what are the limitations of a qualitative research study

23 Advantages and Disadvantages of Qualitative Research

Investigating methodologies. Taking a closer look at ethnographic, anthropological, or naturalistic techniques. Data mining through observer recordings. This is what the world of qualitative research is all about. It is the comprehensive and complete data that is collected by having the courage to ask an open-ended question.

Print media has used the principles of qualitative research for generations. Now more industries are seeing the advantages that come from the extra data that is received by asking more than a “yes” or “no” question.

The advantages and disadvantages of qualitative research are quite unique. On one hand, you have the perspective of the data that is being collected. On the other hand, you have the techniques of the data collector and their own unique observations that can alter the information in subtle ways.

That’s why these key points are so important to consider.

What Are the Advantages of Qualitative Research?

1. Subject materials can be evaluated with greater detail. There are many time restrictions that are placed on research methods. The goal of a time restriction is to create a measurable outcome so that metrics can be in place. Qualitative research focuses less on the metrics of the data that is being collected and more on the subtleties of what can be found in that information. This allows for the data to have an enhanced level of detail to it, which can provide more opportunities to glean insights from it during examination.

2. Research frameworks can be fluid and based on incoming or available data. Many research opportunities must follow a specific pattern of questioning, data collection, and information reporting. Qualitative research offers a different approach. It can adapt to the quality of information that is being gathered. If the available data does not seem to be providing any results, the research can immediately shift gears and seek to gather data in a new direction. This offers more opportunities to gather important clues about any subject instead of being confined to a limited and often self-fulfilling perspective.

3. Qualitative research data is based on human experiences and observations. Humans have two very different operating systems. One is a subconscious method of operation, which is the fast and instinctual observations that are made when data is present. The other operating system is slower and more methodical, wanting to evaluate all sources of data before deciding. Many forms of research rely on the second operating system while ignoring the instinctual nature of the human mind. Qualitative research doesn’t ignore the gut instinct. It embraces it and the data that can be collected is often better for it.

4. Gathered data has a predictive quality to it. One of the common mistakes that occurs with qualitative research is an assumption that a personal perspective can be extrapolated into a group perspective. This is only possible when individuals grow up in similar circumstances, have similar perspectives about the world, and operate with similar goals. When these groups can be identified, however, the gathered individualistic data can have a predictive quality for those who are in a like-minded group. At the very least, the data has a predictive quality for the individual from whom it was gathered.

5. Qualitative research operates within structures that are fluid. Because the data being gathered through this type of research is based on observations and experiences, an experienced researcher can follow-up interesting answers with additional questions. Unlike other forms of research that require a specific framework with zero deviation, researchers can follow any data tangent which makes itself known and enhance the overall database of information that is being collected.

6. Data complexities can be incorporated into generated conclusions. Although our modern world tends to prefer statistics and verifiable facts, we cannot simply remove the human experience from the equation. Different people will have remarkably different perceptions about any statistic, fact, or event. This is because our unique experiences generate a different perspective of the data that we see. These complexities, when gathered into a singular database, can generate conclusions with more depth and accuracy, which benefits everyone.

7. Qualitative research is an open-ended process. When a researcher is properly prepared, the open-ended structures of qualitative research make it possible to get underneath superficial responses and rational thoughts to gather information from an individual’s emotional response. This is critically important to this form of researcher because it is an emotional response which often drives a person’s decisions or influences their behavior.

8. Creativity becomes a desirable quality within qualitative research. It can be difficult to analyze data that is obtained from individual sources because many people subconsciously answer in a way that they think someone wants. This desire to “please” another reduces the accuracy of the data and suppresses individual creativity. By embracing the qualitative research method, it becomes possible to encourage respondent creativity, allowing people to express themselves with authenticity. In return, the data collected becomes more accurate and can lead to predictable outcomes.

9. Qualitative research can create industry-specific insights. Brands and businesses today need to build relationships with their core demographics to survive. The terminology, vocabulary, and jargon that consumers use when looking at products or services is just as important as the reputation of the brand that is offering them. If consumers are receiving one context, but the intention of the brand is a different context, then the miscommunication can artificially restrict sales opportunities. Qualitative research gives brands access to these insights so they can accurately communicate their value propositions.

10. Smaller sample sizes are used in qualitative research, which can save on costs. Many qualitative research projects can be completed quickly and on a limited budget because they typically use smaller sample sizes that other research methods. This allows for faster results to be obtained so that projects can move forward with confidence that only good data is able to provide.

11. Qualitative research provides more content for creatives and marketing teams. When your job involves marketing, or creating new campaigns that target a specific demographic, then knowing what makes those people can be quite challenging. By going through the qualitative research approach, it becomes possible to congregate authentic ideas that can be used for marketing and other creative purposes. This makes communication between the two parties to be handled with more accuracy, leading to greater level of happiness for all parties involved.

12. Attitude explanations become possible with qualitative research. Consumer patterns can change on a dime sometimes, leaving a brand out in the cold as to what just happened. Qualitative research allows for a greater understanding of consumer attitudes, providing an explanation for events that occur outside of the predictive matrix that was developed through previous research. This allows the optimal brand/consumer relationship to be maintained.

What Are the Disadvantages of Qualitative Research?

1. The quality of the data gathered in qualitative research is highly subjective. This is where the personal nature of data gathering in qualitative research can also be a negative component of the process. What one researcher might feel is important and necessary to gather can be data that another researcher feels is pointless and won’t spend time pursuing it. Having individual perspectives and including instinctual decisions can lead to incredibly detailed data. It can also lead to data that is generalized or even inaccurate because of its reliance on researcher subjectivisms.

2. Data rigidity is more difficult to assess and demonstrate. Because individual perspectives are often the foundation of the data that is gathered in qualitative research, it is more difficult to prove that there is rigidity in the information that is collective. The human mind tends to remember things in the way it wants to remember them. That is why memories are often looked at fondly, even if the actual events that occurred may have been somewhat disturbing at the time. This innate desire to look at the good in things makes it difficult for researchers to demonstrate data validity.

3. Mining data gathered by qualitative research can be time consuming. The number of details that are often collected while performing qualitative research are often overwhelming. Sorting through that data to pull out the key points can be a time-consuming effort. It is also a subjective effort because what one researcher feels is important may not be pulled out by another researcher. Unless there are some standards in place that cannot be overridden, data mining through a massive number of details can almost be more trouble than it is worth in some instances.

4. Qualitative research creates findings that are valuable, but difficult to present. Presenting the findings which come out of qualitative research is a bit like listening to an interview on CNN. The interviewer will ask a question to the interviewee, but the goal is to receive an answer that will help present a database which presents a specific outcome to the viewer. The goal might be to have a viewer watch an interview and think, “That’s terrible. We need to pass a law to change that.” The subjective nature of the information, however, can cause the viewer to think, “That’s wonderful. Let’s keep things the way they are right now.” That is why findings from qualitative research are difficult to present. What a research gleans from the data can be very different from what an outside observer gleans from the data.

5. Data created through qualitative research is not always accepted. Because of the subjective nature of the data that is collected in qualitative research, findings are not always accepted by the scientific community. A second independent qualitative research effort which can produce similar findings is often necessary to begin the process of community acceptance.

6. Researcher influence can have a negative effect on the collected data. The quality of the data that is collected through qualitative research is highly dependent on the skills and observation of the researcher. If a researcher has a biased point of view, then their perspective will be included with the data collected and influence the outcome. There must be controls in place to help remove the potential for bias so the data collected can be reviewed with integrity. Otherwise, it would be possible for a researcher to make any claim and then use their bias through qualitative research to prove their point.

7. Replicating results can be very difficult with qualitative research. The scientific community wants to see results that can be verified and duplicated to accept research as factual. In the world of qualitative research, this can be very difficult to accomplish. Not only do you have the variability of researcher bias for which to account within the data, but there is also the informational bias that is built into the data itself from the provider. This means the scope of data gathering can be extremely limited, even if the structure of gathering information is fluid, because of each unique perspective.

8. Difficult decisions may require repetitive qualitative research periods. The smaller sample sizes of qualitative research may be an advantage, but they can also be a disadvantage for brands and businesses which are facing a difficult or potentially controversial decision. A small sample is not always representative of a larger population demographic, even if there are deep similarities with the individuals involve. This means a follow-up with a larger quantitative sample may be necessary so that data points can be tracked with more accuracy, allowing for a better overall decision to be made.

9. Unseen data can disappear during the qualitative research process. The amount of trust that is placed on the researcher to gather, and then draw together, the unseen data that is offered by a provider is enormous. The research is dependent upon the skill of the researcher being able to connect all the dots. If the researcher can do this, then the data can be meaningful and help brands and progress forward with their mission. If not, there is no way to alter course until after the first results are received. Then a new qualitative process must begin.

10. Researchers must have industry-related expertise. You can have an excellent researcher on-board for a project, but if they are not familiar with the subject matter, they will have a difficult time gathering accurate data. For qualitative research to be accurate, the interviewer involved must have specific skills, experiences, and expertise in the subject matter being studied. They must also be familiar with the material being evaluated and have the knowledge to interpret responses that are received. If any piece of this skill set is missing, the quality of the data being gathered can be open to interpretation.

11. Qualitative research is not statistically representative. The one disadvantage of qualitative research which is always present is its lack of statistical representation. It is a perspective-based method of research only, which means the responses given are not measured. Comparisons can be made and this can lead toward the duplication which may be required, but for the most part, quantitative data is required for circumstances which need statistical representation and that is not part of the qualitative research process.

The advantages and disadvantages of qualitative research make it possible to gather and analyze individualistic data on deeper levels. This makes it possible to gain new insights into consumer thoughts, demographic behavioral patterns, and emotional reasoning processes. When a research can connect the dots of each information point that is gathered, the information can lead to personalized experiences, better value in products and services, and ongoing brand development.

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CRO Guide   >  Chapter 3.1

Qualitative Research: Definition, Methodology, Limitation & Examples

Qualitative research is a method focused on understanding human behavior and experiences through non-numerical data. Examples of qualitative research include:

• One-on-one interviews,
• Focus groups, Ethnographic research,
• Case studies,
• Record keeping,
• Qualitative observations

In this article, we’ll provide tips and tricks on how to use qualitative research to better understand your audience through real world examples and improve your ROI. We’ll also learn the difference between qualitative and quantitative data.

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Marketers often seek to understand their customers deeply. Qualitative research methods such as face-to-face interviews, focus groups, and qualitative observations can provide valuable insights into your products, your market, and your customers’ opinions and motivations. Understanding these nuances can significantly enhance marketing strategies and overall customer satisfaction.

What is Qualitative Research

Qualitative research is a market research method that focuses on obtaining data through open-ended and conversational communication. This method focuses on the “why” rather than the “what” people think about you. Thus, qualitative research seeks to uncover the underlying motivations, attitudes, and beliefs that drive people’s actions. 

Let’s say you have an online shop catering to a general audience. You do a demographic analysis and you find out that most of your customers are male. Naturally, you will want to find out why women are not buying from you. And that’s what qualitative research will help you find out.

In the case of your online shop, qualitative research would involve reaching out to female non-customers through methods such as in-depth interviews or focus groups. These interactions provide a platform for women to express their thoughts, feelings, and concerns regarding your products or brand. Through qualitative analysis, you can uncover valuable insights into factors such as product preferences, user experience, brand perception, and barriers to purchase.

Types of Qualitative Research Methods

Qualitative research methods are designed in a manner that helps reveal the behavior and perception of a target audience regarding a particular topic.

The most frequently used qualitative analysis methods are one-on-one interviews, focus groups, ethnographic research, case study research, record keeping, and qualitative observation.

1. One-on-one interviews

Conducting one-on-one interviews is one of the most common qualitative research methods. One of the advantages of this method is that it provides a great opportunity to gather precise data about what people think and their motivations.

Spending time talking to customers not only helps marketers understand who their clients are, but also helps with customer care: clients love hearing from brands. This strengthens the relationship between a brand and its clients and paves the way for customer testimonials.

• A company might conduct interviews to understand why a product failed to meet sales expectations.
• A researcher might use interviews to gather personal stories about experiences with healthcare.

These interviews can be performed face-to-face or on the phone and usually last between half an hour to over two hours. 

When a one-on-one interview is conducted face-to-face, it also gives the marketer the opportunity to read the body language of the respondent and match the responses.

2. Focus groups

Focus groups gather a small number of people to discuss and provide feedback on a particular subject. The ideal size of a focus group is usually between five and eight participants. The size of focus groups should reflect the participants’ familiarity with the topic. For less important topics or when participants have little experience, a group of 10 can be effective. For more critical topics or when participants are more knowledgeable, a smaller group of five to six is preferable for deeper discussions.

The main goal of a focus group is to find answers to the “why”, “what”, and “how” questions. This method is highly effective in exploring people’s feelings and ideas in a social setting, where group dynamics can bring out insights that might not emerge in one-on-one situations.

• A focus group could be used to test reactions to a new product concept.
• Marketers might use focus groups to see how different demographic groups react to an advertising campaign.

One advantage that focus groups have is that the marketer doesn’t necessarily have to interact with the group in person. Nowadays focus groups can be sent as online qualitative surveys on various devices.

Focus groups are an expensive option compared to the other qualitative research methods, which is why they are typically used to explain complex processes.

3. Ethnographic research

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

This method aims at understanding the cultures, challenges, motivations, and settings that occur.

• A study of workplace culture within a tech startup.
• Observational research in a remote village to understand local traditions.

Ethnographic research requires the marketer to adapt to the target audiences’ environments (a different organization, a different city, or even a remote location), which is why geographical constraints can be an issue while collecting data.

This type of research can last from a few days to a few years. It’s challenging and time-consuming and solely depends on the expertise of the marketer to be able to analyze, observe, and infer the data.

4. Case study research

The case study method has grown into a valuable qualitative research method. This type of research method is usually used in education or social sciences. It involves a comprehensive examination of a single instance or event, providing detailed insights into complex issues in real-life contexts.  

• Analyzing a single school’s innovative teaching method.
• A detailed study of a patient’s medical treatment over several years.

Case study research may seem difficult to operate, but it’s actually one of the simplest ways of conducting research as it involves a deep dive and thorough understanding of the data collection methods and inferring the data.

5. Record keeping

Record keeping is similar to going to the library: you go over books or any other reference material to collect relevant data. This method uses already existing reliable documents and similar sources of information as a data source.

• Historical research using old newspapers and letters.
• A study on policy changes over the years by examining government records.

This method is useful for constructing a historical context around a research topic or verifying other findings with documented evidence.

6. Qualitative observation

Qualitative observation is a method that uses subjective methodologies to gather systematic information or data. This method deals with the five major sensory organs and their functioning, sight, smell, touch, taste, and hearing.

• Sight : Observing the way customers visually interact with product displays in a store to understand their browsing behaviors and preferences.
• Smell : Noting reactions of consumers to different scents in a fragrance shop to study the impact of olfactory elements on product preference.
• Touch : Watching how individuals interact with different materials in a clothing store to assess the importance of texture in fabric selection.
• Taste : Evaluating reactions of participants in a taste test to identify flavor profiles that appeal to different demographic groups.
• Hearing : Documenting responses to changes in background music within a retail environment to determine its effect on shopping behavior and mood.

Below we are also providing real-life examples of qualitative research that demonstrate practical applications across various contexts:

Qualitative Research Real World Examples

Let’s explore some examples of how qualitative research can be applied in different contexts.

1. Online grocery shop with a predominantly male audience

Method used: one-on-one interviews.

Let’s go back to one of the previous examples. You have an online grocery shop. By nature, it addresses a general audience, but after you do a demographic analysis you find out that most of your customers are male.

One good method to determine why women are not buying from you is to hold one-on-one interviews with potential customers in the category.

Interviewing a sample of potential female customers should reveal why they don’t find your store appealing. The reasons could range from not stocking enough products for women to perhaps the store’s emphasis on heavy-duty tools and automotive products, for example. These insights can guide adjustments in inventory and marketing strategies.

2. Software company launching a new product

Method used: focus groups.

Focus groups are great for establishing product-market fit.

Let’s assume you are a software company that wants to launch a new product and you hold a focus group with 12 people. Although getting their feedback regarding users’ experience with the product is a good thing, this sample is too small to define how the entire market will react to your product.

So what you can do instead is holding multiple focus groups in 20 different geographic regions. Each region should be hosting a group of 12 for each market segment; you can even segment your audience based on age. This would be a better way to establish credibility in the feedback you receive.

3. Alan Pushkin’s “God’s Choice: The Total World of a Fundamentalist Christian School”

Method used: ethnographic research.

Moving from a fictional example to a real-life one, let’s analyze Alan Peshkin’s 1986 book “God’s Choice: The Total World of a Fundamentalist Christian School”.

Peshkin studied the culture of Bethany Baptist Academy by interviewing the students, parents, teachers, and members of the community alike, and spending eighteen months observing them to provide a comprehensive and in-depth analysis of Christian schooling as an alternative to public education.

The study highlights the school’s unified purpose, rigorous academic environment, and strong community support while also pointing out its lack of cultural diversity and openness to differing viewpoints. These insights are crucial for understanding how such educational settings operate and what they offer to students.

Even after discovering all this, Peshkin still presented the school in a positive light and stated that public schools have much to learn from such schools.

Peshkin’s in-depth research represents a qualitative study that uses observations and unstructured interviews, without any assumptions or hypotheses. He utilizes descriptive or non-quantifiable data on Bethany Baptist Academy specifically, without attempting to generalize the findings to other Christian schools.

4. Understanding buyers’ trends

Method used: record keeping.

Another way marketers can use quality research is to understand buyers’ trends. To do this, marketers need to look at historical data for both their company and their industry and identify where buyers are purchasing items in higher volumes.

For example, electronics distributors know that the holiday season is a peak market for sales while life insurance agents find that spring and summer wedding months are good seasons for targeting new clients.

5. Determining products/services missing from the market

Conducting your own research isn’t always necessary. If there are significant breakthroughs in your industry, you can use industry data and adapt it to your marketing needs.

The influx of hacking and hijacking of cloud-based information has made Internet security a topic of many industry reports lately. A software company could use these reports to better understand the problems its clients are facing.

As a result, the company can provide solutions prospects already know they need.

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Qualitative Research Approaches

Once the marketer has decided that their research questions will provide data that is qualitative in nature, the next step is to choose the appropriate qualitative approach.

The approach chosen will take into account the purpose of the research, the role of the researcher, the data collected, the method of data analysis , and how the results will be presented. The most common approaches include:

• Narrative : This method focuses on individual life stories to understand personal experiences and journeys. It examines how people structure their stories and the themes within them to explore human existence. For example, a narrative study might look at cancer survivors to understand their resilience and coping strategies.
• Phenomenology : attempts to understand or explain life experiences or phenomena; It aims to reveal the depth of human consciousness and perception, such as by studying the daily lives of those with chronic illnesses.
• Grounded theory : investigates the process, action, or interaction with the goal of developing a theory “grounded” in observations and empirical data. 
• Ethnography : describes and interprets an ethnic, cultural, or social group;
• Case study : examines episodic events in a definable framework, develops in-depth analyses of single or multiple cases, and generally explains “how”. An example might be studying a community health program to evaluate its success and impact.

How to Analyze Qualitative Data

Analyzing qualitative data involves interpreting non-numerical data to uncover patterns, themes, and deeper insights. This process is typically more subjective and requires a systematic approach to ensure reliability and validity. 

1. Data Collection

Ensure that your data collection methods (e.g., interviews, focus groups, observations) are well-documented and comprehensive. This step is crucial because the quality and depth of the data collected will significantly influence the analysis.

2. Data Preparation

Once collected, the data needs to be organized. Transcribe audio and video recordings, and gather all notes and documents. Ensure that all data is anonymized to protect participant confidentiality where necessary.

3. Familiarization

Immerse yourself in the data by reading through the materials multiple times. This helps you get a general sense of the information and begin identifying patterns or recurring themes.

Develop a coding system to tag data with labels that summarize and account for each piece of information. Codes can be words, phrases, or acronyms that represent how these segments relate to your research questions.

• Descriptive Coding : Summarize the primary topic of the data.
• In Vivo Coding : Use language and terms used by the participants themselves.
• Process Coding : Use gerunds (“-ing” words) to label the processes at play.
• Emotion Coding : Identify and record the emotions conveyed or experienced.

5. Thematic Development

Group codes into themes that represent larger patterns in the data. These themes should relate directly to the research questions and form a coherent narrative about the findings.

6. Interpreting the Data

Interpret the data by constructing a logical narrative. This involves piecing together the themes to explain larger insights about the data. Link the results back to your research objectives and existing literature to bolster your interpretations.

7. Validation

Check the reliability and validity of your findings by reviewing if the interpretations are supported by the data. This may involve revisiting the data multiple times or discussing the findings with colleagues or participants for validation.

8. Reporting

Finally, present the findings in a clear and organized manner. Use direct quotes and detailed descriptions to illustrate the themes and insights. The report should communicate the narrative you’ve built from your data, clearly linking your findings to your research questions.

Limitations of qualitative research

The disadvantages of qualitative research are quite unique. The techniques of the data collector and their own unique observations can alter the information in subtle ways. That being said, these are the qualitative research’s limitations:

1. It’s a time-consuming process

The main drawback of qualitative study is that the process is time-consuming. Another problem is that the interpretations are limited. Personal experience and knowledge influence observations and conclusions.

Thus, qualitative research might take several weeks or months. Also, since this process delves into personal interaction for data collection, discussions often tend to deviate from the main issue to be studied.

2. You can’t verify the results of qualitative research

Because qualitative research is open-ended, participants have more control over the content of the data collected. So the marketer is not able to verify the results objectively against the scenarios stated by the respondents. For example, in a focus group discussing a new product, participants might express their feelings about the design and functionality. However, these opinions are influenced by individual tastes and experiences, making it difficult to ascertain a universally applicable conclusion from these discussions.

3. It’s a labor-intensive approach

Qualitative research requires a labor-intensive analysis process such as categorization, recording, etc. Similarly, qualitative research requires well-experienced marketers to obtain the needed data from a group of respondents.

4. It’s difficult to investigate causality

Qualitative research requires thoughtful planning to ensure the obtained results are accurate. There is no way to analyze qualitative data mathematically. This type of research is based more on opinion and judgment rather than results. Because all qualitative studies are unique they are difficult to replicate.

5. Qualitative research is not statistically representative

Because qualitative research is a perspective-based method of research, the responses given are not measured.

Comparisons can be made and this can lead toward duplication, but for the most part, quantitative data is required for circumstances that need statistical representation and that is not part of the qualitative research process.

While doing a qualitative study, it’s important to cross-reference the data obtained with the quantitative data. By continuously surveying prospects and customers marketers can build a stronger database of useful information.

Quantitative vs. Qualitative Research

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Quantitative and qualitative research are two distinct methodologies used in the field of market research, each offering unique insights and approaches to understanding consumer behavior and preferences.

As we already defined, qualitative analysis seeks to explore the deeper meanings, perceptions, and motivations behind human behavior through non-numerical data. On the other hand, quantitative research focuses on collecting and analyzing numerical data to identify patterns, trends, and statistical relationships.  

Let’s explore their key differences: 

Nature of Data:

• Quantitative research : Involves numerical data that can be measured and analyzed statistically.
• Qualitative research : Focuses on non-numerical data, such as words, images, and observations, to capture subjective experiences and meanings.

Research Questions:

• Quantitative research : Typically addresses questions related to “how many,” “how much,” or “to what extent,” aiming to quantify relationships and patterns.
• Qualitative research: Explores questions related to “why” and “how,” aiming to understand the underlying motivations, beliefs, and perceptions of individuals.

Data Collection Methods:

• Quantitative research : Relies on structured surveys, experiments, or observations with predefined variables and measures.
• Qualitative research : Utilizes open-ended interviews, focus groups, participant observations, and textual analysis to gather rich, contextually nuanced data.

Analysis Techniques:

• Quantitative research: Involves statistical analysis to identify correlations, associations, or differences between variables.
• Qualitative research: Employs thematic analysis, coding, and interpretation to uncover patterns, themes, and insights within qualitative data.

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• Last modified: January 3, 2023
• Conversion Rate Optimization , User Research

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The word qualitative implies an emphasis on the qualities of entities and on processes and meanings that are not experimentally examined or measured [if measured at all] in terms of quantity, amount, intensity, or frequency. Qualitative researchers stress the socially constructed nature of reality, the intimate relationship between the researcher and what is studied, and the situational constraints that shape inquiry. Such researchers emphasize the value-laden nature of inquiry. They seek answers to questions that stress how social experience is created and given meaning. In contrast, quantitative studies emphasize the measurement and analysis of causal relationships between variables, not processes. Qualitative forms of inquiry are considered by many social and behavioral scientists to be as much a perspective on how to approach investigating a research problem as it is a method.

Denzin, Norman. K. and Yvonna S. Lincoln. “Introduction: The Discipline and Practice of Qualitative Research.” In The Sage Handbook of Qualitative Research . Norman. K. Denzin and Yvonna S. Lincoln, eds. 3 rd edition. (Thousand Oaks, CA: Sage, 2005), p. 10.

Characteristics of Qualitative Research

Below are the three key elements that define a qualitative research study and the applied forms each take in the investigation of a research problem.

• Naturalistic -- refers to studying real-world situations as they unfold naturally; non-manipulative and non-controlling; the researcher is open to whatever emerges [i.e., there is a lack of predetermined constraints on findings].
• Emergent -- acceptance of adapting inquiry as understanding deepens and/or situations change; the researcher avoids rigid designs that eliminate responding to opportunities to pursue new paths of discovery as they emerge.
• Purposeful -- cases for study [e.g., people, organizations, communities, cultures, events, critical incidences] are selected because they are “information rich” and illuminative. That is, they offer useful manifestations of the phenomenon of interest; sampling is aimed at insight about the phenomenon, not empirical generalization derived from a sample and applied to a population.

The Collection of Data

• Data -- observations yield a detailed, "thick description" [in-depth understanding]; interviews capture direct quotations about people’s personal perspectives and lived experiences; often derived from carefully conducted case studies and review of material culture.
• Personal experience and engagement -- researcher has direct contact with and gets close to the people, situation, and phenomenon under investigation; the researcher’s personal experiences and insights are an important part of the inquiry and critical to understanding the phenomenon.
• Empathic neutrality -- an empathic stance in working with study respondents seeks vicarious understanding without judgment [neutrality] by showing openness, sensitivity, respect, awareness, and responsiveness; in observation, it means being fully present [mindfulness].
• Dynamic systems -- there is attention to process; assumes change is ongoing, whether the focus is on an individual, an organization, a community, or an entire culture, therefore, the researcher is mindful of and attentive to system and situational dynamics.

The Analysis

• Unique case orientation -- assumes that each case is special and unique; the first level of analysis is being true to, respecting, and capturing the details of the individual cases being studied; cross-case analysis follows from and depends upon the quality of individual case studies.
• Inductive analysis -- immersion in the details and specifics of the data to discover important patterns, themes, and inter-relationships; begins by exploring, then confirming findings, guided by analytical principles rather than rules.
• Holistic perspective -- the whole phenomenon under study is understood as a complex system that is more than the sum of its parts; the focus is on complex interdependencies and system dynamics that cannot be reduced in any meaningful way to linear, cause and effect relationships and/or a few discrete variables.
• Context sensitive -- places findings in a social, historical, and temporal context; researcher is careful about [even dubious of] the possibility or meaningfulness of generalizations across time and space; emphasizes careful comparative case study analysis and extrapolating patterns for possible transferability and adaptation in new settings.
• Voice, perspective, and reflexivity -- the qualitative methodologist owns and is reflective about her or his own voice and perspective; a credible voice conveys authenticity and trustworthiness; complete objectivity being impossible and pure subjectivity undermining credibility, the researcher's focus reflects a balance between understanding and depicting the world authentically in all its complexity and of being self-analytical, politically aware, and reflexive in consciousness.

Berg, Bruce Lawrence. Qualitative Research Methods for the Social Sciences . 8th edition. Boston, MA: Allyn and Bacon, 2012; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 2nd ed. Thousand Oaks, CA: Sage Publications, 1995; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Basic Research Design for Qualitative Studies

Unlike positivist or experimental research that utilizes a linear and one-directional sequence of design steps, there is considerable variation in how a qualitative research study is organized. In general, qualitative researchers attempt to describe and interpret human behavior based primarily on the words of selected individuals [a.k.a., “informants” or “respondents”] and/or through the interpretation of their material culture or occupied space. There is a reflexive process underpinning every stage of a qualitative study to ensure that researcher biases, presuppositions, and interpretations are clearly evident, thus ensuring that the reader is better able to interpret the overall validity of the research. According to Maxwell (2009), there are five, not necessarily ordered or sequential, components in qualitative research designs. How they are presented depends upon the research philosophy and theoretical framework of the study, the methods chosen, and the general assumptions underpinning the study. Goals Describe the central research problem being addressed but avoid describing any anticipated outcomes. Questions to ask yourself are: Why is your study worth doing? What issues do you want to clarify, and what practices and policies do you want it to influence? Why do you want to conduct this study, and why should the reader care about the results? Conceptual Framework Questions to ask yourself are: What do you think is going on with the issues, settings, or people you plan to study? What theories, beliefs, and prior research findings will guide or inform your research, and what literature, preliminary studies, and personal experiences will you draw upon for understanding the people or issues you are studying? Note to not only report the results of other studies in your review of the literature, but note the methods used as well. If appropriate, describe why earlier studies using quantitative methods were inadequate in addressing the research problem. Research Questions Usually there is a research problem that frames your qualitative study and that influences your decision about what methods to use, but qualitative designs generally lack an accompanying hypothesis or set of assumptions because the findings are emergent and unpredictable. In this context, more specific research questions are generally the result of an interactive design process rather than the starting point for that process. Questions to ask yourself are: What do you specifically want to learn or understand by conducting this study? What do you not know about the things you are studying that you want to learn? What questions will your research attempt to answer, and how are these questions related to one another? Methods Structured approaches to applying a method or methods to your study help to ensure that there is comparability of data across sources and researchers and, thus, they can be useful in answering questions that deal with differences between phenomena and the explanation for these differences [variance questions]. An unstructured approach allows the researcher to focus on the particular phenomena studied. This facilitates an understanding of the processes that led to specific outcomes, trading generalizability and comparability for internal validity and contextual and evaluative understanding. Questions to ask yourself are: What will you actually do in conducting this study? What approaches and techniques will you use to collect and analyze your data, and how do these constitute an integrated strategy? Validity In contrast to quantitative studies where the goal is to design, in advance, “controls” such as formal comparisons, sampling strategies, or statistical manipulations to address anticipated and unanticipated threats to validity, qualitative researchers must attempt to rule out most threats to validity after the research has begun by relying on evidence collected during the research process itself in order to effectively argue that any alternative explanations for a phenomenon are implausible. Questions to ask yourself are: How might your results and conclusions be wrong? What are the plausible alternative interpretations and validity threats to these, and how will you deal with these? How can the data that you have, or that you could potentially collect, support or challenge your ideas about what’s going on? Why should we believe your results? Conclusion Although Maxwell does not mention a conclusion as one of the components of a qualitative research design, you should formally conclude your study. Briefly reiterate the goals of your study and the ways in which your research addressed them. Discuss the benefits of your study and how stakeholders can use your results. Also, note the limitations of your study and, if appropriate, place them in the context of areas in need of further research.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Heath, A. W. The Proposal in Qualitative Research. The Qualitative Report 3 (March 1997); Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 3rd edition. Thousand Oaks, CA: Sage, 1999; Maxwell, Joseph A. "Designing a Qualitative Study." In The SAGE Handbook of Applied Social Research Methods . Leonard Bickman and Debra J. Rog, eds. 2nd ed. (Thousand Oaks, CA: Sage, 2009), p. 214-253; Qualitative Research Methods. Writing@CSU. Colorado State University; Yin, Robert K. Qualitative Research from Start to Finish . 2nd edition. New York: Guilford, 2015.

Strengths of Using Qualitative Methods

The advantage of using qualitative methods is that they generate rich, detailed data that leave the participants' perspectives intact and provide multiple contexts for understanding the phenomenon under study. In this way, qualitative research can be used to vividly demonstrate phenomena or to conduct cross-case comparisons and analysis of individuals or groups.

Among the specific strengths of using qualitative methods to study social science research problems is the ability to:

• Obtain a more realistic view of the lived world that cannot be understood or experienced in numerical data and statistical analysis;
• Provide the researcher with the perspective of the participants of the study through immersion in a culture or situation and as a result of direct interaction with them;
• Allow the researcher to describe existing phenomena and current situations;
• Develop flexible ways to perform data collection, subsequent analysis, and interpretation of collected information;
• Yield results that can be helpful in pioneering new ways of understanding;
• Respond to changes that occur while conducting the study ]e.g., extended fieldwork or observation] and offer the flexibility to shift the focus of the research as a result;
• Provide a holistic view of the phenomena under investigation;
• Respond to local situations, conditions, and needs of participants;
• Interact with the research subjects in their own language and on their own terms; and,
• Create a descriptive capability based on primary and unstructured data.

Anderson, Claire. “Presenting and Evaluating Qualitative Research.” American Journal of Pharmaceutical Education 74 (2010): 1-7; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Limitations of Using Qualitative Methods

It is very much true that most of the limitations you find in using qualitative research techniques also reflect their inherent strengths . For example, small sample sizes help you investigate research problems in a comprehensive and in-depth manner. However, small sample sizes undermine opportunities to draw useful generalizations from, or to make broad policy recommendations based upon, the findings. Additionally, as the primary instrument of investigation, qualitative researchers are often embedded in the cultures and experiences of others. However, cultural embeddedness increases the opportunity for bias generated from conscious or unconscious assumptions about the study setting to enter into how data is gathered, interpreted, and reported.

Some specific limitations associated with using qualitative methods to study research problems in the social sciences include the following:

• Drifting away from the original objectives of the study in response to the changing nature of the context under which the research is conducted;
• Arriving at different conclusions based on the same information depending on the personal characteristics of the researcher;
• Replication of a study is very difficult;
• Research using human subjects increases the chance of ethical dilemmas that undermine the overall validity of the study;
• An inability to investigate causality between different research phenomena;
• Difficulty in explaining differences in the quality and quantity of information obtained from different respondents and arriving at different, non-consistent conclusions;
• Data gathering and analysis is often time consuming and/or expensive;
• Requires a high level of experience from the researcher to obtain the targeted information from the respondent;
• May lack consistency and reliability because the researcher can employ different probing techniques and the respondent can choose to tell some particular stories and ignore others; and,
• Generation of a significant amount of data that cannot be randomized into manageable parts for analysis.

Research Tip

Human Subject Research and Institutional Review Board Approval

Almost every socio-behavioral study requires you to submit your proposed research plan to an Institutional Review Board. The role of the Board is to evaluate your research proposal and determine whether it will be conducted ethically and under the regulations, institutional polices, and Code of Ethics set forth by the university. The purpose of the review is to protect the rights and welfare of individuals participating in your study. The review is intended to ensure equitable selection of respondents, that you have met the requirements for obtaining informed consent , that there is clear assessment and minimization of risks to participants and to the university [read: no lawsuits!], and that privacy and confidentiality are maintained throughout the research process and beyond. Go to the USC IRB website for detailed information and templates of forms you need to submit before you can proceed. If you are  unsure whether your study is subject to IRB review, consult with your professor or academic advisor.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Labaree, Robert V. "Working Successfully with Your Institutional Review Board: Practical Advice for Academic Librarians." College and Research Libraries News 71 (April 2010): 190-193.

Another Research Tip

Finding Examples of How to Apply Different Types of Research Methods

SAGE publications is a major publisher of studies about how to design and conduct research in the social and behavioral sciences. Their SAGE Research Methods Online and Cases database includes contents from books, articles, encyclopedias, handbooks, and videos covering social science research design and methods including the complete Little Green Book Series of Quantitative Applications in the Social Sciences and the Little Blue Book Series of Qualitative Research techniques. The database also includes case studies outlining the research methods used in real research projects. This is an excellent source for finding definitions of key terms and descriptions of research design and practice, techniques of data gathering, analysis, and reporting, and information about theories of research [e.g., grounded theory]. The database covers both qualitative and quantitative research methods as well as mixed methods approaches to conducting research.

SAGE Research Methods Online and Cases

NOTE :  For a list of online communities, research centers, indispensable learning resources, and personal websites of leading qualitative researchers, GO HERE .

For a list of scholarly journals devoted to the study and application of qualitative research methods, GO HERE .

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5 Strengths and 5 Limitations of Qualitative Research

Lauren Christiansen

Insight into qualitative research.

Anyone who reviews a bunch of numbers knows how impersonal that feels. What do numbers really reveal about a person's beliefs, motives, and thoughts? While it's critical to collect statistical information to identify business trends and inefficiencies, stats don't always tell the full story. Why does the customer like this product more than the other one? What motivates them to post this particular hashtag on social media? How do employees actually feel about the new supply chain process? To answer more personal questions that delve into the human experience, businesses often employ a qualitative research process.

10 Key Strengths and Limitations of Qualitative Research

Qualitative research helps entrepreneurs and established companies understand the many factors that drive consumer behavior. Because most organizations collect and analyze quantitative data, they don't always know exactly how a target market feels and what it wants. It helps researchers when they can observe a small sample size of consumers in a comfortable environment, ask questions, and let them speak. Research methodology varies depending on the industry and type of business needs. Many companies employ mixed methods to extract the insights they require to improve decision-making. While both quantitative research and qualitative methods are effective, there are limitations to both. Quantitative research is expensive, time-consuming, and presents a limited understanding of consumer needs. However, qualitative research methods generate less verifiable information as all qualitative data is based on experience. Businesses should use a combination of both methods to overcome any associated limitations.

Strengths of Qualitative Research

• Captures New Beliefs - Qualitative research methods extrapolate any evolving beliefs within a market. This may include who buys a product/service, or how employees feel about their employers.
• Fewer Limitations - Qualitative studies are less stringent than quantitative ones. Outside the box answers to questions, opinions, and beliefs are included in data collection and data analysis.
• More Versatile - Qualitative research is much easier at times for researchers. They can adjust questions, adapt to circumstances that change or change the environment to optimize results.
• Greater Speculation - Researchers can speculate more on what answers to drill down into and how to approach them. They can use instinct and subjective experience to identify and extract good data.
• More Targeted - This research process can target any area of the business or concern it may have. Researchers can concentrate on specific target markets to collect valuable information. This takes less time and requires fewer resources than quantitative studies.

Limitations of Qualitative Research

• Sample Sizes - Businesses need to find a big enough group of participants to ensure results are accurate. A sample size of 15 people is not enough to show a reliable picture of how consumers view a product. If it is not possible to find a large enough sample size, the data collected may be insufficient.
• Bias - For internal qualitative studies, employees may be biased. For example, workers may give a popular answer that colleagues agree with rather than a true opinion. This can negatively influence the outcome of the study.
• Self-Selection Bias - Businesses that call on volunteers to answer questions worry that the people who respond are not reflective of the greater group. It is better if the company selects individuals at random for research studies, particularly if they are employees. However, this changes the process from qualitative to quantitative methods.
• Artificial - It isn't typical to observe consumers in stores, gather a focus group together, or ask employees about their experiences at work. This artificiality may impact the findings, as it is outside the norm of regular behavior and interactions.
• Quality - Questions It's hard to know whether researcher questions are quality or not because they are all subjective. Researchers need to ask how and why individuals feel the way they do to receive the most accurate answers.

Key Takeaways on Strengths and Limitations of Qualitative Research

• Qualitative research helps entrepreneurs and small businesses understand what drives human behavior. It is also used to see how employees feel about workflows and tasks.
• Companies can extract insights from qualitative research to optimize decision-making and improve products or services.
• Qualitative research captures new beliefs, has fewer limitations, is more versatile, and is more targeted. It also allows researchers to speculate and insert themselves more into the research study.
• Qualitative research has many limitations which include possible small sample sizes, potential bias in answers, self-selection bias, and potentially poor questions from researchers. It also can be artificial because it isn't typical to observe participants in focus groups, ask them questions at work, or invite them to partake in this type of research method.

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How to Write Limitations of the Study (with examples)

This blog emphasizes the importance of recognizing and effectively writing about limitations in research. It discusses the types of limitations, their significance, and provides guidelines for writing about them, highlighting their role in advancing scholarly research.

Updated on August 24, 2023

No matter how well thought out, every research endeavor encounters challenges. There is simply no way to predict all possible variances throughout the process.

These uncharted boundaries and abrupt constraints are known as limitations in research . Identifying and acknowledging limitations is crucial for conducting rigorous studies. Limitations provide context and shed light on gaps in the prevailing inquiry and literature.

This article explores the importance of recognizing limitations and discusses how to write them effectively. By interpreting limitations in research and considering prevalent examples, we aim to reframe the perception from shameful mistakes to respectable revelations.

What are limitations in research?

In the clearest terms, research limitations are the practical or theoretical shortcomings of a study that are often outside of the researcher’s control . While these weaknesses limit the generalizability of a study’s conclusions, they also present a foundation for future research.

Sometimes limitations arise from tangible circumstances like time and funding constraints, or equipment and participant availability. Other times the rationale is more obscure and buried within the research design. Common types of limitations and their ramifications include:

• Theoretical: limits the scope, depth, or applicability of a study.
• Methodological: limits the quality, quantity, or diversity of the data.
• Empirical: limits the representativeness, validity, or reliability of the data.
• Analytical: limits the accuracy, completeness, or significance of the findings.
• Ethical: limits the access, consent, or confidentiality of the data.

Regardless of how, when, or why they arise, limitations are a natural part of the research process and should never be ignored . Like all other aspects, they are vital in their own purpose.

Why is identifying limitations important?

Whether to seek acceptance or avoid struggle, humans often instinctively hide flaws and mistakes. Merging this thought process into research by attempting to hide limitations, however, is a bad idea. It has the potential to negate the validity of outcomes and damage the reputation of scholars.

By identifying and addressing limitations throughout a project, researchers strengthen their arguments and curtail the chance of peer censure based on overlooked mistakes. Pointing out these flaws shows an understanding of variable limits and a scrupulous research process.

Showing awareness of and taking responsibility for a project’s boundaries and challenges validates the integrity and transparency of a researcher. It further demonstrates the researchers understand the applicable literature and have thoroughly evaluated their chosen research methods.

Presenting limitations also benefits the readers by providing context for research findings. It guides them to interpret the project’s conclusions only within the scope of very specific conditions. By allowing for an appropriate generalization of the findings that is accurately confined by research boundaries and is not too broad, limitations boost a study’s credibility .

Limitations are true assets to the research process. They highlight opportunities for future research. When researchers identify the limitations of their particular approach to a study question, they enable precise transferability and improve chances for reproducibility. 

Simply stating a project’s limitations is not adequate for spurring further research, though. To spark the interest of other researchers, these acknowledgements must come with thorough explanations regarding how the limitations affected the current study and how they can potentially be overcome with amended methods.

How to write limitations

Typically, the information about a study’s limitations is situated either at the beginning of the discussion section to provide context for readers or at the conclusion of the discussion section to acknowledge the need for further research. However, it varies depending upon the target journal or publication guidelines. 

Don’t hide your limitations

It is also important to not bury a limitation in the body of the paper unless it has a unique connection to a topic in that section. If so, it needs to be reiterated with the other limitations or at the conclusion of the discussion section. Wherever it is included in the manuscript, ensure that the limitations section is prominently positioned and clearly introduced.

While maintaining transparency by disclosing limitations means taking a comprehensive approach, it is not necessary to discuss everything that could have potentially gone wrong during the research study. If there is no commitment to investigation in the introduction, it is unnecessary to consider the issue a limitation to the research. Wholly consider the term ‘limitations’ and ask, “Did it significantly change or limit the possible outcomes?” Then, qualify the occurrence as either a limitation to include in the current manuscript or as an idea to note for other projects. 

Writing limitations

Once the limitations are concretely identified and it is decided where they will be included in the paper, researchers are ready for the writing task. Including only what is pertinent, keeping explanations detailed but concise, and employing the following guidelines is key for crafting valuable limitations:

1) Identify and describe the limitations : Clearly introduce the limitation by classifying its form and specifying its origin. For example:

• An unintentional bias encountered during data collection
• An intentional use of unplanned post-hoc data analysis

2) Explain the implications : Describe how the limitation potentially influences the study’s findings and how the validity and generalizability are subsequently impacted. Provide examples and evidence to support claims of the limitations’ effects without making excuses or exaggerating their impact. Overall, be transparent and objective in presenting the limitations, without undermining the significance of the research. 

3) Provide alternative approaches for future studies : Offer specific suggestions for potential improvements or avenues for further investigation. Demonstrate a proactive approach by encouraging future research that addresses the identified gaps and, therefore, expands the knowledge base.

Whether presenting limitations as an individual section within the manuscript or as a subtopic in the discussion area, authors should use clear headings and straightforward language to facilitate readability. There is no need to complicate limitations with jargon, computations, or complex datasets.

Examples of common limitations

Limitations are generally grouped into two categories , methodology and research process .

Methodology limitations

Methodology may include limitations due to:

• Sample size
• Lack of available or reliable data
• Lack of prior research studies on the topic
• Measure used to collect the data
• Self-reported data

The researcher is addressing how the large sample size requires a reassessment of the measures used to collect and analyze the data.

Research process limitations

Limitations during the research process may arise from:

• Access to information
• Longitudinal effects
• Cultural and other biases
• Language fluency
• Time constraints

The author is pointing out that the model’s estimates are based on potentially biased observational studies.

Final thoughts

Successfully proving theories and touting great achievements are only two very narrow goals of scholarly research. The true passion and greatest efforts of researchers comes more in the form of confronting assumptions and exploring the obscure.

In many ways, recognizing and sharing the limitations of a research study both allows for and encourages this type of discovery that continuously pushes research forward. By using limitations to provide a transparent account of the project's boundaries and to contextualize the findings, researchers pave the way for even more robust and impactful research in the future.

Charla Viera, MS

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• Volume 18, Issue 2
• Issues of validity and reliability in qualitative research
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• Helen Noble 1 ,
• Joanna Smith 2
• 1 School of Nursing and Midwifery, Queens's University Belfast , Belfast , UK
• 2 School of Human and Health Sciences, University of Huddersfield , Huddersfield , UK
• Correspondence to Dr Helen Noble School of Nursing and Midwifery, Queens's University Belfast, Medical Biology Centre, 97 Lisburn Rd, Belfast BT9 7BL, UK; helen.noble{at}qub.ac.uk

https://doi.org/10.1136/eb-2015-102054

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Evaluating the quality of research is essential if findings are to be utilised in practice and incorporated into care delivery. In a previous article we explored ‘bias’ across research designs and outlined strategies to minimise bias. 1 The aim of this article is to further outline rigour, or the integrity in which a study is conducted, and ensure the credibility of findings in relation to qualitative research. Concepts such as reliability, validity and generalisability typically associated with quantitative research and alternative terminology will be compared in relation to their application to qualitative research. In addition, some of the strategies adopted by qualitative researchers to enhance the credibility of their research are outlined.

Are the terms reliability and validity relevant to ensuring credibility in qualitative research?

Although the tests and measures used to establish the validity and reliability of quantitative research cannot be applied to qualitative research, there are ongoing debates about whether terms such as validity, reliability and generalisability are appropriate to evaluate qualitative research. 2–4 In the broadest context these terms are applicable, with validity referring to the integrity and application of the methods undertaken and the precision in which the findings accurately reflect the data, while reliability describes consistency within the employed analytical procedures. 4 However, if qualitative methods are inherently different from quantitative methods in terms of philosophical positions and purpose, then alterative frameworks for establishing rigour are appropriate. 3 Lincoln and Guba 5 offer alternative criteria for demonstrating rigour within qualitative research namely truth value, consistency and neutrality and applicability. Table 1 outlines the differences in terminology and criteria used to evaluate qualitative research.

• View inline

Terminology and criteria used to evaluate the credibility of research findings

What strategies can qualitative researchers adopt to ensure the credibility of the study findings?

Unlike quantitative researchers, who apply statistical methods for establishing validity and reliability of research findings, qualitative researchers aim to design and incorporate methodological strategies to ensure the ‘trustworthiness’ of the findings. Such strategies include:

Accounting for personal biases which may have influenced findings; 6

Acknowledging biases in sampling and ongoing critical reflection of methods to ensure sufficient depth and relevance of data collection and analysis; 3

Meticulous record keeping, demonstrating a clear decision trail and ensuring interpretations of data are consistent and transparent; 3 , 4

Establishing a comparison case/seeking out similarities and differences across accounts to ensure different perspectives are represented; 6 , 7

Including rich and thick verbatim descriptions of participants’ accounts to support findings; 7

Demonstrating clarity in terms of thought processes during data analysis and subsequent interpretations 3 ;

Engaging with other researchers to reduce research bias; 3

Respondent validation: includes inviting participants to comment on the interview transcript and whether the final themes and concepts created adequately reflect the phenomena being investigated; 4

Data triangulation, 3 , 4 whereby different methods and perspectives help produce a more comprehensive set of findings. 8 , 9

Table 2 provides some specific examples of how some of these strategies were utilised to ensure rigour in a study that explored the impact of being a family carer to patients with stage 5 chronic kidney disease managed without dialysis. 10

Strategies for enhancing the credibility of qualitative research

In summary, it is imperative that all qualitative researchers incorporate strategies to enhance the credibility of a study during research design and implementation. Although there is no universally accepted terminology and criteria used to evaluate qualitative research, we have briefly outlined some of the strategies that can enhance the credibility of study findings.

• Sandelowski M
• Lincoln YS ,
• Barrett M ,
• Mayan M , et al
• Greenhalgh T
• Lingard L ,

Twitter Follow Joanna Smith at @josmith175 and Helen Noble at @helnoble

Competing interests None.

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Research Limitations & Delimitations

What they are and how they’re different (with examples)

By: Derek Jansen (MBA) | Expert Reviewed By: David Phair (PhD) | September 2022

If you’re new to the world of research, you’ve probably heard the terms “ research limitations ” and “ research delimitations ” being thrown around, often quite loosely. In this post, we’ll unpack what both of these mean, how they’re similar and how they’re different – so that you can write up these sections the right way.

Overview: Limitations vs Delimitations

• Are they the same?
• What are research limitations
• What are research delimitations
• Limitations vs delimitations

First things first…

Let’s start with the most important takeaway point of this post – research limitations and research delimitations are not the same – but they are related to each other (we’ll unpack that a little later). So, if you hear someone using these two words interchangeably, be sure to share this post with them!

Research Limitations

Research limitations are, at the simplest level, the weaknesses of the study , based on factors that are often outside of your control as the researcher. These factors could include things like time , access to funding, equipment , data or participants . For example, if you weren’t able to access a random sample of participants for your study and had to adopt a convenience sampling strategy instead, that would impact the generalizability of your findings and therefore reflect a limitation of your study.

Research limitations can also emerge from the research design itself . For example, if you were undertaking a correlational study, you wouldn’t be able to infer causality (since correlation doesn’t mean certain causation). Similarly, if you utilised online surveys to collect data from your participants, you naturally wouldn’t be able to get the same degree of rich data that you would from in-person interviews .

Simply put, research limitations reflect the shortcomings of a study , based on practical (or theoretical) constraints that the researcher faced. These shortcomings limit what you can conclude from a study, but at the same time, present a foundation for future research . Importantly, all research has limitations , so there’s no need to hide anything here – as long as you discuss how the limitations might affect your findings, it’s all good.

Research Delimitations

Alright, now that we’ve unpacked the limitations, let’s move on to the delimitations .

Research delimitations are similar to limitations in that they also “ limit ” the study, but their focus is entirely different. Specifically, the delimitations of a study refer to the scope of the research aims and research questions . In other words, delimitations reflect the choices you, as the researcher, intentionally make in terms of what you will and won’t try to achieve with your study. In other words, what your research aims and research questions will and won’t include.

As we’ve spoken about many times before, it’s important to have a tight, narrow focus for your research, so that you can dive deeply into your topic, apply your energy to one specific area and develop meaningful insights. If you have an overly broad scope or unfocused topic, your research will often pull in multiple, even opposing directions, and you’ll just land up with a muddy mess of findings .

So, the delimitations section is where you’ll clearly state what your research aims and research questions will focus on – and just as importantly, what they will exclude . For example, you might investigate a widespread phenomenon, but choose to focus your study on a specific age group, ethnicity or gender. Similarly, your study may focus exclusively on one country, city or even organization. As long as the scope is well justified (in other words, it represents a novel, valuable research topic), this is perfectly acceptable – in fact, it’s essential. Remember, focus is your friend.

Need a helping hand?

Conclusion: Limitations vs Delimitations

Ok, so let’s recap.

Research limitations and research delimitations are related in that they both refer to “limits” within a study. But, they are distinctly different. Limitations reflect the shortcomings of your study, based on practical or theoretical constraints that you faced.

Contrasted to that, delimitations reflect the choices that you made in terms of the focus and scope of your research aims and research questions. If you want to learn more about research aims and questions, you can check out this video post , where we unpack those concepts in detail.

Psst... there’s more!

This post was based on one of our popular Research Bootcamps . If you're working on a research project, you'll definitely want to check this out ...

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18 Comments

Good clarification of ideas on how a researcher ought to do during Process of choice

Thank you so much for this very simple but explicit explanation on limitation and delimitation. It has so helped me to develop my masters proposal. hope to recieve more from your site as time progresses

Thank you for this explanation – very clear.

Thanks for the explanation, really got it well.

This website is really helpful for my masters proposal

Thank you very much for helping to explain these two terms

I spent almost the whole day trying to figure out the differences

when I came across your notes everything became very clear

thanks for the clearly outlined explanation on the two terms, limitation and delimitation.

Very helpful Many thanks 🙏

Excellent it resolved my conflict .

I would like you to assist me please. If in my Research, I interviewed some participants and I submitted Questionnaires to other participants to answered to the questions, in the same organization, Is this a Qualitative methodology , a Quantitative Methodology or is it a Mixture Methodology I have used in my research? Please help me

How do I cite this article in APA format

Really so great ,finally have understood it’s difference now

Getting more clear regarding Limitations and Delimitation and concepts

I really appreciate your apt and precise explanation of the two concepts namely ; Limitations and Delimitations.

This is a good sources of research information for learners.

thank you for this, very helpful to researchers

Very good explained

Great and clear explanation, after a long confusion period on the two words, i can now explain to someone with ease.

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Limitations and Weaknesses Of Qualitative Research

• Post author: Edeh Samuel Chukwuemeka ACMC
• Post published: August 31, 2022
• Post category: Scholarly Articles

Limitations and Weaknesses Of Qualitative Research: To make informed conclusions, research involves obtaining data. The analysis is founded on logical thinking, as accuracy is one of the most important components of research. Research takes several forms and may serve various purposes, depending on the methodology used. There are primarily two main research methodologies: quantitative (focused on measurement and figures) and qualitative (concerned with understanding and words).

Anyone who has looked through a lot of figures, though, is aware of how impersonal it might feel. What do figures tell us about someone’s views, motivations, and thoughts? Even while it’s important to gather statistical data to spot company trends and inefficiencies, statistics don’t always provide the whole picture.

For a long time, qualitative research has been conducted using its guiding principles. Findings from this research approach have frequently been utilized by media and marketing to provide targeted content or provide a personalized brand message.

Data from qualitative research mostly comes from observations made by people. It can provide a deeper, more complete picture of consumer behavior by providing a window into audiences’ brains that quantitative data simply cannot. Customers appreciate hearing from businesses, so talking to them helps marketers better understand who their target market is. It also helps with customer service. This improves a company’s interaction with its customers and prepares the road for consumer endorsements.

As we’ve previously said, qualitative research is done to learn more about the underlying causes and motives in-depth. Qualitative research does have constraints, though. So, in this essay, we’ll talk about the Limitations and weaknesses of qualitative research.

Recommended: Limitations and Weaknesses Of Quantitative Research

Table of Contents

What is qualitative research?

A market research technique called qualitative research concentrates on gathering information through conversational and open-ended dialogue. This approach emphasizes “ why ” rather than “ what ” others think of you. Marketers like penetrating their target audience’s brains. But to achieve that, they must conduct a qualitative study. Qualitative observations, focus groups, and in-person interviews may all give you insightful information about your market, your goods, and the attitudes and motives of your consumers.

Consider that you operate a general audience web store. Demographic investigation reveals that the majority of your consumers are men. Naturally, you’ll be curious to know why ladies aren’t making purchases from you. And you’ll be able to discover it through qualitative research.

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Limitations and Weaknesses of Qualitative Research Methods

1. The data quality is very debatable: This is where the subjective aspect of data collection in qualitative research may potentially be a drawback. Another researcher may view data that one believes is relevant and necessary to collect as meaningless and choose not to pursue it.

Individual viewpoints and instinctive choices might result in very comprehensive data. Because of its dependence on researcher subjectivism, it can also result in data that is oversimplified or even erroneous.

2. It is based on the researcher’s experience: Only the experience of the researchers participating in the process will determine the quality of the data gathered through qualitative research. A researcher who is knowledgeable about the sector must gather data that is particular to that business.

For the data to be accurate, researchers must also be skilled at conducting effective interviews, brave enough to follow up with participants, and able to establish rapport with them on a professional level.

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3. It is more challenging to evaluate and prove data rigidity: It is more challenging to demonstrate rigidity in collective data since individual viewpoints frequently serve as the basis of data collected in qualitative research. The human mind frequently recalls information in the way that it desires. Because of this, even if the events themselves may have been rather upsetting at the time, recollections are frequently viewed with nostalgia.

Researchers find it challenging to show the veracity of their findings because of our fundamental tendency to see the bright side of things.

4. It could take a lot of time: Data collection takes longer since researchers go off in many different directions. Additionally, sorting through all of that additional data takes time. The value of every data point is never certain since it is appraised subjectively.

In contrast to data gathered via qualitative research, data gathered through other research forms are subject to strict criteria and expectations that enable it to be reviewed and used more quickly.

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5. Data with uncertain values are produced: Due to the diversity of their viewpoints, even researchers may disagree on the importance of the data being gathered. The qualitative research method depends on the researcher engaged to determine what is included and what is eliminated. Due to its very subjective nature, this data collecting procedure. It is always feasible to offer detailed data, but only in cases when the researcher can put their prejudice and viewpoint aside and present the material in its unprocessed state.

6. It is not statistically significant: Its absence of statistical representation is the one drawback of qualitative research that is always present. The replies provided are not quantified because it is a perspective-based research approach only.

Although it is possible to compare results and this may result in the necessary duplication. Most situations that call for statistical representation and are outside the scope of qualitative research need quantitative data.

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7. Repeated qualitative research periods may be necessary for difficult conclusions: For brands and enterprises that must make a difficult or possibly divisive decision, the smaller sample sizes of qualitative research may be both an advantage and a drawback.

Even though the people in the sample share a lot of characteristics, a small sample is not always indicative of wider general demography. This indicates that a follow-up with a bigger quantitative sample may be required to track data points with more precision and make a better overall judgment.

8. Qualitative research-generated data isn’t often taken seriously: Findings from qualitative research are not always embraced by the scientific community because of the subjective character of the data that is gathered. To start the process of community acceptability, it is frequently required to conduct a second independent qualitative research project that can yield comparable findings.

Also see: Differences Between Objective And Subjective

9. In the course of qualitative study, hidden facts may vanish: It is entrusted to the researcher with a great deal of faith that they will obtain and then compile the hidden data that a supplier makes available. The ability of the researcher to make all the connections is essential to the research’s success.

If the researcher is successful in doing this, the data will be significant and will aid brands in advancing their goals. Otherwise, until the initial findings are acquired, there is no ability to change the course of action. The next step is to start a fresh qualitative procedure.

10. Researcher influence may have a detrimental impact on the data gathered: Qualitative research relies heavily on the abilities and observation of the researcher to provide high-quality data. A researcher’s point of view will be integrated with the data gathered if they have a biased viewpoint, which will affect the results.

Controls must be in place to assist in removing the possibility of bias so that the data gathered may be examined honestly. Otherwise, a researcher might assert anything and then utilize their bias in qualitative research to support their claim.

Also see: Advantages And Disadvantages of Cooperative Society

Any qualitative research project, in practice, has advantages and disadvantages. Thus, being aware of the constraints is essential to successful and relevant data collection. Qualitative research studies have the drawbacks of being more difficult to comprehend and are less likely to generalize to the entire community. It is essential to have a better understanding of how certain individuals and even groups think. But someone will always doubt the data’s dependability and truthfulness because of how subjective it is.

Edeh Samuel Chukwuemeka, ACMC, is a lawyer and a certified mediator/conciliator in Nigeria. He is also a developer with knowledge in various programming languages. Samuel is determined to leverage his skills in technology, SEO, and legal practice to revolutionize the legal profession worldwide by creating web and mobile applications that simplify legal research. Sam is also passionate about educating and providing valuable information to people.

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Home » Limitations in Research – Types, Examples and Writing Guide

Limitations in Research – Types, Examples and Writing Guide

Table of Contents

Limitations in Research

Limitations in research refer to the factors that may affect the results, conclusions , and generalizability of a study. These limitations can arise from various sources, such as the design of the study, the sampling methods used, the measurement tools employed, and the limitations of the data analysis techniques.

Types of Limitations in Research

Types of Limitations in Research are as follows:

Sample Size Limitations

This refers to the size of the group of people or subjects that are being studied. If the sample size is too small, then the results may not be representative of the population being studied. This can lead to a lack of generalizability of the results.

Time Limitations

Time limitations can be a constraint on the research process . This could mean that the study is unable to be conducted for a long enough period of time to observe the long-term effects of an intervention, or to collect enough data to draw accurate conclusions.

Selection Bias

This refers to a type of bias that can occur when the selection of participants in a study is not random. This can lead to a biased sample that is not representative of the population being studied.

Confounding Variables

Confounding variables are factors that can influence the outcome of a study, but are not being measured or controlled for. These can lead to inaccurate conclusions or a lack of clarity in the results.

Measurement Error

This refers to inaccuracies in the measurement of variables, such as using a faulty instrument or scale. This can lead to inaccurate results or a lack of validity in the study.

Ethical Limitations

Ethical limitations refer to the ethical constraints placed on research studies. For example, certain studies may not be allowed to be conducted due to ethical concerns, such as studies that involve harm to participants.

Examples of Limitations in Research

Some Examples of Limitations in Research are as follows:

Research Title: “The Effectiveness of Machine Learning Algorithms in Predicting Customer Behavior”

Limitations:

• The study only considered a limited number of machine learning algorithms and did not explore the effectiveness of other algorithms.
• The study used a specific dataset, which may not be representative of all customer behaviors or demographics.
• The study did not consider the potential ethical implications of using machine learning algorithms in predicting customer behavior.

Research Title: “The Impact of Online Learning on Student Performance in Computer Science Courses”

• The study was conducted during the COVID-19 pandemic, which may have affected the results due to the unique circumstances of remote learning.
• The study only included students from a single university, which may limit the generalizability of the findings to other institutions.
• The study did not consider the impact of individual differences, such as prior knowledge or motivation, on student performance in online learning environments.

Research Title: “The Effect of Gamification on User Engagement in Mobile Health Applications”

• The study only tested a specific gamification strategy and did not explore the effectiveness of other gamification techniques.
• The study relied on self-reported measures of user engagement, which may be subject to social desirability bias or measurement errors.
• The study only included a specific demographic group (e.g., young adults) and may not be generalizable to other populations with different preferences or needs.

How to Write Limitations in Research

When writing about the limitations of a research study, it is important to be honest and clear about the potential weaknesses of your work. Here are some tips for writing about limitations in research:

• Identify the limitations: Start by identifying the potential limitations of your research. These may include sample size, selection bias, measurement error, or other issues that could affect the validity and reliability of your findings.
• Be honest and objective: When describing the limitations of your research, be honest and objective. Do not try to minimize or downplay the limitations, but also do not exaggerate them. Be clear and concise in your description of the limitations.
• Provide context: It is important to provide context for the limitations of your research. For example, if your sample size was small, explain why this was the case and how it may have affected your results. Providing context can help readers understand the limitations in a broader context.
• Discuss implications : Discuss the implications of the limitations for your research findings. For example, if there was a selection bias in your sample, explain how this may have affected the generalizability of your findings. This can help readers understand the limitations in terms of their impact on the overall validity of your research.
• Provide suggestions for future research : Finally, provide suggestions for future research that can address the limitations of your study. This can help readers understand how your research fits into the broader field and can provide a roadmap for future studies.

Purpose of Limitations in Research

There are several purposes of limitations in research. Here are some of the most important ones:

• To acknowledge the boundaries of the study : Limitations help to define the scope of the research project and set realistic expectations for the findings. They can help to clarify what the study is not intended to address.
• To identify potential sources of bias: Limitations can help researchers identify potential sources of bias in their research design, data collection, or analysis. This can help to improve the validity and reliability of the findings.
• To provide opportunities for future research: Limitations can highlight areas for future research and suggest avenues for further exploration. This can help to advance knowledge in a particular field.
• To demonstrate transparency and accountability: By acknowledging the limitations of their research, researchers can demonstrate transparency and accountability to their readers, peers, and funders. This can help to build trust and credibility in the research community.
• To encourage critical thinking: Limitations can encourage readers to critically evaluate the study’s findings and consider alternative explanations or interpretations. This can help to promote a more nuanced and sophisticated understanding of the topic under investigation.

When to Write Limitations in Research

Limitations should be included in research when they help to provide a more complete understanding of the study’s results and implications. A limitation is any factor that could potentially impact the accuracy, reliability, or generalizability of the study’s findings.

It is important to identify and discuss limitations in research because doing so helps to ensure that the results are interpreted appropriately and that any conclusions drawn are supported by the available evidence. Limitations can also suggest areas for future research, highlight potential biases or confounding factors that may have affected the results, and provide context for the study’s findings.

Generally, limitations should be discussed in the conclusion section of a research paper or thesis, although they may also be mentioned in other sections, such as the introduction or methods. The specific limitations that are discussed will depend on the nature of the study, the research question being investigated, and the data that was collected.

Examples of limitations that might be discussed in research include sample size limitations, data collection methods, the validity and reliability of measures used, and potential biases or confounding factors that could have affected the results. It is important to note that limitations should not be used as a justification for poor research design or methodology, but rather as a way to enhance the understanding and interpretation of the study’s findings.

Importance of Limitations in Research

Here are some reasons why limitations are important in research:

• Enhances the credibility of research: Limitations highlight the potential weaknesses and threats to validity, which helps readers to understand the scope and boundaries of the study. This improves the credibility of research by acknowledging its limitations and providing a clear picture of what can and cannot be concluded from the study.
• Facilitates replication: By highlighting the limitations, researchers can provide detailed information about the study’s methodology, data collection, and analysis. This information helps other researchers to replicate the study and test the validity of the findings, which enhances the reliability of research.
• Guides future research : Limitations provide insights into areas for future research by identifying gaps or areas that require further investigation. This can help researchers to design more comprehensive and effective studies that build on existing knowledge.
• Provides a balanced view: Limitations help to provide a balanced view of the research by highlighting both strengths and weaknesses. This ensures that readers have a clear understanding of the study’s limitations and can make informed decisions about the generalizability and applicability of the findings.

Advantages of Limitations in Research

Here are some potential advantages of limitations in research:

• Focus : Limitations can help researchers focus their study on a specific area or population, which can make the research more relevant and useful.
• Realism : Limitations can make a study more realistic by reflecting the practical constraints and challenges of conducting research in the real world.
• Innovation : Limitations can spur researchers to be more innovative and creative in their research design and methodology, as they search for ways to work around the limitations.
• Rigor : Limitations can actually increase the rigor and credibility of a study, as researchers are forced to carefully consider the potential sources of bias and error, and address them to the best of their abilities.
• Generalizability : Limitations can actually improve the generalizability of a study by ensuring that it is not overly focused on a specific sample or situation, and that the results can be applied more broadly.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Table of contents

• 1 Defining Limitations in Qualitative Research
• 2.1 Limitations may lead to potentially biased observational studies
• 2.2 How to address limitations in research?
• 3 Impact of Study Limitations on Research Outcomes: How to Find Limitations of a Study
• 4.1 Limited Access to Outstanding Future Study

Research for academic purposes is always challenging and requires much prep. This includes careful research design and an understanding of experiment limitations. Even though you have analyzed and prepared things, the results may still differ.

There are many reasons for this, and one of the main reasons is limitations in research. Unfortunately, a study can’t consider all options or circumstances at once. For example, you are studying how nutrition affects student performance. But you are not considering each student’s traits, routines, relationships, weather, age, and so on.

The study must include confounding factors in its conclusions and results, which can distort the final result. This article will help you understand the strengths and limitations of research and guide you on how to consider them. This is when you reach valid conclusions and plan future investigations.

Defining Limitations in Qualitative Research

What are limitations in research? Many factors confound the study, including its reliability, validity, and generalizability. These can limit the research problem. Internal limitations are constraints within the researcher’s control, including sample bias or method flaws. But external research limits come from factors like population or environmental factors. They are beyond the researcher’s control.

The limitations of research studies are significant in defining the scope of research inquiry. It outlines the results’ extent and meaning. It finds areas where the outcome might be less reliable or relevant.

Acknowledging and writing limits fosters honesty. It reminds researchers and readers of science’s complexity and uncertainties. Researchers can improve methods. They do this by understanding and fixing limitations in a research paper. It helps to interpret research findings more. This advances knowledge in their fields and literature review.

If you need help with writing a research paper , our writing service is ready to assist you.

Common Limitations of Research Studies

In general, there are four types of limitations in a research study:

Limitations may lead to potentially biased observational studies

Many things can become limitations in a dissertation. They affect the study’s reliability, internal and external validity, and generalizability. However, the research method impacts the whole study.

The dissertation has methodological limitations. These include problems in the study’s design and execution and constraints. Simple limitation examples: a small sample size can weaken statistical power. Flaws in prior research design can also hurt the study’s validity.

Collecting precise and complete data in the scientific literature is hard. These challenges are known as data collection limitations in research. The study’s limitations can come from measurement errors. These errors are caused by imperfect tools or human error. They lead to inaccuracies in the data. Also, response bias comes from participants’ tendency to answer in socially desirable ways.  It can distort results and hurt the study’s credibility.

A study’s limited resources can be a big obstacle for research. For instance, time constraints may require shorter periods, which can curtail the breadth and depth of the study’s findings. When funds are limited, researchers may lack resources for good methods or thorough analyses. This further hinders research.

External validity limits research. It refers to how well a study’s conclusions apply to contexts beyond where it was conducted. Factors like the study population or setting have distinct characteristics. They can make extending the findings to other groups or places hard.

How to address limitations in research?

It is essential for researchers to be aware of common research limitations and to plan their research process. They need to know their topic and know the limitations in research examples. Identifying limits in their research paper helps researchers. It can cut flaws, improve data collection, and save resources. They can also judge how their findings apply. Acknowledging these limits can help researchers. It can increase the credibility and impact of their results. This fosters more confidence in their findings. It is in the scientific community and in future research. If you struggle with the limitation, ask for help with research paper .

Impact of Study Limitations on Research Outcomes: How to Find Limitations of a Study

Methodological limitations can compromise research results. These include small sample sizes and flawed research designs. These possible limitations of the study increase the likelihood of chance findings or bias. Similarly, limits on data collection cause inaccuracies. They come from things like response bias or measurement errors and can distort data. These problems harm the validity of the findings.

Unsolved limitations and a lack of research examples greatly affect how we interpret and use study results. Without mitigation, researchers risk drawing wrong conclusions and overgeneralizing findings. For instance, a scientific study may have limited external validity. Its findings may not represent the broader population or apply to different contexts, leading to misguided information in the existing literature or interventions.

Case studies provide valuable insights into the real-world effects of those examples of limitations of a study. For instance, a study may aim to test a new medication. But, it may face limits on resources. These limits could lead to a small sample size and low statistical power. As a result, the study may fail to detect the drug’s subtle, yet clinically significant effects. This could lead to wrong conclusions about its effectiveness. Presenting limitations and alternative approaches is part of the methods section and discussion.

Consider another scenario where a survey aims to investigate public opinion on a social issue. However, the research topic itself may lead to response bias, potentially creating limitations in a study. Ignoring such limits could lead to distorted findings. It would misrepresent the beliefs and attitudes of the surveyed people. This would damage the study’s credibility. So, admitting research’s limits is crucial. The impact of these limits on results is clear. It shows the importance of careful methods and clear reporting. Researchers can improve their findings’ trustworthiness.

They can do this by finding and fixing limitations. In doing so, they can ensure that their research contributes greatly to advancing knowledge. It also informs evidence-based decision-making in future research. If you need help, our writing service specialists will gladly assist you.

Strategies for Addressing and Presenting Studies Limitations

We must acknowledge the limits of the research if we want to keep academic papers authentic and reliable. Below are a few tactics to accomplish this:

• Transparent Reporting : Researchers should openly acknowledge and describe limitations in their academic publications. Transparently reported findings let readers evaluate their credibility and accuracy, which promotes further investigations.
• Sensitivity analyses are essential in research writing. They examine the potential limitations of a study. By changing key parameters or assumptions, researchers can check the strength of their findings. They can also find any sources of bias or uncertainty.
• We recommend using various methods or data sources . This will improve the trust and accuracy of research conclusions. By using all the results, researchers can avoid relying on one method. This helps lessen the impact of method problems on study outcomes.
• Working with teams of people from different disciplines can beat resource limits . It also expands the toolkit available to researchers. By sharing expertise and resources across fields, researchers can do better research. They can also fix limitations.
• Considering alternatives will lessen the impact of limits on study conclusions . Researchers should carefully assess and analyze other explanations or interpretations of results. Considering other ideas is crucial. It ensures the findings are robust. They won’t depend only on specific methods or assumptions.

In the future, researchers can use strategies to find limits. They can then fix and cut them in qualitative research. This will ensure their findings are reliable, valid, and credible. It involves a clear understanding of limitations vs implications. Also, being clear about limitations in writing fosters trust. It makes the scientific community more confident. Researchers should communicate any limitations in the discussion section and research limitations section. So, the importance of limitations in research is hard to overestimate.

Limited Access to Outstanding Future Study

Accepting and addressing limits is not a sign of weakness. It is a testament to the difficulty and honesty of science. They can do this by reporting limits in past studies. They can also do this by doing sensitivity analyses and working with other fields. They should also consider alternative explanations. Over these efforts, we can create a culture of humility, transparency, and confidence. This will ensure that research findings add to our understanding. They will do so in a meaningful way. Embracing limits when you write becomes a pathway to better integrity and knowledge.

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• Open access
• Published: 21 May 2024

Exploring shared decision-making needs in lung cancer screening among high-risk groups and health care providers in China: a qualitative study

• Xiujing Lin 1 ,
• Fangfang Wang 1 ,
• Yonglin Li 1 ,
• Fang Lei 2 ,
• Weisheng Chen 3 ,
• Rachel H. Arbing 4 ,
• Wei-Ti Chen   ORCID: orcid.org/0000-0002-2342-045X 4 &
• Feifei Huang   ORCID: orcid.org/0000-0003-0197-8687 1  

BMC Cancer volume  24 , Article number:  613 ( 2024 ) Cite this article

133 Accesses

Metrics details

The intricate balance between the advantages and risks of low-dose computed tomography (LDCT) impedes the utilization of lung cancer screening (LCS). Guiding shared decision-making (SDM) for well-informed choices regarding LCS is pivotal. There has been a notable increase in research related to SDM. However, these studies possess limitations. For example, they may ignore the identification of decision support and needs from the perspective of health care providers and high-risk groups. Additionally, these studies have not adequately addressed the complete SDM process, including pre-decisional needs, the decision-making process, and post-decision experiences. Furthermore, the East-West divide of SDM has been largely ignored. This study aimed to explore the decisional needs and support for shared decision-making for LCS among health care providers and high-risk groups in China.

Informed by the Ottawa Decision-Support Framework, we conducted qualitative, face-to-face in-depth interviews to explore shared decision-making among 30 lung cancer high-risk individuals and 9 health care providers. Content analysis was used for data analysis.

We identified 4 decisional needs that impair shared decision-making: (1) LCS knowledge deficit; (2) inadequate supportive resources; (3) shared decision-making conceptual bias; and (4) delicate doctor-patient bonds. We identified 3 decision supports: (1) providing information throughout the LCS process; (2) providing shared decision-making decision coaching; and (3) providing decision tools.

Conclusions

This study offers valuable insights into the decisional needs and support required to undergo LCS among high-risk individuals and perspectives from health care providers. Future studies should aim to design interventions that enhance the quality of shared decision-making by offering LCS information, decision tools for LCS, and decision coaching for shared decision-making (e.g., through community nurses). Simultaneously, it is crucial to assess individuals’ needs for effective deliberation to prevent conflicts and regrets after arriving at a decision.

Peer Review reports

Low-dose computed tomography (LDCT) is an effective tool for early lung cancer detection and has been proven to enhance survival rates in individuals at high-risk for lung cancer [ 1 , 2 ]. However, global LDCT usage is limited, with only 2-35% of eligible individuals undergoing screening [ 3 , 4 , 5 , 6 , 7 ], in contrast to 16-68% of eligible candidates undergoing colorectal cancer screening [ 8 ]. Improvements in LDCT screening rates for high-risk groups have been modest. The intricate balance between the advantages and risks of LDCT impedes the utilization of lung cancer screening (LCS) [ 9 ]. Notably, compared to their non-screened counterparts, high-risk individuals who underwent LDCT had a remarkable 24% decrease in lung cancer mortality [ 2 ]. However, the benefits of LDCT come with potential drawbacks, such as radiation-induced cancer, needless examinations, invasive procedures stemming from false positives, overdiagnosis, incidental discoveries, and psychological burdens [ 10 ]. These complexities render the LDCT screening decision-making process multifaceted and reliant on personal preferences. Hence, guiding high-risk groups toward well-informed choices regarding LCS is pivotal and represents a substantial mechanism for advancing the secondary prevention of lung cancer.

Shared decision-making is defined as “a collaborative approach for health care providers and patients in making informed health decisions”, which involves considering evidence regarding the benefits and risks of medical options, as well as individuals’ preferences and values [ 11 ]. This decision-making process allows both health care providers and individuals as well as their family members to engage in deliberation which leads to identifying the most appropriate decision for the situation [ 12 ]. Multiple guidelines strongly recommend shared decision-making as an essential step before patients undergo LDCT. Shared decision-making is also stipulated as a prerequisite for LDCT reimbursement by the Centers for Medicare and Medicaid Services in the United States [ 13 , 14 , 15 , 16 ]. Regrettably, the utilization of shared decision-making in clinical practice is currently not optimal [ 17 , 18 ]. Patients do not know what LDCT is, and they often report a lack of about the risks and benefits of LDCT. As a result, patients often have concerns about the risks of LDCT, and health care providers frequently fail to inquire about individuals’ preferences [ 19 ]. Consequently, there has been a notable increase in the literature focusing on barriers to shared decision-making from the perspectives of both health care providers and lung cancer high-risk groups. For example, studies have shown that the barriers to shared decision-making include different perceptions about the use of shared decision-making and a lack of time to communicate with providers. However, there are some limitations in terms of methodology and the comparative nature of the studies that focus on LCS shared decision-making. First, previously published studies focused on identifying barriers to shared decision-making and neglected decision support from physicians and patients. For instance, one study found that a lack of professionalism in health care providers is a barrier to shared decision-making, yet no studies have examined specific LCS shared decision-making decision supports for health care providers [ 19 ]. Second, current research centers on short-term decision-making experiences, such as cognitive consequences experienced immediately following shared decision-making. However, studies have not adequately addressed the complete shared decision-making process – pre-decisional needs, the decision-making process itself, and post-decision experiences, such as decision regret. Third, the COVID-19 pandemic has introduced a new risk of LDCT usage (exposure to the health-care environment) [ 20 ]. The added risk alters the benefit-risk ratio of LDCT under pre-COVID-19 guideline recommendations. Fourth, shared decision-making, developed in Western societies, is rarely discussed in China. The national climate and medical systems of China and Western countries differ greatly [ 21 ], and the lack of evidence on LCS shared decision-making in China indicates a need for an assessment of shared decision-making in those who require LDCT.

This study aimed to explore the decisional needs and decision support of shared decision-making for LCS among Chinese high-risk individuals and their health care providers using data collected through in-depth one-on-one interviews.

Theoretical framework

The Ottawa Decision-Support Framework (ODSF) is an evidence-based conceptual framework that is structured around three key components [ 22 ]: (1) assessing decisional needs, such as insufficient knowledge, complex decision types, and limited resources; (2) providing decision support, which encompasses clinical counseling, decision-making tools, and decision coaching; and (3) evaluating decisional outcomes, which includes assessing the quality of the decision-making process and its impact. According to the ODSF, successful decision support should be guided by an assessment of the individual’s knowledge and his/her ability to make his/her own decision to reduce their unmet needs and achieve a final health decision with the support of health care providers and family members. The ODSF has been successfully used within several populations with health needs to guide health decisions and provide decision support [ 23 , 24 ].

This qualitative study emphasizes the “who, what, and where” of events or experiences [ 25 ]. The central research question posed was, “What are the decisional needs and supports of LCS shared decision-making among individuals at high-risk of lung cancer and health care providers?” Consequently, a descriptive qualitative approach was deemed appropriate for exploring the decisional needs and supports for LCS shared decision-making among individuals at high-risk of lung cancer and health care providers [ 26 ]. This descriptive qualitative study adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist [ 27 ]. Ethical approval for this study was obtained from the ethics committee of Fujian Medical University (Approval No. 2,023,098).

Inclusion and exclusion criteria

Aligned with the guidelines for the early detection of lung cancer in China [ 14 ], the inclusion criteria used for the high-risk group for lung cancer were as follows: (a) aged between 50 and 74 years; (b) had at least one of the following risk factors for lung cancer: a smoking history ≥ 30 pack-years, which includes current smokers or individuals who quit smoking within the last 15 years; prolonged exposure to passive smoking (living or working with smokers for 20 years or more); a history of COPD; a history of occupational exposure to asbestos, radon, beryllium, chromium, cadmium, nickel, silicon, soot, or coal soot for a minimum of 1 year; or a family history of lung cancer; (c) verbal confirmation of undergoing LCS shared decision-making; (d) undergone LDCT within the past 5 years; (e) Able to converse in Mandarin; (f) absence of cognitive or psychological disorders; and (g) willingness to share their personal stories. The exclusion criteria used for the high-risk group for lung cancer were as follows: (a) previous history of lung cancer; and (b) cognitive or psychological disorders (such as depression and anxiety). The inclusion criteria used for health care providers were as follows: (a) certified physicians or nurses; (b) expertise in LCS; and (c) willingness to share their experiences. Healthcare providers who were receiving external training were excluded from participation in the study.

Qualitative data collection

The data were collected from March 2023 to May 2023. A purposive sampling method was used to identify and recruit individuals at high-risk for lung cancer, as well as local health care providers from five community healthcare centers and two surgical oncology departments of tertiary hospitals. Study flyers provided information on the purpose of the study and the inclusion and exclusion criteria and were distributed to potential participants on site. After participants expressed their interest in the study, they were screened for eligibility to participate and their informed consent was secured. Next, a one-on-one interview was scheduled and a questionnaire was completed by participants to obtain their demographic data (gender, age, residential area, smoking status, etc.). One-on-one interviews were conducted in Mandarin, digitally recorded, with study data stored on a passworded encrypted laptop. Each interview lasted approximately 20 to 40 min. A private room in the clinic was used for all the in-depth interviews.

The interview questions were formulated based on the ODSF and after a comprehensive literature review [ 28 ], with extensive discussions among researchers of the study (Feifei Huang, PhD, RN, Professor, specializing in lung cancer prevention and psycho-oncology; Weisheng Chen, MD, specializing in lung cancer prevention, diagnosis and treatment; and Wei-Ti Chen PhD, RN, CNM, FAAN, specializing in intervention design and qualitative data collection). To ensure the acceptability and credibility of the interview guide, the interview questions were pilot tested with four participants in total, including two health care providers and two individuals at high-risk of lung cancer. As a result, some misconceptions regarding the interview questions were identified and subsequently modified. For instance, we replaced the term “decision tools” with “patient decision aids” to help participants to better understand the posed questions. The final interview questions are outlined in Table 1 . Tables 2 and 3 summarize key demographic data collected on the high-risk individuals and health care providers, respectively.

The sample size was determined by data saturation, that is, recruitment ended at the point where no new themes emerged from the participants’ experiences [ 29 ]. Data saturation was reached at approximately the twenty-seventh in-depth interview with a high-risk lung cancer individual, with another three high-risk lung cancer individuals being interviewed to ensure that the data reached complete saturation. Data saturation was reached at approximately the seventh in-depth interview with healthcare providers, with another two healthcare providers interviewed to ensure data saturation.

Data analysis

Since the interviews were conducted in Mandarin, a bilingual coding technique was used to keep the data in the original Chinese format, and the coding assignments were in English (e.g., decision negotiation). To ensure accuracy and minimize potential translation errors, two bilingual researchers (Chinese and English) reviewed and confirmed the translations [ 30 ]. The process of data analysis began with data collection. To analyze the data, content analysis was guided by the ODSF and Nvivo software version 12 was used [ 31 ]. The classification of themes was performed both inductively (derived from the quotes of research participants) and deductively (derived from the ODSF theoretical framework) under the principle of complementarity. The detailed steps of the data analysis process are illustrated in Fig. 1 .

Directed content analysis flowchart

Trustworthiness

Credibility, dependability, confirmability and transferability were employed to assure the trustworthiness of this study’s findings [ 32 ]. To enhance credibility, the researcher dedicated ample time to establishing meaningful interactions with the participants, thereby building trust for effective data collection. Regarding dependability, two researchers cross-checked and rectified codes that did not precisely reflect participants’ perspectives. Furthermore, an audit trail and reflexivity techniques were used during the data analysis process, which included tracking the interview and data analysis notes and memos. To ensure confirmability, the supervisor reviewed and selected quotations, codes, and categories, thereby validating the accuracy of the coding process. In terms of transferability, participants were purposefully selected from both urban and rural areas to incorporate a wide range of perspectives. Herein, a comprehensive description of the entire research process is presented to facilitate reproducibility of the study.

Out of a total of 44 participants consented, five participants (4 high-risk individuals and 1 health care provider) dropped out of the study due to their busy schedules and lack of interest in participating. A total of 39 eligible volunteers composed the study sample. Among them, 30 individuals were classified as at high-risk for lung cancer with an average age of 61.27 ± 7.92 years, while nine health care providers had an average age of 36.78 ± 7.45 years. Five health care provider participants specialized in lung cancer prevention, diagnosis, and treatment, and four specialized in general medical education and community cancer screening education. Detailed demographic information on the participants can be found in Tables  2 and 3 .

A total of 546 unique codes related to LCS shared decision-making were identified. Following the framework of the ODSF, participants’ decisional needs and supports for shared decision-making were categorized (refer to Fig.  2 ; Table  4 ).

Participants’ viewpoints on shared decision-making based on ODSF

Decisional needs

We identified four categories related to the theme of decisional needs, including LCS knowledge deficits, inadequate supportive resources, shared decision-making conceptual bias, and delicate doctor-patient bonds.

Theme 1: LCS knowledge deficit

Many high-risk study participants expressed that they did not have access to reliable and authoritative medical information. Many of the high-risk participants shared their inability to access LCS-related information and their limited capacity to distinguish accurate LCS information from misinformation. Furthermore, participants mentioned that a negative personal view of life influenced their active engagement in shared decision-making with health care providers and/or family, which diminished their comprehensive understanding of LCS.

“Some people are negative, they believe God’s will can decide everything, so when they faced a decision, they will ask the gods instead of making a decision according to their actual situation” H13 (high-risk individual, female, 53 years-old).

Theme 2: inadequate supportive resources

Participants emphasized that shared decision-making was hindered by financial, transportation and time-related barriers to hospital visits. Furthermore, unfamiliarity with the process of seeking medical treatment also presented an obstacle to shared decision-making. Notably, participants expressed negative emotions related to the LDCT test which influenced their shared decision-making. In particular, the LDCT process was not well received by individuals who had claustrophobia. Participants described feeling claustrophobic during the process of the imagological examination. The requirement for patients to lie flat during the examination, combined with the confined and dim space, can lead to feelings of depression and suffocation. Additionally, the machine’s noise and concerns about potential risks (such as radiation and false positives) from having LDCT scans may have heightened patients’ negative emotions and fears.

“Since I smoke, I’m always scared of getting bad test results. If the results are bad, it’s just really scary, I don’t think I have the sanity to make shared decisions with my doctors. I need help.” H11 (a high-risk individual, female, 54 years-old).

“I struggle with claustrophobia, and every time I have a test, I feel really trapped. It would be difficult for me to have shared decision-making when I have a claustrophobia. It felt like my mind was blank.” H12 (a high-risk individual, male, 52 years-old).

Several participants mentioned experiencing anxiety regarding the test results. They expressed their apprehension about potential adverse outcomes and indicated that this anxiety affected their ability to engage in shared decision-making with their doctors. Moreover, after experiencing claustrophobia, some participants expressed that they felt an inability to make shared decisions with their doctors in a rational manner.

Theme 3: Shared decision-making conceptual bias

Some participants mentioned that they were not familiar with the specific term ‘shared decision-making’. Health care providers shared the perspective that excessive communication with the high-risk group about their condition might lead to a refusal of subsequent treatment, potentially jeopardizing their health.

“I believe that when it comes to professional matters, it’s best to rely on trained professionals. Most patients don’t have expert medical knowledge, and even if they do, they might be hesitant about certain exams. That, in my opinion, doesn’t do much good for their health.” M8 (a general practitioner, female, 36 years-old).

Additionally, participants had misconceptions about shared decision-making. For example, health care providers had misconceptions about shared decision-making in LDCT screenings – some believed that shared decision-making meant merely providing information about the benefits and risks of LDCT; others confused the concepts of informed consent and shared decision-making all together; and a few providers viewed encouraging high-risk groups to conduct LDCT screening to be a part of shared decision-making. Some participants believed shared decision-making to be merely a procedural step to schedule a test appointment.

“I think shared decision-making means thoroughly informing those in high-risk groups about the pros and cons of a particular exam and ultimately letting them make the call.” M5 (a physician specialist, male, 25 years-old).

“When we suggest undergoing a medical examination, doctors might assume that this visit is a necessary step for patients to get a chance to be examined, not a step for shared decision-making. As a result, they may believe that there’s no necessity for patient education.” H13 (a high-risk individual, female, 53 years-old).

Theme 4: delicate doctor-patient bonds

Both health care providers and high-risk individuals emphasized that time constraints pose a significant barrier to shared decision-making. Some participants noted that doctors, who often express concerns about work-related burnout, were hesitant to provide comprehensive information about LDCT.

“I believe that doctor burnout contributes to their reluctance to discuss lung cancer screening with patients.” H9 (a high-risk individual, male, 57 years-old).

Furthermore, health care providers and participants encountered challenges with communication. Health care providers struggled to simplify complex information for easy understanding, while participants had difficulty clearly expressing their needs.

“Effective communication is essential for both doctors and patients. The doctor’s ability to convey information and the patient’s capacity to express their needs are crucial. Insufficient communication skills represent a challenge for both parties.” M6 (a physician specialist, male, 27 years-old).

Participants also mentioned that they were hesitant to express their thoughts to doctors whom they do not know well.

“Building trust is not a simple task. When patients and I have a strong connection and they trust us enough to share their true thoughts, it significantly reduces barriers to shared decision-making. On the other hand, some doctors who aren’t deeply connected with the community may struggle to gain patients’ trust, leading to communication challenges that hinder shared decision-making.” M2 (a nurse in grade A tertiary hospital, female, 41 years-old).

Others believe that the professional competence of doctors plays a pivotal role in shared decision-making in LCS. People often opt for doctors from tertiary hospitals who were perceived to have a higher level of professionalism, which is conducive to shared decision-making.

“Personally, I believe that the expertise of doctors in county-level hospitals may not be as advanced, which affects my level of trust in them. I tend to find doctors in top-tier tertiary hospitals to be more credible.” H12 (a high-risk individual, male, 52 years-old).

Decision support

Three categories related to the theme of decision support were identified: provide information throughout the LCS process, providing a shared decision-making coach, and provide decision tools.

Theme 1: provide information throughout the LCS process

Participants shared that they would like to know information about LDCT before and after undergoing the screening test. Desired information prior to screening included: eligibility criteria for LCS; benefits and risks of LDCT, the LDCT process itself, primary and secondary prevention of lung cancer, the cost of LDCT, potential emergencies and appropriate responses during LDCT, guidelines for Medicare reimbursement related to LDCT, and the medical visit steps. Most participants wanted information after the screening to include the interpretation and monitoring of LDCT results as well as the recommended frequency of LDCT.

Theme 2: providing a shared decision-making decision coach

Several participants said that it is necessary to enhance shared decision-making beliefs to better support the decision-making process for LCS, which is inherently a preference-sensitive decision.

“In China, shared decision-making isn’t commonly practiced. Many physicians here may not be familiar with the concept, even though it’s something they should consider adopting. Personally, I strongly believe in the importance of implementing shared decision-making.” H6 (a high-risk individual, male, 58 years-old).

High-risk individuals emphasize the importance of establishing a foundation for knowledge before engaging in shared decision-making. Participants advocated for a basic understanding of medical concepts, with decision counselors possessing specialized medical expertise.

“Before participating in shared decision-making, I’d like to gain some basic medical knowledge.” H4 (a high-risk individual, female, 53 years-old).

Due to time and energy constraints, clinicians found it challenging to engage in shared decision-making. However, the community doctors in our study stated that they had more time to communicate and share opinions and that their closer patient-provider relationships could facilitate the shared decision-making process in China.

“We only present the benefit and harm of LDCT briefly. We don’t have enough time to describe these in more detail. You know, lung cancer pathology and knowledge of imaging are too complex for high-risk individuals of lung cancer. For individuals who don’t have professional backgrounds, it is impossible for them to understand totally, what we can do is try to get them to understand as much as possible in a limited time.” M5 (a doctor in grade A tertiary hospital, male, 25 years-old).

“It’s important to involve community health providers in shared decision-making for a couple of reasons. Firstly, we tend to establish a strong rapport with patients, and they often trust us more compared to clinicians. Additionally, we have the advantage of spending more time communicating with patients, which makes us better suited to facilitate shared decision-making.” M9 (a general practitioner, male, 42 years-old).

Theme 3: providing decision tools

Participants expressed the need for decision tools and made several suggestions for decision tools to better cater to diverse groups. Decision tools are instruments that aid users in clarifying the congruence between their decisions and their individual values by presenting relevant options along with their associated benefits and potential drawbacks. Through the use of decision tools, users are assisted in arriving at clear, high-quality decisions.

The participants had several suggestions for providing decision tools. First, various information modalities such as videos, images, and written content should be integrated into tools to accommodate varying education levels and preferences. Second, tailored information that aligns with LCS decision-making is preferred. Third, a three-way interaction model involving patients, decision tools, and health care providers could enhance effectiveness. Fourth, medical knowledge should be presented in a comprehensible manner to improve accessibility. Additionally, access to more detailed information is necessary. Fifth, the time spent using decision tools should be less than 20 min to prevent impatience. Sixth, most participants emphasized addressing credibility concerns, through incorporating medical professionals into the tool’s development team, emphasizing authoritative sources, and involving experts from reputable hospitals. Finally, most participants acknowledged that value clarification exercises should be integrated to help users articulate their personal screening preferences to ensure a comprehensive approach to decision support.

Shared decision-making plays a crucial role in enhancing the understanding of LCS and LDCT in high-risk groups. Shared decision-making can also establish realistic expectations for health outcomes and ultimately improve decision-making for the best treatment or screening option [ 33 ]. This qualitative study provides insights into the decisional needs and necessary support for shared decision-making in LDCT screening, from the perspectives of health care providers and high-risk individuals in China. Specifically, LDCT screening decisions should evaluate the knowledge, availability of supportive resources, health care providers’ understanding of shared decision-making concepts, and quality of doctor-patient relationships. At present, both providers and screeners require decision support surrounding LDCT information and need shared decision-making coaching to effectively arrive at a decision. This study finding is valuable for shaping the design of future interventions that aim to facilitate decision-making and has the potential to increase the use of LDCT screening in Chinese society.

Our findings also contribute to the classification refinement of the ODSF. Regarding LCS knowledge, we have observed that high-risk groups not only lack specific knowledge of LCS, but also face challenges accessing relevant information and struggle with their capacity to distinguish accurate LCS information from misinformation. Previous multimodel public health interventions have focused on education related to specific LCS knowledge and ignored the need to access correct information, insufficiently addressing the needs of populations at high-risk of lung cancer [ 34 ]. Therefore, in addition to limited knowledge, limited access to information and lack of identification undermine the contributions of high-risk groups in shared decision-making.

In terms of support and resources, it is essential to consider not only conventional limitations such as financial and health system resources, but also the psychological well-being of high-risk populations. The proportion of smokers is greater among those at high-risk for lung cancer than among those at high-risk for other types of cancers (such as breast cancer and colorectal cancer) [ 35 ]. Being a smoker can affect the execution of shared decision-making due to perceived stigma, lung cancer fatalism, and heightened levels of worry and fear of contracting lung cancer [ 35 ]. Additionally, concerns about potential risks associated with LDCT serve as a barrier to the shared decision-making process with health care providers [ 9 ].

Our findings provide new insights into the core constructs of decisional needs, including awareness of shared decision-making and doctor-patient bonds. Additionally, shared decision-making awareness studies have demonstrated that bias can lead to differences in individual preferences, which can hinder the initiation of shared decision-making and result in higher levels of decision conflict [ 36 ]. Additionally, studies have shown that poor doctor-patient communication can lead to low-quality shared decision-making. For example, dismissive clinicians who dominate decision-making encounters, use negative verbal or nonverbal cues, or fail to respect patients’ concerns have been shown to act as barriers to shared decision-making for many patients [ 37 ]. Conversely, clinicians who strive to understand individual needs and preferences can foster a sense of partnership and facilitate their involvement in shared decision-making processes [ 38 ]. It has also been found that allocating limited time for consultations as well as poor communication skills results in ineffective shared decision-making [ 39 ]. Limitations in skill and time can impede the ability to be fully informed by health care providers, to process and reflect on the information received, and to engage in meaningful discussions between providers and individuals [ 37 ]. Furthermore, the presence of trust is identified as a facilitator of shared decision-making. Establishing a trusting relationship with health care providers encourages patients to feel more comfortable asking questions, sharing personal information, and discussing their concerns [ 39 ].

Currently, the use of shared decision-making in clinical practice is suboptimal in China [ 11 ]. Fortunately, our study provides potential mitigation strategies. First, the need for comprehensive decision tools that appeal to diverse groups of patients was emphasized by both high-risk groups and health providers. A decision tool can furnish information, facilitate patient-doctor dialog, and enhance therapeutic outcomes [ 33 ]. However, the availability of decision tools for LCS is limited and their applications are less than ideal, partly due to their failure to be tailored to personal needs. For instance, most LCS decision tools are presented as single-page materials or premade videos, which may not fully address participants’ needs. Our findings highlight the demand for personalized decision tools for LCS in China. Second, some participants suggested that decision counselors should not be limited solely to clinicians; community health care providers can also serve as counselors for decision-making. This aligns with the concept that shared decision-making requires multisectoral collaboration [ 40 ]. Community nurses in particular, share similar ethnic, linguistic, and geographic backgrounds with the residents they serve compared to other nurses. Consequently, they are more likely to encounter high-risk populations in the community [ 41 ]. Additionally, due to the nature of their work, they have more time to engage in shared decision-making discussions with high-risk groups. Research has revealed that community nurses, in their roles as coordinators, educators, researchers, navigators, and practitioners, can play multidimensional roles essential for leading successful LCS [ 42 ]. Hence, future research should actively promote the development of community nurses as counsellors for LCS to alleviate the burden on hospital-based physicians. Third, both health care providers and high-risk groups should receive education on shared decision-making. Our findings reveal that both sides still possess a vague understanding of shared decision-making, often conflating it with informed consent (patient-led) and paternalism (physician-led) models. Unlike in Western countries, humanistic medicine education in China is lacking, resulting in an inadequate grasp of patient-centered medical-ethical principles among health providers and patients [ 21 ]. Future interventions in China should emphasize humanistic medicine to establish the foundation of shared decision-making.

Our findings are rooted in Chinese culture, which, along with broader Asian cultural influences, places a significant emphasis on Confucianism and sociocultural values such as family support, care, and respect for familial hierarchy and authority [ 43 ]. Therefore, the insights provided by this paper may be applicable to other Asian countries. Despite the rapid development of SDM research in the West, the actual implementation of SDM in clinical practice is not as favorable [ 44 ]. One contributing factor is that highly developed patient decision aids often overly focus on standardized processes, deviating from a more humanistic approach that can be applied universally [ 44 ]. Moreover, the ongoing wave of globalization has resulted in increasingly multicultural societies, necessitating a broader scope of SDM coverage that includes individuals from diverse cultural backgrounds. Therefore, avoiding cultural stereotypes and actively inquiring about patients’ preferences become especially crucial. The results of our study contribute valuable insights into individual decisional needs and decision support from the perspectives of both individuals at high-risk for lung cancer and health care providers. These perspectives can assist patient decision aids in avoiding excessive standardization. Simultaneously, the perspective embedded in our findings is well-suited to accommodate the multicultural nature of Western countries. Future studies should seek to bridge the gap in SDM between Eastern and Western contexts.

Limitations

There are several limitations in this study. First, since the high-risk lung cancer individuals in our study did not undergo LCS shared decision-making recently, their views on LCS shared decision-making may have been subject to recall bias. Second, all study participants were from Fujian Province, which is a southeastern province in China. It is possible that recruitment from a broader geographical area may have led to a wider range of perspectives and experiences and thus influenced the point at which data saturation was reached. Third, as a qualitative, in-depth interview study, generalizations of findings to a larger population are not possible. Future quantitative studies should explore decision-making experiences among a broad range of high-risk groups and health care providers in China to enhance data triangulation and thus, the credibility and reliability of the study’s findings.

Guiding high-risk groups toward well-informed choices regarding LCS represents a substantial gain toward advancing secondary prevention of lung cancer. This descriptive qualitative study offers valuable insights into decision-making regarding LDCT screening among Chinese high-risk groups and their health care providers. The findings from this study highlight the decisional needs and decision support for shared decision-making for LCS using the ODSF conceptual framework. Future studies should target intervention development to offer decision support by evaluating individuals’ decisional needs, enabling them to make choices confidently, and with minimal conflict and decisional regret. In addition, this study may also serve as a starting point for the development of more effective decision tools for LDCT screening.

Availability of data and materials

The de-identified datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Low-dose computed tomography

Lung cancer screening

The Ottawa Decision-Support Framework

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The authors are grateful to all the participants in this study.

This work was supported by the National Natural Science Foundation of China [grant number 72304068] and the General Project of Fujian Provincial Nature Science Foundation (grant number 2021J01133126).

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Lin, X., Wang, F., Li, Y. et al. Exploring shared decision-making needs in lung cancer screening among high-risk groups and health care providers in China: a qualitative study. BMC Cancer 24 , 613 (2024). https://doi.org/10.1186/s12885-024-12360-0

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Toward enhanced decentralized palliative care services in Neno District, Malawi: a qualitative study.

• Atupere S. Phiri   ORCID: orcid.org/0000-0001-9451-5758 1 ,
• Manuel Mulwafu 1 ,
• Haules Robbins Zaniku 2 , 3 ,
• Moses Banda Aron 1 , 4 ,
• Judith Kanyema 1 ,
• Stellar Chibvunde 1 ,
• Enoch Ndarama 2 ,
• Grace Momba 2 ,
• Fabien Munyaneza 1 ,
• Lameck Thambo 5 ,
• Chiyembekezo Kachimanga 1 &
• Beatrice Matanje 1  

BMC Palliative Care volume  23 , Article number:  132 ( 2024 ) Cite this article

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Palliative care remains key in assisting patients who have life-threatening conditions. In most low- and middle-income countries, it is often offered through a centralized system with limitations, including Malawi. In 2014, the World Health Organization called for improving palliative care access through primary health care and community models. Malawi and Neno District subsequently decentralized palliative care delivery to local health centers. This qualitative study explored the decentralization of palliative care services in Neno District, Malawi.

The descriptive qualitative study was conducted between 2021 and 2022 in two conveniently selected health centers providing palliative care in the Neno District. Fourteen healthcare workers were purposefully selected to participate in two focus groups. Fifteen patients were conveniently selected and participated in three focus groups. Data was analyzed using deductive and inductive approaches. Focused group discussions were conducted in Chichewa (Malawi’s official local language), audio recorded, transcribed, translated into English, and analyzed thematically.

Four main themes emerged from the focus groups. Patients described positive relationships with healthcare workers built on trust and holistic care over time. Accessing care included transport, social support, time constraints, and distance issues. Facilities effectively responded to needs through coordinated care and follow-up. Decentralization was perceived to benefit patients by reducing travel challenges and improving local access to efficient and inclusive palliative care services. However, challenges with resources, distance, and social support remained. Limitations in sampling and missing participant details necessitate further research with broader sampling.

Overall, the study provides empirical evidence that can optimize palliative care delivery in similar low-resource contexts by informing policies to address barriers through decentralized approaches.

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Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who face problems associated with life-threatening illness [ 1 , 2 , 3 , 4 ]. It prevents and relieves suffering by early identification, correct assessment, and symptom control, including pain and other problems, whether physical, psychosocial, or spiritual [ 5 ].

Globally, 40% of nations indicated that palliative care was provided (having reached at least 50% of those in need) in a community- or home-based setting. In comparison, 39% reported that it was available in the primary healthcare [ 6 ]. Only 5% of the estimated 56.8 million individuals in need of palliative care each year have access to it; most individuals reside in low- and middle-income countries (LMICs) [ 7 , 8 , 9 ]. According to estimates from the World Health Organization (WHO), 98% of children in need of palliative care reside in regions where these facilities are non-existent in the majority of LMICs, especially in Africa [ 10 ]. Palliative care was more widely offered in primary health care settings (19% of low-income countries), Malawi not spared, than in community- or home-based settings [ 6 ].

In Malawi, Palliative care services are provided to a relatively small population facing irreversible, progressive illness during what should be their most economically productive years [ 11 ], and only 58% of the target population has been reached in the 94 established palliative care sites in the country available at all levels of care [ 8 , 12 ]. In the Neno district, the palliative care program registered 921 out of the 1,380 target population at the end of 2021 [ 1 , 13 ].

In 2014, the first-ever global resolution on palliative care, World Health Assembly (WHA) resolution WHA67.19, called upon the World Health Organization (WHO) and its member states to improve access to palliative care as a core component of health systems, with emphasis on primary health care and community/home-based care model [ 9 ]. In the same year, Malawi adopted the resolution and decentralized the responsibility to the health centers as primary implementers of palliative care service delivery, and the Palliative Care Programme of the Neno District Health Office followed suit in 2020 [ 14 ].

Using Deming’s Plan, Do, Check, and Act (PDCA) Model cycle of continuous improvement [ 15 ], the Neno palliative care program embarked on decentralizing palliative care services to improve the uptake and quality of care provided to patients with life-threatening illnesses. With the approval of the Ministry of Health through the Neno District Health Office, two health centers, Ligowe and Magaleta, were identified as the first sites for decentralization.

Decentralization included four steps: (1) needs assessment to assess capacity building requirements, availability of essential medical supplies, infrastructure capacity to accommodate palliative care patients, and an estimation of potential palliative care patients using patient diagnoses recorded in the facility outpatient registers (OPR), (2) orientation of the healthcare workers in health centers on the principles of palliative care, (3) clinic setup, and (4) monthly mentoring for six months.

All stable ambulatory patients from the Ligowe and Magaleta catchment areas were transferred from the Neno District Hospital static clinic to their nearest facility for follow-up. In 2021, a year after decentralization, it was noted that the program had registered a lower patient uptake (less than 1% of the population required in a given catchment area), as suggested by WHO [ 14 , 16 ] [ 14 , 16 ]. . A year later, a study explored the perceived benefits, challenges, and opportunities of decentralizing palliative care to primary-level health facilities.

Therefore, the study explored the effectiveness of palliative care service decentralization by examining the interaction between healthcare workers and patients. It assessed service agility and reliability post-decentralization and examined perceived benefits, challenges, and opportunities. These objectives provided insights into the impact of decentralization on palliative care delivery, focusing on the Neno District in Malawi.

Study design

This descriptive qualitative research employed a deductive and inductive approach to data analysis [ 17 , 18 ]. It aimed to explore the effectiveness of service decentralization by understanding the interaction between healthcare staff members and patients, ascertaining the agility and reliability of palliative care services, and evaluating the efficiency of palliative care service decentralization.

Neno is in the southern region of Malawi, one of the country’s poorest districts. In 2022, the Neno district had an estimated population of 138,291 [ 19 ]. Most of the Neno population lives in rural areas and relies on subsistence agriculture as their primary source of income [ 20 ]. According to the Malawi National Statistical Office (NSO), the Neno district’s poverty rate was approximately 75% in 2016 [ 20 , 21 ].

The district has 15 health facilities that provide primary and secondary care to its residents [ 21 ]. Neno District Hospital, five health centers (Dambe, Nsambe, Matandani, Neno Parish, and Margareta), and one dispensary (Ligowe) that covers the western side. Lisungwi Community Hospital, three health centers (Luwani, Chifunga, and Matope), and four dispensaries (Midzemba, Zalewa, Nkula, and Tedzani) covering the eastern side. Tedzani is a co-shared facility between the Blantyre District Health Office and the Neno District Health Office regarding administration and management.

Since 2009, the Neno District Health Office has provided palliative care services only in one main referral hospital until 2018, when services were decentralized to the other referral hospital. In 2020, the service was further decentralized to two health centers: Ligowe and Magaleta. These are government-owned public health facilities under the Neno District Health Office. In 2018, the National Statistical Office (NSO) estimated that Ligowe and Magaleta serve a population of 10,941 and 8,723, respectively [ 22 ]. Most of the services are government-sponsored, while some are supported by a nongovernmental organization called Partners In Health/Abwenzi Pa Za Umoyo (PIH/APZU) Malawi, palliative care being one of them. Data was collected in a private room or at the nearest health facility. Only the research assistants (RAs) and participants were present during data collection.

Target population

The target population was all healthcare workers in the Ligowe and Magaleta health centers and all adult patients (18 years and older) who received palliative care services in the Ligowe and Magaleta health centers at the time of data collection. In the study, healthcare workers referred to formally trained and informally trained healthcare providers, including those in the laboratory (on-job trained), ground labour, pharmacy (on-job oriented), clinicians, nurses, and hospital attendants.

Sample size and sampling technique

Participants were both purposefully and conveniently selected to form five FGD groups. For the healthcare workers at the health centers, two FGDs were conducted, one at each facility. The facility in charge purposefully chose participants based on the staff members’ duty stations. The selection was based on workstations directly in contact with palliative care patients. For patient participants, two male and one female FGDs were conducted, with participants conveniently selected based on who came first to the facility to form a group of 4–6 participants based on the number of patients enrolled.

Inclusion and exclusion criteria

The inclusion criteria were (a) healthcare workers in the two health centers and (b) all adult palliative care patients who received palliative care services at the Ligowe and Magaleta Health Centre clinics during data collection. The exclusion criteria included (a) patients who were incapacitated at the time of data collection and, (b) patients aged less than 18 years old, (c) All healthcare workers who were not in close contact in their work with palliative care patients.

Data collection

Patients were contacted face-to-face and were informed about the study by community health workers before they were interviewed. Upon agreement, the patients were told to come to the health center for interviews. The RAs collaborated with the facility in charge, who briefed the healthcare worker participants, scheduled the interview day at the health center, and helped identify the patient participants. The study participants knew the questions during the interview sessions. All invited participants agreed and took part in the study.

Two research assistants (RAs) were hired and trained to administer the FGD guide. The guide was translated from English to Chichewa by a palliative care expert and verified by a qualitative research fellow from Partners In Health/Abwenzi Pa Za Umoyo (PIH/APZU). A pilot FGD was conducted with one group of patients and one group of healthcare workers to test the questions. Two RAs, a qualitative research fellow and a palliative care expert, then reviewed and revised the translated Chichewa question guide based on pilot feedback from the RAs. The translated questions were checked to ensure accurate meaning compared to the English version. Data from the pilot study were not included in the main study.

The RAs did not know the participants before the data collection. Before involving the participants in the study, the information sheet was read aloud and shared with them. Then, the participants were asked to sign or provide a thumbprint to confirm their willingness to participate in the study. No repeat FGDs were needed. The two RAs conducted the interviews and audio-recorded the FGD sessions in the local language. During the interview, one acted as an observer while the other interviewing participants as moderator. On average, the FGD lasted about 90 min. The RAs then transcribed and translated the audio recordings into English.

Data analysis

Participants’ demographic data was analysed using Microsoft Excel, and counts and percentages were reported. The R.A. transcribed the recorded interviews into Chichewa and translated them into English. The transcribed data was never referred back to participants for corrections or their review. Before developing the codes, AP listened and verified that the recording was transcribed according to the recorded audio. Three researchers (AP, HRZ, and MM) read two transcripts, developed a codebook using phrases, and simultaneously coded sample interviews. Then, the three later converged to resolve any discordant codes. The codes were categorized using the framing and linking approach [ 17 , 18 ]. To accomplish this, the study utilized Dedoose software (v 9.0.107) for sorting data, and the team iteratively read and analyzed data, continually discussing and refining it until four themes were developed. In the final report, the study adhered to the guidelines provided by the ‘Consolidated Criteria for Reporting Qualitative Research’ (COREQ) [ 23 ].

The study utilized a qualitative research design to explore the experiences and perspectives of key stakeholders involved in the decentralization of palliative care services in Malawi. No participant refused or withdrew from participating in the study. A total of 29 individuals participated across two rural health centers – Ligowe and Magaleta. Specifically, 14 healthcare workers were engaged through focus group discussions, with the majority ( n  = 10, 71%) being male participants from roles such as nursing, pharmacy assistants, laboratory assistants, security, and community health work supervisor. Additionally, 15 palliative care patients at these facilities participated in separate focus groups. Overall patient enrollment across the sites was 18, of which 15 participated in the study with more than half ( n  = 9, 55.6%) were male. While Ligowe Health Center had a slightly higher representation of both staff and enrolled patients, the study drew from a diverse range of viewpoints to understand how decentralization has impacted service delivery from the perspective of both healthcare providers and the recipients of palliative care in these rural Malawian communities (Table  1 ).

The interviews led to developing 610 excerpts and 49 codes and identified four key themes (S2) interconnected with palliative care services. The first theme, “patient and healthcare worker relationship,” focuses on courteousness, privacy and confidentiality, time spent per consultation, and services beyond patients’ expectations. The second theme, “perceived benefits of palliative care program decentralization,” explores advantages such as reduced travel distances, shorter waiting times, and short distances to the clinic. The third theme, “patients’ perceived challenges in accessing palliative care services,” addresses obstacles such as travel costs and the need for increased social support. Lastly, the fourth theme, “facility responsiveness to patients’ needs,” underscores the importance of standardized screening protocols and the provision of equitable care.

Theme one: patient and healthcare worker relationship

Some participants viewed the service offered near their communities as a good development as they could access it nearby. These patients-provider relationships were seen as a value addition to service accessibility, time allotted for presenting problems, helping patients with courtesy, patient-centered care, privacy, and confidentiality. These patient participants expressed gratitude for how they were treated when seeking palliative care services. This gratitude was evidenced by what one of the patient participants had to say;

“The healthcare workers at this facility are very friendly and allow me to talk freely in a way that allows me to express my [problems and concerns] without being interrupted.” (Magaleta Male Patient # 02). “[We] can see with the way things [demonstrating how worsted he was] are; that is why they [nurses and clinicians] give [us] the [option] of being two when [we] are [going to] the consultation room. [We] are told that our information will not be disclosed to anyone. Therefore, our privacy is assured as [we] talk inside [closed the doors]. Our privacy is more valued by these doctors here [clinic].” (Ligowe male patient # 03).

The healthcare worker participants also ensure privacy and confidentiality by consulting patients inside consultation rooms. This practice was evidenced by what one participant had to say;

“[We] do not see patients in an open space; there is a room where patients consultations are done for [the] sake of privacy. This [pointing at the consultation room] room is where [patients] are seen alone or with their caregivers to discuss the [complaints or condition] the patient is experiencing.” (Ligowe HC worker # 02).

Theme two: perceived benefits of palliative care program decentralization

Some participants describe how significant it meant to move the program closer to communities. To patient participants, the move meant reduced transport costs to and from their homes, which helped them cut travel costs. Some participants were unhappy as traveling to Neno District Hospital Clinic meant spending much of their day at the hospital, and some participants enjoyed the fact that they could travel a short distance to the clinic. Some of the patient participants had to say;

“………having the services right here [at the clinic] is something nice because it was hard for [me] to leave for Chikonde [Neno District Hospital Clinic] for the clinicians to refill my medications. At times, [I] could find that the [severity] of the illness is so intense that [I] cannot manage [do some peace work] to find the money for transport [for my caregiver and myself] to go to [Neno District Hospital Clinic] [for] medications. In such instances, [I] end up [worsening at home] since [money for] transport is unavailable. Therefore, [we] are thankful that the palliative care service has come close to our community.” (Ligowe male patient # 03). “…… when [we] [used to receive] care at Neno DHO, [many patients met] there. [We] would go in the morning and return late in the afternoon, around 01:00 PM and 02:00 PM. Here [referring to the health center], there are few of us patients at [a time], and [we] receive assistance in good time and leave [for homes] in good time.” (Magaleta Male Patient # 02).

Theme three: facility response to patients’ needs

Some participants observed that the facilities were more patient-focused, had good rapport development, and were screened thoroughly, including screening for other conditions that were not their main reason for seeking medical care. Participants praised the practice, saying it promoted rapport establishment and standardized care. One of the patient participants had to say this:

“Once [we] arrive here [clinic], they assist us well. When [we] have arrived, we are weighed on the scale. After being weighed, they [checked] our vital signs, and [we] are asked questions about how [we] feel in our bodies. When this is done, [we] are told to go to the doctor, [who] decides where [we] should go next.” (Ligowe Male Patient # 03).

Theme four: challenges in accessing palliative care services

Even though many participants, both patients and healthcare workers, had viewed decentralization to the health center as a good development, some participants still felt that this decentralization was partial. Participants who viewed decentralization partially cited reasons such as distance remaining challenge. Some noted that social services needed to be improved at the health centers. Others complained about essential drugs needing to be stocked consistently, leading to patients traveling long distances without plans if they needed specific medications or social support. Some of the patient participants had to say this:

‘Where I stay is far, and the means of transport are [complicated] even though the services are now closer to us. When [I] am having body pain, walking a long distance is hard [for me]. [This makes me] walk [slowly to get to the hospital], and [I] rest [often along the way] to gain strength. These are some of the problems [I] still find.” (Ligowe Female Patient # 03). “Let [me] explain [this way] that what [this] woman is saying is true: [we] are receiving drugs, but in terms of food, we do not have the strength to do peace works on our own or farming to bring food to our tables. [For instance, we] did not do farming last rainy season. However, [we] are still receiving drugs and are advised to eat enough before taking medications. On this [emphasizing a point], I am begging the officials at the district level for them to think of us in terms of food.” (Ligowe Female Patient # 05).

In agreement with patients’ sentiments, healthcare workers viewed the decentralization as incomplete, as some essential services remained at the referral sites. Occasionally, these services could necessitate healthcare workers to refer the patients to the referral facility for care. One healthcare worker had to say,

“ …. Let me start by saying that [at times] [we] have a drug issue. Yes, let us say some patients have severe pain and need morphine, so currently, in Ligowe, [we] do not keep the drug, and it is [the Neno District team does provide [us] with the [drug]. Therefore, [if we meet] such patients, [we] refer them to Neno DHO clinic to access morphine even POSER support [social support]. ” (Ligowe HC worker # 02).

Discussions

This study aimed to explore the effectiveness of palliative care services from a patient and provider perspective following the decentralization of palliative care services from a district hospital to two rural health centers. Decentralization appeared to improve patient-provider relationships. Patients received palliative care closer to home, reducing cost and travel time for patients and caregivers. Furthermore, patients experienced care that was thorough and standardized. However, both healthcare workers and patients were worried about decentralization concerning some aspects of palliative care, as they experienced that the health centers needed more access to social support and essential medication.

The study’s findings illuminate a nuanced exploration of the symbiotic relationship between patients and healthcare workers within palliative care services. Research by Street et al. (2014) underscores the pivotal role of a positive patient-provider relationship, emphasizing its influence on service accessibility and patient satisfaction [ 24 ]. The study aligns with the sentiments expressed by participants, where courteous treatment, patient-centered care, and respect for privacy contribute to robust healthcare accessibility. As highlighted by participants, the proximity of services to communities resonates with findings from a study by Saurman (2016), which emphasizes the importance of geographical accessibility in healthcare utilization [ 25 ]. Patient testimonials provide experiential evidence supporting the positive impact of friendly and open communication on patient well-being, aligning with research by Beach et al. (2006) [ 26 ]. Furthermore, the commitment of healthcare worker participants to ensuring privacy and confidentiality within consultation rooms aligns with the principles of patient-centered care advocated by Varkey (2021) [ 27 ]. The discussion extends beyond individual experiences, drawing on established literature to enrich our understanding of the dynamics shaping palliative care experiences and emphasizing the broader implications for healthcare practices to service accessibility.

The study’s findings further demonstrate the benefits of palliative care program decentralization aligning with existing literature. In a publication by Robert et al. (2021), the positive impact of bringing health services closer to communities was highlighted, resonating with our participants’ experiences [ 28 ]. The observed reduction in transport costs, echoing the study by Shrank et al. (2021), underscores the financial burden associated with distant healthcare access [ 29 ]. These findings contribute to the broader literature, offering insights for program planners and stakeholders seeking to enhance palliative care accessibility and effectiveness in community-based settings.

The theme “facility response to patients’ needs,” as identified in the study, is substantiated by existing research on patient-centered care. Notably, studies like Ford (2004) underscore the positive outcomes of robust physician-patient relationships, aligning with the observed development of good rapport in the facilities [ 30 ]. The emphasis on interpersonal connections reflects the importance of patient-centered practices in healthcare. Moreover, the comprehensive screenings implemented in the facilities, extending beyond the primary reason for seeking care, align with recommendations from authoritative bodies such as the Institute of Medicine (IOM) [ 31 ]. The IOM advocates for patient-centered, evidence-based healthcare, resonating with global initiatives by the World Health Organization (WHO) and the Agency for Healthcare Research and Quality (AHRQ) to promote equitable healthcare and reduce health disparities [ 32 , 33 ].

Challenges in accessing palliative care services reveal concerns despite the optimistic view of decentralization. Participants cited distance as a persistent challenge, supported by Bossert et al.‘s (2003) acknowledgment of distance as a barrier even with decentralization [ 34 , 35 ]. The social support participants mentioned align with Andermann (2016), emphasizing the need to address social determinants for effective healthcare [ 36 ]. The inconsistency in essential drug stocking at health centers echoes supply chain challenges noted by Vledder (2019), highlighting the practical issues in healthcare supply chains [ 37 ]. These references provide a comprehensive understanding of the challenges in decentralized health services, including in rural settings.

A previous study on service decentralization has emphasized the importance of building a robust social support system to achieve positive outcomes [ 38 ]. The study also found that patients in peripheral health facilities face challenges accessing social support compared to those in referral facilities. The lack of a vibrant social support system in rural areas means that palliative care services are not holistic, as psychosocial support services are often unavailable [ 2 , 39 , 40 ]. Therefore, it is imperative for district-level programs to devolve power to rural facilities, allowing them to function optimally and provide comprehensive care that includes psycho-social support services [ 41 , 42 , 43 ].

Strengths and limitations of the present study

Some strengths and limitations of this study were subjected to include;

The study used FGDs to get in-depth views from patients and healthcare workers. Participants were purposefully selected from key workstations to bring diverse perspectives of males and females. The study used a rigorous data analysis process involving coding by multiple researchers and the use of software to ensure reliability. The study also used a reporting method to adhere to international reporting standards of research findings (COREQ guidelines) to improve transparency.

Limitations

The health centers involved limit the generalizability of the results to other areas. Again, convenience sampling of some patients may have introduced information bias. The study should have collected demographic data reports of participants, limiting understanding of their backgrounds.

The study explored the decentralization of palliative care in two Malawian health centers through focus group discussions with healthcare workers and patients. Findings provided support for decentralizing services, with improved relationships and accessibility reported. However, resource constraints, distance, and lack of social support highlighted ongoing challenges. While offering insights, limitations in sampling and lack of participant demographics necessitate further research with broader sampling to strengthen understanding of decentralization’s effects. The study contributes empirical evidence to optimize palliative care delivery in similar low-resource settings by informing policies and programs addressing barriers to comprehensive care through decentralized models.

Data availability

The datasets supporting the article’s conclusions are included, with hyperlinks to the data where applicable within the references. The datasets used for simulations in the current study are available from the corresponding author upon reasonable request.

Abbreviations

Focused Group Discussion

Low-Middle Income Countries

World Health Organisation

World Health Assembly

Plan, Do, Check, Act

Outpatient Register

National Statistical Office

Partners In Health/Abwenzi Pa Za Umoyo

Atupere Phiri

Haules Robbins Zaniku

Manuel Mulwafu

Consolidated Criteria for Reporting Qualitative Research

HealthCare Worker

Community Health Worker

District Health Office

Coronavirus Disease 2019

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Acknowledgements

The authors are thankful to the Neno District Health Office and PIH/APZU leadership for their support during the implementation of the study. Especially the authors would like to thank the following: Daniel Kaunga, the Palliative Care District Coordinator; the entire Palliative Care Team; Ligowe and Magaleta Health Centre In-charges and Staff members; the Research Assistants (Matamando Mwendera, Karen Kasambala), and all Palliative Care patients involved in the study, as well as the entire Neno District and Partners In Health Research Team members for the feedback and support rendered during the research project.

The work was made possible by the support of the Wagner Foundation. The funding source was not involved in the study design, data collection, analysis, or report writing.

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Atupere S. Phiri, Manuel Mulwafu, Moses Banda Aron, Judith Kanyema, Stellar Chibvunde, Fabien Munyaneza, Chiyembekezo Kachimanga & Beatrice Matanje

Neno District Health Office, Ministry of Health, Neno, Malawi

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School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi

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AP was involved in the conceptualization, study design, analysis, and drafted the manuscript. MM, HRZ, and AP conducted data analysis. BM supervised the whole project from conceptualization to report and manuscript writing. CK, GM, EN, MBA, ST, JK, and FM provided guidance and feedback during data collection, analysis, and manuscript writing. All authors read and approved the final manuscript.

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Correspondence to Atupere S. Phiri .

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Ethical principles for medical research involving human subjects by Helsinki’s declaration were followed throughout the study. Before involving the participants, ethical approval was sought from the Malawi National Health Science Research Committee, Protocol number 1216 (Evaluation of Clinical Care in Neno District, Malawi), dated August 25, 2021, and from the Neno District Research and Ethics Committee. Participants received verbal and written informed consent before participating in the study. Collected data was stored privately, and only those involved in the study had access to it. Participants were also informed about the voluntary nature of their participation and that they could withdraw from the study at any time without specifying a reason for doing so.

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S. Phiri, A., Mulwafu, M., Robbins Zaniku, H. et al. Toward enhanced decentralized palliative care services in Neno District, Malawi: a qualitative study.. BMC Palliat Care 23 , 132 (2024). https://doi.org/10.1186/s12904-024-01455-x

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Stein RC, Dunn JA, Bartlett JMS, et al.; on behalf of the OPTIMA Trial Management Group. OPTIMA prelim: a randomised feasibility study of personalised care in the treatment of women with early breast cancer. Southampton (UK): NIHR Journals Library; 2016 Feb. (Health Technology Assessment, No. 20.10.)

OPTIMA prelim: a randomised feasibility study of personalised care in the treatment of women with early breast cancer.

Appendix 10 limitations of the qualitative research study methods.

In addition to the limitations presented in Chapter 6 , the discussion below relates to the specific limitations of the QRS methodology.

Data saturation was achieved within the interview study, as sampling was under the control of the QRS researcher. Such claims cannot be made for collection of audio-recorded consultations. It should be kept in mind that listening to audio-recorded consultations primarily served a practical purpose, and to this end, successfully identified challenges that recruiters were able to engage with in feedback meetings. However, the study would have benefited from a larger sample of audio-recordings, from a wider range of centres. Despite encouragement from the QRS team and TMG, recording of consultations did not occur as a matter of routine and the full range of interactions with patients was not captured. This is particularly true for second oncology consultations (where patients sometimes gave their decisions about participation). Incomplete recordings of each patient’s ‘journey’ made it difficult to track events, and made deciphering patients’ reasons for declining the trial problematic. In addition, limited numbers of audio-recordings for each individual recruiter restricted opportunities to assess the impact of QRS interventions through ‘before-and-after’ comparisons. Reluctance to routinely record consultations may have been an indirect consequence of recruiters perceiving the QRS as an ‘optional’ additional task. Future studies of this nature will need to frame the QRS as an integrated component of the trial.

The practices reported in interviews might have been influenced by recollection bias and/or the temptation to offer socially desirable answers. This is particularly true given the potentially sensitive nature of subjects discussed in consultations and the possibility of clinicians perceiving that their actions were under scrutiny. Similar sources of bias may also have influenced behaviours in consultations that were audio-recorded. In some cases, interviews focused on recruiters’ perceptions of why patients declined participation in OPTIMA prelim. Recruiters’ responses will have been based on their subjective interpretation of events, which may not have reflected reality. This consideration is also applicable to the data reported in screening logs, where recruiters were required to state the reason(s) why patients declined the OPTIMA prelim. Interviewing patients directly could have provided source triangulation (or contradictions), but the OPTIMA prelim QRS prioritised addressing the challenges already identified through recruiter interviews and audio-recorded consultations. There was an intention to interview patients if necessary, but given the exploratory nature of the QRS, the nature and extent of challenges identified early on could not be anticipated when the QRS was designed. Consideration should be given to interviewing patients if the OPTIMA main study proceeds.

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• Cite this Page Stein RC, Dunn JA, Bartlett JMS, et al.; on behalf of the OPTIMA Trial Management Group. OPTIMA prelim: a randomised feasibility study of personalised care in the treatment of women with early breast cancer. Southampton (UK): NIHR Journals Library; 2016 Feb. (Health Technology Assessment, No. 20.10.) Appendix 10, Limitations of the qualitative research study methods.
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Improving The Care of Critically Ill Patients: Lessons Learned from The Promotion of Essential Emergency and Critical Care In Tanzania: A Qualitative Study.

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Objective: To describe the lessons learned during the promotion of a new approach to the care of critically ill patients - Essential Emergency and Critical Care (EECC) - in Tanzania Design: A descriptive qualitative study using thematic analysis of structured interviews Setting and Participants: The study was conducted in Dar es Salaam and Dodoma regions in Tanzania, involving eleven policy makers, researchers and senior clinicians who participated in the promotion of EECC in the country. Results: The five lessons that emerged from the promotion of EECC in Tanzania were: (i) ensure early and close collaboration with the government and stakeholders; (ii) conduct research and utilize evidence; (iii) prioritize advocacy and address misconceptions about EECC; (iv) leverage events and embed activities in other health system interventions and (v) employ a multifaceted implementation strategy. Conclusion: The results from this study show the efficacy of a holistic, comprehensive approach in promoting EECC as each strategy reinforces the others. This approach led the to the successful promotion of EECC and the development by the government of Tanzania of a National Strategic Plan for EECC. Article Summary Strengths and Limitations of this study: Strengths: - High Credibility of Findings due to the in-depth data collection process, which continued until data saturation was reached. - Mitigation of Personal Biases by sharing findings with participants at various stages of manuscript writing. - Diverse Perspectives from the professional diversity of participants enriched the findings. Weaknesses: - Lack of Translation and Transcription; instead, a codebook and audio recordings were used for cross-referencing. - The purposeful selection of participants may have resulted in a sample that is homogeneous in their perspectives on EECC, limiting the diversity of viewpoints and experiences that could be explored.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This work was supported by the Welcome Trust [221571/Z/20/Z], as part of the Innovation in low-and middle-income countries Flagship.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study was granted ethical approval from the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/3537).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

As the project lacks ethical approval for public data sharing, we are unable to provide access to the data used in this study.

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