using interview in qualitative research

Chapter 11. Interviewing

Introduction.

Interviewing people is at the heart of qualitative research. It is not merely a way to collect data but an intrinsically rewarding activity—an interaction between two people that holds the potential for greater understanding and interpersonal development. Unlike many of our daily interactions with others that are fairly shallow and mundane, sitting down with a person for an hour or two and really listening to what they have to say is a profound and deep enterprise, one that can provide not only “data” for you, the interviewer, but also self-understanding and a feeling of being heard for the interviewee. I always approach interviewing with a deep appreciation for the opportunity it gives me to understand how other people experience the world. That said, there is not one kind of interview but many, and some of these are shallower than others. This chapter will provide you with an overview of interview techniques but with a special focus on the in-depth semistructured interview guide approach, which is the approach most widely used in social science research.

An interview can be variously defined as “a conversation with a purpose” ( Lune and Berg 2018 ) and an attempt to understand the world from the point of view of the person being interviewed: “to unfold the meaning of peoples’ experiences, to uncover their lived world prior to scientific explanations” ( Kvale 2007 ). It is a form of active listening in which the interviewer steers the conversation to subjects and topics of interest to their research but also manages to leave enough space for those interviewed to say surprising things. Achieving that balance is a tricky thing, which is why most practitioners believe interviewing is both an art and a science. In my experience as a teacher, there are some students who are “natural” interviewers (often they are introverts), but anyone can learn to conduct interviews, and everyone, even those of us who have been doing this for years, can improve their interviewing skills. This might be a good time to highlight the fact that the interview is a product between interviewer and interviewee and that this product is only as good as the rapport established between the two participants. Active listening is the key to establishing this necessary rapport.

Patton ( 2002 ) makes the argument that we use interviews because there are certain things that are not observable. In particular, “we cannot observe feelings, thoughts, and intentions. We cannot observe behaviors that took place at some previous point in time. We cannot observe situations that preclude the presence of an observer. We cannot observe how people have organized the world and the meanings they attach to what goes on in the world. We have to ask people questions about those things” ( 341 ).

Types of Interviews

There are several distinct types of interviews. Imagine a continuum (figure 11.1). On one side are unstructured conversations—the kind you have with your friends. No one is in control of those conversations, and what you talk about is often random—whatever pops into your head. There is no secret, underlying purpose to your talking—if anything, the purpose is to talk to and engage with each other, and the words you use and the things you talk about are a little beside the point. An unstructured interview is a little like this informal conversation, except that one of the parties to the conversation (you, the researcher) does have an underlying purpose, and that is to understand the other person. You are not friends speaking for no purpose, but it might feel just as unstructured to the “interviewee” in this scenario. That is one side of the continuum. On the other side are fully structured and standardized survey-type questions asked face-to-face. Here it is very clear who is asking the questions and who is answering them. This doesn’t feel like a conversation at all! A lot of people new to interviewing have this ( erroneously !) in mind when they think about interviews as data collection. Somewhere in the middle of these two extreme cases is the “ semistructured” interview , in which the researcher uses an “interview guide” to gently move the conversation to certain topics and issues. This is the primary form of interviewing for qualitative social scientists and will be what I refer to as interviewing for the rest of this chapter, unless otherwise specified.

Types of Interviewing Questions: Unstructured conversations, Semi-structured interview, Structured interview, Survey questions

Informal (unstructured conversations). This is the most “open-ended” approach to interviewing. It is particularly useful in conjunction with observational methods (see chapters 13 and 14). There are no predetermined questions. Each interview will be different. Imagine you are researching the Oregon Country Fair, an annual event in Veneta, Oregon, that includes live music, artisan craft booths, face painting, and a lot of people walking through forest paths. It’s unlikely that you will be able to get a person to sit down with you and talk intensely about a set of questions for an hour and a half. But you might be able to sidle up to several people and engage with them about their experiences at the fair. You might have a general interest in what attracts people to these events, so you could start a conversation by asking strangers why they are here or why they come back every year. That’s it. Then you have a conversation that may lead you anywhere. Maybe one person tells a long story about how their parents brought them here when they were a kid. A second person talks about how this is better than Burning Man. A third person shares their favorite traveling band. And yet another enthuses about the public library in the woods. During your conversations, you also talk about a lot of other things—the weather, the utilikilts for sale, the fact that a favorite food booth has disappeared. It’s all good. You may not be able to record these conversations. Instead, you might jot down notes on the spot and then, when you have the time, write down as much as you can remember about the conversations in long fieldnotes. Later, you will have to sit down with these fieldnotes and try to make sense of all the information (see chapters 18 and 19).

Interview guide ( semistructured interview ). This is the primary type employed by social science qualitative researchers. The researcher creates an “interview guide” in advance, which she uses in every interview. In theory, every person interviewed is asked the same questions. In practice, every person interviewed is asked mostly the same topics but not always the same questions, as the whole point of a “guide” is that it guides the direction of the conversation but does not command it. The guide is typically between five and ten questions or question areas, sometimes with suggested follow-ups or prompts . For example, one question might be “What was it like growing up in Eastern Oregon?” with prompts such as “Did you live in a rural area? What kind of high school did you attend?” to help the conversation develop. These interviews generally take place in a quiet place (not a busy walkway during a festival) and are recorded. The recordings are transcribed, and those transcriptions then become the “data” that is analyzed (see chapters 18 and 19). The conventional length of one of these types of interviews is between one hour and two hours, optimally ninety minutes. Less than one hour doesn’t allow for much development of questions and thoughts, and two hours (or more) is a lot of time to ask someone to sit still and answer questions. If you have a lot of ground to cover, and the person is willing, I highly recommend two separate interview sessions, with the second session being slightly shorter than the first (e.g., ninety minutes the first day, sixty minutes the second). There are lots of good reasons for this, but the most compelling one is that this allows you to listen to the first day’s recording and catch anything interesting you might have missed in the moment and so develop follow-up questions that can probe further. This also allows the person being interviewed to have some time to think about the issues raised in the interview and go a little deeper with their answers.

Standardized questionnaire with open responses ( structured interview ). This is the type of interview a lot of people have in mind when they hear “interview”: a researcher comes to your door with a clipboard and proceeds to ask you a series of questions. These questions are all the same whoever answers the door; they are “standardized.” Both the wording and the exact order are important, as people’s responses may vary depending on how and when a question is asked. These are qualitative only in that the questions allow for “open-ended responses”: people can say whatever they want rather than select from a predetermined menu of responses. For example, a survey I collaborated on included this open-ended response question: “How does class affect one’s career success in sociology?” Some of the answers were simply one word long (e.g., “debt”), and others were long statements with stories and personal anecdotes. It is possible to be surprised by the responses. Although it’s a stretch to call this kind of questioning a conversation, it does allow the person answering the question some degree of freedom in how they answer.

Survey questionnaire with closed responses (not an interview!). Standardized survey questions with specific answer options (e.g., closed responses) are not really interviews at all, and they do not generate qualitative data. For example, if we included five options for the question “How does class affect one’s career success in sociology?”—(1) debt, (2) social networks, (3) alienation, (4) family doesn’t understand, (5) type of grad program—we leave no room for surprises at all. Instead, we would most likely look at patterns around these responses, thinking quantitatively rather than qualitatively (e.g., using regression analysis techniques, we might find that working-class sociologists were twice as likely to bring up alienation). It can sometimes be confusing for new students because the very same survey can include both closed-ended and open-ended questions. The key is to think about how these will be analyzed and to what level surprises are possible. If your plan is to turn all responses into a number and make predictions about correlations and relationships, you are no longer conducting qualitative research. This is true even if you are conducting this survey face-to-face with a real live human. Closed-response questions are not conversations of any kind, purposeful or not.

In summary, the semistructured interview guide approach is the predominant form of interviewing for social science qualitative researchers because it allows a high degree of freedom of responses from those interviewed (thus allowing for novel discoveries) while still maintaining some connection to a research question area or topic of interest. The rest of the chapter assumes the employment of this form.

Creating an Interview Guide

Your interview guide is the instrument used to bridge your research question(s) and what the people you are interviewing want to tell you. Unlike a standardized questionnaire, the questions actually asked do not need to be exactly what you have written down in your guide. The guide is meant to create space for those you are interviewing to talk about the phenomenon of interest, but sometimes you are not even sure what that phenomenon is until you start asking questions. A priority in creating an interview guide is to ensure it offers space. One of the worst mistakes is to create questions that are so specific that the person answering them will not stray. Relatedly, questions that sound “academic” will shut down a lot of respondents. A good interview guide invites respondents to talk about what is important to them, not feel like they are performing or being evaluated by you.

Good interview questions should not sound like your “research question” at all. For example, let’s say your research question is “How do patriarchal assumptions influence men’s understanding of climate change and responses to climate change?” It would be worse than unhelpful to ask a respondent, “How do your assumptions about the role of men affect your understanding of climate change?” You need to unpack this into manageable nuggets that pull your respondent into the area of interest without leading him anywhere. You could start by asking him what he thinks about climate change in general. Or, even better, whether he has any concerns about heatwaves or increased tornadoes or polar icecaps melting. Once he starts talking about that, you can ask follow-up questions that bring in issues around gendered roles, perhaps asking if he is married (to a woman) and whether his wife shares his thoughts and, if not, how they negotiate that difference. The fact is, you won’t really know the right questions to ask until he starts talking.

There are several distinct types of questions that can be used in your interview guide, either as main questions or as follow-up probes. If you remember that the point is to leave space for the respondent, you will craft a much more effective interview guide! You will also want to think about the place of time in both the questions themselves (past, present, future orientations) and the sequencing of the questions.

Researcher Note

Suggestion : As you read the next three sections (types of questions, temporality, question sequence), have in mind a particular research question, and try to draft questions and sequence them in a way that opens space for a discussion that helps you answer your research question.

Type of Questions

Experience and behavior questions ask about what a respondent does regularly (their behavior) or has done (their experience). These are relatively easy questions for people to answer because they appear more “factual” and less subjective. This makes them good opening questions. For the study on climate change above, you might ask, “Have you ever experienced an unusual weather event? What happened?” Or “You said you work outside? What is a typical summer workday like for you? How do you protect yourself from the heat?”

Opinion and values questions , in contrast, ask questions that get inside the minds of those you are interviewing. “Do you think climate change is real? Who or what is responsible for it?” are two such questions. Note that you don’t have to literally ask, “What is your opinion of X?” but you can find a way to ask the specific question relevant to the conversation you are having. These questions are a bit trickier to ask because the answers you get may depend in part on how your respondent perceives you and whether they want to please you or not. We’ve talked a fair amount about being reflective. Here is another place where this comes into play. You need to be aware of the effect your presence might have on the answers you are receiving and adjust accordingly. If you are a woman who is perceived as liberal asking a man who identifies as conservative about climate change, there is a lot of subtext that can be going on in the interview. There is no one right way to resolve this, but you must at least be aware of it.

Feeling questions are questions that ask respondents to draw on their emotional responses. It’s pretty common for academic researchers to forget that we have bodies and emotions, but people’s understandings of the world often operate at this affective level, sometimes unconsciously or barely consciously. It is a good idea to include questions that leave space for respondents to remember, imagine, or relive emotional responses to particular phenomena. “What was it like when you heard your cousin’s house burned down in that wildfire?” doesn’t explicitly use any emotion words, but it allows your respondent to remember what was probably a pretty emotional day. And if they respond emotionally neutral, that is pretty interesting data too. Note that asking someone “How do you feel about X” is not always going to evoke an emotional response, as they might simply turn around and respond with “I think that…” It is better to craft a question that actually pushes the respondent into the affective category. This might be a specific follow-up to an experience and behavior question —for example, “You just told me about your daily routine during the summer heat. Do you worry it is going to get worse?” or “Have you ever been afraid it will be too hot to get your work accomplished?”

Knowledge questions ask respondents what they actually know about something factual. We have to be careful when we ask these types of questions so that respondents do not feel like we are evaluating them (which would shut them down), but, for example, it is helpful to know when you are having a conversation about climate change that your respondent does in fact know that unusual weather events have increased and that these have been attributed to climate change! Asking these questions can set the stage for deeper questions and can ensure that the conversation makes the same kind of sense to both participants. For example, a conversation about political polarization can be put back on track once you realize that the respondent doesn’t really have a clear understanding that there are two parties in the US. Instead of asking a series of questions about Republicans and Democrats, you might shift your questions to talk more generally about political disagreements (e.g., “people against abortion”). And sometimes what you do want to know is the level of knowledge about a particular program or event (e.g., “Are you aware you can discharge your student loans through the Public Service Loan Forgiveness program?”).

Sensory questions call on all senses of the respondent to capture deeper responses. These are particularly helpful in sparking memory. “Think back to your childhood in Eastern Oregon. Describe the smells, the sounds…” Or you could use these questions to help a person access the full experience of a setting they customarily inhabit: “When you walk through the doors to your office building, what do you see? Hear? Smell?” As with feeling questions , these questions often supplement experience and behavior questions . They are another way of allowing your respondent to report fully and deeply rather than remain on the surface.

Creative questions employ illustrative examples, suggested scenarios, or simulations to get respondents to think more deeply about an issue, topic, or experience. There are many options here. In The Trouble with Passion , Erin Cech ( 2021 ) provides a scenario in which “Joe” is trying to decide whether to stay at his decent but boring computer job or follow his passion by opening a restaurant. She asks respondents, “What should Joe do?” Their answers illuminate the attraction of “passion” in job selection. In my own work, I have used a news story about an upwardly mobile young man who no longer has time to see his mother and sisters to probe respondents’ feelings about the costs of social mobility. Jessi Streib and Betsy Leondar-Wright have used single-page cartoon “scenes” to elicit evaluations of potential racial discrimination, sexual harassment, and classism. Barbara Sutton ( 2010 ) has employed lists of words (“strong,” “mother,” “victim”) on notecards she fans out and asks her female respondents to select and discuss.

Background/Demographic Questions

You most definitely will want to know more about the person you are interviewing in terms of conventional demographic information, such as age, race, gender identity, occupation, and educational attainment. These are not questions that normally open up inquiry. [1] For this reason, my practice has been to include a separate “demographic questionnaire” sheet that I ask each respondent to fill out at the conclusion of the interview. Only include those aspects that are relevant to your study. For example, if you are not exploring religion or religious affiliation, do not include questions about a person’s religion on the demographic sheet. See the example provided at the end of this chapter.

Temporality

Any type of question can have a past, present, or future orientation. For example, if you are asking a behavior question about workplace routine, you might ask the respondent to talk about past work, present work, and ideal (future) work. Similarly, if you want to understand how people cope with natural disasters, you might ask your respondent how they felt then during the wildfire and now in retrospect and whether and to what extent they have concerns for future wildfire disasters. It’s a relatively simple suggestion—don’t forget to ask about past, present, and future—but it can have a big impact on the quality of the responses you receive.

Question Sequence

Having a list of good questions or good question areas is not enough to make a good interview guide. You will want to pay attention to the order in which you ask your questions. Even though any one respondent can derail this order (perhaps by jumping to answer a question you haven’t yet asked), a good advance plan is always helpful. When thinking about sequence, remember that your goal is to get your respondent to open up to you and to say things that might surprise you. To establish rapport, it is best to start with nonthreatening questions. Asking about the present is often the safest place to begin, followed by the past (they have to know you a little bit to get there), and lastly, the future (talking about hopes and fears requires the most rapport). To allow for surprises, it is best to move from very general questions to more particular questions only later in the interview. This ensures that respondents have the freedom to bring up the topics that are relevant to them rather than feel like they are constrained to answer you narrowly. For example, refrain from asking about particular emotions until these have come up previously—don’t lead with them. Often, your more particular questions will emerge only during the course of the interview, tailored to what is emerging in conversation.

Once you have a set of questions, read through them aloud and imagine you are being asked the same questions. Does the set of questions have a natural flow? Would you be willing to answer the very first question to a total stranger? Does your sequence establish facts and experiences before moving on to opinions and values? Did you include prefatory statements, where necessary; transitions; and other announcements? These can be as simple as “Hey, we talked a lot about your experiences as a barista while in college.… Now I am turning to something completely different: how you managed friendships in college.” That is an abrupt transition, but it has been softened by your acknowledgment of that.

Probes and Flexibility

Once you have the interview guide, you will also want to leave room for probes and follow-up questions. As in the sample probe included here, you can write out the obvious probes and follow-up questions in advance. You might not need them, as your respondent might anticipate them and include full responses to the original question. Or you might need to tailor them to how your respondent answered the question. Some common probes and follow-up questions include asking for more details (When did that happen? Who else was there?), asking for elaboration (Could you say more about that?), asking for clarification (Does that mean what I think it means or something else? I understand what you mean, but someone else reading the transcript might not), and asking for contrast or comparison (How did this experience compare with last year’s event?). “Probing is a skill that comes from knowing what to look for in the interview, listening carefully to what is being said and what is not said, and being sensitive to the feedback needs of the person being interviewed” ( Patton 2002:374 ). It takes work! And energy. I and many other interviewers I know report feeling emotionally and even physically drained after conducting an interview. You are tasked with active listening and rearranging your interview guide as needed on the fly. If you only ask the questions written down in your interview guide with no deviations, you are doing it wrong. [2]

The Final Question

Every interview guide should include a very open-ended final question that allows for the respondent to say whatever it is they have been dying to tell you but you’ve forgotten to ask. About half the time they are tired too and will tell you they have nothing else to say. But incredibly, some of the most honest and complete responses take place here, at the end of a long interview. You have to realize that the person being interviewed is often discovering things about themselves as they talk to you and that this process of discovery can lead to new insights for them. Making space at the end is therefore crucial. Be sure you convey that you actually do want them to tell you more, that the offer of “anything else?” is not read as an empty convention where the polite response is no. Here is where you can pull from that active listening and tailor the final question to the particular person. For example, “I’ve asked you a lot of questions about what it was like to live through that wildfire. I’m wondering if there is anything I’ve forgotten to ask, especially because I haven’t had that experience myself” is a much more inviting final question than “Great. Anything you want to add?” It’s also helpful to convey to the person that you have the time to listen to their full answer, even if the allotted time is at the end. After all, there are no more questions to ask, so the respondent knows exactly how much time is left. Do them the courtesy of listening to them!

Conducting the Interview

Once you have your interview guide, you are on your way to conducting your first interview. I always practice my interview guide with a friend or family member. I do this even when the questions don’t make perfect sense for them, as it still helps me realize which questions make no sense, are poorly worded (too academic), or don’t follow sequentially. I also practice the routine I will use for interviewing, which goes something like this:

Introduce myself and reintroduce the study
Provide consent form and ask them to sign and retain/return copy
Ask if they have any questions about the study before we begin
Ask if I can begin recording
Ask questions (from interview guide)
Turn off the recording device
Ask if they are willing to fill out my demographic questionnaire
Collect questionnaire and, without looking at the answers, place in same folder as signed consent form
Thank them and depart

A note on remote interviewing: Interviews have traditionally been conducted face-to-face in a private or quiet public setting. You don’t want a lot of background noise, as this will make transcriptions difficult. During the recent global pandemic, many interviewers, myself included, learned the benefits of interviewing remotely. Although face-to-face is still preferable for many reasons, Zoom interviewing is not a bad alternative, and it does allow more interviews across great distances. Zoom also includes automatic transcription, which significantly cuts down on the time it normally takes to convert our conversations into “data” to be analyzed. These automatic transcriptions are not perfect, however, and you will still need to listen to the recording and clarify and clean up the transcription. Nor do automatic transcriptions include notations of body language or change of tone, which you may want to include. When interviewing remotely, you will want to collect the consent form before you meet: ask them to read, sign, and return it as an email attachment. I think it is better to ask for the demographic questionnaire after the interview, but because some respondents may never return it then, it is probably best to ask for this at the same time as the consent form, in advance of the interview.

What should you bring to the interview? I would recommend bringing two copies of the consent form (one for you and one for the respondent), a demographic questionnaire, a manila folder in which to place the signed consent form and filled-out demographic questionnaire, a printed copy of your interview guide (I print with three-inch right margins so I can jot down notes on the page next to relevant questions), a pen, a recording device, and water.

After the interview, you will want to secure the signed consent form in a locked filing cabinet (if in print) or a password-protected folder on your computer. Using Excel or a similar program that allows tables/spreadsheets, create an identifying number for your interview that links to the consent form without using the name of your respondent. For example, let’s say that I conduct interviews with US politicians, and the first person I meet with is George W. Bush. I will assign the transcription the number “INT#001” and add it to the signed consent form. [3] The signed consent form goes into a locked filing cabinet, and I never use the name “George W. Bush” again. I take the information from the demographic sheet, open my Excel spreadsheet, and add the relevant information in separate columns for the row INT#001: White, male, Republican. When I interview Bill Clinton as my second interview, I include a second row: INT#002: White, male, Democrat. And so on. The only link to the actual name of the respondent and this information is the fact that the consent form (unavailable to anyone but me) has stamped on it the interview number.

Many students get very nervous before their first interview. Actually, many of us are always nervous before the interview! But do not worry—this is normal, and it does pass. Chances are, you will be pleasantly surprised at how comfortable it begins to feel. These “purposeful conversations” are often a delight for both participants. This is not to say that sometimes things go wrong. I often have my students practice several “bad scenarios” (e.g., a respondent that you cannot get to open up; a respondent who is too talkative and dominates the conversation, steering it away from the topics you are interested in; emotions that completely take over; or shocking disclosures you are ill-prepared to handle), but most of the time, things go quite well. Be prepared for the unexpected, but know that the reason interviews are so popular as a technique of data collection is that they are usually richly rewarding for both participants.

One thing that I stress to my methods students and remind myself about is that interviews are still conversations between people. If there’s something you might feel uncomfortable asking someone about in a “normal” conversation, you will likely also feel a bit of discomfort asking it in an interview. Maybe more importantly, your respondent may feel uncomfortable. Social research—especially about inequality—can be uncomfortable. And it’s easy to slip into an abstract, intellectualized, or removed perspective as an interviewer. This is one reason trying out interview questions is important. Another is that sometimes the question sounds good in your head but doesn’t work as well out loud in practice. I learned this the hard way when a respondent asked me how I would answer the question I had just posed, and I realized that not only did I not really know how I would answer it, but I also wasn’t quite as sure I knew what I was asking as I had thought.

—Elizabeth M. Lee, Associate Professor of Sociology at Saint Joseph’s University, author of Class and Campus Life , and co-author of Geographies of Campus Inequality

How Many Interviews?

Your research design has included a targeted number of interviews and a recruitment plan (see chapter 5). Follow your plan, but remember that “ saturation ” is your goal. You interview as many people as you can until you reach a point at which you are no longer surprised by what they tell you. This means not that no one after your first twenty interviews will have surprising, interesting stories to tell you but rather that the picture you are forming about the phenomenon of interest to you from a research perspective has come into focus, and none of the interviews are substantially refocusing that picture. That is when you should stop collecting interviews. Note that to know when you have reached this, you will need to read your transcripts as you go. More about this in chapters 18 and 19.

Your Final Product: The Ideal Interview Transcript

A good interview transcript will demonstrate a subtly controlled conversation by the skillful interviewer. In general, you want to see replies that are about one paragraph long, not short sentences and not running on for several pages. Although it is sometimes necessary to follow respondents down tangents, it is also often necessary to pull them back to the questions that form the basis of your research study. This is not really a free conversation, although it may feel like that to the person you are interviewing.

Final Tips from an Interview Master

Annette Lareau is arguably one of the masters of the trade. In Listening to People , she provides several guidelines for good interviews and then offers a detailed example of an interview gone wrong and how it could be addressed (please see the “Further Readings” at the end of this chapter). Here is an abbreviated version of her set of guidelines: (1) interview respondents who are experts on the subjects of most interest to you (as a corollary, don’t ask people about things they don’t know); (2) listen carefully and talk as little as possible; (3) keep in mind what you want to know and why you want to know it; (4) be a proactive interviewer (subtly guide the conversation); (5) assure respondents that there aren’t any right or wrong answers; (6) use the respondent’s own words to probe further (this both allows you to accurately identify what you heard and pushes the respondent to explain further); (7) reuse effective probes (don’t reinvent the wheel as you go—if repeating the words back works, do it again and again); (8) focus on learning the subjective meanings that events or experiences have for a respondent; (9) don’t be afraid to ask a question that draws on your own knowledge (unlike trial lawyers who are trained never to ask a question for which they don’t already know the answer, sometimes it’s worth it to ask risky questions based on your hypotheses or just plain hunches); (10) keep thinking while you are listening (so difficult…and important); (11) return to a theme raised by a respondent if you want further information; (12) be mindful of power inequalities (and never ever coerce a respondent to continue the interview if they want out); (13) take control with overly talkative respondents; (14) expect overly succinct responses, and develop strategies for probing further; (15) balance digging deep and moving on; (16) develop a plan to deflect questions (e.g., let them know you are happy to answer any questions at the end of the interview, but you don’t want to take time away from them now); and at the end, (17) check to see whether you have asked all your questions. You don’t always have to ask everyone the same set of questions, but if there is a big area you have forgotten to cover, now is the time to recover ( Lareau 2021:93–103 ).

Sample: Demographic Questionnaire

ASA Taskforce on First-Generation and Working-Class Persons in Sociology – Class Effects on Career Success

Supplementary Demographic Questionnaire

Thank you for your participation in this interview project. We would like to collect a few pieces of key demographic information from you to supplement our analyses. Your answers to these questions will be kept confidential and stored by ID number. All of your responses here are entirely voluntary!

What best captures your race/ethnicity? (please check any/all that apply)

White (Non Hispanic/Latina/o/x)
Black or African American
Hispanic, Latino/a/x of Spanish
Asian or Asian American
American Indian or Alaska Native
Middle Eastern or North African
Native Hawaiian or Pacific Islander
Other : (Please write in: ________________)

What is your current position?

Grad Student
Full Professor

Please check any and all of the following that apply to you:

I identify as a working-class academic
I was the first in my family to graduate from college
I grew up poor

What best reflects your gender?

Transgender female/Transgender woman
Transgender male/Transgender man
Gender queer/ Gender nonconforming

Anything else you would like us to know about you?

Example: Interview Guide

In this example, follow-up prompts are italicized. Note the sequence of questions. That second question often elicits an entire life history , answering several later questions in advance.

Introduction Script/Question

Thank you for participating in our survey of ASA members who identify as first-generation or working-class. As you may have heard, ASA has sponsored a taskforce on first-generation and working-class persons in sociology and we are interested in hearing from those who so identify. Your participation in this interview will help advance our knowledge in this area.

The first thing we would like to as you is why you have volunteered to be part of this study? What does it mean to you be first-gen or working class? Why were you willing to be interviewed?
How did you decide to become a sociologist?
Can you tell me a little bit about where you grew up? ( prompts: what did your parent(s) do for a living? What kind of high school did you attend?)
Has this identity been salient to your experience? (how? How much?)
How welcoming was your grad program? Your first academic employer?
Why did you decide to pursue sociology at the graduate level?
Did you experience culture shock in college? In graduate school?
Has your FGWC status shaped how you’ve thought about where you went to school? debt? etc?
Were you mentored? How did this work (not work)? How might it?
What did you consider when deciding where to go to grad school? Where to apply for your first position?
What, to you, is a mark of career success? Have you achieved that success? What has helped or hindered your pursuit of success?
Do you think sociology, as a field, cares about prestige?
Let’s talk a little bit about intersectionality. How does being first-gen/working class work alongside other identities that are important to you?
What do your friends and family think about your career? Have you had any difficulty relating to family members or past friends since becoming highly educated?
Do you have any debt from college/grad school? Are you concerned about this? Could you explain more about how you paid for college/grad school? (here, include assistance from family, fellowships, scholarships, etc.)
(You’ve mentioned issues or obstacles you had because of your background.) What could have helped? Or, who or what did? Can you think of fortuitous moments in your career?
Do you have any regrets about the path you took?
Is there anything else you would like to add? Anything that the Taskforce should take note of, that we did not ask you about here?

Library Support for Qualitative Research

Interview Research
Resources for Methodology
Remote Research & Virtual Fieldwork

Resources for Research Interviewing

Nih-funded qualitative research.

Oral History
Data Management & Repositories
Campus Access

Types of Interviews

Engaging Participants

Interview Questions

Conducting Interviews
Transcription
Coding and Analysis
Managing & Finding Interview Data
UX & Market Research Interviews

Textbooks, Guidebooks, and Handbooks

The Ethnographic Interview by James P. Spradley “Spradley wrote this book for the professional and student who have never done ethnographic fieldwork (p. 231) and for the professional ethnographer who is interested in adapting the author’s procedures (p. iv). Part 1 outlines in 3 chapters Spradley’s version of ethnographic research, and it provides the background for Part 2 which consists of 12 guided steps (chapters) ranging from locating and interviewing an informant to writing an ethnography. Most of the examples come from the author’s own fieldwork among U.S. subcultures . . . Steps 6 and 8 explain lucidly how to construct a domain and a taxonomic analysis” (excerpted from book review by James D. Sexton, 1980).
Fundamentals of Qualitative Research by Johnny Saldana (Series edited by Patricia Leavy) Provides a soup-to-nuts overview of the qualitative data collection process, including interviewing, participant observation, and other methods.
InterViews by Steinar Kvale Interviewing is an essential tool in qualitative research and this introduction to interviewing outlines both the theoretical underpinnings and the practical aspects of the process. After examining the role of the interview in the research process, Steinar Kvale considers some of the key philosophical issues relating to interviewing: the interview as conversation, hermeneutics, phenomenology, concerns about ethics as well as validity, and postmodernism. Having established this framework, the author then analyzes the seven stages of the interview process - from designing a study to writing it up.
Practical Evaluation by Michael Quinn Patton Surveys different interviewing strategies, from, a) informal/conversational, to b) interview guide approach, to c) standardized and open-ended, to d) closed/quantitative. Also discusses strategies for wording questions that are open-ended, clear, sensitive, and neutral, while supporting the speaker. Provides suggestions for probing and maintaining control of the interview process, as well as suggestions for recording and transcription.
The SAGE Handbook of Interview Research by Amir B. Marvasti (Editor); James A. Holstein (Editor); Jaber F. Gubrium (Editor); Karyn D. McKinney (Editor) The new edition of this landmark volume emphasizes the dynamic, interactional, and reflexive dimensions of the research interview. Contributors highlight the myriad dimensions of complexity that are emerging as researchers increasingly frame the interview as a communicative opportunity as much as a data-gathering format. The book begins with the history and conceptual transformations of the interview, which is followed by chapters that discuss the main components of interview practice. Taken together, the contributions to The SAGE Handbook of Interview Research: The Complexity of the Craft encourage readers simultaneously to learn the frameworks and technologies of interviewing and to reflect on the epistemological foundations of the interview craft.
The SAGE Handbook of Online Research Methods by Nigel G. Fielding, Raymond M. Lee and Grant Blank (Editors) Bringing together the leading names in both qualitative and quantitative online research, this new edition is organised into nine sections: 1. Online Research Methods 2. Designing Online Research 3. Online Data Capture and Data Collection 4. The Online Survey 5. Digital Quantitative Analysis 6. Digital Text Analysis 7. Virtual Ethnography 8. Online Secondary Analysis: Resources and Methods 9. The Future of Online Social Research

ONLINE RESOURCES, COMMUNITIES, AND DATABASES

Interviews as a Method for Qualitative Research (video) This short video summarizes why interviews can serve as useful data in qualitative research.
Companion website to Bloomberg and Volpe's Completing Your Qualitative Dissertation: A Road Map from Beginning to End, 4th ed Provides helpful templates and appendices featured in the book, as well as links to other useful dissertation resources.
International Congress of Qualitative Inquiry Annual conference hosted by the International Center for Qualitative Inquiry at the University of Illinois at Urbana-Champaign, which aims to facilitate the development of qualitative research methods across a wide variety of academic disciplines, among other initiatives.
METHODSPACE An online home of the research methods community, where practicing researchers share how to make research easier.
SAGE researchmethods Researchers can explore methods concepts to help them design research projects, understand particular methods or identify a new method, conduct their research, and write up their findings. A "methods map" facilitates finding content on methods.

The decision to conduct interviews, and the type of interviewing to use, should flow from, or align with, the methodological paradigm chosen for your study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

Structured:

Structured Interview. Entry in The SAGE Encyclopedia of Social Science Research Methodsby Floyd J. Fowler Jr., Editors: Michael S. Lewis-Beck; Alan E. Bryman; Tim Futing Liao (Editor) A concise article noting standards, procedures, and recommendations for developing and testing structured interviews. For an example of structured interview questions, you may view the Current Population Survey, May 2008: Public Participation in the Arts Supplement (ICPSR 29641), Apr 15, 2011 at https://doi.org/10.3886/ICPSR29641.v1 (To see the survey questions, preview the user guide, which can be found under the "Data and Documentation" tab. Then, look for page 177 (attachment 8).

Semi-Structured:

Semi-Structured Interview. Entry in The SAGE Encyclopedia of Qualitative Research Methodsby Lioness Ayres; Editor: Lisa M. Given The semi-structured interview is a qualitative data collection strategy in which the researcher asks informants a series of predetermined but open-ended questions. The researcher has more control over the topics of the interview than in unstructured interviews, but in contrast to structured interviews or questionnaires that use closed questions, there is no fixed range of responses to each question.

Unstructured:

Unstructured Interview. Entry in The SAGE Encyclopedia of Qualitative Research Methodsby Michael W. Firmin; Editor: Lisa M. Given Unstructured interviews in qualitative research involve asking relatively open-ended questions of research participants in order to discover their percepts on the topic of interest. Interviews, in general, are a foundational means of collecting data when using qualitative research methods. They are designed to draw from the interviewee constructs embedded in his or her thinking and rationale for decision making. The researcher uses an inductive method in data gathering, regardless of whether the interview method is open, structured, or semi-structured. That is, the researcher does not wish to superimpose his or her own viewpoints onto the person being interviewed. Rather, inductively, the researcher wishes to understand the participant's perceptions, helping him or her to articulate percepts such that they will be understood clearly by the journal reader.

Genres and Uses

Focus groups:.

"Focus Groups." Annual Review of Sociology 22 (1996): 129-1524.by David L. Morgan Discusses the use of focus groups and group interviews as methods for gathering qualitative data used by sociologists and other academic and applied researchers. Focus groups are recommended for giving voice to marginalized groups and revealing the group effect on opinion formation.
Qualitative Research Methods: A Data Collector's Field Guide (See Module 4: "Focus Groups")by Mack, N., et al. This field guide is based on an approach to doing team-based, collaborative qualitative research that has repeatedly proven successful in research projects sponsored by Family Health International (FHI) throughout the developing world. With its straightforward delivery of information on the main qualitative methods being used in public health research today, the guide speaks to the need for simple yet effective instruction on how to do systematic and ethically sound qualitative research. The aim of the guide is thus practical. In bypassing extensive discussion on the theoretical underpinnings of qualitative research, it distinguishes itself as a how-to guide to be used in the field.

In-Depth (typically One-on-One):

A Practical Introduction to in-Depth Interviewingby Alan Morris Are you new to qualitative research or a bit rusty and in need of some inspiration? Are you doing a research project involving in-depth interviews? Are you nervous about carrying out your interviews? This book will help you complete your qualitative research project by providing a nuts and bolts introduction to interviewing. With coverage of ethics, preparation strategies and advice for handling the unexpected in the field, this handy guide will help you get to grips with the basics of interviewing before embarking on your research. While recognising that your research question and the context of your research will drive your approach to interviewing, this book provides practical advice often skipped in traditional methods textbooks.
Qualitative Research Methods: A Data Collector's Field Guide (See Module 3: "In-Depth Interviews")by Mack, N., et al. This field guide is based on an approach to doing team-based, collaborative qualitative research that has repeatedly proven successful in research projects sponsored by Family Health International (FHI) throughout the developing world. With its straightforward delivery of information on the main qualitative methods being used in public health research today, the guide speaks to the need for simple yet effective instruction on how to do systematic and ethically sound qualitative research. The aim of the guide is thus practical. In bypassing extensive discussion on the theoretical underpinnings of qualitative research, it distinguishes itself as a how-to guide to be used in the field.

Folklore Research and Oral Histories:

In addition to the following resource, see the Oral History page of this guide for helpful resources on Oral History interviewing.

American Folklife Center at the Library of Congress. Folklife and Fieldwork: A Layman’s Introduction to Field Techniques Interviews gathered for purposes of folklore research are similar to standard social science interviews in some ways, but also have a good deal in common with oral history approaches to interviewing. The focus in a folklore research interview is on documenting and trying to understand the interviewee's way of life relative to a culture or subculture you are studying. This guide includes helpful advice and tips for conducting fieldwork in folklore, such as tips for planning, conducting, recording, and archiving interviews.

An interdisciplinary scientific program within the Institute for Quantitative Social Science which encourages and facilitates research and instruction in the theory and practice of survey research. The primary mission of PSR is to provide survey research resources to enhance the quality of teaching and research at Harvard.

Internet, Phone, Mail, and Mixed-Mode Surveysby Don A. Dillman; Jolene D. Smyth; Leah Melani Christian The classic survey design reference, updated for the digital age. The new edition is thoroughly updated and revised, and covers all aspects of survey research. It features expanded coverage of mobile phones, tablets, and the use of do-it-yourself surveys, and Dillman's unique Tailored Design Method is also thoroughly explained. This new edition is complemented by copious examples within the text and accompanying website. It includes: Strategies and tactics for determining the needs of a given survey, how to design it, and how to effectively administer it. How and when to use mail, telephone, and Internet surveys to maximum advantage. Proven techniques to increase response rates. Guidance on how to obtain high-quality feedback from mail, electronic, and other self-administered surveys. Direction on how to construct effective questionnaires, including considerations of layout. The effects of sponsorship on the response rates of surveys. Use of capabilities provided by newly mass-used media: interactivity, presentation of aural and visual stimuli. The Fourth Edition reintroduces the telephone--including coordinating land and mobile.

User Experience (UX) and Marketing:

See the "UX & Market Research Interviews" tab on this guide, above. May include Focus Groups, above.

Screening for Research Site Selection:

Research interviews are used not only to furnish research data for theoretical analysis in the social sciences, but also to plan other kinds of studies. For example, interviews may allow researchers to screen appropriate research sites to conduct empirical studies (such as randomized controlled trials) in a variety of fields, from medicine to law. In contrast to interviews conducted in the course of social research, such interviews do not typically serve as the data for final analysis and publication.

ENGAGING PARTICIPANTS

Research ethics .

Human Subjects (IRB) The Committee on the Use of Human Subjects (CUHS) serves as the Institutional Review Board for the University area which includes the Cambridge and Allston campuses at Harvard. Find your IRB contact person , or learn about required ethics training. You may also find the IRB Lifecycle Guide helpful. This is the preferred IRB portal for Harvard graduate students and other researchers. IRB forms can be downloaded via the ESTR Library (click on the "Templates and Forms" tab, then navigate to pages 2 and 3 to find the documents labelled with “HUA” for the Harvard University Area IRB. Nota bene: You may use these forms only if you submit your study to the Harvard University IRB). The IRB office can be reached through email at [email protected] or by telephone at (617) 496-2847.
Undergraduate Research Training Program (URTP) Portal The URTP at Harvard University is a comprehensive platform to create better prepared undergraduate researchers. The URTP is comprised of research ethics training sessions, a student-focused curriculum, and an online decision form that will assist students in determining whether their project requires IRB review. Students should examine the URTP's guide for student researchers: Introduction to Human Subjects Research Protection.
Ethics reports From the Association of Internet Researchers (AoIR)
Respect, Beneficence, and Justice: QDR General Guidance for Human Participants If you are hoping to share your qualitative interview data in a repository after it has been collected, you will need to plan accordingly via informed consent, careful de-identification procedures, and data access controls. Consider consulting with the Qualitative Research Support Group at Harvard Library and consulting with Harvard's Dataverse contacts to help you think through all of the contingencies and processes.
"Conducting a Qualitative Child Interview: Methodological Considerations." Journal of Advanced Nursing 42/5 (2003): 434-441 by Kortesluoma, R., et al. The purpose of this article is to illustrate the theoretical premises of child interviewing, as well as to describe some practical methodological solutions used during interviews. Factors that influence data gathered from children and strategies for taking these factors into consideration during the interview are also described.
"Crossing Cultural Barriers in Research Interviewing." Qualitative Social Work 63/3 (2007): 353-372 by Sands, R., et al. This article critically examines a qualitative research interview in which cultural barriers between a white non-Muslim female interviewer and an African American Muslim interviewee, both from the USA, became evident and were overcome within the same interview.
Decolonizing Methodologies: Research and Indigenous Peoples by Linda Tuhiwai Smith This essential volume explores intersections of imperialism and research - specifically, the ways in which imperialism is embedded in disciplines of knowledge and tradition as 'regimes of truth.' Concepts such as 'discovery' and 'claiming' are discussed and an argument presented that the decolonization of research methods will help to reclaim control over indigenous ways of knowing and being. The text includes case-studies and examples, and sections on new indigenous literature and the role of research in indigenous struggles for social justice.

This resource, sponsored by University of Oregon Libraries, exemplifies the use of interviewing methodologies in research that foregrounds traditional knowledge. The methodology page summarizes the approach.

Ethics: The Need to Tread Carefully. Chapter in A Practical Introduction to in-Depth Interviewing by Alan Morris Pay special attention to the sections in chapter 2 on "How to prevent and respond to ethical issues arising in the course of the interview," "Ethics in the writing up of your interviews," and "The Ethics of Care."
Handbook on Ethical Issues in Anthropology by Joan Cassell (Editor); Sue-Ellen Jacobs (Editor) This publication of the American Anthropological Association presents and discusses issues and sources on ethics in anthropology, as well as realistic case studies of ethical dilemmas. It is meant to help social science faculty introduce discussions of ethics in their courses. Some of the topics are relevant to interviews, or at least to studies of which interviews are a part. See chapters 3 and 4 for cases, with solutions and commentary, respectively.
Research Ethics from the Chanie Wenjack School for Indigenous Studies, Trent University (Open Access) An overview of Indigenous research ethics and protocols from the across the globe.
Resources for Equity in Research Consult these resources for guidance on creating and incorporating equitable materials into public health research studies that entail community engagement.

The SAGE Handbook of Qualitative Research Ethics by Ron Iphofen (Editor); Martin Tolich (Editor) This handbook is a much-needed and in-depth review of the distinctive set of ethical considerations which accompanies qualitative research. This is particularly crucial given the emergent, dynamic and interactional nature of most qualitative research, which too often allows little time for reflection on the important ethical responsibilities and obligations. Contributions from leading international researchers have been carefully organized into six key thematic sections: Part One: Thick Descriptions Of Qualitative Research Ethics; Part Two: Qualitative Research Ethics By Technique; Part Three: Ethics As Politics; Part Four: Qualitative Research Ethics With Vulnerable Groups; Part Five: Relational Research Ethics; Part Six: Researching Digitally. This Handbook is a one-stop resource on qualitative research ethics across the social sciences that draws on the lessons learned and the successful methods for surmounting problems - the tried and true, and the new.

RESEARCH COMPLIANCE AND PRIVACY LAWS

Research Compliance Program for FAS/SEAS at Harvard : The Faculty of Arts and Sciences (FAS), including the School of Engineering and Applied Sciences (SEAS), and the Office of the Vice Provost for Research (OVPR) have established a shared Research Compliance Program (RCP). An area of common concern for interview studies is international projects and collaboration . RCP is a resource to provide guidance on which international activities may be impacted by US sanctions on countries, individuals, or entities and whether licenses or other disclosure are required to ship or otherwise share items, technology, or data with foreign collaborators.

Harvard Global Support Services (GSS) is for students, faculty, staff, and researchers who are studying, researching, or working abroad. Their services span safety and security, health, culture, outbound immigration, employment, financial and legal matters, and research center operations. These include travel briefings and registration, emergency response, guidance on international projects, and managing in-country operations.

Generative AI: Harvard-affiliated researchers should not enter data classified as confidential ( Level 2 and above ), including non-public research data, into publicly-available generative AI tools, in accordance with the University’s Information Security Policy. Information shared with generative AI tools using default settings is not private and could expose proprietary or sensitive information to unauthorized parties.

Privacy Laws: Be mindful of any potential privacy laws that may apply wherever you conduct your interviews. The General Data Protection Regulation is a high-profile example (see below):

General Data Protection Regulation (GDPR) This Regulation lays down rules relating to the protection of natural persons with regard to the processing of personal data and rules relating to the free movement of personal data. It protects fundamental rights and freedoms of natural persons and in particular their right to the protection of personal data. The free movement of personal data within the Union shall be neither restricted nor prohibited for reasons connected with the protection of natural persons with regard to the processing of personal data. For a nice summary of what the GDPR requires, check out the GDPR "crash course" here .

SEEKING CONSENT

If you would like to see examples of consent forms, ask your local IRB, or take a look at these resources:

Model consent forms for oral history, suggested by the Centre for Oral History and Digital Storytelling at Concordia University
For NIH-funded research, see this resource for developing informed consent language in research studies where data and/or biospecimens will be stored and shared for future use.

POPULATION SAMPLING

If you wish to assemble resources to aid in sampling, such as the USPS Delivery Sequence File, telephone books, or directories of organizations and listservs, please contact our data librarian or write to [email protected] .

Research Randomizer A free web-based service that permits instant random sampling and random assignment. It also contains an interactive tutorial perfect for students taking courses in research methods.
Practical Tools for Designing and Weighting Survey Samples by Richard Valliant; Jill A. Dever; Frauke Kreuter Survey sampling is fundamentally an applied field. The goal in this book is to put an array of tools at the fingertips of practitioners by explaining approaches long used by survey statisticians, illustrating how existing software can be used to solve survey problems, and developing some specialized software where needed. This book serves at least three audiences: (1) Students seeking a more in-depth understanding of applied sampling either through a second semester-long course or by way of a supplementary reference; (2) Survey statisticians searching for practical guidance on how to apply concepts learned in theoretical or applied sampling courses; and (3) Social scientists and other survey practitioners who desire insight into the statistical thinking and steps taken to design, select, and weight random survey samples. Several survey data sets are used to illustrate how to design samples, to make estimates from complex surveys for use in optimizing the sample allocation, and to calculate weights. Realistic survey projects are used to demonstrate the challenges and provide a context for the solutions. The book covers several topics that either are not included or are dealt with in a limited way in other texts. These areas include: sample size computations for multistage designs; power calculations related to surveys; mathematical programming for sample allocation in a multi-criteria optimization setting; nuts and bolts of area probability sampling; multiphase designs; quality control of survey operations; and statistical software for survey sampling and estimation. An associated R package, PracTools, contains a number of specialized functions for sample size and other calculations. The data sets used in the book are also available in PracTools, so that the reader may replicate the examples or perform further analyses.
Sampling: Design and Analysis by Sharon L. Lohr Provides a modern introduction to the field of sampling. With a multitude of applications from a variety of disciplines, the book concentrates on the statistical aspects of taking and analyzing a sample. Overall, the book gives guidance on how to tell when a sample is valid or not, and how to design and analyze many different forms of sample surveys.
Sampling Techniques by William G. Cochran Clearly demonstrates a wide range of sampling methods now in use by governments, in business, market and operations research, social science, medicine, public health, agriculture, and accounting. Gives proofs of all the theoretical results used in modern sampling practice. New topics in this edition include the approximate methods developed for the problem of attaching standard errors or confidence limits to nonlinear estimates made from the results of surveys with complex plans.
"Understanding the Process of Qualitative Data Collection" in Chapter 13 (pp. 103–1162) of 30 Essential Skills for the Qualitative Researcher by John W. Creswell Provides practical "how-to" information for beginning researchers in the social, behavioral, and health sciences with many applied examples from research design, qualitative inquiry, and mixed methods.The skills presented in this book are crucial for a new qualitative researcher starting a qualitative project.
Survey Methodology by Robert M. Groves; Floyd J. Fowler; Mick P. Couper; James M. Lepkowski; Eleanor Singer; Roger Tourangeau; Floyd J. Fowler coverage includes sampling frame evaluation, sample design, development of questionnaires, evaluation of questions, alternative modes of data collection, interviewing, nonresponse, post-collection processing of survey data, and practices for maintaining scientific integrity.

The way a qualitative researcher constructs and approaches interview questions should flow from, or align with, the methodological paradigm chosen for the study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

Constructing Your Questions

Helpful texts:.

"Developing Questions" in Chapter 4 (pp. 98–108) of Becoming Qualitative Researchers by Corrine Glesne Ideal for introducing the novice researcher to the theory and practice of qualitative research, this text opens students to the diverse possibilities within this inquiry approach, while helping them understand how to design and implement specific research methods.
"Learning to Interview in the Social Sciences" Qualitative Inquiry, 9(4) 2003, 643–668 by Roulston, K., deMarrais, K., & Lewis, J. B. See especially the section on "Phrasing and Negotiating Questions" on pages 653-655 and common problems with framing questions noted on pages 659 - 660.
Qualitative Research Interviewing: Biographic Narrative and Semi-Structured Methods (See sections on “Lightly and Heavily Structured Depth Interviewing: Theory-Questions and Interviewer-Questions” and “Preparing for any Interviewing Sequence") by Tom Wengraf Unique in its conceptual coherence and the level of practical detail, this book provides a comprehensive resource for those concerned with the practice of semi-structured interviewing, the most commonly used interview approach in social research, and in particular for in-depth, biographic narrative interviewing. It covers the full range of practices from the identification of topics through to strategies for writing up research findings in diverse ways.
"Scripting a Qualitative Purpose Statement and Research Questions" in Chapter 12 (pp. 93–102) of 30 Essential Skills for the Qualitative Researcher by John W. Creswell Provides practical "how-to" information for beginning researchers in the social, behavioral, and health sciences with many applied examples from research design, qualitative inquiry, and mixed methods.The skills presented in this book are crucial for a new qualitative researcher starting a qualitative project.
Some Strategies for Developing Interview Guides for Qualitative Interviews by Sociology Department, Harvard University Includes general advice for conducting qualitative interviews, pros and cons of recording and transcription, guidelines for success, and tips for developing and phrasing effective interview questions.
Tip Sheet on Question Wording by Harvard University Program on Survey Research

Let Theory Guide You:

The quality of your questions depends on how you situate them within a wider body of knowledge. Consider the following advice:

A good literature review has many obvious virtues. It enables the investigator to define problems and assess data. It provides the concepts on which percepts depend. But the literature review has a special importance for the qualitative researcher. This consists of its ability to sharpen his or her capacity for surprise (Lazarsfeld, 1972b). The investigator who is well versed in the literature now has a set of expectations the data can defy. Counterexpectational data are conspicuous, readable, and highly provocative data. They signal the existence of unfulfilled theoretical assumptions, and these are, as Kuhn (1962) has noted, the very origins of intellectual innovation. A thorough review of the literature is, to this extent, a way to manufacture distance. It is a way to let the data of one's research project take issue with the theory of one's field.

McCracken, G. (1988), The Long Interview, Sage: Newbury Park, CA, p. 31

When drafting your interview questions, remember that everything follows from your central research question. Also, on the way to writing your "operationalized" interview questions, it's helpful to draft broader, intermediate questions, couched in theory. Nota bene: While it is important to know the literature well before conducting your interview(s), be careful not to present yourself to your research participant(s) as "the expert," which would be presumptuous and could be intimidating. Rather, the purpose of your knowledge is to make you a better, keener listener.

If you'd like to supplement what you learned about relevant theories through your coursework and literature review, try these sources:

Annual Reviews Review articles sum up the latest research in many fields, including social sciences, biomedicine, life sciences, and physical sciences. These are timely collections of critical reviews written by leading scientists.
HOLLIS - search for resources on theories in your field Modify this example search by entering the name of your field in place of "your discipline," then hit search.
Oxford Bibliographies Written and reviewed by academic experts, every article in this database is an authoritative guide to the current scholarship in a variety of fields, containing original commentary and annotations.
ProQuest Dissertations & Theses (PQDT) Indexes dissertations and masters' theses from most North American graduate schools as well as some European universities. Provides full text for most indexed dissertations from 1990-present.
Very Short Introductions Launched by Oxford University Press in 1995, Very Short Introductions offer concise introductions to a diverse range of subjects from Climate to Consciousness, Game Theory to Ancient Warfare, Privacy to Islamic History, Economics to Literary Theory.

CONDUCTING INTERVIEWS

Equipment and software: .

Lamont Library loans microphones and podcast starter kits, which will allow you to capture audio (and you may record with software, such as Garage Band).
Cabot Library loans digital recording devices, as well as USB microphones.

If you prefer to use your own device, you may purchase a small handheld audio recorder, or use your cell phone.

Audio Capture Basics (PDF) - Helpful instructions, courtesy of the Lamont Library Multimedia Lab.
Getting Started with Podcasting/Audio: Guidelines from Harvard Library's Virtual Media Lab for preparing your interviewee for a web-based recording (e.g., podcast, interview)
Camtasia Screen Recorder and Video Editor
Zoom: Video Conferencing, Web Conferencing
Visit the Multimedia Production Resources guide! Consult it to find and learn how to use audiovisual production tools, including: cameras, microphones, studio spaces, and other equipment at Cabot Science Library and Lamont Library.
Try the virtual office hours offered by the Lamont Multimedia Lab!

TIPS FOR CONDUCTING INTERVIEWS

Quick handout: .

Research Interviewing Tips (Courtesy of Dr. Suzanne Spreadbury)

Remote Interviews:

For Online or Distant Interviews, See "Remote Research & Virtual Fieldwork" on this guide .
Deborah Lupton's Bibliography: Doing Fieldwork in a Pandemic

Seeking Consent:

Books and articles: .

"App-Based Textual Interviews: Interacting With Younger Generations in a Digitalized Social Reallity."International Journal of Social Research Methodology (12 June 2022). Discusses the use of texting platforms as a means to reach young people. Recommends useful question formulations for this medium.
"Learning to Interview in the Social Sciences." Qualitative Inquiry, 9(4) 2003, 643–668 by Roulston, K., deMarrais, K., & Lewis, J. B. See especially the section on "Phrasing and Negotiating Questions" on pages 653-655 and common problems with framing questions noted on pages 659-660.
"Slowing Down and Digging Deep: Teaching Students to Examine Interview Interaction in Depth." LEARNing Landscapes, Spring 2021 14(1) 153-169 by Herron, Brigette A. and Kathryn Roulston. Suggests analysis of videorecorded interviews as a precursor to formulating one's own questions. Includes helpful types of probes.
Using Interviews in a Research Project by Nigel Joseph Mathers; Nicholas J Fox; Amanda Hunn; Trent Focus Group. A work pack to guide researchers in developing interviews in the healthcare field. Describes interview structures, compares face-to-face and telephone interviews. Outlines the ways in which different types of interview data can be analysed.
“Working through Challenges in Doing Interview Research.” International Journal of Qualitative Methods, (December 2011), 348–66 by Roulston, Kathryn. The article explores (1) how problematic interactions identified in the analysis of focus group data can lead to modifications in research design, (2) an approach to dealing with reported data in representations of findings, and (3) how data analysis can inform question formulation in successive rounds of data generation. Findings from these types of examinations of interview data generation and analysis are valuable for informing both interview practice as well as research design.

Videos:

The way a qualitative researcher transcribes interviews should flow from, or align with, the methodological paradigm chosen for the study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

TRANSCRIPTION

Before embarking on a transcription project, it's worthwhile to invest in the time and effort necessary to capture good audio, which will make the transcription process much easier. If you haven't already done so, check out the audio capture guidelines from Harvard Library's Virtual Media Lab , or contact a media staff member for customized recommendations. First and foremost, be mindful of common pitfalls by watching this short video that identifies the most common errors to avoid!

SOFTWARE:

Adobe Premiere Pro Speech-To-Text automatically generates transcripts and adds captions to your videos. Harvard affiliates can download Adobe Premiere in the Creative Cloud Suite.
GoTranscript provides cost-effective human-generated transcriptions.
pyTranscriber is an app for generating automatic transcription and/or subtitles for audio and video files. It uses the Google Cloud Speech-to-Text service, has a friendly graphical user interface, and is purported to work nicely with Chinese.
Otter provides a new way to capture, store, search and share voice conversations, lectures, presentations, meetings, and interviews. The startup is based in Silicon Valley with a team of experienced Ph.Ds and engineers from Google, Facebook, Yahoo and Nuance (à la Dragon). Free accounts available. This is the software that Zoom uses to generate automated transcripts, so if you have access to a Zoom subscription, you have access to Otter transcriptions with it (applicable in several languages ). As with any automated approach, be prepared to correct any errors after the fact, by hand.
Panopto is available to Harvard affiliates and generates ASR (automated speech recognition) captions . You may upload compatible audio files into it. As with any automatically generated transcription, you will need to make manual revisions. ASR captioning is available in several languages . Panopto maintains robust security practices, including strong authentication measures and end-to-end encryption, ensuring your content remains private and protected.
REV.Com allows you to record and transcribe any calls on the iPhone, both outgoing and incoming. It may be useful for recording phone interviews. Rev lets you choose whether you want an AI- or human-generated transcription, with a fast turnaround. Rev has Service Organization Controls Type II (SOC2) certification (a SOC2 cert looks at and verifies an organization’s processing integrity, privacy practices, and security safeguards).
Scribie Audio/Video Transcription provides automated or manual transcriptions for a small fee. As with any transcription service, some revisions will be necessary after the fact, particularly for its automated transcripts.
Sonix automatically transcribes, translates, and helps to organize audio and video files in over 40 languages. It's fast and affordable, with good accuracy. The free trial includes 30 minutes of free transcription.
TranscriptionWing uses a human touch process to clean up machine-generated transcripts so that the content will far more accurately reflect your audio recording.
Whisper is a tool from OpenAI that facilitates transcription of sensitive audiovisual recordings (e.g., of research interviews) on your own device. Installation and use depends on your operating system and which version you install. Important Note: The Whisper API, where audio is sent to OpenAI to be processed by them and then sent back (usually through a programming language like Python) is NOT appropriate for sensitive data. The model should be downloaded with tools such as those described in this FAQ , so that audio is kept to your local machine. For assistance, contact James Capobianco .

EQUIPMENT:

Transcription pedals are in circulation and available to borrow from the Circulation desk at Lamont, or use at Lamont Library's Media Lab on level B. For hand-transcribing your interviews, they work in conjunction with software such as Express Scribe , which is loaded on Media Lab computers, or you may download for free on your own machine (Mac or PC versions; scroll down the downloads page for the latter). The pedals are plug-and-play USB, allow a wide range of playback speeds, and have 3 programmable buttons, which are typically set to rewind/play/fast-forward. Instructions are included in the bag that covers installation and set-up of the software, and basic use of the pedals.

NEED HELP?

Try the virtual office hours offered by the Lamont Multimedia Lab!
If you're creating podcasts, login to Canvas and check out the Podcasting/Audio guide .

Helpful Texts:

"Transcription as a Crucial Step of Data Analysis" in Chapter 5 of The SAGE Handbook of Qualitative Data Analysisby Uwe Flick (Editor) Covers basic terminology for transcription, shares caveats for transcribers, and identifies components of vocal behavior. Provides notation systems for transcription, suggestions for transcribing turn-taking, and discusses new technologies and perspectives. Includes a bibliography for further reading.
"Transcribing the Oral Interview: Part Art, Part Science " on p. 10 of the Centre for Community Knowledge (CCK) newsletter: TIMESTAMPby Mishika Chauhan and Saransh Srivastav

QUALITATIVE DATA ANALYSIS

Software .

Free download available for Harvard Faculty of Arts and Sciences (FAS) affiliates
Desktop access at Lamont Library Media Lab, 3rd floor
Desktop access at Harvard Kennedy School Library (with HKS ID)
Remote desktop access for Harvard affiliates from IQSS Computer Labs . Email them at [email protected] and ask for a new lab account and remote desktop access to NVivo.
Virtual Desktop Infrastructure (VDI) access available to Harvard T.H. Chan School of Public Health affiliates

CODING AND THEMEING YOUR DATA

Data analysis methods should flow from, or align with, the methodological paradigm chosen for your study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these). Some established methods include Content Analysis, Critical Analysis, Discourse Analysis, Gestalt Analysis, Grounded Theory Analysis, Interpretive Analysis, Narrative Analysis, Normative Analysis, Phenomenological Analysis, Rhetorical Analysis, and Semiotic Analysis, among others. The following resources should help you navigate your methodological options and put into practice methods for coding, themeing, interpreting, and presenting your data.

Users can browse content by topic, discipline, or format type (reference works, book chapters, definitions, etc.). SRM offers several research tools as well: a methods map, user-created reading lists, a project planner, and advice on choosing statistical tests.
Abductive Coding: Theory Building and Qualitative (Re)Analysis by Vila-Henninger, et al. The authors recommend an abductive approach to guide qualitative researchers who are oriented towards theory-building. They outline a set of tactics for abductive analysis, including the generation of an abductive codebook, abductive data reduction through code equations, and in-depth abductive qualitative analysis.
Analyzing and Interpreting Qualitative Research: After the Interview by Charles F. Vanover, Paul A. Mihas, and Johnny Saldana (Editors) Providing insight into the wide range of approaches available to the qualitative researcher and covering all steps in the research process, the authors utilize a consistent chapter structure that provides novice and seasoned researchers with pragmatic, "how-to" strategies. Each chapter author introduces the method, uses one of their own research projects as a case study of the method described, shows how the specific analytic method can be used in other types of studies, and concludes with three questions/activities to prompt class discussion or personal study.
"Analyzing Qualitative Data." Theory Into Practice 39, no. 3 (2000): 146-54 by Margaret D. LeCompte This article walks readers though rules for unbiased data analysis and provides guidance for getting organized, finding items, creating stable sets of items, creating patterns, assembling structures, and conducting data validity checks.
"Coding is Not a Dirty Word" in Chapter 1 (pp. 1–30) of Enhancing Qualitative and Mixed Methods Research with Technology by Shalin Hai-Jew (Editor) Current discourses in qualitative research, especially those situated in postmodernism, represent coding and the technology that assists with coding as reductive, lacking complexity, and detached from theory. In this chapter, the author presents a counter-narrative to this dominant discourse in qualitative research. The author argues that coding is not necessarily devoid of theory, nor does the use of software for data management and analysis automatically render scholarship theoretically lightweight or barren. A lack of deep analytical insight is a consequence not of software but of epistemology. Using examples informed by interpretive and critical approaches, the author demonstrates how NVivo can provide an effective tool for data management and analysis. The author also highlights ideas for critical and deconstructive approaches in qualitative inquiry while using NVivo. By troubling the positivist discourse of coding, the author seeks to create dialogic spaces that integrate theory with technology-driven data management and analysis, while maintaining the depth and rigor of qualitative research.
The Coding Manual for Qualitative Researchers by Johnny Saldana An in-depth guide to the multiple approaches available for coding qualitative data. Clear, practical and authoritative, the book profiles 32 coding methods that can be applied to a range of research genres from grounded theory to phenomenology to narrative inquiry. For each approach, Saldaña discusses the methods, origins, a description of the method, practical applications, and a clearly illustrated example with analytic follow-up. Essential reading across the social sciences.
Flexible Coding of In-depth Interviews: A Twenty-first-century Approach by Nicole M. Deterding and Mary C. Waters The authors suggest steps in data organization and analysis to better utilize qualitative data analysis technologies and support rigorous, transparent, and flexible analysis of in-depth interview data.
From the Editors: What Grounded Theory is Not by Roy Suddaby Walks readers through common misconceptions that hinder grounded theory studies, reinforcing the two key concepts of the grounded theory approach: (1) constant comparison of data gathered throughout the data collection process and (2) the determination of which kinds of data to sample in succession based on emergent themes (i.e., "theoretical sampling").
“Good enough” methods for life-story analysis, by Wendy Luttrell. In Quinn N. (Ed.), Finding culture in talk (pp. 243–268). Demonstrates for researchers of culture and consciousness who use narrative how to concretely document reflexive processes in terms of where, how and why particular decisions are made at particular stages of the research process.
The Ethnographic Interview by James P. Spradley “Spradley wrote this book for the professional and student who have never done ethnographic fieldwork (p. 231) and for the professional ethnographer who is interested in adapting the author’s procedures (p. iv) ... Steps 6 and 8 explain lucidly how to construct a domain and a taxonomic analysis” (excerpted from book review by James D. Sexton, 1980). See also: Presentation slides on coding and themeing your data, derived from Saldana, Spradley, and LeCompte Click to request access.
Qualitative Data Analysis by Matthew B. Miles; A. Michael Huberman A practical sourcebook for researchers who make use of qualitative data, presenting the current state of the craft in the design, testing, and use of qualitative analysis methods. Strong emphasis is placed on data displays matrices and networks that go beyond ordinary narrative text. Each method of data display and analysis is described and illustrated.
"A Survey of Qualitative Data Analytic Methods" in Chapter 4 (pp. 89–138) of Fundamentals of Qualitative Research by Johnny Saldana Provides an in-depth introduction to coding as a heuristic, particularly focusing on process coding, in vivo coding, descriptive coding, values coding, dramaturgical coding, and versus coding. Includes advice on writing analytic memos, developing categories, and themeing data.
"Thematic Networks: An Analytic Tool for Qualitative Research." Qualitative Research : QR, 1(3), 385–405 by Jennifer Attride-Stirling Details a technique for conducting thematic analysis of qualitative material, presenting a step-by-step guide of the analytic process, with the aid of an empirical example. The analytic method presented employs established, well-known techniques; the article proposes that thematic analyses can be usefully aided by and presented as thematic networks.
Using Thematic Analysis in Psychology by Virginia Braun and Victoria Clark Walks readers through the process of reflexive thematic analysis, step by step. The method may be adapted in fields outside of psychology as relevant. Pair this with One Size Fits All? What Counts as Quality Practice in Reflexive Thematic Analysis? by Virginia Braun and Victoria Clark

TESTING OR GENERATING THEORIES

The quality of your data analysis depends on how you situate what you learn within a wider body of knowledge. Consider the following advice:

Once you have coalesced around a theory, realize that a theory should reveal rather than color your discoveries. Allow your data to guide you to what's most suitable. Grounded theory researchers may develop their own theory where current theories fail to provide insight. This guide on Theoretical Models from Alfaisal University Library provides a helpful overview on using theory.

MANAGING & FINDING INTERVIEW DATA

Managing your elicited interview data, general guidance: .

Research Data Management @ Harvard A reference guide with information and resources to help you manage your research data. See also: Harvard Research Data Security Policy , on the Harvard University Research Data Management website.
Data Management For Researchers: Organize, Maintain and Share Your Data for Research Success by Kristin Briney. A comprehensive guide for scientific researchers providing everything they need to know about data management and how to organize, document, use and reuse their data.
Open Science Framework (OSF) An open-source project management tool that makes it easy to collaborate within and beyond Harvard throughout a project's lifecycle. With OSF you can manage, store, and share documents, datasets, and other information with your research team. You can also publish your work to share it with a wider audience. Although data can be stored privately, because this platform is hosted on the Internet and designed with open access in mind, it is not a good choice for highly sensitive data.
Free cloud storage solutions for Harvard affiliates to consider include: Google Drive , DropBox , or OneDrive ( up to DSL3 )

Data Confidentiality and Secure Handling:

Data Security Levels at Harvard - Research Data Examples This resource provided by Harvard Data Security helps you determine what level of access is appropriate for your data. Determine whether it should be made available for public use, limited to the Harvard community, or be protected as either "confidential and sensitive," "high risk," or "extremely sensitive." See also: Harvard Data Classification Table
Harvard's Best Practices for Protecting Privacy and Harvard Information Security Collaboration Tools Matrix Follow the nuts-and-bolts advice for privacy best practices at Harvard. The latter resource reveals the level of security that can be relied upon for a large number of technological tools and platforms used at Harvard to conduct business, such as email, Slack, Accellion Kiteworks, OneDrive/SharePoint, etc.
“Protecting Participant Privacy While Maintaining Content and Context: Challenges in Qualitative Data De‐identification and Sharing.” Proceedings of the ASIST Annual Meeting 57 (1) (2020): e415-420 by Myers, Long, and Polasek Presents an informed and tested protocol, based on the De-Identification guidelines published by the Qualitative Data Repository (QDR) at Syracuse University. Qualitative researchers may consult it to guide their data de-identification efforts.
QDS Qualitative Data Sharing Toolkit The Qualitative Data Sharing (QDS) project and its toolkit was funded by the NIH National Human Genome Research Institute (R01HG009351). It provides tools and resources to help researchers, especially those in the health sciences, share qualitative research data while protecting privacy and confidentiality. It offers guidance on preparing data for sharing through de-identification and access control. These health sciences research datasets in ICPSR's Qualitative Data Sharing (QDS) Project Series were de-identified using the QuaDS Software and the project’s QDS guidelines.
Table of De-Identification Techniques
Generative AI Harvard-affiliated researchers should not enter data classified as confidential ( Level 2 and above ), including non-public research data, into publicly-available generative AI tools, in accordance with the University’s Information Security Policy. Information shared with generative AI tools using default settings is not private and could expose proprietary or sensitive information to unauthorized parties.
Harvard Information Security Quick Reference Guide Storage guidelines, based on the data's security classification level (according to its IRB classification) is displayed on page 2, under "handling."
Email Encryption Harvard Microsoft 365 users can now send encrypted messages and files directly from the Outlook web or desktop apps. Encrypting an email adds an extra layer of security to the message and its attachments (up to 150MB), and means only the intended recipient (and their inbox delegates with full access) can view it. Message encryption in Outlook is approved for sending high risk ( level 4 ) data and below.

Sharing Qualitative Data:

Repositories for Qualitative Data If you have cleared this intention with your IRB, secured consent from participants, and properly de-identified your data, consider sharing your interviews in one of the data repositories included in the link above. Depending on the nature of your research and the level of risk it may present to participants, sharing your interview data may not be appropriate. If there is any chance that sharing such data will be desirable, you will be much better off if you build this expectation into your plans from the beginning.
Guide for Sharing Qualitative Data at ICPSR The Inter-university Consortium for Political and Social Research (ICPSR) has created this resource for investigators planning to share qualitative data at ICPSR. This guide provides an overview of elements and considerations for archiving qualitative data, identifies steps for investigators to follow during the research life cycle to ensure that others can share and reuse qualitative data, and provides information about exemplars of qualitative data

International Projects:

Research Compliance Program for FAS/SEAS at Harvard The Faculty of Arts and Sciences (FAS), including the School of Engineering and Applied Sciences (SEAS), and the Office of the Vice Provost for Research (OVPR) have established a shared Research Compliance Program (RCP). An area of common concern for interview studies is international projects and collaboration . RCP is a resource to provide guidance on which international activities may be impacted by US sanctions on countries, individuals, or entities and whether licenses or other disclosure are required to ship or otherwise share items, technology, or data with foreign collaborators.

Finding Extant Interview Data

Finding journalistic interviews: .

Academic Search Premier This all-purpose database is great for finding articles from magazines and newspapers. In the Advanced Search, it allows you to specify "Document Type": Interview.
Guide to Newspapers and Newspaper Indexes Use this guide created to Harvard Librarians to identify newspapers collections you'd like to search. To locate interviews, try adding the term "interview" to your search, or explore a database's search interface for options to limit your search to interviews. Nexis Uni and Factiva are the two main databases for current news.
Listen Notes Search for podcast episodes at this podcast aggregator, and look for podcasts that include interviews. Make sure to vet the podcaster for accuracy and quality! (Listen Notes does not do much vetting.)
NPR and ProPublica are two sites that offer high-quality long-form reporting, including journalistic interviews, for free.

Finding Oral History and Social Research Interviews:

To find oral histories, see the Oral History page of this guide for helpful resources on Oral History interviewing.
Repositories for Qualitative Data It has not been a customary practice among qualitative researchers in the social sciences to share raw interview data, but some have made this data available in repositories, such as the ones listed on the page linked above. You may find published data from structured interview surveys (e.g., questionnaire-based computer-assisted telephone interview data), as well as some semi-structured and unstructured interviews.
If you are merely interested in studies interpreting data collected using interviews, rather than finding raw interview data, try databases like PsycInfo , Sociological Abstracts , or Anthropology Plus , among others.

Finding Interviews in Archival Collections at Harvard Library:

In addition to the databases and search strategies mentioned under the "Finding Oral History and Social Research Interviews" category above, you may search for interviews and oral histories (whether in textual or audiovisual formats) held in archival collections at Harvard Library.

HOLLIS searches all documented collections at Harvard, whereas HOLLIS for Archival Discovery searches only those with finding aids. Although HOLLIS for Archival Discovery covers less material, you may find it easier to parse your search results, especially when you wish to view results at the item level (within collections). Try these approaches:

Search in HOLLIS :

To retrieve items available online, do an Advanced Search for interview* OR "oral histor*" (in Subject), with Resource Type "Archives/Manuscripts," then refine your search by selecting "Online" under "Show Only" on the right of your initial result list. Revise the search above by adding your topic in the Keywords or Subject field (for example: African Americans ) and resubmitting the search.
To enlarge your results set, you may also leave out the "Online" refinement; if you'd like to limit your search to a specific repository, try the technique of searching for Code: Library + Collection on the "Advanced Search" page .

Search in HOLLIS for Archival Discovery :

To retrieve items available online, search for interview* OR "oral histor*" limited to digital materials . Revise the search above by adding your topic (for example: artist* ) in the second search box (if you don't see the box, click +).
To preview results by collection, search for interview* OR "oral histor*" limited to collections . Revise the search above by adding your topic (for example: artist* ) in the second search box (if you don't see the box, click +). Although this method does not allow you to isolate digitized content, you may find the refinement options on the right side of the screen (refine by repository, subject or names) helpful. Once your select a given collection, you may search within it (e.g., for your topic or the term interview).

UX & MARKET RESEARCH INTERVIEWS

Ux at harvard library .

User Experience and Market Research interviews can inform the design of tangible products and services through responsive, outcome-driven insights. The User Research Center at Harvard Library specializes in this kind of user-centered design, digital accessibility, and testing. They also offer guidance and resources to members of the Harvard Community who are interested in learning more about UX methods. Contact [email protected] or consult the URC website for more information.

Websites

User Interviews: The Beginner’s Guide (Chris Mears)
Interviewing Users (Jakob Nielsen)

Books

Interviewing Users: How to Uncover Compelling Insights by Steve Portigal; Grant McCracken (Foreword by) Interviewing is a foundational user research tool that people assume they already possess. Everyone can ask questions, right? Unfortunately, that's not the case. Interviewing Users provides invaluable interviewing techniques and tools that enable you to conduct informative interviews with anyone. You'll move from simply gathering data to uncovering powerful insights about people.
Rapid Contextual Design by Jessamyn Wendell; Karen Holtzblatt; Shelley Wood This handbook introduces Rapid CD, a fast-paced, adaptive form of Contextual Design. Rapid CD is a hands-on guide for anyone who needs practical guidance on how to use the Contextual Design process and adapt it to tactical projects with tight timelines and resources. Rapid Contextual Design provides detailed suggestions on structuring the project and customer interviews, conducting interviews, and running interpretation sessions. The handbook walks you step-by-step through organizing the data so you can see your key issues, along with visioning new solutions, storyboarding to work out the details, and paper prototype interviewing to iterate the design all with as little as a two-person team with only a few weeks to spare *Includes real project examples with actual customer data that illustrate how a CD project actually works.

Videos

Instructional Presentations on Interview Skills

Interview/Oral History Research for RSRA 298B: Master's Thesis Reading and Research (Spring 2023) Slideshow covers: Why Interviews?, Getting Context, Engaging Participants, Conducting the Interview, The Interview Guide, Note Taking, Transcription, File management, and Data Analysis.
Interview Skills From an online class on February 13, 2023: Get set up for interview research. You will leave prepared to choose among the three types of interviewing methods, equipped to develop an interview schedule, aware of data management options and their ethical implications, and knowledgeable of technologies you can use to record and transcribe your interviews. This workshop complements Intro to NVivo, a qualitative data analysis tool useful for coding interview data.

NIH Data Management & Sharing Policy (DMSP) This policy, effective January 25, 2023, applies to all research, funded or conducted in whole or in part by NIH, that results in the generation of scientific data , including NIH-funded qualitative research. Click here to see some examples of how the DMSP policy has been applied in qualitative research studies featured in the 2021 Qualitative Data Management Plan (DMP) Competition . As a resource for the community, NIH has developed a resource for developing informed consent language in research studies where data and/or biospecimens will be stored and shared for future use. It is important to note that the DMS Policy does NOT require that informed consent obtained from research participants must allow for broad sharing and the future use of data (either with or without identifiable private information). See the FAQ for more information.

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Except where otherwise noted, this work is subject to a Creative Commons Attribution 4.0 International License , which allows anyone to share and adapt our material as long as proper attribution is given. For details and exceptions, see the Harvard Library Copyright Policy ©2021 Presidents and Fellows of Harvard College.

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Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

P. Gill 1 &
J. Baillie 2

British Dental Journal volume 225 , pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

You have full access to this article via your institution.

A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

Interviews in the social sciences

People are surprisingly hesitant to reach out to old friends

Introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Introduction to Research Methods

6 qualitative research and interviews.

So we’ve described doing a survey and collecting quantitative data. But not all questions can best be answered by a survey. A survey is great for understanding what people think (for example), but not why they think what they do. If your research is intending to understand the underlying motivations or reasons behind peoples actions, or to build a deeper understanding on the background of a subject, an interview may be the more appropriate data collection method.

Interviews are a method of data collection that consist of two or more people exchanging information through a structured process of questions and answers. Questions are designed by the researcher to thoughtfully collect in-depth information on a topic or set of topics as related to the central research question. Interviews typically occur in-person, although good interviews can also be conducted remotely via the phone or video conferencing. Unlike surveys, interviews give the opportunity to ask follow-up questions and thoughtfully engage with participants on the spot (rather than the anonymous and impartial format of survey research).

And surveys can be used in qualitative or quantitative research – though they’re more typically a qualitative technique. In-depth interviews , containing open-ended questions and structured by an interview guide . One can also do a standardized interview with closed-ended questions (i.e. answer options) that are structured by an interview schedule as part of quantitative research. While these are called interviews they’re far closer to surveys, so we wont cover them again in this chapter. The terms used for in-depth interviews we’ll cover in the next section.

6.1 Interviews

In-depth interviews allow participants to describe experiences in their own words (a primary strength of the interview format). Strong in-depth interviews will include many open-ended questions that allow participants to respond in their own words, share new ideas, and lead the conversation in different directions. The purpose of open-ended questions and in-depth interviews is to hear as much as possible in the person’s own voice, to collect new information and ideas, and to achieve a level of depth not possible in surveys or most other forms of data collection.

Typically, an interview guide is used to create a soft structure for the conversation and is an important preparation tool for the researcher. You can not go into an interview unprepared and just “wing it”; what the interview guide allows you to do is map out a framework, order of topics, and may include specific questions to use during the interview. Generally, the interview guide is thought of as just that — a guide to use in order to keep the interview focused. It is not set in stone and a skilled researcher can change the order of questions or topics in an interviews based on the organic conversation flow.

Depending on the experience and skill level of the researcher, an interview guide can be as simple as a list of topics to cover. However, for consistency and quality of research, the interviewer may want to take the time to at least practice writing out questions in advance to ensure that phrasing and word choices are as clear, objective, and focused as possible. It’s worth remembering that working out the wording of questions in advance allows researchers to ensure more consistency across interview. The interview guide below, taken from the wonderful and free textbook Principles of Sociological Inquiry , shows an interview guide that just has topics.

Alternatively, you can use a more detailed guide that lists out possible questions, as shown below. A more detailed guide is probably better for an interviewer that has less experience, or is just beginning to work on a given topic.

The purpose of an interview guide is to help ask effective questions and to support the process of acquiring the best possible data for your research. Topics and questions should be organized thematically, and in a natural progression that will allow the conversation to flow and deepen throughout the course of the interview. Often, researchers will attempt to memorize or partially memorize the interview guide, in order to be more fully present with the participant during the conversation.

6.2 Asking good Questions

Remember, the purposes of interviews is to go more in-depth with an individual than is possible with a generalized survey. For this reason, it is important to use the guide as a starting point but not to be overly tethered to it during the actual interview process. You may get stuck when respondents give you shorter answers than you expect, or don’t provide the type of depth that you need for your research. Often, you may want to probe for more specifics. Think about using follow up questions like “How does/did that affect you?” or “How does X make you feel?” and “Tell me about a time where X…”

For example, if I was researching the relationship between pets and mental health, some strong open-ended questions might be: * How does your pet typically make you feel when you wake up in the morning? * How does your pet generally affect your mood when you arrive home in the evening? * Tell me about a time when your pet had a significant impact on your emotional state.

Questions framed in this manner leave plenty of room for the respondent to answer in their own words, as opposed to leading and/or truncated questions, such as: * Does being with your pet make you happy? * After a bad day, how much does seeing your pet improve your mood? * Tell me about how important your pet is to your mental health.

These questions assume outcomes and will not result in high quality research. Researchers should always avoid asking leading questions that give away an expected answer or suggest particular responses. For instance, if I ask “we need to spend more on public schools, don’t you think?” the respondent is more likely to agree regardless of their own thoughts. Some wont, but humans generally have a strong natural desire to be agreeable. That’s why leaving your questions neutral and open so that respondents can speak to their experiences and views is critical.

6.3 Analyzing Interview Data

Writing good questions and interviewing respondents are just the first steps of the interview process. After these stages, the researcher still has a lot of work to do to collect usable data from the interview. The researcher must spend time coding and analyzing the interview to retrieve this data. Just doing an interview wont produce data. Think about how many conversations you have everyday, and none of those are leaving you swimming in data.

Hopefully you can record your interviews. Recording your interviews will allow you the opportunity to transcribe them word for word later. If you can’t record the interview you’ll need to take detailed notes so that you can reconstruct what you heard later. Do not trust yourself to “just remember” the conversation. You’re collecting data, precious data that you’re spending time and energy to collect. Treat it as important and valuable. Remember our description of the methodology section from Chapter 2, you need to maintain a chain of custody on your data. If you just remembered the interview, you could be accused of making up the results. Your interview notes and the recording become part of that chain of custody to prove to others that your interviews were real and that your results are accurate.

Assuming you recorded your interview, the first step in the analysis process is transcribing the interview. A transcription is a written record of every word in an interview. Transcriptions can either be completed by the researcher or by a hired worker, though it is good practice for the researcher to transcribe the interview him or herself. Researchers should keep the following points in mind regarding transcriptions: * The interview should take place in a quiet location with minimal background noise to produce a clear recording; * Transcribing interviews is a time-consuming process and may take two to three times longer than the actual interview; * Transcriptions provide a more precise record of the interview than hand written notes and allow the interviewer to focus during the interview.

After transcribing the interview, the next step is to analyze the responses. Coding is the main form of analysis used for interviews and involves studying a transcription to identify important themes. These themes are categorized into codes, which are words or phrases that denote an idea.

You’ll typically being with several codes in mind that are generated by key ideas you week seeking in the questions, but you can also being by using open coding to understand the results. An open coding process involves reading through the transcript multiple times and paying close attention to each line of the text to discover noteworthy concepts. During the open coding process, the researcher keeps an open mind to find any codes that may be relevant to the research topic.

After the open coding process is complete, focused coding can begin. Focused coding takes a closer look at the notes compiled during the open coding stage to merge common codes and define what the codes mean in the context of the research project.

Imagine a researcher is conducting interviews to learn about various people’s experiences of childhood in New Orleans. The following example shows several codes that this researcher extrapolated from an interview with one of their subjects.

6.4 Using interview data

The next chapter will address ways to identify people to interview, but most of the remainder of the book will address how to analyze quantitative data. That shouldn’t be taken as a sign that quantitative data is better, or that it’s easier to use interview data. Because in an interview the researcher must interpret the words of others it is often more challenging to identify your findings and clearly answer your research question. However, quantitative data is more common, and there are more different things you can do with it, so we spend a lot of the textbook focusing on it.

I’ll work through one more example of using interview data though. It takes a lot of practice to be a good and skilled interviewer. What I show below is a brief excerpt of an interview I did, and how that data was used in a resulting paper I wrote. These aren’t the only way you can use interview data, but it’s an example of what the intermediary and final product might look like.

The overall project these are drawn from was concerned with minor league baseball stadiums, but the specific part I’m pulling from here was studying the decline and rejuvenation of downtown around those stadiums in several cities. You’ll see that I’m using the words of the respondent fairly directly, because that’s my data. But I’m not just relying on one respondent and trusting them, I did a few dozen interviews in order to understand the commonalities in people’s perspectives to build a narrative around my research question.

Excerpt from Notes

Excerpt from Resulting Paper

How many interviews are necessary? It actually doesn’t take many. What you want to observe in your interviews is theoretical saturation , where the codes you use in the transcript begin to appear across conversations and groups. If different people disagree that’s fine, but what you want to understand is the commonalities across peoples perspectives. Most research on the subject says that with 8 interviews you’ll typically start to see a decline in new information gathered. That doesn’t mean you won’t get new words , but you’ll stop hearing completely unique perspectives or gain novel insights. At that point, where you’ve ‘heard it all before’ you can stop, because you’ve probably identified the answer to the questions you were trying to research.

6.5 Ensuring Anonymity

One significant ethical concern with interviews, that also applies to surveys, is making sure that respondents maintain anonymity. In either form of data collection you may be asking respondents deeply personal questions, that if exposed may cause legal, personal, or professional harm. Notice that in the excerpt of the paper above the respondents are only identified by an id I assigned (Louisville D) and their career, rather than their name. I can only include the excerpt of the interview notes above because there are no details that might lead to them being identified.

You may want to report details about a person to contextualize the data you gathered, but you should always ensure that no one can be identified from your research. For instance, if you were doing research on racism at large companies, you may want to preface people’s comments by their race, as there is a good chance that white and minority employees would feel differently about the issues. However, if you preface someones comments by saying they’re a minority manager, that may violate their anonymity. Even if you don’t state what company you did interviews with, that may be enough detail for their co-workers to identify them if there are few minority managers at the company. As such, always think long and hard about whether there is any way that the participation of respondents may be exposed.

6.6 Why not both?

We’ve discussed surveys and interviews as different methods the last two chapters, but they can also complement each other.

For instance, let’s say you’re curious to study people who change opinions on abortion, either going from support to opposition or vice versa. You could use a survey to understand the prevalence of changing opinions, i.e. what percentage of people in your city have changed their views. That would help to establish whether this is a prominent issue, or whether it’s a rare phenomenon. But it would be difficult to understand from the survey what makes people change their views. You could add an open ended question for anyone that said they changed their opinion, but many people won’t respond and few will provide the level of detail necessary to understand their motivations. Interviews with people that have changed their opinions would give you an opportunity to explore how their experiences and beliefs have changed in combination with their views towards abortion.

6.7 Summary

In the last two chapters we’ve discussed the two most prominent methods of data collection in the social sciences: surveys and interviews. What we haven’t discussed though is how to identify the people you’ll collect data from; that’s called a sampling strategy. In the next chapter

Interviewing in Qualitative Research

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The interview is one of the basic methods of data collection employed in the social sciences. It is worth noting that this method is not restricted solely to the qualitative research. Interviews have been actively taken advantage of by representatives of various scientific traditions. Both the supporters of the positivist paradigm and the interpretivist one use the technique of the interview to collect data even though the expectations and assumptions of researchers as well as the process of preparing the interview and the conclusion sphere differ fundamentally. The chapter presents different types of interviews employed by the researchers to collect the data in a qualitative research and discusses the process of preparation and conducting the interviews.

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Gudkova, S. (2018). Interviewing in Qualitative Research. In: Ciesielska, M., Jemielniak, D. (eds) Qualitative Methodologies in Organization Studies. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-65442-3_4

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How to carry out great interviews in qualitative research.

11 min read An interview is one of the most versatile methods used in qualitative research. Here’s what you need to know about conducting great qualitative interviews.

What is a qualitative research interview?

Qualitative research interviews are a mainstay among q ualitative research techniques, and have been in use for decades either as a primary data collection method or as an adjunct to a wider research process. A qualitative research interview is a one-to-one data collection session between a researcher and a participant. Interviews may be carried out face-to-face, over the phone or via video call using a service like Skype or Zoom.

There are three main types of qualitative research interview – structured, unstructured or semi-structured.

Structured interviews Structured interviews are based around a schedule of predetermined questions and talking points that the researcher has developed. At their most rigid, structured interviews may have a precise wording and question order, meaning that they can be replicated across many different interviewers and participants with relatively consistent results.
Unstructured interviews Unstructured interviews have no predetermined format, although that doesn’t mean they’re ad hoc or unplanned. An unstructured interview may outwardly resemble a normal conversation, but the interviewer will in fact be working carefully to make sure the right topics are addressed during the interaction while putting the participant at ease with a natural manner.
Semi-structured interviews Semi-structured interviews are the most common type of qualitative research interview, combining the informality and rapport of an unstructured interview with the consistency and replicability of a structured interview. The researcher will come prepared with questions and topics, but will not need to stick to precise wording. This blended approach can work well for in-depth interviews.

Free eBook: The qualitative research design handbook

What are the pros and cons of interviews in qualitative research?

As a qualitative research method interviewing is hard to beat, with applications in social research, market research, and even basic and clinical pharmacy. But like any aspect of the research process, it’s not without its limitations. Before choosing qualitative interviewing as your research method, it’s worth weighing up the pros and cons.

Pros of qualitative interviews:

provide in-depth information and context
can be used effectively when their are low numbers of participants
provide an opportunity to discuss and explain questions
useful for complex topics
rich in data – in the case of in-person or video interviews , the researcher can observe body language and facial expression as well as the answers to questions

Cons of qualitative interviews:

can be time-consuming to carry out
costly when compared to some other research methods
because of time and cost constraints, they often limit you to a small number of participants
difficult to standardize your data across different researchers and participants unless the interviews are very tightly structured
As the Open University of Hong Kong notes, qualitative interviews may take an emotional toll on interviewers

Qualitative interview guides

Semi-structured interviews are based on a qualitative interview guide, which acts as a road map for the researcher. While conducting interviews, the researcher can use the interview guide to help them stay focused on their research questions and make sure they cover all the topics they intend to.

An interview guide may include a list of questions written out in full, or it may be a set of bullet points grouped around particular topics. It can prompt the interviewer to dig deeper and ask probing questions during the interview if appropriate.

Consider writing out the project’s research question at the top of your interview guide, ahead of the interview questions. This may help you steer the interview in the right direction if it threatens to head off on a tangent.

Avoid bias in qualitative research interviews

According to Duke University , bias can create significant problems in your qualitative interview.

Acquiescence bias is common to many qualitative methods, including focus groups. It occurs when the participant feels obliged to say what they think the researcher wants to hear. This can be especially problematic when there is a perceived power imbalance between participant and interviewer. To counteract this, Duke University’s experts recommend emphasizing the participant’s expertise in the subject being discussed, and the value of their contributions.
Interviewer bias is when the interviewer’s own feelings about the topic come to light through hand gestures, facial expressions or turns of phrase. Duke’s recommendation is to stick to scripted phrases where this is an issue, and to make sure researchers become very familiar with the interview guide or script before conducting interviews, so that they can hone their delivery.

What kinds of questions should you ask in a qualitative interview?

The interview questions you ask need to be carefully considered both before and during the data collection process. As well as considering the topics you’ll cover, you will need to think carefully about the way you ask questions.

Open-ended interview questions – which cannot be answered with a ‘yes’ ‘no’ or ‘maybe’ – are recommended by many researchers as a way to pursue in depth information.

An example of an open-ended question is “What made you want to move to the East Coast?” This will prompt the participant to consider different factors and select at least one. Having thought about it carefully, they may give you more detailed information about their reasoning.

A closed-ended question , such as “Would you recommend your neighborhood to a friend?” can be answered without too much deliberation, and without giving much information about personal thoughts, opinions and feelings.

Follow-up questions can be used to delve deeper into the research topic and to get more detail from open-ended questions. Examples of follow-up questions include:

What makes you say that?
What do you mean by that?
Can you tell me more about X?
What did/does that mean to you?

As well as avoiding closed-ended questions, be wary of leading questions. As with other qualitative research techniques such as surveys or focus groups, these can introduce bias in your data. Leading questions presume a certain point of view shared by the interviewer and participant, and may even suggest a foregone conclusion.

An example of a leading question might be: “You moved to New York in 1990, didn’t you?” In answering the question, the participant is much more likely to agree than disagree. This may be down to acquiescence bias or a belief that the interviewer has checked the information and already knows the correct answer.

Other leading questions involve adjectival phrases or other wording that introduces negative or positive connotations about a particular topic. An example of this kind of leading question is: “Many employees dislike wearing masks to work. How do you feel about this?” It presumes a positive opinion and the participant may be swayed by it, or not want to contradict the interviewer.

Harvard University’s guidelines for qualitative interview research add that you shouldn’t be afraid to ask embarrassing questions – “if you don’t ask, they won’t tell.” Bear in mind though that too much probing around sensitive topics may cause the interview participant to withdraw. The Harvard guidelines recommend leaving sensitive questions til the later stages of the interview when a rapport has been established.

More tips for conducting qualitative interviews

Observing a participant’s body language can give you important data about their thoughts and feelings. It can also help you decide when to broach a topic, and whether to use a follow-up question or return to the subject later in the interview.

Be conscious that the participant may regard you as the expert, not themselves. In order to make sure they express their opinions openly, use active listening skills like verbal encouragement and paraphrasing and clarifying their meaning to show how much you value what they are saying.

Remember that part of the goal is to leave the interview participant feeling good about volunteering their time and their thought process to your research. Aim to make them feel empowered , respected and heard.

Unstructured interviews can demand a lot of a researcher, both cognitively and emotionally. Be sure to leave time in between in-depth interviews when scheduling your data collection to make sure you maintain the quality of your data, as well as your own well-being .

Recording and transcribing interviews

Historically, recording qualitative research interviews and then transcribing the conversation manually would have represented a significant part of the cost and time involved in research projects that collect qualitative data.

Fortunately, researchers now have access to digital recording tools, and even speech-to-text technology that can automatically transcribe interview data using AI and machine learning. This type of tool can also be used to capture qualitative data from qualitative research (focus groups,ect.) making this kind of social research or market research much less time consuming.

Data analysis

Qualitative interview data is unstructured, rich in content and difficult to analyze without the appropriate tools. Fortunately, machine learning and AI can once again make things faster and easier when you use qualitative methods like the research interview.

Text analysis tools and natural language processing software can ‘read’ your transcripts and voice data and identify patterns and trends across large volumes of text or speech. They can also perform khttps://www.qualtrics.com/experience-management/research/sentiment-analysis/

which assesses overall trends in opinion and provides an unbiased overall summary of how participants are feeling.

Another feature of text analysis tools is their ability to categorize information by topic, sorting it into groupings that help you organize your data according to the topic discussed.

All in all, interviews are a valuable technique for qualitative research in business, yielding rich and detailed unstructured data. Historically, they have only been limited by the human capacity to interpret and communicate results and conclusions, which demands considerable time and skill.

When you combine this data with AI tools that can interpret it quickly and automatically, it becomes easy to analyze and structure, dovetailing perfectly with your other business data. An additional benefit of natural language analysis tools is that they are free of subjective biases, and can replicate the same approach across as much data as you choose. By combining human research skills with machine analysis, qualitative research methods such as interviews are more valuable than ever to your business.

Related resources

Market intelligence 10 min read, marketing insights 11 min read, ethnographic research 11 min read, qualitative vs quantitative research 13 min read, qualitative research questions 11 min read, qualitative research design 12 min read, primary vs secondary research 14 min read, request demo.

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Qualitative Research 101: Interviewing

5 Common Mistakes To Avoid When Undertaking Interviews

By: David Phair (PhD) and Kerryn Warren (PhD) | March 2022

Undertaking interviews is potentially the most important step in the qualitative research process. If you don’t collect useful, useable data in your interviews, you’ll struggle through the rest of your dissertation or thesis. Having helped numerous students with their research over the years, we’ve noticed some common interviewing mistakes that first-time researchers make. In this post, we’ll discuss five costly interview-related mistakes and outline useful strategies to avoid making these.

Overview: 5 Interviewing Mistakes

Not having a clear interview strategy /plan
Not having good interview techniques /skills
Not securing a suitable location and equipment
Not having a basic risk management plan
Not keeping your “ golden thread ” front of mind

1. Not having a clear interview strategy

The first common mistake that we’ll look at is that of starting the interviewing process without having first come up with a clear interview strategy or plan of action. While it’s natural to be keen to get started engaging with your interviewees, a lack of planning can result in a mess of data and inconsistency between interviews.

There are several design choices to decide on and plan for before you start interviewing anyone. Some of the most important questions you need to ask yourself before conducting interviews include:

What are the guiding research aims and research questions of my study?
Will I use a structured, semi-structured or unstructured interview approach?
How will I record the interviews (audio or video)?
Who will be interviewed and by whom ?
What ethics and data law considerations do I need to adhere to?
How will I analyze my data?

Let’s take a quick look at some of these.

The core objective of the interviewing process is to generate useful data that will help you address your overall research aims. Therefore, your interviews need to be conducted in a way that directly links to your research aims, objectives and research questions (i.e. your “golden thread”). This means that you need to carefully consider the questions you’ll ask to ensure that they align with and feed into your golden thread. If any question doesn’t align with this, you may want to consider scrapping it.

Another important design choice is whether you’ll use an unstructured, semi-structured or structured interview approach . For semi-structured interviews, you will have a list of questions that you plan to ask and these questions will be open-ended in nature. You’ll also allow the discussion to digress from the core question set if something interesting comes up. This means that the type of information generated might differ a fair amount between interviews.

Contrasted to this, a structured approach to interviews is more rigid, where a specific set of closed questions is developed and asked for each interviewee in exactly the same order. Closed questions have a limited set of answers, that are often single-word answers. Therefore, you need to think about what you’re trying to achieve with your research project (i.e. your research aims) and decided on which approach would be best suited in your case.

It is also important to plan ahead with regards to who will be interviewed and how. You need to think about how you will approach the possible interviewees to get their cooperation, who will conduct the interviews, when to conduct the interviews and how to record the interviews. For each of these decisions, it’s also essential to make sure that all ethical considerations and data protection laws are taken into account.

Finally, you should think through how you plan to analyze the data (i.e., your qualitative analysis method) generated by the interviews. Different types of analysis rely on different types of data, so you need to ensure you’re asking the right types of questions and correctly guiding your respondents.

Simply put, you need to have a plan of action regarding the specifics of your interview approach before you start collecting data. If not, you’ll end up drifting in your approach from interview to interview, which will result in inconsistent, unusable data.

Your interview questions need to directly link to your research aims, objectives and research questions - your "golden thread”.

2. Not having good interview technique

While you’re generally not expected to become you to be an expert interviewer for a dissertation or thesis, it is important to practice good interview technique and develop basic interviewing skills .

Let’s go through some basics that will help the process along.

Firstly, before the interview , make sure you know your interview questions well and have a clear idea of what you want from the interview. Naturally, the specificity of your questions will depend on whether you’re taking a structured, semi-structured or unstructured approach, but you still need a consistent starting point . Ideally, you should develop an interview guide beforehand (more on this later) that details your core question and links these to the research aims, objectives and research questions.

Before you undertake any interviews, it’s a good idea to do a few mock interviews with friends or family members. This will help you get comfortable with the interviewer role, prepare for potentially unexpected answers and give you a good idea of how long the interview will take to conduct. In the interviewing process, you’re likely to encounter two kinds of challenging interviewees ; the two-word respondent and the respondent who meanders and babbles. Therefore, you should prepare yourself for both and come up with a plan to respond to each in a way that will allow the interview to continue productively.

To begin the formal interview , provide the person you are interviewing with an overview of your research. This will help to calm their nerves (and yours) and contextualize the interaction. Ultimately, you want the interviewee to feel comfortable and be willing to be open and honest with you, so it’s useful to start in a more casual, relaxed fashion and allow them to ask any questions they may have. From there, you can ease them into the rest of the questions.

As the interview progresses , avoid asking leading questions (i.e., questions that assume something about the interviewee or their response). Make sure that you speak clearly and slowly , using plain language and being ready to paraphrase questions if the person you are interviewing misunderstands. Be particularly careful with interviewing English second language speakers to ensure that you’re both on the same page.

Engage with the interviewee by listening to them carefully and acknowledging that you are listening to them by smiling or nodding. Show them that you’re interested in what they’re saying and thank them for their openness as appropriate. This will also encourage your interviewee to respond openly.

Need a helping hand?

3. Not securing a suitable location and quality equipment

Where you conduct your interviews and the equipment you use to record them both play an important role in how the process unfolds. Therefore, you need to think carefully about each of these variables before you start interviewing.

Poor location: A bad location can result in the quality of your interviews being compromised, interrupted, or cancelled. If you are conducting physical interviews, you’ll need a location that is quiet, safe, and welcoming . It’s very important that your location of choice is not prone to interruptions (the workplace office is generally problematic, for example) and has suitable facilities (such as water, a bathroom, and snacks).

If you are conducting online interviews , you need to consider a few other factors. Importantly, you need to make sure that both you and your respondent have access to a good, stable internet connection and electricity. Always check before the time that both of you know how to use the relevant software and it’s accessible (sometimes meeting platforms are blocked by workplace policies or firewalls). It’s also good to have alternatives in place (such as WhatsApp, Zoom, or Teams) to cater for these types of issues.

Poor equipment: Using poor-quality recording equipment or using equipment incorrectly means that you will have trouble transcribing, coding, and analyzing your interviews. This can be a major issue , as some of your interview data may go completely to waste if not recorded well. So, make sure that you use good-quality recording equipment and that you know how to use it correctly.

To avoid issues, you should always conduct test recordings before every interview to ensure that you can use the relevant equipment properly. It’s also a good idea to spot check each recording afterwards, just to make sure it was recorded as planned. If your equipment uses batteries, be sure to always carry a spare set.

Where you conduct your interviews and the equipment you use to record them play an important role in how the process unfolds.

4. Not having a basic risk management plan

Many possible issues can arise during the interview process. Not planning for these issues can mean that you are left with compromised data that might not be useful to you. Therefore, it’s important to map out some sort of risk management plan ahead of time, considering the potential risks, how you’ll minimize their probability and how you’ll manage them if they materialize.

Common potential issues related to the actual interview include cancellations (people pulling out), delays (such as getting stuck in traffic), language and accent differences (especially in the case of poor internet connections), issues with internet connections and power supply. Other issues can also occur in the interview itself. For example, the interviewee could drift off-topic, or you might encounter an interviewee who does not say much at all.

You can prepare for these potential issues by considering possible worst-case scenarios and preparing a response for each scenario. For instance, it is important to plan a backup date just in case your interviewee cannot make it to the first meeting you scheduled with them. It’s also a good idea to factor in a 30-minute gap between your interviews for the instances where someone might be late, or an interview runs overtime for other reasons. Make sure that you also plan backup questions that could be used to bring a respondent back on topic if they start rambling, or questions to encourage those who are saying too little.

In general, it’s best practice to plan to conduct more interviews than you think you need (this is called oversampling ). Doing so will allow you some room for error if there are interviews that don’t go as planned, or if some interviewees withdraw. If you need 10 interviews, it is a good idea to plan for 15. Likely, a few will cancel , delay, or not produce useful data.

You should consider all the potential risks, how you’ll reduce their probability and how you'll respond if they do indeed materialize.

5. Not keeping your golden thread front of mind

We touched on this a little earlier, but it is a key point that should be central to your entire research process. You don’t want to end up with pages and pages of data after conducting your interviews and realize that it is not useful to your research aims . Your research aims, objectives and research questions – i.e., your golden thread – should influence every design decision and should guide the interview process at all times.

A useful way to avoid this mistake is by developing an interview guide before you begin interviewing your respondents. An interview guide is a document that contains all of your questions with notes on how each of the interview questions is linked to the research question(s) of your study. You can also include your research aims and objectives here for a more comprehensive linkage.

You can easily create an interview guide by drawing up a table with one column containing your core interview questions . Then add another column with your research questions , another with expectations that you may have in light of the relevant literature and another with backup or follow-up questions . As mentioned, you can also bring in your research aims and objectives to help you connect them all together. If you’d like, you can download a copy of our free interview guide here .

Recap: Qualitative Interview Mistakes

In this post, we’ve discussed 5 common costly mistakes that are easy to make in the process of planning and conducting qualitative interviews.

To recap, these include:

If you have any questions about these interviewing mistakes, drop a comment below. Alternatively, if you’re interested in getting 1-on-1 help with your thesis or dissertation , check out our dissertation coaching service or book a free initial consultation with one of our friendly Grad Coaches.

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How to conduct qualitative interviews (tips and best practices)

Last updated

18 May 2023

Reviewed by

Miroslav Damyanov

However, conducting qualitative interviews can be challenging, even for seasoned researchers. Poorly conducted interviews can lead to inaccurate or incomplete data, significantly compromising the validity and reliability of your research findings.

When planning to conduct qualitative interviews, you must adequately prepare yourself to get the most out of your data. Fortunately, there are specific tips and best practices that can help you conduct qualitative interviews effectively.

What is a qualitative interview?

A qualitative interview is a research technique used to gather in-depth information about people's experiences, attitudes, beliefs, and perceptions. Unlike a structured questionnaire or survey, a qualitative interview is a flexible, conversational approach that allows the interviewer to delve into the interviewee's responses and explore their insights and experiences.

In a qualitative interview, the researcher typically develops a set of open-ended questions that provide a framework for the conversation. However, the interviewer can also adapt to the interviewee's responses and ask follow-up questions to understand their experiences and views better.

How to conduct interviews in qualitative research

Conducting interviews involves a well-planned and deliberate process to collect accurate and valid data.

Here’s a step-by-step guide on how to conduct interviews in qualitative research, broken down into three stages:

1. Before the interview

The first step in conducting a qualitative interview is determining your research question . This will help you identify the type of participants you need to recruit . Once you have your research question, you can start recruiting participants by identifying potential candidates and contacting them to gauge their interest in participating in the study.

After that, it's time to develop your interview questions. These should be open-ended questions that will elicit detailed responses from participants. You'll also need to get consent from the participants, ideally in writing, to ensure that they understand the purpose of the study and their rights as participants. Finally, choose a comfortable and private location to conduct the interview and prepare the interview guide.

2. During the interview

Start by introducing yourself and explaining the purpose of the study. Establish a rapport by putting the participants at ease and making them feel comfortable. Use the interview guide to ask the questions, but be flexible and ask follow-up questions to gain more insight into the participants' responses.

Take notes during the interview, and ask permission to record the interview for transcription purposes. Be mindful of the time, and cover all the questions in the interview guide.

3. After the interview

Once the interview is over, transcribe the interview if you recorded it. If you took notes, review and organize them to make sure you capture all the important information. Then, analyze the data you collected by identifying common themes and patterns. Use the findings to answer your research question.

Finally, debrief with the participants to thank them for their time, provide feedback on the study, and answer any questions they may have.

What kinds of questions should you ask in a qualitative interview?

Qualitative interviews involve asking questions that encourage participants to share their experiences, opinions, and perspectives on a particular topic. These questions are designed to elicit detailed and nuanced responses rather than simple yes or no answers.

Effective questions in a qualitative interview are generally open-ended and non-leading. They avoid presuppositions or assumptions about the participant's experience and allow them to share their views in their own words.

In customer research , you might ask questions such as:

What motivated you to choose our product/service over our competitors?

How did you first learn about our product/service?

Can you walk me through your experience with our product/service?

What improvements or changes would you suggest for our product/service?

Have you recommended our product/service to others, and if so, why?

The key is to ask questions relevant to the research topic and allow participants to share their experiences meaningfully and informally.

How to determine the right qualitative interview participants

Choosing the right participants for a qualitative interview is a crucial step in ensuring the success and validity of the research . You need to consider several factors to determine the right participants for a qualitative interview. These may include:

Relevant experiences : Participants should have experiences related to the research topic that can provide valuable insights.

Diversity : Aim to include diverse participants to ensure the study's findings are representative and inclusive.

Access : Identify participants who are accessible and willing to participate in the study.

Informed consent : Participants should be fully informed about the study's purpose, methods, and potential risks and benefits and be allowed to provide informed consent.

You can use various recruitment methods, such as posting ads in relevant forums, contacting community organizations or social media groups, or using purposive sampling to identify participants who meet specific criteria.

How to make qualitative interview subjects comfortable

Making participants comfortable during a qualitative interview is essential to obtain rich, detailed data. Participants are more likely to share their experiences openly when they feel at ease and not judged.

Here are some ways to make interview subjects comfortable:

Explain the purpose of the study

Start the interview by explaining the research topic and its importance. The goal is to give participants a sense of what to expect.

Create a comfortable environment

Conduct the interview in a quiet, private space where the participant feels comfortable. Turn off any unnecessary electronics that can create distractions. Ensure your equipment works well ahead of time. Arrive at the interview on time. If you conduct a remote interview, turn on your camera and mute all notetakers and observers.

Build rapport

Greet the participant warmly and introduce yourself. Show interest in their responses and thank them for their time.

Use open-ended questions

Ask questions that encourage participants to elaborate on their thoughts and experiences.

Listen attentively

Resist the urge to multitask . Pay attention to the participant's responses, nod your head, or make supportive comments to show you’re interested in their answers. Avoid interrupting them.

Avoid judgment

Show respect and don't judge the participant's views or experiences. Allow the participant to speak freely without feeling judged or ridiculed.

Offer breaks

If needed, offer breaks during the interview, especially if the topic is sensitive or emotional.

Creating a comfortable environment and establishing rapport with the participant fosters an atmosphere of trust and encourages open communication. This helps participants feel at ease and willing to share their experiences.

How to analyze a qualitative interview

Analyzing a qualitative interview involves a systematic process of examining the data collected to identify patterns, themes, and meanings that emerge from the responses.

Here are some steps on how to analyze a qualitative interview:

1. Transcription

The first step is transcribing the interview into text format to have a written record of the conversation. This step is essential to ensure that you can refer back to the interview data and identify the important aspects of the interview.

2. Data reduction

Once you’ve transcribed the interview, read through it to identify key themes, patterns, and phrases emerging from the data. This process involves reducing the data into more manageable pieces you can easily analyze.

The next step is to code the data by labeling sections of the text with descriptive words or phrases that reflect the data's content. Coding helps identify key themes and patterns from the interview data.

4. Categorization

After coding, you should group the codes into categories based on their similarities. This process helps to identify overarching themes or sub-themes that emerge from the data.

5. Interpretation

You should then interpret the themes and sub-themes by identifying relationships, contradictions, and meanings that emerge from the data. Interpretation involves analyzing the themes in the context of the research question .

6. Comparison

The next step is comparing the data across participants or groups to identify similarities and differences. This step helps to ensure that the findings aren’t just specific to one participant but can be generalized to the wider population.

7. Triangulation

To ensure the findings are valid and reliable, you should use triangulation by comparing the findings with other sources, such as observations or interview data.

8. Synthesis

The final step is synthesizing the findings by summarizing the key themes and presenting them clearly and concisely. This step involves writing a report that presents the findings in a way that is easy to understand, using quotes and examples from the interview data to illustrate the themes.

Tips for transcribing a qualitative interview

Transcribing a qualitative interview is a crucial step in the research process. It involves converting the audio or video recording of the interview into written text.

Here are some tips for transcribing a qualitative interview:

Use transcription software

Transcription software can save time and increase accuracy by automatically transcribing audio or video recordings.

Listen carefully

When manually transcribing, listen carefully to the recording to ensure clarity. Pause and rewind the recording as necessary.

Use appropriate formatting

Use a consistent format for transcribing, such as marking pauses, overlaps, and interruptions. Indicate non-verbal cues such as laughter, sighs, or changes in tone.

Edit for clarity

Edit the transcription to ensure clarity and readability. Use standard grammar and punctuation, correct misspellings, and remove filler words like "um" and "ah."

Proofread and edit

Verify the accuracy of the transcription by listening to the recording again and reviewing the notes taken during the interview.

Use timestamps

Add timestamps to the transcription to reference specific interview sections.

Transcribing a qualitative interview can be time-consuming, but it’s essential to ensure the accuracy of the data collected. Following these tips can produce high-quality transcriptions useful for analysis and reporting.

Why are interview techniques in qualitative research effective?

Unlike quantitative research methods, which rely on numerical data, qualitative research seeks to understand the richness and complexity of human experiences and perspectives.

Interview techniques involve asking open-ended questions that allow participants to express their views and share their stories in their own words. This approach can help researchers to uncover unexpected or surprising insights that may not have been discovered through other research methods.

Interview techniques also allow researchers to establish rapport with participants, creating a comfortable and safe space for them to share their experiences. This can lead to a deeper level of trust and candor, leading to more honest and authentic responses.

What are the weaknesses of qualitative interviews?

Qualitative interviews are an excellent research approach when used properly, but they have their drawbacks.

The weaknesses of qualitative interviews include the following:

Subjectivity and personal biases

Qualitative interviews rely on the researcher's interpretation of the interviewee's responses. The researcher's biases or preconceptions can affect how the questions are framed and how the responses are interpreted, which can influence results.

Small sample size

The sample size in qualitative interviews is often small, which can limit the generalizability of the results to the larger population.

Data quality

The quality of data collected during interviews can be affected by various factors, such as the interviewee's mood, the setting of the interview, and the interviewer's skills and experience.

Socially desirable responses

Interviewees may provide responses that they believe are socially acceptable rather than truthful or genuine.

Conducting qualitative interviews can be expensive, especially if the researcher must travel to different locations to conduct the interviews.

Time-consuming

The data analysis process can be time-consuming and labor-intensive, as researchers need to transcribe and analyze the data manually.

Despite these weaknesses, qualitative interviews remain a valuable research tool . You can take steps to mitigate the impact of these weaknesses by incorporating the perspectives of other researchers or participants in the analysis process, using multiple data sources , and critically analyzing your biases and assumptions.

Mastering the art of qualitative interviews is an essential skill for businesses looking to gain deep insights into their customers' needs , preferences, and behaviors. By following the tips and best practices outlined in this article, you can conduct interviews that provide you with rich data that you can use to make informed decisions about your products, services, and marketing strategies.

Remember that effective communication, active listening, and proper analysis are critical components of successful qualitative interviews. By incorporating these practices into your customer research, you can gain a competitive edge and build stronger customer relationships.

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Guide to Thematic Analysis

Abductive Thematic Analysis
Collaborative Thematic Analysis
Deductive Thematic Analysis
How to Do Thematic Analysis
Inductive Thematic Analysis
Reflexive Thematic Analysis
Advantages of Thematic Analysis
Thematic Analysis for Case Studies
Thematic Coding
Disadvantages of Thematic Analysis
Thematic Analysis in Educational Research
Thematic Analysis Examples
Thematic Analysis for Focus Groups
Thematic Analysis vs. Grounded Theory
What is Thematic Analysis?
Increasing Rigor in Thematic Analysis
Introduction

Interviews in qualitative research

Can you use thematic analysis for interviews, how to do thematic analysis of interviews.

Thematic Analysis Literature Review
Thematic Analysis in Mixed Methods Approach
Thematic Analysis in Observations
Peer Review in Thematic Analysis
How to Present Thematic Analysis Results
Thematic Analysis in Psychology
Thematic Analysis of Secondary Data
Thematic Analysis in Social Work
Thematic Analysis Software
Thematic Analysis in Surveys
Thematic Analysis in UX Research
Thematic vs. Content Analysis
Thematic Analysis vs. Discourse Analysis
Thematic Analysis vs. Framework Analysis
Thematic Analysis vs. Narrative Analysis
Thematic Analysis vs. Phenomenology

Thematic Analysis for Interviews

Thematic analysis is a widely used method in qualitative research for identifying, analyzing, and reporting patterns (themes) within data . It organizes and describes the data set in detail and interprets various aspects of the research topic. When applied to interview data, thematic analysis allows researchers to sift through large volumes of text and distill meaningful patterns relevant to their research questions.

This introductory guide provides a straightforward approach to conducting a thematic analysis of interview data . It outlines the key steps involved in the process, from data preparation to theme identification and analysis .

Interviews are a fundamental data collection method in qualitative research , offering deep insights into participants' perspectives, experiences, and motivations. They are particularly valuable for exploring complex issues, understanding individual experiences, and gathering detailed information that would be difficult to obtain through other methods.

In qualitative research, interviews can vary widely in structure, from highly structured interviews where specific questions are asked in a set order, to semi-structured interviews that allow for more flexibility and follow-up questions based on the respondent's answers. Unstructured interviews , on the other hand, are more like guided conversations and are the least restrictive.

Regardless of the format, the primary goal of using interviews in qualitative research is to gain a nuanced understanding of the topic at hand. Researchers can probe deeper into participants' responses, clarify ambiguities, and explore new avenues that emerge during the conversation. This depth and detail are what set interviews apart from other data collection methods like surveys or questionnaires, which may not allow for such in-depth exploration.

To ensure the effectiveness of interviews in qualitative research, researchers must be skilled in question formulation, active listening, and respondent engagement. They must also be adept at creating a comfortable environment for participants, encouraging them to share openly and honestly.

After conducting the interviews, the qualitative researcher faces the critical task of analyzing the collected data . Transcribing the interviews is typically the first step, transforming audio recordings into text for detailed analysis. The researcher then reads through these transcripts meticulously to identify themes and other data segments of interest, laying the groundwork for a thorough thematic analysis. Qualitative researchers may pursue other approaches like narrative analysis and discourse analysis depending on their research question and objectives, while converting transcripts into quantitative data may be useful for a content analysis .

Thematic analysis can be an effective method for analyzing interview data in qualitative research due to its ability to uncover, analyze, and report themes within complex datasets. When researchers use thematic analysis to scrutinize interview data, they engage deeply with the content, enabling a nuanced understanding of participants' experiences and perspectives.

This method is particularly adept at handling the rich, qualitative depth that interviews provide, allowing researchers to extract meaningful patterns and insights from the narratives shared by participants. Thematic analysis respects the detail and individuality of each respondent's contribution, translating intricate personal stories into broader insights that are relevant to the research question .

In the context of interviews, thematic analysis is beneficial because it is adaptable to a range of theoretical frameworks and research objectives, making it a versatile choice for many studies. It supports researchers in identifying not just the explicit content of what was said, but also the underlying ideas and themes that emerge across different interviews. This approach ensures a comprehensive understanding of the data, taking into account both the diversity and the commonalities of participants' experiences.

Furthermore, thematic analysis is a method that suits various levels of research expertise. It does not demand advanced methodological training, making it accessible while still providing robust and systematic guidance for analyzing complex data sets. This accessibility, combined with its analytical depth, makes thematic analysis an excellent choice for researchers aiming to derive meaningful themes from their interview data, thus ensuring a thorough and insightful analysis.

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Thematic analysis is a methodical process that allows researchers to identify, analyze, and report patterns within their interview data , offering a deep and nuanced understanding of the data's content. This approach requires a careful and detailed engagement with the textual data gathered from interviews, organized through a series of structured steps.

This section will guide you through the critical stages of this research process: starting from immersing yourself in the data to generate a profound understanding, moving on to coding the data to unearth initial insights, identifying overarching themes, and finally, reviewing themes to accurately reflect the data's depth. Each step is pivotal in transforming raw interview content into meaningful, actionable findings.

Familiarizing yourself with the data

The first crucial step in conducting thematic analysis on interview data is to familiarize yourself thoroughly with the material. This involves engaging deeply with the content of your interviews to ensure a comprehensive understanding of the data you will be analyzing.

Begin by listening to the audio recordings of your interviews several times, if available, to capture not just the words but also the nuances of how things are said, including tone, emphasis, and pauses. This can provide additional layers of meaning that are not always evident in a written transcript . Next, read and reread the transcripts meticulously. While reading, take detailed notes on your initial impressions, including any interesting or recurring themes that jump out at you.

During this stage, it's essential to approach your data with an open mind, setting aside any preconceived notions or theoretical assumptions. This openness ensures that you remain receptive to the data's inherent messages rather than imposing your interpretations. It also prepares you for the subsequent stages of analysis by helping you develop a nuanced understanding of the dataset as a whole.

For interview data, specifically, paying attention to the context in which statements were made is crucial. Reflect on the interview setting, the relationship dynamics between the interviewer and participant, and any external factors that might have influenced the responses. This contextual understanding can be invaluable when you later attempt to code the data and interpret its meaning.

Generating initial codes

Generating initial codes is a systematic and meticulous step in thematic analysis where you start segmenting and labeling your interview data to identify significant features and patterns. This phase is critical for organizing your data into meaningful groups that will later facilitate the identification of broader themes.

When coding interview data, you can approach each transcript line-by-line or paragraph-by-paragraph, assigning concise codes that capture the essence of each segment. These codes should reflect the content and context of what is being conveyed, staying as close to the data as possible. It is beneficial to use a mix of descriptive and in vivo codes—the former describing the content and the latter using key phrases spoken by the participants themselves.

As you progress through your interviews, compare and contrast your codes across different transcripts. This comparison helps to ensure consistency in your coding approach and allows you to start identifying patterns across the entire data set. Remember, the goal at this stage is not to force the data into pre-existing categories but to remain open to what the data reveals.

Searching for themes

After generating your initial codes, the next step in thematic analysis is to search for overarching themes that convey broader patterns in your interview data. This involves reviewing your codes to identify significant clusters of related or interconnected codes that suggest a higher level of conceptualization.

Begin by organizing your codes into potential theme categories, considering how individual codes combine to form a more comprehensive narrative. This categorization should not be purely based on the frequency of certain codes but should also take into account their relevance to your research questions and the overall data set. During this process, it's essential to remain flexible and open-minded, as themes may evolve or merge together.

For interview data, it's particularly important to consider the context in which responses were given. Reflect on how the themes relate to the broader socio-cultural context, the specific circumstances of the interview, and the interactions between interviewer and participant. These considerations can provide deeper insights into the significance and nuances of your emerging themes.

As you delineate these themes, create visual representations , such as thematic maps or charts, to help you conceptualize the relationships between codes and themes. These visualizations can aid in identifying the core essence of each theme and its connection to the overall story your data is telling.

Reviewing and defining themes

The phase of reviewing and defining themes is crucial for refining the preliminary themes you've identified and ensuring they accurately represent your interview data. This step involves a thorough examination and possible reconfiguration of your themes to ensure they are coherent, consistent, and distinct.

Begin by reviewing each theme in relation to the coded extracts to verify that they form a coherent pattern. This may require you to split broad themes into more nuanced sub-themes, combine closely related themes, or discard themes that lack sufficient evidence across the dataset. For interview data, it is particularly important to ensure that the themes reflect the participants' perspectives and experiences rather than the researcher's interpretations.

Next, define and name each theme. Provide a clear, concise, and descriptive name for each theme, capturing its essence. Then, develop a detailed analysis for each theme, explaining what it represents and how it contributes to the overall understanding of the data. Include illustrative quotations from your interviews to demonstrate how each theme is grounded in the participants' accounts.

Finally, ensure that your themes 'tell a story' about your data, addressing your research questions and offering insightful interpretations. The themes should provide a rich, detailed, and complex picture of the data, highlighting the depth and diversity of the participants' experiences and perspectives.

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Open access
Published: 05 May 2024

A qualitative interview study to determine barriers and facilitators of implementing automated decision support tools for genomic data access

Vasiliki Rahimzadeh 1 ,
Jinyoung Baek 2 ,
Jonathan Lawson 2 &
Edward S. Dove 3

BMC Medical Ethics volume 25 , Article number: 51 ( 2024 ) Cite this article

Metrics details

Data access committees (DAC) gatekeep access to secured genomic and related health datasets yet are challenged to keep pace with the rising volume and complexity of data generation. Automated decision support (ADS) systems have been shown to support consistency, compliance, and coordination of data access review decisions. However, we lack understanding of how DAC members perceive the value add of ADS, if any, on the quality and effectiveness of their reviews. In this qualitative study, we report findings from 13 semi-structured interviews with DAC members from around the world to identify relevant barriers and facilitators to implementing ADS for genomic data access management. Participants generally supported pilot studies that test ADS performance, for example in cataloging data types, verifying user credentials and tagging datasets for use terms. Concerns related to over-automation, lack of human oversight, low prioritization, and misalignment with institutional missions tempered enthusiasm for ADS among the DAC members we engaged. Tensions for change in institutional settings within which DACs operated was a powerful motivator for why DAC members considered the implementation of ADS into their access workflows, as well as perceptions of the relative advantage of ADS over the status quo. Future research is needed to build the evidence base around the comparative effectiveness and decisional outcomes of institutions that do/not use ADS into their workflows.

Peer Review reports

Introduction

Genomics is among the most data-prolific scientific fields and is expected to surpass the storage needs and analytic capacities of Twitter, YouTube, and astronomy combined by as soon as 2025 [ 1 ]. To meet rising demands for genomic data and their efficient collection and use, national genomics initiatives [ 2 ] rely on largescale repositories to pool data resources and incentivize data sharing [ 3 , 4 , 5 ]. The “data commons” model has since become the flagship approach for many of these initiatives [ 6 ], and prioritizes research collaboration and data access over proprietary exclusion in the data [ 3 ]. Data access committees (DACs) are principally charged with ensuring only bona fide researchers conducting research permitted by participants’ informed consent are approved to access the data [ 7 ]. DACs are typically staffed by research compliance officers, researchers, and sometimes data security professionals. DAC members can be paid or serve as volunteers and, at a basic level, arbitrate access to data given requests meet minimum requirements for data protection and compliance. Critiques of compliance-only responsibilities and the growing appreciation of data privacy risks among the general public has raised questions about whether DACs ought to weigh in on issues of social and scientific value of the data projects [ 8 ]. Our prior empirical work [ 9 ] suggests there is debate around this scope of DAC oversight, particularly as it relates to considerations of data ethics that are traditionally the domain of institutional ethics committees.

Cheah and Piasecki, for example, propose that DACs have responsibilities to both promote data sharing and protect the interests of individuals and communities about whom the shared data relate: “data access should be granted as long as the data reuse fulfils the criterion of having even a minimal social value, and minimal risk to data subjects and their communities” [ 7 ]. In this way, DACs anchor responsible data sharing ecosystems since they govern access to and compliant use of genomic and, increasingly, other health data [ 10 , 11 , 12 ].

However, DACs may not contribute to efficient data access provisions as effectively as other review models may allow [ 13 ]. In the standard model of data access review, DACs manually review a data requester’s application and assess it against pre-defined criteria. Criteria may include appropriateness of the data requested, data use terms set by data providers, and data privacy and security requirements set by the institution and by law [ 7 ]. As with most, if not all, human-mediated activities, manual review of these criteria can be a laborious and error-prone process. For example, DACs may interpret language describing permitted data uses differently, and the terms themselves can sometimes be ambiguous [ 14 ]. Faced with this ambiguity, DACs are forced to make subjective judgments about whether requests for data access truly align with permitted data uses, if these permissions have been preserved at all. Inconsistencies in how data use terms are articulated in consent forms and subsequently interpreted and executed by DACs across the biomedical ecosystem [ 14 ] can lead to delayed and inconsistent data access decisions, and risk violating the terms by which patients or participants contributed their data in the first place.

Other steps in the data access pipeline can also contribute to research delays. Emerging research suggests there is growing inefficiency, inconsistency, and error in the manual, entirely human-mediated review of data access agreements [ 13 , 15 ] which are executed in finalizing approved data access requests. Many researchers furthermore still rely on the traditional method of copying-and-downloading data once approved. The copy-download approach multiplies security risks [ 11 ], and is quickly becoming unreasonable given the expanding size and complexities of genomic datasets [ 16 , 17 ].

Standards’ developers and software engineers have therefore sought to semi-automate three axes of data access control within cloud environments – user authentication, review of access requests, and concordance of the proposed research with the data use terms of the data requested [ 14 ]. Automated decision support (ADS) systems are a coordinated system of algorithms, software, and ontologies [ 18 ] that aid in categorizing, archiving, and/or acting on decision tasks for data access review. The Data Use Oversight System (DUOS) typifies one such automated decision support [ 19 ]. In recent beta tests, DUOS was successfully shown to concur 100% of the time with human-decided access requests [ 15 ], and also codifies 93% of genomic datasets in NIH’s dbGaP [ 20 ].

While ADS can supplement human DACs with semi-automated technical solutions, no systematic investigation has sought to characterize relevant barriers and facilitators to ADS in practice [ 21 ]. Moreover, we lack understanding of how DAC members perceive the value added by ADS, if any, on the quality and effectiveness of data access review decisions, as well as what challenges they anticipate in adopting ADS considering the myriad organizational structures within which DACs operate.

Now is an opportune time to study the implementation barriers and facilitators to using ADS solutions for data access as their development converges with large-scale data migration to the cloud that can result in near-instant data access decisions. The genomics community can learn important lessons from previous attempts at (premature) ADS implementation without purposeful stakeholder engagement in public health [ 22 ], law enforcement [ 23 ] and in clinical care [ 24 ]. In this article, we report empirical findings on the “constellation of processes” relevant for implementing ADS for genomic data access management and provide practical recommendations for institutional data stewards that are considering or have already implemented ADS in this context.

We conducted a qualitative description study that engaged prospective end users of ADS for genomic data governance to explore: What are the barriers and opportunities of implementing automated workflows to manage access requests to genomic data collections, and what effect do ADS have on DAC review quality and effectiveness? We adopted Damshroder and colleagues’ definition of implementation as the “critical gateway between an organizational decision to adopt an intervention and the routine use of that intervention” [ 25 ] in order to “study the constellation of processes intended to get an intervention into use within an organization” [ 25 ]. We applied the Consolidated Framework for Implementation Research (CFIR) to compare genomic data access processes and procedures to better understand implementation processes for automated workflows to manage genomic data access across international, publicly funded genomic data repositories. The CFIR provides a “menu of constructs” associated with five domains of effective implementation which have been rigorously meta-theorized—that is, synthesized from many implementation theories (Fig. 1 ). In addition, the CFIR provides a practical guide to systematically assess potential barriers and facilitators ahead of an innovation’s implementation (L. Damschroder et al. 2015). The CFIR is also easily customizable to unveiling bioethical issues during implementation in genomics and has been applied in prior work (Burke and Korngiebel, 2015; Smit et al., 2020).

Adapted Consolidated Framework for Implementation Research (CFIR) and associated domains (Intervention Characteristics, Individuals, Process, Inner Setting, Outer Setting) used to structure 13 qualitative interviews on the relevant factors mediating implementation of automated decision support tools for genomic data access management and sharing among publicly funded genomic data repositories worldwide

The interview guide was developed specifically for this study and is available in Supplementary Materials 2 .

Data collection

We conducted a total of 13 semi-structured interviews with 17 DAC members between 27 April and 24 August 2022. Prospective interviewees indicated their interest in being invited to a follow up interview following their participation in a previous survey published elsewhere [ 9 ]. All interviews were conducted virtually and audio/video recorded on Zoom. We used validated interview guides from the official CFIR instrument repository ( https://cfirguide.org/evaluation-design/qualitative-data/ ) to probe the barriers and opportunities of implementing ADS solutions for DAC review of data access requests. Interviews lasted between 45 and 60 min and included 29 questions adapted from the CFIR instrument to fit the ADS context (e.g. Inner Setting, Outer Setting, Intervention Characteristics etc.). The specific interview guide used is available in Supplementary Materials 2 . Interviewees were also recruited from the Data Access Committee Review Standards Working Group (DACReS WG) chaired by authors VR, JL, and ESD, as well as from an internet search of publicly funded genomic data repositories worldwide.

Data analysis

We first applied a deductive coding frame to the interview transcripts based on a framework analysis approach (Pope, Ziebland, and Mays 2000) and the publicly accessible CFIR codebook available in the Supplemental Materials 1 . To ensure the reliability of conclusions drawn, two independent reviewers (VR and JB) tested the coding schema on three transcripts until reaching a recommended interrater reliability score of 0.83 before analyzing the remaining qualitative dataset. All coding discrepancies during the coding pilot were resolved by consensus discussion.

Geographical, Institutional, and Demographic Background of Participants

41% of interviewees worked within U.S.-based DACs, while the remaining 59% of interviewees represented DACs at institutions in Canada, the U.K., Spain, Tunisia, Australia, and Japan (Table 1 ). Nearly 60% of interviewees worked at a non-profit research institute, 24% represented an academic-affiliated research institution, 12% represented a government research agency, and 6% were affiliated with a research consortium. 76% of interview participants identified as female, and 24% as male.

Opportunities for ADS

We categorized the frequency of CFIR implementation factors referenced in our interviews in Table 2 . Our findings suggest that there are three major facilitators to implementing ADS for genomic data governance: (1) external policy and need for efficient workflows, (2) institutional ability to scale the ADS, and (3) interoperability.

External policy and need for efficient workflows

Participants considered adopting ADS to comply with new data sharing mandates from research funders (e.g. National Institutes of Health) and those imposed by peer reviewed journals. The demand for and scope of compliant data access review has had a ripple effect on ethics oversight bodies [ 26 ], including DACs, as a result of these new requirements [ 9 ]. Most DAC members we engaged with currently perform their reviews manually. Members review all data access requests individually or as a committee and make decisions on each request received in the order they were received. Given the anticipated increase in the number of data access requests [ 27 ], our participants noted the reduced workload and costs associated with ADS could contribute to better review efficiencies, without a concomitant loss in review quality and risk of noncompliance with data use conditions.

We found that participants perceived that ADS could reduce DAC member workload by streamlining the intake process for data access requests and verifying that the request matched the terms of use in the original consent obtained at data collection. Indeed, participants noted the initial screening of Data Access Requests (DARs) was a common rate-limiting step in the submission to decision process. DACs often begin the review process by verifying that all necessary information is documented in the request (e.g. study purpose, datasets requested, ethics review). This step can be time-consuming because the requirements can vary depending on the researcher’s institution and the datasets they request. We requested that participants share a copy of their DAR form before, during, or after the interview to compare what information DACs typically required to process a DAR. We found the form fields as well as length of the DAR (from 3 to 18 pages) differed considerably. Our participants believed that this is where ADS could be useful by automatically flagging missing information and documents, verifying the authenticity of a requester’s identity and the submitted documents, and then sending notifications to requesters if more information is needed. As one interviewee put it:

Because one of the biggest concerns in our DAC is that sometimes it takes too much time to be read by all the nine members. … They’re institutional directors or university professors. So I think it will help. Maybe if you have 50% of the work done by an automated system, so you just have to do the 50%. I think … this will be a good motivation for them saying ‘OK’ [to implement ADS]. ‑ Participant M.

Scalability and cost effectiveness

Participants also believed ADS-enabled workflows could be scalable, cost-effective solutions to management of not just newly generated data, but also for legacy data when grant funding ends because ADS can easily store and quickly present data use conditions and audit past DAC reviews. Two interviewees discussed the challenges of finding cost effective solutions to managing legacy datasets:

Actually there are lots of costs related to data sharing, particularly if I’m sharing data from the 1990s, for example. I don’t have any money or budget anymore to prepare the data [for secondary uses]. … And similarly, when it comes to these reports [on data sharing activities], there’s no extra money for doing the work to create those reports. But we’re having to report back over assets from years, decades in fact. And there was always just a little bit of a hint ‘oh well, maybe we’ll find some money’. No, no, you have to find it out on your own. ‑ Participant F. I mean potentially as we grow over the years, you know what’s going to happen. … we’ve also discussed some scenarios, where, for example, we find ourselves with a larger amount of requests coming in, [and] we only accept applications up to certain days and then, we open this next quarter, close it again. But there potentially could be room for automation depending on the increase in request in the coming years. ‑ Participant A.

Retention and sustainability of human resources

Participants also discussed retention of repository staff and DAC membership as an evolving human resource factor that would motivate ADS adoption. For example, some participants shared that ADS could be helpful when DAC members or data generators leave the institution, disrupting review continuity and consistency. Unlike for large, well-funded government repositories, many DACs at smaller institutions lack human resources to ensure long-term data preservation and access management for data of increasing complexity and volume:

As the program scales, the participant diversity scales, the data diversity scales. I think it is almost impossible to see a scenario where we do not rely on some level of automation to support human decision making about what is responsible use. ‑ Participant J.

Interoperability

According to the DAC members we interviewed, ADS tools could provide centralized, interoperable solutions to facilitate inter-organizational and international data sharing. Participants perceived that ADS could motivate use of standardized request forms, access agreements, dataset identifiers, and methods for verifying researcher identities. For example, one participant commented:

But this [ADS] will free up a lot of time in the process is it also potentially means that it will become easier for, if you’re working in a team to hand off tasks as well because you will have a single system. … Also, consistency between organizations. If we have multiple organizations take this up, it’s going to mean less lead time. [Let’s] say people take a new job in a new place. We’ll actually have some software that people will recognize and be able to use and uptake, which we’ve been trying to go towards without ethics approval processes within the hospital and health services… [standardized] systems makes it easier for actual communication between organizations on processes, because everyone kind of begins to know what’s happening. ‑ Participant E.

(b) Barriers to implementing ADS .

Despite clear advantages of ADS for genomic data access management, our interviewees identified significant barriers to implementation within DAC workflows, including: (1) lower priority compared to more immediate governance challenges, (2) ill equipped personnel and structures within the institution, (3) costs, and (4) degree of human oversight.

Prioritization

Many participants reported that institutional leadership prioritized other competing research data needs over investing in new data governance structures (e.g. generating quality data, increasing diversity in datasets, collaborating with underrepresented groups of researchers and participants, and releasing datasets). Participants believed researchers in general understand why quality and effective review of data access is important for responsible genomic data sharing but are firstly concerned with data quality. Another suspected reason that ADS implementation ranked lower on institutional priorities was that there had not yet been a significant data incident. As one participant put it:

I don’t think that the program thinks it is a very high priority to streamline any of the [data access oversight] process. I think that it will either take something bad happening and then realizing that we need additional capacities on [DAC], or some other hiccup to really promote that need. ‑ Participant O.

Because budgets for data governance are not always included in grants, researchers may be less motivated to invest in the additional, largely unpaid work related to data governance. Insufficient resourcing for data sharing and governance mechanisms prospectively in research study design inevitably challenge the downstream execution of data governance upon deposit of the research data once generated, according to at least one DAC member we interviewed:

We found that some people don’t prioritize [data governance] because it’s not helpful to them, because it’s not our primary function as a department. You know, we’re producing new data. That’s usually what people, researchers are doing. They’re not thinking about what happens to their old data. So, it’s not much of a priority. Having said that, research funders are getting very keen for us to use their data. So, there is that sort of tug [of war]. … If I go into a senior team meeting, you know, something else will be the priority. ‑ Participant F.

Structural characteristics of an organization

We also found a close correlation between several structural characteristics of the institution (e.g. years in operation, number of personnel, and database size) and participants’ perceived barriers to ADS implementation. For instance, many participants served on DACs that were established within the last 1–3 years coinciding with the creation of the institution’s database. As the datasets grow, and more researchers are attracted to the resource, there is greater potential to overwhelm existing management processes. It is precisely at this early juncture that DACs would benefit from weighing their ADS options, and proactively address relevant barriers ahead of any plans for implementation. Some DAC members preferred to gain more experience with existing data access management in these early years of data release before integrating ADS “because we’re not sure how [name of participant’s country] citizens feel or consider about the automatic decision on data sharing.” Participant K.

While cost was not a primary concern for ADS implementation at well-funded big data repositories, it was a significant barrier for DAC members working at smaller repositories, individual research departments, or research programs associated with a genomics consortium who were more often supported by research grants or contracts rather than an independent funding source.

“We [data governance office] are supported through project-specific funding. … Governance ends up being a little bit of this indirectly supported component of our work and services. That has limited the ways in which we can innovate around governance. … We don’t have a huge budget.” ‑ Participant N.

Without dedicated budget for human and material resources, some DAC members were concerned that the initial investment in ADS and significant changes to current workflows would be key issues, to say nothing of new education and training materials and updates to internal policies, among other ancillary revisions to internal workflows.

Lack of human oversight

While some DAC members were enthusiastic about improvements in efficiency and consistency of ADS, participants unanimously rejected the idea of fully automating access management: “no matter what we do with automation that I feel there always needs to be that human element who’s coming in and checking. So, there will always be that barrier to upscaling” Participant E. Other participants emphasized that prior to implementation, they would need to gauge how research participants at their own institution as well as the general public would react to ADS for data access review.

Participants were also skeptical that ADS could adequately assess complex, sensitive data reuse issues which they felt required a deep understanding of ethical, legal, and sociocultural contexts within which data were collected, used, and shared. Some DAC members reported asking data requesters to clarify their study purpose and justify their need for specific datasets in recognition of these sociocultural dimensions.

I’m also someone who thinks that it’s important to be very critical about what’s the nature of the work being done. Maybe it’s solid from a scientific point of view. But are there other concerns from other perspectives that need to be taken into account? That is partly why we have community members on the [committee], and that’s something I’m not sure can be simplified or automated.”

However, when it comes to automating anything that requires reviewing information where there might be a lot of nuances, where there might be a lot of interpretation that’s required, I’m a little bit more hesitant simply because I think to some extent you do need some room for a little bit of mulling over the information, … and I think there are some information that come through with requests, that don’t neatly fit into check boxes. ‑ Participant B.

Overall, participants perceived that ADS tools could be well positioned to help DACs streamline data access compliance. While believed to beneficial, ADS solutions were unlikely to immediately or directly advance the research organization’s core mission (e.g. collecting quality data and driving scientific discoveries and innovations). One of the most challenging barriers to implementation is the relative low priority of, and lack of institutional investment in, data infrastructures that could adapt as the dynamics of genomic data generation and storage change over time. Participants tended to regard ADS implementation, as well as data governance workflow solutions, as a lower priority compared to regulatory compliance, investigator support, and database curation, among other competing demands on DAC member time.

Most research grants allow investigators to apply for support for data collection and analysis, but rarely establish actual governance structures needed to stand up access management services. We found that executive buy-in was a major driver for ADS support in the cases of some repositories and the lack or administrative or leadership buy in a major detractor for others, namely repositories at smaller research institutions or laboratories. Therefore, part of the challenge of making ADS adoption a higher institutional priority is convincing institutional leadership of their added value and the net benefit of investing in data governance solutions and infrastructures generally.

Delaying infrastructure upgrades has consequences for the future utility of the repository in the longer term. Some of our study participants, for example, believed researchers were drawn to their databases not because of their data access policies and practices, but because of the quality and diversity of their datasets. However, this quality-driven perspective contrasts with findings from a study of genetic researchers suggesting that ease of access is at least marginally important when choosing a database for their research [ 28 ]. We reason that repositories which invest in efficient, scalable, and compliant access decision processes are likely to attract more users to their resources than repositories which do not evolve such processes to meet the pace of data generation and higher data demand. It is also worth noting that funders have a direct role to play in accelerating the pace of data science as researchers are expected to do more with fewer resources and in less time.

Developing more streamlined workflows emerged as a primary benefit that many participants anticipated from adopting ADS. Participants were most enthusiastic about applying ADS for time consuming and tedious tasks, such as preliminary review and quality control checks for data access request forms that are needed to initiate the data access decision process. Applying ADS to facilitate these workflows could free DAC members to dedicate more time to deliberate on more substantive ethics issues raised by data access requests.

While data governance has often been considered auxiliary work, new research findings and new U.S. federal government policies, such as the National Institutes of Health Data Management and Sharing (DMS) Policy, have elevated its importance by placing additional requirements for data sharing [ 29 ]. The new DMS Policy was but one example of distinct legislative reforms that have influenced cultures of data sharing shaping DAC work, as well as the institutional practices and governance tools developed to complement this culture. To be sure, such legislative and institutional context influenced participant responses and particular implementation preparedness factors for ADS such as “structural characteristics of the organization.”

The DMS Policy will accelerate the accumulation of an enormous number of datasets. In the absence of interventions, including but not limited to ADS, the DMS Policy will significantly raise costs associated with data storage and management. We concluded from our participants that databases/repositories are frequently developed specifically to share research data generated from federal funds without attention to existing databases and other resources in mind within which to deposit their data. “Blind” database creation is often done with good intentions; however, it can inadvertently introduce myriad access pathways that make the data effectively “shared” but undiscoverable and is another issue where ADS tools could intervene. One participant’s narrative about their need to transfer legacy data from a repository facing permanent closure puts the problem of unsustainable databases in sharp relief. The participant’s example suggested that there is need for more efficient and sustainable solutions for data access management and sharing that can endure even when repositories themselves do not. Moreover, there is reasonable cause to have a contingency plan for publicly funded data shared via non-publicly supported repositories in the event the repository closes or changes in policy or personnel. Standardized ADS solutions could easily interoperate between the two types of repositories and facilitate legacy data transfer, if and when required.

Limitations

Our results should be considered in light of several methodological limitations. While geographically diverse, many of our interview participants were affiliated with DACs based at large, well-resourced research institutions. It is likely that responses and perceptions of implementation factors related to ADS would differ substantially if more DACs from low- or under-resourced institutions were represented in our sample. Our data collection design relies on self-reports of institutional data access policy and procedures. Many interview participants were aware of the Global Alliance for Genomics and Health, and the data access committee review standards we were principally involved in developing [ 30 ]. Thus, while we endeavored to create a safe, open environment for participants to share their honest views, social desirability bias related to our prior work may have influenced how participants responded. Lastly, CFIR predefines sociological constructs relevant to implementation. Our analysis was therefore limited only to those constructs covered in the framework, whereas others might have emerged inductively if we adopted an alternative analytic frame.

In this article, we reported findings from semi-structured qualitative interviews with DAC members from around the world on the relevant barriers and facilitators of implementing ADS for genomic data access management. Our findings suggest there is general support for pilot studies that test ADS performance for certain tasks in data access management workflows, such as cataloging data types, verifying user credentials, and tagging datasets for use terms. Participants indicated that ADS should supplement, but not replace, DAC member work. This sentiment was especially strong with respect to tasks that were perceived to require sensitivity and human value-judgments such as privacy protections, group harms, and study purpose. Nonetheless, our findings offer cautious optimism regarding the ways in which algorithms, software, and other machine-readable ontologies could streamline aspects of DAC decision-making while also enabling new opportunities for improving consistency and fairness in DAC decisions.

To that end, we conclude with practical recommendations for institutional data stewards that are considering or have already implemented ADS for data access management. First, repositories and institutions that support databases and other resources should prioritize infrastructural upgrades and factor them into associated budgets. Ensuring proper investment in, and human/material resource support for, these upgrades ensures the repository can help ensure its utility even as the complexity and volume of genomic and associated health datasets grow. Second, DACs should prepare to put in place today what data access management and sharing processes they foresee the repository needing tomorrow. For DAC members looking to integrate ADS or other semi-automated tools into their workflows, buy-in from executive leadership should be obtained at the earliest stages of this transition. DAC members should consider substantiating the need for semi/automated solutions with concrete trend data about the frequency of data access requests relative to the time from request to decision and extrapolate these numbers to judge what the anticipated demand for repository will be in 1, 5, and 10 years. Tracking and transparently reporting data access request volume, access decisions, and other committee operations is likewise important not just for internal purposes, but also to demonstrate responsible data stewardship in action to prospective data contributors.

Third, DACs should refrain from implementing ADS wholesale without complementary human oversight of data access request intake and decisions. Pilot testing where ADS tools can be applied to the most time-consuming tasks will require taking inventory of the inputs required for each task along the data access decision workflow. Fourth, DACs should consider what human and material resources will be needed to integrate ADS effectively. These resources include DAC member expertise, computer equipment, and software development, not to mention member education and training resources. Finally, DACs should collaborate on setting standards for how data access requests should be adjudicated and tailor ADS tools in line with these consensus criteria. There is ongoing work to this effect as part of the Ethical Provenance Subgroup of the Global Alliance for Genomics and Health (including the development of an "Ethical Provenance Toolkit"); additional representation from repositories that steward other diverse health datasets would be ideal to coordinate access management strategies across the field.

The explosion in the volume and complexity of genomic and associated health data is converging with the need to manage access more efficiently to these data. Such trends point intuitively to solutions that can help to alleviate, or at least prevent bottlenecks in the access process to preserve the scientific and social value of data generated from public investments in research. To put ADS solutions to the test, future research should compare access decisions and their outcomes between institutions who do/not use such tools for data access management; and examine whether ADS delivers on its efficiency promises and whether it liberates DAC member time previously spent addressing procedural matters – allowing more opportunities for committee deliberation on substantive ethics issues.

Data availability

Materials described in the manuscript and data supporting our findings can be made available upon request. All requests should be directed to Vasiliki Rahimzadeh, PhD at [email protected].

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Acknowledgements

The authors wish to thank members of the Data Access Committee Review Standards Working Group, and the Regulatory and Ethics Work Stream of the Global Alliance for Genomics and Health for their contributions to the intellectual community that inspired this work.

This study was funded by the National Human Genome Research Institute as an Administrative Supplement grant to the AnVIL program for the Study of Bioethical Issues [U24HGO10262].

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Contributions

Authors VR, JL and ED conceptualized, designed, and carried out the study. Author JB led in the data collection and analysis and drafting of early manuscript drafts. All authors, VR, JB, JL and ED took part in writing and editing the manuscript, responding to peer reviewer comments and approved the final version.

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Correspondence to Vasiliki Rahimzadeh .

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Ethical approval.

This study was reviewed and approved the Stanford University Institutional Review Board. All participants were informed of the purpose of the study, funding, risks and benefits at the time of invitation. Informed consent was obtained from all participants prior to the interview and participants were provided opportunities to ask any questions about the study procedures.

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All authors are members of the Regulatory and Ethics Work Stream of the Global Alliance for Genomics and Health. JL is co-lead of the Data Use Ontology, leads the Data Use Oversight System and is a member of the Broad Institute Data Access Committee.

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Rahimzadeh, V., Baek, J., Lawson, J. et al. A qualitative interview study to determine barriers and facilitators of implementing automated decision support tools for genomic data access. BMC Med Ethics 25 , 51 (2024). https://doi.org/10.1186/s12910-024-01050-y

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Identifying gaps in healthcare: a qualitative study of Ukrainian refugee experiences in the German system, uncovering differences, information and support needs

Kristin Rolke 1 ,
Johanna Walter 1 ,
Klaus Weckbecker 1 ,
Eva Münster 1 &
Judith Tillmann 1

BMC Health Services Research volume 24 , Article number: 585 ( 2024 ) Cite this article

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Metrics details

The 5.8 million Ukrainian refugees arriving in European countries must navigate varying healthcare systems and different and often unknown languages in their respective host countries. To date, there has been little exploration of the experiences, perceived differences, information and support needs of these refugees regarding the use of healthcare in Germany.

We conducted ten qualitative interviews with Ukrainian refugees living in Germany from February to May 2023, using Ukrainian, English and German language. The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker with the MAXQDA software.

In general, participants consistently had a positive experience of the German healthcare system, particularly regarding the quality of treatments and insurance. Differences have been reported in the structure of the healthcare systems. The Ukrainian healthcare system is divided into private and state sectors, with no mandatory insurance and frequent out-of-pocket payments. Pathways differ and tend to focus more on clinics and private doctors. General practitioners, often working in less well-equipped offices, have only recently gained prominence due to healthcare system reforms. Initiating contact with doctors is often easier, with much shorter waiting times compared to Germany. Interviewees often found the prescription requirements for many medications in Germany to be unusual. However, the mentioned differences in healthcare result in unmet information needs among the refugees, especially related to communication, navigating the healthcare system, health insurance, waiting times and medication access. These needs were often addressed through personal internet research and informal (social media) networks because of lacking official information provided during or after their arrival.

Conclusions

Despite the positive experiences of Ukrainian refugees in the German healthcare system, differences in the systems and language barriers led to barriers using healthcare and information needs among refugees. The dissemination of information regarding characteristics of the German health care system is crucial for successful integration but is currently lacking.

Trial Registration

German Clinical Trials Register: DRKS00030942, date of registration: 29.12.2022.

Peer Review reports

Since the beginning of the war in Ukraine on 24th February 2022, more than 5.8 million people from Ukraine have been registered as refugees in European countries; in Germany, the number is estimated at more than one million in 2023 [ 1 ]. 80% of adult refugees in Germany are women, nearly half of them came to Germany with their minor children and live mostly in private accommodations [ 2 ]. Since June 2022, refugees from Ukraine are not required to go through an asylum procedure due to the Temporary Protection Directive (2001/55/EG), but receive temporary protection in the European Union for up to three years after registration in the Central Register of Foreigners. They are thus entitled to medical care according to the catalog of the statutory health insurance (SHI) [ 3 ]. In Germany, around 90% of the population is covered by SHI [ 4 ]. There is an obligation to be insured in a SHI up to a fixed income limit. Earners above this limit and some professional groups can opt for private health insurance. Healthcare is primarily financed by contributions from citizens and employers, as along with subsidies from tax revenue [ 5 ]. In Germany, the Standing Committee on Vaccination (STIKO) makes recommendations on the implementation of vaccinations in accordance with § 20 (2) of the Infectious Diseases Protection Act (IfSG). Vaccination is only compulsory for measles for all children aged one year and above who attend community facilities such as kindergartens or schools, as well as some occupational groups. The healthcare system in Germany is divided into outpatient care, the hospital sector and rehabilitation facilities. The general practitioner is often the first point of contact in case of health problems and refers patients to other specialists if necessary; patients can also consult other specialists directly without a referral.

Ukrainian refugees have rarely been prepared for the contact with healthcare in Germany, which can be attributed to the rapid outbreak of war and the sudden flight. German health professionals can often look back on a long history of experience in treating refugees. Nevertheless they now face new regulations due to the EU mass influx directive [ 3 ] and also a lack of information flow, e.g. in regard of information for practice teams and a lack of networking with psychotherapeutic services, contact points, medication databases and regional interpreter services [ 6 ]. Differences in the healthcare systems, such as their structure and initial contacts/pathways in case of illness, prescription rules of medication, and coping with diseases may play a role in becoming familiar with another healthcare system.

Differences in the healthcare system are rarely described in the literature or health data. Findings include, for example, corruption problems with procurement of medication [ 7 ], low vaccination coverage rates e.g. regarding polio or COVID-19, and one of the highest burdens in Europe of chronic infectious diseases such as tuberculosis and HIV in Ukraine [ 8 , 9 ]. Life expectancy at birth in Ukraine is on average 65.2 years for men (Germany: 78.6 years), significantly lower than for women with 74.4 years (Germany: 83.4 years) [ 10 , 11 ]. The Ukrainian healthcare system is underfunded, which leads to high out-of-pocket expenditure on the part of the population in order to achieve adequate care, although formally the healthcare system provides free care in public healthcare facilities. Besides, taking out health insurance is voluntary [ 12 , 13 ].

In 2018 the state healthcare system in Ukraine was reformed. The reform of general practitioner (GP) care in Ukraine has included a free choice of doctor and stronger gatekeeping by the GP in the form of a referral system-similar to that in Germany [ 7 , 13 ]. Literature from UK and Poland indicate that Ukrainian refugees are in need of healthcare services, especially for chronic diseases, gynecological and obstetric treatments as well as mental health [ 14 , 15 ].

Experiences and challenges in contact with Ukrainian refugees in Germany from the viewpoint ofGPs have been researched in 2022 in a quantitative study. Communication, lack of information on previous illnesses, refugees’ expectations of services to be provided (e.g. routine unsubstantiated blood tests, thyroid tests, prescription of multivitamin supplements), and drug prescription due to unavailable or unknown medication were mentioned by GPs as the most common challenges [ 6 ]. A publication from Poland on health system differences between Ukraine and Poland indicates differences in immunization programs and prevalence of some infectious diseases [ 16 ]. However, the experiences and needs of Ukrainian refugees themselves in other healthcare systems, especially the German one, have rarely been studied and are of high current relevance. They are essential to understand patients’ points of view and to develop solutions to improve care and facilitate the arrival and integration of refugees in the German healthcare system.

That is why we focus on this topic in the following study (RefUGe-P) and aim to answer the following research questions in this publication:

How do Ukrainian refugees experience healthcare in Germany regarding major differences to the system in Ukraine and which information and support needs can be identified?

The methodological elaboration of the study was carried out taking into account the COREQ guideline [ 17 ].

Study design

For this study, ten Ukrainian refugees from four cities in the German region of North-Rhine-Westphalia (NRW) were interviewed in person in German, English and Ukrainian. Theoretical saturation was reached after ten interviews were conducted, so no further interview participants were recruited. The two German and two English interviews were conducted by the project staff. The six interviews in Ukrainian were conducted with the help of interpreters who translated in the interview from Ukrainian to German and vice versa. The interpreters worked on a voluntary basis, but had a lot of experience in interpreting for Ukrainian refugees at medical appointments. Additionally, information materials and consent forms were translated into the respective languages and handed out before participation.

The interview participants were recruited in various ways, mostly face-to face, via multipliers (responsible municipal employees, employees of welfare organisations, people of Ukrainian origin who volunteer to translate for refugees in the federal state of North Rhine-Westphalia) known to the project staff in four cities. The multipliers received detailed information about the planned study as well as information about the necessary inclusion criteria for participation, both orally and through a project flyer and a study information sheet. The aforementioned information materials were made available to the multipliers for their workplace and they approached refugees about the project. Interested persons were then able to contact the project staff directly or informed the multipliers about their interest for participation. The prerequisite for participation was that the interviewees were at least 18 years old and had visited a general practitioner in Germany at least once after their arrival. Additionally, it was aimed to achieve diversity among participants in terms of age, gender, family situation and health status. One potential participant was excluded because he/she had not seen a GP himself/herself as a patient.

Participants received an information sheet about the study with information on data protection and filled in a short questionnaire about sociodemographic information. These documents were also explained to every participant in person by the interviewer. All participants were fully informed by the interviewers about the study, data protection and signed written informed consent forms.

The development of the interview guide was based on the guidelines developed by Helfferich [ 18 ] and began with open narrative stimuli (opening question Appendix 1) before progressing to more specific questions. Since the research interest included different topic-specific aspects, the interview form of the problem-centered interview according to Witzel [ 19 ] was considered during guide development.

Additionally, an expert advisory board consisting of five representatives from various disciplines (including general practice, local authorities, welfare organisations and interpreters) was established to accompany the project and was involved in the preparation of the interview guide and preparation and interpretation of results. The interview guide has been newly developed for this study and is available as supplementary material (appendix 1). The main topics of the semi-structured interviews are shown there. The interview guide was pretested in two interview situations. One pretest was conducted in German, one in English whereby no adjustments had to be made.

All interviews were conducted between February and May 2023 and lasted an average of 45 min (35 min to 1 h and 10 min). They were audio-recorded and fully transcribed by an external service provider in German and English and coded in these languages. Interview protocols were written after each interview, noting special incidents and details about the interview location and atmosphere which were included in the analyses.

Data analysis

The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker [ 20 ] with the computer software MAXQDA version 20 and 22. The content analysis according to Kuckartz and Rädiker can be carried out in three forms (to structure content, to evaluate it or to form types) [ 20 ]. The former was used for this project in order to be able to analyse the material in terms of content and topic.

The codes were developed through both deductive and inductive methods (Fig. 1 ). Deductive categories were formed by the subject areas that had already been recorded in the interview guide. Inductive categories were developed directly from the material.

Coding tree with relevant categories for this article, RefUGe-P

The interviews were independently coded by two authors and the results were subsequently compared and discussed. This process aimed to improve the quality of results and mitigate the influence of subjective perspectives. One of these authors is a public health scientist with a PhD and several years of work experience in the field of migration and health and the other is a psychologist and medical student.

Sample characteristics

A total of ten interviews were conducted with seven female and three male participants. The participants had an average age of 47.6 years (min. 29 years, max. 70 years). Additional participant characteristics are presented in Table 1 .

Refugees constitute a vulnerable group of people and this was considered during the study’s conception and research design. The interview questions were checked in advance to ensure that personal events and memories related to the flight experience were not discussed, thus minimizing the potential for retraumatization during the interviews. One interviewer was experienced in working with interview partners who had refugee experiences through prior project experience and workshops regarding this topic. The second interviewer received information and exchange of experiences via the project team. The multipliers assisting with recruitment had established positive relationships with the participants. They personally introduced the interviewers, contributing to the development of trust.

The Ethics Committee of the University Witten/Herdecke, Germany, granted approval for this study (reference number: S-219/2022).

In general, the participants’ experience of the German healthcare system was consistently positive. Interviewees positively mentioned the good and thorough treatment, as well as the extensive technical equipment of the doctors’ offices and health insurance. In particular, the inclusion of patients in treatment decisions and the information provided, for example in the case of upcoming surgical procedures, were positively emphasized in the interviews. Likewise, the reminder of the possibility to participate in preventive check-ups in old age was appreciated.

“So the first thing that comes to my mind and I think is very good, I got the insurance and immediately got the invitations for examinations. Mammography and colonoscopy. What I have never experienced in Ukraine like this.” (I5)

Differences between the German and the Ukrainian healthcare system

Pathways and structure of the healthcare system.

The interviewees reported that the healthcare system in Ukraine consists of a private and a state system, which exist side by side. Since there is no mandatory health insurance in Ukraine, according to the interviewees, citizens have the freedom to choose the services they want to use. Financial viability plays a major role in their decision-making. While many services provided by the state system are free of charge, those provided by private institutions must be paid for privately. The interviewees therefore reported different utilization patterns, which can be summarized in three scenarios: Exclusive use of the state system, exclusive use of the private system, or use of both systems.

“ I had a GP in Ukraine and then another private doctor and I communicated with both of them. Depending on the time (…) and then, because I had money, I got insurance also. ” (I5)

In case of illness, the participants in Ukraine usually went to a (poly)clinic containing many specialized medical fields, presented their concerns and were referred to the appropriate department. Some went to a physician assigned to them according to their place of residence. In urgent cases, private physicians could be visited directly on the same day. Home visits were also common in this context. Patients could request and pay for blood tests at laboratories and could immediately access their test results after processing.

“So suppose you call and it is said that the doctor can only come the day after tomorrow, but you urgently want him to come today, then you can pay money so that he comes today. Which is also not very expensive, so the equivalent of about ten euros.” (I6)

Some of the private institutions were considered to be of higher quality, both in medical treatment and in the equipment. Participants often had the mobile phone number of their doctors and could contact them around the clock. They got a diagnosis from remote and started treatment as suggested.

“If I have a fever or something then I can contact my doctor conveniently via Viber or WhatsApp. I text my doctor, my daughter is sick, she can’t eat and drink and she has a fever, what should I do, and the doctor writes what I should do. For example, you have to go to the hospital now, or go to the pharmacy and buy such tablets.” (I2)

In Ukraine a general practitioner system was also established in 2018. However, according to the interviewees, this has not yet been established everywhere across the country and private payments still exist.

Health insurance

Interviewees reported that health insurance covering major health treatment in case of illness likewise in Germany is not common in Ukraine and just a minority can afford it. Therefore, services are used when needed, often in the private sector, in order to be treated immediately. Surgeries in particular were described as very expensive and often unaffordable. Many Ukrainians save money for years in order to pay a medical treatment. The need for regular medication and its acquisition is described to be particularly challenging for elderly people due to the low pensions.

“(…) I don’t have this system in Ukraine because we don’t have obligatory health insurance. People in Ukraine don’t have this system. That’s why they can pay money for the first visit or for next visits and just came to the doctor and have health (…) treatment. (…) You just need to pay money and go to doctor.” (I1)

Some of the interviewees also reported that since the reform of the healthcare system in Ukraine, health insurance with fixed monthly rates has been introduced, but that it is not functioning effectively. However, state care is often described to be of lower quality and private payments to doctors are still frequent. In Germany, they experienced the insurance system as better and medical care as more affordable.

“Concerning the pediatrician. I can always call him and somehow ask him what medication I have to give my children now or what I should do when she feels ill. But I always send money in return. That means it’s always about money. And if you don’t do it, then nobody cares about you in the health system.” (I7)

Waiting times

All of the interviewees were initially surprised by the long waiting times in Germany. Waiting for months to get specialist appointments and long waiting times in doctor’s offices and clinics were unfamiliar to the refugees. Some found these long waiting times to be stressful and problematic. Furthermore, concerns were expressed about not receiving help quickly enough in case of emergency. Interviewees also reported difficulties in finding a GP who was not busy and still accepting new patients.

“(…) So this is long, long, long everywhere. You need to wait for an appointment, you need to wait in a waiting room. You will need to wait. Yeah, I understand. It’s different from Ukrainian system, but, yes, sometimes it’s exhausting.” (I1)

As a result, some of the interview participants thought about returning to Ukraine for treatment or knew other people who did this.

“She called several doctors nearby, dermatology yes, and the earliest appointment was only in three months. And what did she do? She went to Ukraine. We can go to Ukraine. And she bought a ticket in the bus, and went to city A by bus, and she did everything for one day. In the clinic she made laser, she had all blood tests. In the morning she had all the results.” (I2)

Prescription of medication and vaccination

The requirement for a prescription to obtain medication in Germany was unfamiliar to some interviewees. In Ukraine, various medicines were bought without a prescription, including antibiotics. The interviewees also observed that German doctors prescribe fewer medications than Ukrainian ones and they often recommend alternatives for symptoms like fever and headaches.

“But in Ukraine it is really common (…) when my kids are sick, I always got a prescription with total list of pills, even if it is like common fever or something like that.” (I1)

In addition to people who experienced this as positive, there were also negative statements, for example when antibiotics were not prescribed for infections and therefore then ordered in Ukraine. Additionally, individual reports highlighted differences in medication quality (better in Germany), and availability (certain Ukrainian combination medications were not available in Germany).

“She (the GP) said to me that my daughter must drink more tea and I will be honest with you, I called to my friends. They lived in (city in Germany) and I asked them to call my doctor in Ukraine so I can find an antibiotic.” (I9)

The mothers interviewed also wondered about the vaccinations given to their children, which they did not know from Ukraine. Most Ukrainian participants were also unaware of adult booster vaccinations. The majority was vaccinated only in childhood. Several interviewees reported that there is no structured approach to adult immunization in Ukraine. One person said that he/she did not know where to go as an adult to get vaccinations in Ukraine.

“But what I did here, for example, the doctor here immediately offered to do so and so many vaccinations. After sixty years. And we never got such an offer in Ukraine.” (I3)

Information and support needs

Most of the interviewees did not receive information about the German healthcare system, medical care and insurance in Germany. Instead, they had to seek information themselves, often by doing their own research on the internet. Frequently friends, relatives, hosts, language course teachers, interpreters, etc. were asked for information. Some of the interviewees described this process as difficult. Often they asked other Ukrainians in their place of residence, e.g. through Telegram or other online Ukrainian community groups. There, doctors were recommended, lists were shared, information was spread, questions were asked and translation help was offered or requested. Interpreters are searched for through these networks as well to overcome language barriers.

“We have some webs, there is this group in Telegram (…) and we have the big, big list and people ask maybe who knows some gynecologist or something like this and people help.” (I9)

Table 2 specifies frequently mentioned information needs and improvement requests from refugees in Germany, along with selected quotes.

Our study identified perceived differences between the German and Ukrainian healthcare systems with the Ukrainian system still being shaped by out-of-pocket payments, private care, no mandatory insurance, and a GP system only gaining prominence in the recent years before the war. Easier contact to doctors with shorter waiting times and less prescription requirements for some medications have been reported about Ukraine. These differences in combination with lacking official information provided during or after arrival lead to unmet information and support needs among Ukrainian refugees living in Germany.

The results are particularly relevant in light of the fact that many Ukrainians would like to live in Germany in the long term, recorded in current surveys [ 2 ]. Therefore, it is crucial to ensure the successful integration of this patient group and a mutual understanding of their needs to provide equal healthcare opportunities. Some of the results of this article may also be of interest to other countries, as the findings on the structure and characteristics of the Ukrainian healthcare sector can be compared regionally. In addition, the results show parallels to studies on refugees from other countries of origin in Germany, e.g. persisting communication problems [ 21 , 22 ].

Pathways in the healthcare system and waiting times

In Ukraine, fast access to healthcare, especially if the services are privately paid for, results in short waiting times and easy access to doctors. Therefore, Ukrainians in the German system are not used to experience long waiting times and not to have the ability to expedite the processes themselves. As reported from the interviewees in Ukraine, patients often commission, pay for and receive their own medical analyses. In the interviews it became clear that the different approach and the different circumstances in Germany can cause a feeling of loss of control and unpredictability. As patients in Ukraine, they were able to act in a self-determined manner and, for example, pay money in order to be treated more quickly. In Germany, faster access to care is particularly important in the case of acute or life-threatening conditions. It might be perceived as impatience or high expectations, but it primarily stems from differences in healthcare systems, habits and the lack of information dissemination. Ukrainian-language information on the German healthcare system should be provided to the refugees as soon as they arrive.

Prescription of medication and prevention

The respondents were often unfamiliar with preventive care services and booster vaccinations in adulthood. This lack of awareness may be attributed to the low vaccination rates in Ukraine prior to the war, which led to outbreaks of vaccine-preventable diseases such as measles and polio between 2017 and 2020 [ 23 ]. Despite a national vaccination schedule provided by the Ministry of health in Ukraine [ 24 ], vaccination rates are among the lowest in Europe. Preventive measures in Germany (e.g. cancer screening) were welcomed after information and explanation in our study. At the same time, people with a migration background have an on average lower level of health literacy with regard to preventive care services in Germany compared to people without a migration background [ 25 ]. Therefore, it can be useful to inform and educate patients about this approach to healthcare and to increase health literacy in general.

Participants also reported differences about how medication is prescribed and taken like quick prescription of medications by Ukrainian doctors. Since antibiotics were also sold over-the-counter in Ukraine until recently [ 26 ], self-medication occurred frequently. Having a large number of different medications were not rare in households. This old practice was criticized among some younger respondents and they appreciate the new reform regulations in Ukraine and feel comfortable with the treatment approach in Germany. It is essential for doctors and medical staff to be aware of these differences to address misconceptions and raise awareness about (in)effectiveness of medications.

Participants valued their membership in the German SHI as it provided them with a sense of security. However, not all participants were accustomed to this, as they often had to save up the required amount for healthcare. Because of this difference, the respondents wished to receive more information about the scope of medical services provided by the SHI, as it was not clear to them that most costs of necessary medication are included, whilst dental treatment, for example, partially requires private payment. This information should be made available upon arrival in Germany.

None of our interviewees received information about the German healthcare system or healthcare in general through official channels. The fact that information about the health care system is often obtained via informal channels is also reported in other (inter-)national studies [ 22 , 27 ]. This should be changed urgently to improve care and facilitate access for the refugees. As there is a lot of Ukrainian and Russian information online created for example by the Federal Office for Migration and Refugees ( www.germany4ukraine.de ), but it does not seem to reach the refugees, the distribution should be improved. This should already be done upon arrival, e.g. at registration at the Foreigners’ Registration Office or at the Citizens’ Registration Office in case of residence registration, but can also be useful in doctor’s offices.

As also identified in other studies [ 6 , 16 , 28 ], refugees in our study perceived some information and support needs to healthcare regarding communication. In many cases, the treating physicians demanded that an interpreting person must be present. Refugees, on the one hand, are therefore under pressure to find interpreters, who are often rare, in a country and system they often do not know and on the other hand, they always have to seek help. This situation also led them to bypass the issue and seek out Russian-speaking doctors. Still, the costs for professional interpreters are generally not reimbursed in GP practices and have to be paid by the patient [ 29 ]. There is a need for interpreters, preferably paid and professional, both when making and taking advantage of appointments. This has already been demanded for general practice and practices in general [ 30 , 31 , 32 ]. Biddle et al. [ 21 ] also emphasize the expansion of high-quality interpreting services in Germany. It cannot be the task of the refugees to look for and pay for interpreters. This should be urgently organized by the state, for example through (municipal) contact points for interpreter seekers and (telephone or video) interpreter services for medical consultations.

Limitations

Around half of the interviews were conducted with the help of interpreters. The real-time translation by interpreters demands a high level of concentration. An exact reproduction of all interview content is hardly possible, so that a loss of information cannot be prevented [ 33 ]. The interpreters were known to the patients from previous medical appointments and had already established a relationship of trust with them. However, multipliers, researchers and interpreters involved made it clear that participation was voluntary and emphasised the aims of the research work. Furthermore, the interviews were solely conducted in NRW, Germany’s most populous federal state. The study could therefore be expanded throughout Germany and with more participants in order to gain further insights - including into regional differences. However, through the broad spread of age groups, gender, locations, diseases and the inclusion of several multipliers, we have attempted to get a broad picture.

This study provides important and new information about the healthcare experiences of Ukrainian refugees in Germany, differences in the healthcare systems and resulting information and support needs from the perspective of refugees.

Participants’ experiences of the German healthcare system were predominantly positive, especially because of the quality of treatments and health insurance. Nonetheless, health system differences in pathways, responsibilities, structure, insurance and costs, quality, medication and prevention as well as waiting times are noticeable for Ukrainian refugees in the German healthcare system, and influence their utilization of services. On top of this, the language barrier is a huge and still unsolved problem. Disseminating information about the new healthcare system shortly after the arrival of Ukrainian refugees in Germany, conducting educational efforts and tackling language barriers are essential for successful integration, but are lacking in Germany.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

general practitioner

North Rhine-Westphalia

statutory health insurance

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Acknowledgements

We would like to thank all interview partners for their openness and very informative conversations. We would also like to thank all the experts of our advisory board for the deep and insightful discussions during the meetings and the engagement beyond, especially the two interpreters. We also thank the University of Witten/Herdecke for the financial support of the study.

This research received funding from the internal grant program (project IFF 2023-68) of the Faculty of Health at Witten/Herdecke University, Germany.

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KR developed the interview guide with team support, recruited participants with the assistance of multipliers, conducted the majority of the interviews, wrote big parts of the manuscript. JT mainly devised the basic idea and research concept, conducted background research on the topic, contributed essentially to the development of the interview guide, analysed the interviews in collaboration with JW, wrote big parts of the manuscript and provided guidance as the project leader throughout all phases. JW conducted essential research on the topic, conducted part of the interviews, jointly analysed them with JT and wrote parts of the results section. KW devised the basic idea, provided practical medical expertise and made significant contribution to data interpretation. EM contributed to the discussion section and significantly contribution to data interpretation. All authors read and approved the final manuscript and are accountable for all aspects of the work.

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Rolke, K., Walter, J., Weckbecker, K. et al. Identifying gaps in healthcare: a qualitative study of Ukrainian refugee experiences in the German system, uncovering differences, information and support needs. BMC Health Serv Res 24 , 585 (2024). https://doi.org/10.1186/s12913-024-11052-6

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Delivering clinical tutorials to medical students using the Microsoft HoloLens 2: A mixed-methods evaluation

Murray Connolly 1 ,
Gabriella Iohom 1 ,
Niall O’Brien 2 ,
James Volz 2 ,
Aogán O’Muircheartaigh 3 ,
Paschalitsa Serchan 3 ,
Agatha Biculescu 3 ,
Kedar Govind Gadre 3 ,
Corina Soare 1 ,
Laura Griseto 3 &
George Shorten 1

BMC Medical Education volume 24 , Article number: 498 ( 2024 ) Cite this article

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Mixed reality offers potential educational advantages in the delivery of clinical teaching. Holographic artefacts can be rendered within a shared learning environment using devices such as the Microsoft HoloLens 2. In addition to facilitating remote access to clinical events, mixed reality may provide a means of sharing mental models, including the vertical and horizontal integration of curricular elements at the bedside. This study aimed to evaluate the feasibility of delivering clinical tutorials using the Microsoft HoloLens 2 and the learning efficacy achieved.

Following receipt of institutional ethical approval, tutorials on preoperative anaesthetic history taking and upper airway examination were facilitated by a tutor who wore the HoloLens device. The tutor interacted face to face with a patient and two-way audio-visual interaction was facilitated using the HoloLens 2 and Microsoft Teams with groups of students who were located in a separate tutorial room. Holographic functions were employed by the tutor. The tutor completed the System Usability Scale, the tutor, technical facilitator, patients, and students provided quantitative and qualitative feedback, and three students participated in semi-structured feedback interviews. Students completed pre- and post-tutorial, and end-of-year examinations on the tutorial topics.

Twelve patients and 78 students participated across 12 separate tutorials. Five students did not complete the examinations and were excluded from efficacy calculations. Student feedback contained 90 positive comments, including the technology’s ability to broadcast the tutor’s point-of-vision, and 62 negative comments, where students noted issues with the audio-visual quality, and concerns that the tutorial was not as beneficial as traditional in-person clinical tutorials. The technology and tutorial structure were viewed favourably by the tutor, facilitator and patients. Significant improvement was observed between students’ pre- and post-tutorial MCQ scores (mean 59.2% Vs 84.7%, p < 0.001).

Conclusions

This study demonstrates the feasibility of using the HoloLens 2 to facilitate remote bedside tutorials which incorporate holographic learning artefacts. Students’ examination performance supports substantial learning of the tutorial topics. The tutorial structure was agreeable to students, patients and tutor. Our results support the feasibility of offering effective clinical teaching and learning opportunities using the HoloLens 2. However, the technical limitations and costs of the device are significant, and further research is required to assess the effectiveness of this tutorial format against in-person tutorials before wider roll out of this technology can be recommended as a result of this study

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Introduction

Clinical tutorials which include encounters with real patients are recognised as integral elements in medical education [ 1 , 2 , 3 ]. Sir William Osler famously stated that “medicine is learned by the bedside and not in the classroom.” [ 4 ] However, many medical schools are facing challenges in delivering clinical education to students in an environment where there are increasing numbers of students, a limited number of patients and tutors, and increased scrutiny regarding the costs and environmental impacts of travel [ 5 , 6 , 7 , 8 ]. The COVID-19 pandemic also had a significant impact on in-person medical education in many countries, where students’ access to patients was severely curtailed [ 9 , 10 ]..

The argument that medical education requires interactive tutorials on actual patients is supported by various educational theories. Bandura’s Social Learning Theory and Social Cognitive Theory propose that students learn via attention, retention, reproduction and motivation [ 11 , 12 ]. This supports the need for direct observation and modelling of relevant clinical role-models participating in doctor-patient interactions [ 13 , 14 ]..

The Constructivist theory is based on the premise that the act of learning is based on a process which connects new knowledge to pre-existing knowledge [ 15 , 16 ]. Vertical Integration in medical education involves the integration of aspects of the curriculum across time, namely the integration of basic sciences and clinical sciences [ 17 , 18 , 19 ]..

Providing medical education within these frameworks, prioritising student exposure to direct interactions with clinicians and patients, and vertical integration of curriculum material, in situations where physical access to patients may be limited by numbers, logistics or infection control concerns poses a significant challenge to medical schools around the world. Utilising technology to facilitate the delivery of clinical education remotely may present a solution to these issues.

The broadcast of bedside tutorials to a remote location can be delivered using a “third-person” perspective, via a fixed or mobile broadcasting device, or using a first-person perspective, via a device mounted on the tutor. Devices which provide a first-person perspective are typically head-mounted-display devices (HMDs). The capabilities of these devices range widely, from basic two-way communication with a remote location, to devices with Augmented Reality (AR) and Mixed Reality (MR) functions which allow the integration of holographic artefacts into tutorials.

Augmented reality (AR) is a virtual environment that allows the user to view both their physical environment and virtual elements in real-time. Mixed Reality (MR) is an extension of AR which allows the real and holographic elements to interact [ 20 , 21 ]..

The use of AR and MR are expanding in many industries including healthcare, education, engineering, and manufacturing [ 22 , 23 , 24 ]. MR investigated in a variety of settings pertaining to medical education. Many early studies focused on teaching relevant anatomy, and more recently studies have evaluated the use of MR in procedural training, and its use in streaming of clinical ward-rounds to medical students [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]..

Head-mounted-display devices which offer MR experiences are growing in number and capability [ 34 ].The Microsoft HoloLens2 is one such device which enables the creation of an immersive Mixed Reality environment and can superimpose holographic images onto the user’s surroundings.

The HoloLens 2 has a number of specific capabilities which can be utilised in the virtual delivery of in-person clinical tutorials.The device can facilitate educationally effective, three-way communication between students, tutors and patients, as well as facilitating the incorporation of mixed reality elements into tutorials. The MR capabilities may provide a means of sharing holographic artefacts such as images and diagrams, which can allow the vertical and horizontal integration of curricular elements at the bedside.Utilisation of the MR capabilities of the device may improve student experiences and learning, in particular through instructional scaffolding (e.g rendering cell, organ or system pathways proximate to a patient) [ 35 ] Given the device’s connectivity capabilities, students can be in a separate geographical location to the patient and tutor. This has the potential to decrease student travel requirements and enables the delivery of tutorials to students in multiple different locations simultaneously [ 36 ]. The tutorial can also be delivered to a greater number of students than would be practical in a traditional bedside clinical tutorial environment. This can decrease the burden on both tutors and patients in comparison to multiple smaller group sessions. Finally, infection control risks are reduced as only the tutor enters patients’ environments.

Study goals

There is little published research to date which robustly evaluates the use of the HoloLens in replicating bedside tutorials while also incorporating mixed reality elements into the tutorials. The aims of this study are to evaluate the use of the Microsoft HoloLens 2 device to deliver a tutorial on preoperative anaesthetic history and upper airway examination to medical students in a remote location, while incorporating MR holograms in the tutorial delivery. Specific objectives include evaluating the feasibility of delivering tutorials with the HoloLens device, assessing the learning efficacy of these tutorials, and assessing student, tutor, facilitator, and patient perspectives of the tutorials.

This study was approved by the Clinical Research Ethic Committee of the Cork Teaching Hospitals, and the University College Cork Research and Postgraduate Affairs Committee. All participants including students, patients, tutor and technical facilitator provided written informed consent prior to inclusion in the study.

Study population

University College Cork medical students from two cohorts, third year Graduate-Entry and fourth year Direct-Entry medical students attending a tertiary referral teaching hospital for a clinical attachment with the Department of Anaesthesia and Intensive Care Medicine were invited to participate in the study. Both groups are in their second-last year of medical training, and thus have completed modules and examinations in basic medical sciences and clinical practice in the preceding years, with a maximum of 1 week experience in the field of anaesthesia [ 37 , 38 , 39 ]. Patients attending Cork University Hospital for scheduled surgery were selected and approached for consent by tutors according to clinical relevance. All participants were 18 years or over and were deemed capable of providing consent. Each student provided information on their age, gender and previous third-level qualifications.

Tutorial Sturcture

A one-hour tutorial focusing on completing a preoperative history and focused assessment of the upper airway was developed by MC (adjunct clinical lecturer), GI (Senior Clinical Lecturer) and GS (Professor) in line with the University curriculum’s learning objectives. (Fig. 1 ) Tutorials were delivered on a weekly basis to groups of third year Graduate Entry and fourth year Direct Entry medical students across the 2021–2022 academic year.

Preoperative Anaesthetic History and Focused Preoperative Assessment of the upper airway tutorial structure

All tutorials were delivered by one tutor (MC) and assisted by a technical facilitator (NOB), both males aged in their thirties, who enabled the connection between the site of the clinical encounter and nearby tutorial room. The tutor had no prior experience with the HoloLens 2 device or other AR HMDs prior to participation in this study; the facilitator had significant experience in its use. The tutor was given a period of familiarisation with the device which included using the Microsoft “HoloLens Tips” app, which provides a structured tutorial on the various hand gestures used to control the device, as well as a number of practice calls in order to test the network and audiovisual equipment in the tutorial room [ 40 ]. This familiarisation period totalled approximately 3 hours.

During the tutorial, the tutor (MC) interacted with a patient (face to face) in the pre-or postoperative units and remotely with a small group of [ 6 , 7 , 8 , 9 , 10 ] students in a nearby tutorial room. The remote interaction occurred via Hololens 2 worn by the tutor, institutional Wi-Fi (Eduroam), and Microsoft Teams.He demonstrated and explained the techniques of preoperative history taking and preoperative upper airway assessment.

Throughout the patient assessment the tutor interacted both with the patient and with the students as if conducting an in-person tutorial, providing additional information, asking the students pertinent questions, and expanding on the findings of the patient’s history and physical examination. Students communicated with the patient by asking questions via the tutor.

Resources employed

Resources necessary to provide the tutorials via the HoloLens included capital costs of the HoloLens device (€3500) and microphone (€88) as well as annual licence costs of €275 per user ( n = 4). Human resources employed in developing the tutorials and trialling equipment included approximately 20 hours of training, remote assistance (Microsoft) and collaboration between the tutor (MC), Professor (GS) and facilitator (NOB), as well as 5 hours input from the Senior Clinical Lecturer (GI).

Internet connectivity

An internet connection of at least 1.5mpbs of bandwidth is recommended by Microsoft for best audio, visual and content sharing experience [ 41 ]. Secure, password protected wireless internet access via the University institutional network (Eduroam) was utilised by both tutor and students.

In most tutorials, broadcasts were hosted by an MSI running the Windows 10 operating system, audio was amplified using a Bose SoundLink Mini portable speaker and video was screened via a HDMI cable to a 36″ monitor. In one tutorial students accessed the tutorial via their personal smartphones or laptops. In order to bypass the noise cancellation technology within the HoloLens an external microphone (Saramonic SmartMic+UC L/weight Smartphone Mic USB-C) and 3.5 mm earphone were used.

Dynamics 365 Remote Assist application was used, in-tandem with Microsoft Teams, to host each video call. This connection allowed the students to see the tutors field of vision and hear both the tutor and patient. Hand gestures including the “hand-ray”, “air-tap”, “air-tap and hold” and “start-gesture” were used to control the HMD and manipulate the holographic artefacts. Relevant holographic artefacts were superimposed during the tutorial. This included the insertion of diagramatic representaions of the Mallampati scoring system and Thyromental Distance during the airway assessment portion of the tutorial [Fig. 2 (a) and (b)]. The holographic pointer and “drawing” functions were used by the tutor to highlight relevant upper airway structures and emphasise information on the holographic diagrams [Fig. 2 (c) and (d)].

a Assessment of Mallampati Score. b Assessment of Thyromental Distance. c Identification of thyroid cartilage using holographic pointer. d Illustration of holographic “drawing” function

Assessment of tutor perceptions

Immediately after completion of the first tutorial, the tutor completed a System Usability Scale assessment and on completion of the last tutorial, the tutor and facilitator summarised their perceptions of using the HMD.

Assessment of student perceptions

Immediately after completion of the tutorial, students completed a modified Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions (ETELM-LP) questionnaire in order to assess their perceptions of the tutorial, which incorporated a seven-point Likert Scale and open questions [ 42 ]. Cronbach’s Alpha was calculated after exclusion of question 1 and reverse scoring of questions 13 and 15.

Three students also took part in semi-stuctured interviews via Microsoft Teams. Researchers undertook this study from an interpretive approach [ 43 ]. The interviews were conducted by JV, and followed a template of questions and corresponding probes from which the interviewer expanded as appropriate [Additional file 1 ]. The template served as a foundation from which the interviewer expanded as appropriate. The interviews were recorded and transcribed. Analysis of the interview transcripts and questionnare responses was performed using Dedoose Qualitative Research Software Version 4.3.Qualitative data from interviews and feedback questionnaires were coded thematically in alignment with Clarke and Braun’s suggestions for qualitative analysis [ 44 ]. Following the initial thematic coding, researchers conducted a content analysis to strengthen the interpretation of results. Illustrative quotes were chosen based on the representativeness of the theme or subtheme and the clarity of their intrinsic interpretation. In alignment with current literature, the quotes selected were determined to be illustrative of the point, reflective of patterns observed, and relatively succinct [ 45 ]..

Assessment of patient perceptions

On completion of the tutorials, patients were also asked to complete a mixed quantitative and qualitative questionnaire in order to assess their perceptions of the tutorial.

Assessment of learning efficacy

We carried out a prospective non-comparative study of tutorial efficacy. Students completed a pre-tutorial Multiple Choice Question (MCQ) examination to assess baseline knowledge [Additional file 2 ], and a post-tutorial MCQ two to 3 days later [Additional file 3 ]. Students then completed an end-of-year assessment two to 5 months later consisting of a data interpretation exam and an Objective Structured Clinical Examination (OSCE) which focused on preoperative history taking and preoperative assessment of the upper airway respectively [Additional files 4 and 5 ]. These examinations were written by an investigator and the University Senior Clinical Lecturer in line with University standards. Examination results were converted to percentages and the data interpretation and OSCE results were combined to give a total End-of-Year result.

The Chi-Squared test was used to compare direct-entry and graduate-entry student demographics. Welch’s two-sample t-Test assuming unequal variances was used to compare student group ages. The Shapiro Wilk and Kolmogorov-Smirnov Tests were used to assess to normality of distribution of student assessment scores for data sets less than 50 and greater than 50 respectively. The Mann-Whitney U Test was performed to compare group performance in assessments and overall student performance between the pre- and post-tutorial examinations, and between the post-tutorial and End-of-Year scores. Cohen’s d was calculated for the pre and post-tutorial MCQ scores to assess effect size.

Twelve tutorials were completed involving 12 separate patients and 78 students. Four students did not complete the post-tutorial MCQ and one did not complete the End-of-Year assessments due to illness related absences. These students were excluded from efficacy calculations. Baseline characteristics of the student participants are summarised in Table 1 . As expected the graduate-entry students was a significantly older cohort (graduate-entry median age 26 vs direct-entry mean of 22). Mean age of patient participants was 43.25, with an SD of 16.48, and a range of 18–64.

Feasibility

We found that it was feasible to use the HoloLens2 to facilitate weekly bedside tutorials on live patients in a busy, tertiary referral teaching hospital. No tutorials were cancelled or postponed due to technology-related issues. Of note, in order to improve the audio quality of the patient’s voice, it was neccessary to add the USB microphone, which is not routinely supplied with the HoloLens 2. The tutorials were also dependent on secure Wi-Fi access for both tutor and students, the presence of a tutorial facilitator to control the equipment at the student end, and access to a quiet space to examine the patient.

Tutor feedback

The sole tutor (MC) completed the System Usability Scale score, which was 72.5 (a score > 68 is deemed above average). The tutor (MC) stated that the HoloLens 2 was found to be comfortable to wear, the visor was unobtrusive and did not interfere with interaction with the patient or impede visualisation of clinical signs. The interaction with the device via hand gestures was relatively smooth and intuitive after the intial familiarisation period and the MR functions including the insertion of holographic diagrams, pointing, drawing and highlighting were useful. The holographic artefacts were visible throughout the tutorials at a “brightness” setting of seven out of 10.

Occasionally when talking to the students via the HMD, it was not clear to the patient if the tutor was talking to the patient or to the students. Utilising a structured pattern of speech such as “I am now talking to the students” was found to be useful to overcome this issue.

Facilitator feedback

The technical facilitator (NOB) found that the set-up of the live broadcast to the students was akin to that of a video presentation and that the learning curve for hosting the tutorials was short as the Dynamic 365 Remote Assist application was quite similar to general videoconferencing software. He noted that patient proximity to the tutor was essential to ensure adequate audio quality and referenced an example where a supine patient was farther from the device than normal and that patient responses had to be repeated by the tutor. Backgound noise was noted as a “minor issue and transient in nature”, and the technical facilitator accepted that a certain amount of background noise was unavoidable in an active hospital ward.

Student feedback

Quantitative student feedback via the modified ETELM-LP questionnaire is summarised in Fig. 3 . Results are presented as (mean, SD) and refer to a seven-point Likert scale. Students had little experience in MR prior to the tutorial (1.7, 1.29). They found the audio and visual quality was clear and that the MR elements of the tutorial were useful. Most agreed the tutorial approximated a live patient encounter (5.69, 1.26), was more beneficial than a PowerPoint-based tutorial, and were neutral when asked if it was as beneficial as a live clinical encounter (5, 1.69). They did not agree that the tutorial structure required inappropriately high technology skill levels on the part of the students, nor that the MR elements served as a distraction. Most agreed that they would like MR to be incorporated into further tutorials (6.05, 1). Cronbach’s Alpha, excluding question 1 was calculated as 0.86, displaying good internal consistency.

Student Modified ETELM-LP Scores. 7 point Likert scale with 7 as strongly agree and 1 as strongly disagree. Presented as Mean +/− 1 Standard Deviation

Student qualitative feedback results

Analysis of written and verbal feedback from 78 students identified 90 specific positive excerpts and 62 negatives (Table 2 ). Positive feedback included the technology’s ability to broadcast the tutor’s point-of-vision, the inclusion of holographic artefacts, and the remote nature of the tutorial. Negative feedback included issues with the audio-visual stream quality, the fact that students were not able to individually carry out the practical examination, and 11 students expressed concerns that the tutorial was not as useful as traditional in-person bedside clinical tutorials.

Three students participated in semi-structured interviews. The limited sense of “presence” and interaction with the patient were identified as limitations to the format by all three interviewees. With respect to the physical examination one student explained he would have preferred to “experience it yourself, and have a look and feel and touch”. Specific mention was made of the value of combining broadcast (patient) and rendered (schematics) images, “The adding of the images … right next to the patient was really, really helpful”. This may indicate the potential to employ this format to support vertical and horizontal integration of curricular elements. All three interviewed students reported either a six or seven (on a verbal scale of 1–7) when asked to recommend this technology for inclusion in the medical curriculum.

Patient feedback

Quantitative feedback data from patient questionnaires is summarised in Fig. 4 . Most patients had little experience with MR in the past (mean, SD: 1.75, 1.48) apart from one patient who scored 6. All agreed that the communication with the tutor was clear, that they felt safe, that the experience was enjoyable and that they would participate in a similar session in the future. Six of seven expressed that it was preferable to both small (5 or less) and large group in-person tutorials. Most patients did not agree that the HoloLens served as a distraction or made them uncomfortable.

Patient Feedback Questionnaire Results. 7 point Likert scale with 7 as strongly agree and 1 as strongly disagree. Presented as Mean +/− 1 Standard Deviation

Five patients gave qualitative feedback. Positive comments included that “it is good to see that you are moving on with new technology”, “it was well explained beforehand so I was very comfortable” and “it was fantastic to teach students when they can’t be at the bedside. Very unobtrusive”. One patient commented that “sometimes not sure if he [the tutor] was talking to me or the students” and another commented that “it would be lovely to see who I was talking to [the student group]”.

Learning efficacy

Student examination scores are sumarised in Table 3 and Fig. 5 . Student assessment scores were not normally distrubuted. A statistically significant improvement was observed between overall students’ pre and post tutorial MCQ scores (mean 59.2% Vs 84.7%, p < 0.001). Cohen’s d was 0.612, indicating a medium effect size. There was a statistically significant difference in student performance between the post tutorial MCQ and the composite End-of-Year scores (84.7% Vs 82.2%, p < 0.05). There were no statistically significant differences found between the graduate-entry and direct-entry students for any individual examination.

Boxplot of overall student assessment scores

Mixed Reality headsets offer several novel capabilities which can facilitate remote education and vertical and horizontal integration of curriculum elements, particularly when aligned with appropriate educational theories such as Constructivism and Social Cognitive Theory. A large number of studies have focused on applying the technology in surgical and anatomical subject fields [ 46 ]. However, there are significant gaps in the evidence base, particularly studies specific to anaesthesiology, clinical exam, and addressing the provision of interactive tutorials to remote locations. Our study has demonstrated that it is feasible and effective to use the Microsoft HoloLens 2, incorporating its Mixed Reality functions to provide a live bedside tutorial on anaesthetic preoperative assessment to students situated in a remote location. Feedback from students, patients and the tutor were generally positive. Quantitative feedback from students regarding the audio-visual quality was mainly positive, however technical issues were noted, and preference for in-person tutorials was expressed by a minority of students.

Mill et al. previously examined the feasibility of the HoloLens 2 in broadcasting medical ward rounds [ 26 ]. While papers such as that by Mill et al. demonstrated the feasibility of utilizing the HoloLens 2 HMD to stream educational ward-rounds, they did not utilize the MR functions of the HMD, nor assess the learning efficacy of the device [ 26 ]. This study incorporates both quantitative and qualitative feedback from multiple sources, namely students, patients, the tutor, and tutorial facilitator. We believe this demonstrates a robust examination of the perceptions of the relevant stakeholders involved in the provision of clinical tutorials to medical students. Our findings that the tutorials were feasible, agreeable to both patients and students, and that students had occasional audio-visual difficulties are consistent with those of Mill et al. Our study additionally demonstrates that incorporation of holographic artefacts is both feasible and regarded by the tutor and students as useful, and that the tutorials provide effective knowledge acquisition.

Our tutorial format aimed to reproduce some of the educationally relevant components of an in-person tutorial. Other suggested structures advocate streaming video of the physician as opposed to the physician’s point-of-view [ 47 ]. The HoloLens 2 device allows the students to view the tutor’s field of vision which we argue is superior, and student feedback reflected this. This viewpoint allows students to appreciate in real time the clinical signs demonstrated during the clinical examination and correlate these with the holographic diagrammatic examples used. The MR environment provides an ideal setting to facilitate vertical integration in real time by displaying holographic artefacts of anatomical, physiological and pathological information, as well as patient specific data such as radiological imaging or lab results while interacting with a patient. Furthermore, delivering tutorials remotely reduces infection-control concerns and allows delivery to greater numbers of students in multiple locations.

Preserving patient confidentiality is essential in medical practice and education. In our study, both the HMD and devices at the student end were connected to secure institutional Wi-Fi and accessed via University accounts. Also, access to the audio-visual stream was controlled by the technical facilitator, and the students were located in a supervised tutorial room. It would be essential to control both access to the tutorial and the environment to which it is broadcast to maintain confidentiality.

Limitations

Our study design has a number of limitations. It is non-comparative, and thus we are unable to draw conclusions regarding the relative learning experience or efficacy associated with tutorials delivered via the HoloLens device and the more traditional in-person bedside tutorials. Additionally, the different assessment methods between the MCQs and end of year examinations make direct measurement of knowledge retention difficult. The number of patients involved in the study was relatively small, and thus interpretation of both quantitative and qualitative data must be viewed in this context, and the generalisability of the data is low. The feedback from the tutor and tutorial facilitator must be viewed in the context that they were study investigators.

There are a number of limitations specific to research involving the HoloLens. Common limitations in studying the learning effects of the HoloLens in tested roles include the absence of validated measures and comprehensive evaluation instruments. Unlike other technologies, there are no benchmarks, datasets, or standard standardized protocols to specifically evaluate augmented reality systems, experiences, and methodologies [ 48 , 49 , 50 ]. Although the viewpoint offered to the students by the HoloLens allows the students to appreciate what the tutor is demonstrating, one drawback to this is that the focus of attention is primarily controlled by the tutor, and thus it is difficult for the tutorial to challenge the students to select the relevant areas to attend to. Depending on the tutorial topic and structure, an ideal virtual format may provide three perspectives: the tutors view, a third person view of the clinical encounter, and where applicable, an instrument’s view.

Regarding the generalisability of our study to other tutorial topics, the appreciation of clinical signs which would require palpation or auscultation would be beyond the current capabilities of the HoloLens 2 and therefore, careful tutorial design and topic selection is necessary.

Our results demonstrate the feasibility of facilitating remote bedside tutorials on preoperative anaesthetic assessment using the HoloLens 2. The tutorial structure was found to be agreeable to students, patients, and tutors. Provision of tutorials in the format described in this study may be an option for situations where students’ access to live bedside tutorials are limited. However, further research is required to characterise the role, potential and limitations of incorporating Mixed Reality into clinical medical education in a broader context. Poor audio-visual quality and lack of hands-on practice were found to be the most frequent issues identified in our study and may be significant limitations to the use of this technology in wider medical education. There are significant costs involved in developing the infrastructure and expertise necessary to provide tutorials in this format. Prior to this technology being adopted by educational institutions, we recommend the completion studies to compare the learning efficacy of MR facilitated remote tutorials and traditional in-person bedside tutorials.

Availability of data and materials

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

Abbreviations

Augmented Reality

Evaluation of Technology-Enhanced Learning Materials: Learner Perceptions

Head-Mounted Display

Interquartile Range

Multiple Choice Question

Mixed Reality

Objective Structured Clinical Examination

Standard Deviation

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Acknowledgements

The authors would like to acknowledge the assistance from members of the UCC College of Medicine and Health, including Dr. Colm O’Tuathaigh, Dr. Gabriella Rizzo, Dr. Pat Henn and Professor Paula O’Leary, as well as Ms. Michelle Donovan in the UCC Centre for Digital Education.

This study received funding and research support through the UCC Learning Analytics LITE programme, which is funded through the Strategic Alignment of Teaching and Learning Enhancement fund. The UCC Learning Analytics LITE programme provided logistical and research support in study design and funds were used to hire assistance in data interpretation.

This study also received funding from the UCC College of Medicine and Health which was utilised to purchase the HoloLens 2 Device and associated licences.

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MC lead the design of the study, carried out the tutorials, analysed both quantitative and qualitative data and was the primary author of the manuscript. GI contributed to the design of the study, the student examinations contributed to writing the manuscript. NOB contributed to the technical and logistical design of the study and acted as technical facilitator for the tutorials and contributed to manuscript composition. JV designed, completed and analysed the semi-structured student interviews and contributed to manuscript composition. AOM, PS, AB, LG and supervised and analysed student examination data. KGG analysed student demographic data and student examination data. CS contributed to initial evaluation of the HoloLens device and tutorial design. GS played a central role in study design and completion and was a major contributor in manuscript composition.

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Connolly, M., Iohom, G., O’Brien, N. et al. Delivering clinical tutorials to medical students using the Microsoft HoloLens 2: A mixed-methods evaluation. BMC Med Educ 24 , 498 (2024). https://doi.org/10.1186/s12909-024-05475-2

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Original research article, older adults' experiences of wellbeing during the covid-19 pandemic: a comparative qualitative study in italy and switzerland.

1 Faculty of Social Sciences, University of Geneva, Geneva, Switzerland
2 Swiss Center of Expertise in Life Course Research (LIVES), Geneva, Switzerland
3 Faculty of Social Work, University of Applied Sciences and Arts Western Switzerland (HETSL/HES-SO), Lausanne, Switzerland

Background: Particularly at the beginning of the pandemic, adults aged 65 and older were portrayed as a homogeneously vulnerable population due to the elevated health risks associated with contracting the COVID-19 disease. This portrayal, combined with travel restrictions, closures of economic sectors, country-wide lockdowns, and suggestions by governmental authorities to limit social contact, had important implications for the wellbeing of older individuals. However, older adults are a heterogeneous population who relies on different resources to cope with stressful periods, like the COVID-19 pandemic. Simultaneously, countries also employed different measures to contain the virus. Research thus far has focused on the short-term consequences of the pandemic, but studies have yet to address its long-term consequences.

Objectives: We explore older adults' lived experiences nearly 2 years after the pandemic onset. Moreover, we focus on the bordering countries of Switzerland and Italy, who employed contrasting containment measures. This paper analyzes (1) How the COVID-19 pandemic impacted the experiences of wellbeing of older adults in these regions and (2) How older adults coped with the stressors brought about by the pandemic, in particular social distancing.

Methods: The paper draws on 31 semi-structured interviews with 11 Swiss natives residing in Switzerland, 10 Italian migrants residing in Switzerland, and 10 Italian natives residing in Italy. Interviews were conducted from December 2021 to March 2022.

Results: Coping mechanisms of the three groups related to acceptance, hobbies, cognitive reframing, telephone use, vaccine use and social distancing. However, results show heterogeneous experiences of wellbeing, with Swiss natives sharing more positive narratives than the other two groups. Moreover, Italian migrants and Italian natives expressed the long-term negative consequences of the pandemic on their experienced wellbeing.

1 Introduction

In March of 2020, the WHO declared COVID-19 a pandemic, making it an international public health problem ( WHO, 2020 ). Beyond physical illness, the pandemic disrupted millions of lives around the globe through closures of schools, shops, and borders; it separated individuals from friends and family, and it caused job losses and financial strain ( Hiscott et al., 2020 ). However, in the public discourse it was especially older adults who were portrayed as a homogeneously vulnerable and frail group ( Jordan et al., 2020 ; Ayalon et al., 2021 ; Maggiori et al., 2022 ). Indeed, older people had higher mortality rates than younger ones ( Dadras et al., 2022 ). They also suffered from decreased physical activity due to social distancing measures, impacting their physical health ( Oliveira et al., 2022 ). Moreover, in comparison to pre-pandemic levels, older adults reported higher rates of anxiety and depression ( Webb and Chen, 2022 ; Segerstrom et al., 2023 ) and lower subjective wellbeing ( Maggiori et al., 2022 ).

However, compared to their younger counterparts, older adults also reported less pandemic-related stress, less social isolation, less life changes ( Birditt et al., 2021 ), and lower rates of anxiety and depression ( Webb and Chen, 2022 ). Furthermore, older adults' resilience was shown through their ability to develop coping strategies to maintain a certain level of subjective and psychological wellbeing ( Finlay et al., 2021 ; Fuller and Huseth-Zosel, 2021 ; Bustamante et al., 2022 ; Facal et al., 2022 ; Mau et al., 2022 ).

Nonetheless, the ability to cope with the stressors brought about by the pandemic was influenced by factors on the micro-, meso-, and macro- levels. On the micro-level, studies have revealed that characteristics like being in good health, previous experiences of adversity, stable financial status, and social networks positively affected individuals' ability to cope with the pandemic ( Guzman et al., 2023 ), while having a migration background was associated with increased pandemic-related worry ( Ludwig-Dehm et al., 2023 ) and loneliness ( Pan et al., 2021 ). At the meso-level, neighborhood parks and nature were positively related to mental and physical health ( Bustamante et al., 2022 ; Guzman et al., 2023 ). At the macro-level, stricter physical distancing measures mandated by governments were associated with worse mental health ( Mendez-Lopez et al., 2022 ). The heterogeneity of older adults' characteristics, resources, and lived experiences, as well as the differences in countries' containment measures thus call for research further exploring how older adults coped with the pandemic in different contexts.

Most studies to date focus on older individuals' wellbeing during the first lockdown in the spring of 2020 ( Seifert and Hassler, 2020 ; Cipolletta and Gris, 2021 ; Falvo et al., 2021 ; Finlay et al., 2021 ; Fuller and Huseth-Zosel, 2021 ; McKinlay et al., 2021 ; Whitehead and Torossian, 2021 ; Bustamante et al., 2022 ; Facal et al., 2022 ; Gonçalves et al., 2022 ; Kremers et al., 2022 ) or during the first year following the pandemic onset ( Fiocco et al., 2021 ; Atzendorf and Gruber, 2022 ; Brooks et al., 2022 ; Cohn-Schwartz et al., 2022 ; Derrer-Merk et al., 2022a ; Garner et al., 2022 ; Maggiori et al., 2022 ; Mau et al., 2022 ; Donizzetti and Capone, 2023 ). However, few studies have been published thus far addressing the second year of the pandemic and its long-term impact on older adults' wellbeing ( Gallè et al., 2021 ; König and Isengard, 2023 ). Moreover, studies have analyzed the pandemic's impact on the physical health of migrants of all ages in comparison to native-born populations in Western Europe ( Canevelli et al., 2020 ; Aldea, 2022 ; Khlat et al., 2022 ), but to the best of our knowledge, none have addressed the differences in the lived experiences of wellbeing among older migrant and native populations with a focus on coping strategies. Furthermore, there is a paucity of literature comparing the experiences of wellbeing and coping strategies between countries that implemented contrasting COVID-19 containment measures.

We aim to bridge this gap by comparing the experiences of older adults in Italy and Switzerland – countries that implemented different COVID-19 containment measures – nearly 2 years after the pandemic onset. Specifically, we study older Swiss natives residing in Switzerland, older Italian natives residing in Italy, and older Italian migrants residing in Switzerland. This allows us to explore the experiences of wellbeing of older adults who lived under strict restriction measures, namely Italian residents, to those of adults who lived under more relaxed measures, namely Swiss natives and Italian migrants living in Switzerland. Furthermore, comparing Swiss natives and Italian migrants allows us to analyze the experiences of two groups who lived the pandemic in the same context, yet who have had different life courses. More particularly, because older Italian migrants in Switzerland often have attachments to Italy and take part in transnational practices ( Ludwig-Dehm et al., 2023 ), their inclusion in the study allows us to explore how the situation in their country of origin impacted their COVID-19 experiences from abroad.

This paper aims to analyze (1) How the COVID-19 pandemic impacted the experiences of wellbeing of older adults in Switzerland and Italy and (2) How older adults coped with the stressors brought about by the pandemic, in particular social distancing.

2 Contextual background: the Swiss and Italian contexts

Despite the geographical proximity between Switzerland and Italy, the two countries implemented quite different containment measures as a response to the virus.

Compared to other European countries, on average Switzerland implemented less stringent containment measures throughout the pandemic, despite being just as impacted ( Pleninger et al., 2022 ). The first phase of the pandemic, classified by the Federal Council as an “extraordinary situation,” lasted from March 16 to June 19, 2020 ( Sager and Mavrot, 2020 ; Maggiori et al., 2022 ; Pleninger et al., 2022 ). From March 16 until April 26, the Swiss government gradually imposed measures closing borders, canceling cultural and sports events, banning all public and private manifestations, closing schools, restaurants, bars, as well as shops and services deemed to be unessential, and banning gatherings of more than five people. Older adults in particular were advised to stay at home and to avoid in-person social interactions with members outside their household. From April 26, 2020 containment measures were slowly eased, and on June 19, 2020, the classification of the pandemic changed from “extraordinary” to “special” ( Sager and Mavrot, 2020 ; Pleninger et al., 2022 ).

During the next 2 years, Switzerland saw a series of tightening and easing of containment measures, which included regulations on mandatory vaccines or COVID-19 tests to access bars and restaurants, and mandatory masks to be worn in shops and public transport. All restrictions were then lifted on April 1, 2022 ( FOPH, 2022 ).

Throughout the pandemic up until the data collection for this article – between December 2021 and March 2022 – the Swiss government largely relied on cooperation from the public. Although in certain periods shops, restaurants, and schools were closed, Swiss residents still enjoyed a certain amount of freedom to move and have social gatherings, albeit limited. Overall, it was left up to the individuals to regulate their behaviors within certain limits.

The Italian government, on the other hand, imposed more stringent measures throughout the pandemic. Late January 2020, the government declared a national emergency, and in February 2020, Italy was the epicenter of the health crisis in Europe ( Ferrante, 2022 ). The Italian government quickly established lockdown “red” zones in certain areas of Northern Italy, which led to the closure of schools and restrictions of movement: residents could leave their areas of residence only for necessities like work, health reasons or family emergencies, or grocery shopping. These restrictions were applied in waves to the entire country, and on March 11 the government imposed a national lockdown, also named the “stay at home” decree ( Bull, 2021 ). This entailed closure of borders, schools, restaurants and bars, and all nonessential shops and services. Travel between regions was prohibited and residents' movement was only allowed for essential reasons. The first Italian lockdown ended on May 3, 2020, after which most shops, restaurants, bars, and services gradually reopened while maintaining COVID-19 safety protocols ( Bosa et al., 2021 ).

During the next 2 years, Italy also experienced a series of loosening and tightening of restrictions, but these were often more stringent than the ones imposed in Switzerland. For instance, during the second wave of the pandemic, which took place in autumn of 2020 and winter of 2021, curfews from 11 pm to 5 am were mandated and restaurants and bars had to close at 6 pm. During this time, Italian residents were strongly recommended to leave their homes only for work or health reasons, and these restrictions were gradually eased by mid-2021 ( SkyTG24, 2020 ; Bosa et al., 2021 ). In April 2022, Italy declared an end to the state of emergency, and thereafter lifted all restrictions ( Amanto, 2022 ).

Both Italy and Switzerland were successful in containing the spread of the virus ( Ferrante, 2022 ; Pleninger et al., 2022 ), but at what cost to people's wellbeing?

3 A theoretical framework to understand wellbeing and coping strategies among older adults

3.1 wellbeing.

Research on wellbeing largely encompasses two forms: objective wellbeing and subjective wellbeing. The first refers to objective indicators like income, health, and living conditions. The second refers to individuals' experiences of wellbeing and to their evaluations of their lives. It is often measured with indicators like positive and negative affect, happiness, life satisfaction, and satisfaction with various life domains like social relationships, financial situation, and neighborhood conditions ( Bartram, 2012 ; Diener, 2012 ; Veenhoven, 2012 , 2017 ). In this paper, we use the term wellbeing to refer to the latter concept – to individuals' subjective experiences of wellbeing.

Some objective indicators are indeed correlated to subjective indicators – being in good health, for instance is positively associated with life satisfaction ( Helliwell, 2003 ; Deaton, 2008 ; Clark et al., 2018 ) and, to a certain extent, so is income ( Clark et al., 2008 ; Clark, 2011 ; De Jong, 2015 ). Studies have also debated to what extent wellbeing is dependent on genes and individual personality traits ( Bartels, 2015 ; Røysamb et al., 2018 ), and to what extent it is dependent on external factors like social contexts and life events ( Helliwell and Putnam, 2004 ). But overall, the consensus is that wellbeing is influenced by both genetic and environmental characteristics ( Røysamb et al., 2014 ; Luhmann et al., 2021 ).

Most studies employ a quantitative approach and explore a wide array of determinants of wellbeing, ranging from age, to health, to income and education, to relationships and divorce, to social norms and institutions, and so on ( Clark et al., 2018 ). Qualitative studies on wellbeing are less common ( Bartram, 2012 ), but they valuably provide information on participants' perceptions, views and beliefs that are unaffected by researchers' pre-determined ideologies ( Delle Fave et al., 2011 ). Especially in a context like that of the COVID-19 pandemic – a disruptive process that homogeneously categorized an entire group as vulnerable and forced individuals world-wide to reorganize their lives – a qualitative approach allows for nuanced, in-depth analyses of people's experiences of wellbeing (and vulnerability).

3.2 Older adults' vulnerability

Independently of the pandemic context, older adults are often characterized as particularly frail and vulnerable ( Fried et al., 2001 ; Clegg et al., 2013 ). This is often due the age-related decline in physiological and psychological systems, which renders this population vulnerable to falls, hospitalization, or sudden health changes triggered by minor events, and makes them more reliant on others for care ( Fried et al., 2001 ; Clegg et al., 2013 ). But vulnerability in old age is not a dichotomous state of vulnerable vs. not vulnerable, as was suggested in the public discourse during the COVID-19 pandemic. According to the life-course approach employed by Spini et al. (2017) , vulnerability is defined as:

“a weakening process and a lack of resources in one or more life domains that, in specific contexts, exposes individuals or groups to (1) negative consequences related to sources of stress, (2) an inability to cope effectively with stressors, and (3) an inability to recover from stressors or to take advantage of opportunities by a given deadline.” ( Spini et al., 2017 , p. 8)

It is a dynamic process between stress and resources that occurs at the intersection of different areas of life (like health, work, family, etc.), and on several levels (macro-, meso-, or micro-levels) throughout the life course ( Spini et al., 2017 ). When faced with a stressful situation like the COVID-19 pandemic, individuals must rely on the resources they accumulated throughout the life course – referred to as reserves ( Cullati et al., 2018 ) – in order to cope with life adversities. These reserves include, but are not limited to, physical and mental health, economic savings, cultural capital resulting from education, social networks, and emotional and cognitive reserves ( Cullati et al., 2018 ). It is in times of shocks that these reserves become the most important and mediate the impact of stressors on individuals' wellbeing; it is also during these adverse periods that inequalities between individuals' reserves become the most apparent ( Widmer, 2022 ), leading to situations of vulnerability.

In old age, physical reserves diminish, and older adults' ability to fight infectious diseases decreases, putting them in a vulnerable situation ( Bajaj et al., 2021 ). However, physical reserves are related to events and conditions throughout the lifespan. For example, the combination of disadvantageous childhood socioeconomic conditions, coupled with adverse adult socioeconomic conditions, increase the probability of chronic health diseases ( Galobardes et al., 2007 ). Aging adults are thus not all equally vulnerable to the risks associated with COVID-19; their vulnerability is associated to a wide variety of life-course experiences and factors, only some of which directly related to age ( Oris et al., 2020 ; Sneed and Krendl, 2022 ).

3.3 Pandemic impact on older adults' wellbeing

In the context of the COVID-19 pandemic, researchers have studied different measures related to wellbeing, like loneliness, social isolation, worry, anxiety, and others. This section draws on the literature focusing on various experiences of wellbeing during the pandemic among older adults.

Following the implementation of virus containment and social distancing measures, many countries reported an increase in loneliness among older adults in comparison to pre-pandemic levels ( Luchetti et al., 2020 ; Seifert and Hassler, 2020 ; Holaday et al., 2021 ; Macdonald and Hülür, 2021 ; Rodney et al., 2021 ; Van Tilburg et al., 2021 ; Zaninotto et al., 2022 ; see also literature review by Su et al., 2023 ). Feelings of loneliness were particularly prevalent among older adults with no children, lower-income individuals, those living alone, and those reporting depressive symptoms ( Seifert and Hassler, 2020 ; O'Shea et al., 2021 ), which highlights the role of resources and reserves in mediating the pandemic's impact on wellbeing.

Furthermore, older adults in countries all around the world experienced higher levels of stress, worry, anxiety, and depression in comparison to pre-pandemic levels. These negative mental health outcomes were more common among older single adults, among older adults of lower socioeconomic groups ( Kola et al., 2021 ; Webb and Chen, 2022 ; Wettstein et al., 2022a ; Zaninotto et al., 2022 ), among those with poor self-rated health ( Wettstein et al., 2022a ), and among those who were already socially isolated prior to the pandemic ( Macleod et al., 2021 ). Social isolation is correlated to declining physical and mental health, increased mortality, and lower quality of life, and the social distancing measures introduced by the pandemic exacerbated these risks ( Macleod et al., 2021 ).

Most studies published to date, in May 2023, concentrate on the initial weeks of the pandemic and largely focus on singular countries. Atzendorf and Gruber (2022) 's research, however, focused on the weeks following the first wave, between June and August 2020 and used SHARE data to analyze the medium-term consequences of the first pandemic wave across 25 European countries and Israel. They found that older adults in countries with high death rates and stringent measures were at increased risk of feeling depressed or lonely. Similarly, Mendez-Lopez et al. (2022) used the same data and revealed that countries' greater stringency in physical distancing measures was associated with worse mental health. This is particularly pertinent for this paper, as both Italy and Switzerland were badly hit by the pandemic ( Ferrante, 2022 ; Pleninger et al., 2022 ), but they differed in containment strategies: while Italian residents were severely limited in their mobility, Swiss residents benefitted from a certain amount of freedom. Atzendorf and Gruber (2022) revealed that Italian older adults reported increased feelings of loneliness and depression after the pandemic onset to a greater extent than Swiss older adults.

The only study to date analyzing older adults' wellbeing during the two years following the pandemic onset showed that most older Europeans did not feel lonely before or during the pandemic. However, for some, feelings of loneliness increased, particularly among the less educated, those living alone, and those isolated at home ( König and Isengard, 2023 ).

Moreover, the characterization of older adults as a homogeneous, exceptionally vulnerable population ( Petretto and Pili, 2020 ; Seifert, 2021 ) engendered negative self-perceptions of aging ( Losada-Baltar et al., 2021 ; Seifert, 2021 ), which have been associated with loneliness and psychological distress among older adults ( Losada-Baltar et al., 2021 ). Their homogenous representation and the resulting ageist narrative also led to feelings of anger, increased anxiety, and perceptions of loss of autonomy and individualism by this older population ( Derrer-Merk et al., 2022a , b ).

Although research has documented the negative impact of the pandemic on older adults, studies have also suggested that in some ways, older adults did not suffer as much as their younger counterparts, as documented in the literature review by Seckman (2023) . Older adults in the United States reported less pandemic-related stress, less social isolation ( Birditt et al., 2021 ), and greater emotional wellbeing ( Carstensen et al., 2020 ) than younger adults. The same result was found among Chinese adults ( Jiang, 2020 ). Similarly, in Italy older adults reported less loneliness compared to younger age groups ( Luchetti et al., 2020 ).

Independently of the pandemic context, older migrants are more vulnerable to loneliness and social isolation due to language and cultural barriers, low social capital, and dependence on children for support ( Neville et al., 2018 ; Sidani et al., 2022 ). Moreover, older migrants often occupy disadvantaged socioeconomic positions and are in worse health than natives in the host country ( Bolzman and Vagni, 2018 ; WHO, 2018 ). The pandemic and the related reduced social contacts may have thus rendered older migrants particularly vulnerable to social isolation, loneliness and negative mental health outcomes ( Pan et al., 2021 ; Sidani et al., 2022 ). In fact, a study on older Chinese migrants in Belgium and the Netherlands revealed that reduced social participation and financial insecurity increased migrants' loneliness levels ( Pan et al., 2021 ).

Furthermore, migrants often engage in transnational practices, linking them in various ways to their country of origin ( Ciobanu and Ludwig-Dehm, 2020 ). The pandemic restrictions changed some of these transnational practices through travel bans and border closures ( Nehring and Hu, 2022 ), which may influence older migrants' wellbeing. A survey conducted within the same research project as this paper, found that Italian migrants in Switzerland reported higher levels of worry about the COVID-19 pandemic than Swiss natives, and this difference is largely explained by engagement in transnational practices ( Ludwig-Dehm et al., 2023 ).

Despite the increasing proportion of older migrants in Europe ( UNDESA, 2020 ), research on the impact of the pandemic on older migrants' wellbeing is scarce.

3.4 Coping strategies of older adults

Research has shown that aging adults are capable of adapting and coping to various events and circumstances ( Klausen, 2020 ; Settersten et al., 2020 ). Coping refers to the cognitive and behavioral efforts one carries out to prevent, tolerate, or diminish certain situations ( Lazarus and Folkman, 1984 ; Carver, 2013 ; Biggs et al., 2017 ), and studies have found that older adults are particularly able to engage in such behaviors to diminish stressors ( Yancura and Aldwin, 2008 ; Carstensen et al., 2020 ). Coping strategies are often grouped into emotion-focused and problem-focused strategies ( Lazarus and Folkman, 1984 ; Aldwin and Revenson, 1987 ; Biggs et al., 2017 ). The first refers to strategies intended to regulate one's emotional reactions to the problem, while the latter refers to behaviors and cognitions aimed at directly managing or solving a problem ( Yancura and Aldwin, 2008 ; Biggs et al., 2017 ). This includes strategies aimed at avoiding thinking about the problem – like keeping oneself busy – as well as strategies aimed at finding the positive aspects of a stressful situation ( Aldwin and Yancura, 2004 ).

Older adults' ability to engage in these strategies can be partly explained by Carstensen's (2021) Socioemotional Selectivity Theory, which posits that social and emotional goals change depending on the perception of how much time one has left to live. As one grows older or approaches the end of their life due to illnesses or frailty, goals shift and people tend to value smaller and more meaningful social networks, they tend to spend more time with close partners, and they use cognitive resources to process more positive information ( Carstensen, 2021 ).

Another aspect related to older adults' coping abilities concerns the aforementioned reserves accumulated throughout the life-course. Accumulation of social resources, cultural and economic capital, health reserves, and the acquisition of coping skills allow older adults to endure stressful situations or, on the contrary, the lack of such reserves can penalize them ( Grundy, 2006 ; Cullati et al., 2018 ; Settersten et al., 2020 ).

In addition to the wellbeing consequences for older adults, studies have addressed the coping mechanisms developed by this population throughout the first wave of the pandemic. In a qualitative study, Gonçalves et al. (2022) interviewed older adults in Brazil, the United States, Italy, and Portugal, and revealed that social isolation engendered feelings of restriction in terms of interaction with friends and family and ability to participate in leisure activities. At the same time, older adults were also able to cope with the situation by dedicating their time to hobbies, using technological resources to stay close to friends and family, or involving themselves in religious and spiritual activities. Despite the different cultures and contexts of this study's participants, researchers found homogeneity in their coping mechanisms. Several studies confirmed these findings with different samples of older U.S. American adults ( Finlay et al., 2021 ; Fuller and Huseth-Zosel, 2021 ; Whitehead and Torossian, 2021 ), and Bustamante et al. (2022) revealed that time spent in parks and outdoor spaces boosted physical, mental, and social wellbeing.

Similarly, Mau et al. (2022) found that for older Danish adults, adapting to the situation by reframing their mindset, finding ways to maintain social contacts and a sense of community, and staying active were important coping behaviors that helped them maintain a good level of wellbeing. In Italy, older adults experienced the first pandemic wave in heterogeneous ways: those who felt alone pre-pandemic expressed that isolation had a negative impact on their wellbeing. Others were able to cope with the situation by exploring hobbies and maintaining contacts with friends and family through telephone use ( Cipolletta and Gris, 2021 ).

However, the only study on older migrants' wellbeing and coping strategies by Pan et al. (2021) found that neither problem-focused coping strategies, nor emotion-focused coping protected against increased loneliness during the pandemic.

These studies reveal that, at least for the first half of 2020, older adults employed coping mechanisms to endure the pandemic, but we still know little of their experiences after the first COVID-19 wave. A longitudinal qualitative study on Canadian older persons explored their experiences over a 10-month period from May 2020 to February 2021 ( Brooks et al., 2022 ). It found that the longevity of pandemic restrictions was partially responsible for older adults' declines in wellbeing. Simultaneously, participants used similar coping mechanism employed during the first pandemic wave to maintain their wellbeing: they stayed active, found ways to stay in contact with friends and family, and adopted positive mindsets.

Nonetheless, cross-country research on the experiences of wellbeing among older adults, and more particularly in the years following the pandemic onset, is still scarce. We therefore aim to bridge this gap by exploring the lived experiences and coping mechanisms of older individuals in two countries that had contrasting COVID-19 containment measures like Italy and Switzerland. Furthermore, we analyze how having connections to both countries, as is the case of Italian migrants in Switzerland, influences the lived experiences of these individuals.

4 Data and methods

Our study focuses on three groups of older adults (65+): (1) Swiss natives, defined as individuals who were born in Switzerland and whose parents were also born in Switzerland, (2) Italian international migrants from the south of Italy, defined as individuals who were born in southern Italy, whose parents were also born in Italy, and who migrated to Switzerland, and (3) Italian natives, defined as those who were born in the south of Italy, resided in the south of Italy at the time of the research, and whose parents were also born in Italy. There are several reasons for the inclusion of these specific groups in our study. First, Italians constitute one of the largest cohorts of foreign nationals aged 65 and above residing in Switzerland ( FSO, 2020 ). Second, a significant part of older Italians migrated to Switzerland between the 1950s and 1970s, with the majority originating from economically disadvantaged regions of Southern Italy ( Wessendorf, 2007 ). They primarily migrated for financial reasons or to reunite with family who had relocated as labor migrants ( Bolzman et al., 2004 ; Riaño and Wastl-Walter, 2006 ), and we therefore analyze older adults with a very specific migration background. Third, by comparing migrants from Southern Italy to natives from the same regions, we can explore the lived experiences of individuals who were raised in similar social contexts.

The sample for this paper is derived from an original quantitative survey conducted between June and November 2020 in the project TransAge: “Transnational aging among older migrants and natives: A strategy to overcome vulnerability.” Respondents to the qualitative interviews had already participated to the TransAge survey and had agreed to be further contacted for a follow-up interview. In total, 31 individuals participated to the study, of which 11 were Swiss natives, 10 were Italian migrants residing in Switzerland, and 10 were Italian natives residing in Italy.

To ensure diversity of wellbeing experiences among each of the three groups, we attempted to recruit individuals with low and high levels of life satisfaction. To do so, we based ourselves on Diener's Satisfaction with Life Scale ( Diener et al., 1985 ), included in the TransAge questionnaire. More specifically, we focused on the scale item “I am satisfied with my life.” In the survey, participants were asked to indicate the strength of their agreement with this statement on a scale ranging from 1 (strongly agree) to 7 (strongly disagree). We thus contacted a roughly equal number of participants who stated being satisfied with their lives (scores 6 or 7) and participants who were less satisfied (scores 5 or less). Simultaneously, we checked the general life satisfaction scores drawing on the 5-item scale to assure coherence between the single-item and the total score ( Diener et al., 1985 ).

The first author conducted semi-structured one-to-one interviews with the 31 community-dwelling older adults between December 2021 and March 2022, during the fifth wave of COVID-19, when social distancing was still strongly advised. Consequently, all interviews were done by telephone, 1 except for one participant who preferred to meet in person. Participation in the study was voluntary, and all participants gave oral consent to be interviewed and recorded. Interviews lasted an average of 45 min, and they were conducted in French or Italian. They were audio-recorded and subsequently transcribed verbatim and anonymized. Participant quotes in this paper were translated into English by the first author, and every participant was given a pseudonym.

Participants were asked open-ended questions that prompted them to reflect on their experiences throughout the pandemic. First, they were asked to describe their feelings at the beginning of the pandemic, any impact that the confinement period had on their wellbeing, on their social habits, oron their daily lives. They were also encouraged to share how they coped with this period. They were then asked to reflect on the years after the onset of the sanitary crisis and describe any difficulties they faced and any strategies used to surmount these difficulties. Participants were also invited to share what their daily and social lives looked like at the time of interview, and how they felt about any long-lasting changes they may have experienced.

Interviews were analyzed using an inductive thematic analysis using qualitative coding software NVivo. The study was approved by the Ethics Committee of the Faculty of Social Sciences of the University of Geneva.

5.1 Sample description

The 11 Swiss natives and 10 Italian migrants resided in the Swiss cantons of Geneva, Vaud, or Ticino, while the 10 Italian natives resided in the Italian regions of Sicily, Apulia, Sardinia, Abruzzo, Basilicata, or Campania. Participant characteristics by group are shown in Table 1 . In comparison to the larger TransAge quantitative study, there is an over-representation of participants with medium and higher level of education among Italian migrants and natives, which will be taken into consideration in the discussion of the results.

Table 1 . Sample charactertistics.

5.2 Comparative accounts of wellbeing in times of pandemic

When recounting their experiences throughout the first 2 years of the pandemic in Switzerland and Italy, participants across the three groups coupled their narratives, whether positive or negative, with coping strategies they employed to manage the impact of the pandemic on their wellbeing. The themes that we identified correspond to emotion-focused coping and problem-focused coping strategies documented in the coping literature ( Lazarus and Folkman, 1984 ; Aldwin and Revenson, 1987 ; Biggs et al., 2017 ). Emotion-focused coping refers to strategies aimed at regulating the emotions that arise because of a stressful situation, which also includes engagement in activities as a way to distract oneself. Problem-focused coping, on the other hand, refers to behaviors and cognitions targeted toward solving or managing a problem ( Yancura and Aldwin, 2008 ). Strategies like social contact through telephone use involves elements of both emotion-focused and problem-focused coping. It refers to emotional support received by friends and family, it can entail concrete help in understanding how to confront an adverse situation, and it is a strategy directed at compensating for decreased in-person contact ( Aldwin and Yancura, 2004 ).

Table 2 shows the behaviors adopted by participants that correspond to these two overarching coping mechanisms. We found that certain strategies adopted during the first lockdown were no longer used at the time of interview. Thus, in Table 2 , we list the themes found in the data by pandemic period.

Table 2 . Coping strategies used at pandemic onset and at time of interview.

During the first months of the pandemic, the primary emotion-focused strategies adopted by older adults in our sample related to acceptance of the health crisis, keeping busy through hobbies and exercise, appreciation of the natural environment, and attitudes aimed at “finding the silver lining,” which involves strategies aimed at trying to find the positive aspects of the problem at hand, and which the literature often refers to as cognitive reframing ( Aldwin and Yancura, 2004 ; Robson and Troutman-Jordan, 2014 ). In terms of problem-focused coping, participants evoked the importance of social distancing measures both during the initial lockdown and at the time of interview, and many later relied on vaccines as a mean to decrease the probability of severe illness.

The subsequent sections are organized as follows: First, we detail, by group, participants' experiences of wellbeing during the first lockdown and the coping strategies they adopted to face this period. Then, we analyze how social distancing measures and decreased social contacts impacted participants in each of the three groups, and we outline participants' social habits and coping strategies at the time of interview.

5.2.1 Wellbeing during the first lockdown

Although participants in all three groups used similar coping strategies throughout the pandemic, their narratives of wellbeing differed.

5.2.1.1 Experiences of Swiss natives

All Swiss native older adults, except for one, described the first confinement period in positive terms and expressed not having been particularly bothered by it. They often associated their wellbeing to being able to keep busy through various hobbies and interests, and by enjoying the natural landscapes around them, as indicated in the following excerpts:

“I think I was very relaxed…I have so many books at home...I have the watercolors, I have so many things to do here, creatively, with my hands or with my head, it doesn't bother me, so...the confinement didn't bother me at all.” (Irène, 77, F, Swiss native) “So, at home, my wife plays the piano. She has a gentleman who comes to the house. Oh yeah, she hasn't had a lesson in a year at home, but she took lessons with Zoom. You know how it is. So, she has a lot of work, piano homework. I did a little bit of crafting. I did a little bit of Spanish with French-Spanish classes.” (Nicolas, 71, M, Swiss native) “We remained a little locked up. But we had…it was a beautiful weather. There was the spring and everything, everything was beautiful. We enjoyed our patio. We got back to reading. We did a lot of stuff like that.” (Lydia, 79, F, Swiss native)

Some Swiss participants mentioned increased telephone use to share moments with friends and family. Others described their wellbeing by comparing themselves to others, thus engaging in cognitive strategies to frame their attitude and outlook on the situation. François, for instance, often spends part of the year in Barcelona, and when talking about his wellbeing, he compares the Swiss restrictions to those of Barcelona. He elaborates:

“We were very lucky because we weren't confined like…in Barcelona. In Switzerland, that wasn't the case. Of course, there were things we couldn't do any more, but there was still a lot for us to do. We could take the car, we could go for a walk. Well, the borders were closed. Well, we didn't suffer, my wife and I…our sons either.” (François, 81, M, Swiss native)

When reflecting on the virus-containment measures, others simply stated that they just had to accept the situation and adapt their behaviors accordingly. Pierre, for example, states:

“You have to adapt. We adapt by respecting the rules, not like people who cheat [by not following the rules]. We respect the rules, but we adapt.” (Pierre, 71, M, Swiss native)

Overall, the first months of the pandemic were described in positive terms by most of Swiss older adults. Most of them portrayed themselves as being in good health and they did not evoke fears related to the virus. However, one Swiss participant expressed the negative impact of this period on his wellbeing. He recounts:

“[We lived this period] quite badly because we were old, very old. The Ticino police chief was more or less telling everybody to put us in the freezer. I mean, not quite like that…he made a statement that caused quite a stir…[The situation] was not very conducive to being cheerful, let's say.” (Gianni, 88, M, Swiss Native)

For Gianni, the government lockdown meant being “stuck at home,” as he says, and relying on institutional support. His quote shows the way he experienced the confinement measures and the public discourse as an older-old person.

5.2.1.2 Experiences of Italian migrants in Switzerland

Similarly to Swiss natives, Italian migrants residing in Switzerland used cognitive strategies to frame the lockdown's impact on their wellbeing. They, too, evoked Switzerland's lenient containment measures as an important aspect that helped them surmount this period, particularly in terms of the freedom it gave them to spend time in nature. Giulia, for example, explains:

“Here in Switzerland, here in Geneva, I didn't feel this need for freedom like in other countries. For me, we were free here. I live near a park, I could take my walk every day. I have a small but very nice little apartment that has visibility on both sides, left and right, so I didn't feel like I was in prison.” (Giulia, 70, F, Italian migrant)

Italian migrants also turned to activities like reading, taking walks, and exercising to keep themselves busy during this period. However, although they lived the pandemic in the same context as the Swiss natives, there was more heterogeneity in Italian migrants' narratives of this containment period. While most stated that they simply accepted the situation and the lockdown did not negatively impact their wellbeing, some expressed feelings of loneliness and isolation. Gabriele (69, M), for example, says he felt isolated from the outside world at the beginning of the pandemic, he described his life during this period as monotonous. However, he kept himself busy by going on walks and exercising.

Others tried to overcome their feelings of loneliness by staying in communication with family, but it was not always helpful. When asked about any difficulties he faced during the lockdown, Alberto explains:

“A little bit of loneliness and missing family, that's it. It weighed on me a little bit. We used to phone my children, but no luck. My children also suffered; my youngest daughter suffered a lot and now we slowly recover.” (Alberto, 77, M, Italian migrant)

Italian migrants in Switzerland still hold transnational ties to their country of origin; a quantitative analysis of the TransAge survey found a higher level of worry about the pandemic among Italian migrants in Switzerland in comparison to Swiss natives ( Ludwig-Dehm et al., 2023 ). We were therefore interested in investigating whether Italian migrants evoked the COVID-19 situation in Italy when describing their own experiences of wellbeing, but none of our participants organically elicited Italy's situation in their narratives. We subsequently asked participants whether they were impacted in any way by the pandemic in Italy, and responses were heterogeneous. A large part expressed not having been impacted at all, others stated that they were sorry for the high numbers of deaths in Italy and they kept in contact with family, but were not particularly affected. Few of our participants, however, disclosed the emotional suffering they experienced due to Italy's high death rates, as demonstrated by the following quotes:

“I felt tremendous suffering […] I followed a lot, every day I was watching the Italian news. And it was, for me it was just – I don't want to say worse than the war, it was a virtual war, people dying without weapons, people dying without the bombs, without being machine-gunned, but they were dying like flies.” (Giulia, 70, F, Italian migrant) “Terrible, I felt really bad, I mean I don't know why we got to that point.” (Sara, 78, F, Italian migrant)

Although Italian migrants and Swiss natives lived the pandemic in the same context and both used similar coping strategies during the first confinement period, interviews show that Italian migrants' experiences were slightly more heterogeneous than Swiss natives', with a few migrants expressing feelings of loneliness and emotional anguish, emotions that were absent in Swiss natives' accounts.

5.2.1.3 Experiences of Italian natives

In comparison to Swiss natives and Italian migrants in Switzerland, most Italian natives residing in Italy expressed feelings of worry, sadness, and fear when recounting their lockdown experiences, but most of them coupled their hardships with feelings of acceptance. Tommaso, for example, recounts:

“To hear on television, from the media, that there are deaths and deaths and deaths, obviously the concern is there. The fear, the terror even, of suffering these negative effects.” (Tommaso 84, M, Italian native)

But later, when discussing the lockdown, he continues:

“I stayed peacefully at home with a nice long beard, growing it out. I accepted it, though, because those were the rules. You had to accept them.” (Tommaso, 84, M, Italian native)

Similarly, Paolino couples the dismay brought on by the pandemic lockdown with feelings of acceptance, as well as behaviors aimed at avoiding contagion. He explains:

“The beginning of the pandemic I accepted it begrudgingly, at home, and I stayed at home despite my habits, because having lived a life always on the move – until now I was always around. That thing, the pandemic, I accepted it, and for 3 months I stayed at home, I would only go get some groceries, the bare minimum.” (Paolino, 86, M, Italian native)

In contrast to Swiss natives and Italian migrants, few Italian natives mentioned having turned to hobbies to fill up their time during the first lockdown. Some mentioned the importance of spending time outside, of having a balcony or a garden. Most of them cited phoning friends and family for emotional support, to pass time, and to update each other on their health, and most declared having used the phone for communication more than pre-COVID times. To respect social distancing rules, one participant even used intercom to communicate with family in the same building; she says:

“We used to talk to each other by intercom and by phone, we all live in the same building, so by intercom, by phone we used to talk to each other, and then if somebody went out, they would walk by the kitchen door, which was made of glass, and then we would see each other.” (Rosa, 71, F, Italian native)

Despite the coping strategies employed by Italian natives, their narratives of the lockdown presented an overarching theme of dejection, which was less present in Italian migrants' experiences and nearly absent in those of the Swiss natives in our sample.

5.2.2 Wellbeing after 2 years of the COVID-19 pandemic: the role of social contacts

Notwithstanding the different narratives of wellbeing among the three groups, the previous sections indicate that everyone inevitably experienced a decrease in physical social contacts resulting from the COVID-19 containment policies. Given the importance of social networks for individuals' wellbeing ( Helliwell and Putnam, 2004 ; Elgar et al., 2011 ; Amati et al., 2018 ), we aimed to inquire how social distancing regulations impacted participants' perceived wellbeing in the 2 years after the onset of the pandemic.

Our interviews reveal heterogeneous responses to social distancing; nonetheless, regardless of the perceived impact on their wellbeing, most participants employed behavior-focused coping strategies aimed at reducing probability of contagion and illness. These strategies consisted of either vaccination for the participant, social distancing habits, or a combination of the two. In some cases, these strategies were successful in supporting participants' experienced wellbeing. In other cases, they preserved one's physical wellbeing at the cost of their subjective wellbeing.

In the next sections, we explore how each of the three groups was impacted by decreased social contacts, how these sentiments developed throughout the pandemic, and how participants employed the above-mentioned coping strategies at the time of interview.

5.2.2.1 Experiences of Swiss natives

Just like the lockdown did not seem to negatively impact most Swiss older adults in our study, neither did the imposed social distancing measures and related decrease in social contacts. Most of them experienced a slight change of social habits, which entailed seeing friends and family less frequently during the previous 2 years in comparison to pre-COVID times. However, these changes did not have a consequential negative impact for most of our Swiss participants. Social distancing was often described as bothersome or strange, but easily managed. Martin, for example, states:

“Yeah, [the pandemic] restricts our freedom to see – as I'm a pretty tactile person, it's true that it changes me a little bit. Friends, I kiss them less. That's what affects me a little bit more – I have to be less, much less tactile than I was with everyone, to give kisses to the left and to the right. Well, it's a bit weird.” (Martin, 75, Swiss Native)

This quote represents the sentiments expressed by most Swiss natives: they were not completely unaffected, but they were able to adapt to the changes in social habits without important repercussions for their wellbeing. At the time of interview, nearly 2 years after the pandemic onset, most Swiss older adults explained their social habits were similar to their pre-pandemic habits, but they also adopted strategies to be able to fulfill their social desires while avoiding contagion or severe illness. Most Swiss participants mentioned being vaccinated and expressed the importance of listening to scientists' advice on the preventative measures to take. These strategies helped them adjust their behaviors accordingly and feel more protected. Martin, for instance, has resumed seeing friends, but only under certain self-imposed rules. He explains,

“If we see each other, we are all vaccinated. We are not safe from catching it but at least we are less likely to get sick. And then, we avoid those who don't want to be vaccinated or those who are not vaccinated.” (Martin, 75, Swiss native)

However, one Swiss participant shared the negative experiences that followed him and his wife throughout the course of the pandemic. During the lockdown, Gianni expressed being “stuck at home,” and this lack of freedom and decreased social contacts persisted until the time of the interview, 2 years later. He says,

“Now with these problems of…the danger of contagion, and so it makes us less, less mobile, less free to live, right? Basically now, even though the lockdown has not been declared, we try to go out as little as possible, not to mingle with people so we don't get infected.” (Gianni, M, 88, Swiss native)

While most Swiss older adults were able to resume their social lives by adopting behaviors to avoid illness, the social distancing measured employed by Gianni – the oldest among our Swiss participants – allow him to preserve his physical wellbeing at the cost of his subjective wellbeing.

5.2.2.2 Experiences of Italian migrants in Switzerland

In comparison to older Swiss natives, the perceived impact of social distancing measures was more heterogeneous among Italian migrants. At the time of interview, only a minority of participants said they had resumed their pre-pandemic social habits, although most slowly started seeing small groups of friends again. Like in Gianni's case, for many Italian migrants, the social distancing strategies adopted to preserve their physical wellbeing had negative repercussions on their experienced wellbeing. One participant, for example, shared that the fear of contagion remained even after containment restrictions were eased, and his personal relationships suffered. He explains,

“I lost touch with friends, you couldn't get together, you couldn't go shopping, the only thing I could do was go [walk] in the forest. Then, even when the restrictions were eased, it had affected me so much that it was hard to get together. When we got together […] we had a drink and then left. There was always that fear between us.” (Giacomo, 68, M, Italian migrant)

Giacomo looks back at his life before the pandemic with melancholy, but he also elicits the importance of acceptance and reframing one's mindset to surmount the situation. He shares:

“[Before COVID-19] we used to get together on Friday nights, play cards, drink, smoke, and for 2 years we haven't done it and I don't think we're going to start again. It's difficult because people have become distrustful, we've been wounded and we're licking our wounds. Let's put it this way. You have to get over it, direct your life differently and move on. I don't want to stay at home waiting for death.” (Giacomo, 68, M).

Although some participants were wary of resuming social activities at the time of interview, most slowly started seeing friends again while continuing to employ social distancing measures. Giulia, for instance, explains:

“[Before the pandemic] maybe we went to the restaurant once a month, or once every 2 months. But that was a lot. But we haven't done this anymore, and I didn't – and we don't even feel like doing it anymore. Now if we go to a restaurant, we go at noon…and we stand outside on the terrace because we keep being careful.” (Giulia, 70, F, Italian migrant)

Despite the slow return to a social life and the continued safety measures employed, the pandemic had a long-lasting impact on the wellbeing of most Italian older migrants, as evidenced by the following excerpts:

“I feel insecure, maybe because of the pandemic, because of the war that's going on 2 […] I feel insecure and I tell myself I don't need this […] Insecure in the sense that I say, enough of the pandemic; insecure not physically, but in the sense that it destabilizes me [mentally] […] In the sense that I used to be able to imagine the following years and now I can't.” (Sara, 78, F, Italian migrant) “It's 2 years that I lost and that I cannot get back. […] I lost 2 years that I won't get back. I don't even know if I'll be able to – to feel better.” (Giulia, 70, F, Italian migrant).

5.2.2.3 Experiences of Italian natives in Italy

The perceived impact of the social distancing measures was notably detrimental for the experienced wellbeing of Italian natives in Italy. Most cited the lack of social contacts as the primary difficulty faced throughout the pandemic. For many, the fear instilled by the pandemic prevented them from resuming their social activities at the time of interview, despite most participants being vaccinated. This engendered feelings of sadness, anxiety, and loneliness among many Italian participants, as evidence by the following quotes:

“What I dislike is not being able to have company, because I'm all about friendships, company, laughter, and I don't like loneliness. […Before the pandemic] we used to organize trips with an association, so we would spend 15 days together, and every 2 months we would meet in an institution and spend the day together, we would eat together. With girlfriends, we would go out and take a walk in the countryside when we had nice days, and so I miss all of that now.” (Martina, 84, F, Italian native) “Now the fact of going out and putting the mask on […], continually having to disinfect your hands when you go out, when you go get groceries, having to be careful not to get too close to people, [hoping] that in stores there aren't too many people. These – this anxiety that it gives you, that as long as you are at home, it's different. But when you go out for necessities, or go to the hospital for a visit – in short, it's anxiety, that's it. You try to – every person you meet seems to be an enemy.” (Rosa, 72, F, Italian Native) “I have a lot of fear, really a lot, and this has prevented me from going out and also from having a social life. My social life has almost disappeared, because partly the fear, partly my age, and so the result is that while before I used to go to concerts, I used to go to the movies, now we have – my husband and I – we have canceled everything, we don't go anymore, and so there is a lot of sadness.” (Alice, 75, F, Italian native)

Although some expressed feeling safer due to the vaccine, the fear induced by the virus was still present 2 years following the pandemic onset. Many Italian natives described the continued use of their phones to communicate with friends and family – more so than during pre-pandemic times – and this kept them company. Nonetheless, most expressed that while at the beginning they tried to accept the circumstances, the pandemic had started to weigh on them and negatively influence their wellbeing. Only one Italian native shared that the changes in social habits did not have a substantial impact on his wellbeing:

“[The pandemic] did not substantially change my life, nor my family's. Of course, there were occasions when we would have liked – during the holidays, for example – to spend more time with friends. We gave this up, and we think and hope that it was accepted by our friends. In any case, this withdrawal was nothing out the ordinary, so it was nothing irrational. Let's say that it did not affect our life, our wellbeing.” (Lorenzo, 74, M, Italian native)

Yet, even for a person like Lorenzo who estimates that his wellbeing was not lowered by the pandemic, his social habits have changed, which was observed for most of the Italian natives in Italy.

6 Discussion

The objective of this study was to provide insight into older adults' experiences of wellbeing as well as the coping strategies employed to overcome difficulties brought about by the pandemic, in particular social distancing. Our contribution to the existing literature is 4-fold: (1) we explored older adults' lived experiences not only through their recollection of the first months of the pandemic, but also through their narratives of wellbeing and coping 2 years after the pandemic onset, (2) we analyzed the experiences of older migrants, an underrepresented population in wellbeing and COVID-19-related research, (3) we compared the experiences of two groups – Swiss natives and Italian migrants – who lived the pandemic in the same context, and (4) we compared the experiences of older adults who were subject to strict containment measures – as was the case of Italian natives – to those of adults who benefitted from more lax restrictions.

The following section discusses the results of the qualitative interviews, as well as the study limitations and implications for future policy.

While many of our interviews highlight the negative consequences of the pandemic for older adults' wellbeing in Switzerland and Italy, they also emphasize the heterogeneity of older individuals' experiences, as well as their ability to adapt and cope with stressful situations. Swiss natives and Italian migrants lived the pandemic in the same context, one that did not impose strong stay-at-home order and allowed for a certain freedom of movement. Yet, we found pronounced differences in their descriptions of wellbeing, both in the narratives concerning the first lockdown in 2020, and in the narratives addressing the following years, until time of interview.

Most Swiss natives presented positive accounts of the lockdown period; their descriptions were often coupled with coping strategies they employed to address the COVID-19 containment measures. Consistently with previous studies on coping during the pandemic, in the first months of the pandemic Swiss older adults relied on hobbies to keep busy, closeness to nature, acceptance of the sanitary situation, and cognitive strategies to find the silver lining of living through a world-wide crisis ( Finlay et al., 2021 ; Fuller and Huseth-Zosel, 2021 ; Whitehead and Torossian, 2021 ; Brooks et al., 2022 ; Bustamante et al., 2022 ; Mau et al., 2022 ). Most participants described their wellbeing as unaffected even at the time of interview, 2 years after the pandemic onset. Although they described the inevitable decrease in physical contacts as bothersome, most were able to adopt behavioral strategies that involved vaccination and continued social distancing measures that kept them safe while fulfilling their social needs.

Even though Italian migrants experienced the pandemic in the same context as Swiss natives, their accounts of the lockdown and the following years were more heterogeneous. During the first months of the pandemic, they used coping strategies like those of the Swiss natives: they spent their time in nature, kept busy through hobbies, and they, too, positively referred to the freedom they felt due to Switzerland's relaxed containment measures. At this time, only some participants expressed feelings of sadness and loneliness. However, when reflecting on the entirety of the previous 2 years, most participants shared the negative impact of the pandemic on their wellbeing. Although many slowly resumed social activities at the time of interview, they evoked a continued sense of fear, distrust, and dejection. Many of their interviews demonstrated that the social distancing behaviors that allowed them to keep themselves physically safe diminished their wellbeing.

Due to the qualitative nature of this article, it is not possible to firmly assert that the different experiences of wellbeing among Swiss natives and Italian migrants are due to inequalities in reserves. However, we can posit that, at least for some Italian migrants in Switzerland, their ability to cope with the pandemic may have been partly influenced by their lower level of reserves in comparison to those of Swiss natives.

Most Italian migrants in our study migrated to Switzerland in the 1960s and 1970s, as part of the wave of labor migrants who moved from regions of Italy that lacked economic opportunities ( Bolzman and Vagni, 2018 ; Dones and Ciobanu, 2022 ). Quantitative studies have revealed that, compared to older Swiss natives, older Italian migrants in Switzerland have lower education levels, report themselves in worse health, and generally occupied lower-skilled jobs ( Bolzman and Vagni, 2018 ). For many, the migration to Switzerland as labor workers was followed by a lack of opportunities to improve their socio-economic circumstances, leaving them in worse situations in comparison to their Swiss counterparts. These disadvantaged conditions may have engendered psychological stresses that may have accumulated over the life course ( Dannefer, 2003 ; Settersten et al., 2020 ), thereby impacting migrants' ability to build the adequate reserves to successfully cope with life shocks.

In our qualitative sample of Italian migrants there is an overrepresentation of highly educated participants and of participants in a comfortable financial situation, as represented by the measure “making ends meet” in Table 1 ( Dones, 2023 ). However, on average they still have lower education levels than Swiss natives. Moreover, independently of current socioeconomic status, most participants spoke of the poverty and lack of jobs they experienced during their youth in Italy, which ultimately led them to migrate. In addition, when reflecting on other hardships encountered during their lifetimes, most cited the difficulties encountered when they migrated: discrimination, having to learn another language, detachment from family in Italy, and getting accustomed to a foreign country. Along with the disadvantaged socioeconomic conditions some participants experienced throughout the lifespan, most experienced migration-related stressors that, accumulated over the life course, may have impacted their capacity to cope with life shocks and with the pandemic in the same way that Swiss natives did. Moreover, the capacity to act in old age is dependent on the life course and the accumulation of reserves ( Settersten et al., 2020 ), making in this case a difference between the older Swiss and older migrants.

Although Italian migrants did employ similar coping mechanisms, for most, these coping strategies were not successful in combatting the negative impact of the pandemic on their experienced wellbeing. This finding is in line with research by Pan et al. (2021) , which revealed that coping strategies like increased telephone contact and increased participation in individual activities did not protect older Chinese migrants against loneliness.

Another possible explanation for the lower wellbeing expressed by Italian migrants compared to Swiss natives relates to transnational practices and attachment to the home country. Although participants did not mention their attachment to Italy when recounting their pandemic experiences, some did share the negative impact the Italian situation had on their wellbeing. Previous research stemming from the TransAge project has revealed that greater attachment to Italy correlates to greater worry about the COVID-19 pandemic ( Ludwig-Dehm et al., 2023 ), which may have thereby impacted Italian migrants' lived experiences. Similarly, we found one case of transnational attachment among Swiss natives. The ties to Barcelona led François to value the confinement situation in Switzerland.

In comparison to older adults residing in Switzerland, older Italian natives expressed more negative emotions and difficulties when describing both the first COVID-19 lockdown and the subsequent years. Most adopted coping strategies like acceptance and increased telephone use for social contact, but the fear brought about by the virus followed them until the time of interview. This prevented most from resuming social activities, despite being vaccinated, and many expressed continued feelings of sadness, loneliness, and anxiety.

When considering the particularly negative experiences of Italian natives in Italy, we cannot propose that these were related to the various types of reserves accumulated through life, as our participants led heterogeneous life-courses. Indeed, there may be a variety of influencing factors that have the potential to affect the wellbeing of older Italian adults. One of these factors could hypothetically relate to the strict confinement measures employed by the Italian government throughout the first 2 years of the pandemic. Research thus far has revealed that countries' stringency of physical distancing regulations was associated with higher incidence of loneliness and depression among older adults ( Atzendorf and Gruber, 2022 ; Mendez-Lopez et al., 2022 ). Additionally, a study on older adults in Italy showed that restrictive measures significantly impacted the quality of life, psychological wellbeing, and mobility of older adults ( Tosato et al., 2022 ). Although no studies have yet been published on the long-term consequences of strict containment measures, our exploratory results could point to the negative impact of such regulations on older adults' experiences of wellbeing. However, this is simply a theoretical proposition and further studies on the subject are needed to firmly establish a correlation between stringency of confinement regulations and wellbeing.

Moreover, Italian natives relied on telephone communication as a coping mechanism more than the other two groups. While staying in touch with family and friends through phone and other media use has been correlated with life satisfaction during the first semi-lockdown in Switzerland ( Dones et al., 2022 ), studies found that non-personal communication does not substitute face-to-face interactions and it is not a protective strategy against loneliness among older adults ( Pan et al., 2021 ; König and Isengard, 2023 ). Further research should thus address the effectiveness of different coping strategies in times of crisis.

6.1 Limitations, strengths, and suggestions for future research

This study does not come without limitations. Due to the qualitative nature of the research and the relatively small sample size, results cannot be generalized even though saturation of responses was reached. In addition, our study did not explore the experiences of many people who lived alone during the pandemic, a population that might have been particularly at risk of social isolation. Similarly, there is a possibility that older adults with lower levels of wellbeing may not have been willing to participate to the research, although some research participants shared their difficulties and negative experiences of the pandemic. Lastly, to be able to better understand the role of reserves in older adults' experiences of the pandemic, longitudinal, quantitative data would be necessary.

Nonetheless, this article sheds light on several aspects. First, despite the homogeneous representation of older adults as frail and vulnerable ( Petretto and Pili, 2020 ; Ayalon et al., 2021 ; Maggiori et al., 2022 ), the pandemic impact on wellbeing is not the same for all older adults, as demonstrated by emerging studies ( Wettstein et al., 2022a , b ) and by the different experiences of this article's older populations. Second, despite the employment of coping strategies used by all participants, their effectiveness in mediating the long-term impact of the pandemic on experiences of wellbeing differed among groups. Third, the long-term impact of the pandemic and the various containment strategies needs further examination. As the case of Italian migrants in Switzerland shows, some older migrants experienced the beginning of the pandemic in quite positive ways, but their narratives of their situation 2 years after the pandemic onset showed an overall negative effect on their wellbeing.

The share of older adults in Europe continues to increase ( Eurostat, 2023 ), as does the share of older migrants ( UNDESA, 2020 ). The advancements of the last few decades have reduced the dependence of older adults and have increased life expectancy. At the same time, social inequalities and inter-individual diversity make of today's older adults an increasingly heterogeneous group ( Oris et al., 2020 ). The consideration of this heterogeneity should be at the core of not only scientific research, but also of policy interventions, as grouping all older adults under the “vulnerable and frail” umbrella propagates against narratives that can lead to increased psychological distress and negative self-perceptions of aging ( Losada-Baltar et al., 2021 ; Derrer-Merk et al., 2022a , b ).

To account for the diversity in older adults' lives, research on the long-term impact of the pandemic should adopt a life-course approach to further analyze how differing trajectories engender situations of resilience or vulnerability. Given the increase of share of older migrants, their underrepresentation in COVID-19 and wellbeing research, and the possible long-term effects of having a migration background, special consideration should be allotted to them. Moreover, studies should further address the effectiveness of coping strategies among different populations. Lastly, in cases of future health crises, governments should have an increased regard for the negative consequences of stringent confinement measures, as social isolation and physical inactivity among older adults are correlated with increased hospitalization, depression, cognitive impairment, and reduced quality of life ( Cacioppo et al., 2010 ; Cacioppo and Cacioppo, 2014 ; Ozemek et al., 2019 ).

Data availability statement

The datasets presented in this article are not readily available because the qualitative interviews analyzed in this study are not publicly available. For now, they are available from RC on reasonable request. Requests to access the datasets should be directed to RC, oana.ciobanu@hetsl.ch .

Ethics statement

The studies involving humans were approved by the Ethics Committee of the Faculty of Social Sciences of the University of Geneva. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin because participation in the study was voluntary, and all participants gave oral consent to be interviewed and recorded.

Author contributions

ID drafted the interview guidelines, carried out the data collection and analysis, and was the major contributor in writing the manuscript. RC supervised the project, reviewed and approved the interview guidelines, provided article references, read parts of the interviews, and contributed to the discussion and conclusion. All authors read and approved the final manuscript.

This work was funded by the Swiss National Science Foundation through the Professorship Grant “Transnational Aging among Older Migrants and Natives: A Strategy to Overcome Vulnerability” (Grant Number PP00P1_179077/1).

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.

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Keywords: migration, coping, subjective wellbeing, health crisis, vulnerability

Citation: Dones I and Ciobanu RO (2024) Older adults' experiences of wellbeing during the COVID-19 pandemic: a comparative qualitative study in Italy and Switzerland. Front. Sociol. 9:1243760. doi: 10.3389/fsoc.2024.1243760

Received: 21 June 2023; Accepted: 15 April 2024; Published: 01 May 2024.

Reviewed by:

Copyright © 2024 Dones and Ciobanu. 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: Iuna Dones, iuna.dones@hesge.ch

This article is part of the Research Topic

Community Series in Mental Illness, Culture, and Society: Dealing with the COVID-19 Pandemic, volume VIII

Open access
Published: 30 April 2024

Explaining the barriers faced by veterinarians against preventing antimicrobial resistance: an innovative interdisciplinary qualitative study

Razie Toghroli 1 ,
Laleh Hassani 1 ,
Teamur Aghamolaei 1 ,
Manoj Sharma 2 ,
Hamid Sharifi 3 , 5 &
Maziar Jajarmi 4

BMC Infectious Diseases volume 24 , Article number: 455 ( 2024 ) Cite this article

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Considering the significance of increased antimicrobial resistance (AMR) and its adverse effects on individual and social health and the important and effective role that veterinarians play in controlling this growing issue worldwide, it is essential to have effective preventive control programs. To this aim, the first step is to identify the factors behind the prevalence of AMR in Iran and the barriers veterinarians face to controlling this problem. Thus, the present study was conducted to explain the barriers veterinarians faced in the prevention of AMR from an Iranian veterinarian’s perspective.

The present research was done in three cities in Iran in 2021. The data were collected through in-depth interviews with 18 veterinarians selected through purposive and snowball sampling and analyzed using conventional qualitative content analysis.

The data analysis results were classified into 4 main categories and 44 subcategories. The former included: educational factors, administrative/legal factors, client-related factors, and veterinarian-related factors.

Conclusions

The increased AMR can be approached from multiple aspects. Considering the different factors that affect the increased AMR, it is necessary to consider them all through effective planning and policy-making at multi-level and multidisciplinary dimensions. There is special attention needed to scientific and practical interventions at the individual, interpersonal, social, and even political levels. At the same time, measures should be taken to rehabilitate and maintain the health of society to strengthen supervision and attract the full participation of interested organizations.

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Introduction

Antimicrobial resistance (AMR) refers to the reduced effectiveness of antimicrobial agents, such as antibiotics, antivirals, antifungals, and antiparasitics, against infections caused by bacteria, viruses, fungi, and parasites [ 1 ]. This phenomenon makes infections harder to treat and increases the risk of disease spread, severe illness, and death. Misuse and overuse of these agents in humans, animals, and plants are key contributors to the development of AMR. AMR is a natural process that occurs gradually over time through genetic changes in microorganisms, but human activities, particularly the improper use of antimicrobials, significantly speed up this process. Veterinarians play a vital role in managing AMR, as they frequently prescribe antimicrobials to protect animal health. However, overprescription and misuse of antimicrobials in veterinary practice contribute to the development of AMR in humans. AMR presents a substantial challenge to global public health and economic stability. If left unchecked, AMR will lead to increased healthcare costs, decreased productivity, and potentially millions of avoidable deaths annually. To combat AMR, governments, healthcare providers, and researchers must collaborate to implement policies promoting judicious antimicrobial use, invest in innovative therapies, and foster educational initiatives to empower individuals to understand the importance of responsible antimicrobial stewardship [ 2 ].

AMR is an increasingly global issue that needs to be settled cooperatively. Resistant organisms exist in animals, humans, the environment, the food, and the main cause of this, is antimicrobial usage. AMR will become a leading cause of mortality in the world in the near future. As reported by some studies, by 2050, AMR will be the main cause of death on a global scale, which surpasses cancer deaths [ 3 , 4 ].

The mortality rate caused by microbial resistance is higher than the total number of deaths induced by cancer worldwide. Yet, the former has been largely neglected and, instead, issues such as cancer and how to treat it have been addressed more [ 5 , 6 , 7 ].

Unintentional antibiotic ingestion occurs frequently due to the widespread use of antibiotics in society. According to a report from 2010, approximately 10 pills, capsules, or teaspoons of antibiotics are taken annually by every person on Earth, which suggests a high degree of accidental consumption. Healthy individuals who consume significant amounts of antibiotics unintentionally may experience negative impacts on their health, particularly concerning the disturbance of the normal microbiome. This disturbance can lead to long-term complications, such as an increased risk of developing conditions like type 1 and 2 diabetes, inflammatory bowel diseases, celiac disease, allergies, and asthma [ 8 ]. Additionally, antibiotic exposure can contribute to the emergence of antibiotic-resistant strains, posing a challenge to public health. It is essential to note that antibiotics are necessary and lifesaving medicines when used appropriately under medical supervision. However, excessive or unnecessary use of antibiotics can pose risks to individual and population health [ 9 , 10 ].

According to the report of the World Health Organization, half of the antibiotics produced in the world are used in medicine and the other half in veterinary, agriculture and aquaculture [ 11 ]. In general, there is no difference between antibiotics used in veterinary medicine and antibiotics used in medicine. These drugs are used to prevent and treat diseases and promote growth in animal farms (pigs and poultry), unfortunately, the use of antibiotics in veterinary medicine leads to leaving residues in meat, milk and eggs [ 12 ]. Drug residues in food have adverse effects such as antibiotic resistance in humans, allergies, and inhibition of bacterial starter cultures used in dairy fermentation industries [ 13 ]. Despite the beneficial effects of antibiotics on the treatment of livestock infectious diseases, the presence of their residues in milk and animal meat, as well as their transfer to the human body have adverse effects on health, industry, and economics. As reported by the National Center for Rational Prescription of Antibiotics, consuming antibiotics in Iran is 16 times as high as the global standard. Some researchers believe that the spread of microbial resistance to antibiotics results not only from the unnecessary prescription and use of these compounds in humans but also from the widespread use of antimicrobial drugs in veterinary medicine. It has caused the transfer of such pathogenic bacteria from animals to human pathogens. The main difference between microbial resistance to antimicrobial drugs in humans and animals is that microbial resistance in humans affects the individual, whereas microbial resistance in livestock affects a large population due to the consumption of raw animal products by humans. Exposure to both resistant bacteria and antibiotic compounds prescribed for the treatment of infectious diseases for livestock through transmission causes the accumulation of drugs and drug residues in raw livestock products. It seems that attempts to prevent the occurrence of microbial resistance in livestock and its consequences for humans are effective and can be implemented efficiently by veterinarians and those active in this domain. What veterinarians can do with this respect is wide-ranging.

Most of the studies conducted in Iran in the field of antimicrobial resistance were in the medical and human fields, and the studies conducted in the veterinary field were mostly quantitative. A systematic review and meta-analysis showed a high level of antibiotic resistance in Staphylococcus aureus bovine mastitis in Iran. This pathogen is the common and main cause of bovine bacterial mastitis, which leads to high economic losses and can easily lead to the transmission of these treatment-resistant bacteria to humans [ 14 ]. In a qualitative study, which is one of the few qualitative and phenomenological studies conducted in Iran in the field of AMR, the lived experience of livestock breeders, their role and views in this field has been investigated. The results of this study have confirmed the importance of antibiotic resistance in Iran and the lack of existing research in this field, especially with a qualitative approach [ 15 ]. In another study that was conducted with semi-structured interviews with key stakeholders in Iran, including managers of the Ministry of Health, Iran Veterinary Organization, national professional associations and researchers through thematic analysis, the international enabling and predisposing factors related to It identified the control of AMR in Iran. The enabling factors that have been highlighted in this review were discussed in general, and more attention was paid to political factors such as formulation and implementation processes, and AMR surveillance, and challenges such as the smuggling of infected animals and antimicrobial drugs and livestock from neighboring countries and the impact of imposed sanctions. The review emphasizes the global nature of AMR as a challenge that requires consensus and international cooperation to effectively deal with this issue, but it does not specifically and specifically deal with why and analyze how AMR occurs and examine ways to prevent it, and only generally with the approaches Emphasizes political, including health diplomacy, to strengthen national efforts in the fight against AMR [ 16 ]. However, the present study, in an interdisciplinary manner, has specifically addressed one of the most important fields involved in the occurrence of AMR in human societies, and a field similar to it has received less attention before.

Yet, it is hard to make interventions with veterinarians directly involved because they are not easily available for research; therefore, veterinary students are the best and closest population for interventional studies. If this population adequately understand the principles of prescribing antibiotics, this successful learning will be productive in practice too [ 17 ].

Overcoming this problem will be possible with an One health approach, taking into account humans, animals, and environmental health altogether [ 18 , 19 , 20 ].

Today, AMR occurs in humans, wildlife, domestic animals, plants, and our environment directly by using antibiotics, and there is a risk on a much larger and more significant scale in animal-source foods consumed by humans indirectly. So it is logical to take a multidisciplinary health approach to solve this problem by eliminating the inappropriate use of antibiotics [ 21 , 22 ].

In the medical domain, extensive research has been done to examine physicians’ beliefs about prescribing antibiotics [ 23 ]. Many interventions have been made to reduce physicians’ over-prescription. The various aspects of antibiotic prescription have been extensively investigated so far in medical and clinical sciences. However, these interventions alone have not managed to prevent the occurrence of this important event. Thus, resolving this problem needs a multidimensional approach [ 24 ] .

Moreover, veterinarians prescribing drugs without using paraclinical services and selling over-the-counter (OTC) drugs are very common in several countries including Iran. In many stockbreeding industries, antibiotics are widely used not only for medical purposes but also as growth stimulants. There has been a serious lack of effective monitoring of these patterns of use. Similarly, there has scarcely been any strict preventive rule for this. Thus, it is likely that the AMR incidence rate is high in countries such as Iran [ 25 , 26 ].

A vast majority of research so far on the effect of AMR has only addressed this issue in human health [ 16 , 24 ]. In veterinary medicine, the body of existing literature has been limited to laboratory research and animal health. Veterinarians’ role in integrated health, especially AMR has not been adequately addressed. Therefore, there is no complete and clear understanding of veterinarians’ mental patterns and perceived social barriers to their decisions during diagnosis and treatment [ 27 ].

The over-prescribing of drugs is very common in animal products and animal-source foods (to be consumed by humans) in Iran. Moreover, each of these foods contains antimicrobial residues. Thus, it can be conjectured that people ingest significant amounts of antibiotics every day unintentionally without suffering from any infectious disease. Therefore, veterinarians must pay adequate attention to AMR in human health [ 28 ].

Overall, the world is faced with increasing availability and misuse of antibiotics in veterinary medicine, which threatens public health. There is a significant increase in AMR on a global scale, and there is a threat of increasing infections that do not respond well to treatment. It is essential to take appropriate measures and plan to prevent the over-prescription of antibiotics by veterinarians. There is an increasing need for education and empowerment policies, all deemed impossible unless the barriers facing veterinarians are recognized in appropriate prescribing. In other words, to deal with the AMR issue, the first step is to identify the causes and underlying contributing factors to this event in veterinary medicine and the disastrous conditions veterinarians face in Iran and the world. It is not possible to adequately approach what veterinarians go through and how they perceive the existing context only through quantitative research. A qualitative approach is needed to explore all aspects of this problem. Therefore, the present study employed this approach to explore the Iranian veterinarians’ perceptions of barriers to AMR prevention. We hope that the results generated from this study will help promote programs to curb slow down and the development of AMR in Iran and the world. The present findings can be used to make new social, economic, and even political decisions.

Materials and methods

Research design.

This research was conducted with a qualitative approach and qualitative content analysis method from three cities of Iran: Kerman (with a large population of large and small livestock), Bandar Abbas (a fishing and aquaculture hub), and Tehran (with a large population of pets and industrial poultry). The present qualitative study used semi-structured interviews with veterinarians who had experience in treating and prescribing antibiotics or office work in veterinary medicine, or those with sufficient experience and knowledge of issues in veterinary diagnosis and treatment. The interviews were held face-to-face from May 3, 2021 to August 13, 2021. In this study, theme analysis was used, which is a common type of qualitative content analysis. It seeks a deep understanding of the complexity, details, and embedded context of a given phenomenon. In this type of analysis, interviews with individuals provide a better understanding and richer information about participants’ experiences and perspectives. This research approach allows for an in-depth and rich exploration of participants’ experiences.

The panel of experts offering advice on research questions and reviewing the transcripts for reliability consisted of one epidemiologist, three health education and health promotion specialists, and two veterinary professors collaborating with three organizations: (Hormozgan University of Medical Sciences, Veterinary Department of Kerman University and Iranian Veterinary Organization). The present participants were selected through maximum variation and snowball sampling.

Participants

The research population consisted of veterinarians from three cities (Tehran, Kerman, and Bandar Abbas) in Iran, all dealing with a large population of livestock, poultry, and aquatic animals in 2021. The inclusion criteria were: veterinary work experience at least three years, the experience of therapeutic clinical work or working as a veterinary administrative and supervisory staff, willingness to participate (in the research), and ability to answer the questions. The exclusion criteria were unwillingness to participate and withdrawal from the interview. Purposive sampling was used with maximum variation (in terms of the province of work, age, sex, the field of work in a clinic or pharmacy, and affiliation with the public or private sector) at first steps and snowball sampling methods In the following. That means some veterinarians were concerned about expressing their opinions or reporting any illegal case they had dealt with. Therefore, they had to be selected through snowball sampling. After reaching the first participant and holding the interview, s/he was asked to suggest the next veterinarian who was aware of or was experienced in prescribing antibiotics against paraclinical rules. Therefore, each participant connected and introduced us to the next participant. Interviews were held in a public place at the interviewee’s convenience. In some cases, the interview was held in the clinic, and in others in the interviewee’s office. The data were collected and analyzed simultaneously. The interviews continued until the data were saturated (i.e. when no new information was obtained) and until all the extracted themes were sufficiently supported by the data. After the 17th interview, no new data were collected, but to be on the safe side, another interview was also conducted, and after the interview with the 18th participant, the sampling was stopped.

Data collection

Guided questions and semi-structured interviews were used for data collection. The interviews were held face-to-face and video calls. When required, a trained research assistant conducted a qualitative interview to increase the accuracy and speed of data collection. The interview questions were derived from a review of the existing literature on AMR with a focus on the underlying causes and also the comments made by a panel of experts. At the beginning of the interview, the purpose of the study was revealed to the participants and they were assured of the confidentiality of the information they provided and the anonymity of their responses. The interviewees were ensured they could withdraw from the study upon their will. Then, an informed letter of consent was signed. The required permission was gained to record all the conversations. The main focus of the questions included:

What are the barriers to veterinarians’ prevention of increased AMR? Explain.

What do you know about the causes and precursors of AMR occurrence in Iran?

What are the determinants of prescribing and using antibiotics in veterinary medicine in Iran in your opinion? Explain.

What are the determinants of the increased AMR in your opinion as a veterinarian?

Based on the participants’ previous answers, more exploratory questions were asked and, as a result, we extracted the main reasons why veterinarians over-prescribed drugs and why antibiotics were overconsumed in the animal source food industry. The sample size was determined by the theoretical data saturation criterion. In other words, during the data collection, when we concluded that more interviews and observations could not add any new information and only led to repeated findings, we stopped the data collection. Therefore, 18 active veterinarians in clinical, medical, educational and administrative fields were interviewed in Tehran, Kerman and Hormozgan (provinces). Individual interviews lasted between 42 and 57 min.

Data analysis

The process of data analysis was done using Granheim and Lundman method [ 29 , 30 ] and with the help of MAXQDA-2010 software by the first and second authors of the article. The first and second authors listened to recorded interviews and transcribed them into a written format in Word 2017 software immediately after every interview and on the same day with the help of other research colleagues. In the second step, the text of the interviews was read by the researchers very carefully to get a general view of their text. In the third stage, all the texts of the interviews were read line by line and very carefully, and the initial codes were started.

In the fourth step, the researchers placed the codes that were similar in terms of meaning and concept and were placed in a category in a subcategory and determined the relationship between them. In the fifth step, the codes and categories were placed in the main categories, which were conceptually more comprehensive and abstract [ 31 ]. Finally, in a joint meeting, the entire process of data analysis was shared and conflicting opinions on the content of a topic were discussed by a research team with two qualitative health researchers and two veterinarians.

Guba and Lincoln evaluation criteria [ 32 ] were used to check the trustworthiness of the findings. To substantiate the validity of the findings, the researcher’s self-review technique was used in data collection and analysis as well as a peer check during which the codes were provided to two participants to resolve misunderstandings. To substantiate the reliability of findings, intra- and inter-rater reliability tests were used. To this aim, the recorded and transcribed conversations were given to several experts for review. After analyzing the data, they were re-analyzed by colleagues. The next step was documentation to test the accuracy and comprehensibility of the procedures, and the underlying mechanisms of errors.

Ethical considerations

This research was approved by the Ethics Committee of Hormozgan University of Medical Sciences (IR.HUMS.REC.1400.207). In the interviews, the researcher, by introducing herself and also explaining the purposes of the study, tried to create an amicable atmosphere for the interview. The participants were also ensured of the confidentiality of the information they provided, the anonymity of recorded conversations, and also why they were selected. They consented to their voice being recorded. The participants were free to withdraw or leave the interview any time they requested.

The present study was conducted as interviews with 18 veterinarian participants in Tehran, Kerman, and Hormozgan provinces. Both sexes were included. There were 11 male and 7 female participants whose ages ranged between 27 and 58, with an average age of 42.5 years. The participants’ work experience ranged between 3 and 27 years, with an average of 15 years. The demographic information is summarized in Table 1 .

The data analysis led to the extraction of 4 main categories and 44 subcategories (see Table 2 ), each examined separately.

Educational factors

The first determinant of the increased AMR deals with academic issues in university. Among the most important issues are those concerning students, clients’ lacking awareness and knowledge of AMR in animals, and its transmission to humans (from animal source foods).

Unsystematic internship

During the summer holidays of the final 2–3 academic years of veterinary students, they are required to take the internship. Yet, some participants complained about the unsystematic and inefficiency of this internship.

“During our student days, we took up the internship, but we did not learn anything special at all”. (Participant #13)

Unadjusted curricula

The majority of participants agreed that during their studies, only in the bacteriology course, they learn about AMR (only superficially) and that in the university curriculum, this subject was not adequately included.

“All faculty members should teach something about AMR, not just the bacteriology professor. Also, do we not prescribe antibiotics once we diagnose viral diseases in clinical sciences and the like? If so, then why are we not taught what AMR actually is”? (Participant # 9)

Outdated education

As the participants described, it was essential to teach new things about AMR and to develop strict, principled, written instructions on this subject. The participants recommended following effective and efficient exemplar instructions (in foreign countries) to strengthen the educational system not also at university but in food and drug administrative organizations. It is essential to update basic and clinical sciences curricula and add AMR to all courses, as most participants agreed.

“We should keep up with the global community in this regard so that we can be fully aware of the new knowledge and instructions, and can create new instructions based on the preexisting ones”. (Participant #2) ”I think one thing that can definitely help is to see how successful projects in developed countries proceed. Let us follow their example”. (Participant #13) ”They still teach the way they did a hundred years ago. The subject matter should be changed. It seems as if discussing AMR does not matter at all”. (Participant #9)

Lack of specialized training courses

A key determinant of AMR prevention was the need for useful and effective training courses for all those somehow affected or affected by the AMR, including vets, the health staff, medics, therapists, as well as the livestock and poultry breeders, and the like.

“It is essential to hold relevant and useful training courses for ranchers, poultry farmers, pharmacists, as well as veterinarians, veterinary staff who perform inspection and monitoring work for others. So, everyone is expected to cooperate”. (Participant #2). “Farmers should know that adhering to the (medical) interval helps decrease antibiotic concentration in the animal being treated. Thus, the farmer or breeder needs to postpone the slaughter time. Or he is advised not to consume animal source foods while they are being medically treated”. (Participant #7).

Low specialized study index

As in many other sciences, gaining up-to-date knowledge requires studying the most recent research findings.

“We should not only encourage those who influence drug resistance to study about this subject, but universities should also encourage professors to study more about the specialized topic. If a professor fails to have updated knowledge, s/he cannot teach students well. Thus, how can we expect the students to act efficiently in near future”? (Participant #5)

Lack of empowering educational system

Some participants expressed concerns that the educational system did not adequately prepare students for accurate diagnosis and prescription in near future.

“At university, nothing matters more than studying and getting good marks. The educational system does not actually prepare students for the work market. In other words, it does not simulate real conditions before students leave academic life and enter the work market”. (Participant #9)

Lacking cooperation of all medical sectors affiliated with the university

In the present study, participants, all veterinary graduates or instructors, raised the question why discussing AMR was limited to the bacteriology course and not included in clinical and practical courses.

“Why is medical resistance only limited to bacteriology? All other basic and clinical sciences sectors at university are talking about diagnosis and treatment, and are prescribing drugs. But, when they come to medical resistance, they only refer to bacteriologists and the bacteriology labs”. (Participant #9)

Administrative and legal factors

There are issues about the rules/regulations and policies on veterinarians’ practice and that of all people somehow concerned with animal source foods, which can add to the existing problems. Here are the categories and the relevant excerpts:

Problems with rules and regulations

As the participants pinpointed, there is a strong need for food safety rules and regulations especially in terms of AMR. Adherence to these rules and regulations should be closely monitored too.

“Though there are rules, you can never be sure they are abided by fully. No one is afraid of not following the rules. Even I myself, who is doing clinical work, am not sure whether there is any prohibitory rule for this or not!” (Participant #8) . “Breeders who administer drugs themselves or those who slaughter animals being medically treated should be fined or prosecuted because they threaten public health. But, in reality there is no way to stop them”. (Participant #5)

Poor monitoring and administration

A number of participants acknowledged that even if there are rules and regulations, they are not fully observed. There has not been any efficient monitoring over how rules and regulations are followed. That is why rules have been ineffective.

“ All these are just instructions. In practice, there is no veterinary body monitoring how things are done. The rules are ineffective“(Participant #7) .

Selling over-the-counter (OTC) drugs or those without laboratory-based approval

Selling all kinds of drugs, including antibiotics without prescription, without laboratory approval and freely in Iran has caused serious trouble.

“ You can get any medicine you want from any pharmacy at any time. Actually, the main customers of pharmacies are those who buy drugs arbitrarily”. (Participant# 11) ” In my opinion, pharmacies should not sell every kind of drug especially antibiotics unless they receive a laboratory approval for the antibiogram test. Likewise, a vet should not prescribe antibiotics unless s/he receives the lab test result first”. (Participant #2) ” In my opinion, the sale of medicine, especially antibiotics, should be subject to laboratory approval. That is, a person should not be allowed to buy medicine until the laboratory has determined the type of disease or at least the effective antibiotic, even if the vet has prescribed it”. (Participant #9)

Inadequate advocacy

As some participants commented, gaining the full support of international, national and regional communities was a great issue.

“ We need the help of international and national organizations to solve this global issue. When a problem is global, the solution will definitely be achieved with the cooperation of international organizations”. (Participant #2)

Lack of interdisciplinary cooperative approach

According to some participants, to achieve an optimal solution to this problem, all administrative, supervisory, diagnostic, and medical sectors should cooperate.

“ Solving this problem is not what only one organization can do. Universities should teach students in the right way; veterinary administrative organizations should do their job efficiently; the private sector (e.g., clinics and pharmacies) should obey the rules. Most importantly, there should be strict rules made and abided by with all sectors cooperating”. (Participant #4) ” Our clients should be aware of the importance of AMR and also aware of how the drugs are cycled among the environment, animals, and humans. The Environment and Veterinary Organization, public health and agriculture, and the like should all take serious actions. If one ring is missing from this chain, the whole chain is broken. All efforts will end up fruitless”. (Participant #6).

Problems with the production and use of electronic health records (EHRs)

Developing systems such as the integrated prescription system and the use of EHRs can significantly help to prevent AMR occurrence.

“ If the EHR system was used, things would be better now. No pharmacy could then sell OTC drugs. Thus, no customer could buy antibiotics arbitrarily”. (Participant #14)

Slaughtering medically treated livestock

According to some participants, a stock not responding to an antibiotic treatment does not need any lab test. Neither does it need any abstinence interval. It can easily gain slaughter permission even in emergency cases.

“Here, an animal that is taking medicine and is not becoming well or is getting worse is sent for emergency slaughter. Is there any organization in charge here? Only if a buyer comes to know that an animal shows symptoms of a disease, he may buy it at a lower price”. “Before the slaughter, the antibiotic residues are controlled in poultry but not in macro-livestock (e.g., cattle, sheep and goat)”. (Participant #12)

Non-compulsory training courses before issuing a license for animal husbandry

Some participants insisted that the government should make it compulsory for applicants (for stockbreeding or husbandry) to complete AMR training courses before issuing a license for stock breeding. Here are some comments.

“ Certainly, people seeking for an establishment and operation license for livestock, poultry, fish ponds, and in short, any kind of livestock, must be obliged by the relevant governmental body to first pass a series of training courses and then get a license”. (Participant# 2)

Lacking coordination between medical and veterinary organizations

Due to the lack of the required infrastructure in veterinary medicine, this organization needs to cooperate with the Ministry of Health (for service provision), and medical and laboratory sectors especially to perform laboratory tests.

“ We can say that great concern is that veterinary medicine and medical sciences are affiliated with two different ministries. The former is deprived of the facilities provided by the ministry of health. Even for simple antibiogram tests, we should visit veterinary labs provincial centers, or big cities”. (Participant #11)

Lacking attention to micro-industries and micro-breeders

With the expansion and development of livestock, poultry, and aquaculture industries, the main attention has been focused on this group (of industries), and domestic and micro-breeders have been neglected.

“ If there are any rules and regulations, they are mostly about industries such as macro-level poultry breeding or husbandries. Yet, in practice, the national livestock is to a great extent bred by domestic and micro-level breeders that are largely neglected”. (Participant #3)

Limited facilities in small towns

The lack of diagnostic facilities such as laboratories equipped with antibiogram testing for cases sent from veterinary clinics have caused serious problems for clients and veterinarians.

“ For a simple antibiogram test, we have to refer to the provincial center, and this is both time-consuming and costly. More importantly, most of our livestock population is in small towns, not in provincial centers”! (Participant #1)

Client-related factors

Another determinant of the increased AMR as perceived by Iranian veterinarians is the factors related to livestock/poultry breeding and animal owners (termed here as “clients”). The clients’ choices, decisions, and behaviors will have significant effects on increasing AMR.

Quick response : Among the reasons for an emergent antibiotic prescription without any diagnostic test are: concerns about high mortality rate if the drug is not used immediately, the breeder’s referral at the onset or peak of a disease spread, or substantial losses in the herd, or the referral rush to improve conditions.

“ Mostly, livestock farmers especially poultry farmers or any other breeder with a significant number of livestock, poultry, or aquatic animals, insist on getting a strong antibiotic immediately so that the mortality rate does not rise any further. They cannot even wait for the antibiogram test result. If we do not prescribe antibiotics for them, they go get it from somewhere else, and even if they go for the antibiogram test, they may not be patient enough to receive the test result and, thus, arbitrarily begin other antibiotics”. (Participant #6)

Customer satisfaction

Some clients have used several specific drugs for years and found them effective. Thus, they have no faith in the lab diagnostic test result. Besides, some clinicians and especially vets are sometimes subject to too many demands, which can be tempting. They might occasionally be tempted to violate the existing rules and, upon a client’s persistence, they may neglect the protocols and easily give in.

“ For our clients, the drug manufacturing company even matters. Sometimes, they carry the former drug vial to show us and insist that the same drug be prescribed”. (Participant #3) ” Even when the required facilities were available, I faced too many suggestions. Some guys came to tell us to take it easy and let them get away with it (by granting or renewing their permit)”. (Participant #16)

Low purchasing power

As there is no drug and treatment insurance for animals in veterinary medicine in Iran, the cost of treatment or the price of drugs was found as another determinant of antibiotic prescription, as mentioned by the present veterinarian participants.

“ Sometimes prescriptions are written out according to the customer’s affordance. Sometimes, customers ask us to prescribe something they can afford to buy. As there is no insurance coverage for veterinary medicine, the price matters, and it significantly affects the act of prescription”. (Participant #7)

Social learning

An effective factor in antibiotic self-medication or arbitrary use of antibiotics is to learn about it. There are often others living in the same place (city or village) where the clients live, who used a certain drug and found it effective. Now the clients tend to follow their steps. Besides, self-medication cuts down on the diagnostic and therapeutic costs too.

“A farmer might come to us and insist on buying the same drug that his neighbor has already bought. He does not consider that the diseases might be different. Overall, clients are more influenced by neighbors than us”!

Pharmaceutical determinants

In some cases, what causes the clients to insist on our prescribing OTC drugs is the price and effectiveness of the drug (as perceived by the clients) and even the drug manufacturing company.

“ Some clients insist on buying a certain antibiotic because either they have already used and found it effective. Thus, they may ignore what the vet’s diagnosis is”. (Participant #11)

Unawareness of antibiotic residues and abstinence interval

While using antibiotics, the livestock, poultry, and aquaculture breeders should be aware of the animal source food abstinence interval. But in reality, they are mostly unaware of that.

“Many clients are not adequately aware of the abstinence interval after taking antibiotics, and this issue makes them send the animal products into the food cycle during the treatment period”. (Participant # 11)

Drug replacement or early cessation

When seemingly the symptoms of the disease are gone, some breeders ignore the medical instructions and cease the drug sooner than they should.

“For example, a drug should be taken for not shorter than a week. But when a client takes the drug for two days and feels the disease is gone, he stops administering the drug. He does not care about the medical resistance and how it occurs. He ignores them all”. (Participant # 5) ”A client may purchase an antibiotic (either prescribed or self-medicated) and begin the treatment. After one or two days, when there is no sign of recovery, he replaces the drug easily”. (Participant #8)

Antibiotics use as a growth stimulant

Antibiotics have long been used as growth stimulants on a large scale by breeders of raw animal products in Iran.

“ In large breeding industries such as livestock and poultry farming, antibiotics are used as a growth stimulant, and this is very common”. (Participant #4)

Self-medication or arbitrary use of drugs

As the participants mentioned, many clients take some therapeutic measures before visiting a veterinary diagnostic and medical center. They have already begun taking several antibiotics or have quit the treatment half in the way.

“ Sometimes a farmer arbitrarily buys and consumes several drugs before going to any veterinary, diagnostic or medical center”. (Participant #5) ” Some ranchers already take many antibiotics. When we ask them why they say they had it refrigerated since the last time they ever purchased and consumed the drug. They intended to use the remains of the drug and visit a clinic only if their self-medication did not prove effective”. (Participant #8)

The unconventionality of the antibiogram test

As perceived by the present participants, antibiogram testing is a new thing that has not been yet received well by many clients. Not many participants welcome or even prioritize this test. They think doing this test is not compulsory and, thus, they do not feel obliged to take it at all.

“Unless the customer is obliged to, he does not go for the test to a laboratory at all. Thus, it needs to be mandatory; yet in reality, it is not”! (Participant #15) ” When we tell a client that he should take a sample for an antibiogram test and wait until then, he is surprised. It seems as if he has never heard of such a thing. He wonders why none of his fellow breeders were already sent for such a test when they faced the same problem”. (Participant #18) ”Nobody cares about AMR in the future. They laugh at us and wonder what the consequences are”. (Participant #2)

Clients’ preference for over-prescribing vets

As perceived by the present participants, any veterinarian or clinician who prescribes more drugs to treat animals is more popular.

“ If you do not prescribe any drug, the client prefers to go to another vet. He will not wait at all for you to tell him about the importance of drug resistance. Now every doctor who prescribes more drugs becomes more popular and he is perceived as a better doctor”. (Participant #18)

Clients’ lacking foresight

Some participants acknowledged that the AMR problem is unthinkable in the future and far-fetched to many clients.

“ People do not really know what will happen in the future and people will suffer from drug resistance. No one can even imagine what will happen in the future. It is not tangible to them”. (Participant #2)

Rejection of paraclinical costs

Some clients, as the participants’ accounts, revealed, do not bear costs higher than those of the visit, including the cost of a laboratory.

“ Our clients are mostly reluctant to pay much, especially when the cost of the treatment is higher than that of, for example, a domestic chicken that they bring here for treatment”. (Participant #18)

Materialistic view

Many ranchers ignore many important things and are just concerned with more production and productivity, and gaining as much money as they can. So, they do things that are sometimes unethical and illegal but just cost-effective.

“I don’t think it matters how you make money. You just need to be smart and know when to do what. For example, I know a guy who drugs his chickens the day before slaughter but keeps some of them apart for his own family’s use. He sends one of the undrugged chickens to the laboratory so that he gets a negative lab test result. This way, if there is any loss, it will happen to the undrugged chickens and not the whole poultry”. (Participant #9) “Sometimes they breed a few chickens apart from others only to send them later on to the laboratory. The lab also cooperates with them and hides things in the actual report”. (Participant #13)

Veterinarian-related factors

In addition to the above-mentioned factors, veterinarians also sometimes cause an increase in AMR. Here we see how their characteristics affect their decisions on AMR development.

Inadequate job security

The current job market for veterinarians in Iran is not very prosperous and any factor that endangers the current position of activists in this field will fail.

“If you cannot keep the customer satisfied with yourself in the job market right now and put extra costs on the customer, he will quickly go to another clinic and another vet”. (Participant #14)

Lacking experience in the correct act of prescription

As perceived by the participants, many veterinarians who have just entered the work market lack any experience in prescribing drugs. Thus, they significantly account for the increased AMR.

“ As novice veterinarians do not have much experience in prescribing medicine, they prescribe several antibiotics together, with the hope that one of them works”. (Participant #13)

Prescription based on prior experience

Prescribing drugs based solely on diagnostic experience is common practice in more experienced veterinarians.

“ As soon as most colleagues see cases similar to what they have already faced and treated, they begin to write out the same prescription. It is generally well-established that certain drugs are always prescribed for respiratory infections, some for gastrointestinal infections, and so on”. (Participant #14)

The unconventionality of diagnostic tests among veterinarians

Many veterinarians have diagnosed diseases and prescribed them mainly based on their own experience. Antibiogram testing is a new therapeutic measure that has not been welcomed warmly by vets.

“There are very few vets who wait for the antibiogram test before writing out any prescription. Actually, antibiogram tests are still very uncommon”. (Participant #9)

Being labeled as inexperienced if dependent on laboratory diagnosis

As our participants described, a veterinarian who does not make a diagnosis or give treatment immediately and independently (from lab tests) and hinders it until the paraclinical test results are labeled as inexperienced.

“We have no problem sending the client to the lab, but unfortunately it seems as if we were unable to make a diagnosis ourselves and we were inexperienced and because of that we got help from the lab”. (Participant #12)

Fear of losing clients

Some veterinarians acknowledged if they delayed the diagnosis to a later time (to receive the lab test result), they could easily lose many customers.

“If you keep the client waiting or send him to a lab to fetch the test results, he will for sure prefer to visit another vet”. (Participant #5)

Diminishing ethical values

Another determining factor raised by the participants was the need to have a working conscience and commitment to livestock/poultry breeders, laboratories, and those having contracts with labs. In other words, the vets should rely on the lab test results.

“When I used to work on a poultry farm, I saw a separate hall for raising chickens with no antibiotics. The sample sent to the lab was taken from this hall. Or the chickens were slaughtered for the farmer’s own family. The other (drugged) chickens were sent to the slaughterhouse for public use”. (Participant #10) “Some colleagues are not committed enough to their job and do not feel it on their conscience. Similarly, the test results coming from some labs are not reliable either. So, the negative antibiotic results we receive from them might be false”. (Participant #5)

Lacking foresight

AMR is not familiar to many people in society. They do not adequately know what AMR is, which can affect their practice.

“Veterinarians cannot even imagine how dangerous AMR can be to human health in the future. When they have no idea what AMR is and can be, how can we expect them to be worried about it”? (Participant #8)

The insignificance of AMR

The AMR issue is not very important for some veterinarians in diagnosis, treatment, and monitoring.

“Rarely does veterinarian care about drug resistance. I do not think it is even their last priority to consider”! (Participant #10)

Lack of self-efficacy in overcoming barriers

A few interviewees admitted that they or some colleagues have a specific drug classification for most diseases according to which they act spontaneously. It means that they do not take different therapeutic measures when faced with different cases.

“Some clinicians do not consider that everyone can have his disease. I mean, they treat all patients the same way and prescribe strong broad-spectrum antibiotics for 90% of cases”. (Participant #5)

Competitive drug market

Many veterinarians are not required to sell drugs on a prescription, and selling without a prescription is a legal and common task. So active veterinarians in the field compete with each other for selling drugs and evidently for more income.

“Everyone likes to open up a pharmacy because he can easily earn money with no trouble with diagnostic and surgical measures. It is much better if you can persuade customers to buy more”. (Participant #8)

Apparent issues with prescriptions

The last subcategory of veterinarian-related factors was the appearance of prescriptions. The present prescriptions encourage vets to prescribe more drugs.

“The size and shape of prescriptions are such that the vet is encouraged to prescribe more drugs. The prescriptions should be refined in shape to allow for one or two drugs only and no more”. (Participant #5)

The present study aimed to explore the barriers faced by Irainian veterinarians against preventing Antimicrobial resistance. A few qualitative studies have been conducted on AMR, which dealt with the causes of progress and the obstacles faced by those involved in this problem, especially in the veterinary profession [ 33 , 34 ]. The results showed that different educational, legal/administrative and veterinarian-related factors account for the increased AMR in Iranian society. The first category included factors related to the educational system, such as the lack of any specialized training course for veterinary students, those in charge of monitoring veterinary practice, veterinary departments, and ranchers struggling with educational problems who may all be implicated in increasing AMR. In Iran, various educational initiatives have been implemented, such as the publication of a book on rational prescription principles, academic papers, and reports from the National Committee on Prescribing and Rational Drug Use. Despite these efforts, there are numerous educational obstacles in veterinary colleges in Iran when it comes to instructing students on prescription fundamentals and the rational utilization of medications.

The required material has been also developed; training and retraining programs have been planned based on eclectic drug use criteria; workshops, conferences, and seminars have been held too. A prescription can simply be representative of a whole nation’s sociocultural values and medical conditions. Many studies have been conducted worldwide to improve rational drug prescription and consumption [ 35 ]. The effects of educational interventions on the improved prescription pattern have been reported in Iranians and other studies too [ 36 , 37 ]. Continued training on rational drug prescription and pharmacy education has been recommended to doctors in the existing literature [ 38 , 39 ].

In Zareh’s study, the most commonly prescribed drugs were injections and antibiotics. The research findings showed that, after the training, there was an increase in the rational prescriptions for most prescribed drugs [ 40 ]. As for teaching strategies, the WHO has published The Guide to Good Prescribing for medical students. This guidebook contains six rational steps that can significantly reduce the irrational prescription of drugs: 1- defining the patient’s problem 2- defining the goals of treatment 3- ensuring that the treatment is appropriate for the patient. 4 – initiating the therapeutic measure 5 - providing information, instructions and warnings (if any) 6 - monitoring and ceasing the treatment [ 41 ]. Outdated education was a sub-category found in this study. Different studies showed that dentists often, due to a lack of knowledge about the side effects of improper prescribing of antibiotics, tend to over-prescribe them [ 42 , 43 ].

Veterinarians also are central to antimicrobial stewardship on farms, with their prescribing decisions significantly impacting AMR.A study on Canadian dairy cattle veterinarians’ revealed factors influencing their antimicrobial prescribing, attitudes towards reducing antimicrobial use, awareness of AMR, and perceived barriers to improving stewardship [ 44 ]. In addition educational resources have been developed to enhance veterinarians’ understanding of AMR and promote rational antimicrobial use. Online courses such as “Antimicrobial stewardship in veterinary practice” and “Farmed Animal Antimicrobial Stewardship Initiative” aim to educate veterinarians on responsible antimicrobial use [ 45 , 46 ].

What we need is a high-quality time management element added to the existing curricula so that students can be well-equipped with whatever they need to act professionally. Excessive imitation of medical sciences in specialized courses can only lower the efficiency of a vet’s profession. Rather, there is a need for incorporating courses on different animal species both at the general practitioner’s level and the specialized doctorate degrees [ 47 ].

There is also the issue of time management in the curriculum. Decreasing the quantity of content and increasing the quality (by adding more useful content) can better reform the veterinary curriculum. Goal-setting in veterinary sciences has already been revolutionized, and veterinary universities cannot ignore it. Thus, it is essential to consider the present and future needs in defining the required specialties to handle the existing national health issues, each of which can impose a loss of millions of dollars nationally. For many years, curricula have been developed in the European Union to achieve the necessary specializations by the existing needs, at least in the cattle breeding industry [ 48 ]. A deficient educational system is one factor that increases the overuse of antibiotics. Therefore, it is necessary to take basic measures based on the macro-planning of students’ knowledge and increase the quality of internships. In a study by Wushouer et al. in China, it was observed that an increasing awareness was followed by a decreasing rate of antibiotic administration [ 49 ]. Therefore, it is necessary to increase knowledge through a different approach in the educational system. Most experts believe that education in medical sciences should follow a different approach than other fields of study because knowledge construction in these fields of study (i.e., medicine, veterinary medicine) affects the content that students receive and the experiences they gain [ 50 ].

Failure to hold training courses for producers of raw animal products and unsystematic student internships can significantly lower the quality of education. Raising the study index in AMR and modeling on successful examples can be considered in curriculum design. Moreover, all departments of the veterinary faculties should cooperate and the heavy burden of teaching AMR should be removed from the bacteriology department only, and be shared by all basic sciences and clinical courses. Only then can we hope to see improved practice in students’ learning experiences and professional life in the near future.

The present findings showed that currently in our country, the educational system needs to be seriously reformed by appropriate training programs and pre-employment awareness-raising programs for veterinarians and ranchers [ 51 ]. People working in this field should be more empowered, better aware, and skilled enough at a correct diagnosis or proper functioning [ 52 ]. Only then we can hope that their self-efficacy is increased and they can learn to act more responsibly. These can help to prevent the occurrence of AMR and to begin to resolve it rather than worsening the issue.

The second category of the determinants of increased AMR was administrative and legal factors. Problems with the law, monitoring, and selling OTC drugs are important issues that can increase the costs of treatment too. This finding is consistent with several studies. For example, it is estimated that about 100,000 people in the United States die every year from the adverse effects of drugs [ 53 ]. In the United Kingdom, problems in 11% of prescriptions cost over € 400 million in loss, and about 16% of these problems harm patients [ 54 ]. Most of these errors are preventable, including drugs prescribed heedless of contraindications, those taken incorrectly, or those not having been properly monitored. The WHO, along with other relevant international organizations, proposed certain criteria to evaluate the quality of prescriptions to prevent the occurrence of problems and lower treatment costs [ 55 , 56 ]. A useful way of evaluating the prescription pattern in a country is to evaluate the doctors’ prescriptions. A simple prescription can represent the current state of medical education in a country, how laws and regulations affect the medical community, socio-cultural beliefs, and the medical condition [ 36 ]. Based on WHO guidelines use of medically important antimicrobials in food-producing animals, any level of restriction in antibiotic prescription should be considered, including a complete cessation of the use of one or more antibiotics. Examples of restrictions that WHO considered are: any prohibition on the use of antibiotics, such as but not limited to the prohibited use for specific indications (e.g., for prophylaxis of disease or growth promotion), the requirement of a prescription by a veterinarian for the use of antibiotics, voluntary restrictions on farms or organic interventions [ 55 ]. Drugs that need confirmation from a specially qualified person or organization should not be sold over the counter. Prescribed drugs are regulated by the US Food and Drug Administration (FDA). Having a federal license with a medical leaflet is a prerequisite for the packing of any drug. A medical leaflet usually consists of four parts: indications, contraindications, warnings, and dosage [ 57 ]. He who writes out a prescription decides who can consume the drug. A pharmacist can buy drugs, but he should sell them only to those authorized by a legally qualified person. Thus, a prescribed drug has 3 parts [ 58 ]: (1) The doctor’s prescription, (2) The pharmacist’s written prescription while delivering the drug, and (3) the drug package with a label on it. That is why officials are expected to always think about formulating new and public policies to implement correct and new strategies for the use of antibiotics [ 59 ]. Educational and political interventions, establishing and implementing laws regarding AMR stewardship may be effective and acceptable either before or during the livestock and poultry breeding programs, even for pet owners [ 60 ]. Success in the coordinated implementation of related laws is not possible without the advocacy of various stakeholders, including policymakers, veterinarians and ranchers, pet owners, public sector employees, farmers, and consumers [ 51 ]. It seems that the use of effective legislation, contractual requirements, professional obligations and the distribution of suitable facilities in more distant areas makes the implementation of this plan possible [ 21 , 22 ].

The third category was the client-related factors. Quick response and arbitrary drug use were among the sub-categories. With the expansion of public access to the internet system, people may want to refer less to vets and, instead, self-medicate or they may expect a quick response and begin to use antibiotics. In their research, Hofmeister et al. investigated veterinary visitors and found the internet connection speed as the third most important source of retrieving pet health information after GPs and specialized vets and before family and friends and other mass media [ 61 ]. Kogan et al. maintained that internet-based sources are considered an extra source of information about pet health for pet owners besides visiting vets for consultation [ 62 ]. Volk et al. reckoned that the internet and online health information could replace veterinarians and lead to fewer pet owners visiting veterinary clinics [ 63 ]. Thus, since some clients do not want to pay the visit and para clinic fees, by searching on the Internet and cyberspace, or based on their previous experience or else, they prescribe and take antibiotics arbitrarily before any visit to vets. If they do not find some proper treatment, they try other antibiotics, which leads to the problem of changing or stopping the antibiotics early before the end of the treatment period.

Some other poultry or aquatic breeders who have farms of several thousand pieces are very worried about the loss of their livestock, poultry and the aquatic population at the beginning of the disease. Since there may be a large population of their herd while waiting for the antibiogram test, they prefer to use a broad-spectrum and preferably cheaper antibiotic (for large-scale use for a large herd) to begin with and prevent their economic loss to a large extent [ 60 ]. Therefore, both in the producers and breeders of animal-origin food and in the owners of pets, the customer’s demand needs quick response and the customer’s demand should be prioritized [ 22 ].

In addition, a person who once used a broad-spectrum antibiotic without a prescription and got a response, suggests that to his/her colleagues or other breeders, and by promoting social learning, this behavior promotes the progress of antimicrobial resistance. In addition, many of these people are unaware of antibiotic residues and abstinence intervals, and currently do not feel threatened about the future of antimicrobial resistance. When they go to the vet, they prefer to go to a vet who prescribes some antibiotics to return home without any drug prescribed [ 33 ].

Another subcategory extracted from the present findings was the use of antibiotics as growth stimulants by poultry farmers. The use of antibiotics, both as a treatment in humans and as a therapeutic measure or growth stimulant in animals, has a great effect on the microbial flora of the intestine and also induces resistant strains in these animals [ 64 ]. When used as a growth stimulant, antibiotics can have adverse effects on humans and animals [ 65 ].

The fourth category was the veterinarian-related factors. The lack of an inter-sectoral approach was one subcategory extracted from the findings. Foreign studies mentioned a multi-sectoral approach and knowledge sharing in educational environments [ 66 ]. There seems to be a need for all institutions to have the required knowledge about the use of antibiotics through shared efforts between universities, the government, and the various professions. One subcategory was the insignificance of antimicrobial resistance to veterinarians. Antibiotic-containing products have harmful effects and there is a significant increase in the resistance of different types of infectious bacteria [ 67 ] besides the important role that antibiotic-containing animal products play in this process. Thus, global efforts are needed to reduce antibiotic use and attempt to control it. More control is needed over veterinary drugs and their use in livestock and poultry farms [ 68 ].

In line with the qualitative study in the UK, this study showed various behavioral and contextual factors involved in the participants’ beliefs about AMR stewardship and their responsibilities in the right direction [ 33 ]. One of these issues is the lack of experience in writing correct prescriptions among novice vets who prescribe several antibiotics at the same time in the hope that at least one works. This finding is in line with some studies that acknowledged that, when uncertain, most new clinicians tend to over-treat with antimicrobial drugs instead of refraining from treatment [ 1 , 69 , 70 , 71 ]. They prescribe several antibiotics in the hope that one works. The other extreme case is also possible when experienced veterinarians prescribe drugs based on their long-held experience. These clinicians have more faith in a series of antibiotics. On the other hand, the diagnosis of the disease and the prescription are dependent n each other. When they are told about the laboratory evidence, they react as if their credibility has been damaged. Therefore, they provide waves of unprincipled recommendations and increase antimicrobial resistance. If a veterinarian intends to prescribe antibiotics based on the principles and guidelines, s/he will face other problems, including the fear of losing clients because, as mentioned earlier, if the prescription is not in accordance with the client’s wishes or the urgency of responding to it, the client will prefer to go to another vet, and this issue will endanger the job security even more.

Another sub-category is lacking self-efficacy in dealing with different visits.In other words, the approach of veterinarians to prescribing antibiotics is to a great extent pre-established and classified. For example, oxytetracycline is the preferred antibiotic for most respiratory diseases. Any cause of disease that requires more attention to the self-efficacy of veterinarians and clinicians can be improved by training methods and participation in appropriate courses. Diminishing moral values becomes important in cases where full-time monitoring of antibiotic residues in animal products and their transfer to society and the environment is not possible, and where the government and regulatory agencies fail due to poor enforcement of laws. The regulatory forces cannot monitor and take care of the veterinary private sector employees and breeders. We can only hope that the vets will feel committed enough in their acts of diagnosis and prescription and the resultant effect on antimicrobial resistance. In the end, it is possible to recommend the modification of the appearance of prescriptions as a solution, because most of the headers of the veterinarians’ prescriptions in Iran are designed in a large way, which encourages the person to fill most of the prescription with writing the unnecessary drugs, so maybe it is recommended to design and implement a single protocol in limiting the written space of the prescriptions, we can take a step in reducing the obstacles facing the control of antimicrobial resistance.

Limitations, strengths and future directions

There were certain limitations in this study. As the interviews were face-to-face, participants might have been tempted to provide socially acceptable answers. Also, some veterinarians showed concerns about the illegal cases they were aware of and reported. So, they were selected through snowball sampling. In addition, selecting interviewees with work experience and an adequate understanding of the relevant problems and interviewing them in a private place were somehow difficult.

As in other qualitative studies, researchers’ beliefs may have influenced the study procedure from conceptualization to interaction with participants and data interpretation [ 72 ].There were chances that the interviewees’ comments did not cover all factors possibly because of the limited sample size. Sampling in qualitative studies continues until the saturation happens. Thus, in this study also the interviews continued until the data were saturated (i.e., when no new information was obtained) and until all the extracted themes were sufficiently supported by the data. No formula was included.

It is possible that besides the factors mentioned by the present participants, other experiences are gained in other parts of the country that cannot be subsumed under the present categories.

Despite the potential limitations, the present study has several strengths. The first is the sampling method with maximum variation (in terms of the province of work, age, sex, and work in the clinic or drug supply or employed in public and private sectors). The next strength is that during the interviews, some participants were dissatisfied with the current conditions, and this study provided an opportunity for them to find solutions. Moreover, there has been extensive research on AMR, but the vast majority of them are quantitative. Few have explored AMR determinants in society. The present study goes beyond the laboratory work, and with the One Health approach, using numerous interviews, it gains a deep understanding of work experience, and comprehensive and valid data to solve the AMR issue. The authors of this study intend to use the data from this study or at least part of the data for future educational interventions. A focus on the categories extracted from these studies helps to plan effective multidimensional interventions. This study can also guide future lines of research.

The results showed that AMR in veterinary medicine induced by veterinarians active in the clinical field occurs under the influence of different factors. To increase AMR stewardship, in the first step, the barriers facing all people involved should be deeply studied and identified. Appropriate plans and policies should be made to deal with the underlying factors. Educational, administrative and legal, client-related factors, and veterinarian-related factors should be considered as the determinants of the increased AMR. It is essential to reform the education system and strengthhen the interdisciplinary relationships, especially among universities and between the university and regulatory organizations. Removing the barriers these people face and reducing the consequent trouble can make the widespread emergence of AMR more evident. Its adverse effects on society will become a crisis which increases the causes of mortality due to the resistance produced to the antibiotics prescribed to patients.

Data availability

The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding authors.

Abbreviations

Antimicrobial Resistance

over-the-counter

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Acknowledgements

The authors would like to acknowledge all participants for their participation who patiently participated in this study.

This study received funding from Hormozgan University of Medical Sciences. The funder was not involved in the research design, collection, interpretation of data, analysis, the writing of the article or the decision to submit it for publication.

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Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran

Razie Toghroli, Laleh Hassani & Teamur Aghamolaei

Department of Social and Behavioral Health, School of Public Health, University of Nevada, Las Vegas (UNLV), Las Vegas, NV, 89119, USA

Manoj Sharma

HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

Hamid Sharifi

Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran

Maziar Jajarmi

Institute for Global Health Sciences, University of California, San Francisco, CA, USA

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Contributions

RT, LH, TA and M-SH designed the study. MJ and RT conducted the laboratory analyses. RT, MJ collected the specimens. H-SH conducted the data analysis. RT, LH and M-SH wrote the main manuscript text. All authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Laleh Hassani .

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Ethics approval and consent to participate.

The study was approved by the Research Ethics Committee of Hormozgan University of Medical Sciences (IR.HUMS.REC.1400.207). A written informed consent was obtained from all the study participants. All methods were performed in accordance with the relevant guidelines and regulations by including a statement in the declarations.

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Note: Here, what we mean by “Livestock” is all animals, including cattle, sheep, goats, camels, poultry, and aquatic animals bred and consumed by humans and consumed as animal-origin food.

By “stockbreeder”, “breeder” and “client”, we mean all those who own livestock and pet. AMR represents antimicrobial resistance.

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Toghroli, R., Hassani, L., Aghamolaei, T. et al. Explaining the barriers faced by veterinarians against preventing antimicrobial resistance: an innovative interdisciplinary qualitative study. BMC Infect Dis 24 , 455 (2024). https://doi.org/10.1186/s12879-024-09352-7

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DOI : https://doi.org/10.1186/s12879-024-09352-7

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Chapter 11. Interviewing

Types of Interviews

Creating an Interview Guide

Type of Questions

Background/Demographic Questions

Temporality

Question Sequence

Probes and Flexibility

The Final Question

Conducting the Interview

How Many Interviews?

Your Final Product: The Ideal Interview Transcript

Final Tips from an Interview Master

Sample: Demographic Questionnaire

Example: Interview Guide

Further Readings

Library Support for Qualitative Research

Resources for Research Interviewing

Types of Interviews

Interview Questions

Textbooks, Guidebooks, and Handbooks

ONLINE RESOURCES, COMMUNITIES, AND DATABASES

Structured:

Semi-Structured:

Unstructured:

Genres and Uses

In-Depth (typically One-on-One):

Folklore Research and Oral Histories:

User Experience (UX) and Marketing:

Screening for Research Site Selection:

ENGAGING PARTICIPANTS

RESEARCH COMPLIANCE AND PRIVACY LAWS

SEEKING CONSENT

POPULATION SAMPLING

Constructing Your Questions

Let Theory Guide You:

CONDUCTING INTERVIEWS

TIPS FOR CONDUCTING INTERVIEWS

Remote Interviews:

Seeking Consent:

Videos:

TRANSCRIPTION

SOFTWARE:

EQUIPMENT:

NEED HELP?

Helpful Texts:

QUALITATIVE DATA ANALYSIS

CODING AND THEMEING YOUR DATA

TESTING OR GENERATING THEORIES

MANAGING & FINDING INTERVIEW DATA

Data Confidentiality and Secure Handling:

Sharing Qualitative Data:

International Projects:

Finding Extant Interview Data

Finding Oral History and Social Research Interviews:

Finding Interviews in Archival Collections at Harvard Library:

Search in HOLLIS :

Search in HOLLIS for Archival Discovery :

UX & MARKET RESEARCH INTERVIEWS

Websites

Books

Videos

Instructional Presentations on Interview Skills

Interviews and focus groups in qualitative research: an update for the digital age

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