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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Home » Qualitative Research – Methods, Analysis Types and Guide

Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

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

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

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

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

Focus Groups

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

Ethnographic Studies

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

Text Analysis

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

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

Process of Observation

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

Record Keeping

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

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

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

Qualitative Research Analysis Methods

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

Thematic Analysis

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

Content Analysis

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

Discourse Analysis

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

Grounded Theory Analysis

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

Narrative Analysis

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

Phenomenological Analysis

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

Comparative Analysis

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

Applications of Qualitative Research

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

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

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

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

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

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

Purpose of Qualitative Research

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

Qualitative research can serve multiple purposes, including:

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

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

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

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

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

Advantages of Qualitative Research

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

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

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

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

Also see Research Methods

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• Open access
• Published: 27 May 2020

How to use and assess qualitative research methods

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

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

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

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Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalisability

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

• Labour-intensive

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Qualitative Research Using R: A Systematic Approach pp 1–19 Cite as

Qualitative Research: An Overview

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• Liang Shang 4  
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Qualitative research is one of the most commonly used types of research and methodology in the social sciences. Unfortunately, qualitative research is commonly misunderstood. In this chapter, we describe and explain the misconceptions surrounding qualitative research enterprise, why researchers need to care about when using qualitative research, the characteristics of qualitative research, and review the paradigms in qualitative research.

• Qualitative research
• Gioia approach
• Yin-Eisenhardt approach
• Langley approach
• Interpretivism

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Qualitative research is defined as the practice used to study things –– individuals and organizations and their reasons, opinions, and motivations, beliefs in their natural settings. It involves an observer (a researcher) who is located in the field , who transforms the world into a series of representations such as fieldnotes, interviews, conversations, photographs, recordings and memos (Denzin and Lincoln 2011 ). Many researchers employ qualitative research for exploratory purpose while others use it for ‘quasi’ theory testing approach. Qualitative research is a broad umbrella of research methodologies that encompasses grounded theory (Glaser and Strauss 2017 ; Strauss and Corbin 1990 ), case study (Flyvbjerg 2006 ; Yin 2003 ), phenomenology (Sanders 1982 ), discourse analysis (Fairclough 2003 ; Wodak and Meyer 2009 ), ethnography (Geertz 1973 ; Garfinkel 1967 ), and netnography (Kozinets 2002 ), among others. Qualitative research is often synonymous with ‘case study research’ because ‘case study’ primarily uses (but not always) qualitative data.

The quality standards or evaluation criteria of qualitative research comprises: (1) credibility (that a researcher can provide confidence in his/her findings), (2) transferability (that results are more plausible when transported to a highly similar contexts), (3) dependability (that errors have been minimized, proper documentation is provided), and (4) confirmability (that conclusions are internally consistent and supported by data) (see Lincoln and Guba 1985 ).

We classify research into a continuum of theory building — >   theory elaboration — >   theory testing . Theory building is also known as theory exploration. Theory elaboration refers to the use of qualitative data and a method to seek “confirmation” of the relationships among variables or processes or mechanisms of a social reality (Bartunek and Rynes 2015 ).

In the context of qualitative research, theory/ies usually refer(s) to conceptual model(s) or framework(s) that explain the relationships among a set of variables or processes that explain a social phenomenon. Theory or theories could also refer to general ideas or frameworks (e.g., institutional theory, emancipation theory, or identity theory) that are reviewed as background knowledge prior to the commencement of a qualitative research project.

For example, a qualitative research can ask the following question: “How can institutional change succeed in social contexts that are dominated by organized crime?” (Vaccaro and Palazzo 2015 ).

We have witnessed numerous cases in which committed positivist methodologists were asked to review qualitative papers, and they used a survey approach to assess the quality of an interpretivist work. This reviewers’ fallacy is dangerous and hampers the progress of a field of research. Editors must be cognizant of such fallacy and avoid it.

A social enterprises (SE) is an organization that combines social welfare and commercial logics (Doherty et al. 2014 ), or that uses business principles to address social problems (Mair and Marti 2006 ); thus, qualitative research that reports that ‘social impact’ is important for SEs is too descriptive and, arguably, tautological. It is not uncommon to see authors submitting purely descriptive papers to scholarly journals.

Some qualitative researchers have conducted qualitative work using primarily a checklist (ticking the boxes) to show the presence or absence of variables, as if it were a survey-based study. This is utterly inappropriate for a qualitative work. A qualitative work needs to show the richness and depth of qualitative findings. Nevertheless, it is acceptable to use such checklists as supplementary data if a study involves too many informants or variables of interest, or the data is too complex due to its longitudinal nature (e.g., a study that involves 15 cases observed and involving 59 interviews with 33 informants within a 7-year fieldwork used an excel sheet to tabulate the number of events that occurred as supplementary data to the main analysis; see Chandra 2017a , b ).

As mentioned earlier, there are different types of qualitative research. Thus, a qualitative researcher will customize the data collection process to fit the type of research being conducted. For example, for researchers using ethnography, the primary data will be in the form of photos and/or videos and interviews; for those using netnography, the primary data will be internet-based textual data. Interview data is perhaps the most common type of data used across all types of qualitative research designs and is often synonymous with qualitative research.

The purpose of qualitative research is to provide an explanation , not merely a description and certainly not a prediction (which is the realm of quantitative research). However, description is needed to illustrate qualitative data collected, and usually researchers describe their qualitative data by inserting a number of important “informant quotes” in the body of a qualitative research report.

We advise qualitative researchers to adhere to one approach to avoid any epistemological and ontological mismatch that may arise among different camps in qualitative research. For instance, mixing a positivist with a constructivist approach in qualitative research frequently leads to unnecessary criticism and even rejection from journal editors and reviewers; it shows a lack of methodological competence or awareness of one’s epistemological position.

Analytical generalization is not generalization to some defined population that has been sampled, but to a “theory” of the phenomenon being studied, a theory that may have much wider applicability than the particular case studied (Yin 2003 ).

There are different types of contributions. Typically, a researcher is expected to clearly articulate the theoretical contributions for a qualitative work submitted to a scholarly journal. Other types of contributions are practical (or managerial ), common for business/management journals, and policy , common for policy related journals.

There is ongoing debate on whether a template for qualitative research is desirable or necessary, with one camp of scholars (the pluralistic critical realists) that advocates a pluralistic approaches to qualitative research (“qualitative research should not follow a particular template or be prescriptive in its process”) and the other camps are advocating for some form of consensus via the use of particular approaches (e.g., the Eisenhardt or Gioia Approach, etc.). However, as shown in Table 1.1 , even the pluralistic critical realism in itself is a template and advocates an alternative form of consensus through the use of diverse and pluralistic approaches in doing qualitative research.

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The Oxford Handbook of Qualitative Research (2nd edn)

Patricia Leavy Independent Scholar Kennebunk, ME, USA

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The Oxford Handbook of Qualitative Research, second edition, presents a comprehensive retrospective and prospective review of the field of qualitative research. Original, accessible chapters written by interdisciplinary leaders in the field make this a critical reference work. Filled with robust examples from real-world research; ample discussion of the historical, theoretical, and methodological foundations of the field; and coverage of key issues including data collection, interpretation, representation, assessment, and teaching, this handbook aims to be a valuable text for students, professors, and researchers. This newly revised and expanded edition features up-to-date examples and topics, including seven new chapters on duoethnography, team research, writing ethnographically, creative approaches to writing, writing for performance, writing for the public, and teaching qualitative research.

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Qualitative Research: Characteristics, Design, Methods & Examples

Lauren McCall

MSc Health Psychology Graduate

MSc, Health Psychology, University of Nottingham

Lauren obtained an MSc in Health Psychology from The University of Nottingham with a distinction classification.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

“Not everything that can be counted counts, and not everything that counts can be counted“ (Albert Einstein)

Qualitative research is a process used for the systematic collection, analysis, and interpretation of non-numerical data (Punch, 2013). 

Qualitative research can be used to: (i) gain deep contextual understandings of the subjective social reality of individuals and (ii) to answer questions about experience and meaning from the participant’s perspective (Hammarberg et al., 2016).

Unlike quantitative research, which focuses on gathering and analyzing numerical data for statistical analysis, qualitative research focuses on thematic and contextual information.

Characteristics of Qualitative Research 

Reality is socially constructed.

Qualitative research aims to understand how participants make meaning of their experiences – individually or in social contexts. It assumes there is no objective reality and that the social world is interpreted (Yilmaz, 2013). 

The primacy of subject matter 

The primary aim of qualitative research is to understand the perspectives, experiences, and beliefs of individuals who have experienced the phenomenon selected for research rather than the average experiences of groups of people (Minichiello, 1990).

Variables are complex, interwoven, and difficult to measure

Factors such as experiences, behaviors, and attitudes are complex and interwoven, so they cannot be reduced to isolated variables , making them difficult to measure quantitatively.

However, a qualitative approach enables participants to describe what, why, or how they were thinking/ feeling during a phenomenon being studied (Yilmaz, 2013). 

Emic (insider’s point of view)

The phenomenon being studied is centered on the participants’ point of view (Minichiello, 1990).

Emic is used to describe how participants interact, communicate, and behave in the context of the research setting (Scarduzio, 2017).

Why Conduct Qualitative Research? 

In order to gain a deeper understanding of how people experience the world, individuals are studied in their natural setting. This enables the researcher to understand a phenomenon close to how participants experience it. 

Qualitative research allows researchers to gain an in-depth understanding, which is difficult to attain using quantitative methods. 

An in-depth understanding is attained since qualitative techniques allow participants to freely disclose their experiences, thoughts, and feelings without constraint (Tenny et al., 2022). 

This helps to further investigate and understand quantitative data by discovering reasons for the outcome of a study – answering the why question behind statistics. 

The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively (Busetto et al., 2020).

To design hypotheses, theory must be researched using qualitative methods to find out what is important in order to begin research. 

For example, by conducting interviews or focus groups with key stakeholders to discover what is important to them. 

Examples of qualitative research questions include: 

• How does stress influence young adults’ behavior?
• What factors influence students’ school attendance rates in developed countries?
• How do adults interpret binge drinking in the UK?
• What are the psychological impacts of cervical cancer screening in women?
• How can mental health lessons be integrated into the school curriculum? 

Collecting Qualitative Data

There are four main research design methods used to collect qualitative data: observations, interviews,  focus groups, and ethnography.

Observations

This method involves watching and recording phenomena as they occur in nature. Observation can be divided into two types: participant and non-participant observation.

In participant observation, the researcher actively participates in the situation/events being observed.

In non-participant observation, the researcher is not an active part of the observation and tries not to influence the behaviors they are observing (Busetto et al., 2020). 

Observations can be covert (participants are unaware that a researcher is observing them) or overt (participants are aware of the researcher’s presence and know they are being observed).

However, awareness of an observer’s presence may influence participants’ behavior. 

Interviews give researchers a window into the world of a participant by seeking their account of an event, situation, or phenomenon. They are usually conducted on a one-to-one basis and can be distinguished according to the level at which they are structured (Punch, 2013). 

Structured interviews involve predetermined questions and sequences to ensure replicability and comparability. However, they are unable to explore emerging issues.

Informal interviews consist of spontaneous, casual conversations which are closer to the truth of a phenomenon. However, information is gathered using quick notes made by the researcher and is therefore subject to recall bias. 

Semi-structured interviews have a flexible structure, phrasing, and placement so emerging issues can be explored (Denny & Weckesser, 2022).

The use of probing questions and clarification can lead to a detailed understanding, but semi-structured interviews can be time-consuming and subject to interviewer bias. 

Focus groups 

Similar to interviews, focus groups elicit a rich and detailed account of an experience. However, focus groups are more dynamic since participants with shared characteristics construct this account together (Denny & Weckesser, 2022).

A shared narrative is built between participants to capture a group experience shaped by a shared context. 

The researcher takes on the role of a moderator, who will establish ground rules and guide the discussion by following a topic guide to focus the group discussions.

Typically, focus groups have 4-10 participants as a discussion can be difficult to facilitate with more than this, and this number allows everyone the time to speak.

Ethnography

Ethnography is a methodology used to study a group of people’s behaviors and social interactions in their environment (Reeves et al., 2008).

Data are collected using methods such as observations, field notes, or structured/ unstructured interviews.

The aim of ethnography is to provide detailed, holistic insights into people’s behavior and perspectives within their natural setting. In order to achieve this, researchers immerse themselves in a community or organization. 

Due to the flexibility and real-world focus of ethnography, researchers are able to gather an in-depth, nuanced understanding of people’s experiences, knowledge and perspectives that are influenced by culture and society.

In order to develop a representative picture of a particular culture/ context, researchers must conduct extensive field work. 

This can be time-consuming as researchers may need to immerse themselves into a community/ culture for a few days, or possibly a few years.

Qualitative Data Analysis Methods

Different methods can be used for analyzing qualitative data. The researcher chooses based on the objectives of their study. 

The researcher plays a key role in the interpretation of data, making decisions about the coding, theming, decontextualizing, and recontextualizing of data (Starks & Trinidad, 2007). 

Grounded theory

Grounded theory is a qualitative method specifically designed to inductively generate theory from data. It was developed by Glaser and Strauss in 1967 (Glaser & Strauss, 2017).

 This methodology aims to develop theories (rather than test hypotheses) that explain a social process, action, or interaction (Petty et al., 2012). To inform the developing theory, data collection and analysis run simultaneously. 

There are three key types of coding used in grounded theory: initial (open), intermediate (axial), and advanced (selective) coding. 

Throughout the analysis, memos should be created to document methodological and theoretical ideas about the data. Data should be collected and analyzed until data saturation is reached and a theory is developed. 

Content analysis

Content analysis was first used in the early twentieth century to analyze textual materials such as newspapers and political speeches.

Content analysis is a research method used to identify and analyze the presence and patterns of themes, concepts, or words in data (Vaismoradi et al., 2013). 

This research method can be used to analyze data in different formats, which can be written, oral, or visual. 

The goal of content analysis is to develop themes that capture the underlying meanings of data (Schreier, 2012). 

Qualitative content analysis can be used to validate existing theories, support the development of new models and theories, and provide in-depth descriptions of particular settings or experiences.

The following six steps provide a guideline for how to conduct qualitative content analysis.

• Define a Research Question : To start content analysis, a clear research question should be developed.
• Identify and Collect Data : Establish the inclusion criteria for your data. Find the relevant sources to analyze.
• Define the Unit or Theme of Analysis : Categorize the content into themes. Themes can be a word, phrase, or sentence.
• Develop Rules for Coding your Data : Define a set of coding rules to ensure that all data are coded consistently.
• Code the Data : Follow the coding rules to categorize data into themes.
• Analyze the Results and Draw Conclusions : Examine the data to identify patterns and draw conclusions in relation to your research question.

Discourse analysis

Discourse analysis is a research method used to study written/ spoken language in relation to its social context (Wood & Kroger, 2000).

In discourse analysis, the researcher interprets details of language materials and the context in which it is situated.

Discourse analysis aims to understand the functions of language (how language is used in real life) and how meaning is conveyed by language in different contexts. Researchers use discourse analysis to investigate social groups and how language is used to achieve specific communication goals.

Different methods of discourse analysis can be used depending on the aims and objectives of a study. However, the following steps provide a guideline on how to conduct discourse analysis.

• Define the Research Question : Develop a relevant research question to frame the analysis.
• Gather Data and Establish the Context : Collect research materials (e.g., interview transcripts, documents). Gather factual details and review the literature to construct a theory about the social and historical context of your study.
• Analyze the Content : Closely examine various components of the text, such as the vocabulary, sentences, paragraphs, and structure of the text. Identify patterns relevant to the research question to create codes, then group these into themes.
• Review the Results : Reflect on the findings to examine the function of the language, and the meaning and context of the discourse. 

Thematic analysis

Thematic analysis is a method used to identify, interpret, and report patterns in data, such as commonalities or contrasts. 

Although the origin of thematic analysis can be traced back to the early twentieth century, understanding and clarity of thematic analysis is attributed to Braun and Clarke (2006).

Thematic analysis aims to develop themes (patterns of meaning) across a dataset to address a research question. 

In thematic analysis, qualitative data is gathered using techniques such as interviews, focus groups, and questionnaires. Audio recordings are transcribed. The dataset is then explored and interpreted by a researcher to identify patterns. 

This occurs through the rigorous process of data familiarisation, coding, theme development, and revision. These identified patterns provide a summary of the dataset and can be used to address a research question.

Themes are developed by exploring the implicit and explicit meanings within the data. Two different approaches are used to generate themes: inductive and deductive. 

An inductive approach allows themes to emerge from the data. In contrast, a deductive approach uses existing theories or knowledge to apply preconceived ideas to the data.

Phases of Thematic Analysis

Braun and Clarke (2006) provide a guide of the six phases of thematic analysis. These phases can be applied flexibly to fit research questions and data. 

Template analysis

Template analysis refers to a specific method of thematic analysis which uses hierarchical coding (Brooks et al., 2014).

Template analysis is used to analyze textual data, for example, interview transcripts or open-ended responses on a written questionnaire.

To conduct template analysis, a coding template must be developed (usually from a subset of the data) and subsequently revised and refined. This template represents the themes identified by researchers as important in the dataset. 

Codes are ordered hierarchically within the template, with the highest-level codes demonstrating overarching themes in the data and lower-level codes representing constituent themes with a narrower focus.

A guideline for the main procedural steps for conducting template analysis is outlined below.

• Familiarization with the Data : Read (and reread) the dataset in full. Engage, reflect, and take notes on data that may be relevant to the research question.
• Preliminary Coding : Identify initial codes using guidance from the a priori codes, identified before the analysis as likely to be beneficial and relevant to the analysis.
• Organize Themes : Organize themes into meaningful clusters. Consider the relationships between the themes both within and between clusters.
• Produce an Initial Template : Develop an initial template. This may be based on a subset of the data.
• Apply and Develop the Template : Apply the initial template to further data and make any necessary modifications. Refinements of the template may include adding themes, removing themes, or changing the scope/title of themes. 
• Finalize Template : Finalize the template, then apply it to the entire dataset. 

Frame analysis

Frame analysis is a comparative form of thematic analysis which systematically analyzes data using a matrix output.

Ritchie and Spencer (1994) developed this set of techniques to analyze qualitative data in applied policy research. Frame analysis aims to generate theory from data.

Frame analysis encourages researchers to organize and manage their data using summarization.

This results in a flexible and unique matrix output, in which individual participants (or cases) are represented by rows and themes are represented by columns. 

Each intersecting cell is used to summarize findings relating to the corresponding participant and theme.

Frame analysis has five distinct phases which are interrelated, forming a methodical and rigorous framework.

• Familiarization with the Data : Familiarize yourself with all the transcripts. Immerse yourself in the details of each transcript and start to note recurring themes.
• Develop a Theoretical Framework : Identify recurrent/ important themes and add them to a chart. Provide a framework/ structure for the analysis.
• Indexing : Apply the framework systematically to the entire study data.
• Summarize Data in Analytical Framework : Reduce the data into brief summaries of participants’ accounts.
• Mapping and Interpretation : Compare themes and subthemes and check against the original transcripts. Group the data into categories and provide an explanation for them.

Preventing Bias in Qualitative Research

To evaluate qualitative studies, the CASP (Critical Appraisal Skills Programme) checklist for qualitative studies can be used to ensure all aspects of a study have been considered (CASP, 2018).

The quality of research can be enhanced and assessed using criteria such as checklists, reflexivity, co-coding, and member-checking. 

Co-coding 

Relying on only one researcher to interpret rich and complex data may risk key insights and alternative viewpoints being missed. Therefore, coding is often performed by multiple researchers.

A common strategy must be defined at the beginning of the coding process  (Busetto et al., 2020). This includes establishing a useful coding list and finding a common definition of individual codes.

Transcripts are initially coded independently by researchers and then compared and consolidated to minimize error or bias and to bring confirmation of findings. 

Member checking

Member checking (or respondent validation) involves checking back with participants to see if the research resonates with their experiences (Russell & Gregory, 2003).

Data can be returned to participants after data collection or when results are first available. For example, participants may be provided with their interview transcript and asked to verify whether this is a complete and accurate representation of their views.

Participants may then clarify or elaborate on their responses to ensure they align with their views (Shenton, 2004).

This feedback becomes part of data collection and ensures accurate descriptions/ interpretations of phenomena (Mays & Pope, 2000). 

Reflexivity in qualitative research

Reflexivity typically involves examining your own judgments, practices, and belief systems during data collection and analysis. It aims to identify any personal beliefs which may affect the research. 

Reflexivity is essential in qualitative research to ensure methodological transparency and complete reporting. This enables readers to understand how the interaction between the researcher and participant shapes the data.

Depending on the research question and population being researched, factors that need to be considered include the experience of the researcher, how the contact was established and maintained, age, gender, and ethnicity.

These details are important because, in qualitative research, the researcher is a dynamic part of the research process and actively influences the outcome of the research (Boeije, 2014). 

Reflexivity Example

Who you are and your characteristics influence how you collect and analyze data. Here is an example of a reflexivity statement for research on smoking. I am a 30-year-old white female from a middle-class background. I live in the southwest of England and have been educated to master’s level. I have been involved in two research projects on oral health. I have never smoked, but I have witnessed how smoking can cause ill health from my volunteering in a smoking cessation clinic. My research aspirations are to help to develop interventions to help smokers quit.

Establishing Trustworthiness in Qualitative Research

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability.

Credibility in Qualitative Research

Credibility refers to how accurately the results represent the reality and viewpoints of the participants.

To establish credibility in research, participants’ views and the researcher’s representation of their views need to align (Tobin & Begley, 2004).

To increase the credibility of findings, researchers may use data source triangulation, investigator triangulation, peer debriefing, or member checking (Lincoln & Guba, 1985). 

Transferability in Qualitative Research

Transferability refers to how generalizable the findings are: whether the findings may be applied to another context, setting, or group (Tobin & Begley, 2004).

Transferability can be enhanced by giving thorough and in-depth descriptions of the research setting, sample, and methods (Nowell et al., 2017). 

Dependability in Qualitative Research

Dependability is the extent to which the study could be replicated under similar conditions and the findings would be consistent.

Researchers can establish dependability using methods such as audit trails so readers can see the research process is logical and traceable (Koch, 1994).

Confirmability in Qualitative Research

Confirmability is concerned with establishing that there is a clear link between the researcher’s interpretations/ findings and the data.

Researchers can achieve confirmability by demonstrating how conclusions and interpretations were arrived at (Nowell et al., 2017).

This enables readers to understand the reasoning behind the decisions made. 

Audit Trails in Qualitative Research

An audit trail provides evidence of the decisions made by the researcher regarding theory, research design, and data collection, as well as the steps they have chosen to manage, analyze, and report data. 

The researcher must provide a clear rationale to demonstrate how conclusions were reached in their study.

A clear description of the research path must be provided to enable readers to trace through the researcher’s logic (Halpren, 1983).

Researchers should maintain records of the raw data, field notes, transcripts, and a reflective journal in order to provide a clear audit trail. 

Discovery of unexpected data

Open-ended questions in qualitative research mean the researcher can probe an interview topic and enable the participant to elaborate on responses in an unrestricted manner.

This allows unexpected data to emerge, which can lead to further research into that topic. 

Flexibility

Data collection and analysis can be modified and adapted to take the research in a different direction if new ideas or patterns emerge in the data.

This enables researchers to investigate new opportunities while firmly maintaining their research goals. 

Naturalistic settings

The behaviors of participants are recorded in real-world settings. Studies that use real-world settings have high ecological validity since participants behave more authentically. 

Limitations

Time-consuming .

Qualitative research results in large amounts of data which often need to be transcribed and analyzed manually.

Even when software is used, transcription can be inaccurate, and using software for analysis can result in many codes which need to be condensed into themes. 

Subjectivity 

The researcher has an integral role in collecting and interpreting qualitative data. Therefore, the conclusions reached are from their perspective and experience.

Consequently, interpretations of data from another researcher may vary greatly. 

Limited generalizability

The aim of qualitative research is to provide a detailed, contextualized understanding of an aspect of the human experience from a relatively small sample size.

Despite rigorous analysis procedures, conclusions drawn cannot be generalized to the wider population since data may be biased or unrepresentative.

Therefore, results are only applicable to a small group of the population. 

Extraneous variables

Qualitative research is often conducted in real-world settings. This may cause results to be unreliable since extraneous variables may affect the data, for example:

• Situational variables : different environmental conditions may influence participants’ behavior in a study. The random variation in factors (such as noise or lighting) may be difficult to control in real-world settings.
• Participant characteristics : this includes any characteristics that may influence how a participant answers/ behaves in a study. This may include a participant’s mood, gender, age, ethnicity, sexual identity, IQ, etc.
• Experimenter effect : experimenter effect refers to how a researcher’s unintentional influence can change the outcome of a study. This occurs when (i) their interactions with participants unintentionally change participants’ behaviors or (ii) due to errors in observation, interpretation, or analysis. 

What sample size should qualitative research be?

The sample size for qualitative studies has been recommended to include a minimum of 12 participants to reach data saturation (Braun, 2013).

Are surveys qualitative or quantitative?

Surveys can be used to gather information from a sample qualitatively or quantitatively. Qualitative surveys use open-ended questions to gather detailed information from a large sample using free text responses.

The use of open-ended questions allows for unrestricted responses where participants use their own words, enabling the collection of more in-depth information than closed-ended questions.

In contrast, quantitative surveys consist of closed-ended questions with multiple-choice answer options. Quantitative surveys are ideal to gather a statistical representation of a population.

What are the ethical considerations of qualitative research?

Before conducting a study, you must think about any risks that could occur and take steps to prevent them. Participant Protection : Researchers must protect participants from physical and mental harm. This means you must not embarrass, frighten, offend, or harm participants. Transparency : Researchers are obligated to clearly communicate how they will collect, store, analyze, use, and share the data. Confidentiality : You need to consider how to maintain the confidentiality and anonymity of participants’ data.

What is triangulation in qualitative research?

Triangulation refers to the use of several approaches in a study to comprehensively understand phenomena. This method helps to increase the validity and credibility of research findings. 

Types of triangulation include method triangulation (using multiple methods to gather data); investigator triangulation (multiple researchers for collecting/ analyzing data), theory triangulation (comparing several theoretical perspectives to explain a phenomenon), and data source triangulation (using data from various times, locations, and people; Carter et al., 2014).

Why is qualitative research important?

Qualitative research allows researchers to describe and explain the social world. The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively.

In qualitative research, participants are able to express their thoughts, experiences, and feelings without constraint.

Additionally, researchers are able to follow up on participants’ answers in real-time, generating valuable discussion around a topic. This enables researchers to gain a nuanced understanding of phenomena which is difficult to attain using quantitative methods.

What is coding data in qualitative research?

Coding data is a qualitative data analysis strategy in which a section of text is assigned with a label that describes its content.

These labels may be words or phrases which represent important (and recurring) patterns in the data.

This process enables researchers to identify related content across the dataset. Codes can then be used to group similar types of data to generate themes.

What is the difference between qualitative and quantitative research?

Qualitative research involves the collection and analysis of non-numerical data in order to understand experiences and meanings from the participant’s perspective.

This can provide rich, in-depth insights on complicated phenomena. Qualitative data may be collected using interviews, focus groups, or observations.

In contrast, quantitative research involves the collection and analysis of numerical data to measure the frequency, magnitude, or relationships of variables. This can provide objective and reliable evidence that can be generalized to the wider population.

Quantitative data may be collected using closed-ended questionnaires or experiments.

What is trustworthiness in qualitative research?

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability. 

Credibility refers to how accurately the results represent the reality and viewpoints of the participants. Transferability refers to whether the findings may be applied to another context, setting, or group.

Dependability is the extent to which the findings are consistent and reliable. Confirmability refers to the objectivity of findings (not influenced by the bias or assumptions of researchers).

What is data saturation in qualitative research?

Data saturation is a methodological principle used to guide the sample size of a qualitative research study.

Data saturation is proposed as a necessary methodological component in qualitative research (Saunders et al., 2018) as it is a vital criterion for discontinuing data collection and/or analysis. 

The intention of data saturation is to find “no new data, no new themes, no new coding, and ability to replicate the study” (Guest et al., 2006). Therefore, enough data has been gathered to make conclusions.

Why is sampling in qualitative research important?

In quantitative research, large sample sizes are used to provide statistically significant quantitative estimates.

This is because quantitative research aims to provide generalizable conclusions that represent populations.

However, the aim of sampling in qualitative research is to gather data that will help the researcher understand the depth, complexity, variation, or context of a phenomenon. The small sample sizes in qualitative studies support the depth of case-oriented analysis.

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Qualitative Research 101: Everything you need to know

How to choose the right software for qualitative research

What does psychology say about qualitative research via webcam?

Which is better - online or face-to-face qual (according to psychology)?

If you are keen on learning more about qualitative research, it can be hard to find an overview of all the key things you need to know, and how to apply everything that is available in the qualitative research sphere to your particular needs. This article has been designed to be that overview - a "pillar page" that will provide everything you need to know before spreading your search further into specific areas that interest you or that directly relate to what you are trying to achieve using the latest qualitative research tools and methods.

In this article you will discover:

The difference between qualitative and quantitative research The difference between online and offline qualitative research Common qualitative research methodologies The powerful market research trend towards video that is changing the qualitative research landscape Modern approaches to qualitative data analysis How to choose qualitative research software

When talking about research methods, there are generally two distinct styles of research that need to be considered - qualitative and quantitative. Any discussion about qualitative research, what it is, and how it can be used inevitably must also consider how it is different from quantitative research - so that is where we will begin!

Qualitative vs quantitative research

Quantitative research: all about the numbers.

Quantitative research is most often associated with the social sciences, natural sciences, and business administration. It often involves measuring the impact of certain events on a population. Specifically, it is research that measures something with numbers.

For example, in medicine, a researcher might investigate the efficacy of a new vaccine on patients by conducting a quantitative research study. A simpler example might be finding out how many people have heard of a particular brand, and how many like the brand.

Data collection for quantitative studies is often through running Web surveys, and there are a large number of platforms available to create such surveys, ranging from the relatively cheap Survey Monkey through to Confirmit and Qualtrics at the high end.

Due to the nature of quantitative research - the collection and analysis of numbers - research is heavily biased towards online methods, and data analysis takes advantage of all the intrinsic benefits of computers ("crunching" large amounts of data, performing analytics to uncover trends and producing digestible summaries of big data sets).

Qualitative research: Analysis of non-numerical data

Qualitative research is literally everything quantitative research is not. It involves the collection and analysis of non-numerical data (e.g., text, video, audio). Rather than resulting in "statistics", it results in "insights" (i.e. it helps to understand concepts, opinions, or experiences). The goal is often to delve into what problems exist or to generate new ideas for research.

The purpose of qualitative research is to "explain rather than describe". Qualitative research projects are often exploratory rather than explanatory, aiming to explore phenomenon rather than test a hypothesis. As such, the research may be used to generate or contribute evidence towards new hypotheses.

One of the biggest concerns when conducting qualitative research is sampling. Because most studies aim to understand a larger group through intensive observation (e.g. ethnography), samples are typically smaller than in quantitative research where random sampling is more common. Sampling may also be more purposive rather than random. Participants may be selected by convenience, snowball, or judgemental methods, which raises concerns that findings cannot be generalised beyond the sample.

An effort is usually made to avoid this problem by collecting data from multiple, diverse sources and triangulating findings so that different perspectives are considered at the same time. Rather than looking for statistical significance in the results, "thematic findings" are what is important in qualitative research.

Factors to determine your sample size for qualitative research

Qualitative research is often overshadowed by quantitative research due to the sheer size of the quantitative research industry, and the ease with which the benefits of quantitative methods can be understood and applied. The broadness of qualitative research is both a strength and a weakness. While it provides insights that are impossible to get through numbers, the broadness of approaches and the ever-improving suite of tools and technologies available can make it harder to understand (and keep up with).

Gaining an understanding of qualitative research methods and approaches and applying them to your clients can distinguish you from your competitors, so it is certainly worth the effort to understand what is possible. Providing something different, and better, that results in deeper insights is always going to be of greater value than a "quant only" offering.

The best way to expand your quant-based research firm is to move into qual and provide a hybrid approach that gives clients the best of both worlds. Because of the more open-ended and emergent nature of the qualitative inquiry, the field is more amenable to using mixed-methods approaches. For instance, researchers can use a qualitative methodology such as ethnography to guide the focus of a larger, quantitative survey.

How to conduct qualitative market research successfully

Online vs. offline qualitative research

The qualitative research methods being used most commonly today fall into two distinct "camps" - online and offline. Online qualitative research is defined as research where the qualitative data is collected "digitally" - usually over the Internet. Offline research is where more traditional data collection methods are used involving physical contact between moderators and participants.

Online research methods are on the rise

Online research is on the rise because it enables fast and wide-scale access to participants (e.g. through social media recruitment) without needing any specific fieldwork abilities (e.g. recruiting on the street). Furthermore, it enables researchers to be more flexible with whom they can communicate with (e.g. online focus groups that involve geographically remote participants).

Advantages of online research: Why you should move your project online

Due to these advantages, more and more researchers are embracing digital technologies for at least some of their qualitative research data collection. Lastly, it can be argued that digital research not only enhances but also move beyond traditional qualitative methods such as interviews and observations.

As with any form of research, it is important to take all of the key advantages and disadvantages of going online into account before making a final decision about which way to take a particular project.

The top 7 advantages of online research

Data can be collected from anywhere in the world (e.g., recruitment through social media) Approach participants quickly and with minimal costs (e.g., data is crowd-sourced) Data can be analyzed automatically (e.g., using an online platform that analyses textual data such as words and phrases used or frequency of self-reported emotions). Enables researchers to be more flexible with whom they can communicate with (e.g., online focus groups) Allows researchers to easily create their own coding schemes when using specific platforms for data collection. Data provides insight into unmeasured or under-researched phenomena that are not typically covered by traditional qualitative methods (e.g., consumer loyalty) The ability to protect anonymity and confidentiality of respondents due to its largely distance-based nature

Offline qualitative research methods are still important

Online research is never going to completely replace offline methods. Regardless of any other reasons, online methods are simply not right for every circumstance.

Critics of online research believe that the main disadvantages in collecting qualitative data digitally are related to the quality and reliability of the data being collected. Some of their specific concerns are:

That without in-depth knowledge about how these platforms work, researchers might not be able to prevent participants from breaking their anonymity rules for example. In some cases it is difficult if not impossible for researchers to identify who exactly is behind a certain set of data. Data which is collected online will most likely only give one interpretation, since there is no way to verify what respondents mean/intend by their responses . Because of the lack of control over study participants (e.g. drop out rates), drawing definitive conclusions about phenomena becomes harder.

What is interesting about all of these concerns is they all appear to be the result of poor platform choice, platform training, or project management. For researchers who what to take the lead into online research, a key point from all of these concerns is going online requires both careful research and personal commitment to make these online research methods work.

How to choose qualitative research software

The reason offline qualitative research will continue to be important has nothing really to do with pitfalls of going online that can be avoided with the right platform and training. It has much more to do with the simple fact that offline will always be better in certain circumstances . An example would be a taste test or a group trial of a physical product where initial reactions are key.

Common qualitative research methodologies

Qualitative research methods are designed to discover what people "think" about a particular topic. It can involve looking at how they behave, and what their perceptions are. While there are many different types of research that can be classed as "qualitative research" - including things like document analysis - here we will focus on the main types of research requested from market research professionals by their clients.

In-depth interviews

These are known by various names - including one-on-one interviews and "IDIs". This method involves directly asking research participants questions in order to gain their opinions on specific subjects.

Focus groups

Focus groups are one of the more commonly used qualitative research methods, and they play an important role in many qualitative research projects. A focus group usually includes a relatively small group of respondents (usually between 6-10) who will meet together either (i.e. in a "group") in person or virtually on a zoom call or through an online platform.

The use of a focus group has some benefits and some disadvantages when compared to one-on-one interviews as discussed below.

Advantages over in-depth interviews

Focus groups allow for more people to be covered in a shorter period of time so you can reach more people outside your group faster than you could with just one-on-one interviews Because multiple people are involved it's easier to see how certain people may affect others' thoughts and opinions It allows for a much faster response time because all of your information is being collected from multiple sources at once.

Disadvantages to in-depth interviews

Much can be lost in translation when trying to interpret everyone's answers Much depends on the quality and experience of the moderator It may be difficult for people who are interacting with other people to remain completely unbiased.

Taking focus groups online is one of the key "battlegrounds" between online and offline research methods. There is a lot to consider when deciding if taking your next project online is a good option.

Online consumer research panels: Are they the right method for your next project?

Ethnography

Another common method of qualitative research is known as "Ethnography". This type of research involves immersing yourself within a group or culture for an extended period of time.

For example, you might want to learn about the daily life of teenagers living on their own or what it's like to be a stay-at-home mom.

Online-specific research methodologies

The research methodologies that we have discussed above all have a common trait - they existed before online research was even an option. There is a long history of these research methods being used, and the move to online for all of these methodologies does not change their fundamental structure and purpose.

For example, video groups on Zoom and other video-based platforms can replicate focus groups and one-on-one interviews. These are still essentially the same "methodologies" - they are just conducted online rather than offline.

New online methodologies

The rise of online research has led to the creation of a whole series of new online tools that have created opportunities for completely new methodologies that have no equivalent in the offline research world. Since they have been designed specifically for online, they provide an optimised digital experience for participants.

Online discussions

Online discussions can have many different names, including bulletin boards, forums and short-term communities. Regardless of what they are called, they all have the same traits:

They generally have between 10-60 participants (though they can have more)

The discussion is run over a few days of weeks

Generally there will be a couple of activities each day to complete

A moderator will probe participants for further information or engage with them in other ways to help get deeper insights

Participants may be able to engage with each other to give more of a "community feel" to a particular activity.

Advanced activities - like ideations - may provide specific functionality for certain types of research that can be conducted within a wider discussion project.

Online discussions can be accessed on any modern device - including mobile phones, tablets and laptops - making access easy regardless of where a participant is at any particular time. This makes them perfect for longer term research that will need participants to be involved for multiple days or weeks. Such involvement would be impossible in the "real world" because the amount of time that would have to be allocated to performing activities in person would be impossibly high.

The technologies available to you to complete online discussions is extensive, with a number of platforms offering suites of 15 or more activity types for all types of data collection. These collection methods can be mixed and matched to create a more engaging experience for the people taking part - perhaps a video and a quick poll today, followed by a pin task and some picture taking tomorrow.

Long-term communities

For many years, long-term communities were simply "panels". They existed mainly as a pool of people that could be used as respondents to Web surveys. Qualitative research wasn't part of the research process, and these panels were just a means to get the people required to collect quantitative data.

Over the years, as qualitative research grew online, qualitative researchers started see whether they could run a qualitative study as a semi structured project directly from within these panels. What they found was using a new research method with people who were used to Web surveys meant they didn't always get the quality of results they expected.

This has led to the growth of something designed to be used in qualitative research from the very start - smaller panels of people (as small as a few hundred up to a thousand people in total) specifically recruited to provide valuable qualitative insights for a long period of time.

Long-term communities differ from short-term communities (i.e. discussions) in a number of ways:

Discussions tend to be very structured - e.g. three days of activities, with four activities on each day. Long-term communities are much less structured - "add a task whenever needed" is a common approach. Clients often use a long-term community as an easily accessible pool of people to ask opinions of at a moment's notice. Discussions are very "ad-hoc" - it's all over in a matter of days or weeks. Long-term communities are much more of a commitment for participants. They feel more like their own Web site, and things like logins, ongoing rewards and additional content like blogs are much more common. Discussions are quicker to set up and recruit for, but once they are done, the recruits are gone. Each discussion usually needs to be recruited for all over again. Long-term communities require more set up including theming and various content pages, but once set up and recruited for you don't necessarily have to recruit again - you keep going back to the same pool of people.

From a qualitative research perspective, the thing that is the same regardless of whether you are doing a short-term or long-term community is the suite of activities available to you.

The powerful market research trend towards video

We live in a world right now, however, where the speed of change is being forced upon a market research professional is much faster than normal. Remote working has become much more common, and all manner of research (for example - tracking a customer journey) has had to be adjusted to consider new restrictions on practical aspects of conducting market research - particularly in terms of how data collection will need to be done.

Online research has primarily grown through the use of technology to add to the existing research methods in ways that can not be replicated in the "real world". Huge scale, the ability to leverage social media, and the ability to crunch a lot of data are just some of the things that have made certain online research methods so important for literally decades.

As an increasing slice of new projects moves online, the replacement for "in-person" will primarily be "on video". It will be easier to get participants (because being in the vicinity of a central location is no longer necessary, and attending virtually is less of a "hassle"), and moderator location is also unimportant. Incentives can be less, and some costs - like the cost of a group room - will disappear completely.

Understanding the bigger picture by including video as part of any research project is considered to be extremely important by clients who want to make informed decisions, understand the biggest trends and get a better understanding of what various different types of people think - regardless of whether they are looking at consumers online through, people using social media, employees of many companies or anyone else. Video is almost always a powerful tool to go beyond text-based responses.

As the amount of video being collected grows, and the level of analysis and quality of expected outputs also becomes higher - this all begs the question... how is this even achievable? Watching hours and hours of video and trying to make sense of it all is extremely time-consuming, so manually solving this problem is expensive at best, and near-impossible at worst.

Fortunately, analysis of the ever-growing amount of video being collected is made feasibly through the use of automated "video analytics". Harnessing these new technologies has been made possible by taking the capabilities of Google, Microsoft, Amazon and others, and using them as building blocks to create a solution that is specific to market research.

The 3 Market Research Trends taking the industry by storm

Modern approaches to qualitative data analysis

The process of analyzing data and your research findings is critical when it comes to making decisions; this is why it's vital you make the process of analysing qualitative data as easy and as simple as possible.

Traditional analysis is undertaken by researchers while in the room with focus groups or conducting the interviews - benefiting from the social context of being able to read and individuals emotions and keep participants from straying off course. The quality of the analysis is directly related to the skill and experience of the researchers themselves, which can be a limiting factor.

Online approaches to qualitative study help foster creativity and ingenuity - with researchers always looking for new ways of engaging with participants. The great thing about modern online data analysis is that sky is indeed the limit in terms of developing new ideas and methodologies when collecting data and how to analyse it.

Qualitative analysis does not need to take up your time - modern approaches enable you to receive responses in real-time so that you can start to analyze data right from the get-go. As part of any campaign, you should be given access to a dashboard that provides you with the tools to start your data analysis.

Your dashboard is the start of your qualitative data analysis and shows you how your sample is responding or engaging to your research questions; it'll display all data collected and the level of engagement from your sample.

The modern approach of using a dedicated platform empowers the researcher to track respondent behaviour and the wider community.

How to make qualitative data analysis easy and simple

Any venture into the world of online qualitative research necessitates to use of a platform to create and run your projects. Finding the right platform can be a daunting task, but there are a few basic things to consider when taking this journey of discovery.

Avoid lock-in to untried solutions

Unfortunately, we live in a world where "subscriptions are king" and locking you into a particular platform - preferably for a few years - is the end goal of many platform providers. Big promises linked to a long-term commitment or large upfront costs are quite common.

There is no need to lock into anything, ever, if you don't want to . A number of providers will offer very reasonable per-project pricing that will not only suit your existing project but will also let you try the platform, set up your project design, and show your client a preview of what they will be getting before making you pay for anything. Providers who are happy to back their platform and show you everything you need to make an informed decision without trying to first lock you in are the ones to look for.

Ensure you will get the support you need

Even the best qualitative research platforms can fall down due to poor support - particularly when you are new to the platform. Confirm what support is provided - and if it costs extra factor this into your costs. Online research often requires quick support response times - particularly when you are dealing with real-time research like a live group.

There are various levels of support available, but some of the things to look out for:

You may be able to get free setup included for your first project - some suppliers offer this to help make this first experience as smooth as possible, and to help you get the most out of the platform from day one.

Some platforms give you instant access to the support team through an online chat. Often this is also a great way to get quick access to their knowledgebase.

When looking at testimonials for a platform, pay particular attention to what is said about support - the quality and level of support is hard to gauge prior to getting involved in a project (it's easy to promise good support - harder to confirm the promises).

Try to discover the true capabilities of a platform

At first glance, all platforms can seem very similar. Same promise about how great they are. Similar list of qualitative research methods is available to you. Similar indications that they would be perfect for "you". The trick is to look around the edges of all these claims to determine whether what you need is truly available. Examples of things to consider are:

Does the platform use an app on phones and tablets? A few years ago apps were necessary to support some of the more advanced activities, however advances in browsers make them redundant nowadays, so all you are left with is their limitations. If they don't install as expected or crash when running, fixing the specific issue with a specific device is near impossible. Completely browser-based solutions can be used by participants on any device from a single link. Access is instant, and if a device is playing up, simply move to another one. Does the platform do what you want with videos? This point leads on from what we discussed earlier in this article - the rise of video in qualitative research. If you don't need video, or you just want to collect the video and deal with it yourself this is not a big issue - all platforms will do that. If, however, the idea of video analytics excites you (and more importantly your clients) make sure you pick a platform with powerful analytics features. All platforms will offer some sort of text transcription - the question is whether they go beyond that to identify sentiment and themes, and whether they help you build showreels (often also known as highlight reels). Does the platform cost rise steeply as the number of participants or days rise? Platforms can often appear to be around the same price, but always make sure you get a final price based on your exact needs. So of the pricing offered by platforms is for as few as 10 participants, while other platforms provide the same price all the way to 200 participants. If you have a discussion with 50 participants, the final cost between these platforms is likely to be substantial.

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• Open access
• Published: 27 March 2024

Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon

• Reem Hoteit   ORCID: orcid.org/0000-0001-8139-9321 1 ,
• Aya Hassoun 2 ,
• Elie Bou Sanayeh 3 ,
• Marie Christelle Saade 3 ,
• Gladys Honein-AbouHaidar 4 &
• Elie A. Akl   ORCID: orcid.org/0000-0002-3444-8618 3 , 5  

Health Research Policy and Systems volume  22 , Article number:  38 ( 2024 ) Cite this article

Metrics details

The coronavirus disease 2019 (COVID-19) pandemic has strained healthcare systems globally, particularly in terms of access to medicines. Lebanon has been greatly affected by the pandemic, having faced concomitant financial and economic crises. The objective of the study was to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines.

For this qualitative study, we conducted 28 semi-structured interviews. We used purposive sampling to recruit participants with a diverse range of perspectives. The data collection phase spanned from August to November 2021 and was conducted virtually. After transcribing and translating the interviews, we employed thematic analysis to identify recurring themes and patterns.

In total, 28 individuals participated in this study. Participants highlighted challenges owing to the COVID-19 pandemic and economic crisis. Accessing COVID-19 medicines posed major hurdles for physicians and patients, given limited availability, global shortages, local circumstances, community hoarding and stockpiling by pharmacies. Providers based treatment decisions on research, local and international practice guidelines, experiences and expert feedback. Patients sought information from social media, community members and physicians, as well as through word of mouth. Accessing medicines involved navigating the healthcare system, the black market, charities, personal networks and political parties and sourcing from abroad. The medicines were either free, subsidized or at inflated costs.

Conclusions

This study highlights the diversity and complexity of factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon. Future research should explore strategies for ensuring medicine access during crises, drawing insights from comparative studies across different countries.

Peer Review reports

Introduction

The emergence of the coronavirus disease 2019 (COVID-19) instigated a global health crisis, presenting formidable challenges to healthcare systems and economies across the world [ 1 , 2 ]. Since its first appearance in December 2019 in China, severe acute respiratory coronavirus 2 (SARS-CoV-2) has infected around 700 million individuals, resulting in a staggering death toll exceeding 6.9 million by November 2023 [ 3 , 4 ]. Owing to COVID-19-related lockdowns and the heightened demand for essential medications, drug shortages have become a significant global problem [ 5 , 6 ].

Prior to the pandemic, healthcare systems in low- and middle-income countries (LMICs) suffered from limited financial resources, healthcare workforce shortages and unavailability of medications [ 7 , 8 , 9 ]. The pandemic further strained these already fragile health systems [ 2 ]. For example, the strong demand for medications to treat COVID-19 patients, including analgesics, sedatives, antibiotics, hydroxychloroquine and remdesivir, considerably affected medication accessibility and inadvertently encouraged black market activity [ 10 , 11 , 12 , 13 ]. Escalating medication prices rendered these crucial medications unaffordable for many patients, particularly in LMICs [ 13 , 14 , 15 ].

The economic and financial crises in Lebanon, coupled with the Beirut Port’s destruction, severely impacted the entire healthcare sector, affecting hospitals, healthcare providers and the pharmaceutical and medical supply industry [ 16 ]. The COVID-19 pandemic worsened this situation, posing two major challenges: the selection of appropriate therapies and ensuring access to these treatments [ 17 , 18 ]. This shortage of prescription drugs in Lebanon peaked during the COVID-19 pandemic [ 19 ].

Factors influencing decisions regarding COVID-19 treatment can be complicated and multidimensional. They encompass an individual patient’s medical history, comorbidities and risk factors, as well as the availability and efficacy of various therapeutic options [ 20 ]. Therapeutic management in the early stages of the pandemic was challenging owing to uncertainty and continuously evolving evidence [ 21 ]. Clinicians attempted to manage COVID-19 using a variety of treatments that targeted numerous possible mechanisms, such as antiviral, anti-inflammatory and immunomodulatory drugs [ 22 ]. There was also misinformation in various media outlets about the benefits of some medications for either preventing or treating COVID-19 [ 23 ]. This resulted in an increase in risky self-medication with several over-the-counter medications [ 2 , 24 ].

The objective of the study is to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, and healthcare providers, with regards to their treatment decisions and accessibility to COVID-19 medicines.

Study design

This study adopted a descriptive qualitative research design using semi-structured individual interviews (refer to Appendix 1 for the interview guide). The qualitative approach utilized is rooted in naturalistic inquiry and offers a wide array of theoretical or philosophical orientations, sampling techniques and data-gathering strategies [ 25 ].

Participants

We recruited participants from different regions in Lebanon. Eligible participants belonged to one of the following groups:

physicians and nurses directly involved in caring for patients diagnosed with COVID-19

hospital and community pharmacists involved in dispensing medications for patients diagnosed with COVID-19

patients previously diagnosed with COVID-19

family members or caregivers of patients previously diagnosed with COVID-19.

We excluded patients who were psychologically unable to participate or provide coherent and clear descriptions of their experiences.

Sampling and recruitment

We used purposeful sampling by approaching individuals belonging to the groups of interest. We also used snowballing sampling by asking participants to refer us to other eligible individuals. Additionally, physicians and pharmacists assisted in the recruitment of potential former patients and caregivers. The Institutional Review Board (IRB) at the American University of Beirut (AUB) approved the study. All participants provided oral consent prior to participation. The interviewers took all precautions to guarantee participants’ anonymity and confidentiality. Participants were informed that their participation was entirely voluntary and that they could opt-out at any time.

Data collection

Following an explanation of the study’s objectives, we interviewed participants virtually in either English or Arabic, depending on their preferences. We audio-recorded interviews following participants’ consent. We conducted a total of 28 interviews, and we ceased to collect data when thematic saturation was reached, that is, no new themes emerged from the data analysis [ 26 ].

Two team members (AH and EBS) conducted the interviews between August and November of 2021. The individuals received thorough training on conducting interviews, focusing on techniques to remain neutral and nonjudgemental and to sustain the interviewees’ engagement in the subject matter. To enhance the quality of data collection, we held regular debriefing meetings following the initial interviews. These meetings provided an opportunity for reflection on the data collection process and identification of areas of improvement.

Data analysis

The interviewers transcribed the audio-recorded interviews, and translated them into English when applicable. Another team member (RH) verified transcript accuracy by checking them against the audio recordings. We employed Quirkos, a qualitative analysis software, for coding and organizing the data. We applied Braun and Clarke’s six-step thematic analysis approach [ 27 ]. In phase 1, GHA and RH read a few transcripts independently to familiarize themselves with the information and established a preliminary framework for data coding. In phase 2, they independently annotated the transcripts line by line. They assigned labels to each idea (coding), leaving room for new codes as they emerged. In phase 3, GHA, EAA and RH reviewed the coded transcripts and identified emerging themes, along with quotes that illustrated each theme. In phase 4, GHA, EAA and RH reviewed and refined the list of emerging themes, and created a thematic map. In phase 5, they outlined the final thematic framework. Finally, in phase 6, we developed a complete narrative of the findings and selected interviewee quotes for each theme and sub-theme.

Increasing rigour

All interviewers received training in interviewing skills, maintaining consistency and rigour [ 28 ]. We also made sure that interviewers had no prior relationship with participants, fostering objectivity and minimizing bias [ 28 ]. We interviewed participants in their preferred language as a way to ensure their understanding of the questions and their ability to easily express their thoughts [ 28 , 29 ]. To ensure transferability, we employed triangulation by compiling viewpoints of various population groups [ 29 ]. We halted data collection upon reaching saturation [ 30 ], ensuring comprehensive data coverage and depth. We verified transcript accuracy by checking them against the audio recordings [ 31 ]. Three members of our research team (GHA, EAA and RH) actively participated in the analysis and the generation of codes, themes and subthemes. In reporting this study, we adhered to the highest standards by following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [ 32 ].

Demographics

We recruited 28 participants: 3 community pharmacists, 4 hospital pharmacists, 8 physicians, 1 nurse, 3 patients and 9 caregivers. The interviews lasted about 40 min on average.

Emerging themes

The following themes emerged in relation to the experiences of participants with regards to treatment decisions and accessibility to COVID-19 medicines: country crises, access challenges, cost challenges, drivers for providers’ decision-making, drivers for patients and caregivers’ decision-making and accessing medicines (Fig.  1 ).

Factors influencing decision-making and accessing medicines during the COVID-19 pandemic in Lebanon

When the majority of participants expressed the same opinions, we used the term “most participants”; otherwise, we used the terms “many” or “few” as appropriate. When citing quotes from participants, we used the following acronyms: physicians (Phys), nurses (Nurse), community pharmacists (C-Pharm), hospital pharmacists (H-Pharm), patients (Pt) and caregivers (Cg).

Country crises

Most participants discussed current events in the country, including the COVID-19 pandemic, the economic crisis and the financial crisis. “Because of the current situation in Lebanon, we’re seeing things we never thought we would” (H-Pharm 02). “COVID-19 came around in March 2020, and Lebanon had already started its economic crisis” (H-Pharm 04).

Participants noted their experiences with the financial crisis and the closure of banks. “I woke up in the morning at 6:45 am, wore my clothes and went down to the bank but found it closed […], I went down to [..], same thing, it closed as I was on my way so I said, ‘where should I get them the money now?; they asked for money for the tests” (Cg 08).

One caregiver also mentioned that the economic crisis had forced them to work multiple jobs. “I work two jobs but now if you work in Lebanon the salaries are not enough” (Cg 08).

In addition to this, participants complained about how the country’s financial situation impacted access to medicines. “The purchasing power of the patients had already decreased. And like all countries when it comes to medication and the healthcare system, which was already collapsing in Lebanon, it’s common that in the end, the patient has to self-fund their treatment. And patients in low economical standing will have no access to treatment” (H-Pharm 04).

Access challenges

The crisis impacted the supply of COVID-19 medications. First, there were drug shortages directly related to the COVID-19 medicines, similar to the global crisis “… we saw that everyone is facing this, worldwide… Then we went into shortages, we didn’t have anymore because the consumption had increased” (H-Pharm 02). “Even the Colchicine, we heard about it, and we went around and looked for it and it was very hard for us to find it easily” (Cg 02).

“For example, remdesivir they used for my mother-in-law we got six injections, and the first day we tried to get it we called the pharmacies they told us they don’t have it. In the hospital, there was no remdesivir because it was getting brought based on an order from the company and it needed a prescription from the doctor to obtain” (Cg 01).

Second, the challenging circumstances in Lebanon had an additional impact on the accessibility of medicines. “The effect of the medications is unrelated to COVID-19. I mean, the availability of the medications. Now, even after COVID-19 has decreased, we have shortages in medications that are unrelated to COVID-19, it has to do with the economic situation. So, it’s not COVID-19 that made the crisis in medications, not at all” (Phys 08). “It was hard to provide medications because of the terrible situation of Lebanon” (Nurse 01).

Many pharmacists discussed community hoarding. “People were running to the pharmacies to secure one of these medications even if they did not need it at the time, just for the sake of keeping it at home just in case, which led to a huge shortage of supply” (C-Pharm 02).

However, patients were concerned about pharmacies stockpiling medications. “Exactly, because of the economic crisis selling the drug was not beneficial for the pharmacies so they started keeping it for emergency cases and selling it at the black market rate. After all the demand was very high” (Cg 07).

Few physicians mentioned lack of availability of medicines specifically in the hospitals, particularly for the new medications. “They had to get the medications outside of the hospital…the shortage was due to the fact that basically, this is a new medication, and it hasn’t been brought to Lebanon yet.” (Phys 08).

A few pharmacists stated that they always had a backup plan. “To be honest we never had really bad shortages, we never fully ran out, we always had a plan B. When there was no more dexamethasone for IV, we prepared other corticoids, even if it wasn’t mentioned in any studies or guidelines. We used to prepare them and keep them as backups in case they were ever needed” (H-Pharm 04).

Cost challenges

Both providers and patients noted unaffordable costs as another factor affecting access to medications, considering the devaluation of the currency. “The single pill got to about 50 USD, it was very expensive. So, it was really expensive for most people. Its actual price was 5000 Lira” [H-Pharm 04; note that at the time 5000 Lira was worth less than 5 US dollars (USD)]. “Even tablets like vitamins are available but they are very expensive, not everyone can afford them” (Cg 04).

Patients complained about price manipulation. “The prices were definitely manipulated because when I would buy a medication I would find more than one price tag… The lozenges for her throat used to cost 19 000 Lira and now it costs 45 000 Lira. They put more than one label on the box of medication, there are about three price tags on it” (Cg 06).

Additionally, it was mentioned that the pricing of medications was changed to the US currency. “Yes, most of the time they were fresh dollar” (Phys 08).

Drivers of decision-making for providers

During the COVID-19 pandemic, several factors influenced decisions by providers, patients and caregivers about which medicines to use or not use.

Owing to the rapid development of evidence, providers were compelled to rely on research to prescribe certain medications. “There was a committee that used to review the data available and to review all the evidence at the time and make the decisions.” (Phys 04). “… the COVID-19 protocol changed every couple of days. Every once in a while, a new study would appear, a new update, and it would change again” (H-Pharm 01).

Providers also relied on clinical practice guidelines developed either locally or internationally, for example, by the WHO. “The medications we were prescribing were based on WHO” (Phys 03). Although they relied on those guidelines, some providers expressed hesitations about them. “Yes, we were following the guidelines of treatment of COVID-19, we would tell this is the medication that needs to be taken because this is what the guidelines say. We are not sure of the guidelines, but this is what is needed now” (Phys 09).

Additionally, the providers’ prior experience or trial and error played a role in the decision-making process. “At first, personally, I did not have much experience with this disease but later on and after I acquired some experience, I was finally able to give my own opinion on the matter” (C-Pharm 01).

Reliance on local peers with different specialities played a significant role in decision-making. “Because we had several specialities – cardiovascular, internal medicine, and others – everyone did their research and every week we would meet and explain to each other… Everyone gave their inputs and propositions, in their own specialities, about which drugs might be good, and which drugs were used in which cases” (H-Pharm 04).

International expertise was also sought during the pandemic. “We also had video conferences with hospitals and ICUs in France and the United States, because we had physicians that went and studied in those countries and still had contacts, we did one video conference with France, and one with the US to ask about their protocols. And there were discussions about what’s best. And when Actemra was first being used by the ones we talked to somewhere in Houston, we weren’t using it yet in our hospital. After the video conference, they found that their patients are showing good results, so it was added to our protocol..” (H-Pharm 04).

It is of note that the country’s situation and drug availability influenced the decision-making process. As expressed by many doctors: “We were following the new guidelines, taking into consideration the situation of the country and the availability of the drugs and imaging” (Phys 02).

Drivers of decision-making for patients and caregivers

Patients and caregivers relied on social media to decide on drug purchases. “Yes. Honestly, they saw me crying and I had posted on Instagram that if anyone please could help with their experience because there were no studies at that time” (Cg 03). “At first people used to wait for what the media says and then come running to the pharmacies to buy these medications, it happened first with vitamin C then 2 weeks later with vitamin D then it was the zinc 25 mg and then zinc 50 mg turns” (C-Pharm 01). “Even the colchicine, we heard about it on social media, and we went around and looked for it and it was very hard for us to find easily” (Cg 02).

Patients and caregivers were also influenced by people in their communities, some of whom had experience with COVID-19. “Other people around us who also had corona, everyone that got corona would say take this and do this” (Pt 02). “My dad caught it in the beginning, so I started asking people to see what we could do. One of my friends told me that there was a person who took this medicine, and they told me to try it, so I decided to do that” (Cg 03).

Patients reported different attitudes about consulting with their doctors. “We heard about remdesivir and asked the doctor, he told us he can’t advise us to take it or not, if we would like to try it based on other patients and not on medical research then go ahead” (Cg 07). Some made decisions on their own on the basis of word of mouth. “My friend called me and told to me not listen to the doctors and to take zithromax. I bought it and took one pill” (Pt 08).

Accessing medicines

We have identified two subthemes under the theme of “accessing medicines”: information about how to get the medicines and the sources of medicines.

Information about how to get the medicines

Typically, patients obtained information about how to get the medicines from healthcare providers, including nurses, physicians and pharmacists. “Yes sure!… [local charities] used to give those medications (remdesivir, Actemra, etc.) for free. And there were some other providers. We used to indicate the providers to the families of the patients” (Nurse 01).

Patients also inquired about the source of medicines from recovered COVID-19 patients: “From other people around us who also had corona” (Pt 02).

Sources of medicines

Patients and their caregivers obtained the medicines either through the healthcare system or from outside the healthcare systems, including the black market, nongovernmental organizations (NGOs), personal networks, political parties and outside of the country.

• Healthcare system

When patients were admitted, few reported that COVID-19 medicines were available in the hospital. “They were all found in the hospital” (Cg 05). However, for several patients, their family members had to seek medicines from community pharmacies. “We got them from the pharmacy” (Cg 01).

Medicines were obtained at no cost thanks to a subsidy by the Lebanese government. “So, it was for free if it was from the Ministry” (Cg 02). However, some other medicines were purchased on an unsubsidized basis and at high cost. “A few pills were for 1 300 000 Lebanese Lira in the pharmacy” (Cg 02).

• Black market

Owing to the limited supply and urgent need for COVID-19 medications, the black market flourished. “There were two more weeks, and the Ministry was supposed to secure it, but we needed it urgently, so they gave us the number of someone who sells it in the black market and he got it for us” (Pt 03).

The black market was viewed as a double-edged sword because it allowed access but at an inflated cost. “They gave us five remdesivir and one Actemra for US$ 1200” (Cg 07). “The remdesivir is like. So, he made us pay US$ 700 for one,.. So, US$ 4200 for six pills” (Pt 03).

Because of the country’s financial crisis, inflated black market prices presented a major challenge for patients. “… it was a challenge for us to financially secure the medicine. And of course, him asking for US$ 4200 cash was not something easy for someone to get and pay, but if it is the only solution of course we would do it” (Pt 03).

Charities supported patients in accessing their medicines either for free or through financial support. “Suppose I were to get COVID-19 now, my name would go down at the municipality and they get you vitamin C and vitamin D – a charity organization, not from the government” (Cg 08). “I paid 1 million and the rest was on the charity organization” (Cg 08); “For ivermectin there were a lot of organizations trying to supply it, it’s a very cheap drug… that costs US$ 4. There were also a lot of organizations trying to supply remdesivir, ‘Hariri’ (a local charity) was trying to help with it since hospitals did not have it, people were going to her villa to get it, it costs I think about US$ 4000” (Phys 02).

Personal network

Caregivers of patients with COVID-19 used their personal networks, including family and friends: “Also, from a person who knows a pharmacist he’s friends with, they got them for us” (Cg 02). “We had to get the baricitinib from someone we know, who got it for us from the Ministry” (Cg 02).

Political parties

Political parties also supplied medicines to their supporters. “There were parties that were obtaining them, like [name of political parties]. Those were for free as a donation from [name of political party]” (Pt 02).

From outside of the country

Typically, family or friends helped by purchasing medicines while travelling. “At the time, an Iraqi who is friends with my relative got it and he paid US$ 400” (Pt 08).

Out-of-country purchases were driven by either lack of local supply or inflated costs. “The ivermectin was still not in Lebanon, so we got it elsewhere, from a woman who lives in Africa, she got it for us and sent it. And we started with cortisone, this is from day 1” (Cg 02). “My cousin sent it from Sweden, she sent zinc and vitamin C because vitamin C here now costs 60 000 Lira, before it cost 14 000 Lira and now it costs 60 000” (Cg 06).

This study aimed to to understand the experiences of patients with COVID-19 in Lebanon, as well as those of their families, physicians, nurses and pharmacists, with regards to their treatment decisions and accessibility to COVID-19 medicines.

The participants highlighted the country’s difficulties, especially the severe impact of COVID-19 pandemic and the economic crisis. Access to COVID-19 medicines and their costs were major challenges according to the three groups interviewed. Limited access related to global shortage of medicines, the local challenging circumstances, community hoarding (according to pharmacists) and stockpiling by pharmacies (according to patients). For providers, the decision-making process for COVID-19 treatments was shaped by research evidence, local and international practice guidelines, previous experiences and feedback from both local and international experts. Patients and their caregivers relied on social media, community members, physicians and word of mouth. Information on how to get the medicines was obtained from either healthcare providers or patients who recovered from COVID-19. Accessing medicines involved navigating through the healthcare system (hospitals and pharmacies), as well as outside that system, including the black market, charities, personal networks, political parties and outside of the country. Across these different sources, the medicines were either free, subsidized or at inflated costs.

Comparison to similar studies

A major finding in our study was the accessibility of patients and healthcare providers to needed medicines. This is corroborated by other studies conducted in Lebanon [ 33 , 34 ] and low-and middle-income countries [ 35 ]. The global impact of lockdowns on medicine manufacturing, supply and distribution contributed to shortages during the high-demand period of the COVID-19 pandemic [ 36 , 37 ]. Furthermore, Lebanon has faced severe economic and financial crises starting in 2019, which severely hindered the capacity to import vital healthcare equipment and medicines [ 38 , 39 ]. Indeed, the World Bank characterized the crisis as “among the world’s worst since the 1850s” [ 40 ]. The lack of government reimbursement further hindered hospitals in procuring necessary medications and medical supplies [ 41 ]. Consequently, individuals affected by COVID-19 in Lebanon resorted to unregulated sources, including the black market, often resulting in inflated prices and the risk of expired or counterfeit drugs [ 13 , 14 , 15 , 42 ].

Moreover, in line with our findings, other studies found that healthcare providers followed both international and national guidelines when deciding on potential treatments for COVID-19 patients [ 43 , 44 ]. However, in the absence of effective medications, discussion on various social media platforms encouraged self-medication and the use of herbal medicines [ 45 , 46 ]. In addition, a recent study conducted in Jordan assessing the usage of medications and natural products amidst the second wave of COVID-19 revealed that individuals primarily sought guidance from family and friends, with social media platforms serving as significant sources of advice concerning the use of these medications [ 47 ]. The same study showed that pharmacists notably played a significant role in guiding individuals on choosing these treatments compared with other healthcare providers [ 47 ].This highlights the impact of social media on treatment choices and emphasizes the need for disseminating accurate and evidence-based information.

Strengths and limitations

To our knowledge, this is the first study in Lebanon to comprehensively explore the interplay between country crises and medication accessibility during the COVID-19 pandemic, offering valuable insights into the unique challenges faced by the country. We explored in-depth the lived experiences of our participants, ensuring the representation of the perspectives of healthcare providers, patients and caregivers. Also, we used a rigorous qualitative methodology (please refer to the “Increasing rigour” section).

There are several limitations to consider. Firstly, the study focuses primarily on Lebanon, which may limit the findings’ generalizability to other countries with distinct settings and healthcare systems. Moreover, there is a possibility of recall bias among participants, as their recollections of events and experiences concerning medication accessibility during the crisis might be influenced by subjective interpretations or memory lapses. Additionally, the sampling technique employed might introduce selection bias, as participants were recruited through purposive sampling. Furthermore, it is important to note that this study is based on a specific snapshot in time during the COVID-19 pandemic. Consequently, its findings may not fully encapsulate the dynamic and evolving nature of the crisis or account for potential shifts in medication accessibility and decision-making processes over time.

This study sheds light on the wide range of factors influencing treatment decisions during the COVID-19 pandemic in Lebanon. It also unveils how patients and their families had to access medications either through the formal healthcare systems or through black markets and other channels. Plans are needed to address medicine availability, affordability and equitable distribution during similar future crises. There is an urgent need for collaborative efforts involving stakeholders, policy-makers and key systems such as Meditrack and AMAN within the Ministry of Public Health [ 48 , 49 ]. These initiatives are intended to establish resilient and sustainable drug supply chains and to ensure timely and equitable access to medications for all individuals, particularly in times of crisis. Furthermore, improving collaboration among healthcare providers, expediting medication access and creating patient support programs can alleviate the difficulties that people seeking treatment confront. For example, streamlining communication between hospitals, pharmacies and primary care doctors could speed up the prescription and dispensing processes.

Future research should focus on effective strategies to ensure medicine access during crises. Comparative research across different countries can provide valuable insights into successful tactics that can be tailored across different countries.

What is already known on this topic

global healthcare systems have been strained owing to the COVID-19 pandemic, leading to challenges in medicine access; and

Lebanon’s healthcare system has been significantly impacted by the pandemic and financial crises, affecting the availability of medicines.

What this study adds

it uncovers key factors influencing both healthcare providers and patients in their treatment decisions, providing a comprehensive perspective; and

it describes varied sources for medicines, including informal networks and the black market.

How this study might affect research, practice or policy

the findings emphasize the necessity for strategies that ensure continuous medicine access, particularly during times of crises and economic instability.

Availability of data and materials

The datasets analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

American University of Beirut

Consolidated Criteria for Reporting Qualitative Research

Coronavirus disease 2019

Community pharmacists

Hospital pharmacists

Institutional review board

Low- and middle-income countries

Lebanese Ministry of Public Health

Nongovernmental organizations

Severe acute respiratory syndrome coronavirus 2

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Reem Hoteit

School of Public Health, University of Saskatchewan, Saskatoon, SK, S7N 5A2, Canada

Aya Hassoun

Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon

Elie Bou Sanayeh, Marie Christelle Saade & Elie A. Akl

Rafic Hariri School of Nursing, American University of Beirut, Beirut, Lebanon

Gladys Honein-AbouHaidar

Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Canada

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Contributions

Concept and design: AH and EAA. Data collection: EBS, AH and MCS. Data analysis: RH, GHA and EAA. Data interpretation: RH, GHA and EAA. Drafting of the manuscript: RH, AH and EAA . All authors reviewed and approved the submitted version of the manuscript.

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Correspondence to Elie A. Akl .

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Hoteit, R., Hassoun, A., Bou Sanayeh, E. et al. Choosing and accessing COVID-19 treatment options: a qualitative study with patients, caregivers, and health care providers in Lebanon. Health Res Policy Sys 22 , 38 (2024). https://doi.org/10.1186/s12961-024-01131-9

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• Volume 41, Issue 4
• Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study
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• http://orcid.org/0000-0003-3067-9416 Jo Daniels 1 , 2 ,
• http://orcid.org/0000-0002-8013-3297 Emilia Robinson 1 ,
• http://orcid.org/0000-0001-5686-5132 Elizabeth Jenkinson 3 ,
• http://orcid.org/0000-0002-2064-4618 Edward Carlton 4 , 5
• 1 Department of Psychology , University of Bath , Bath , UK
• 2 Psychology , North Bristol NHS Trust , Westbury on Trym , Bristol , UK
• 3 Department of Health and Social Sciences , University of the West of England , Bristol , UK
• 4 Emergency Department, Southmead Hospital , North Bristol NHS Trust , Westbury on Trym , UK
• 5 Bristol Medical School , University of Bristol , Bristol , UK
• Correspondence to Dr Jo Daniels, Department of Psychology, University of Bath, Bath, UK; j.daniels{at}bath.ac.uk

Background Staff retention in Emergency Medicine (EM) is at crisis level and could be attributed in some part to adverse working conditions. This study aimed to better understand current concerns relating to working conditions and working practices in Emergency Departments (EDs).

Methods A qualitative approach was taken, using focus groups with ED staff (doctors, nurses, advanced care practitioners) of all grades, seniority and professional backgrounds from across the UK. Snowball recruitment was undertaken using social media and Royal College of Emergency Medicine communication channels. Focus group interviews were conducted online and organised by profession. A semi-structured topic guide was used to explore difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Data were analysed using a directive content analysis to identify common themes.

Results Of the 116 clinical staff who completed the eligibility and consent forms, 46 met criteria and consented, of those, 33 participants took part. Participants were predominantly white British (85%), females (73%) and doctors (61%). Four key themes were generated: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data pertaining to barriers and opportunities for change were identified as sub-themes. In particular, strong leadership emerged as a key driver of change across all aspects of working practices.

Conclusion This study identified four key themes related to workplace concerns and their associated barriers and opportunities for change. Culture, working environment and need for support echoed current narratives across healthcare settings. Leadership emerged more prominently than in prior studies as both a barrier and opportunity for well-being and retention in the EM workplace. Further work is needed to develop leadership skills early on in clinical training, ensure protected time to deliver the role, ongoing opportunities to refine leadership skills and a clear pathway to address higher levels of management.

• qualitative research
• staff support

Data availability statement

Data are available upon reasonable request. Requests go to the corresponding author - Jo Daniels ([email protected], University of Bath, UK). De-identified participant data can be made available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/emermed-2023-213189

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Retention of staff in emergency medicine is at crisis level and has been a high priority area for over a decade.

Multiple guidelines have been published to outline improvements that need to be made to retain staff; however, little improvement has been seen on the ground in EDs.

Key factors such as staff burnout and poor working conditions are known to influence intention to leave; however, it is unclear why change has not taken place despite knowledge of these problems and existing guidelines seeking to address these issues.

WHAT THIS STUDY ADDS

This qualitative study assessed perceived barriers that may be inhibiting the implementation to working conditions and working practices in EDs.

Leadership is identified as an important driver of change in working practices and can play an important role in workplace well-being and retention.

Key recommendations for avenues of improvement are made, identifying key actions at government, professional, organisational and personal level.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

This study identifies leadership as a key opportunity for change and as a result makes specific recommendations for policy and practice regarding leadership in emergency medicine.

Introduction

Emergency Medicine (EM) is facing a global staffing crisis. 1 Record numbers of staff continue to leave the UK NHS with EM the most affected specialty. 2 EM reports the highest work intensity of all medical specialties, 3 with ‘intensity’ recognised as one of the leading factors in job dissatisfaction, attrition and career burnout. 3–5 These factors are amplified in an already stretched workforce. 2 Psychological well-being of the EM workforce is compromised, with working conditions recognised as playing a key role. 6 7 Staff attrition has a systemic impact: lower staff ratios lead to higher workloads, reduced quality of care, 8 higher levels of medical errors 9 and poorer staff well-being, 10 all factors associated with staff absence and intention to leave. 11 The landscape of EM has also changed; increased prevalence of high patient acuity, multimorbidity and an ageing population all bear considerable impact.

Key sector stakeholder initiatives and policy recommendations relating to retention and well-being 12–14 are largely generic and forfeit relevance to the specialty due to the lack of specificity to the clinical context within which these guidelines need to be implemented. Retention improvement programmes suggest approaches should be tailored per organisation, 12 however, this assumes that the challenges faced by staff across specialities and disciplines are homogeneous. In a specialty which reports the highest pressured environment, highest attrition and rates of burnout, 15 considerations of workplace context and specificity of policy recommendations are likely to be crucial. Interventions or initiatives must take account of the unique demands of the EM working environment, and how feasible it is to implement recommendations.

The James Lind Alliance (JLA) priority setting partnership in EM 16 identified initiatives to improve staff retention as research priorities in 2017 and again in the 2022 JLA refresh, 17 signalling the need for further research in this area due to a deepening workforce crisis. Current guidelines and initiatives target working conditions which are known to be associated with retention; however, these initiatives have been poorly implemented or enforced, with few formal evaluations of such interventions. 5 Moreover, current research is limited to the perspectives of specific professional groups and most are survey-based studies. 18

In order to better address current working conditions, with a view to improving retention, this research was aimed at determining practical barriers and opportunities for change in the ED working environment as perceived by professional staff working in this environment. This will tooffer insight into the shared experiences, constraints and priorities of those working within the ED.

Enhanced understanding of these issues can provide a firm basis from which to shape, inform and underpin future policies and workplace initiatives, ensuring that practical barriers and opportunities for change are embedded in a way that optimises relevance and feasibility of implementation in the ED working environment.

Study aims and objectives

This study sought to engage three core professional groups (doctors, nurses, advanced care practitioners; ACPs) who work within an EM context to better understand (a) primary concerns relating to working conditions; (b) perceived barriers to implementing change and (c) perceived opportunities and targets for change. Findings will be used to underpin key recommendations that are tailored to the needs of an over-burdened and under-resourced ED.

This qualitative study forms part of a larger collaborative project between the University of Bath and the Royal College of Emergency Medicine (RCEM), funded by a UKRI Policy Fund. The full recommendations relating to the four core themes are available on the RCEM website (Psychologically Informed Practice and Policy (PIPP) | RCEM).

Methodology

This study uses a qualitative approach involving online focus groups in order to gain a rich and detailed understanding of participant perspectives and views, unrestricted by closed question responses. Focus groups offer the opportunity to gain an understanding of shared experiences and narratives, using a dynamic approach to the subject matter, allowing further probing for clarification and participant interaction for deeper insights. The COVID Clinicians Cohort (CoCCo) study 19 was used to organise data into key categories; this model mirrors Maslow’s Hierarchy of Needs 20 from a workplace perspective.

Participants

To be eligible for participation, ED staff must have been currently employed in a UK NHS ED as either a doctor, nurse or ACP.

ACPs are a recently developed workforce of accredited clinicians who have received advanced training to expand the scope of their usual role (eg, paramedic, nurse), permitting them to take on additional clinical responsibility in the ED.

These three groups are core affiliates of the RCEM and represent the majority of the workforce in the ED. The ED setting was used as the focus (rather than all acute care settings) as this represents the core and central setting for EM.

Recruitment and procedure

Online adverts and qualtrics survey links were distributed through social media (ie, Twitter) and RCEM communication channels using snowball recruitment methods. Profession-specific focus group interviews were conducted online using MS teams by two study researchers (JD, ER) using a semi-structured topic guide (see online supplemental materials ). The guide was shaped by the scope of study aims and the current evidence base and explored difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Focus groups were 60–90 min in duration and were recorded using encrypted audio recorders, transcribed and stored securely. Participants were given debrief information sheets following the focus group. Transcripts were not returned to participants and no repeat focus groups were carried out.

Supplemental material

Directive content analysis was applied to the data. 21 This analysis strategy was used to identify common themes from participant responses, using deductive codes by identifying key concepts from existing theory 19 and prior research. Two researchers (ER, JD) read through each transcript, highlighting passages that could be categorised in the pre-determined codes. Any passages that could not be categorised within the initial coding theme were given new codes. Further coding was then conducted and this iteration was reviewed and updated. After coding was completed, initial notes from the focus groups were revisited to ensure all reflective notes were incorporated where relevant. Final themes were refined through an iterative process between JD, ER and EJ (qualitative analysis expert), with all stages of analysis reaching consensus agreement with regard to the content and labelling of codes and themes.

Patient and public involvement

As this study focused on staff experiences in an EM workplace, a Clinical Advisory Group (CAG) was used in place of patient or public involvement. The CAG comprised of five clinicians working in the ED who advised on the scope and priorities of the study. This included two medical consultants, one charge nurse, one trainee and one specialty grade doctor. Of those, three were males and two were females. All CAG members were offered renumeration for their time.

Of the 117 total responses to the study advert, 16 respondents were eligible but not available to attend focus groups and 55 either did not consent or were not eligible based on their role and/or department. From the remaining 46 respondents, 13 of these could not attend or cancelled, leaving a final sample of N=33 (28% of total responses). Due to higher response rates from doctors, these focus groups were further grouped by grade; nurses and ACPs were grouped by profession only and were organised base on availability. There were 11 groups in total (see table 1 ). Participants were mostly female, and from a white British background. Ages were spread fairly evenly across the categories, except ages 35–44 which included substantially fewer participants.

• View inline

Participant and focus group characteristics

Following analysis of the qualitative data, four key themes were generated. These were termed: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data within these themes that were identified as ‘barriers’ or ‘opportunities’ for change were extracted ( table 2 ). Illustrative participant quotes are identified by researcher codes, which reflect the profession and a recoded group number, to preserve anonymity.

Primary concerns, barriers and opportunities for change

Culture of blame and negativity

When asked about the most difficult aspects of their working conditions, participants commonly reported a culture of blame and negativity in the ED. The work culture not only felt unsupportive and ‘toxic’ but had a marked effect on well-being. Participants described a culture which was quick to blame rather than support:

You worry about making a mistake, and if you did make a mistake who would have your back. (ACP, G7) You very rarely get anyone saying that was a good job. (SAS doctor, G8)

This was particularly felt top-down, where those in management position were perceived to take an unsympathetic view of extended waiting times and unmet targets, despite the tangible constraints of operating at overcapacity and ‘exit block’, problems that participants perceived to be out of their control. Participants in all groups indicated that the negative culture instils anxiety over how they might be perceived by peers, but particularly by senior colleagues:

That’s a classic example… she’s a senior member of the team, really knows her job…. She was quite critical really, in a very negative way about how you managed that patient. (Nurse, G11)

Some participants reported senior colleagues having unrealistic expectations of the more junior staff, with little consideration of the increased pressures that have arisen in recent years:

It’s ridiculous to compare the needs, even for our senior colleagues who were registrars five years ago, the reality of running the department overnight is not the same as it was then. (SAS doctor, G1)

Existing structures and working practices of the NHS were described as ‘archaic’ and ‘old fashioned’, leading staff to feel blamed if they could not cope with the pressures and disempowered to seek support due to the expectation that they should be ‘unbreakable’ (Trainee, G9). Participants also voiced that they were unclear on lines of accountability, who to approach for what problem. This barrier to escalating their concerns was further compounded by the belief that both clinical leadership and higher management were generally overburdened and unreceptive to discussions on workplace concerns.

Increasing pressure and longer waiting times were described as driving antisocial behaviour from patients, exposing staff to risks to physical and psychological well-being:

So the long wait causes verbal or physical violence and aggression, which has a massive impact on staff well-being. (Nurse, G11)

Participants highlighted the desire to be supported to learn from difficult experiences and develop in light of them, suggesting that a simple checking in on how individual staff members are progressing would be well received and beneficial to well-being:

We have intermittent debriefs… but it’s not every time. It doesn’t necessarily need to be every time, but it’s not as frequent as it should be. Even if it is just ask are you okay? (Trainee, G5)

Interprofessional respect and development of a more empathic culture of shared responsibility were flagged as key opportunities for change that would support better team cohesion:

We need to change how we speak and respect each group, and we need to try and understand each other’s point of view, and if we could get better ways of working, but just talking to each other about what are my problems, what are your problems, why is this stressing you, what’s stressing us, how can we work together to do that. (ACP, G2)

Findings suggest that EM professionals are confronted with outdated perceptions of clinical demand from within teams and systems, with unrealistic expectations which compound a blame and shame culture when expectations are not met. Operating within this chronically under-resourced system was framed as compromising workforce well-being and risking burnout, yet participants indicated that simple interventions such as check-ins, clearer lines of accountability and a more civil and respectful culture would offer key opportunities for growth and sustainability even in the face of a staffing crisis.

Untenable work environments

The complex work environment within the ED was described as being of significant concern, compromising care and leaving staff feeling undervalued due to basic needs being unmet. Participants frequently reported poor quality or inadequate facilities, such as provision of toilets, lockers and changing rooms, hot food only available within limited hours, poorly functioning IT systems and rest spaces being in a different building.

So you’re just basically sharing (toilets) with the patients. In the urgent care centre there’s two toilets for the whole of the department in there, often one of those is broken…and not enough lockers for every member of staff. (ACP, G2) Stuff like working computers, a consistently working POD system… those little things I think make a bigger impact on your life than how many people come in through the front door. (Trainee, G5)

A lack of physical space for administrative tasks was highlighted by many clinical staff, being described as ‘woefully inadequate’ (ACP, G2). Wards were described as ‘unfit for purpose ’ (Nurse, G11), which was attributed, in part, to higher management lacking understanding of the needs and practices of the ED. One example highlighted the long-term impact of ED workspace changes that were not fit for purpose:

…it was clear that no clinical staff had been involved. Doors were in the wrong space, no sinks in the right place, not enough storage, poor flow, poor layout (ACP, G2)

Existing rest spaces or staff rooms were reported to be taken over to provide more clinical room, limiting the space for staff to change, rest and decompress.

The nurses were getting changed in a corridor, now they seem to have a cubicle they can get changed in. But the facilities for the same trust are really very different. (Nurse, G10)

This was perceived to be particularly important due to working in the high-pressure environments of a crowded ED, where staff voiced concerns regarding the sustainability of working with a high workload safely without private spaces.

EDs were perceived to be more busy, for reasons associated with shifts in societal expectations and perceptions of the scope and role of ED:

Go back ten years ago in the emergency department and people would try their best at home, would take painkillers, will see how it goes, not wanting to trouble A&E, but seems like now it seems like A&E is the open door for everybody just to come in with everything. (ACP, G7)

Participants used emotionally laden language when describing the intensity of the workload itself, with parallels drawn between being at war and working on the NHS frontline, where staff worked under similar levels of intensity but longer term and without rest.

…when people are deployed (in the forces) they are deployed for 6 months…because that 6 months is intense, it’s intense on your body, it’s intense on your mind, it’s intense on your family, it’s intense on everything about you, and that’s while you were deployed for 6 months, and then there’s some recovery time coming back. (Consultant, G4)

Comparisons were also made to the sinking of ‘the Titanic’:

There is the jollying everybody along, being the redcoat on the shift, cheering everybody up, saying everything is going to be okay, but feeling like you’re just rearranging the deckchairs on the Titanic (Nurse, G10)

The impact of a consistently high workload was described as being compacted by a lack of agency and autonomy over working patterns, which was perceived to be related to non-clinical staff making decisions about shifts without understanding the inherent pressures:

The people who control our rotas are… her job is a rota co-ordinator, she works in an office, she is administrative, and the person who signs that off is the manager for the department, again non-clinical, and getting leave is a nightmare, it’s awful. (Trainee doctor, G5)

Consultants identified that there were limited options to reduce workload when approaching retirement, and they did not necessarily feel well-equipped to continue operating under high pressure and for long hours. Those in training posts reported insufficient time to meet requirements or study due to workload, influencing both career progression and confidence in the role.

You are getting no progression because you’re not getting your training, and I know that personally in the last year I made my decision that I will not continue to work clinically, I will step back in the next few years because there’s… why would I stay doing something that there’s no reward for? (Nurse, G11)

Participants agreed that there was both a need and an opportunity for the ED to be a ‘nicer place to work’ (ACP, G2). Specific suggestions included a full staffing quota, ensuring staff are adequately rested to return to work and the opportunity for peer support:

My top three things would be coming on with a full staffing quote so you know there’s no gaps in the rota, so you’re all there. Everyone is well rested and ready for the shift, just being able to talk to each other on the shop floor and being quite open with each other on how everyone is feeling. (ACP, G7)

Many of the suggested changes directed at making working conditions in the ED more sustainable related to basic needs such as being able to take breaks, access healthy food and functioning IT when needed:

…having those opportunities to go off and have a five minutes when you need to, to be able to continue your shift. (ACP, G7) It would be really nice to be able to have some healthy nice food in the department. (Nurse, G11) As more and more of our job goes electronic, electronic notes, electronic prescribing, actually having IT systems that are fit for purpose, everyone has access to (Trainee doctor, G9)

Self-rostering was frequently mentioned as a positive experience for participants and a useful avenue to help participants to deliver better care and improve well-being:

One day off between a set of shifts is not enough to decompress and be re-energised to start back on your next set of shifts. So I think the rota, we have moved to a more self-rostering method now, and I think that’s helping with staff well-being, especially in our team. (A7)

Overall, working in existing ED environments was described as ‘untenable’ and ‘unsustainable’ in terms of both the working environment and the lack of agency and autonomy over high-intensity workloads. Many of the problems and solutions relate to provision of resources to meet basic needs, many of which are subject to professional and NHS regulations; however, due to pressures this is not being implemented.

Compromised leadership

Clinical leads in the ED were perceived to hold responsibility for setting the tone for culture and behaviour in the ED, leading by example:

And you lead by example as well, so if your consultant in charge is not taking a break you feel like you can’t ask to take a break. It’s the same with the nurses, if the nurse in charge is not taking a break then a lot of the junior nurses won’t come and ask for a break because again you’re guided by the leadership aren’t you? (A7)

The clinical lead in the ED is a key conduit for change, from a cultural and environmental perspective especially. However, participants expressed frustration about feeling that their voices were not heard or valued outside of the department, in part due to clinical leads being reluctant to escalate their concerns due to the discrepancies between clinical priorities within the ED and the priorities expressed by trust level executive management:

You’ve got the clinical side, and we are to one degree or another worried about the patients, and then you have got the management side and they are worried about figures, times or money, and those two things don’t really mesh together (ACP, G2)

Yet, within the EDs, leadership was described as being poorly supported in terms of protected time to train and deliver the role fully. Consultants voiced reluctance to take on a leadership role due to lack of ‘visible leaders’ to provide inspiration or exemplar: ‘There is no one for us to look up to, to lead us’ (Consultant, G4), ‘We need compassionate leadership’ (SAS doctor, G1).

A lack of definition or clear understanding of what the clinical role entailed was reported to make it difficult for clinical leads to be effective in their role:

People tell you that you’re there to lead, and you’re like I know but what does that mean? And then you don’t know if you’ve got to go to all these meetings, which ones you really need to go to, which ones can I not go to, also for me I do the job on my own. (Clinical lead, G6)

Participants emphasised they need a ‘clear definition of what the college would see the role to be, and how much time they would expect it to take of your job ’ (Clinical lead, G6). Any possibility for growth was hampered by a lack of training or support from colleagues to help with even the practicalities of the role (such as recruitment and personnel management):

I have literally started last week on a leadership course that’s been for other clinical leads in the organisation. But I feel a bit could have done with this maybe earlier. But that’s more about your leadership qualities and conflict resolution, it’s all that side of it as opposed to the actual practicalities of the job. (Clinical Lead, G6)

When considering possible solutions to these difficulties, participants suggested that an accessible time to do the job and an online repository may offer an opportunity to share resources, learn from one another and foster development:

I think sharing all the stuff we shared on the WhatsApp, trying to share stuff, so how to write a business case, what you need to do. (Clinical lead, G6) I should be doing work at a time I am getting paid, so you need to give me that time. (Trainee doctor, G9)

Mentorship was also deemed to be important for successful delivery of the role:

I think personally as leads and stuff we should all have some kind of mentoring type…Supervision, that’s the thing, we don’t get any. (Nurses, G10)

Participants described having difficulties feeding into emerging issues to address unmet need, blocked from communication with leaders by ‘layers of bureaucratic sediment’. This was compounded by the career trajectory of NHS management, where often those in post would swiftly move on for promotion.

Overall, clinical leadership within the ED was described as compromised, unsupported and, ultimately, a key barrier or missed opportunity for change in culture and working practices in the ED. However, there were clear indications of opportunities for growth and change, including a need for compassionate leadership, shared resources, time to do the job and mentorship.

Striving for support

This final theme encompasses the concerns raised by participants regarding well-being and staff support, specifically the barriers to accessing well-being support and their preferences in relation to what changes are likely to improve their well-being. Common barriers included having to attend support or well-being services during time off, with the scheduling of support geared to a ‘nine to five’ non-clinical workforce (ACP, G2). Mental health stigma in the ED was also cited as a key barrier.

I think for me it still feels like a bit of a stigma about saying I am struggling what should I do next. (Nurses, G11) There’s nowhere that I can express how I am feeling or even understand how I am feeling. (Consultant, G4)

This was reinforced by well-being not being viewed as a priority, with team check-ins or formal appraisals described as having ‘nothing in there about wellbeing’ (Clinical lead, G6), despite suggestions that simple well-being check-ins would suffice.

Participants suggested that support should not be purely accessed after the fact but something that should be prioritised and routinely available to staff to safeguard mental health:

… psychological support…it shouldn’t be something that we access when there is a problem, it should be something where we go well every month on a Friday at this time I go and talk to someone about what I have seen. (Trainee, G9)

Participants’ lack of understanding about which services were being offered was raised by many, with participants often able to list services available, or where the staff support centre was based, but not how or when one might access them. This offers a key opportunity for collaboration between staff support services and the ED to develop clearer pathways or a clear role for a departmental well-being lead.

Peer support was consistently highlighted as a highly valued resource that should be considered part of supportive culture ‘gives you somebody else to share the load with, and not be that single voice’ (Trainee doctor, G9). However, limited physical space and time to engage in peer activities were cited as barriers:

Well yeah it would be lovely to sit down and chat with my peers, apart from the fact that 1) we’re constantly busy, 2) we don’t have anywhere where we can sit and have a confidential gas. (SAS doctor, G8)

Overall, accounts suggested that existing support was largely unfit for purpose, and where it was easy to access (such as peer support) and available, it was often incompatible with ED working practices and within a culture where seeking support was often stigmatised.

Some participants expressed that having a psychologist embedded within the department was highly valued as a resource, particularly the different levels of support dependent on need:

…(during the pandemic) we setup weekly drop-in sessions with the psychologist… and it was really great for a lot of people to be able to drop-in, and then that led on to having one to one for people who felt they needed that, and also within ED we had a psychologist come round to our supervision when we needed them. (ACP, G7)

Participants reflected that psychological input introduced in response to the impact of the COVID-19 pandemic was highly valued. While many were open to discussion about their mental health and well-being, for many, stigma still permeates the ED culture and is further compounded by poor understanding and communication of available resources. Appointment of well-being leads, more value placed on well-being (including informal peer support) and routine access to psychology are suggested as opportunities to make strides towards improved well-being.

This study identified four key themes describing the difficulties in the ED work place. Working culture, physical working environment, pathways to care and leadership represent the core workplace concerns within our sample. These issues were perceived to play an instrumental role in their ability to sustain good working practices, well-being and, importantly, their intention to leave. Participants identified key barriers and opportunities within their work contexts which resonate with existing research and policy and can be used to shape the future policy and research development. 22 , 2 5 These findings act as a basis for the development of specialty-specific targets for change that are aligned with the views and voices of those working in this working environment and also take account the barriers and opportunities faced in the fast-paced unique environment of the ED. For a full set of EM-specific recommendations to underpin change across all of these four areas, see the Psychologically Informed Practice and Policy (PIPP) recommendations ( https://rcem.ac.uk/workforce/psychologically-informed-practice-and-policy-pipp/ )

Several of our findings have been noted in previous studies, particularly the role of culture, environment and access to support. 22 Most of the research examining factors associated with working conditions and retention in EM are profession specific 3 6 18 19 and are not readily generalisable to other professional groups in the ED. However, our study included doctors, nurses and ACPs from which emerged common cross-cutting themes affecting all of these professions working in the ED, themes which are consistent with the broader literature 9 10 but specific to the EM working environment.

As reflected in the work by Darbyshire et al , 5 the nature of the problems described were systemic; the workplace challenges were interrelated and appeared reciprocal in influence, arguably maintaining one another. The cyclical nature itself proves a key barrier to change, which raises the question: which is the primary target to effect most change? Leadership has a pivotal influence across these themes and is unequivocally vital to workforce transformation; however, this is an area that has been largely neglected in EM, with very little research seeking to develop or evaluate leadership interventions in this environment. Indeed, there is an assumption that leadership naturally develops over time and is fully formed on appointment to the role. 23 However, leadership within the ED is particularly complex and demanding due to the range of competencies required (clinical, managerial and administrative) 23 and the high-pressured environment within which this role needs to be delivered. This warrants tailored training and support to fully succeed. In settings where the nature of the work is unpredictable and at times clinically critical, leadership is pivotal to patient outcomes and team functioning, 23 24 which are particularly crucial in the ED setting. Leadership has the potential to be a powerful driver in workforce transformation, cultural change 25 and team functioning within these highly skilled, professionally interdependent teams. 26 To fully harness the capacity of leaders as agents of change, those in leadership positions must be sufficiently skilled, 27 feel supported to act on important issues 27 and have time to do the job. Yet, participants in this study reported poor role definition, lack of training and absence of protected time to deliver the role. This was compounded by blurred lines of accountability that led to impotence to effect change.

Implications

The development of leadership in EM should now be a primary focus. There are clear steps that can be taken to begin to mobilise and maximise the pivotal influence of leadership in effecting change, across government, professional, organisational and individual levels.

On a public policy level, there has been a rapid growth of government level publications and resources to recognise the role of leadership as a conduit to better patient and team health. 28 However, recommended leadership training is often generic and never mandated. This is surprising given the clear links with patient safety and team functioning. 23 24 Leadership training in healthcare should be mandated by government bodies, not least due to links with patient safety. 29

Significant work has been undertaken by RCEM to integrate and embed mandatory leadership training into the training curriculum for EM trainees, without which they cannot progress. While this demonstrates forward thinking and some future-proofing for the medical profession, it cannot cease at this point, it must be supported with continuing professional development post-training. The relevant professional bodies provide access to good quality leadership training such as the RCEM EM Leaders Programme and the RCN Leadership Programme, however, this is largely online without protected time to access or support development. More work is needed to ensure leadership training is visible, supported as part of a workplan, and a priority area championed by all relevant professional bodies.

Further work is needed to ensure that leadership competencies are introduced at an early stage of training 23 so the necessary skills are embedded and cultivated on the pathway towards and within leadership roles, rather than ad hoc when necessity dictates. This falls to both training and professional bodies to work together to ensure that theory-driven leadership is a core part of the teaching curriculum, with mentorship and practical resources (such as role definition, a personal development plan, human resource support) to complement and facilitate the necessary continuing professional development throughout a clinical career. Responsibility then moves to the employing local NHS trusts to support the development of those individuals within leadership positions. It is at this level that ED clinical leads and their teams can harness their influence; local NHS trust policies are driven by guidance from government and professional bodies, however, they have the power to shape local policy and mandate change in view of the needs of a service. We summarise key recommendations to underpin change at a local NHS level in Box 1 .

Key leadership recommendations for local NHS trust level commissioning

Those in leadership positions should be supported to attend leadership training as part of their workplan, within their workplace hours. This would include top-up training and training assignments.

Support to engage with a leadership mentorship or coaching programme as part of their workplan, with a view to continuing professional leadership development and creating safe spaces to problem-solve, reflect and seek support.

Access to the consultation service within the local NHS staff support services.

Appointment of a designated ‘Wellbeing Lead’ with protected time and support to deliver the role.

Clear description of roles and responsibilities, to include protected time dedicated to undertaking additional responsibilities associated with a leadership role and a professional development plan that is reviewed annually.

Support to engage with the EM clinical lead network in order to access resources to support the delivery of the role and access peer support when necessary.

Clear lines of accountability at an NHS organisational level with identified pathways to escalate concerns.

EM, emergency medicine.

Appointment of well-being leads within the ED, as outlined in the RCEM PIPP recommendations 30 and other key documents, 22 is also a key step towards workplace transformation through leadership; however, it is imperative this role is also supported with protected time and development. A well-being lead with a clearly defined remit and role would play a pivotal gatekeeper role in encouraging attitudes towards well-being in the ED by delivering ‘warm handovers’ and well-being initiatives, such as informal check-ins, staff team activities (ie, safety huddles), and well-being surveys.

On an individual level, those in leadership positions are more likely to succeed by harnessing the influence and opportunity that accompanies the role, identifying and taking inventory of challenges and barriers, clarifying lines of accountability to drive forward change and advocating for the needs of their team. Two mechanisms by which leadership bears the greatest influence include leading and prioritising a continuous cycle of quality improvement (eg, autonomy over work patterns, access to rest spaces, patient flow, taking steps to address the diversity gap) and role modelling of positive professional behaviours. 26 The latter includes compassionate and inclusive attributes but also speaks to the necessity to meet basic needs: taking breaks, adhering to annual leave, destigmatising views on mental health and openness to learning and change. Those in leadership roles should be encouraged to engage with the leadership networks, broadened to encompass a platform or virtual environment (ie, repository) to share and access resources and be granted access to leadership consultation with the well-being team as and when necessary. Those in leadership positions should also be provided with clear referral processes and internal professional standards to help address any incivility, including bullying, harassment and issues of inclusion. This would help promote a culture of care and interprofessional valuing and respect, improving team cohesion.

Finally, it is imperative that lines of accountability are clear for those in a leadership position. While many NHS trusts differ in their management structures, each trust will have communication pathways to divisional and executive management leadership teams. In order to drive the full potential of leaders to action change through these mechanisms, it is fundamental that pathways from ‘shop floor’ to the chief executive are clear and opinions and concerns of ED leadership are welcomed.

Flow through the ED, staff ratios, pay and pension structures are of course prime targets for change and where the current high-profile focus lies. However, leadership is a key conduit to change and those with mandatory powers must now move to recognise this in order to unlock the full potential of this role.

Limitations and future directions

There are inherent limitations in the small size of some of the participant groups, and as such the views and opinions expressed cannot be considered transferable across their respective professions. While many prospective participants did not proceed to focus group meetings due to last minute requests to cover shifts, the participant pool was comfortably within the bounds of what is acceptable for a qualitative study.

Findings should be interpreted in light of the sample consisting mainly of white women, therefore the views of males and minority groups may not be fully represented. Doctors made up a higher proportion of the final sample; this may be a consequence of using RCEM communication channels as a primary recruitment method, which has more members registered as doctors than nurses. As not all professions working in ED were included (eg, physiotherapy, psychology) it is possible that additional themes or differences might have been missed.

The geographical spread reflects a broad reach; however, there was a preponderance towards the South West, where the research was conducted. While none of the interviewees were known to the research team, those in the South West may have been more exposed to recruitment drives through mutual connections.

The development and testing of leadership training and packages should be a priority for professional bodies and at organisational level. This should take account of the overlapping and competing competencies required of ED leadership, including managerial, administrative and clinical components and the high-pressured context within which these skills are required.

This study identified key themes in understanding workplace concerns in the ED, and their associated barriers and opportunities for change. Leadership in EM should now be a primary focus, with further investment and support to target the development of leadership skills early on in training and provide protected time to refine these leadership skills and qualities across the working lifetime. This will serve to harness the pivotal influence of leadership in EM, which, if properly supported, holds the potential to act as a conduit for change across all areas of focus.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by University of Bath Psychology Research Ethics Committee (22-039). The Health Research Authority toolkit confirmed further approval was not required. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The study authors would like to extend thanks to all who contributed to this project including participants and the clinical advisory group. The authors would also like to acknowledge and thank RCEM President (AB) and policy advisor (SMcI) who advised on the policy priorities of RCEM and wellbeing clinical leads (Dr Jo Poitier, Consultant Clinical Psychologist at Alder Hey Children's NHS Foundation Trust; Dr Olivia Donnelly, Consultant Clinical Psychologist at North Bristol NHS Trust) who were consulted on their respective areas of expertise. They also thank Rita De Nicola for help in preparing the manuscript.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3

Handling editor Caroline Leech

Twitter @drjodaniels

Contributors The original concept for the paper was developed by JD and shaped in consultation with EC and the RCEM President AB. JD was the primary contributor, guarantor and lead for the content and refinement of the paper. EJ gave expert methodological advice and contributed to the reporting and refinement of results. ER and JD performed the analysis, both contributing to the reporting of the results. ER prepared the manuscript for publication. EC gave expert advice on all aspects of the study from an Emergency Medicine standpoint and also contributed to the write-up of the paper. All authors contributed to the final version of the paper and approved for publication.

Funding This research has been carried out through funding from the UK Research and Innovation Policy (UKRI) Support Fund. The funder did not provide a grant number for this project, it is part of block 'UKRI Policy Support' funding from UKRI directly to Universities who distribute within their institutions. The funders had no role in considering the study design or in the collection, analysis or interpretation of data; the writing of the report or the decision to submit the article for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Published on 25.3.2024 in Vol 8 (2024)

Community Members’ Perceptions of a Resource-Rich Well-Being Website in California During the COVID-19 Pandemic: Qualitative Thematic Analysis

Authors of this article:

Original Paper

• MarySue V Heilemann 1 , PhD   ; 
• Jianchao Lai 2 , MSW, PhD   ; 
• Madonna P Cadiz 2 , MSW   ; 
• Jocelyn I Meza 3 , PhD   ; 
• Daniela Flores Romero 4 , BA   ; 
• Kenneth B Wells 4 , MPH, MD  

1 School of Nursing, University of California, Los Angeles, Los Angeles, CA, United States

2 Department of Social Welfare, Luskin School of Public Affairs, University of California, Los Angeles, Los Angeles, CA, United States

3 Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States

4 Research Center for Health Services and Society, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, United States

Corresponding Author:

MarySue V Heilemann, PhD

School of Nursing

University of California, Los Angeles

700 Tiverton Avenue

Los Angeles, CA, 90095-6919

United States

Phone: 1 310 206 4735

Fax:1 310 206 3241

Email: [email protected]

Background: To address needs for emotional well-being resources for Californians during the COVID-19 pandemic, the Together for Wellness/Juntos por Nuestro Bienestar (T4W/Juntos) website was developed in collaboration with multiple community partners across California, funded by the California Department of Health Care Services Behavioral Health Division federal emergency response.

Objective: This qualitative study was designed to explore and describe the perspectives of participants affiliated with California organizations on the T4W/Juntos website, understand their needs for web-based emotional health resources, and inform iterative website development.

Methods: After providing informed consent and reviewing the website, telephone interviews were conducted with 29 participants (n=21, 72% in English and n=8, 28% in Spanish) recruited by partnering community agencies (October 2021-February 2022). A 6-phase thematic analysis was conducted, enhanced using grounded theory techniques. The investigators wrote reflexive memos and performed line-by-line coding of 12 transcripts. Comparative analyses led to the identification of 15 overarching codes. The ATLAS.ti Web software (ATLAS.ti Scientific Software Development GmbH) was used to mark all 29 transcripts using these codes. After examining the data grouped by codes, comparative analyses led to the identification of main themes, each with a central organizing concept.

Results: Four main themes were identified: (1) having to change my coping due to the pandemic, (2) confronting a context of shifting perceptions of mental health stigma among diverse groups, (3) “Feels like home”—experiencing a sense of inclusivity and belonging in T4W/Juntos, and (4) “It’s a one-stop-shop”—judging T4W/Juntos to be a desirable and useful website. Overall, the T4W/Juntos website communicated support and community to this sample during the pandemic. Participants shared suggestions for website improvement, including adding a back button and a drop-down menu to improve functionality as well as resources tailored to the needs of groups such as older adults; adolescents; the lesbian, gay, bisexual, transgender, and queer community; police officers; and veterans.

Conclusions: The qualitative findings from telephone interviews with this sample of community members and service providers in California suggest that, during the COVID-19 pandemic, the T4W/Juntos website was well received as a useful, accessible tool, with some concerns noted such as language sometimes being too “professional” or “clinical.” The look, feel, and content of the website were described as welcoming due to pictures, animations, and videos that showcased resources in a personal, colorful, and inviting way. Furthermore, the content was perceived as lacking the stigma typically attached to mental health, reflecting the commitment of the T4W/Juntos team. Unique features and diverse resources, including multiple languages, made the T4W/Juntos website a valuable resource, potentially informing dissemination. Future efforts to develop mental health websites should consider engaging a diverse sample of potential users to understand how to tailor messages to specific communities and help reduce stigma.

Introduction

The COVID-19 pandemic brought unexpected difficulties related to activities of daily living for people worldwide. In addition to affecting physical health, COVID-19 also threatened emotional health. Diverse groups were impacted, including people of different ages [ 1 - 4 ], gender identities [ 5 - 9 ], races and ethnicities [ 10 , 11 ], and geographic locations [ 12 - 15 ]. Those who faced financial concerns [ 16 , 17 ] or lost their jobs [ 8 , 18 ] and those caring for children at home [ 5 ] struggled with a variety of additional pressures. For workers [ 19 , 20 ], including health care workers [ 21 , 22 ] and community-based service providers [ 23 - 26 ] in the United States, attempts to serve clients or patients were confounded by pandemic-related challenges such as concerns about infection, reductions in staffing, and transitions to remote care, making their jobs even more complex and challenging.

As stay-at-home orders proliferated, people began to look for ways to strengthen their ability to cope emotionally during the pandemic. Many turned to media outlets such as television, radio, and social media for news and information [ 27 ]. Unfortunately, the news often led to increased fear and worries about the COVID-19 virus, illness, death, loss of jobs, economic concerns, and more. Many used Twitter to read the views of others and express their own negative sentiments about the pandemic [ 28 ]. Social media use contributed to experiences of stress [ 27 ], whereas engagement in self-care activities such as being able to access and use personal support resources helped protect against mental health distress [ 29 ]. Consequently, researchers [ 27 , 30 ] called for creative developments to connect individuals with social support and mental health services. To overcome stigma and other barriers, researchers and developers turned to web-based digital tools to make resources for coping and information on emotional well-being more accessible.

In this context, the Together for Wellness/Juntos por Nuestro Bienestar (T4W/Juntos) website was developed in collaboration with multiple community partners across California, funded by the California Department of Health Care Services Behavioral Health Division federal emergency response, to directly address needs for free web-based emotional well-being resources for Californians during the pandemic. The purpose of this paper is to report the findings of a qualitative study on the perspectives of a sample of participants affiliated with California organizations who engaged with the T4W/Juntos website.

Development of the T4W/Juntos Website

The T4W/Juntos website was developed as part of the Federal Emergency Management Agency and Substance Abuse and Mental Health Services Administration crisis counseling contract with California. The goals for T4W/Juntos were developed with a multidisciplinary team of researchers, clinicians, digital resource development experts, and staff from community-based agencies in California. Goals centered on creating inclusive and accessible resources that would provide evidence-informed and evidence-based information to Californians to ease the stress experienced during the pandemic [ 31 ].

Meetings were held via Zoom (Zoom Video Communications) with the large collaborative team (4 to 18 members per meeting) to maximize input from community members. The community and study team members made decisions collaboratively about which types of resources to include on the website. The priority was to feature resources that facilitated learning about COVID-19 or offered ways to address anxiety and stress (eg, web-based meditations, breathing exercises, and direct links to warmlines and hotlines), strengthen resilience, cope with grief due to a recent loss, connect with other people (such as through web-based support groups), or support social justice (eg, antiracism and reducing hate crime). Resources included links to web-based toolkits, websites, videos, web-based applications, articles, and downloadable pamphlets. Some resources were available in multiple (up to 10) languages. Community partners’ emphasis on using neutral, nonclinical language to increase comprehension and relatability and reduce stigma led to a monitoring of the length and complexity of messaging for the website. In response to the community partner prioritization of videos to engage users, the team created videos of community members speaking about the website’s purpose and features in English and Spanish [ 31 ].

A previous paper related to T4W/Juntos described the process of website development [ 31 ]. A second paper described the results of an analysis of quantitative data from an electronically administered web-based survey that were collected at 2 time points (approximately 6 wk apart) from English- and Spanish-speaking adult participants. Of the 366 eligible participants, 315 (86.1%) completed the baseline survey and 193 (61.3%) completed the follow-up survey, with baseline results showing substantial diversity in gender, gender identity, and race and ethnicity and 32.7% (103/315) having moderate depression or anxiety (2-item Patient Health Questionnaire or 2-item Generalized Anxiety Disorder score of ≥3) [ 32 , 33 ]. Significant predictors of baseline website engagement were Hispanic versus other race or ethnicity and COVID-19–related behavior changes. The use of the T4W/Juntos website during the month before the follow-up survey was significantly associated with a pretest-posttest reduction in depression (2-item Patient Health Questionnaire score), and greater website engagement at baseline predicted reduced hotline use before follow-up [ 34 ]. An analysis of short qualitative answers that 199 (63.2%) out of 315 participants typed into textboxes in response to open-ended questions in the previously described web-based survey led to insights into safety concerns and fears during the pandemic and perceived benefits from and suggestions for improving the website [ 35 ].

Research Aims

With the goal of supplementing the quantitative results, the aim of this qualitative study was to describe the perspectives of a diverse subset of participants associated with various California community organizations who completed the baseline surveys regarding their experiences with the T4W/Juntos website. We also focused on participants’ needs for website resources that could support emotional well-being for themselves, their families, their clients, or their community. Finally, we sought insight to inform iterative website development in the future.

Recruitment

The larger sample described previously was recruited during the pandemic through invitations that were sent primarily by email, while stay-at-home orders were in effect, from 11 community partner agencies throughout the state of California to their affiliated community members with information about the website, its purpose, and the research study. Each of the 315 participants who consented and completed the baseline survey was given the option to indicate their interest in participating in a potential future telephone interview by clicking a box at the end of the survey. In total, 73.9% (233/315) of the participants clicked on the box to indicate their interest in being interviewed. Inclusion criteria were being aged ≥18 years, having access to the internet, having already completed the baseline web-based survey in English or Spanish, and agreeing to provide contact information. Using convenience sampling, participants who spoke English or Spanish were contacted via telephone by research staff approximately 2 weeks after completion of the baseline survey, starting with those who were the first to finish the survey, to offer an interview, confirm availability, and set a date and time for the interview. After 15 interviews were conducted, purposive sampling was used to maximize diversity in race and ethnicity, gender, and age. The final sample comprised 29 participants. The interviews (in English or Spanish) were conducted between October 2021 and February 2022.

Ethical Considerations

This study was reviewed and approved by the University of California, Los Angeles, Institutional Review Board of UCLA’s Human Research Protection Program (20-002163-AM-00008). After reading the web-based consent document, each participant clicked to give consent at the time of enrollment in the larger survey study, which included consent to a future potential interview. Our team only contacted individuals who agreed to be contacted for interviews using the contact information they provided. Participants reconfirmed their approval to participate and be audio recorded at the time of the interview. To protect the privacy and confidentiality of participants, the list of the names of the participants and their assigned codes was kept in a password-protected file available only to the principal investigator and project director. Their confidential contact and personal information were kept separate from all other data. Any potentially identifying information was deidentified on the transcriptions of audio-recorded interviews, including any names or descriptors that could possibly identify a participant; all names were changed to code numbers that were used instead of names by the researchers during data analysis. Participants received a US $25 e-gift card after completing the interview.

Data Collection

Demographic data were retrieved from the baseline survey for each of the 29 interview participants. A semistructured interview guide in English and Spanish that was developed by a multidisciplinary team was subsequently used by 2 research team members to conduct all interviews via telephone. Interview questions were designed to explore participants’ perceptions of any aspect of the T4W/Juntos website; gain insight into participants’ needs for support in relation to the resources available via the website for themselves and their families, clients, or communities; and obtain guidance on further development of the website. Audio recordings of interviews in Spanish were professionally translated into English, and all interviews were professionally transcribed verbatim and checked for accuracy. As already noted, identifiers were removed, and code numbers were used instead of names to label transcripts and organize the data.

Data Analysis

Demographic data were analyzed for frequencies using Stata/MP (version 17; StataCorp LLC) [ 36 ] for the sample of 29 participants. For the thematic analysis of the 29 transcripts, the study team was guided by a modification of the 6-phase process outlined by Braun and Clarke [ 37 , 38 ]. First, the study team familiarized themselves with the data in all transcripts. Second, the team engaged in initial coding using techniques from grounded theory methodology to enrich our approach [ 39 ]. Thus, most codes were developed using the gerund form of verbs, known as process codes, to heighten our focus on the actions taken by participants, as shown in the data [ 39 , 40 ]. To create process codes, coders used heuristic questions to ask What is happening here? and What are they doing here? This allowed coders to get closer to the participants’ point of view while reducing the tendency to prematurely project their own interpretations onto the data [ 39 ]. In the third and fourth phases, coders scrutinized the first 12 coded transcripts to identify the most frequently occurring and significant codes and, through discussion and debate, identified a total of 15 overarching codes. Then, the data from all 29 transcripts were imported into ATLAS.ti Web (version 22.1.5; ATLAS.ti Scientific Software Development GmbH) [ 41 ] and coded based on the 15 overarching codes. In the fifth phase of analysis, data reports were created using ATLAS.ti Web [ 41 ] based on each of the 15 overarching codes. These were exported to Microsoft Excel (Microsoft Corp) so that the data in each code group could be further examined. Using constant comparison, we sifted, sorted, combined, and collapsed the data in the 15 groupings to form 4 themes, each with a central organizing concept that provided a clear definition of the theme [ 38 ]. We continued to compare data with data to develop the properties for each of the 4 themes. Finally, in the sixth phase, each theme was named, and its properties were refined. With a focus on the research aims, the research team then produced a written report interpreting the meaning of each theme.

The overall process of data collection and analysis was influenced by the team’s commitment to social justice and to the goal of understanding the data of each participant while considering their context. Thus, at various points during the research process, each member of the 5-member analysis team engaged in dialogue together and in individual writing of reflexive memos to name any judgments (positive and negative) or concerns that were felt while engaged in the research process, with the goal of reducing the influence of bias on the collection and interpretation of data [ 38 , 39 ].

Participant Characteristics and Sample Demographics

The demographics of our sample of 29 participants are presented in Table 1 . Of the 29 participants, 16 (55%) voluntarily shared that they were employed in peer support, hospice care, or health care sales or at a community agency doing health-related work. A total of 72% (21/29) of the interviews were conducted in English, and 28% (8/29) were conducted in Spanish. The duration of the Spanish interviews ranged from 22 to 72 (mean 32, SD 16.61) minutes, and that of the English interviews ranged from 15 to 85 (mean 38, SD 15.49) minutes.

a GED: General Educational Development.

b JD: Juris Doctor.

c PhD: Doctor of Philosophy.

d MD: Medical Doctor.

e GAD-2: 2-item Generalized Anxiety Disorder scale. A GAD-2 score of 3 is the recommended cutoff point for identifying possible cases of generalized anxiety disorder.

f PHQ-2: Patient Health Questionnaire–2. A PHQ-2 score of 3 is the recommended cutoff point for identifying possible cases of depression.

Qualitative Thematic Analysis Results

Thematic analysis of the qualitative data led to the identification of four themes: (1) having to change my coping due to the pandemic, (2) confronting shifting perceptions of diverse groups on mental health stigma, (3) “Feels like home”—experiencing a sense of inclusivity and belonging in T4W/Juntos, and (4) “It’s a one-stop-shop”—judging T4W/Juntos to be a desirable and useful website.

Theme 1: Having to Change My Coping Due to the Pandemic

Participants shared that, during the pandemic, they had to change the way in which they coped with daily life stressors. This was represented by 5 properties: increased use of technology to connect with others on the internet, intentionally identifying self-care tips and techniques, coping by helping other people, relying on in-home socialization, and drawing on spiritually oriented coping ( Figure 1 ).

Increased Use of Technology to Connect

Participants found that their use of technology increased during the pandemic, and they had to learn to accept their increased reliance on the internet to be connected in various ways. For example, they used technology to connect with information on a variety of topics and be able to accomplish work for their jobs. They used technology to connect with other people for social reasons; this included using Zoom to connect with friends, family, and their faith communities. They also joined web-based support groups and community groups where they could engage in dialogue with others. One participant described how they felt more “comfortable” having conversations on the internet:

I think I’ve become more dependent on the internet. I also found that not having to deal with people face to face most of the time makes me feel more comfortable. Honestly, it’s easier for me to have a chat on the computer than in real life.

Participants said that they relied on technology to meet their therapeutic needs more than before the pandemic. They found web-based resources to be “easier to forward” and share with others. They described resources on the internet to be “more documented” and viewable. They reported how they learned to click links to use web-based resources, which, for many, was a new behavior.

Intentionally Identifying Self-Care Tips and Techniques

Participants helped themselves by seeking out practical approaches, including self-care tips and techniques. This meant that they were using technology to meet their therapeutic needs, something they had not necessarily done before. They used warmlines, crisis lines, and teletherapy to meet their needs. They learned about meditation and breathing exercises, which they found especially desirable because the stress of the pandemic was experienced as personally difficult. However, participants found it challenging to find “accurate” resources. This put them on a quest to find “reliable” web-based resources they could use to reduce stress. Participants explained that they continued searching on the internet even if their immediate need was resolved because they wanted to have resources ready just in case they needed them in the future. In addition, some used art to self-soothe during the pandemic, whereas others sought “self-improvement” strategies.

Coping by Helping Other People

When asked to say more about how they handled their own stressful experiences during the pandemic, participants repeatedly spoke of helping other people in their personal lives and on the job. It seemed that helping other people was itself a strategy they used to cope. A participant spoke of others who felt “invisible” and as if other “people don’t respect them” and how difficult it was for them because “they’ve lost their purpose because they can’t go to work or can’t do the job they used to” do. They noted how important it was to share with others that “there’s hope...that there are people out there trying to make a difference, trying to help, trying to listen . ” Participants’ efforts were extended to various types of people, including family members, friends, and coworkers, and those who self-identified as health workers reported that they helped both individual clients and families. Experiences of helping others stood out to them; they felt a sense of “satisfaction” from their helping work. One participant said the following:

And the reason I liked it is—and the reason is the feedback, the participation and everything, is actually one of the ways that it makes me feel like not only I’m sharing a resource, but I’m sharing a resource that I know is good—I hate sharing things that I know are not good—and I wanted to like what I’m doing here.

Relying on in-Home Socialization

Finding others to fulfill social needs and desires was mainly limited to whoever was in the home. Participants relied on their family members or roommates for dialogue, socialization, and friendship during the pandemic. However, pets also played an important role as they provided “joy, stress relief, and companionship.” Many described the importance of going on walks with their dogs as it brought about daily exercise and also could open up dialogue with neighbors, which was highly valued at this time of social isolation. One participant shared how meaningful it was to live with their 2 dogs and son. They said the following:

If I had to live by myself, I don’t know how I would get through this. I really mean it. I’m being perfectly honest.

Drawing on a Spiritually Oriented Approach to Cope

With few options for socialization, participants shared that they turned to spiritually oriented routes for coping. They turned to “God” and relied on their faith to keep them going. One participant stated that they could not imagine how anyone could “get through” the pandemic “without God.” For some, listening to religious radio programs filled a crucial need in their daily lives during the pandemic. Others reported using prayer or reading scriptures. A participant described how religion provided “guidance” on daily life:

[Faith in God] helps me first and foremost, that helps me not to have fear. I think that a lot of people now are controlled by fear. And so that helps me, y’know; that strengthens me and gives peace to my heart. I feel secure with my health habits, with my diet, well, because I’m connected to God, and because I get my health practices from the Bible. So, I feel that all around, my mental, my physical, my emotional, all my wellbeing, I dedicate that to God for his blessing. And so, y’know, I think that’s the biggest part of it.

Theme 2: Confronting a Context of Shifting Perceptions of Mental Health Stigma Among Diverse Groups

When discussing T4W/Juntos and its purpose in helping with emotional well-being, participants were concerned about the context during the pandemic related to public views on mental health. They raised the issue of shifting views on mental health stigma within different communities and how it impacts people. They reported how stigma differs based on age or generation, race, or ethnicity and how the T4W/Juntos website would be received within a context of overarching stigma in various communities. They also suggested ways to reduce stigma. This is reflected in 3 properties ( Figure 2 ).

Experiences With Mental Health Stigma Vary Across Generations

Mental health stigma was perceived as an issue for all generations. Participants explained that stigma itself was the backdrop that set the stage for how the T4W/Juntos website would or would not be received. This could have an impact on whether community members would embrace the website.

Participants explained that there was a difference in how older and younger generations experienced mental health stigma. Older adults who grew up during a time when mental illness was considered “bad” and “dangerous” were described as rejecting the possibility of seeking treatment for their mental health problems. They described a dual process in which the older generation felt too stigmatized to seek mental health support, but at the same time, they perpetuated the stigma surrounding mental health within their communities. Older adults were perceived as having negative beliefs about mental health concerns, sometimes viewing them as a personal “weakness” or a result of lack of religious practice (eg, “devil’s work”) rather than a psychological condition. They were seen as discouraging other people from reaching out for such treatment, help, or resources. One participant shared how older people spoke about mental health treatment:

Looking for help, like, with a therapist...they shouldn’t be sharing their opinions. That’s what I’ve heard, “Why would you see a therapist, if they’re not God?”...that’s what I’ve heard. Like, “Why should you go around telling them your problems?”

Isolation was perceived as a major contributor to older adults’ mental health issues, especially for those who lived in residential settings. This raised concerns during the pandemic because participants reported that resources tailored to older adults living in such settings were not available, especially for those who were “losing loved ones” due to COVID-19. Participants worried about older adults “not being able to see their families” during the COVID-19 pandemic and how they would cope as stigma could be a barrier to obtaining the help they needed.

Younger generations were perceived as having grown up with greater awareness of mental health and, therefore, were affected by stigma in a different way. They were thought to be “more empowered” to openly discuss mental health issues. In particular, participants noted a more welcoming conversation about mental health on social media among younger generations, including during the pandemic. The differences between generations were described by one participant as follows:

I feel like that [the older generation] was like, “We’re not telling anyone our business.” And “This is family business, keep it to yourself.” Whereas like the mid-30s and maybe late 20s, they’re like, “You know what? Let’s talk to somebody, let’s get help, let’s like—We’re not going to suffer in silence.”

Stigma Is Experienced in Unique Ways in Different Racial and Ethnic Communities

Mental health stigma was perceived as experienced variably based on race and ethnicity, which had implications for the context of the pandemic. Participants shared examples of how Black, Latine, Asian, and other minoritized communities faced more mental health stigma in general compared with other communities due to a combination of societal and cultural factors. One Latine participant said the following:

Because I grew up culturally Latino, so, there is a huge stigma around mental health where you couldn’t just say, “Oh, I’m feeling anxious,” or “I’m feeling a little depressed.”

Another participant said that, in their Asian American community, mental health was “heavily stigmatized” and people “don’t tend to like to ask for help.”

The words participants heard being used to stigmatize mental health or people with emotional challenges, such as “crazy” and “weak,” were similar across racial and ethnic minoritized groups. While all people were seen as actively avoiding being labeled as having a mental health issue, those from minoritized communities were perceived as especially cautious because such negative mental health labels could be used as “leverage” against them. Therefore, a winning strategy used by community-based health workers in our sample was to “give them the information without having to use that word [mental health].” Others described avoiding being labeled by addressing physical rather than psychological symptoms. This provided a perspective for addressing mental health by taking care of physical health. One participant explained this as follows:

I think if the focus is not so much on mental illness but mental wellness, mental health, and that connection between the mind and the body, and that it’s all important, and addresses the person as a whole.

Recommending Effective Ways to Combat Mental Health Stigma

Participants recommended providing accessible educational resources on mental health to the public. One suggested that stigma could be reduced if mental health was discussed in the same way in which health providers engaged in “teaching someone how cancer works . ” Other suggestions included the strategy of individuals openly sharing their personal stories of mental health struggles to dismantle stigma and encourage help-seeking behaviors. One participant explained that we need “to recognize that we all have trauma, and to set the example ourselves.”

In terms of sharing the T4W/Juntos website and other resources, participants suggested that, rather than just directing people where to go, we should share our experiences honestly. One participant recommended saying things such as “This happened to me and I went here to get help. That helped me a lot because I did this” or “I also went through the same situation.”

Participants encouraged efforts to create safe and supportive spaces, especially for marginalized individuals who may face additional stressors, such as “LGBTQAI+ students,” adolescents, and older adults. Participants reported that they would feel more comfortable recommending a warmline where individuals could connect with trained volunteers, therapists, or peers who could listen and provide support rather than “an Excel [sheet] of resources.” While participants endorsed efforts such as the T4W/Juntos website, they recommended investing in “more intersectional conversations” where leaders “that really represent a community” could share things such as “this is me, and this is what I’m going through. This is what I do to deal with it. This is where I go for help . ” This approach was perceived to increase “comfort” and “acceptance,” unlike “faceless” things, because it could reduce stigma and negative perceptions of help seeking.

Theme 3 “Feels Like Home”: Experiencing a Sense of Inclusivity and Belonging in T4W/Juntos

Participants provided robust reports of feeling welcomed and included when visiting the T4W/Juntos website. This sentiment is reflected in 4 properties: feeling included due to welcoming tone and visuals; feeling included due to the substantial, diverse, and quality resources on T4W/Juntos; many languages making T4W/Juntos “more accessible”; and recommending ways to increase inclusivity on T4W/Juntos ( Figure 3 ).

Feeling Included Due to Welcoming Tone and Diverse Visuals

The images and overall tone of T4W/Juntos gave participants a sense of belonging when using the website. They described the site’s imagery as “cheerful,” “friendly,” “bright,” “happy,” “fun,” “calming,” and “light and airy.” One participant explained the following:

...the color scheme and the font, it’s just very inviting and not intimidating. ‘Cause I think finding like health resources or mental health services or any of these topics, they’re very heavy. So, having a page that’s bright and makes it simple and has the cute little icon next to each topic makes it a little more digestible.

Other participants focused on T4W/Juntos’ esthetics. One participant indicated that it was “well-balanced” with “just enough seriousness.” Another participant highlighted the site’s “high production value” in terms of visual and auditory content. The quality of the content was valued, including the mix of both cartoon and real images, the “scenery” in graphics, and the quality of the spoken Spanish in videos.

Participants noted the importance of diversity in T4W/Juntos’ images in helping them feel included. They appreciated seeing the “authentic representation” of various ages, gender identities, abilities, sexualities, and races and ethnicities, among other characteristics, in “these beautiful faces” they saw on the website. Participants indicated that T4W/Juntos “feels like home” because the images were specifically representative of California’s population. One participant stated the following:

I feel like it covered populations and community members across California who would be possibly using the website. And also, just showing that diversity. So, I think that creates a welcoming environment as well if people can see themselves represented in some capacity on the website, especially on the front page. 

Unlike other mental health websites that participants described as judgmental or exclusionary, participants felt that T4W/Juntos was not overly “clinical” or “bashing you with some mental illness stigma.” Furthermore, T4W/Juntos’ diverse representation was different from that of other sites where “only one type of person” was represented, which meant that visitors to T4W/Juntos would not “feel like they’re an outsider,” as one participant succinctly explained:

...if there’s nobody on the website that I can identify with, maybe it doesn’t...doesn’t apply to me kind of thing. There’s plenty of opportunity, I think, for anyone to feel like they fit [on T4W /Juntos ].

Feeling Included Due to the Substantial, Diverse, and Quality Resources on T4W/Juntos

The quality, quantity, and variety of resources present on the T4W/Juntos site greatly contributed to participants feeling welcome and included. Some expressed appreciation in broad strokes, noting that there were resources for “every ethnicity” and “different ages” and that the T4W/Juntos team “took many different things into account.” Other participants valued the inclusion of resources for specific groups, such as African American individuals, American Indian and Alaska Native individuals, the “LGBTQIA2+ community,” parents, children, and people living with disabilities. Knowing that the resources were intentionally selected for T4W/Juntos mattered. One participant noted that “...the thought put into making [T4W/Juntos] usable or worthwhile to a number of different communities was made and paid attention to . ” Another interviewee found it “refreshing to realize that the [T4W/Juntos] project...had equity kinda built from the top up.” One participant encapsulated this by saying the following:

It just felt like I was coming to a buffet, a big place to finally like heal, y’know? It was like “Oh, I don’t even have to eat this. There’s like a little bit of that, more of that.” And there’s really—the variety of choices, and the way that it was put, it was very inviting. Also, it was very welcoming, and I left feeling satisfied, but also, I left—like there was stuff that I could share with people. And I did.

“This Is Kinda Cool”: Many Languages Make T4W/Juntos “More Accessible”

Linguistic accessibility was another important aspect of the T4W/Juntos site that made participants feel included. Because of California’s multicultural population, participants believed that T4W/Juntos needed to be offered in multiple languages, especially Spanish and Vietnamese, for it to be considered “culturally appropriate” and widely accessible. One participant stated that “I love that the website already has a few options in different languages...Just thinking about the different audiences [will] make it that much more accessible . ” The creation and availability of a Spanish translation contributed to another participant’s feelings of inclusion:

So, it made me welcome and then it also made me understand more, like I said, because it was in Spanish and English.

Others noted the need for content in more languages; some specified a desire for content in Vietnamese, Indigenous languages (broadly), and Mixtec due to the large population of Mixtec-speaking migrant workers in California.

In addition to being offered in multiple languages, many participants lauded the site for being written in “everyday” and “plain” language that was “easy to understand” and “basic.” Another participant expressed their thought process upon first hearing about T4W/Juntos:

I was like, “This is kinda cool. Let’s check this out.” It wasn’t something like, “Oh, wait, this is way beyond my expertise, or this is something I don’t fully understand.”

Although many found T4W/Juntos easy to understand, a few respondents said that the language was inaccessible or overly professional. For instance, one person commented that the “writing [in T4W/Juntos] was too academic,” and therefore, it “wasn’t an easy read. It was like reading a textbook or a law book . ” Others noted that terms such as “resilience” or “anxiety” made the site feel overly clinical and not intended for the average user.

There was concern that some users with low computer literacy may not be able to use the site. For example, one participant cautioned that some Spanish speakers may not necessarily know the word for “link” in English or Spanish ( enlace ). Furthermore, several participants who worked with immigrant communities indicated that many in these groups cannot read or write in Spanish or English, which precludes them from making use of the T4W/Juntos site.

Recommending Ways to Increase Inclusivity on T4W/Juntos

Some participants advocated for changes or additions that would further widen the net of inclusivity. For example, participants suggested adding information on mental health symptoms and treatment options; trauma and its potential effects; support for basic needs such as housing, rental assistance, and financial support; information about civic engagement (eg, how to register to vote and contacting local officials); and recreational activities such as art classes and book clubs.

Although many participants found the wide breadth of representation on T4W/Juntos to be quite impressive, some wanted even more diverse visual representation. Some perceived a few groups to be conspicuously absent on the site, such as the lack of representation of older adults. One participant stated the following:

...older adults have really had a hard time with isolation and access and I don’t really see older adults represented, at all—at all, at all, at all, like, at all, in this whole thing. Not just the graphics, but the people you’ve chosen to be on the little videos, the images, the content, there’s nothing about older adults, that I found.

Another participant specified the need for more youth representation:

...make sure that we have as many opportunities for youth to be able to see themselves talking, working with each other, reaching out, but really knowing that we’re all here for them. And I think that was one of the things...that I would really suggest, is that opportunity.

Other suggestions included adding more representation of men of color, including “African American men, Latino men and Armenian men,” as well as police officers and military veterans as these groups tend to avoid seeking treatment due to stigma against mental health. Others suggested that representation be enhanced with more images or voices of people with disabilities; individuals from the lesbian, gay, bisexual, transgender, and queer community; and actual community members.

Theme 4 “It’s a One-Stop-Shop”: Judging T4W/Juntos to Be a Desirable and Useful Website

Participants judged the website as a hub that brought many things together in one place, making it a “one-stop-shop.” For this reason, most described it as a desirable website. Their perceptions reflect 4 main ways in which they experienced the website: perceiving T4W/Juntos as trustworthy, being equipped with a “first step” tool to use and share, finding navigation to be simple and clear, and easily accessing useful information ( Figure 4 ).

Perceiving T4W/Juntos as Trustworthy

Participants valued the website due to the reliable information on it that had been curated from credible sources, which was able to combat misinformation. One participant reported the following:

I feel like it’s done by UCLA, UC Davis, all names that I really trust...it’s a name that people recognize and that you can trust. So, I have no reservations whatsoever about this website...I know that when I scroll all the way at the end with the different sponsors or collaborations made it legit.

Seeing the real faces and hearing the real voices of community members in the videos plus the logos of respected agencies on the website enhanced the sense that it was “legitimate.” Trustworthy information was especially desirable to combat the misinformation they reported hearing about in many communities.

Being Equipped With a “First Step” Tool to Use and Share

Participants felt equipped because the website gave them tools necessary not just for learning about resources but also for sharing with clients, friends, and family members. One participant noted how T4W/Juntos was something they had been searching for but had not found:

And it just was primarily what it felt like, a resource portal. And so, it felt like the right door to go get help, rather than the wrong door. So that’s a good way of putting it. It felt like I had finally opened the right door that I’d been looking for.

As a tool, T4W/Juntos was judged as helpful because it allowed participants to gain access to needed mental health resources during the pandemic, with options so that clients could start “where they want to” with the goal of receiving help. They liked having access to specialized information that addressed a wide range of topics, such as resources on grief for pregnant women or up-to-date COVID-19 information. They found it desirable because it was designed for the “average person,” so it was useful as a “first step” even for those with no previous knowledge about mental health resources.

Navigating Is Simple and Clear

Participants perceived T4W/Juntos to have appealing features such as inviting colors and fonts, which made the content “more digestible.” The technology functioned smoothly, including the hyperlinks and videos. One participant said the following:

And it’s really easy to go on there, navigate, and look for information. And it’s also a good way to empower the clients I work with, so they can go and do their own research about any resources they may need in regards to mental health.

The process of searching for information was clear even when working with groups lacking digital literacy, which they noted was required for some websites. One participant noted the following:

Honestly, this is one of the pages that I remember my mom and I—even though we were dazed and emotionally exhausted—we were able to understand and get the information because it was all so simple. That was the only thing I can tell you. Despite everything that happened, we saw that if we were going from one place to another looking for information or trying to analyze, sometimes it was very elaborate. We needed something like they say in English, “short and sweet,” not fancy or too negative. Something within the positive and informative things but without being research papers that we had to be reviewing and analyzing, because we didn’t have the capacity to do that. We needed simple and easy to understand information.

Easily Accessing Useful Information

The ease of using T4W/Juntos to access information was a valued feature. Participants found the website to be a user-friendly “one-stop-shop,” a place where they could find plenty of useful resources to choose from all at once. They preferred this to having to type specific topic words into a search engine to find needed resources individually. Some especially endorsed the feature that allowed them to receive immediate active help through a direct crisis number, whereas others favored the option to receive informational help by downloading materials to read. While participants overall considered T4W/Juntos to be easy to use, some suggested making the pages more “scroll-friendly...like Instagram,” and another participant suggested adding an “emergency exit” button so that users could quickly switch to a different site if needed for safety reasons.

Principal Findings

The qualitative findings from telephone interviews as a complement to quantitative surveys suggest that, during the COVID-19 pandemic, the T4W/Juntos website was well received by both community health service providers and community members in the interview sample as a useful, accessible tool, with some concerns noted such as language sometimes being too “professional.” Our findings further suggest that the pandemic catalyzed significant changes in the way people coped, which fueled a shift to digital solutions when other options were suddenly off-limits due to stay-at-home orders. Our participants tended to their own emotional well-being personally and assisted their friends and families, and some also engaged in trying to help clients or patients as well. Their pivot to reliance on technology during the pandemic ranged from finding new techniques for soothing stress to connecting with others in a meaningful way via the internet to meet socialization and support needs. Roommates were crucial for socializing, as was also suggested by Shigeto et al [ 42 ], because social distancing limited social contact. Similar to other studies [ 43 - 45 ], our participants found pets to provide companionship and effective ways to cope with the isolation of stay-at-home orders. Notably, as other researchers found, being able to help other people during the pandemic in and of itself gave participants a mood boost [ 43 , 46 ]; this made the T4W/Juntos website even more valuable because participants could share it with others.

Similar to the findings of other studies [ 47 - 49 ], our participants shared that mental health stigma and taboo attitudes had often thwarted attempts to access needed mental health care, and this was especially the case for those from ethno-racially minoritized communities and older adults. However, participants did not perceive the T4W/Juntos site as invoking stigma, judgment, or condescension. They were particularly cognizant of the efforts of the development team to create a site that was neither intimidating nor shaming. They found it to be a digital space that successfully communicated that someone was out there trying to help others in a world that was otherwise shut down due to COVID-19. The collaborative approach to the development of the website may have been why the written text and verbal communication in the site’s videos were described as an example of a positive way to talk about mental health.

To combat stigma through a website, input from potential users, such as our participants, is crucial for design enhancement. As already noted, during the development of T4W/Juntos, input from various members of diverse California communities addressed the making of the website, including the goal of reducing stigma related to mental health [ 31 ]. Efforts to reduce stigma require sensitivity to the language used; with T4W/Juntos, we intentionally used neutral, nonclinical language so that experiences such as stress, anxiety, depression, and grief were addressed as normal aspects of life that many of us deal with [ 31 ]. Our participants recommended featuring pictures, animations, and videos to showcase resources in a personal way that is colorful and inviting without stigma and that reflects the commitment of the T4W/Juntos team. In addition, several short videos in English and Spanish were created to introduce each section of the T4W/Juntos website with the goal of making users feel more comfortable with the topics; volunteers from diverse California communities served as relatable actors who were filmed during the pandemic via Zoom in their homes. The diverse representation is likely why participants said that the website felt comfortable. We also included links to active warmlines and hotlines so communication with an actual human being was possible through telephone and texting [ 31 , 34 , 35 ]. However, consistent attention to making these links convenient and prominent on the website is needed over time to maintain a steady focus on reducing stigma. Additional efforts could be made in the future to link to more and different venues available on the internet where diverse community leaders talk about their own emotional health concerns or share what they have found helpful. In addition to the immediate sense of welcome, participants found the extent and variety of the content on T4W/Juntos (ie, the plentiful links to various resources) to communicate supply rather than unmet demand. The sense of options for resources was understood as high accessibility, which somehow also reduced stigma. Participants seemed to relish what they perceived to be a bounty of ready resource links, including content in multiple languages. This, during the pandemic, was appreciated because it was a time when avenues for the typical sources of useful or desirable material were severely reduced.

The sense of belonging reported by participants suggests the profound impact of a culturally competent design in enhancing user engagement with and experience on the website. For example, the colorful look of T4W/Juntos was developed in collaboration with community members [ 31 ]. The decisions to give T4W/Juntos an upbeat feel, feature relatable people from diverse California communities in the videos, and provide options in diverse languages were all made collaboratively with community partners. The team’s intentional efforts and commitment to convey diversity resonated with participants, making the website “feel like home.” Furthermore, as the partnering organizations behind the creation of the website were clearly listed on the site for the purpose of transparency regarding who was behind the website, participants perceived it to be a trustworthy tool.

Overall, our findings highlight that the T4W/Juntos website functions as a comprehensive, inclusive, and user-friendly platform for coping with mental health challenges, particularly during the pandemic. It was a web-based “one-stop-shop” due to the culmination of several integrated features that generated positive regard. However, despite its many strengths, there were also suggestions for improvements to the website to further enhance inclusivity. As was suggested by some participants, more resources, pictures, stories, and testimonials are needed to reduce stigma, specifically for older adults; adolescents; lesbian, gay, bisexual, transgender, and queer communities; police officers; and veterans. In terms of functionality, certain adjustments were requested, including a “back” button and a drop-down menu for a better user experience.

Limitations

Some aspects of this study were restrained due to the pandemic. For example, we were only able to interview English- and Spanish-speaking adults. In addition, we used convenience sampling with recruitment based on invites from clients and community partners of staff and providers of community partner agencies. While this approach resulted in a diverse sample, it included community-based health and wellness workers and is not necessarily representative of California residents. Nonetheless, during the COVID-19 pandemic, these voices were extremely valuable and garnered important insights. While 55% (16/29) of the participants indicated that they worked in community-based support or health care, we did not collect specific data on employment status or occupation. We can only assume based on education and other factors that approximately half of our sample were community members not employed in health care. Thus, future research should systematically collect employment data as context for participants’ level of familiarity with health-related resources.

Relatedly, the COVID-19 pandemic put limits on potential participants’ ability to engage in a study when they were dealing with other worries. Thus, our sample was diverse in some ways but could have been more reflective of California’s population. For example, we were successful in recruiting 7% (2/29) of participants who were Southeast Asian; however, no participants self-identified as being from South Asian or East Asian communities despite the large numbers in California. Future research should expand recruitment efforts to be inclusive of the many subgroups in the state to bring insight from a more diverse sample.

Conclusions and Future Implications

Our results complement the findings of the quantitative evaluation that showed engagement in website use and an association with reduced depression over time [ 34 ]. The results underscore the value of collaborating with members of the target community to have a meaningful impact when designing a digital tool for the public. Specific partner website design suggestions to include videos; language accessibility; diverse representation; and colorful, cheerful visuals contributed to the positive reception of this website. The findings suggest that, while T4W/Juntos has been effective in addressing diverse needs, there are ongoing opportunities to maximize inclusivity and user experience.

First, future studies on mental health website development would benefit from engaging with a diverse sample of the target group and conducting pilot tests to learn more specifically what accessibility means to potential users. Second, the results showed that mental health stigma continues to be an issue, especially among minoritized communities. Hence, resources tailored to such groups must consider what stigma looks like to members of each group and how to address it in the specific context of minoritized communities so that valuable information about mental health will be received and accepted. Finally, participants indicated that the T4W/Juntos website was useful for their personal needs, sharing with loved ones, or incorporating into their work with minoritized communities. The website’s unique features—especially its diverse representation and availability in multiple languages—make it a valuable addition to the mental health resource landscape, and thus, it may be recommended for dissemination throughout the state of California, especially when including input from other diverse populations.

Acknowledgments

The authors would like to acknowledge the community partner agencies in the state of California who collaborated in the development of the Together for Wellness/Juntos por Nuestro Bienestar website and assisted in disseminating information that led to the recruitment of our sample, including African Communities Public Health Coalition, Boat People SOS, Cal Voices, California LGBTQ Health and Human Services Network, Healthy African American Families II, Health Education Council, National Alliance on Mental Illness California, United Parents, and Visión y Compromiso, and our collaborators at Chorus Innovations and University of California, Davis. Funding was obtained from a Federal Emergency Management Agency and Substance Abuse and Mental Health Services Administration grant (which was managed by the California Mental Health Services Authority through the California Department of Health Care Services for COVID-19 crisis intervention prevention; 700-FEMA-2021-UCLA), a California Health Care Foundation grant (award G-31202), and an award from the California Department of Health Care Services (award 21-10458).

Data Availability

The data sets generated during and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

MVH, KBW, and DFR conceived and designed the study. MVH analyzed and interpreted the data and drafted and revised the manuscript. JL, MPC, and JIM analyzed and interpreted the data and made substantial contributions to drafting and revising the manuscript. DFR collected and participated in the analysis and interpretation of the data. KBW also critically revised the draft for important intellectual content. All authors granted final approval for the version to be published.

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 14.12.23; peer-reviewed by C Watfern, D Levine; comments to author 15.01.24; revised version received 23.01.24; accepted 31.01.24; published 25.03.24.

©MarySue V Heilemann, Jianchao Lai, Madonna P Cadiz, Jocelyn I Meza, Daniela Flores Romero, Kenneth B Wells. Originally published in JMIR Formative Research (https://formative.jmir.org), 25.03.2024.

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

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What is Qualitative in Qualitative Research

Patrik aspers.

1 Department of Sociology, Uppsala University, Uppsala, Sweden

2 Seminar for Sociology, Universität St. Gallen, St. Gallen, Switzerland

3 Department of Media and Social Sciences, University of Stavanger, Stavanger, Norway

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

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

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

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

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

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

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

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

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

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

Towards a Definition of Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Analysis – What is Qualitative Research?

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

Qualitative and Quantitative

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

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

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

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

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

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

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

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

Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

Grounded Theory

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

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

Defining Qualitative Research

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

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

Distinctions

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

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

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

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

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

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

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

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

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

Improved Understanding

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

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

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

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

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

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

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

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

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

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

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

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

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

Acknowledgements

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

Biographies

is professor of sociology at the Department of Sociology, Uppsala University and Universität St. Gallen. His main focus is economic sociology, and in particular, markets. He has published numerous articles and books, including Orderly Fashion (Princeton University Press 2010), Markets (Polity Press 2011) and Re-Imagining Economic Sociology (edited with N. Dodd, Oxford University Press 2015). His book Ethnographic Methods (in Swedish) has already gone through several editions.

is associate professor of sociology at the Department of Media and Social Sciences, University of Stavanger. His research has been published in journals such as Social Psychology Quarterly, Sociological Theory, Teaching Sociology, and Music and Arts in Action. As an ethnographer he is working on a book on he social world of big-wave surfing.

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Contributor Information

Patrik Aspers, Email: [email protected] .

Ugo Corte, Email: [email protected] .

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