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What is phenomenology in qualitative research?

Last updated

7 February 2023

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Take a closer look at this type of qualitative research along with characteristics, examples, uses, and potential disadvantages.

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• What is phenomenological qualitative research?

Phenomenological research is a qualitative research approach that builds on the assumption that the universal essence of anything ultimately depends on how its audience experiences it .

Phenomenological researchers record and analyze the beliefs, feelings, and perceptions of the audience they’re looking to study in relation to the thing being studied. Only the audience’s views matter—the people who have experienced the phenomenon. The researcher’s personal assumptions and perceptions about the phenomenon should be irrelevant.

Phenomenology is a type of qualitative research as it requires an in-depth understanding of the audience’s thoughts and perceptions of the phenomenon you’re researching. It goes deep rather than broad, unlike quantitative research . Finding the lived experience of the phenomenon in question depends on your interpretation and analysis.

• What is the purpose of phenomenological research?

The primary aim of phenomenological research is to gain insight into the experiences and feelings of a specific audience in relation to the phenomenon you’re studying. These narratives are the reality in the audience’s eyes. They allow you to draw conclusions about the phenomenon that may add to or even contradict what you thought you knew about it from an internal perspective.

• How is phenomenology research design used?

Phenomenological research design is especially useful for topics in which the researcher needs to go deep into the audience’s thoughts, feelings, and experiences.

It’s a valuable tool to gain audience insights, generate awareness about the item being studied, and develop new theories about audience experience in a specific, controlled situation.

• Examples of phenomenological research

Phenomenological research is common in sociology, where researchers aim to better understand the audiences they study.

An example would be a study of the thoughts and experiences of family members waiting for a loved one who is undergoing major surgery. This could provide insights into the nature of the event from the broader family perspective.

However, phenomenological research is also common and beneficial in business situations. For example, the technique is commonly used in branding research. Here, audience perceptions of the brand matter more than the business’s perception of itself.

In branding-related market research, researchers look at how the audience experiences the brand and its products to gain insights into how they feel about them. The resulting information can be used to adjust messaging and business strategy to evoke more positive or stronger feelings about the brand in the future.

• The 4 characteristics of phenomenological research design

The exact nature of phenomenological research depends on the subject to be studied. However, every research design should include the following four main tenets to ensure insightful and actionable outcomes:

A focus on the audience’s interpretation of something . The focus is always on what an experience or event means to a strictly defined audience and how they interpret its meaning.

A lack of researcher bias or prior influence . The researcher has to set aside all prior prejudices and assumptions. They should focus only on how the audience interprets and experiences the event.

Connecting objectivity with lived experiences . Researchers need to describe their observations of how the audience experienced the event as well as how the audience interpreted their experience themselves.

• Types of phenomenological research design

Each type of phenomenological research shares the characteristics described above. Social scientists distinguish the following three types:

Existential phenomenology —focuses on understanding the audience’s experiences through their perspective. 

Hermeneutic phenomenology —focuses on creating meaning from experiences through the audience’s perspective.

Transcendental phenomenology —focuses on how the phenomenon appears in one consciousness on a broader, scientific scale.

Existential phenomenology is the most common type used in a business context. It’s most valuable to help you better understand your audience.

You can use hermeneutic phenomenology to gain a deeper understanding of how your audience perceives experiences related to your business.

Transcendental phenomenology is largely reserved for non-business scientific applications.

• Data collection methods in phenomenological research

Phenomenological research draws from many of the most common qualitative research techniques to understand the audience’s perspective.

Here are some of the most common tools to collect data in this type of research study:

Observing participants as they experience the phenomenon

Interviewing participants before, during, and after the experience

Focus groups where participants experience the phenomenon and discuss it afterward

Recording conversations between participants related to the phenomenon

Analyzing personal texts and observations from participants related to the phenomenon

You might not use these methods in isolation. Most phenomenological research includes multiple data collection methods. This ensures enough overlap to draw satisfactory conclusions from the audience and the phenomenon studied.

Get started collecting, analyzing, and understanding qualitative data with help from quickstart research templates.

• Limitations of phenomenological research

Phenomenological research can be beneficial for many reasons, but its downsides are just as important to discuss.

This type of research is not a solve-all tool to gain audience insights. You should keep the following limitations in mind before you design your research study and during the design process:

These audience studies are typically very small. This results in a small data set that can make it difficult for you to draw complete conclusions about the phenomenon.

Researcher bias is difficult to avoid, even if you try to remove your own experiences and prejudices from the equation. Bias can contaminate the entire outcome.

Phenomenology relies on audience experiences, so its accuracy depends entirely on how well the audience can express those experiences and feelings.

The results of a phenomenological study can be difficult to summarize and present due to its qualitative nature. Conclusions typically need to include qualifiers and cautions.

This type of study can be time-consuming. Interpreting the data can take days and weeks.

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Qualitative study design: Phenomenology

• Qualitative study design

Phenomenology

• Grounded theory
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Used to describe the lived experience of individuals.

• Now called Descriptive Phenomenology, this study design is one of the most commonly used methodologies in qualitative research within the social and health sciences.
• Used to describe how human beings experience a certain phenomenon. The researcher asks, “What is this experience like?’, ‘What does this experience mean?’ or ‘How does this ‘lived experience’ present itself to the participant?’
• Attempts to set aside biases and preconceived assumptions about human experiences, feelings, and responses to a particular situation.
• Experience may involve perception, thought, memory, imagination, and emotion or feeling.
• Usually (but not always) involves a small sample of participants (approx. 10-15).
• Analysis includes an attempt to identify themes or, if possible, make generalizations in relation to how a particular phenomenon is perceived or experienced.

Methods used include:

• participant observation
• in-depth interviews with open-ended questions
• conversations and focus workshops. 

Researchers may also examine written records of experiences such as diaries, journals, art, poetry and music.

Descriptive phenomenology is a powerful way to understand subjective experience and to gain insights around people’s actions and motivations, cutting through long-held assumptions and challenging conventional wisdom.  It may contribute to the development of new theories, changes in policies, or changes in responses.

Limitations

• Does not suit all health research questions.  For example, an evaluation of a health service may be better carried out by means of a descriptive qualitative design, where highly structured questions aim to garner participant’s views, rather than their lived experience.
• Participants may not be able to express themselves articulately enough due to language barriers, cognition, age, or other factors.
• Gathering data and data analysis may be time consuming and laborious.
• Results require interpretation without researcher bias.
• Does not produce easily generalisable data.

Example questions

• How do cancer patients cope with a terminal diagnosis?
• What is it like to survive a plane crash?
• What are the experiences of long-term carers of family members with a serious illness or disability?
• What is it like to be trapped in a natural disaster, such as a flood or earthquake? 

Example studies

• The patient-body relationship and the "lived experience" of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment . Individual interviews were carried out for this study.
• The use of group descriptive phenomenology within a mixed methods study to understand the experience of music therapy for women with breast cancer . Example of a study in which focus group interviews were carried out.
• Understanding the experience of midlife women taking part in a work-life balance career coaching programme: An interpretative phenomenological analysis . Example of a study using action research.
• Holloway, I. & Galvin, K. (2017). Qualitative research in nursing and healthcare (Fourth ed.): John Wiley & Sons Inc.
• Rodriguez, A., & Smith, J. (2018). Phenomenology as a healthcare research method . Journal of Evidence Based Nursing , 21(4), 96-98. doi: 10.1136/eb-2018-102990
• << Previous: Methodologies
• Next: Grounded theory >>
• Last Updated: Mar 19, 2024 9:32 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

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Phenomenology

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Phenomenology helps us to understand the meaning of people's lived experience.  A phenomenological study explores what people experienced and focuses on their experience of a phenomenon.  As phenomenology has a strong foundation in philosophy, it is recommended that you explore the writings of key thinkers such as Husserl, Heidegger, Sartre and Merleau-Ponty before embarking on your research. Duquesne's Simon Silverman Phenomenology Center maintains a collection of resources connected to phenomenology as well as hosting lectures, and is a good place to start your exploration.

• Simon Silverman Phenomenology Center
• Husserl, Edmund, 1859–1938
• Heidegger, Martin, 1889–1976
• Sartre, Jean Paul, 1905–1980
• Merleau-Ponty, Maurice, 1908–1961

Books and eBooks

Online Resources

• Phenomenology Stanford Encyclopedia of Philosophy entry.

• << Previous: Qualitative Methods Overview
• Next: Case Studies >>
• Last Updated: Aug 18, 2023 11:56 AM
• URL: https://guides.library.duq.edu/qualitative_research

• Open access
• Published: 13 March 2024

Sexuality and self-concept of morbidly obese women who are sexually attracted to men after bariatric surgery: a phenomenological study

• José Granero-Molina 1 , 2 ,
• María del Mar Jiménez-Lasserrotte 1 ,
• Cristina Arias Hoyos 3 ,
• María José Torrente Sánchez 4 ,
• Cayetano Fernández-Sola 1 &
• María Dolores Ruiz-Fernández 1  

BMC Women's Health volume  24 , Article number:  174 ( 2024 ) Cite this article

154 Accesses

Metrics details

Morbid Obesity (MO) is a public health problem that affects a person’s physical, psychological and sexual well-being. Women with MO are affected by their body image and self-concept, and obesity stigma may affect women in social and sexual relationships.

To describe and understand the experiences of morbidly obese heterosexual women (who are sexually attracted to men) in relation to their body image and sexuality after bariatric surgery.

Methodology

Qualitative study using Merleau-Ponty’s hermeneutic phenomenology as a philosophical framework. Data collection took place between 2020 and 2021 in a southern Spanish province. A total of 22 in-depth interviews were conducted using open-ended questions until data saturation was reached.

Two main themes were identified: (1) “Escaping from a cruel environment”: weight loss to increase self-esteem; with the sub-themes: ‘I love myself now’, and ‘Body image and social relationships; a vicious circle; (2) “Now, I am truly me”: accepting my body to reclaim my sexuality, with the sub-themes: ‘The body as the focal point of sexuality’, and ‘When regaining your sex drive reignites your sex life and relationship’.

Weight loss and body acceptance radically change morbidly obese women’s sex lives after bariatric surgery. They rediscover their bodies, have increased self-esteem, and see improvements in their social relationships and sexuality. These women feel seen, loved and desired, and now value their body image and femininity. As they go through continuous improvements following bariatric surgery, they gradually regain self-esteem, acceptance of their bodies and control over their sex life. Even though the women’s partners benefit from these improvements, they seem to be afraid of being left.

Plain English Summary

Obesity is a problem that affects women’s physical, psychological and sexual well-being, as well as their social relationships. It is important to explore and understand the experiences of heterosexual women regarding their body and sexuality. After other treatments, women undergo surgery to reduce their obesity. After bariatric surgery women feel happier about themselves, experience less stigma and progressively recover their social and sex lives.

Peer Review reports

The World Health Organisation (WHO) defines being overweight as having a body mass index (BMI) ≥ 25 kg/m2, and obesity as a BMI ≥ 30 kg/m2 [ 1 ]. Morbid obesity (MO) is a serious health condition as it means having a BMI greater than 40 kg/m², combined with at least one serious obesity-related condition [ 2 , 3 ]. MO is considered a public health challenge [ 4 ]; almost 40% of adults worldwide are overweight and almost 15% are obese [ 1 , 5 ]. In Spain, 15.5% of women aged ≥ 18 years are obese [ 6 ]. MO is a precursor of high mortality [ 7 ], associated with comorbidities such as cardio-vascular disease, diabetes mellitus, hypertension, cancer, osteoarthritis, pelvic floor dysfunction or urinary incontinence [ 8 , 9 ]. MO is also associated with psychological problems such as anxiety, depression, low self-esteem and disorders related to self-perception and body image [ 10 ]. This is compounded by social problems such as weight-related discrimination, sexual dysfunction and social stigma [ 11 ].

MO is associated with female sexual dysfunction (FSD), which is characterised by hypoactive sexual desire disorder, sexual aversion disorder, sexual arousal disorder, orgasmic disorder and sexual pain disorders [ 12 ]. This is in addition to disorders affecting libido, pleasure, reproduction [ 13 , 14 ], intimacy, affection and self-care [ 15 ]. People with MO are affected in terms of self-perception and are dissatisfied with their body image, this is associated with worse mental and sexual health [ 7 , 16 ]. Women with MO experience depression, anxiety, low self-esteem, limited acceptance of their body image and difficulty in interpersonal relationships. Negative correlations have been found between BMI, sex drive and the ability to experience orgasm [ 17 ]. Female sexuality is related to quality of life and body image, and a woman’s perception of her own body is associated with sexual satisfaction [ 18 , 19 ]. Negative body image is linked to lower sexual activity, less satisfaction, poor communication and seeking professional help [ 20 ]. Women are a more vulnerable group because of society’s idealisation of their bodies.

The treatment of MO focuses on nutrition, physical exercise, lifestyle habits and surgical treatment. Bariatric surgery is an effective therapeutic measure for treatment of MO and its comorbidities, as it improves diabetes mellitus, dyslipidaemia and hypertension [ 11 ], as well as quality of life, sex hormones, fertility and sexual function [ 5 , 11 , 14 , 15 , 20 ]. Body perception and sex life are key factors in the decision to undergo bariatric surgery. Reviews suggest improved sexual function in women with MO after surgery [ 21 ], and almost half of patients dissatisfied with their sex life experienced improvements after surgery at their 5-year follow-up [ 22 ]. Body image also improved after bariatric surgery, although this is not always maintained over time [ 23 ]. Body image plays a relevant role in psychological disorders after bariatric surgery and is a key factor in the assessment and treatment of patients with MO [ 24 ]. Much of the motivation for people to opt for bariatric surgery is due to dissatisfaction with their appearance and body image [ 25 ]. The women’s motives for undergoing bariatric surgery stem from a desire to improve their fertility [ 26 ], as well as the expectation of better physical health, stronger personal identity, and improved social relationships; they consider surgery to be their last option [ 27 ]. Studies such as that of Mento et al. [ 28 ] recommend further research on self-concept and body image before and after bariatric surgery. In addition to epidemiological, nutritional, diagnostic or therapeutic studies, there is a need to understand morbidly obese heterosexual women’s experiences regarding their body image and sexuality after bariatric surgery [ 19 , 29 ]. While the relationship between body image and sexual function has been examined in epidemiological or intervention studies, qualitative studies where women describe their own experiences are scarce [ 19 ]. Some studies have explored men’s and women’s experiences of MO prior to bariatric surgery [ 29 , 30 ], but such experiences after surgery remain to be studied. Understanding these experiences could better prepare women for the life changes that follow bariatric surgery [ 31 ]. The aim of our study is to describe and understand the experiences of morbidly obese heterosexual women regarding their body image and sexuality after bariatric surgery.

Research design

This is a qualitative study that used Merleau-Ponty’s hermeneutic phenomenology as a framework. According to Merleau-Ponty, we perceive the world through our body [ 32 ], human consciousness is linked to corporeality, and the notion of ‘self’ is inextricably linked to our body and experiences. The participants live their experiences according to a body schema; we seek to understand the complexity of the phenomenon of sexuality, self-perception and body image in the different ways in which women with MO embody it. Merleau-Ponty advocates phenomenological reduction to capture experiences and the lifeworld (Lebenswelt) covering four existentials: lived space, lived body, lived time and lived relationships. In writing the manuscript, the Consolidated Criteria for Reporting Qualitative Research were applied (COREQ) [ 33 ].

Participants and recruitment

The participants were selected through purposive sampling. A total of 22 women diagnosed with MO were recruited. The study took place in southern Spain between 2021 and 2022. Inclusion criteria: to be a heterosexual woman, aged 18 to 60 years, included in the Bariatric Surgery Programme, to have undergone surgery 2 or more years ago, to speak Spanish and to give informed consent. Exclusion criteria: a recent pregnancy, currently breastfeeding, going through menopause, previous bariatric surgery or refusal to participate in the study. The sociodemo-graphic characteristics of the participants are listed in Table  1 .

Data collection

After obtaining permission, the researchers contacted the participants. The researchers knew the patients because they monitor them for up to 5 years post-intervention. Of thirty-four women with MO contacted, four did not answer the phone and eight refused to participate. In-depth interviews were conducted in which open-ended questions allowed for the women’s narratives to be told. Interviews, with an average duration of 52 min, took place in a room at the Department of Nursing, Physiotherapy and Medicine at the University of …., between November 2021 and April 2022. The interviews were conducted in Spanish by two researchers (M.J.T.S., C.A.H.) with more than 8 years of experience in bariatric surgery, which allowed for in-depth data collection. Before starting, the participants were given an explanation of the aim and ethical issues of the study, sociodemographic data were collected and informed consent was obtained. The interview began with an open-ended question: ‘What does the topic of sexuality after bariatric surgery suggest to you?’ The participants shared their experiences, and the interviewers took notes of verbal and non-verbal elements of communication. The interview ended with the question: ‘Do you have anything else to add?’ The researchers’ interpretations and reflections were continuously edited during the data analysis process. Data collection was stopped when data saturation was reached. Focus groups were ruled out as the participants refused to discuss their sexuality with other women.

Data analysis

All annotations and in-depth interviews were transcribed and incorporated into a hermeneutic unit of the ATLAS programme. Ti 9.0. The analysis process was organised in three steps according to Merleau-Ponty’s phenomenology [ 34 ]: (1) Description: interviews were transcribed verbatim, transcripts were read and then re-read to understand the experiences of the participants. (2) Phenomenological reduction: a process of coding the transcripts without incorporating standpoints, concepts, memories or personal experiences of the researchers. (3) Phenomenological interpretation: the researchers develop themes and sub-themes drawn from the inductive data analysis to understand the study phenomenon. Analysis was conducted by the researchers who did not know the participants. Discrepancies in the analysis were discussed with the other mem-bers of the research team until a consensus was reached.

To ensure rigour, quality criteria were followed [ 35 ]. (1) Credibility: all phases of data collection are detailed, data interpretation followed a descriptive process verified by independent researchers (surgeon and nurse, bariatric surgery). (2) Transferability: exhaustive description of setting, participants, context and method. (3) Dependability: an expert not involved in data collection and analysis examined the results. (4) Confirmability: all researchers read the transcripts and agreed on the units of meaning, themes and subthemes.

Ethical considerations

Permission was obtained from the Ethics and Research Committee of the Department of Nursing, Physiotherapy and Medicine of the University of Almeria (EFM/45/2018). The study complies with the requirements and ethical principles of the Declaration of Helsinki. Participants provided informed consent upon commencing the study.

A total of 22 women with MO who underwent bariatric surgery 2 or > years ago were interviewed. The mean age was 42.7 years, SD = 9.7. MO started during childhood for 40.9% of the participants, during adolescence for 27.3%, after getting married for 13.65%, and after pregnancy for 18.2%. The mean BMI was 39.1625 kg/m2 before surgery and 28.08 25 kg/m2 two or more years after bariatric surgery. 59.2% of the women were married, 31.8% were single, 4.5% were unmarried and 4.5% were living with a partner. Two main themes were extracted from the inductive data analysis: (1) “Escaping a cruel environment”: weight loss to increase self-esteem; and (2) “Now, I am truly me”: accepting my body to reclaim my sexuality (see Table  2 ).

“Escaping a cruel environment”: weight loss to increase self-esteem

The lives of women with MO change dramatically before and after undergoing bariatric surgery. A key aspect is increased self-esteem, which is linked to improved self-perception and social relationships. Two subthemes emerged.

I love myself now

The participants highlighted two fundamental factors in their decision to undergo bariatric surgery: a feeling of self-consciousness brought about by not being comfortable with their own body, and an awareness of the deterioration of their health and quality of life due to MO. This is compounded by the aggravation of associated conditions, such as thyroid disease and difficulties in getting pregnant.

I had surgery because I had a lot of complexes, because I had thyroid problems that were getting worse, and because I wanted to be a mother and I couldn’t because of my MO. ” (IDI1).

One of the most significant changes in women after bariatric surgery is the improvement in their self-esteem. The participants recognised that, prior to surgery, their attitude towards life was very negative; it affected the way they dressed, communication, leisure activities, establishing relationships and dating. Surgery changes their body physically and mentally, which gives them more confidence in decision-making.

I have learned to say yes to what I used to say no to. What does the operation change for you? Confidence, physique, will to live and health, … they’re all very important.” (IDI4).

Prior to surgery the participants rejected their own bodies; they did not look at themselves in the mirror because they did not like what they saw. They did not care about their appearance and neglected their sense of femininity. They did not find themselves attractive and did nothing to make others find them attractive either. One of the participants described her situation as follows:

I saw this shapeless thing, an amorphous, ugly, very fat body with cellulite. I was disgusted to look at myself.” (IDI5).

Surgery has many positive consequences. As one participant stated, she started to pay more attention to her physical appearance after the operation because she felt good about herself and her body. Likewise, the participants have better social and romantic relationships, and experience improvements in their overall quality of life. Now that they see a future that MO was hiding, they want to take care of their body and their appearance because it is an essential element of their new life.

I like to get dressed up a lot more than I used to, …you feel prettier and better. ” (IDI2).

Another factor that helps them is the positive feedback from the people around them. According to the participants, since undergoing surgery, they get positive comments from others, which reaffirms their self-esteem and desire to improve every day.

It motivates you, it makes you want to get dolled up. They say, “My goodness, look at you today!” That makes you feel motivated, not because you’re sexually interested in the men but because they’re looking at you, they’re telling you you’re beautiful…. tomorrow I’ll be even more beautiful!” (IDI6).

Body image and social relationships: a vicious circle

Social relationships are a fundamental aspect of people’s lives; the participants defined theirs as negative prior to bariatric surgery. At this stage, it is very difficult for them to relate to others, they lose their self-confidence, and insecurity isolates them socially.

I used to be very withdrawn, I seemed to dislike everyone, I didn’t talk much, and, of course, you lose touch with people … You lose your self-confidence and, when you regain it and feel good, you also feel good around other people. ” (IDI7).

The participants said that contacting and interacting with people or social groups made them feel rejected, so they made excuses not to meet up with them. They felt ashamed and knew that they were the centre of attention and did not want to be. The participants have experienced stigma related to their MO, such as unpleasant jokes and mockery due to their physique. They have felt the accusatory gaze of a society that blames them for having become morbidly obese from not taking care of their health. Weight-related stigma isolated them and kept them stuck at home.

I always made excuses, …that I didn’t feel like going, that I was tired, that I had a headache…a thousand excuses not to go.” (IDI3).

Bariatric surgery has had a very positive effect on their willingness to interact with others. Improved self-image leads to improved self-esteem, which has a positive impact on recovering their social relationships:

Now I feel more confident, I’m not ashamed to speak. When you are fat you are ashamed to talk, you think the others think: “look at what this fat woman is saying.” (IDI4).

The women expressed how after surgery they wanted to take up activities that they had given up, such as physical exercise, outdoor activities and other hobbies. They have recovered their social relationships through spending time with friends, family or at patient associations.

Now I feel like talking, being with people I know, meeting new people … I feel like going out more, having a coffee. When I was fat this didn’t happen, I feel like a new person and yes, …. I want to say it, I want you to see it!” (IDI8).

Society’s cruelty is a factor that has caused them to have negative attitudes towards others. Most of the participants have had negative experiences due to comments about their body image or being made to feel uncomfortable. Society seems to deny them the right to be attractive to others and to be able to choose a partner. The women still have painful memories of these experiences, but they no longer suffer.

They told me: “as you’re fat, you can’t expect to find the partner you want… you have to settle for whatever comes along, even if it’s not someone you really like”. All that … it’s all nonsense, but it gets stuck in your head and it wears you down.” (IDI14).

The participants say that after surgery and weight loss, everything changes. They now receive compliments and positive comments from most people. This helps them to open up and relate to others. This is how one participant put it:

They start by looking at you, then they say: “how beautiful, I don’t know what you’ve done to yourself…”. And maybe one of them is saying something to you and another one comes along and says: “it’s true, she’s very pretty”. It puts a smile on your face.” (IDI20).

The women reaffirmed that bariatric surgery has radically changed their lives. They have higher self-esteem and confidence because of a transformation in their relationships and sexuality. The women with partners feel that they can respond to their partners’ sexual needs, that their husbands look at them lustfully, and they are proud of that.

Yes, my husband now suggests going out for dinner, dancing, sexy clothes … everything has changed. I always used to be hidden, in the background… I didn’t want him to see me naked.” (1DI16).

But despite improvements after bariatric surgery, the stigma of obesity does not disappear completely, and is still present. The women continue to receive negative comments after having undergone successful surgery. They recognise that it no longer affects them as much, but they feel the social stigma. The notion of an ideal body shape continues to influence their social and intimate relationships. As one participant said, she gets negative comments from those around her even after having lost weight. It is as if society does not accept the change and expects her to become morbidly obese again in the near future.

Some people say: “keep your clothes, you’ll need them” and those words stick in your head, they are cruel, they hurt you deeply …. Puff.” (IDI12).

“Now, I am truly me”: accepting my body to reclaim my sexuality

Improvements in body self-perception and increased self-esteem directly influence the sexuality of women who undergo bariatric surgery. Two subthemes were developed from the data analysis.

The body as the focal point of sexuality

The participants reported that the operation was a turning point in their sexual relations. Prior to bariatric surgery, the women with MO had serious mobility impairments, and symptoms of asphyxia, dyspnoea, tiredness and excessive sweating. This caused discomfort for them and their partners during sexual intercourse. After bariatric surgery, the women saw improvements in their sex life and relationships. They broke the monotony of always having sex in the same position, in the same places and under the same circumstances. This is what one woman said:

“Before, you couldn’t move, you just went along with it, you weren’t active …. Now you are active, you can move, you feel good and you work out what you like. You get on top, on the bottom, on the side…” (IDI16). “Before, sex could only be in bed. Now we change positions, places … everything. What my husband likes the most is for me to get on top of him, … that was unthinkable before. Now I can, I can get on top, I can enjoy it !” (IDI21).

Most of the participants acknowledged that before the surgery they avoided sexual intercourse because they were ashamed of exposing their bodies and being touched. They all agreed that having sex with the light on was impossible, but this was no longer the case after the operation. In addition, they also claimed that their partners have noticed this positive change.

Before, I didn’t like to be touched, … I was ashamed. Now I like him to touch me, to caress me, for it to last for a long time, everything is different, and he tells me so.” (IDI1). “You feel much better (ha, ha … you don’t mind if the light is on), whether it’s in the evening or in the morning … Before it had to be at night, with the light off. Why? Because of my body weight, because I looked horrible, … he also saw it even though he didn’t tell me so.” (IDI2).

After bariatric surgery, the participants stated that they no longer felt ashamed to be naked in front of their partners. Many of them agreed that even the skin that is visible due to weight loss does not bother them during sexual intercourse.

“Before, I didn’t undress in front of my husband, now I look forward to being naked, I want my partner to be excited by my body, ….” (IDI15). “The skin flaps are visible, I don’t like it, it’s a memory of what I was, …but they’re obvious, it’s as if you don’t see them. ” (IDI12).

Before the intervention, the women did not care about other aspects such as clothing or lingerie, which they struggled to find in their size; this is no longer a concern for them. Their body image is crucial to them now as it helps them to increase their sex drive and have sexual relations.

“I didn’t buy clothes before. I never went to the shops, my mother would bring me clothes and tell me what looked good on me, … and that was it. Now, since I had the operation, I have started to lose weight and the dressing room seems too small” (IDI18). “I can wear lingerie now, I go to the shops now. I look around, I can choose things for myself. I want to buy things because I’m going to wear them, they fit me well. I’ll wear this tonight, then I’m going to take a shower and wait for him (partner) in the bedroom…. I’m doing a lot of things I’ve never done before.” (IDI14).

When regaining your sex drive reignites your sex life and relationship

The participants confessed that their sex drive was very low before the operation, blaming their lack of confidence and self-esteem. Even in an intimate setting with their partners, they did not feel comfortable revealing their bodies. Their partners accepted them and wanted sex, but the women had no sex drive; the thought of having sex was repulsive to them.

That idea is in your head… Even if your partner is telling you: “it’s me and I love you like this (with MO), who are you going to trust more? But you don’t… you close yourself off and you lose all desire.” (IDI19).

The women described a shift in their sex drive after bariatric surgery, which was linked to changes in their body image and self-concept. Low libido even led some participants not to have sex for years or even throughout their lives, until they underwent surgery and lost weight.

““I have never had a partner. I have had some opportunities, but as I didn’t love myself and I wasn’t comfortable with myself, if a man approached me, I would pull back. I wasn’t ready to discover more, … I lost my virginity at the age of 40.” (IDI7)”.

The women described how their sex drive was reawakened after bariatric surgery. The participants with partners have noticed that both of them have increased libido, which directly improves their sex lives.

“You feel great and you see that he looks at you differently, he’s more sexually at- tracted to you. Although he used to tell me that he loved me and that I was attractive, … I didn’t quite believe him. Yes, he loves you, he loved you with MO, but now with a better body you are more beautiful, more attractive, you feel better… he also has more sexual appetite, more desire to touch you, … you notice it and it’s nice .” (IDI9).

One aspect that has improved considerably is taking initiative in sexual relations. Before the surgery, the women recognised that they were incapable of taking the initiative, suggesting sex games or introducing changes in their sex life. After gaining confidence and increased libido, they are looking to make changes, to innovate, to know what they want and to suggest it to their partners.

Now I initiate things, and it’s clear that he (partner) wants to (have sex). In the past, he didn’t feel like it because he was always taking the initiative. I said no a lot and he was getting tired of it, … that has changed completely. Now I say what I want and what I don’t like.” (IDI11).

The participants expressed how they did not fully enjoy sexual intercourse before surgery and often did not experience pleasure. The women mentioned having painful sexual experiences, and frequently not reaching orgasm. One participant spoke of how she would fake orgasms to avoid her partner feeling uncomfortable.

It’s complicated, he wants to satisfy you, but you can’t, you don’t feel like it and you don’t have orgasms. It often bothered him (partner), he felt inadeqate as a man. I won’t deny it, … I have faked it because I was afraid of losing my partner .” (IDI6).

This situation changes radically after surgery; the women now achieve a state of relaxation and confidence that allows them to enjoy sex more. Some participants acknowledged that they have been able to deal with problems in their sex life with their partner that they were unable to solve before.

You are always thinking about not lying this way, that way, … I was always tense. When I was fat, I rarely ever reached orgasm with my partner. More than enjoying it … you are thinking about when it’s going to end.” (IDI5).

Improved body image boosts both partners’ sex drive. These improvements go beyond penetrative sex and have an impact on other sexual behaviours such as masturbation. In addition, improve-ments in female sexuality have a positive impact on the relationship when the man also has problems due to andropause or other sexual dysfunctions.

He had a (sexual) problem before my operation… Although penetration is still difficult, we masturbate, do our own thing and have a good time. It’s not just about penetration, there’s more to it, I go for it and, as he sees me feeling better about myself, he’s encouraged to do it.” (IDI3).

Another noteworthy aspect are the changes that are brought about by improved self-confidence. Some of the women become empowered after bariatric surgery; they feel more attractive, want to be more feminine and attract men. This situation can change the status of their relationships, occasionally leading to break-ups or their male partners feeling jealous.

You suddenly feel pretty, you are noticed, you are liked, you go out and socialise more …. It is difficult for both you and your partner to deal with this situation. He doesn’t always handle it well, he is not used to people looking at me like that (with desire). Yes, it can lead to arguments and problems. If the couple does not have a solid relationship, you can lose it all .” (IDI15).

The aim of our study was to describe and understand the experiences of morbidly obese heterosexual women regarding their body image and sexuality two or more years after bariatric surgery. Our results show that the changes in the participants’ sex lives are positive for both themselves and their partners. Merleau-Ponty’s phenomenology has allowed us to explore the self-perception of the body and its influence on these women’s sexuality and life, confirming experiences in lived space, body, time and relationships [ 32 ]. According to Nilsson-Condori et al. (2020), a key factor in women with MO opting for surgery is the associated improvement in self-concept and self-esteem [ 36 ]. Additional motives for our participants, previously described by Paul et al. (2023) and Cohn et al. (2019), were to better their physical health and social relationships [ 26 , 27 ]. In line with other studies [ 17 , 37 ], our results confirm that weight loss after bariatric surgery improves the perception of sexual function, body image satisfaction and self-esteem in women with MO [ 38 , 39 ]. Our results contrast with the study by Abdelsamea et al. (2023), who associate weight loss with psychological and quality of life improvements, but not with improvements in female sexual dysfunction [ 40 ]. Consistent with our findings, weight reduction after surgery boosts confidence and self-esteem, thereby improving social interactions [ 29 , 41 ]. In line with the study by Wingfield et al. (2016), two years after bariatric surgery, the patients rediscover themselves and seem to regain lost hope [ 42 ]. Although some women suffer postoperative anxiety [ 22 ], our results do not reflect this, perhaps because several years have passed since the intervention. Body image and physical appearance are fundamental in the process; surgery results in temporal, spatial and relational changes in sexuality [ 32 ]. According to our results, the process is not static; surgery is not the end of the journey with MO, but rather the beginning of a new journey that involves sexuality. Women with partners acknowledge having support before and after surgery, and their partners also benefit from their improved sexuality [ 18 ]. Our results regarding the women’s partners are ambivalent, because while they seem to experience improvements in their sex life after the women undergo bariatric surgery, female empowerment leads the men to feel insecure. Indeed, studies such as that of Braming et al. (2021) have found that bariatric surgery is associated with increased likelihood of finding a partner for single people and increased risk of separation from a partner for those in a relationship [ 43 ]. Our participants agreed that the improvement of female self-concept and body image can lead to a lack of trust in their relationship as the men fear that their partners will leave them [ 17 ]. Our findings on the participants’ experiences corroborate that bariatric surgery improves sexual activity, sex drive, orgasm, intimacy, mobility, variety of sex positions and games [ 11 , 21 , 36 , 37 , 42 , 44 ]. Even negative effects, such as excess skin, seem to be overlooked by the women in our study [ 45 ]. Understanding the concept of poor body image in bariatric surgery patients allows healthcare providers to provide preoperative preparation and postoperative interventions [ 46 ]. Implementing psychological care focusing on body functionality [ 28 , 39 , 47 ], promoting sex education and encouraging self-care [ 48 ], could be the key to a long-term recovery of morbidly obese women’s well-being, body image and sexuality after bariatric surgery. We concur with Lindberg et al. (2022) that the partners’ preparation for the life changes that arise after bariatric surgery may not be adequate; more time and a dialogic approach are needed for each individual to be able to manage and improve their sexual health [ 31 ]. Our study is one of the few that addresses the sexuality of women with MO after bariatric surgery, focusing on corporeality and their own experiences. This is a strength as women suffer from the social stigma of being overweight and struggle to talk about their sexuality, making it difficult to get them to participate in qualitative studies.

Limitations

We acknowledge several limitations. Part of our sample was collected from a private hospital so women with fewer financial resources could be under-represented. The women knew one of the researchers; although it led them to agree to participate in the study, their accounts could have been biased. Part of our sample also participated in previous studies on experiences in the pre-operative phase. The more time that passes after bariatric surgery, the more the participants’ experiences of their sexuality can change. Therefore, findings may differ at much later stages. Our results only reflect the experiences of women who are sexually attracted to men; conclusions cannot be extended to other female sexual identities or partners.

Sexual health has been shown to be key in improving the quality of life of women with MO after bariatric surgery. Weight loss and improved body image change the lives of these women; reconciliation with their bodies is linked to improvements in perceived self-esteem, communication and social relationships. The participants stated that since bariatric surgery they are once again able to enjoy a sense of sexuality they thought they had lost. The progressive increase in their self-confidence and desire is empowering. The women regain initiative and control of their sex lives, which has a direct impact on their social and sex lives, as well as on those of their partners. Going from a life as an obese person to having a radically slimmer body brings them face to face with an unexpected reality of mixed consequences. Despite the improvements they experience following bariatric surgery, they still have to deal with the stigma of being overweight and the impact it has on their relationships. This study is an exploration of the experiences of women with MO who have undergone bariatric surgery in relation to their sexuality. Further research could delve into these experiences at later stages among women with different sexual identities. There is also potential to develop interventions for improvement or to study the partners’ perceptions of changes in their social and sex lives.

Implications for practice

Changes in body image, sexuality and social relationships should be addressed systematically by healthcare providers throughout the care of women with MO after bariatric surgery. Sexuality should be incorporated into care protocols and clinical practice guidelines right from when women are admitted into bariatric surgery programmes, given that progressive changes in post-surgical stages call for more long-term follow-up and support. The evolution of female sexuality after bariatric surgery affects both the individual and her partner; understanding the experiences of these women is key for designing specific interventions to provide coping strategies and support, which could benefit from including their partners.

Data availability

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

WHO (World Health Organization). Obesity and Overweight. WHO, Geneva, 2020.

Mechanick JI, Kushner RF, Sugerman HJ, Michael, Collazo-Clavell ML, Spitz AF, et al. Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity. 2009;17:S1–70.

Article   PubMed   Google Scholar  

Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient – 2013. Surg Obes Relat Dis. 2013;9:159–91.

Liu S, Cao D, Ren Z, Li J, Peng L, Zhang Q. The relationships between bariatric surgery and sexual function: current evidence based medicine. BMC Urol. 2020;20(1):1–10.

Article   Google Scholar  

Mazer L, Morton JM. The obesity epidemic. In: Reavis KM, Barrett AM, Kroh MD, editors. Editors. The SAGES manual of bariatric surgery. Switzerland: Springer; 2018. pp. 81–92.

Chapter   Google Scholar  

INE (Instituto nacional de estadística. National Institute of statistics). Encuesta europea de salud en España 2020 [European Health Survey in Spain 2020]. 2020. https://www.ine.es/ss/Satellite?L=es_ES&c=INESeccion_C&cid=1259926457058&p=1254735110672&pagename=ProductosYServicios%2FPYSLayout . Accessed 4 Octr 2023.

WHO (World Health Organization). 2023. WHO acceleration plan to stop obesity. https://iris.who.int/bitstream/handle/10665/367784/9789240073234-eng.pdf?sequence=1 . Accessed 2 oct 2023.

Sfahani SB, Pal S. Does metabolic syndrome impair sexual functioning in adults with overweight and obesity? Int J Sex Health. 2019;31:170–85.

Rowland DL, McNabney SM, Mann AR. Sexual function, obesity, and weight loss in men and women. Sex Med Rev. 2016;5:323–38.

Taskin F, Karakoc A, Demirel G. The effect of body image on sexual quality of life in obese married women. Health Care Women Int. 2019;40:479–92.

Loh HH, Shahar MA, Loh HS, Yee A. Female sexual dysfunction after bariatric surgery in women with obesity: a systematic review and meta-analysis. Scand J Surg. 2022;111(1):14574969211072395.

Deniz A, Okuyucu M. The impact of obesity on fertility and sexual function in women of child bearing age. J Obstet Gynaecol. 2022;42:3129–33.

Jans G, Matthys C, Bel S, Ameye L, Lannoo M, Van der Schueren B, et al. AURORA: bariatric surgery registration in women of reproductive age - a multicenter prospective cohort study. BMC Pregnancy Childbirth. 2016;16(1):1–11.

Salari N, Hasheminezhad R, Sedighi T, Zarei H, Shohaimi S, Mohammadi M. The global prevalence of sexual dysfunction in obese and overweight women: a systematic review and meta-analysis. BMC Womens Health. 2023;23(1):375.

Article   PubMed   PubMed Central   Google Scholar  

Ferrández A, Novella B, Khan KS, Zamora J, Jurado AR, Fragoso M, Suárez C. Obesity and female sexual dysfunctions: a systematic review of prevalence with meta-analysis. Semergen. 2023;49:102022.

Ivezaj V, Grilo CM. The complexity of body image following bariatric surgery: a systematic review of the literature. Obes Rev. 2018;19:1116–40.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Pichlerova D, Bob P, Zmolikova J, Herlesova J, Ptacek R, Laker MK, Raboch J, Fait T, Weiss P. Sexual dysfunctions in obese women before and after bariatric surgery. Med Sci Monit. 2019;27:3108–14.

Frederick DA, Gordon AR, Cook-Cottone CP, Brady JP, Reynolds TA, Alley J, Murray S. Demographic and sociocultural predictors of sexuality-related body image and sexual frequency: the U.S. Body Project I. Body Image. 2022;41:109–27.

Thomas HN, Hamm M, Borrero S, Hess R, Thurston RC. Body image, attractiveness, and sexual satisfaction among midlife women: a qualitative study. J Womens Health. 2019;28:100–6.

Ramseyer V, Ruhr L, Pevehouse D, Pilgrim S. Exploring body image, contraceptive use, and sexual health out-comes among an ethnically diverse sample of women. Arch Sex Behav. 2018;47:715–23.

Gao Z, Liang Y, Deng W, Qiu P, Li M, Zhou Z. Impact of bariatric surgery on female sexual function in obese patients: a meta-analysis. Obes Surg. 2019;30:352–64.

Steffen KJ, King WC, White GE, et al. Changes in sexual functioning in women and men in the 5 years after bariatric surgery. JAMA Surg. 2019;154(6):487–98.

Bosc L, Mathias F, Monsaingeon M, Gronnier C, Pupier E, Gatta-Cherifi B. Long-term changes in body image after bariatric surgery: An observational cohort study. PLoS One. 2022; 7;17(12):e0276167.

Campedelli V, Ciacchella C, Veneziani G, Meniconzi I, Paone E, Silecchia G, Lai C. Body image and body mass index influence on psychophysical well-being in bariatric patients: a cross-sectional study. J Pers Med. 2022;12(10):1597.

Makarawung DJS, Monpellier VM, van den Brink F, Woertman L, Zijlstra H, Mink AB, van Ramshorst B, Geenen R. Body image as a potential motivator for bariatric surgery: a case-control study. Obes Surg. 2020;30(10):3768–75.

Article   CAS   PubMed   Google Scholar  

Paul R, Drott J, Olbers T, Frisk J, Andersson E. Motherhood and motivations for bariatric surgery - a qualitative study. Hum Fertil (Camb). 2023;26(2):257–65.

Cohn I, Raman J, Sui Z. Patient motivations and expectations prior to bariatric surgery: a qualitative systematic review. Obes Rev. 2019;20(11):1608–18.

Mento C, Silvestri MC, Muscatello MRA, Rizzo A, Celebre L, Cedro C, Zoccali RA, Navarra G, Bruno A. The role of body image in obese identity changes post bariatric surgery. Eat Weight Disord. 2022;27(4):1269–78.

Granero-Molina J, Torrente-Sánchez MJ, Ferrer-Márquez M, Hernández-Padilla JM, Sánchez-Navarro M, Ruiz-Muelle A, Ruiz-Fernández MD, Fernández-Sola C. Sexuality amongst heterosexual women with morbid obesity in a bariatric surgery programme: a qualitative study. J Adv Nurs. 2021;77(11):4537–48.

Granero-Molina J, Torrente-Sánchez MJ, Ferrer-Márquez M, Hernández-Padilla JM, Ruiz-Muelle A, López-Entrambasaguas OM, Fernández-Sola C. Sexuality amongst heterosexual men with morbid obesity in a bariatric surgery programme: a qualitative study. J Clin Nurs. 2020;29(21–22):4258–69.

Lindberg S, Wennström B, Larsson AK. Facing an unexpected reality - oscillating between health and suffering 4–6 years after bariatric surgery. Scand J Caring Sci. 2022;36(4):1074–82.

Merleau Ponty. M. Phenomenology of perception. London: Routledge; 2013.

Book   Google Scholar  

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57.

Fernández-Sola C. Análisis de datos cualitativos [Qualitative data análisis] In Comprender para cuidar. Avances en Investigación Cualitativa en Ciencias de la Salud; Fernández-Sola, C., Granero-Molina, J. Hernández-Padilla, J.M, editors Servicio Publicaciones Universidad de Almería (Colección Ciencias de la Salud, Almería, 2019, pp. 239–261.

Lincoln YS, Guba EG. Naturalistic inquiry. London: Sage; 1985.

Nilsson-Condori E, Järvholm S, Thurin-Kjellberg A, Hedenbro J, Friberg B. A new beginning: young women’s experiences and sexual function 18 months after bariatric surgery. Sex Med. 2020;8(4):730–9.

Oliveira CFA, Dos Santos PO, de Oliveira RA, Leite-Filho H, de Almeida AF, Bagano GO, Lima EB, Miranda EP, de Bessa J, Arroso U. Changes in sexual function and positions in women with severe obesity af-ter bariatric surgery. Sex Med. 2019;7(1):80–5.

Souza ALL, de Souza PM, Mota BEF, Xavier CLF, Santiago FG, Oliveira JS, Borges SA, Bearzoti E, Gama EF, Souza GGL. Ghost fat: altered female body perception after bariatric surgery. Percept Mot Skills. 2023;130(1):301–16.

Cherick F, Te V, Anty R, Turchi L, Benoit M, Schiavo L, Iannelli A. Bariatric surgery significantly improves the quality of sexual life and self-esteem in morbidly obese women. Obes Surg. 2019;29(5):1576–82.

Abdelsamea GA, Amr M, Tolba AMN, Elboraie HO, Soliman A, Al-Amir B, Ali F, Osman DA. Impact of weight loss on sexual and psychological functions and quality of life in females with sexual dysfunction: a forgotten avenue. Front Psychol. 2023;1(14):1090256.

Pokorski M, Głuch A. Perception of well-being and quality of life in obese patients after bariatric surgery. Adv Exp Med Biol. 2022;1374:81–90.

Wingfield LR, Kulendran M, Laws G, Chahal H, Scholtz S, Purkayastha S. Change in sexual dysfunction following bariatric surgery. Obes Surg. 2016;26(2):387–94.

Bramming M, Hviid SS, Becker U, Jørgensen MB, Neermark S, Bisgaard T, Tolstrup JS. Changes in relation-ship status following bariatric surgery. Int J Obes (Lond). 2021;45(7):1599–606.

Treacy PJ, Mazoyer C, Falagario U, Iannelli A. Sexual activity after bariatric surgery: a prospective monocentric study using the PISQ-IR Questionnaire. J Sex Med. 2019;16(12):1930–7.

Baillot A, Brunet J, Lemelin L, Gabriel SA, Langlois MF, Tchernof A, Biertho L, Rabasa-Lhoret R, Garneau PY, Aimé A, Bouchard S, Romain AJ, Bernard P. Factors associated with excess skin after bariatric surgery: a mixed-method study. Obes Surg. 2023;33(8):2324–34.

Perdue TO, Schreier A, Neil J, Carels R, Swanson MA. Concept analysis of disturbed body image in bariatric surgery patients. Int J Nurs Knowl. 2020;31(1):74–81.

Alleva JM, Atkinson MJ, Vermeulen W, Monpellier VM, Martijn C. Beyond body size: focusing on body func-tionality to improve body image among women who have undergone bariatric surgery. Behav Ther. 2023;54(1):14–28.

Walsh Ó, Dettmer E, Regina A, Dentakos S, Christian J, Hamilton J, Toulany A. Teenagers are into perfect-looking things’: dating, sexual attitudes and experiences of adolescents with severe obesity. Child Care Health Dev. 2022;48(3):406–14.

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Acknowledgements

Authors would like to thank all the women who participated in this study.

This study had the support of the Health Sciences Research Group of the University of Almería (CTS-451).

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José Granero-Molina, María del Mar Jiménez-Lasserrotte, Cayetano Fernández-Sola & María Dolores Ruiz-Fernández

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Bariatric Surgery, Andalusian Health Service, Almería, Spain

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JGM and MMJL conceived the study. MJTS and CAH conducted the interviews. CFS anf MRF performed the transcriptions, led the analysis, and wrote manuscript drafts.JGM, MJTS and MMJL provided critical feedback and helped shape the analysis and manuscript to its fnal version. All authors read and approved the fnal manuscript.

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Granero-Molina, J., Jiménez-Lasserrotte, M.M., Arias Hoyos, C. et al. Sexuality and self-concept of morbidly obese women who are sexually attracted to men after bariatric surgery: a phenomenological study. BMC Women's Health 24 , 174 (2024). https://doi.org/10.1186/s12905-024-03014-1

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Original research article, patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation: a qualitative interview study.

• 1 Faculty of Medicine, Paracelsus Medical University, Salzburg, Austria
• 2 Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
• 3 University Institute of Sports Medicine, Prevention and Rehabilitation and Research Institute of Molecular Sports Medicine and Rehabilitation, Paracelsus Medical University, Salzburg, Austria
• 4 Department of Health Promotion, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands

Introduction: Despite the well-known benefits of exercise-based cardiac rehabilitation for the secondary prevention of cardiovascular disease, participation in cardiac rehabilitation programmes and adherence to secondary prevention recommendations remain limited. Digital technologies have the potential to address low participation and adherence but attempts at implementing digital health interventions in real-life clinical practice frequently encounter various barriers. Studies about patients' experiences and perspectives regarding the use of digital technology can assist developers, researchers and clinicians in addressing or pre-empting patient-related barriers. This study was therefore conducted to investigate the experiences and perspectives of cardiac rehabilitation patients in Austria with regard to using digital technology for physical activity and exercise.

Methods: Twenty-five current and former cardiac rehabilitation patients (18 men and 7 women, age range 39 to 83) with various cardiac conditions were recruited from a clinical site in Salzburg, Austria. Semi-structured qualitative interviews were audio-recorded and transcribed verbatim. The analysis followed a descriptive phenomenological approach, applying the framework analysis method.

Results: The sample was diverse, including interviewees who readily used digital devices to support their physical activity, exercise and health monitoring, and interviewees who did not. Simplicity, convenience and accessibility were highlighted as important facilitators for the use of digital technology, while annoyance with digital devices, concerns about becoming dependent on them, or simply a preference to not use digital technology were commonly stated reasons for non-use. Interviewees' views on data protection, data sharing and artificial intelligence revealed wide variations in individuals' prior knowledge and experience about these topics, and a need for greater accessibility and transparency of data protection regulation and data sharing arrangements.

Discussion: These findings support the importance that is attributed to user-centred design methodologies in the conceptualisation and design of digital health interventions, and the imperative to develop solutions that are simple, accessible and that can be personalised according to the preferences and capabilities of the individual patient. Regarding data protection, data sharing and artificial intelligence, the findings indicate opportunity for information and education, as well as the need to offer patients transparency and accountability in order to build trust in digital technology and digital health interventions.

1 Introduction

The growing prevalence of cardiovascular disease (CVD) presents an increasing global challenge. Accounting for 18.6 million deaths per year in 2019, CVD remains the leading cause of death worldwide ( 1 ). Patients suffering from CVD and its sequelae such as myocardial infarction, heart failure and stroke face severe burden, including reduced quality of life, reduced exercise tolerance and a higher risk of hospital admissions and mortality ( 2 ). In Austria in 2019, the age-standardised CVD incidence was 654 per 100,000, the age-standardised mortality attributed to CVD was 151 per 100,000, and CVD accounted for 5,105 disability-adjusted life-years per 100,000 across all ages in both sexes ( 1 ). Prevention is of utmost importance to reduce morbidity and mortality caused by CVD ( 3 ).

Exercise-based cardiac rehabilitation is an evidence-based secondary prevention model that has been proven to prolong life and improve functional capacity, well-being and quality of life for individuals with CVD ( 4 , 5 ). Exercise-based cardiac rehabilitation is a multidisciplinary intervention comprising clinical assessments, patient education, pharmacological therapy, exercise training, physical activity counselling, psychological support and support to address CVD risk factors and lifestyle modifications. In the setting of this study in Austria, cardiac rehabilitation provision is standardised according to national guidelines and organised in four phases: phase I refers to the acute hospital admission; phase II refers to a structured programme under medical supervision in an inpatient (3 to 4 weeks) or outpatient (up to 6 weeks) setting, with the main focus on improving physical performance; phase III refers to a 6 to 12 months outpatient programme, with the aim of supporting sustainability of lifestyle modifications; and phase IV refers to patients' independent lifelong secondary prevention by continuing the CVD preventive behaviour from the previous phases ( 6 , 7 ). Notably, the structure and organisation of cardiac rehabilitation programmes can differ between countries ( 8 ).

Despite the well-known benefits of exercise-based cardiac rehabilitation, many patients who qualify for it based on their medical history do not participate in cardiac rehabilitation programmes, with reported participation rates among eligible CVD patients in Austria of 30% and 20% for phases II and III, respectively ( 9 ), and 30%–50% in other European countries ( 8 ). Moreover, there is limited adherence and carry-over from the well-supervised cardiac rehabilitation phases to patients' independent secondary prevention behaviour. The maintenance of regular heart-healthy physical activity and exercise, for example, constitutes a crucial secondary prevention behaviour, but the effectiveness of cardiac rehabilitation programmes for establishing long-tern physical activity habits is variable ( 10 , 11 ).

Low participation in cardiac rehabilitation programmes and poor long-term adherence to CVD secondary prevention behaviours are important contributing factors for re-hospitalisation and high rates of morbidity and mortality. The underlying reasons for low participation and poor adherence are many and multi-faceted ( 12 , 13 ), including patients' employment and family responsibilities, location of cardiac rehabilitation centres and resulting travel times for patients, lack of social support from family and friends, and lack of knowledge and low health literacy (i.e., an individual's ability to access, understand and act on health information; 14 ) of individuals with CVD.

Digital technologies have the potential to address or at least alleviate some of these reasons. The term “digital health” describes the implementation of digital technology in the context of healthcare, encompassing “electronic health” (i.e., the use of information and communications technology in the health domain), “mobile health” (i.e., the use of wireless technologies for the purpose of health), “telemedicine” (i.e., the provision of health services at a distance), and emerging areas such as the use of advanced computing sciences in big data and artificial intelligence ( 15 ). Numerous scientific publications describe the vast potential of digital health interventions to advance the care of individuals with CVD, for example by enabling home-based and technology-based cardiac rehabilitation across phases II, III and IV ( 16 ), by supporting regular physical activity and other heart-healthy lifestyle modifications through text-messaging programmes, smartphone applications and wearable devices ( 17 ), or by enhancing clinical decision-making through artificial intelligence-supported analysis of large volumes of patient data ( 18 ). Moreover, systematic reviews provide good evidence of patient safety of digital health interventions for cardiac rehabilitation, with some studies even reporting fewer associated adverse events in digital intervention groups than in control groups ( 19 ). However, attempts at implementing such digital health interventions in real-life clinical practice frequently encounter various barriers ( 20 ). From the perspective of CVD patients, two consistently reported barriers are poor digital literacy and skills (i.e., lack of understanding of, or lack of physical capabilities to interact with digital health interventions) and low acceptability (i.e., lack of perceived effectiveness and low use of digital health interventions; 20 ).

Insight into CVD patients’ experiences and perspectives regarding the use of digital technology can assist developers, researchers and clinicians in addressing or pre-empting these patient-related barriers. These patient perspectives can be incorporated in the design of digital health interventions and in the design of evaluation studies and implementation strategies for digital health interventions. But to date, there have not been any publications of such studies for the Austrian cardiac rehabilitation community.

The present study was therefore conducted to investigate the experiences and perspectives of cardiac rehabilitation patients in Austria with regard to using digital technology, in particular for physical activity and exercise. The study addressed the following research questions: What are the reasons for use or non-use of digital devices? What are obstacles to the implementation of digital health interventions? What is the user experience and acceptance of currently available digital technology? And what are patients' views on recent developments and challenges in digital health around data protection, data sharing and artificial intelligence?

2 Materials and methods

2.1 study design.

We conducted a qualitative study with semi-structured interviews to explore patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation. The reporting of this study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ; 21 ). The COREQ checklist is provided in Supplementary Appendix S1 . In the overarching methodological orientation of this work, we took a phenomenological approach, aiming to explore the topic from the perspective of those who have lived experience of CVD and cardiac rehabilitation ( 22 ).

2.2 Setting and sampling

The study was conducted at the Ludwig Boltzmann Institute for Digital Health and Prevention in Salzburg, Austria. Participants were recruited from among current and previous cardiac rehabilitation patients at the University Institute of Sports Medicine, Prevention and Rehabilitation in Salzburg, Austria. The sampling strategy was purposive, aiming for diverse representation in terms of age, gender and time since cardiac event.

A target sample of 25 participants was possible within the study resources and timeline and expected to yield relevant breadth and depth of data. Eligible were adult patients with a diagnosed CVD who were current or previous participants in phase II cardiac rehabilitation and residents of the city of Salzburg or its surrounding areas. Excluded were individuals with limited German language proficiency. Forty-nine eligible patients were identified from patient records at the recruiting site and invited to take part in the study, either in writing by letter or in person by clinical staff at the site. Patients were provided with a study information leaflet including a contact for patients to inquire further about the study. Patients were given at least 48 h to consider their participation in the study. All patients who agreed to take part in the study gave written informed consent.

2.3 Data collection

The content of the semi-structured interviews was developed based on relevant literature and included questions to explore two major topic areas: physical activity in cardiac rehabilitation, and digital technology. The interview guide was piloted with members of the Ludwig Boltzmann Institute's service user advisory group, consisting of CVD patients who had attended cardiac rehabilitation. All interviews were conducted by JG either face-to-face in a private room at the Ludwig Boltzmann Institute or remotely via video call if preferred by the participant. Interviews lasted between 34 and 92 min. No other persons were present during the interviews. Each participant gave one interview. All interviews took place during July to October 2020. All interviews were conducted in German. Interviews were audio-recorded on two voice recorders. Opening questions were asked verbatim according to the interview guide, and follow-up questions were asked optionally and depending on the course of the conversation. An English translation of the interview guide is attached in Supplementary Appendix S2 .

Concluding the interview, participants were asked to answer demographic and disease-related questions, and to self-complete the German version of the International Physical Activity Questionnaire Short Form (IPAQ-SF; 23 ) and the German TA-EG questionnaire, a measure of affinity for technology ( 24 ). The IPAQ-SF includes seven questions to capture the volume and intensity of physical activity during the past seven days, allowing an estimate of physical activity levels (low, moderate, high) based on metabolic equivalents of tasks. The TA-EG questionnaire comprises 19 statements about technology (enthusiasm in the interaction with technology, subjectively experienced competence, positive consequences and negative consequences of the usage of technology), and respondents rate the extent to which each statement applies to them. Ratings range from 1 to 5, with higher scores reflecting higher affinity for technology. Participants completed the questionnaires independently while the interviewer remained in the room, available to answer questions if needed.

2.4 Data analysis

For our data analysis, we applied a mixed deductive and data-driven inductive approach using framework analysis according to the steps described by Gale et al. ( 25 ): transcription, familiarisation with the interview, coding, developing a working analytical framework, applying the analytical framework, charting data into a framework matrix and interpreting the data.

All audio-recorded interviews were transcribed verbatim, partly by the interviewing researcher (JG) and partly by a professional transcription service. Transcripts were pseudonymised, removing any information that could identify the speaking participant. These transcripts, supplemented by the IPAQ-SF and TA-EG questionnaires, constituted the data for analysis.

Data analysis was conducted by AZ with methodological support from STK and using Delve qualitative analysis software ( https://delvetool.com/ ). During the familiarisation process, AZ read and re-read the interview transcripts several times, listened to the interview recordings, and wrote down her thoughts and impressions in analytical notes. Due to the richness of the data, we decided to restrict the analysis to interview sections related to digital technology, specifically with a focus on understanding the facilitators and barriers to use of digital technology for physical activity and exercise. AZ first read several transcripts and conducted line-by-line coding, describing her interpretation of quotes. These codes gave rise to the initial framework development. As AZ coded further transcripts, the initial framework was discussed and reviewed iteratively with STK and RC until consent was achieved. Afterwards, the coding framework was applied to the remaining transcripts, including one open category (“other”) to allow inductive coding of passages that did not match any of the framework codes but were considered interesting and relevant regarding the aim of the study. The coding framework and definitions of codes are provided in Supplementary Appendix S3 . Once all the transcripts were coded, the data was summarised by category and charted into a thematic matrix. The final step of the data analysis was the interpretation of the data by identifying characteristics and differences, generating typologies and integrating theoretical concepts ( 25 ).

2.5 Research team and reflexivity

At the time of the study, the female interviewer (JG) was a pre-doctoral researcher at the Ludwig Boltzmann Institute with a background in nursing, master's degree and previous experience in qualitative interviewing. Other than communicating and establishing rapport with participants who expressed interest in the study, JG did not have any prior relationship with study participants. Participants knew that the research was conducted by JG in her role as researcher at the institute. The female data analyst (AZ) was a medical student with a previously completed psychology degree and conducted the data analysis as a research project towards her medical degree. AZ worked with the transcripts only and had no contact with study participants. STK was a research group leader at the Ludwig Boltzmann Institute with a background in physiotherapy and a doctoral degree in clinical neuroscience. He led the study and provided supervision and methodological support to JG and AZ. RC was professor of behaviour change and technology. He provided methodological and content expertise in the study design and data analysis. JN was professor of cardiology, scientific director of the Ludwig Boltzmann Institute and medical director of the recruiting site. He provided operational support for study recruitment and content expertise in the study design and data analysis.

Our reflexive stance, and in particular the reflexive stance of AZ as the main data analyst, was to take a descriptive approach aligned with transcendental phenomenology. We sought to bracket our individual subjectivity and to remain vigilant to the bracketing work, so as not to bias the analysis and interpretation ( 22 ).

We employed several strategies for enhancing scientific rigour in qualitative research. AZ recorded reflexive and analytic notes throughout the analysis and interpretation process and discussed these in regular peer review meetings with STK and RC. We did not conduct member checking of interview transcripts or analysis results with study participants. We used the questionnaire data (IPAQ-SF, TA-EG) to incorporate an element of triangulation to the qualitative analysis. In the reporting of this study, we followed an international reporting standard for qualitative research ( 21 ).

2.7 Ethical and regulatory considerations

This study was conducted according to standard ethical practice in healthcare research with humans ( 26 ). Study participation was voluntary, and all participants provided written informed consent. Participants were free to discontinue their participation without giving a reason and without incurring any negative consequences. The study was submitted for review to the medical research ethics committee of the county of Salzburg (reference number 1040/2020) and was exempt from formal ethical review due to its low risk.

Eighteen (72%) male and seven (28%) female patients participated in the study. Participants' age ranged from 39 to 83 years, with a mean age of 65.1 (SD = 9.6) years for male participants and 69.4 (SD = 9.8) years for female participants. Fifteen participants (60%) reported high physical activity levels, two (8%) reported moderate physical activity levels and eight (32%) answered the IPAQ-SF questionnaire incompletely. The sample's affinity for technology according to the TA-EG questionnaire was slightly above average, scoring 2.9 (SD = 0.9) for “enthusiasm”, 3.2 (SD = 1.0) for “competence”, 3.6 (SD = 0.6) for “positive attitude” and 3.2 (SD = 0.8) for “negative attitude”. Participant characteristics are presented in Table 1 .

Table 1 . Participant characteristics.

Figure 1 gives an overview of themes and codes according to the coding framework ( Supplementary Appendix S3 ). For this results section, complementary codes were combined and are presented together to offer meaningful descriptions under the following sub-headings: reasons for using digital devices; reasons for non-use of digital devices; type of technology being used; need for improvement and complaints; attitude towards data protection; preparedness to share personal data; General Data Protection Regulation (GDPR); communication of data protection regulations; awareness of artificial intelligence; and trustworthiness of artificial intelligence. The description of results is supported with direct quotes, which were translated from the original German to English by AZ and STK. Quotes include participant pseudonyms, allowing cross-referencing with participant characteristics in Table 1 .

Figure 1 . Overview of themes and codes. AI, artificial intelligence; GDPR, general data protection regulation.

3.1 Reasons for using digital devices

Although all the participants in the study owned a smartphone, only a little over half used it for more than simply making phone calls. For analytic purposes, participants were categorised into users ( n  = 15, 60%) and non-users ( n  = 10, 40%) of digital devices, whereby those who reported using digital technology such as smartphone applications, smartwatches or other tracking devices to support a healthy lifestyle and exercise in the context of their cardiac rehabilitation were categorised as “users of digital technology”.

The majority of users explained that digital technology had been recommended to them during cardiac rehabilitation and that their awareness of the importance of regular exercise and health monitoring had been created by healthcare professionals:

Since they have actually recommended that [the use of digital devices] in the cardiac rehabilitation centre. (P08)

[I use that] in order to move in a better way, in order to move more. That is quite important! (P03)

For digital device users, features related to health monitoring were of great importance. The three most mentioned health monitoring aspects were heart rate, blood pressure and caloric consumption. Many participants were concerned about being able to track their heart rate during physical activity:

Well, of course, I need a heart rate monitor on my watch, because the heart rate should not rise too much. (P01)

To me, the minimum requirement is the blood pressure measurement. (P04)

Well, the step counter is important to me, because it shows my calorie consumption, doesn't it? (P03)

Some participants not only appreciated the ability to continuously monitor their health through digital devices, but also wished for extended monitoring capabilities, including longer battery life and the ability to monitor health during sleep:

The battery life [needs to be improved]. Because, if you are out and about all day, it needs to work for more than a maximum of four hours, in order to monitor without interruption. (P04)

Apart from being able to monitor health parameters, many participants enjoyed the motivating features of digital devices:

It is simply nice; if I am out and about anywhere, the watch on my wrist is suddenly vibrating, and I realise that I have at least met today's minimum requirement. (P3)

It is kind of motivating! Right now, it is a little fun. (P08)

Some interviewees also highlighted that use of digital devices provided them with a sense of security and encouraged them to reflect on their own health behaviour:

I use that right now because it simply gives me a sense of security. (P23)

Well, it is kind of a reflection tool to me. (P08)

One participant stated that their main reason for exercising and using digital devices to improve their overall health was grounded in self-love. The interviewee explained that any technology was useless, unless one took care of oneself and one's health and well-being:

Actually, it is all about self-love. (P12)

3.2 Reasons for non-use of digital devices

Reasons for not using digital devices in cardiac rehabilitation or for exercise were varied. While some patients claimed to have “too little time” for dealing with technologies, others expressed an aversion to digital devices, due to negative past experiences:

I am annoyed by the sounds […] it stresses me out. (P16)

I once owned such a device. That means, it actually never really worked. (P25)

Several participants stated that they actively avoided handling digital devices:

I actually try to avoid such devices […] I am more the analogue type. (P14)

I am old-fashioned. (P15)

Other participants outright rejected digital devices, finding them unnecessary:

I think I don't need that. Because I got a kind of feeling. I can do things without that. I don't need that. (P20)

Some also considered technology as a threat and expressed concerns about being under constant surveillance and controlled by technology:

I don't want to be controlled by such a device! (P07)

That's my opinion. It is bad for people. (P16)

The difference in attitudes between users and non-users of digital technology was also reflected in the TA-EG scores, which averaged 3.3 (SD = 0,7) vs. 2.3 (SD = 0,8) for “enthusiasm”, 3.4 (SD = 0.8) vs. 2.9 (SD = 1.2) for “competence”, 3.8 (SD = 0.5) vs. 3.4 (SD = 0.6) for “positive attitude” and 3.3 (SD = 0.7) vs. 3.0 (SD = 0.9) for “negative attitude”, respectively.

Notably, many participants among both users and non-users of digital technology mentioned their dependence on younger relatives when handling digital devices, describing that they relied on someone to regularly explain and show them new features and applications:

My son got me a tablet for Christmas, and he showed me how to look at pictures. I cannot do much more than that with it, but I don't want to anyway. (P06)

3.3 Type of technology being used

Participants stated that the devices they predominately used to monitor exercise and health parameters were smartphones and smartwatches. Most participants expressed their appreciation for simple handling and pre-installed health applications on their devices, such as the step counter function:

Yes, the walking function is on it [the phone]. My 6,000 steps are on it. That has already been integrated on the smartphone, completely installed. (P02)

Yes, I have such an app. […] that means I have to always carry my phone with me. It exactly shows how many steps one takes or what one has done in a day. (P18)

[…] so, if I look at my watch today, I look at a quite good, new Suunto. That's where my step counter has been installed automatically. (P21)

Well, the Apple watch is quite convenient, […] insofar as I find all relevant applications in the main menu. (P10)

Only a few participants reported using health and exercise-promotion programmes offered on television or online during the COVID-19 pandemic. Few participants also used more sophisticated devices such as global positioning system (GPS) sensors and other types of monitors incorporated into their bicycles or other sports equipment:

Yes, that's the GPS on the mountain bike. It shows altitude and helps with orientation, geographically, kilometres, and distances and so on. […] That's actually my favourite device. (P04)

3.4 Need for improvement and complaints

With regard to complaints about digital technology and suggestions for improvement, the most often mentioned suggestion for improvement was a call for more simplicity. Participants stated that they did not want to use devices if they were too complicated to handle. Additionally, it was highlighted that the screen design and the text format had to be accessible and appealing:

It has so many features that I do not need at all. (P02)

Some devices go far too much into detail. (P13)

It is important that you don't have to search for applications again and again. It should be clearly visible. Otherwise, one loses one's temper. (P13)

Some interviewees complained about the high level of dependence that technical devices would lead to:

People rely too much on the feedback from those devices and not on things that your body is telling you. (P12)

I have already started to sometimes take the smartwatch off. […] to get a feel for it heart rate] again, otherwise, I would non-stop check the watch. (P23)

A few participants criticised that the price of digital devices was too high and therefore unaffordable to them:

Well, if that [smartwatches] would be available at a reasonable price, then I certainly would be interested. (P08)

Some other users, however, stated that they were very pleased and satisfied with their devices and their handling.

There is not really a thing that I would want to improve. I have not even thought about that. (P03)

There is absolutely nothing irritating about that [device]. (P02)

3.5 Attitude towards data protection

When asked about data protection, interviewees displayed rather divergent attitudes. While some participants had a clear opinion on this issue, others stated that they did not care much about the topic of data protection, or that they simply found it to be an annoying issue:

The problem is, if you want to use certain apps, you have to give your consent anyway. (P02)

[…] the whole data protection issue is the dumbest thing in the world that someone could possibly think of. (P21)

Most participants stated that they were not too concerned about their data because they had “nothing to hide” anyway:

To be honest, when it comes to data protection, I usually say: “I don’t have any secrets!” […] I don't take that too seriously. If they want to know something, let them know. (P02)

In principle, I go through life like that: if you are not really up to anything [secretive], nothing can happen to you with regard to data protection. (P12)

In contrast, a few interviewees expressed their concerns about the use and transfer of data, as well as their wish for more transparency around data usage:

That's why I say: I simply want to be in control of my data. (P10)

Well, when it comes to the internet, I am rather cautious. I am fully aware that all the data is certainly used somehow. In my opinion, more education and transparency on this topic would be quite important. (P16)

3.6 Preparedness to share personal data

Some participants stated that they would be prepared to share all their personal data, and that they did not consider anything to be private data which should be handled confidentially:

I don't have that kind of data that I would not be prepared to share. (P18)

I am like an open book. (P03)

Most participants, however, reported at least one type of personal data that they were not willing to share. Many participants were most concerned about their financial data:

When it comes to financial data, one must be particularly careful. (P04)

I have a small book back home. In there, all my bank data, the credit card number and stuff like that is handwritten and safe. I would never put that sort of data on my phone. (P17)

To other participants, data about their leisure time, their current location or their family life was viewed as most important and confidential, and not to be shared:

Well, I don't want to share my current location. I don't want to disclose any GPS data to any apps. (P15)

[I would not share] anything that has to do with my leisure time. (P12)

Regarding the sharing of personal health data, interviewees' views were divided. Some participants stated that they would never willingly share their own health data, while others considered it their duty to share health data with healthcare institutions and providers, for example for health research purposes:

Yes, of course [I would share my data] for research purposes! (P18)

Concerning medicine, I have to say, due to my personal medical history, I feel kind of obligated to return some favours to the health care system in any manner. (P19)

Some of those who were not prepared to share their personal health data explained that they were afraid that this type of data could disadvantage them or be used against them by health and social care organisations:

I don't have ELGA [Austrian electronic personal health record]. When it comes to health data, they pigeonhole people due to previous illnesses and stuff like that. (P24)

When it comes to health data, like serious diseases that are dealt with by the health insurance, I have to fear that it is passed on or traded. (P13)

If they are going to cut any benefits, then I have concerns! They have been talking about cutting certain things if one is obese. (P02)

3.7 General data protection regulation

Most participants reported that they were not familiar with the meaning or the content of the European Union General Data Protection Regulation (GDPR):

I have heard about it, but I don’t know what it is about. (P16)

Other participants stated that they were well-aware of the GDPR and its content. Moreover, a few interviewees had personally made use of the regulation by asking companies and organisations to delete their data:

[…] and that's when I told them, well, that I didn't [want] my data [to be used] any longer. Well, I think that worked automatically. (P18)

[…] so I sent a text message that referred to the GDPR and told them to delete all of my personal data and to never contact me again. The IT department even sent me a confirmation that everything has been removed. (P12)

Personal attitudes towards the GDPR varied. While some participants expressed their appreciation for the regulation, the majority did not approve of it:

I appreciate that. Yes, that is awesome! […] that I have the right to make use of it; this is very good! (P09)

No, this is totally unnecessary, because I know exactly whom I contact. (P24)

There is no point. (P05)

No, I have no need for that. […] I think I have nothing to hide, so I don't care at all. (P21)

3.8 Communication of data protection regulations

When participants were asked about their opinion regarding the need to confirm data protection declaration or data privacy statements (for example, when downloading apps or programmes), most participants expressed their preference for a shorter, simpler and more appealing presentation of data protection regulations. Some suggested the use of keywords or the highlighting of essential passages:

Of course, that could be designed in a better way. The key points could be highlighted, so there won't be misunderstandings. It could be reduced to the three or four most important questions. (P08)

That's the problem: who would ever have enough time to read and go through all that stuff? (P05)

Others wished for more transparency, larger font size and a more accessible design:

If the content is written in small print on the last page, no one is going to find that. (P21)

[…] if there was more transparency, that would be good! (P18)

[…] it is hard for the user to understand the content. […]no, it is too complicated. (P12)

3.9 Awareness of artificial intelligence

With regard to awareness of artificial intelligence, the sample represented a range from those who had little or no awareness to those who had in-depth knowledge about artificial intelligence. Only very few participants stated that they had never heard of artificial intelligence before:

No, [I have not heard about artificial intelligence yet]. What is it about? (P01)

Most participants reported having some general idea about artificial intelligence and its areas of application:

Well, I think artificial intelligence is becoming increasingly important in the medical sector. (P23)

Sure, Tesla, for example. Self-propelled cars, robots, drones. (P13)

And some participants stated that they had personal experience with artificial intelligence in the past:

Yes, I have been dealing with that. […] well, it is a double-edged sword. (P08)

You see, I have worked for an advertising agency, and artificial intelligence has been an important issue at work. […] everything that's happening in online stores or social media; in the background, there is always an algorithm and artificial intelligence and so on. (P19)

3.10 Trustworthiness of artificial intelligence

In terms of the trustworthiness of artificial intelligence, participants' opinions diverged. Some participants explained that they would feel comfortable relying on artificial intelligence:

I would rely blindly on. I would trust it. […] however, there is always somebody who initially had to program it, hence, the intelligence is still coming from people, in my opinion. (P17)

This is our future, for sure! Artificial intelligence, yes definitely! (P18)

Yes, of course [I would trust artificial intelligence]! It can be controlled. You can always recheck and do another test. (P02)

All that, it is unrealistic to me! I don't comprehend it, that's very suspicious to me. Well, I mean, it is artificial. I have to say; I am always skeptical regarding anything artificial. (P03)

I don't think that artificial intelligence can or should be trusted blindly. (P19)

If I would receive a Tesla S with an autopilot as a gift, I would never hand the steering wheel to artificial intelligence or electronics. (P13)

Some interviewees expressed concerns and fears over the use of artificial intelligence and its applications:

Well, let me put it that way: if a machine suddenly is way more intelligent than its owner, then it's getting worrisome. Jobs are going to be lost! (P25)

Indeed, that's a bit creepy, to be honest! I am scared, yes! (P16)

4 Discussion

We conducted semi-structured interviews to investigate the experiences and perspectives of 25 current and former cardiac rehabilitation patients in Austria with regard to using digital technology. The sample included individuals who readily used digital devices to support their physical activity, exercise and health monitoring, and individuals who did not. Simplicity, convenience and accessibility were highlighted as important facilitators for the use of digital technology, while annoyance with digital devices, concerns about becoming dependent on them, or simply a preference to not use digital technology were commonly stated reasons for non-use. Interviewees' views on data protection, data sharing and artificial intelligence revealed wide variations in individuals' prior knowledge and experience about these topics, and a need for greater accessibility and transparency of data protection regulation and data sharing arrangements.

4.1 Age-specific requirements

Although all participants reported owning a smartphone, only slightly more than half of the study group actually used smartphone applications and features beyond the simple function of calling. This observation is also mirrored in the Austrian general population of the corresponding age groups, although there has been an increasing tendency to use internet-based digital devices over the past 15 years ( 27 ). Reasons for non-use of digital technology may be attributed to generally low affinity for technology—as reflected in the low TA-EG scores for “enthusiasm” in our sample –, negative experiences related to technology, specific fears or concerns about using digital devices, or barriers related to older age ( 28 – 30 ). Krishnaswami and colleagues emphasise that age-specific barriers must be considered in the development and utilisation of technologies for older age groups ( 31 ). Participants in the present study suggested more simplicity of digital technology, including more appealing interfaces and less disrupting or irritating features, which echoes the findings of other studies. This poses the challenge to developers of digital health interventions to identify and be responsive to barriers across different age groups, and to design solutions that meet age-specific needs.

4.2 Dependence on support from others

Interviewees in the present study frequently reported a dependence on younger relatives, as many expressed a need for someone to explain features and applications to them, or to perform the installation and set-up of software and digital devices. Such lack of digital skills and limited knowledge and experience with digital applications present considerable obstacles to implementing digital health interventions in clinical practice ( 32 ). The active involvement of more digitally skilled spouses, partners, family members or friends in care processes might offer a solution ( 33 , 34 ). Nevertheless, not all CVD patients can rely on such a support system, and healthcare providers should consider to also offer formal user training and support to accompany the implementation of a digital health intervention ( 31 ). In addition to equipping patients with the skills to use a specific digital health intervention, such formal training and support provides an opportunity to educate patients about the more general technological background, infrastructure and regulations, thereby helping to reduce reservations and concerns about digital health.

4.3 Peer support

The importance of strategies that promote peer support among cardiac rehabilitation patients is frequently reported in other studies (e.g., 35 ), but interestingly this was not a prominent topic in the present study. Digital technology offers many possibilities to create opportunities for peer support, by connecting patients to each other through remote communication technology (video calls, email, messaging) or social media platforms (Facebook, WhatsApp, etc.), or by incorporating specific behavioural techniques for peer support in digital health interventions, such as the sharing and affirming of one's behavioural intentions, goals and achievements in the digital peer group. In this context, previous studies have highlighted the importance of face-to-face contact and the value of developing a sense of community with other patients as well as with clinical staff ( 30 , 33 , 35 , 36 ). While it is possible to achieve this through digital technology, for example using video conferencing platforms for face-to-face meetings and facilitating online communities via social media platforms, intervention developers may also consider blended formats including periodic in-person meetings for users of a digital health intervention.

4.4 Continuous monitoring and feedback

In Austria, cardiac rehabilitation programmes incorporate a focus on reducing the risk of recurrence by encouraging CVD patients to track their own health parameters ( 6 , 37 ). Hence, it is not surprising that many interviewees in our study talked about their motivation and ambition to monitor heart rate, blood pressure and calorie consumption. Most users of digital technology perceived the monitoring functions of their digital devices as very beneficial for improving their physical activity and health. Some interviewees even expressed an interest in more extended and continuous monitoring capabilities of their devices, for example suggesting that devices should have longer lasting batteries to enable longer and continuous operation. Additionally, receiving frequent or continuous feedback seemed to not only provide users of digital technology with a sense of security, but to also serve as a motivating factor, as reaching one's goals was perceived as increasing one's motivation, self-confidence (self-efficacy) and self-esteem. Other qualitative studies of digital health interventions have reported similarly positive perceptions of self-monitoring and self-evaluation among CVD patients (e.g., 36 ). This was in stark contrast to interviewees in the “non-user” group, some of whom expressed that self-tracking and the generated data from it could lead to uncertainty, anxiety or fear. Some participants stated more nuanced concerns about relying too much on the feedback from digital devices and losing touch with feeling one's own body, while others decidedly considered technology and surveillance a threat. From an intervention developer's perspective this indicates a need to acknowledge these different sides of patients' experiences and to incorporate patients' views about useful features in the design of digital health interventions. Empowering users by giving them control over the extent and pervasiveness of digital monitoring functionalities may offer a solution for catering to different levels of engagement.

4.5 Data protection

Aside from the GDPR, which was introduced in 2018 and has significantly contributed to raising the profile of data protection issues across the European Union ( 38 ), the concept of “do-it-yourself data protection”—describing that comprehensive data protection needs to be done more and more by individuals themselves—has become increasingly relevant, as a growing number of actors are interested in individuals' personal data ( 39 ). This is compounded by the “digital divide”, i.e., the gap between those who have access to forms of modern information technology and those who do not ( 40 , 41 ), placing individuals who lack knowledge, social status or resources to access digital technology or information at a disadvantage, also with regard to the protection of their personal data. Of note, the majority of interviewees in the present study appeared to care little about data protection. The statement “I have nothing to hide” was made frequently, expressing a sense of carefree light-heartedness that may reflect age, as it has been reported that older people are less likely to use tools or strategies that protect their personal data as compared to younger generations ( 39 ).

Conversely, some participants did express concerns about online security, called for more transparency and information about how their data was being processed, and stated a desire to be more in control of what was happening to/with their data and whether/how it was being shared, traded or otherwise used. However, this does not necessarily mean that these participants' online privacy behaviours were consistent with their attitudes, which can be explained by a knowledge gap ( 42 ). It has been reported that, although people express concerns about using and trading their personal data, they still share personal content online and accept that their data is taken and used by online providers. This observation indicates a lack of privacy literacy that prevents people from acting in a way that represents their beliefs and needs ( 42 ). Consistent with this observation, many participants in the present study stated that they provided their consent to privacy policies of websites and apps because, in their opinion, there was no alternative. Fostering knowledge about the technical aspects of online privacy and protection, laws and legal aspects, and strategies for individual privacy regulation is necessary in order to increase privacy literacy.

4.6 Sharing personal health data

There is now great international momentum towards enabling the sharing of personal health data to support healthcare delivery (“primary use of data”), and to facilitate access to health data for research and policy-making purposes (“secondary use of data”), for example through the establishment of the European Health Data Space ecosystem for data sharing ( 43 ). While some participants in the present study were fully prepared to share their personal health data with healthcare or research institutions, others expressed their preference to not share their personal data with anyone. Two main concerns were that health data could in some way be used against the person, and that there was a need for more transparency and information about data processing and trading. In particular, some participants expressed concerns that health insurances would deny payments based on information gained from personal health records. Public health research, however, relies on access to medical records and personal health data. If informed consent is required to access data from health records, this can lead to bias introduced through systematic differences between those who provide consent and those who do not. Therefore, it is essential to foster trust by offering patients information, education and transparency about data sharing processes and across all stages of data collection and processing ( 44 ). Public involvement in the discourse about the use of individual health records for healthcare research is of strategic importance to gain acceptance and reduce concerns and suspicion ( 45 ).

4.7 Artificial intelligence

Artificial intelligence has significantly advanced clinical care, for example by improving software for medical devices, facilitating the processing of large amounts of data and enabling greater precision of imaging technologies ( 46 ). In the past few years, the field has made great strides particularly in the development of large language models and natural language processing tools such as ChatGPT, with predictions that such applications of artificial intelligence could become valuable resources for clinical practice in the future ( 47 ). In this study, many participants viewed artificial intelligence with skepticism or even considered it worrisome or frightening. With regard to medical treatments, some participants stated that they would trust medical doctors more than they would trust any sort of artificial intelligence. This skeptical attitude might arise from a lack of information or a general objection to anything “artificial” as opposed to “natural”. Medical decision-making in general needs to account for uncertainty and often heterogeneous, erroneous, inaccurate or unknown data. While artificial intelligence might offer a way to integrate, fuse or map various data sources to support personalised decision-making and therapy prescription, it needs to be explainable and traceable to the extent that healthcare professionals have a possibility to understand how and why an artificial intelligence has arrived at a certain outcome ( 48 ). This level of transparency of the decision-making process is likely to also increase patients' trust. Some authors warn that the growth of artificial intelligence in healthcare might compound a trend from “hands-on” personal clinical practice to disembodied technological procedures ( 49 ). Others raise concerns whether artificial intelligence applications truly serve the patients' interests, or rather those who developed them ( 50 ). Against the background of these current academic discourses, the skeptical stance of many interviewees in the present study—albeit grounded mainly in intuitive reasoning rather than in an in-depth knowledge of the topic—certainly appears justified.

4.8 Technological solutionism

The terms “technological solutionism” and “technological fix” describe an ideology in which social or individual problems are considered discrete processes that can be improved and optimised by technological interventions ( 51 ). The steadily increasing body of evidence that demonstrates positive impacts of digital health interventions serves to amplify the widely publicised expectations that digital technology will (continue to) transform, or even revolutionise, healthcare ( 52 , 53 ). This plays into a narrative of technological solutionism, placing emphasis on digital technology and its role for improving health. However, some authors criticise technological solutionism for denying the role of intrinsic and personal factors for individual health, as illustrated by one participant in the present study who was asked how CVD patients’ level of physical activity and exercise could be further increased and replied that “[…] actually, it is all about self-love!” (P12). There is therefore a balance to be struck, between, on the one hand, leveraging the fantastic capabilities of the many digital technologies that are available to us today and driving digital development forward, and, on the other hand, maintaining the focus on understanding individual patients' core needs and their personal motivating factors to incorporate these into personalised care that may include digital health interventions.

4.9 Limitations

We acknowledge several limitations to this study. Due to the recruitment of study participants via one clinical service, interviewees could have been influenced to some extent by clinical practice at the site, for example by rehabilitation professionals promoting digital technology as part of their practice. The sample size for this study was determined a priori by available resources, and we did not formally assess data saturation. However, acknowledging differences in interpretations and approaches to data saturation ( 54 ), we suggest that our sampling strategy achieved its purpose and resulted in a dataset that provided diverse views and depth of data. The analysing researcher (AZ) lacked the proximity to interviewees and interviews that comes with conducting interviews oneself, but she developed close familiarity to the data by repeatedly reading the transcripts and listening to the audio recordings of the interviews.

5 Conclusion

This qualitative interview study has provided insights into CVD patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation. The findings support the importance that is attributed to user-centred design methodologies in the conceptualisation and design of digital health interventions, and the imperative to develop solutions that are simple, accessible and that can be personalised according to the personal preferences and capabilities of the individual patient. With regard to data protection, data sharing and artificial intelligence, the findings indicate opportunity for information and education, as well as the need to offer patients transparency and accountability in order to build trust in digital technologies and digital health interventions.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The requirement of ethical approval was waived by Medical Research Ethics Committee of the County of Salzburg for this study involving humans because of its low risk. The study was conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

AZ: Formal Analysis, Writing – original draft, Writing – review & editing. JG: Writing – review & editing, Investigation. JN: Writing – review & editing, Formal Analysis, Methodology. RC: Conceptualization, Formal Analysis, Methodology, Writing – review & editing. SK: Formal Analysis, Methodology, Writing – review & editing, Conceptualization, Writing – original draft.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

The authors would like to thank all study participants for sharing their views and experiences, members of the Ludwig Boltzmann Institute's advisory group of cardiac patients for assistance in piloting the interview guide, and Hannah McGowan for support with manuscript editing.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fspor.2024.1371652/full#supplementary-material

1. World Heart Observatory (2024). World Heart Observatory . Available online at: https://world-heart-federation.org/world-heart-observatory/ (accessed January 2, 2024).

2. Perel P, Avezum A, Huffman M, Pais P, Rodgers A, Vedanthan R, et al. Reducing premature cardiovascular morbidity and mortality in people with atherosclerotic vascular disease: the world heart federation roadmap for secondary prevention of cardiovascular disease. Glob Heart . (2015) 10:99–110. doi: 10.1016/j.gheart.2015.04.003

PubMed Abstract | Crossref Full Text | Google Scholar

3. Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, et al. 2021 ESC guidelines on cardiovascular disease prevention in clinical practice: developed by the task force for cardiovascular disease prevention in clinical practice with representatives of the European society of cardiology and 12 medical societies with the special contribution of the European association of preventive cardiology (EAPC). Eur Heart J . (2021) 42:3227–337. doi: 10.1093/eurheartj/ehab484

4. Ambrosetti M, Abreu A, Corrà U, Davos CH, Hansen D, Frederix I, et al. Secondary prevention through comprehensive cardiovascular rehabilitation: from knowledge to implementation. 2020 update. A position paper from the secondary prevention and rehabilitation section of the European association of preventive cardiology. Eur J Prev Cardiol . (2020) 28(5):460–95. doi: 10.1177/2047487320913379

Crossref Full Text | Google Scholar

5. Hansen D, Abreu A, Ambrosetti M, Cornelissen V, Gevaert A, Kemps H, et al. Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the secondary prevention and rehabilitation section of the European association of preventive cardiology. Eur J Prev Cardiol . (2022) 29:230–45. doi: 10.1093/eurjpc/zwab007

6. Niebauer J, Mayr K, Tschentscher M, Pokan R, Benzer W. Outpatient cardiac rehabilitation: the Austrian model. Eur J Prev Cardiol . (2013) 20:468–79. doi: 10.1177/2047487312446137

7. Niebauer J. Cardiac rehabilitation in Austria. Wien Med Wochenschr . (2018) 168:46–9. doi: 10.1007/s10354-017-0607-x

8. Humphrey R, Guazzi M, Niebauer J. Cardiac rehabilitation in Europe. Prog Cardiovasc Dis . (2014) 56:551–6. doi: 10.1016/j.pcad.2013.08.004

9. Bjarnason-Wehrens B, McGee H, Zwisler A-D, Piepoli MF, Benzer W, Schmid J-P, et al. Cardiac rehabilitation in Europe: results from the European cardiac rehabilitation inventory survey. Eur J Cardiovasc Prev Rehabil . (2010) 17:410–8. doi: 10.1097/HJR.0b013e328334f42d

10. ter Hoeve N, Huisstede BMA, Stam HJ, van Domburg RT, Sunamura M, van den Berg-Emons RJG. Does cardiac rehabilitation after an acute cardiac syndrome lead to changes in physical activity habits? Systematic review. Phys Ther . (2015) 95:167–79. doi: 10.2522/ptj.20130509

11. Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M. Cardiac rehabilitation and physical activity: systematic review and meta-analysis. Heart . (2018) 104:1394–402. doi: 10.1136/heartjnl-2017-312832

12. Ruano-Ravina A, Pena-Gil C, Abu-Assi E, Raposeiras S, van ‘t Hof A, Meindersma E, et al. Participation and adherence to cardiac rehabilitation programs. A systematic review. Int J Cardiol . (2016) 223:436–43. doi: 10.1016/j.ijcard.2016.08.120

13. Resurrección DM, Moreno-Peral P, Gómez-Herranz M, Rubio-Valera M, Pastor L, de Almeida C, et al. Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: a systematic review of prospective cohort studies. Eur J Cardiovasc Nurs . (2019) 18:38–47. doi: 10.1177/1474515118783157

14. Beauchamp A, Talevski J, Niebauer J, Gutenberg J, Kefalianos E, Mayr B, et al. Health literacy interventions for secondary prevention of coronary artery disease: a scoping review. Open Heart . (2022) 9:e001895. doi: 10.1136/openhrt-2021-001895

15. WHO. Recommendations on Digital Interventions for Health System Strengthening . Geneva: World Health Organization (2019). Available online at: https://www.who.int/publications-detail-redirect/9789241550505 (accessed January 2, 2024).

16. Taylor RS, Dalal HM, McDonagh STJ. The role of cardiac rehabilitation in improving cardiovascular outcomes. Nat Rev Cardiol . (2022) 19:180–94. doi: 10.1038/s41569-021-00611-7

17. Santo K, Redfern J. Digital health innovations to improve cardiovascular disease care. Curr Atheroscler Rep . (2020) 22:71. doi: 10.1007/s11883-020-00889-x

18. Amal S, Safarnejad L, Omiye JA, Ghanzouri I, Cabot JH, Ross EG. Use of multi-modal data and machine learning to improve cardiovascular disease care. Front Cardiovasc Med . (2022) 9:840262. doi: 10.3389/fcvm.2022.840262

19. Wongvibulsin S, Habeos EE, Huynh PP, Xun H, Shan R, Rodriguez KAP, et al. Digital health interventions for cardiac rehabilitation: systematic literature review. J Med Internet Res . (2021) 23:e18773. doi: 10.2196/18773

20. Tromp J, Jindal D, Redfern J, Bhatt A, Séverin T, Banerjee A, et al. World heart federation roadmap for digital health in cardiology. Glob Heart . (2022) 17:61. doi: 10.5334/gh.1141

21. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care . (2007) 19:349–57. doi: 10.1093/intqhc/mzm042

22. Neubauer BE, Witkop CT, Varpio L. How phenomenology can help us learn from the experiences of others. Perspect Med Educ . (2019) 8:90–7. doi: 10.1007/s40037-019-0509-2

23. Lee PH, Macfarlane DJ, Lam TH, Stewart SM. Validity of the international physical activity questionnaire short form (IPAQ-SF): a systematic review. Int J Behav Nutr Phys Act . (2011) 8:115. doi: 10.1186/1479-5868-8-115

24. Karrer K, Glaser C, Clemens C, Bruder C. Technikaffinität erfassen–der Fragebogen TA-EG. In: Lichtenstein A, Stößel C, Clemens C, editors. Der Mensch im Mittelpunkt technischer Systeme . Vol. 8. Berliner Werkstatt Mensch-Maschine-Systeme. Düsseldorf: VDI Verlag GmbH (2009). p. 196–201.

Google Scholar

25. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol . (2013) 13:117. doi: 10.1186/1471-2288-13-117

26. CIOMS. International ethical guidelines for health-related research involving humans. In: International Ethical Guidelines for Health-Related Research Involving Humans . Geneva: Council for International Organizations of Medical Sciences (CIOMS) (2016). Available online at: https://cioms.ch/wp-content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.pdf (Accessed March 10, 2024).

27. Statistik Austria. IKT-Einsatz in Haushalten 2021 [Household Use of Information and Communication Technology 2021] . Vienna: Statistik Austria (2021).

28. Devi R, Carpenter C, Powell J, Singh S. Exploring the experience of using a web-based cardiac rehabilitation programme in a primary care angina population: a qualitative study. Int J Ther Rehabil . (2014) 21:434–40. doi: 10.12968/ijtr.2014.21.9.434

29. Mathur S, Janaudis-Ferreira T, Hemphill J, Cafazzo JA, Hart D, Holdsworth S, et al. User-centered design features for digital health applications to support physical activity behaviors in solid organ transplant recipients: a qualitative study. Clin Transplant . (2021) 35:e14472. doi: 10.1111/ctr.14472

30. Kulnik ST, Sareban M, Höppchen I, Droese S, Egger A, Gutenberg J, et al. Outpatient cardiac rehabilitation closure and home-based exercise training during the first COVID-19 lockdown in Austria: a mixed-methods study. Front Psychol . (2022) 13:817912. doi: 10.3389/fpsyg.2022.817912

31. Krishnaswami A, Beavers C, Dorsch MP, Dodson JA, Masterson Creber R, Kitsiou S, et al. Gerotechnology for older adults with cardiovascular diseases: JACC state-of-the-art review. J Am Coll Cardiol . (2020) 76:2650–70. doi: 10.1016/j.jacc.2020.09.606

32. Cartledge S, Rawstorn JC, Tran M, Ryan P, Howden EJ, Jackson A. Telehealth is here to stay but not without challenges: a consultation of cardiac rehabilitation clinicians during COVID-19 in Victoria, Australia. Eur J Cardiovasc Nurs . (2022) 21:548–58. doi: 10.1093/eurjcn/zvab118

33. Walsh DM, Moran K, Cornelissen V, Buys R, Cornelis N, Woods C. Electronic health physical activity behavior change intervention to self-manage cardiovascular disease: qualitative exploration of patient and health professional requirements. J Med Internet Res . (2018) 20:e163. doi: 10.2196/jmir.9181

34. Dinesen B, Nielsen G, Andreasen JJ, Spindler H. Integration of rehabilitation activities into everyday life through telerehabilitation: qualitative study of cardiac patients and their partners. J Med Internet Res . (2019) 21:e13281. doi: 10.2196/13281

35. Anttila M-R, Söderlund A, Sjögren T. Patients’ experiences of the complex trust-building process within digital cardiac rehabilitation. PLoS One . (2021) 16:e0247982. doi: 10.1371/journal.pone.0247982

36. Su JJ, Paguio J, Baratedi WM, Abu-Odah H, Batalik L. Experience of coronary heart disease patients with a nurse-led eHealth cardiac rehabilitation: qualitative process evaluation of a randomized controlled trial. Heart Lung . (2023) 57:214–21. doi: 10.1016/j.hrtlng.2022.10.005

37. Niebauer J, Mayr K, Harpf H, Hofmann P, Müller E, Wonisch M, et al. Long-term effects of outpatient cardiac rehabilitation in Austria: a nationwide registry. Wien Klin Wochenschr . (2014) 126:148–55. doi: 10.1007/s00508-014-0527-3

38. Hussein R, Wurhofer D, Strumegger E-M, Stainer-Hochgatterer A, Kulnik ST, Crutzen R, et al. General data protection regulation (GDPR) toolkit for digital health. Stud Health Technol Inform . (2022) 290:222–6. doi: 10.3233/SHTI220066

39. Matzner T, Masur PK, Ochs C, von Pape T. Do-it-yourself data protection—empowerment or burden? In: Gutwirth S, Leenes R, De Hert P, editors. Data Protection on the Move: Current Developments in ICT and Privacy/Data Protection Law, Governance and Technology Series . Dordrecht: Springer Netherlands (2016). p. 277–305. doi: 10.1007/978-94-017-7376-8_11

40. Gunkel DJ. Second thoughts: toward a critique of the digital divide. New Media Soc . (2003) 5:499–522. doi: 10.1177/146144480354003

41. Selwyn N. Reconsidering political and popular understandings of the digital divide. New Media Soc . (2004) 6:341–62. doi: 10.1177/1461444804042519

42. Trepte S, Teutsch D, Masur PK, Eicher C, Fischer M, Hennhöfer A, et al. Do people know about privacy and data protection strategies? Towards the ‘online privacy literacy scale’ (OPLIS). In: Gutwirth S, Leenes R, de Hert P, editors. Reforming European Data Protection Law Law, Governance and Technology Series . Dordrecht: Springer Netherlands (2015). p. 333–65. doi: 10.1007/978-94-017-9385-8_14

43. Hussein R, Scherdel L, Nicolet F, Martin-Sanchez F. Towards the European health data space (EHDS) ecosystem: a survey research on future health data scenarios. Int J Med Inform . (2023) 170:104949. doi: 10.1016/j.ijmedinf.2022.104949

44. Hutchings E, Loomes M, Butow P, Boyle FM. A systematic literature review of health consumer attitudes towards secondary use and sharing of health administrative and clinical trial data: a focus on privacy, trust, and transparency. Syst Rev . (2020) 9:235. doi: 10.1186/s13643-020-01481-9

45. Hussein R, Stainer-Hochgatterer A, Niebauer J, Palfinger T, Kaisler R. Health data democratization in Austria: patients’ perspective. Stud Health Technol Inform . (2023) 305:18–9. doi: 10.3233/SHTI230412

46. Van den Eynde J, Lachmann M, Laugwitz K-L, Manlhiot C, Kutty S. Successfully implemented artificial intelligence and machine learning applications in cardiology: state-of-the-art review. Trends Cardiovasc Med . (2023) 33:265–71. doi: 10.1016/j.tcm.2022.01.010

47. Goodman RS, Patrinely JR, Stone CA, Zimmerman E, Donald RR, Chang SS, et al. Accuracy and reliability of chatbot responses to physician questions. JAMA Netw Open . (2023) 6:e2336483. doi: 10.1001/jamanetworkopen.2023.36483

48. Holzinger A, Langs G, Denk H, Zatloukal K, Müller H. Causability and explainability of artificial intelligence in medicine. Wiley Interdiscip Rev Data Min Knowl Discov . (2019) 9:e1312. doi: 10.1002/widm.1312

49. van der Niet AG, Bleakley A. Where medical education meets artificial intelligence: “does technology care?”. Med Educ . (2021) 55:30–6. doi: 10.1111/medu.14131

50. De Cremer D, Narayanan D, Deppeler A, Nagpal M, McGuire J. The road to a human-centred digital society: opportunities, challenges and responsibilities for humans in the age of machines. AI Ethics . (2022) 2:579–83. doi: 10.1007/s43681-021-00116-6

51. Richterich A. Can’t fix this? Innovation, social change, and solutionism in design thinking. Media Commun . (2024) 12:7427. doi: 10.17645/mac.7427

52. Redfern J, Gallagher R, O’Neil A, Grace SL, Bauman A, Jennings G, et al. Historical context of cardiac rehabilitation: learning from the past to move to the future. Front Cardiovasc Med . (2022) 9:842567. doi: 10.3389/fcvm.2022.842567

53. Yeung AWK, Kulnik ST, Parvanov ED, Fassl A, Eibensteiner F, Völkl-Kernstock S, et al. Research on digital technology use in cardiology: bibliometric analysis. J Med Internet Res . (2022) 24:e36086. doi: 10.2196/36086

54. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant . (2018) 52:1893–907. doi: 10.1007/s11135-017-0574-8

Keywords: artificial intelligence, cardiovascular disease, data protection, digital health literacy, mobile health, physical activity, secondary prevention, telemedicine

Citation: Zeller A, Gutenberg J, Niebauer J, Crutzen R and Kulnik ST (2024) Patients' experiences and perspectives regarding the use of digital technology to support exercise-based cardiac rehabilitation: a qualitative interview study. Front. Sports Act. Living 6:1371652. doi: 10.3389/fspor.2024.1371652

Received: 16 January 2024; Accepted: 6 March 2024; Published: 18 March 2024.

Reviewed by:

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

*Correspondence: Stefan Tino Kulnik [email protected]

This article is part of the Research Topic

Physical Fitness via Advanced Technology - ICT and AI Solutions for Healthier Ageing

How phenomenology can help us learn from the experiences of others

• A Qualitative Space
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• Published: 05 April 2019
• Volume 8 , pages 90–97, ( 2019 )

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Introduction

As a research methodology, phenomenology is uniquely positioned to help health professions education (HPE) scholars learn from the experiences of others. Phenomenology is a form of qualitative research that focuses on the study of an individual’s lived experiences within the world. Although it is a powerful approach for inquiry, the nature of this methodology is often intimidating to HPE researchers. This article aims to explain phenomenology by reviewing the key philosophical and methodological differences between two of the major approaches to phenomenology: transcendental and hermeneutic. Understanding the ontological and epistemological assumptions underpinning these approaches is essential for successfully conducting phenomenological research.

This review provides an introduction to phenomenology and demonstrates how it can be applied to HPE research. We illustrate the two main sub-types of phenomenology and detail their ontological, epistemological, and methodological differences.

Conclusions

Phenomenology is a powerful research strategy that is well suited for exploring challenging problems in HPE. By building a better understanding of the nature of phenomenology and working to ensure proper alignment between the specific research question and the researcher’s underlying philosophy, we hope to encourage HPE scholars to consider its utility when addressing their research questions.

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A Qualitative Space highlights research approaches that push readers and scholars deeper into qualitative methods and methodologies. Contributors to A Qualitative Space may: advance new ideas about qualitative methodologies, methods, and/or techniques; debate current and historical trends in qualitative research; craft and share nuanced reflections on how data collection methods should be revised or modified; reflect on the epistemological bases of qualitative research; or argue that some qualitative practices should end. Share your thoughts on Twitter using the hashtag: #aqualspace

Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so.—Douglas Adams

Despite the fact that humans are one of few animals who can learn from the experiences of others, we are often loath to do so. Perhaps this is because we assume that similar circumstances could never befall us. Perhaps this is because we assume that, if placed in the same situation, we would make wiser decisions. Perhaps it is because we assume the subjective experience of an individual is not as reliably informative as objective data collected from external reality. Regardless of the assumptions grounding this apprehension, it is essential for scholars to learn from the experiences of others. In fact, it is a foundational premise of research. Research involves the detailed study of a subject (i. e., an individual, groups of individuals, societies, or objects) to discover information or to achieve a new understanding of the subject [ 1 ]. Such detailed study often requires understanding the experiences of others so that we can glean new insights about a particular phenomenon. Scholars in health professions education (HPE) are savvy to the need to learn from the experiences of others. To maximize the effectiveness of feedback, of workplace-based learning, of clinical reasoning, or of any other of a myriad of phenomena, HPE researchers need to be able to carefully explore and learn from the experiences of others. What often curtails these efforts is a lack of methodology. In other words: HPE researchers need to know how to learn from the experiences of others.

Phenomenology is a qualitative research approach that is uniquely positioned to support this inquiry. However, as an approach for engaging in HPE research, phenomenology does not have a strong following. It is easy to see why: To truly understand phenomenology requires developing an appreciation for the philosophies that underpin it. Those philosophies theorize the meaning of human experience. In other words, engaging in phenomenological research requires the scholar to become familiar with the philosophical moorings of our interpretations of human experience. This may be a daunting task, but Douglas Adams never said learning from the experiences of others would be easy.

The questions that phenomenology can answer, and the insights this kind of research can provide, are of foundational importance to HPE: What is the experience of shame and the impact of that experience for medical learners [ 2 ]? What does it mean to be an empathetic clinician [ 3 ]? What is the medical learner’s experience of failure on high stakes exams [ 4 ]? How do experienced clinicians learn to communicate their clinical reasoning in professional practice [ 5 ]? Answers to such questions constitute the underpinnings of our field. To answer such questions, we can use phenomenology to learn from the experiences of others.

In this manuscript, we delve into the philosophies and methodologies of two varieties of phenomenology: hermeneutic and transcendental. Our goal is not to simplify the complexities of phenomenology, nor to argue that all HPE researchers should use phenomenology. Instead, we suggest that phenomenology is a valuable approach to research that needs to have a place in HPE’s body of research. We will place these two approaches in the context of their philosophical roots to illustrate the similarities and differences between these ways of engaging in phenomenological research. In so doing, we hope to encourage HPE researchers to thoughtfully engage in phenomenology when their research questions necessitate this research approach.

What is phenomenology?

In simple terms, phenomenology can be defined as an approach to research that seeks to describe the essence of a phenomenon by exploring it from the perspective of those who have experienced it [ 6 ]. The goal of phenomenology is to describe the meaning of this experience—both in terms of what was experienced and how it was experienced [ 6 ]. There are different kinds of phenomenology, each rooted in different ways of conceiving of the what and how of human experience. In other words, each approach of phenomenology is rooted in a different school of philosophy. To choose a phenomenological research methodology requires the scholar to reflect on the philosophy they embrace. Given that there are many different philosophies that a scientist can embrace, it is not surprising that there is broad set of phenomenological traditions that a researcher can draw from. In this manuscript, we highlight the transcendental and the hermeneutic approaches to phenomenology, but a broader phenomenological landscape exists. For instance, the Encyclopedia of Phenomenology, published in 1997, features articles on seven different types of phenomenology [ 7 ]. More contemporary traditions have also been developed that bridge the transcendental/hermeneutic divide. Several of these traditions are detailed in Tab.  1 [ 8 , 9 , 10 ].

To understand any of these approaches to phenomenology, it is useful to remember that most approaches hold a similar definition of phenomenology’s object of study. Phenomenology is commonly described as the study of phenomena as they manifest in our experience, of the way we perceive and understand phenomena, and of the meaning phenomena have in our subjective experience [ 11 ]. More simply stated, phenomenology is the study of an individual’s lived experience of the world [ 12 ]. By examining an experience as it is subjectively lived, new meanings and appreciations can be developed to inform, or even re-orient, how we understand that experience [ 13 ].

From this shared understanding, we now address how transcendental (descriptive) phenomenology and hermeneutic (interpretive) phenomenology approach this study in different ways. These approaches are summarized in Tab.  2 .

• Transcendental phenomenology

Phenomenology originates in philosophical traditions that evolved over centuries; however, most historians credit Edmund Husserl for defining phenomenology in the early 20th century [ 14 ]. Understanding some of Husserl’s academic history can provide insight into his transcendental approach to phenomenology. Husserl’s initial work focused on mathematics as the object of study [ 15 ], but then moved to examine other phenomena. Husserl’s approach to philosophy sought to equally value both objective and subjective experiences, with his body of work ‘culminating in his interest in “pure phenomenology” or working to find a universal foundation of philosophy and science [ 13 ].’ Husserl rejected positivism’s absolute focus on objective observations of external reality, and instead argued that phenomena as perceived by the individual’s consciousness should be the object of scientific study. Thus, Husserl contended that no assumptions should inform phenomenology’s inquiry; no philosophical or scientific theory, no deductive logic procedures, and no other empirical science or psychological speculations should inform the inquiry. Instead, the focus should be on what is given directly to an individual’s intuition [ 16 ]. As Staiti recently argued, this attitude towards phenomenology is akin to that of ‘a natural scientist who has just discovered a previously unknown dimension of reality [ 17 ].’ This shift in focus requires the researcher to return ‘to the self to discover the nature and meaning of things [ 18 ].’ As Husserl asserted: ‘Ultimately, all genuine and, in particular, all scientific knowledge, rests on inner evidence [ 19 ].’ Inner evidence—that is, what appears in consciousness—is where a phenomenon is to be studied. What this means for Husserl is that subjective and objective knowledge are intimately intertwined. To understand the reality of a phenomenon is to understand the phenomenon as it is lived by a person. This lived experience is, for Husserl, a dimension of being that had yet to be discovered [ 17 ]. For Husserl, phenomenology was rooted in an epistemological attitude; for him, the critical question of a phenomenological investigation was ‘What is it for an individual to know or to be conscious of a phenomenon [ 20 ]?’ In Husserl’s conception of phenomenology, any experienced phenomenon could be the object of study thereby pushing analysis beyond mere sensory perception (i. e. what I see, hear, touch) to experiences of thought, memory, imagination, or emotion [ 21 ].

Husserl contended that a lived experience of a phenomenon had features that were commonly perceived by individuals who had experienced the phenomenon. These commonly perceived features—or universal essences—can be identified to develop a generalizable description. The essences of a phenomenon, according to Husserl, represented the true nature of that phenomenon. The challenge facing the researcher engaging in Husserl’s phenomenology, then, is:

To describe things in themselves, to permit what is before one to enter consciousness and be understood in its meanings and essences in the light of intuition and self-reflection. The process involves a blending of what is really present with what is imagined as present from the vantage point of possible meanings; thus, a unity of the real and the ideal [ 18 ] .

In other words, the challenge is to engage in the study of a person’s lived experience of a phenomenon that highlights the universal essences of that phenomenon [ 22 ]. This requires the researcher to suspend his/her own attitudes, beliefs, and suppositions in order to focus on the participants’ experience of the phenomenon and identify the essences of the phenomenon. One of Husserl’s great contributions to philosophy and science is the method he developed that enables researchers ‘to suspend the natural attitude as well as the naïve understanding of what we call the human mind and to disclose the realm of transcendental subjectivity as a new field of inquiry [ 17 ].’

In Husserl’s’ transcendental phenomenology (also sometimes referred to as the descriptive approach), the researcher’s goal is to achieve transcendental subjectivity —a state wherein ‘the impact of the researcher on the inquiry is constantly assessed and biases and preconceptions neutralized, so that they do not influence the object of study [ 22 ].’ The researcher is to stand apart, and not allow his/her subjectivity to inform the descriptions offered by the participants. This lived dimension of experience is best approached by the researcher who can achieve the state of the transcendental I —a state wherein the objective researcher moves from the participants’ descriptions of facts of the lived experience, to universal essences of the phenomenon at which point consciousness itself could be grasped [ 23 ]. In the state of the transcendental I , the researcher is able to access the participants’ experience of the phenomenon pre-reflectively—that is ‘without resorting to categorization on conceptualization, and quite often includes what is taken for granted or those things that are common sense [ 13 ].’ The transcendental I brings no definitions, expectations, assumption or hypotheses to the study; instead, in this state, the researcher assumes the position of a  tabula rasa, a blank slate, that uses participants’ experiences to develop an understanding of the essence of a phenomenon.

This state is achieved via a series of reductions. The first reduction, referred to as the transcendental stage , requires transcendence from the natural attitude of everyday life through epoche , also called the process of bracketing . This is the process through which the researchers set aside—or bracket off as one would in a mathematical equation—previous understandings, past knowledge, and assumptions about the phenomenon of interest. The previous understandings that must be set aside include a wide range of sources including: scientific theories, knowledge, or explanation; truth or falsity of claims made by participants; and personal views and experiences of the researcher [ 24 ]. In the second phase, transcendental-phenomenological reduction , each participant’s experience is considered individually and a complete description of the phenomenon’s meanings and essences is constructed [ 18 ]. Next is reduction via imaginative variation wherein all the participants’ descriptions of conscious experience are distilled to a unified synthesis of essences through the process of free variation [ 25 ]. This process relies on intuition and requires imagining multiple variations of the phenomenon in order to arrive at the essences of the phenomenon [ 25 ]. These essences become the foundation for all knowledge about the phenomenon.

The specific processes followed to realize these reductions vary across researchers engaging in transcendental phenomenology. One commonly used transcendental phenomenological method is that of psychologist Clark Moustakas, and other approaches include the works of: Colaizzi [ 26 ], Giorgi [ 27 ], and Polkinghorne [ 28 ]. Regardless of the approach used, to engage rigorously in transcendental phenomenology, the researcher must be vigilant in his/her bracketing work so that the researcher’s individual subjectivity does not bias data analysis and interpretations. This is the challenge of reaching the state of the transcendental I where the researcher’s own interpretations, perceptions, categories, etc. do not influence the processes of reduction. It is important to note that modern philosophers continue to wrestle with Husserl’s notions of bracketing. If bracketing is successfully achieved, the researcher sets aside the world and the entirety of its content—including the researcher’s physical body [ 17 ]. While dedication to this bracketing is challenging to maintain, Husserl asserts that it is necessary. Suspending reliance on and foundations in physical reality is the only way to abandon our human experiences in such a way as to find the transcendent I. Researchers might borrow [ 29 ] practices from other qualitative research methods to achieve this goal. For instance, a study could be designed to have multiple researchers triangulate [ 30 ] their reductions to confirm appropriate bracketing was maintained. Alternatively, a study could involve validation of data [ 18 ] via member checking [ 31 ] to ensure that the identified essences resonated with the participants’ experiences.

Husserl’s transcendental phenomenology has been employed by HPE researchers. For example, in 2012, Tavakol et al. studied medical students’ understanding of empathy by engaging in transcendental phenomenological research [ 32 ]. The authors note that medial students’ loss of empathy as they transition from pre-clinical to clinical training is well documented in the medical literature [ 33 ], and has been found to negatively impact patients and the quality of healthcare provided [ 34 ]. Tavakol et al. [ 32 ] used a descriptive phenomenological approach (i. e. using the methodology of Colaizzi and Giorgi) to report on the phenomenon of empathy as experienced by medical students during the course of their training. The authors identified two key factors impacting empathic ability: innate capacity for empathy and barriers to displaying empathy [ 32 ].

• Hermeneutic phenomenology

Hermeneutic phenomenology, also known as interpretive phenomenology, originates from the work of Martin Heidegger. Heidegger began his career in theology, but then moved into academia as a student of philosophy. While Heidegger’s philosophical inquiry began in alignment with Husserl’s work, he later challenged several key aspects of Husserl’s transcendental phenomenology. A foundational break from his predecessor was the focus of phenomenological inquiry. While Husserl was interested in the nature of knowledge (i. e., an epistemological focus), Heidegger was interested in the nature of being and temporality (i. e., an ontological focus) [ 21 ]. With this focus on human experience and how it is lived, hermeneutic phenomenology moves away from Husserl’s focus on ‘acts of attending, perceiving, recalling and thinking about the world [ 13 ]’ and on human beings as knowers of phenomenon. In contrast, Heidegger is interested in human beings as actors in the world and so focuses on the relationship between an individual and his/her lifeworld. Heidegger’s term lifeworld referred to the idea that ‘individuals’ realities are invariably influenced by the world in which they live [ 22 ].’ Given this orientation, individuals are understood as always already having an understanding of themselves within the world, even if they are not constantly, explicitly and/or consciously aware of that understanding [ 17 ]. For Heidegger, an individual’s conscious experience of a phenomenon is not separate from the world, nor from the individual’s personal history. Consciousness is, instead, a formation of historically lived experiences including a person’s individual history and the culture in which he/she was raised [ 22 ]. An individual cannot step out of his/her lifeworld. Humans cannot experience a phenomenon without referring back to his/her background understandings. Hermeneutic phenomenology, then, seeks ‘to understand the deeper layers of human experience that lay obscured beneath surface awareness and how the individual’s lifeworld, or the world as he or she pre-reflectively experiences it, influences this experience [ 35 ].’ Hermeneutic phenomenology studies individuals’ narratives to understand what those individuals experience in their daily lives, in their lifeworlds.

But the hermeneutic tradition pushes beyond a descriptive understanding. Hermeneutic phenomenology is rooted in interpretation—interpreting experiences and phenomena via the individual’s lifeworld. Here, Heidegger’s background in theology can be seen as influencing his approach to phenomenology. Hermeneutics refers to the interpretation of texts, to theories developed from the need to translate literature from different languages and where access to the original text (e. g., the Bible) was problematic [ 36 ]. If all human experience is informed by the individual’s lifeworld, and if all experiences must be interpreted through that background, hermeneutic phenomenology must go beyond description of the phenomenon, to the interpretation of the phenomenon. The researcher must be aware of the influence of the individual’s background and account for the influences they exert on the individual’s experience of being.

This is not to say that the individual’s subjective experience—which is inextricably linked with social, cultural, and political contexts—is pre-determined. Heidegger argued that individuals have situated freedom. Situated freedom is a concept that asserts that ‘individuals are free to make choices, but their freedom is not absolute; it is circumscribed by the specific conditions of their daily lives [ 22 ].’ Hermeneutic phenomenology studies the meanings of an individual’s being in the world, as their experience is interpreted through his/her lifeworld, and how these meanings and interpretations influence the choices that the individual makes [ 13 ]. This focus requires the hermeneutic phenomenologist to interpret the narratives provided by research participants in relation to their individual contexts in order to illuminate the fundamental structures of participants’ understanding of being and how that shaped the decisions made by the individual [ 37 ].

Another key aspect that distinguishes hermeneutic phenomenology is the role of the researcher in the inquiry. Instead of bracketing off the researcher’s subjective perspective, hermeneutic phenomenology recognizes that the researcher, like the research subject, cannot be rid of his/her lifeworld. Instead, the researcher’s past experiences and knowledge are valuable guides to the inquiry. It is the researcher’s education and knowledge base that lead him/her to consider a phenomenon or experience worthy of investigation. To ask the research to take an unbiased approach to the data is inconsistent with hermeneutic phenomenology’s philosophical roots. Instead, researchers working from this tradition should openly acknowledge their preconceptions, and reflect on how their subjectivity is part of the analysis process [ 16 ].

The interpretive work of hermeneutic phenomenology is not bound to a single set of rule-bound analytical techniques; instead, it is an interpretive process involving the interplay of multiple analysis activities [ 35 ]. In general, this process:

Starts with identifying an interesting phenomenon that directs our attention towards lived experience. Members of the research team then investigate experience as it is lived, rather than as it is conceptualized, and reflect on the essential [phenomenological] themes that characterize the participant’s experience with the phenomenon, simultaneously reflecting on their own experiences. Researchers capture their reflections in writing and then reflect and write again, creating continuous, iterative cycles to develop increasingly robust and nuanced analyses. Throughout the analysis, researchers must maintain a strong orientation to the phenomenon under study (i.   e., avoid distractions) and attend to the interactions between the parts and the whole. This last step, also described as the hermeneutic circle, emphasizes the practice of deliberately considering how the data (the parts) contribute to the evolving understanding of the phenomena (the whole) and how each enhances the meaning of the other [ 35 ] .

In the hermeneutic approach to phenomenology, theories can help to focus inquiry, to make decisions about research participants, and the way research questions can be addressed [ 22 ]. Theories can also be used to help understand the findings of the study. One scholar whose engagement with hermeneutic phenomenology is widely respected is Max van Manen [ 38 ]. Van Manen acknowledges that hermeneutic phenomenology ‘does not let itself be deceptively reduced to a methodical schema or an interpretative set of procedures [ 39 ].’ Instead, this kind of phenomenology requires the researcher to read deeply into the philosophies of this tradition to grasp the project of hermeneutic phenomenological thinking, reading, and writing.

A recent study published by Bynum et al. illustrates how hermeneutic phenomenology may be employed in HPE [ 2 ]. In this paper, Bynum et al. explored the phenomenon of shame as an emotion experienced by medical residents and offer insights into the effects of shame experiences on learners. As a means in scholarly inquiry, this study demonstrates how hermeneutic phenomenology can provide insight into complex phenomena that are inextricably entwined in HPE.

Incorporating phenomenological research methodologies into HPE scholarship creates opportunities to learn from the experiences of others. Phenomenological research can broaden our understanding of the complex phenomena involved in learning, behaviour, and communication that are germane to our field. But success in these efforts is dependent upon both improved awareness of the potential value of these approaches, and enhanced familiarization with the underlying philosophical orientation and methodological approaches of phenomenology. Perhaps most critically, HPE scholars must construct research processes that align with the tenets of the methodology chosen and the philosophical roots that underlie it. This alignment is the cornerstone for establishing research rigour and trustworthiness.

Following a specific checklist of verification activities or mandatory processes cannot buoy the quality and rigour of a particular phenomenological study. Instead, beyond maintaining fidelity between research question, paradigm, and selected methodology, robust phenomenological research involves deep engagement with the data via reading, reflective writing, re-reading and re-writing. In Moustakas’s approach to transcendental phenomenology, the researcher reads the data, reduces the data to meaning units, re-reads those reductions to then engage in thematic clustering, compares the data, writes descriptions, and so on in an ongoing process of continually engaging with the data and writing reflections and summaries until the researcher can describe the essence of the lived experience [ 18 ]. In hermeneutic phenomenology, scholars describe engaging in a hermeneutic circle wherein the researcher reads the data, constructs a vague understanding, engages in reflective writing, then re-engages with the text with revised understandings [ 40 ]. In cycles of reading and writing, of attending to the whole of the text and the parts, the hermeneutic researcher constructs an understanding of the lived experience. In both traditions, deep engagement with the data via reading, writing, re-reading and re-writing is foundational. While this engagement work is not standardized, Polkinghorne suggests that rich descriptions of phenomenological research might be characterized by qualities such as vividness, richness, accuracy, and elegance [ 41 ]. While we question how these qualities might be evaluated in a qualitative study, they confirm that attention to the depth of engagement in reading and writing of the phenomenological data is a necessary condition for rigour.

Phenomenology is a valuable tool and research strategy. For those who are not familiar with its philosophical underpinnings or methodological application, it can seem challenging to apply to HPE scholarship. We hope this manuscript will serve to relieve some of the apprehension in considering the use of phenomenology in future work. We believe that the appropriate application of phenomenology to HPE’s research questions will help us to advance our understanding by learning from the experiences of others.

The views expressed herein are those of the authors and do not necessarily reflect those of the Uniformed Services University of the Health Sciences, the United States Department of Defense or other federal agencies.

Cambridge Online Dictionary. 2019. https://dictionary.cambridge.org/us/dictionary/english/research . Accessed 24 Feb 2019, Research.

Bynum W, Artino A, Uijtdehaage S, Webb A, Varpio L. Sentinel emotional events. The nature, triggers, and effects of shame experiences in medical residents. Acad Med. 2018; https://doi.org/10.1097/ACM.0000000000002479 . Oct 1 [cited 2018 Oct 10] Epub ahead of print.

Article   Google Scholar  

Hooker C. Understanding empathy: why phenomenology and hermeneutics can help medical education and practice. Med Health Care Philos. 2015;2015(18):541–52.

Patel RS, Tarrant C, Bonas S, Shaw RL. Medical students’ personal experience of high-stakes failure: case studies using interpretative phenomenological analysis. Bmc Med Educ. 2015;15:1–9.

Ajjawi R, Higgs J. Using hermeneutic phenomenology to investigate how experienced practitioners learn to communicate clinical reasoning. Qual Rep. 2007;12:612:38.

Google Scholar  

Teherani A, Martimianakis T, Stenfors-Hayes T, Wadhwa A, Varpio L. Choosing a qualitative research approach. J Grad Med Educ. 2015;7:669–70.

Contributions to phenomenology. In: Embree L, editor. Encyclopedia of phenomenology. Vol. 18. Netherlands: Springer; 1997.

Ashworth P. An approach to phenomenological psychology: the contingencies of the lifeworld. J Phenom Psychol. 2003;34:145–56.

Vagle M. Crafting phenomenological research. London and New York: Routledge Taylor and Francis Group; 2018.

Book   Google Scholar  

Tuffour I. A critical overview of interpretative phenomenological analysis: a contemporary qualitative research approach. J Healthc Commun. 2017;2(4:52):1–5.

Smith, David Woodruff. Phenomenology. Stanford encyclopedia of philosophy. https://plato.stanford.edu/entries/phenomenology/ . Accessed 9 Oct 2018.

Manen MV. Researching lived experience: human science for an action sensitive pedagogy. London and New York: Routledge Taylor and Francis Group; 1997.

Laverty SM. Hermeneutic phenomenology and phenomenology: a comparison of historical and methodological considerations. Int J Qual Methods. 2003;2:1–29.

Kafle NP. Hermeneutic phenomenological research method simplified. Bodhi: Interdiscip J. 2011;5:181–2.

Jones WT. The twentieth century to Wittgenstein and Sartre. San Francisco, CA: Harcourt Brace Jovanovich; 1975.

Moran D. Introduction to phenomenology. Milton Park: Routledge; 2000.

Staiti A. The pedagogic impulse of Husserl’s ways into transcendental phenomenology: an alternative reading of the Erste Philosophie lecture. Grad Fac Philos J. 2012;33:39–56.

Moustakas CE. Phenomenological research methods. 1st ed. Thousand Oaks: SAGE; 1994.

Husserl E. The crisis of European sciences and transcendental phenomenology. 1st ed. Evanston: Northwestern University Press; 1970.

Barua A. Husserl, Heidegger, and the transcendental dimension of phenomenology. Indo-Pacific J Phenomenol. 2015;7:1–10.

Reiners GM. Understanding the differences between Husserl’s (descriptive) and Heidegger’s (interpretive) phenomenological research. J Nurs Care. 2012;1:1–3.

Lopez KA, Willis DG. Descriptive versus interpretive phenomenology: their contributions to nursing knowledge. Qual Health Res. 2004;14:726–35.

Davidsen AS. Phenomenological approaches in psychology and health sciences. Qual Res Psychol. 2013;10:318–39.

Presuppose Nothing AP. The suspension of assumptions in phenomenological psychological methodology. J Phenomenol Psychol. 1996;27:1–25.

Gill MJ. The possibilities of phenomenology for organizational research. Organ Res Methods. 2014;17:118–37.

Colaizzi P. Psychological research as a phenomenologist views it. In: Valle RS, King M, editors. Existential-phenomenological alternatives for psychology. Oxford, UK: Oxford University Press; 1978.

Giorgi A. Phenomenology and psychological research. Pittsburgh, PA: Duquesne University Press; 1985.

Polkinghorne DE. Phenomenological research methods. In: Valle RS, Halling S, editors. Existential-phenomenological perspectives in psychology: exploring the breadth of human experience. New York: Springer; 1989. pp. 41–60.

Chapter   Google Scholar  

Varpio L, Martimianakis T, Mylopoulos M. Qualitative research methodologies: embracing methodological borrowing, shifting, and importing. In: Durning SJ, Cleland J, editors. Researching medical education. 1st ed. West Sussex: Wiley-Blackwell; 2015. pp. 245–55.

Arksey H, Knight PT. Interviewing for social scientists. London: SAGE; 1999.

Birt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26:1802–11.

Tavakol S, Dennick R, Tavakol M. Medical students’ understanding of empathy: a phenomenological study. Med Educ. 2012;46:306–16.

Neumann M, Edelhauser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86:996–1009.

Del Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med. 2012;87:1243–9.

Bynum W, Varpio L. When I say … hermeneutic phenomenology. Med Educ. 2018;52:252–3.

Enos T, editor. Encyclopedia of rhetoric and composition. New York: Routledge; 2010.

Heidegger M. Being and time. Blackwell: Oxford UK and Cambridge USA; 1867.

Van Manen M. Researching lived experience: human science for an action sensitive pedagogy. Albany, NY: SUNY; 1990.

Van Manen M. Phenomenology of practice. Walnut Creek: Left Coast Press, Inc; 2014.

Grondin J. Gadamer’s basic understanding of understanding. In: Dostal RJ, editor. The cambridge companion to Gadamer. Cambridge: Cambridge University Press; 2002. pp. 36–51.

Polkinghorne D. Methodology for the human sciences. Albany: SUNY; 1983.

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Neubauer, B.E., Witkop, C.T. & Varpio, L. How phenomenology can help us learn from the experiences of others. Perspect Med Educ 8 , 90–97 (2019). https://doi.org/10.1007/s40037-019-0509-2

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Research MethodologyOverview of Qualitative Research

Qualitative research methods are a robust tool for chaplaincy research questions. Similar to much of chaplaincy clinical care, qualitative research generally works with written texts, often transcriptions of individual interviews or focus group conversations and seeks to understand the meaning of experience in a study sample. This article describes three common methodologies: ethnography, grounded theory, and phenomenology. Issues to consider relating to the study sample, design, and analysis are discussed. Enhancing the validity of the data, as well reliability and ethical issues in qualitative research are described. Qualitative research is an accessible way for chaplains to contribute new knowledge about the sacred dimension of people's lived experience.

INTRODUCTION

Qualitative research is, “the systematic collection, organization, and interpretation of textual material derived from talk or conversation. It is used in the exploration of meanings of social phenomena as experienced by individuals themselves, in their natural context” ( Malterud, 2001 , p. 483). It can be the most accessible means of entry for chaplains into the world of research because, like clinical conversations, it focuses on eliciting people's stories. The stories can actually be expressed in almost any medium: conversations (interviews or focus groups), written texts (journal, prayers, or letters), or visual forms (drawings, photographs). Qualitative research may involve presenting data collected from a single person, as in a case study ( Risk, 2013 ), or from a group of people, as in one of my studies of parents of children with cystic fibrosis (CF) ( Grossoehme et al., 2013 ). Whole books are devoted to qualitative research methodology and, indeed, to the individual methods themselves. This article is intended to present, in rather broad brushstrokes, some of the “methods of choice” and to suggest some issues to consider before embarking on a qualitative research project. Helpful texts are cited to provide resources for more complete information.

Although virtually anything may be data, spoken mediums are the most common forms of collecting data in health research, so the focus of this article will mainly be on interviews and to a lesser extent, focus groups. Interviews explore experiences of individuals, and through a series of questions and answers, the meaning individuals give to their experiences ( Tong, Sainsbury, & Craig, 2007 ). They may be “structured” interviews, in which an interview guide is used with pre-determined questions from which no deviation is permitted by the interviewer, or semi-structured interviews, in which an interview guide is used with pre-determined questions and potential follow-up questions. The latter allows the interviewer to pursue topics that arise during the interview that seem relevant ( Cohen & Crabtree, 2006 ). Writing good questions is harder than it appears! In my first unit of CPE, the supervisor returned verbatims, especially our early efforts, with “DCFQ” written in the margin, for “direct, closed, factual question.” We quickly learned to avoid DCFQs in our clinical conversations because they did not create the space for reflection on illness and the sacred the way open-ended questions did. To some extent, writing good open-ended questions that elicit stories can come more readily to chaplains, due perhaps to our training, than to investigators from other disciplines. This is not to say writing an interview guide is easy or an aspect of research that can be taken lightly, as the quality of the data you collect, and hence the quality of your study, depends on the quality of your interview questions.

Data may also be collected using focus groups. Focus groups are normally built around a specific topic. They almost always follow a semi-structured format and include open discussion of responses among participants, which may range from four to twelve people ( Tong et al., 2007 ). They provide an excellent means to gather data on an entire range of responses to a topic, or on the social interactions between participants, or to clarify a process. Once the data are collected, the analytic approach is typically similar to that of interview data.

Qualitative investigators are not disinterested outsiders who merely observe without interacting with participants, but affect and are affected by their data. The investigator's emotions as they read participants' narratives are data to be included in the study. Simply asking “research” questions can itself be a chaplaincy intervention: what we ask affects the other person and can lead them to reflect and change ( Grossoehme, 2011 ). It is important to articulate our biases and understand how they influence us when we collect and analyze data. Qualitative research is often done by a small group of researchers, especially the data coding. This minimizes the bias of an individual investigator. Inevitably, two or more people will code passages differently at times. It is important to establish at the outset how such discrepancies will be handled.

Ensuring Rigor, Validity, and Reliability

Some people do not think qualitative research is not very robust or significant. This attitude is due, in part, to the poor quality of some early efforts. Increasingly, however, qualitative studies have improved in rigor, and reviewers of qualitative manuscripts expect investigators to have addressed problematic issues from the start of the project. Two important areas are validity and reliability. Validity refers to whether or not the final product (usually referred to a “model”) truly portrays what it claims to portray. If you think of a scale on which you weigh yourself, you want a valid reading so that you know your correct weight. Reliability refers to the extent to which the results are repeatable; if someone else repeated this study, would they obtain the same result? To continue the scale analogy, a reliable scale gives the same weight every time I step on it. A scale can be reliable without being valid. The scale could reliably read 72 pounds every time I step on it, but that value is hardly correct, so the measure is not valid.

Swinton and Mowat (2006) discussed ensuring the “trustworthiness” of the data. N narrative data which are “rich” in their use of metaphor and description, and which express deeper levels of meaning and nuance compared to everyday language are likely to yield a trustworthy final model because the investigators have done a credible job of completely describing and understanding the topic that is under study. Validity is also enhanced by some methodologies, such as grounded theory, which use participants' own words to name categories and themes, instead of using labels given by the investigator. The concept of “member checking” also enhances validity. Once the analyses are complete and a final model has been developed, these findings are shown to all or some of the participants (the members) who are invited to check the findings and give feedback. Do they see themselves in the words or conceptual model that is presented? Do they offer participants a new insight, or do they nod agreement without really reengaging the findings?

Reliability

One means of demonstrating reliability is to document the research decisions made along the way, as they were made, perhaps in a research diary ( Swinton & Mowat, 2006 ). Qualitative methodologies accept that the investigator is part of what is being studied and will influence it, and that this does not devalue a study but, in fact, enhances it. Simply deciding what questions to ask or not ask, and who you ask them to (and not) reflect certain decisions that should be consciously made and documented. Another researcher should be able to understand what was done and why from reading the research diary.

ETHNOGRAPHIC RESEARCH

Elisa Sobo (2009) defines ethnography as the presentation of, “… a given group's conceptual world, seen and experienced from the inside” (p. 297). Ethnography answers the question, “what's it like to be this person?” One example of this kind of study comes from the work of Fore and colleagues ( Fore, Goldenhar, Margolis, & Seid, 2013 ). In order to design tools that would enable clinicians and persons with pediatric inflammatory bowel disease (IDB) to work together more efficiently, an ethnographic study was undertaken to learn what it was like for a family when a child had IDB. After 36 interviews, the study team was able to create three parent-child dyad personas: archetypes of parents and children with IDB based directly on the data they gathered. These personas were used by the design team to think about how different types of parents and children adapted to the disease and to think what tools should be developed to help different types of parents and children with IDB. An ethnographic study is the method of choice when the goal is to understand a culture, and to present, or explain, its spoken and unspoken nature to people who are not part of the culture, as in the example above of IDB. Before “outsiders” could think about the needs of people with IDB, it was necessary to learn what it is like to live with this disease.

Determining the sample in ethnographic studies typically means using what is called a purposive sample ( Newfield, Sells, Smith, Newfield, & Newfield, 1996 ). Purposive samples are based on criteria that the investigator establishes at the outset, which describe participant characteristics. In the aforementioned IDB example, the criteria were: (1) being a person with IDB who was between 12 and 22 years old or the parent of such a child; (2) being or having a child whose IDB care was provided at one of a particular group of treatment centers; (3) being a pediatric gastrointestinal nurse at one of the centers; or (4) a physician/researcher at one of five treatment centers. Having a sample that is representative of the larger population, always the goal in quantitative research, is not the point in ethnographic studies. Here, the goal is to recruit participants who have the experience to respond to the questions. Out of their intimate knowledge of their culture, the investigator can build a theory, or conceptual model, which could later be tested for generalizability in an entire population.

Ethnographic study designs typically involve a combination of data collection methods. Whenever possible, observing the participants in the midst of whatever experience is the study's focus is desirable. In the process of an ethnographic project on CF, for instance, two students spent a twelve-hour period at the home of a family with a child who had CF, taking notes about what they saw and heard. Interviews with participants are frequently employed to learn more about the experience of interest. An example of this is the work of Sobo and colleagues, who interviewed parents of pediatric patients in a clinic to ask about the barriers they experienced obtaining health care for their child ( Seid, Sobo, Gelhard, & Varni, 2004 ). Diaries and journals detailing people's lived experience may also be used, alone, or in combination with other methods.

Analysis of ethnographic data is variable, depending on the study's goal. One common analytic approach is to begin analysis after the first few interviews have been completed, and to read them to get a sense of their content. The next step is to name the seemingly important words or phrases. At this point, one might begin to see how the names relate to each other; this is the beginning of theory development. This process continues until all the data are collected. At that point, the data are sorted by the names, with data from multiple participants clustered under each topic name ( Boyle, 1994 ). Similar names may be grouped together, or placed under a larger label name (i.e., category). In a sense, what happens is that each interviewer's voice is broken into individual fragments, and everyone's fragments that have the same name are put together. From individual voices speaking on multiple topics, there is now one topic with multiple voices speaking to it.

GROUNDED THEORY RESEARCH

Grounded theory is “grounded” in its data; this inductive approach collects data while simultaneously analyzing it and using the emerging theory to inform data collection ( Rafuls & Moon, 1996 ). This cycle continues until the categories are said to be “saturated,” which typically means the point when no new information is being learned ( Morse, 1995 ). This methodology is generally credited to Glaser and Strauss, who wanted to create a means of developing theoretical models from empirical data ( Charmaz, 2005 ). Perhaps, more than in any other qualitative methodology, the person of the investigator is the key. The extent to which the investigator notices subtle nuances in the data and responds to them with new questions for future participants, or revises an emerging theory, is the extent to which a grounded theory research truly presents a theory capturing the fullness of the data from which it was built. It is also the extent to which the theory is capable of being used to guide future research or alter clinical practice. Grounded theory is the method of choice when there is no existing hypothesis to test. For instance, there was no published data on how parents use faith to cope after their child's diagnosis with CF. Using grounded theory allowed us to develop a theory, or a conceptual model, of how parents used faith to cope ( Grossoehme, Ragsdale, Wooldridge, Cotton, & Seid, 2010 ). An excellent discussion of this method is provided by Charmaz (2006) .

The nature of the research question should dictate the sample description, which should be defined before beginning the data collection. In some cases, the incidence of the phenomena may set some limits on the sample. For example, a study of religious coping by adults who were diagnosed with CF after age 18 years began with a low incidence: this question immediately limited the number of eligible adults in a four-state area to approximately 25 ( Grossoehme et al., 2012 ). Knowing that between 12 and 20 participants might be required in order to have sufficient data to convince ourselves that our categories were indeed saturated, limiting our sample in other ways: for example, selecting representative individuals spread across the number of years since diagnosis would not have made sense. In some studies, the goal is to learn what makes a particular subset of a larger sample special; these subsets are known as “positive deviants” ( Bradley et al., 2009 ).

Once the sample is defined and data collection begins, the analytic process begins shortly thereafter. As will be described in the following paragraphs, interviews and other forms of spoken communication are nearly always transcribed, typically verbatim. Unlike most other qualitative methods, grounded theory uses an iterative design. Sometime around the third or fourth interview has been completed and transcribed and before proceeding with further interviews, it is time to begin analyzing the transcripts. There are two aspects to this. The first is to code the data that you have. Grounded theory prefers to use the participants' own words as the code, rather than having the investigator name it. For example, in the following transcript excerpt, we coded part of the following except:

• INTERVIEWER: OK. Have your beliefs or perhaps relationship with God changed at all because of what you've gone through the last nine and 10 months with N.?
• INTERVIEWEE: Yeah, I mean, I feel that I'm stronger than I was before actually.
• INTERVIEWER: Hmm-hmm. How so? Can you put that into words? I know some of these could be hard to talk about but …
• INTERVIEWEE: I don't know, I feel like I'm putting his life more in God's hands than I ever was before.

We labeled, or coded, these data as, “I'm putting his life more in God's hands,” whereas in a different methodology we might have simply named it “Trusting God.” Focus on the action in the narrative. Although it can be difficult, you as a researcher must try very hard to set your own ideas aside. Remember you are doing this because there is no pre-existing theory about what you are studying, so you should not be guided by a theory you have in your mind. You must let the data speak for themselves.

The second point is to reflect on the codes and what they are already telling you. What questions are eliciting the narrative data you want? Which ones are not? Questions that are not leading you to the data you want probably need to be changed. Interesting, novel ideas may emerge from the data, or topics that you want to know more about that you did not anticipate and so the interviewer did not' follow up on them. What are the data not telling you that you are seeking? All of this information flows back to revising the semi-structured interview guide ( Charmaz, 2006 ). This issue raised mild concern with the IRB reviewer who had not encountered this methodology before. This concern was overcome by showing that this is an accepted method with voluminous literature behind it, and by showing that the types of item revisions were not expected to significantly alter the study's effect on the participants. From this point onward you collect data, code it, and analyze it simultaneously. As you code a new transcript and come across a statement similar to others, you can begin to put them together. If you are using qualitative analysis software such as NVivo ( “NVivo qualitative data analysis software,” 2012 ), you can make these new codes “children” of a “parent” node (the first statement you encountered on this topic). The next step is called “focused coding” and in this phase you combine what seems to you to be the most significant codes ( Charmaz, 2006 ). These may also be the most frequently occurring, or the topic with the most duplicates, but not necessarily. This is not a quantitative approach in which having large amounts of data is important. You combine codes at this stage in such a way that your new, larger, categories begin to give shape to aspects of the theory you think is going to emerge. As you collect and code more data, and revise your categories, your idea of the theory will change.

Axial coding follows, as you look at your emerging themes or categories, and begin to associate coded data that explains that category. Axial coding refers to coding the words or quotations that are around the category's “axis,” or core. For example, in a study of parental faith and coping in the first year after their child's diagnosis with CF ( Grossoehme et al., 2010 ), one of the categories which emerged was, “Our beliefs have changed.” There were five axial codes which explain aspects of this category. The axial codes were, “Unchanged,” “We've learned how fragile life is,” “Our faith has been strengthened,” “We've gotten away from our parents' viewpoints,” and “I'm better in tune with who I am.” Each of these axial codes had multiple explanatory phrases or sentences under them; together they explain the breadth and dimensions of the category, “Our beliefs have changed.”

The next step is theoretical coding, and here the categories generated during focused coding are synthesized into a theory. Some grounded theorists, notably one of the two most associated with it (Glaser), do not use axial coding but proceed directly to this step as the means of creating coherence out of the data ( Charmaz, 2006 ). As your emerging theory crystallizes, you may pause to see if it has similarities with other theoretical constructs you encountered in your literature search. Does your emerging theory remind you of anything? It would be appropriate to engage in member-checking at this point. In this phase, you show your theoretical model and its supporting categories to participants and ask for their feedback. Does your model make sense to them? Does it help them see this aspect of their experience differently ( Charmaz, 2005 ). Use their feedback to revise your theory and put it in its final form. At this point, you have generated new knowledge: a theory no one has put forth previously, and one that is ready to be tested.

PHENOMENOLOGY RESEARCH

Perhaps the most chaplain-friendly qualitative research approach is phenomenology, because it is all about the search for meaning. Its roots are in the philosophical work of Husserl, Heidegger and Ricoeur ( Boss, Dahl, & Kaplan, 1996 ; Swinton & Mowat, 2006 ). This approach is based on several assumptions: (1) meaning and knowing are social constructions, always incomplete and developing; (2) the investigator is a part of the experience being studied and the investigator's values play a role in the investigation; (3) bias is inherent in all research and should be articulated at the beginning; (4) participants and investigators share knowledge and are partners; (5) common forms of expression (e.g., words or art) are important; and (6) meanings may not be shared by everyone (Boss et al.). John Swinton and Harriet Mowat (2006) described the process of carrying out a phenomenological study of depression and spirituality in adults and reading their book is an excellent way to gain a sense of the whole process. Phenomenology may be the method of choice when you want to study what an experience means to a particular group of people. May not be the best choice when you want to be able to generalize your findings. An accurate presentation of the experience under study is more important in this approach than the ability to claim that the findings apply to across situations or people (Boss et al.). A study of the devil among predominately Hispanic horse track workers is unlikely to be generalizable to experiences of the devil among persons of Scandinavian descent living in Minnesota. Care must be taken not to overstate the findings from a study and extend the conclusions beyond what the data support.

The emphasis on accurately portraying the phenomenon means that large numbers of participants are not required. In fact, relatively small sample sizes are required compared to most quantitative, clinical studies. The goal is to gather descriptions of their lived experience which are rich in detail and imagery, as well as reflection on its theological or psychological meaning. The likelihood of achieving this goal can be enhanced by using a purposeful sample. That is, decide in the beginning approximately how large and how diverse your sample needs to be. For example, CF can be caused by over 1,000 different genetic mutations; some cause more pulmonary symptoms while others cause more gastrointestinal problems. Some people with CF have diabetes and others do not; some have a functioning pancreas and others need to take replacement enzymes before eating or drinking anything other than water. Some CF adolescents may have lung function that is over 100% of what is expected for healthy adolescents of their age and gender, whereas others, with severe pulmonary disease, may have lung function that is just 30% of what is expected for their age and gender. A study of what it is like for an adolescent to live with a life-shortening genetic disease using this approach might benefit from purposive sampling. For example, lung disease severity in CF is broadly described as mild, moderate or severe. A purposeful sample might call for 18 participants divided into 3 age groups (11–13 years; 14–16 years; and 17–19 years old) and disease severity (mild, moderate, and severe). In each of those nine groups there would be one male and one female. In actual practice, one might want to have more than 18 to allow for attrition, but this breakdown gives the basic idea of defining a purposive sample. One could reasonably expect that having the experience of both genders across the spectrum of disease severity and the developmental range of adolescence would permit an accurate, multi-dimensional understanding to emerge of what living with this life-shortening disease means to adolescents. In fact, such an accurate description is more likely to emerge with this purposeful sample of 18 adolescents than with a convenience sample of the first 18 adolescents who might agree to participate in the study during their outpatient clinic appointment. Defining the sample to be studied requires some forethought about what is likely to be needed to gain the fullest understanding of the topic.

Any research design may be used. The design will be dictated by what data are required to understand the phenomena and its meaning. Interviews are by far the most common means of gathering data, although one might also use written texts, such as prayers written in open prayer books in hospital chapels, for example ( ap Sion, 2013 ; Grossoehme, 1996 ), or drawings ( Pendleton, Cavalli, Pargament, & Nasr, 2002 ), or photographs/videos ( Olausson, Ekebergh, & Lindahl, 2012 ). Although the word “text” appears, it should be with the understanding that any form of data is implied.

The theoretical underpinnings of phenomenology, which are beyond the scope of this article, suggest to users that “a method” is unnecessary or indeed, contrary, to phenomenology. However, one phenomenological researcher did articulate a method ( Giorgi, 1985 ), which consists of the following steps. First, the research team immerses themselves in the data. They do this by reading and re-reading the transcribed interviews and listening to the recorded interviews so that they can hear the tone and timbre of the voices. The goal at this stage is to get a sense of the whole. Second, the texts are coded, in which the words, phrases or sentences that stand out as describing the experience or phenomena under study, or which express outright its meaning for the participant are extracted or highlighted. Each coded bit of data is sometimes referred to as a “meaning unit.” Third, similar meaning units are placed into categories. Fourth, for each meaning unit the meaning of the participants' own words is spelled out. For chaplains, this may mean articulating what the experience means in theological language. Other disciplines might transform the participants' words into psychological, sociological or anthropological language. Here the investigators infer the meaning behind the participants' words and articulate it. Finally, each of the transformed statements of meaning are combined into a few thematic statements that describe the experience ( Bassett, 2004 ; Boss et al., 1996 ). After this, it would be appropriate to do member-checking and a subsequent revision of the final model based on participants' responses and feedback.

PRACTICAL CONCERNS

Just as questionnaires or blood samples contain data, in qualitative research it is the recording of people's words, whether in an audio, video, or paper format which hold the data. Interviews, either in-person or by telephone should be recorded using audio, video or both. It is important to have a device with suitable audio quality and fresh batteries. Experience has shown me the benefit of using two audio recorders so that you do not lose data if one of them fails. There are several small recorders available that have USB connections that allow the audio file to be uploaded to a computer easily. To protect participants' privacy, all data should be anonymized by removing any information that could identify individuals. The Standard Operating Procedure in my research group is to replace all participants' names with an “ N .” During the transcription process, all other individuals are identified by their role in square brackets, “[parent].” Depending on the study's goal and the analytic method you have selected, you may want to include symbols for pauses before participants respond, or non-fluencies (e.g., “ummm. …”, “well … uh …”) or non-verbal gestures (if you are video recording). Decide before beginning whether it is important to capture these as data or not. There are conventional symbols which are inserted into transcriptions which capture these data for you. After the initial transcription, these need to be verified by comparing the written copy against the original recording. Verification should be done by someone other than the transcriptionist. There are several tasks at this stage. Depending on the quality of your recording, the clarity of participants' speech and other factors, some words or phrases may have been unintelligible to the transcriptionist, and this is the time to address them. In my research group our Standard Operating Procedure is to highlight unintelligible text during the transcription phase, and a “verifier” attempts three times to clarify the words on the original recording before leaving them marked “unintelligible” in the transcript. No transcriptionist is perfect and if they are unfamiliar with the topic, they may transcribe the recording inaccurately. I recently verified a transcript where a commercial medical transcriptionist changed the participant's gender from “he” to “she” when the word prior to the pronoun ended with an “s.” If this pattern had not been caught during the verification process, it would have been very difficult during the coding to know whether the pronoun referred to the participant or to their daughter.

ETHICAL ISSUES IN QUALITATIVE RESEARCH

Study design.

The issue of power and the possibility of subtle coercion is the concern here. There is an inherent power differential between a research participant and the investigator, which is exacerbated when the investigator is a chaplain. Despite our attempts to be non-threatening, the very words, "chaplain," or "clergy" connote power. For this reason, the chaplain-investigator should not approach potential participants regarding a study. Potential participants may be informed regarding their eligibility to participate by their physician or a chaplain, but the recruitment and informed consent process should be handled by someone else, perhaps a clinical research coordinator. However, as the chaplain-investigator, you will need to teach them how to talk with potential participants about your study and answer their questions. Choose a data collection method that is best-suited to the level of sensitivity of your research topic. Focus groups can provide data with multiple perspectives, and they are a poor choice when there may be pressure to provide socially correct responses, or when disclosures may be stigmatizing. In such cases, it is better to collect data using individual semi-structured interviews.

Develop a plan for assessing participants' discomfort, anxiety, or even more severe reactions during the study. For instance, what will you do when someone discloses his/her current thoughts of self-harm, or experiences a flashback to a prior traumatic event that was triggered during an interview? How will you handle this if you are collecting data in person? By telephone? You will need to be specific who must be informed and who will make decisions about responding to the risk.

Privacy and Confidentiality

In addition to maintaining privacy and confidentiality of your actual data and other study documents, consider how you will protect participants' privacy when you write the study up for publication. Make sure that people cannot be identified by their quotations that you include as you publish data. The smaller the population you are working with, the more diligently you need to work on this. If the transcriptionist is not an employee of your institution and under the same privacy and confidentiality policies, it is up to you to ensure that an external transcriptionist takes steps to protect and maintain the privacy of participants' data.

Qualitative research is an accessible way for chaplains to contribute new knowledge regarding the sacred dimension of people's lived experience. Chaplains are already sensitive to and familiar with many aspects of qualitative research methodologies. Studies need to be designed to be valid and meaningful, and are best done collaboratively. They provide an excellent opportunity to develop working relationships with physicians, medical anthropologists, nurses, psychologists, and sociologists, all of whom have rich traditions of qualitative research. This article can only provide an overview of some of the issues related to qualitative research and some of its methods. The texts cited, as well as others, provide additional information needed before designing and carrying out a qualitative study. Qualitative research is a tool that chaplains can use to develop new knowledge and contribute to professional chaplaincy's ability to facilitate the healing of brokenness and disease.

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• ap Sion T. Coping through prayer: An empirical study in implicit religion concerning prayers for children in hospital. Mental Health, Religion & Culture. 2013; 16 (9):936–952. doi: 10.1080/13674676.2012.756186. [ Google Scholar ]
• Bassett C. Phenomenology. In: Bassett C, editor. Qualitative research in health care. Whurr Publishers, Ltd; London, UK: 2004. pp. 154–177. [ Google Scholar ]
• Boss P, Dahl C, Kaplan L. The use of phenomenology for family therapy research. In: Sprenkle DH, Moon SM, editors. Research methods in family therapy. Guilford Press; New York, NY: 1996. pp. 83–106. [ Google Scholar ]
• Boyle J. Styles of ethnography. In: Morse JM, editor. Critical issues in qualitative research methods. Sage Publications; Thousand Oaks, CA: 1994. pp. 159–185. [ Google Scholar ]
• Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: Using positive deviance to improve quality of health care. Implementation Science. 2009; 4 (25) doi: 10.1186/1748-5908-4-25. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Charmaz K. Grounded theory in the 21st century. In: Denzin NK, Lincoln YS, editors. The SAGE handbook of qualitative research. Sage Publications; Thousand Oaks, CA: 2005. pp. 507–535. [ Google Scholar ]
• Charmaz K. Constructing grounded theory. Sage Publications; Thousand Oaks, CA: 2006. [ Google Scholar ]
• Cohen D, Crabtree B. Qualitative research guidelines project. 2006 Retrieved March 11, 2014, from http://www.qualres.org/HomeSemi-3629.html .
• Fore D, Goldenhar LM, Margolis PA, Seid M. Using goal-directed design to create a novel system for improving chronic illness. JMIR Research Protocols. 2013; 2 (2):343. doi: 10.2196/resprot.2749. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Giorgi A. Phenomenology and psychological research. Dusquesne University Press; Pittsburgh, PA: 1985. [ Google Scholar ]
• Grossoehme DH. Prayer reveals belief: Images of God from hospital prayers. Journal of Pastoral Care. 1996; 50 (1):33–39. [ PubMed ] [ Google Scholar ]
• Grossoehme DH. Research as a chaplaincy intervention. Journal of Health Care Chaplaincy. 2011; 17 (3–4):97–99. doi: 10.1080/08854726.2011.616165. [ PubMed ] [ Google Scholar ]
• Grossoehme DH, Cotton S, Ragsdale J, Quittner AL, McPhail G, Seid M. "I honestly believe God keeps me healthy so I can take care of my child": Parental use of faith related to treatment adherence. Journal of Health Care Chaplaincy. 2013; 19 (2):66–78. doi: 10.1080/08854726.2013.779540. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Grossoehme DH, Ragsdale JR, Cotton S, Meyers MA, Clancy JP, Seid M, Joseph PM. Using spirituality after an adult CF diagnosis: Cognitive reframing and adherence motivation. Journal of Health Care Chaplaincy. 2012; 18 (3–4):110–120. doi: 10.1080/08854726.2012.720544. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Grossoehme DH, Ragsdale J, Wooldridge JL, Cotton S, Seid M. We can handle this: Parents' use of religion in the first year following their child's diagnosis with cystic fibrosis. Journal of Health Care Chaplaincy. 2010; 16 (3–4):95–108. doi: 10.1080/08854726.2010.480833. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Malterud K. Qualitative research: Standards, challenges, and guidelines. The Lancet. 2001; 358 (9280):483–488. [ PubMed ] [ Google Scholar ]
• Morse JM. The significance of saturation. Qualitative Health Research. 1995; 5 :147–149. [ Google Scholar ]
• Newfield N, Sells SP, Smith TE, Newfield S, Newfield F. Ethnographic research methods. In: Sprenkle DH, Moon SM, editors. Research methods in family therapy. The Guilford Press; New York, NY: 1996. pp. 25–63. [ Google Scholar ]
• NVivo qualitative data analysis software . QSR International Pty Ltd. 2012. [ Google Scholar ]
• Olausson S, Ekebergh M, Lindahl B. The ICU patient room: Views and meanings as experienced by the next of kin: A phenomenological hermeneutical study. Intensive and Critical Care Nursing. 2012; 28 (3):176–184. [ PubMed ] [ Google Scholar ]
• Pendleton SM, Cavalli KS, Pargament KI, Nasr SZ. Religious/spiritual coping in childhood cystic fibrosis: A qualitative study. Pediatrics. 2002; 109 (1):E8. [ PubMed ] [ Google Scholar ]
• Rafuls SE, Moon SM. Grounded theory methodology in family therapy research. In: Sprenkle DH, Moon SM, editors. Research methods in family therapy. The Guilford Press; New York, NY: 1996. [ Google Scholar ]
• Risk JL. Building a new life: A chaplain's theory based case study of chronic illness. Journal of Health Care Chaplaincy. 2013; 19 :81–98. [ PubMed ] [ Google Scholar ]
• Seid M, Sobo EJ, Gelhard LR, Varni JW. Parents' reports of barriers to care for children with special health care needs: Development and validation of the barriers to care questionnaire. Ambulatory Pediatrics. 2004; 4 (4):323–331. doi: 10.1367/A03-198R.1. [ PubMed ] [ Google Scholar ]
• Sobo EJ. Culture and meaning in health services research. Left Coast Press, Inc; Walnut Creek, CA: 2009. [ Google Scholar ]
• Swinton J, Mowat H. Practical theology and qualitative research. SCM Press; London, UK: 2006. [ Google Scholar ]
• Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007; 19 (6):349–357. [ PubMed ] [ Google Scholar ]