantial changes to their study in the middle of the research. This wastes time and resources.

Before you start crafting your questions, it is important to know your research objectives. You should know what you aim to discover through your research, or what specific knowledge gaps you are going to fill. With the help of a well-defined research focus, you can develop relevant and meaningful information.

Tip 2: Choose The Structure For Research Questions

There are mostly open-ended questionnaires in qualitative research. They begin with words like “how,” “what,” and “why.” However, the structure of your research questions depends on your research design . You have to consider using broad, overarching questions to explore the main research focus, and then add some specific probes to further research the particular aspects of the topic.

Tip 3: Use Clear Language

The more clear and concise your research questions are, the more effective and free from ambiguity they will be. Do not use complex terminology that might confuse participants. Try using simple and direct language that accurately conveys your intended meaning.

Here is a table to explain the wrong and right ways of writing your qualitative research questions.


How would you characterise your attitude towards e-commerce transactions?	How do you feel about online shopping?
Could you elucidate on the obstacles encountered in your professional role?	What challenges do you face in your job?
What is your evaluation of the innovative product aesthetic?	What do you think about the new product design?
Can you elaborate on the influence of social networking platforms on your interpersonal connections?	How has social media impacted your relationships?

Tip 4: Check Relevance With Research Goals

Once you have developed some questions, check if they align with your research objectives. You must ensure that each question contributes to your overall research questions. After this, you can eliminate any questions that do not serve a clear purpose in your study.

Tip 5: Concentrate On A Single Theme

While it is tempting to cover multiple aspects of a topic in one question, it is best to focus on a single theme per question. This helps to elicit focused responses from participants. Moreover, you have to avoid combining unrelated concepts into a single question.

If your main research question is complicated, you can create sub-questions with a “ladder structure”. These allow you to understand the attributes, consequences, and core values of your research. For example, let’s say your main broad research question is:

How do you feel about your overall experience with our company?

The intermediate questions may be:

What aspects of your experience were positive?
What aspects of your experience were negative?
How likely are you to recommend our company to a friend or colleague?

Types Of Survey Questionnaires In Qualitative Research

It is important to consider your research objectives, target population, resources and needed depth of research when selecting a survey method. The main types of qualitative surveys are discussed below.

Face To Face Surveys

Face-to-face surveys involve direct interaction between the researcher and the participant. This method allows observers to capture non-verbal cues, body language, and facial expressions, and helps adapt questions based on participant responses. They also let you clarify any misunderstandings. Moreover, there is a higher response rate because of personal interaction.

Example: A researcher conducting a study on consumer experiences with a new product might visit participants’ homes to conduct a detailed interview.

Telephone Surveys

These type of qualitative research survey questionnaires provide a less intrusive method for collecting qualitative data. The benefits of telephone surveys include, that it allows you to collect data from a wider population. Moreover, it is generally less expensive than face-to-face interviews and interviews can be conducted efficiently.

Example: A market research firm might conduct telephone surveys to understand customer satisfaction with a telecommunication service.

Online Surveys

Online survey questionnaires are a convenient and cost-effective way to gather qualitative data. You can reach a wide audience quickly, and participants may feel more comfortable sharing sensitive information because of anonymity. Additionally, there are no travel or printing expenses.

Example: A university might use online surveys to explore students’ perceptions of online learning experiences.

Strengths & Limitations Of Questionnaires In Qualitative Research

Questionnaires are undoubtedly a great data collection tool. However, it comes with its fair share of advantages and disadvantages. Let’s discuss the benefits of questionnaires in qualitative research and their cons as well.


Can be inexpensive to distribute and collect	Can suffer from low response rates
Allow researchers to reach a wide audience	There is a lack of control over the environment
Consistent across participants	Once the questionnaire is distributed, it cannot be modified
Anonymity helps make participants feel more comfortable	Participants may not fully understand questions
Open-ended questions provide rich, detailed responses	Open-ended questions may not capture the right answers

Qualitative Research Questionnaire Example

Here is a concise qualitative research questionnaire sample for research papers to give you a better idea of its format and how it is presented.

Thank you for participating in our survey. We value your feedback on our new mobile app. Your responses will help us improve the applications and better meet your needs.

Demographic Information

Occupation:
How long have you been using smartphones:
How would you describe your overall experience with the new mobile app?
What do you like most about the app?
What do you dislike most about the app?
Are there any specific features you find particularly useful or helpful? Please explain.
Are there any features you think are missing or could be improved? Please elaborate.
How easy is the app to navigate? Please explain any difficulties you encountered.
How does this app compare to other similar apps you have used?
What are your expectations for future updates or improvements to the app?
Is there anything else you would like to share about your experience with the app?

Are questionnaires quantitative or qualitative research?

A survey research questionnaire can have both qualitative and quantitative questions. The qualitative questions are mostly open-ended, and quantitative questions take the form of yes/no, or Likert scale rating.

Can we use questionnaires in qualitative research?

Yes, survey questionnaires can be used in qualitative research for data collection. However, instead of a Likert scale or rating, you can post open-ended questions to your respondents. The participants can provide detailed responses to the questions asked.

Why are questionnaires good for qualitative research?

In qualitative research, questionnaires allow you to collect qualitative data. The open-ended and unstructured questions help respondents present their ideas freely and provide insights.

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

Shiraz University of Medical Sciences

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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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“As If They Didn't Know There are More People": A Qualitative Study of Adaptation Experiences in Families with Young Children

26 Pages Posted: 26 Aug 2024

Ana María Quezada-Ugalde

University of La Laguna

Alfonso Miguel García Hernández

BackgroundFew studies have focused on families with young children in Latin America, prompting this research to explore the adaptation experiences of these families during the COVID-19 pandemic restrictions.PurposeTo analyze through the Middle-Range Theory (MRT) of Adapting to Life Events the experiences of families with young children during the COVID-19 pandemic restrictions in Costa Rica and Mexico.MethodsEighteen semi-structured interviews were conducted with families with young children and data saturation was achieved. A phenomenological approach was adopted. Data were analyzed using a descriptive method and an Interpretative Phenomenological Analysis (IPA).ResultsSince the descriptive analysis revealed two types of stimuli: internal challenges and specific event challenges. These encompassed seven coping strategies. The IPA identified three adaptative outcomes: lessened of anxiety and fear, protected mental health, and teamwork.ConclusionsFamilies with young children in Costa Rica and Mexico experienced the COVID-19 pandemic employed a variety of effective coping strategies. These strategies facilitated adaptive behavior that fulfilled their survival and parenting goals.Practice ImplicationsIt is crucial to develop public policies, plans, and programs that enhance the role of pediatric nursing within the community. Such initiatives should assist parents in identifying and applying effective coping strategies to the challenging experiences during their children's early years.

Note: Funding Information: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Interests: None. Ethics Approval Statement: The study was approved by the Ethics Committee of Animal Research and Welfare (CEIBA) at the University of La Laguna (CEIBA2021-3117), the Scientific Ethics Committee (CEC) at the University of Costa Rica (CEC-183-2022), and the Research Ethics Committee of the Manuel Gea González General Hospital (12-90-2022).

Keywords: Children, Families, Adaptation, COVID-19, Qualitative research

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Ana María Quezada-Ugalde (Contact Author)

University of la laguna ( email ).

La Laguna, Tenerife, 38071 Spain

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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

BMC Women's Health volume 24 , Article number: 469 ( 2024 ) Cite this article

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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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What Is Qualitative Research? | Methods & Examples

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Criteria for Good Qualitative Research: A Comprehensive Review

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Good Qualitative Research: Opening up the Debate

What is Qualitative in Research

Introduction

Criteria for Evaluating Qualitative Studies

Qualitative Research: Interpretive Paradigms

Improving Quality: Strategies

How to Assess the Quality of the Research Findings?

Quality Checklists: Tools for Assessing the Quality

Conclusions, Future Directions, and Outlook

Prospects : A Road Ahead for Qualitative Research

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Presenting and Evaluating Qualitative Research

INTRODUCTION

RIGOUR IN QUALITATIVE RESEARCH

STRENGTHS AND LIMITATIONS OF QUALITATIVE RESEARCH

Strengths of Qualitative Research

Limitations of Qualitative Research

PRESENTATION OF QUALITATIVE RESEARCH FINDINGS

Data From an Interview.

Data From Observations

Data From Focus Groups

GUIDANCE FOR PUBLISHING QUALITATIVE RESEARCH

Introduction.

Data Analysis.

Discussion.

Conclusion.

CHECKLIST FOR QUALITATIVE PAPERS

ACKNOWLEDGEMENTS

Appendix 1. Checklist for authors and reviewers of qualitative research.

Pre-implementation planning for a sepsis intervention in a large learning health system: a qualitative study

Conclusions

Trial registration

Contributions to literature

Study design

Data collection

Data analysis

Facilitators influencing the implementation of STAR

Alignment between STAR and health system goals

Fostering engagement with stakeholders

Share positive STAR outcomes data

Good communication between STAR navigators and patient care teams/PCPs

Clinician promotion of STAR with patients

Good rapport and effective communication between STAR navigators and patients, caregivers, and family members

Barriers influencing the implementation of STAR

Competing demands for staff time and resources

Insufficient communication and education of program value and effectiveness

Underlying informational and technology gaps among patients

Lack of access to community resources for patients

Patient distrust of the program and/or healthcare

Study limitations

Availability of data and materials

Abbreviations

Acknowledgements

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