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Qualitative Research: Analyzing Life

Student resources, welcome to the sage edge site for qualitative research , second   edition.

Qualitative Research: Analyzing Life, Second Edition  presents a fresh approach to teaching and learning qualitative methods for social inquiry—one that focuses on analysis from the very beginning of the text. By exploring qualitative research through a unique analytic lens, then cumulatively elaborating on methods in each successive chapter, this innovative work cultivates a skill set and literacy base that prepares readers to work strategically with empirical materials in their own fieldwork. Johnny Saldaña and Matt Omasta combine clear, accessible writing and analytic insight to show that analysis, in its broadest sense, is a process undertaken throughout the entire research experience. The Second Edition provides a number of updates including more on digital materials and methods, including sentiment analysis of social media data, and ethics in social media research.

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Qualitative Research: Analyzing Life Second Edition

• ISBN-10 1544372884
• ISBN-13 978-1544372884
• Edition Second
• Publisher SAGE Publications, Inc
• Publication date February 2, 2021
• Language English
• Dimensions 7.38 x 0.82 x 9.13 inches
• Print length 362 pages
• See all details

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About the author.

Johnny Saldaña is Professor Emeritus from Arizona State University’s (ASU) School of Film, Dance, and Theatre in the Herberger Institute for Design and the Arts, where he taught from 1981 to 2014. He received his BFA in Drama and English Education in 1976, and MFA in Drama Education in 1979 from the University of Texas at Austin.

Saldaña is the author of Longitudinal Qualitative Research: Analyzing Change through Time (AltaMira Press, 2003); Fundamentals of Qualitative Research (Oxford University Press, 2011); Ethnotheatre: Research from Page to Stage (Left Coast Press, 2011); Thinking Qualitatively: Methods of Mind (Sage Publications, 2015); a commissioned title for Routledge’s World Library of Educationalists Series, Writing Qualitatively: The Selected Works of Johnny Saldaña (Routledge, 2018); co-author with the late Matthew B. Miles and A. Michael Huberman for Qualitative Data Analysis: A Methods Sourcebook (4th ed., Sage Publications, 2020); co-author with Matt Omasta for Qualitative Research: Analyzing Life (Sage Publications, 2018); and the editor of Ethnodrama: An Anthology of Reality Theatre (AltaMira Press, 2005). Previous editions of The Coding Manual for Qualitative Researchers have been translated into Korean, Turkish, and Chinese-Simplified.

Saldaña’s methods works have been cited and referenced in more than 16,000 research studies conducted in over 130 countries in disciplines such as K-12 and higher education, medicine and health care, technology and social media, business and economics, government and social services, the fine arts, the social sciences, human development, and communication. He has published a wide range of research articles in journals such as Research in Drama Education , The Qualitative Report , Multicultural Perspectives , Youth Theatre Journal , Journal of Curriculum and Pedagogy , Teaching Theatre , Research Studies in Music Education , Cultural Studies ? Critical Methodologies , the International Journal of Qualitative Methods , the International Review of Qualitative Research , and Qualitative Inquiry , and has contributed several chapters to research methods handbooks. His most popular journal article, “Blue-Collar Qualitative Research: A Rant” ( Qualitative Inquiry , 2014), has been downloaded by over 3,000 readers, according to ResearchGate.

Saldaña’s research in qualitative inquiry, data analysis, and performance ethnography has received awards from the American Alliance for Theatre & Education, the National Communication Association-Ethnography Division, the American Educational Research Association’s Qualitative Research Special Interest Group, New York University’s Program in Educational Theatre, the Children’s Theatre Foundation of America, and the ASU Herberger Institute for Design and the Arts.

Matt Omasta is Associate Professor and Theatre Education Program Director at Utah State University. He received his BA from Ithaca College, his MA from Emerson College, and his PhD from Arizona State University. He is the author of Play, Performance, and Identity: How Institutions Structure Ludic Spaces (Routledge), Playwriting and Young Audiences (Intellect), and numerous articles in journals including Research in Drama Education: The Journal of Applied Theatre and Performance , Youth Theatre Journal , Theatre for Young Audiences Today , Theatre Topics , and the International Journal of Education and the Arts among others. Omasta′s work has been recognized by honors including the Founders′ Award from the Educational Theatre Association, the Lin Wright Special Recognition Award and the Research Award from the American Alliance for Theatre & Education, and the Arts and Learning Special Interest Group (A & L SIG) Dissertation Award from the American Educational Research Association (AERA).

Product details

• Publisher ‏ : ‎ SAGE Publications, Inc; Second edition (February 2, 2021)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 362 pages
• ISBN-10 ‏ : ‎ 1544372884
• ISBN-13 ‏ : ‎ 978-1544372884
• Item Weight ‏ : ‎ 1.35 pounds
• Dimensions ‏ : ‎ 7.38 x 0.82 x 9.13 inches
• #20 in Scientific Research
• #27 in Social Sciences Methodology
• #42 in Education Research (Books)

About the authors

Johnny saldaña.

Johnny Saldaña is Professor Emeritus of Theatre in the Herberger Institute of Design and the Arts' School of Film, Dance, and Theatre at Arizona State University (ASU) where he taught from 1981 to 2014. He has been involved in the field of theatre education as a teacher educator, drama specialist, director, and researcher. His works have been cited in over 21,000 research studies conducted in over 135 countries.

Mr. Saldaña is the author of "Drama of Color: Improvisation with Multiethnic Folklore" (Heinemann, 1995), a teacher's resource text and recipient of the 1996 Distinguished Book Award from the American Alliance for Theatre & Education (AATE); "Longitudinal Qualitative Research: Analyzing Change Through Time" (AltaMira Press, 2003), a research methods book and recipient of the 2004 Outstanding Book Award from the National Communication Association's Ethnography Division; "Ethnodrama: An Anthology of Reality Theatre" (AltaMira Press, 2005), an edited collection of ethnographic-based plays; "The Coding Manual for Qualitative Researchers" (Sage Publications, fourth edition 2021), a handbook on qualitative data analysis; "Ethnotheatre: Research from Page to Stage" (Left Coast Press, 2011), winner of the American Educational Research Association's Qualitative Research SIG's Outstanding Book Award; "Fundamentals of Qualitative Research" (Oxford University Press, 2011), an introductory textbook on the subject; as co-author, the fourth edition of the late Matthew B. Miles and A. Michael Huberman's "Qualitative Data Analysis: A Methods Sourcebook" (Sage Publications, 2020); as co-author with Matt Omasta, a new introductory textbook, "Qualitative Research: Analyzing Life" (Sage Publications, second edition, 2022); and a volume for the World Library of Educationalists' series, "Writing Qualitatively: The Selected Works of Johnny Saldaña" (Routledge, 2018).

Saldaña has published articles in such journals as Youth Theatre Journal, Stage of the Art, Teaching Theatre, Research in Drama Education, Research Studies in Music Education, Multicultural Perspectives, Journal of Curriculum and Pedagogy, and Qualitative Inquiry. He has also published chapters on research methods for such titles as "Arts-Based Research in Education," "Handbook of the Arts in Qualitative Research," "Handbook of Longitudinal Research," and entries for "The Sage Encyclopedia of Qualitative Research Methods."

Saldaña's research methods in longitudinal inquiry, ethnotheatre, coding, and qualitative data analysis have been applied and cited by researchers internationally in disciplines such as K-12 and higher education, business, social sciences, technology, government, social services, communication, human development, interpersonal relationships, sport, health care, and medicine.

Mr. Saldaña's workshops and keynote addresses reflect a broad range of interests including drama in the classroom, drama with multicultural materials, ethnotheatre, theatre for social change, and qualitative research methods. Saldaña has presented for such organizations as: the Arizona Artist/Teacher Institute, the New Orleans Public Schools, the Louisiana Institute for Education in the Arts, the Southeast Institute for Education in Theatre, the Tennessee Arts Academy, Northwestern University, Western Michigan University, New York University, the University of Hartford, the University of Amsterdam, the University of Alberta, the University of Victoria, the University of Leeds, Mary Immaculate College / University of Limerick; and at national conferences of: AATE, the Educational Theatre Association, Pedagogy and Theatre of the Oppressed, the International Drama in Education Research Institute, the American Educational Research Association, the National Association for Multicultural Education, Narrative Inquiry in Music Education, the International Institute for Qualitative Methodology, the European Qualitative Research Conference in Health and Social Care, and the International Congress of Qualitative Inquiry.

Saldaña is a recipient of the 1989 Creative Drama Award from AATE, the 1996, 2001, and 2010 Research Awards from AATE, the 2015 Campton Bell Lifetime Achievement Award, New York University's Swortzell Innovator Award in 2017, the Burlington Resources Foundation Faculty Achievement Award in 1991, the ASU College of the Arts Distinguished Teacher of the Year Award in 1995 and 2008, and the ASU College of the Arts Research Award in 2005. In 2000, 2008, and 2009 he was recognized as a finalist by the ASU Parents Association for Professor of the Year.

Mr. Saldaña received his BFA in Drama and English Education in 1976, and MFA in Drama in 1979 from the University of Texas at Austin. Saldaña has taught at UT-Austin and Washington State University in Pullman. He was born in Austin, Texas, and currently resides in Phoenix. Professional memberships include: the International Association of Qualitative Inquiry, the American Alliance for Theatre & Education, and the American Educational Research Association.

Matt Omasta

Author Website: www.mattomasta.com

Matt Omasta is Associate Dean of the Caine College of the Arts and Professor of Theatre Arts at Utah State University (USU), where he has taught since 2010. His work focuses on theatre and drama in applied, community-engaged, and educational contexts; theatre for young audiences; and audience / spectator studies. He is particularly interested in exploring how performance impacts human experience. His publications, which have been cited over 700 times, include:

• Play, Performance, and Identity (Routledge, 2015) with Drew Chappell

• Playwriting and Young Audiences (Intellect, 2017) with Nicole B. Adkins

• Qualitative Research: Analyzing Life (2nd edition, SAGE, 2021) with Johnny Saldaña

• Impacting Theatre Audiences: Methods for Studying Change (Routledge, 2022) with Dani Snyder-Young

Dr. Omasta was the inaugural recipient of the Johnny Saldaña Outstanding Professor of Theatre Education award from the American Alliance for Theatre and Education (AATE). Other honors include AATE’s Lin Wright Special Recognition Award and the Founders Award from the Educational Theatre Association. At USU, he has received the university-wide Eldon J. Gardner Teacher of the Year award as well as the Scholar / Creative Artist of the Year, Faculty Mentor of the Year, and Undergraduate Research Mentor of the Year awards from the Caine College of the Arts.

An active leader in theatre arts and education, Dr. Omasta has served three terms on the AATE Board of Directors, as an officer of two arts-focused special interest groups of the American Educational Research Association, and on the American Society for Theatre Research’s Executive Committee.

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How to use and assess qualitative research methods

Loraine busetto.

1 Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

Wolfgang Wick

2 Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany

Christoph Gumbinger

Associated data.

Not applicable.

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

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

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

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

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

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

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

The main take-away points of this paper are summarised in Table ​ Table1. 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Take-away-points

Acknowledgements

Abbreviations.

Authors’ contributions

LB drafted the manuscript; WW and CG revised the manuscript; all authors approved the final versions.

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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“ Starting to think that way from the start” : approaching deprescribing decision-making for people accessing palliative care - a qualitative exploration of healthcare professionals views

• Anna Robinson-Barella 1 , 2 ,
• Charlotte Lucy Richardson 1 , 2 ,
• Zana Bayley 1 ,
• Andy Husband 1 , 2 ,
• Andy Bojke 3 ,
• Rona Bojke 3 ,
• Catherine Exley 2 ,
• Barbara Hanratty 2 ,
• Joanna Elverson 4 ,
• Jesse Jansen 5 &
• Adam Todd   ORCID: orcid.org/0000-0003-1496-9341 1 , 2  

BMC Palliative Care volume  23 , Article number:  221 ( 2024 ) Cite this article

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Metrics details

Deprescribing has been defined as the planned process of reducing or stopping medications that may no longer be beneficial or are causing harm, with the goal of reducing medication burden while improving patient quality of life. At present, little is known about the specific challenges of decision-making to support deprescribing for patients who are accessing palliative care. By exploring the perspectives of healthcare professionals, this qualitative study aimed to address this gap, and explore the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context.

Semi-structured interviews were conducted with healthcare professionals in-person or via video call, between August 2022 – January 2023. Perspectives on approaches to deprescribing in palliative care; when and how they might deprescribe; and the role of carers and family members within this process were discussed. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the NHS Health Research Authority (ref 305394).

Twenty healthcare professionals were interviewed, including: medical consultants, nurses, specialist pharmacists, and general practitioners (GPs). Participants described the importance of deprescribing decision-making, and that it should be a considered, proactive, and planned process. Three themes were developed from the data, which centred on: (1) professional attitudes, competency and responsibility towards deprescribing; (2) changing the culture of deprescribing; and (3) involving the patient and family/caregivers in deprescribing decision-making.

Conclusions

This study sought to explore the perspectives of healthcare professionals with responsibility for making deprescribing decisions with people accessing palliative care services. A range of healthcare professionals identified the importance of supporting decision-making in deprescribing, so it becomes a proactive process within a patient’s care journey, rather than a reactive consequence. Future work should explore how healthcare professionals, patients and their family can be supported in the shared decision-making processes of deprescribing.

Trial registration

Ethical approval was obtained from the NHS Health Research Authority (ref 305394).

Peer Review reports

Deprescribing has been defined as the planned process, under the supervision of healthcare professionals, of reducing or stopping medications that may no longer be beneficial or are causing harm, with the goal of reducing medication burden while improving patient quality of life [ 1 , 2 , 3 ]. On a global level, there is a growing recognition of the need for deprescribing [ 4 ], with the World Health Organisation (WHO) including it as a component of safe medication management, stating the process should be ‘as robust as that of prescribing’ [ 5 ]. In a palliative care context, where polypharmacy is common and medication burden is high [ 6 , 7 ], deprescribing is an increasingly important care consideration. Indeed, there is growing evidence that deprescribing can be a safe and effective way to improve outcomes for patients using potentially inappropriate medication [ 8 , 9 , 10 ]. For example, studies concerning the deprescribing of anti-hypertensives, diuretics, benzodiazepines, antipsychotics and statins have demonstrated physical and cognitive benefits, and no significant harm, when these medications are reduced or stopped [ 11 , 12 , 13 , 14 ]. Studies have also shown that deprescribing of medications for patients with life limiting illness can improve quality of life [ 15 ], as well as reducing the risk of developing adverse drug events [ 16 ]. Whilst evidence has demonstrated that some interventions can be used to support deprescribing, practical challenges still remain; these can influence a decision to stop or reduce medication - especially in a palliative care context. For example: how to involve a multi-disciplinary team of healthcare professionals, patients and their family members when making shared decisions about possible deprescribing [ 3 ]. A recent systematic review explored these challenges further and highlighted the importance of involving all stakeholders in the deprescribing decision-making process to ensure a joint decision is made between the patient and healthcare professional [ 17 ]. Whilst several studies have focused on the broader issues of taking steps towards deprescribing in a palliative care context [ 18 , 19 , 20 , 21 ], at present, little is known about the specific challenges of decision-making that support deprescribing to occur. By exploring the perspectives of healthcare professionals with responsibility for prescribing medication, this qualitative study aimed to address this gap, explore the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context.

Recruitment and sampling

The consolidated criteria for reporting qualitative research (COREQ) checklist was followed (see Item 1 , Supplementary File) [ 22 ]. Inclusion criteria comprised: healthcare professionals (such as nurses, pharmacists and medical doctors) with experience of prescribing or reviewing medication for patients in receipt of palliative care. To be included in the study, healthcare professionals had to practice in the UK. Recruitment was facilitated by (i) two hospital and two hospice research sites in the North East of England, United Kingdom (UK), (ii) professional palliative care networks of the research team and (iii) social media. All interested participants were emailed a participant information sheet and consent form detailing the purpose and aims of the research. Those who expressed an interest and gave their informed written consent, were enrolled in the study. There was no relationship established between the researcher and participants prior to study commencement or recruitment. Convenience sampling was used to recruit participants from a variety of job roles and responsibilities, as well as providing generalist or specialist palliative care. Practitioner age and time qualified were also considered within the sampling framework.

Semi-structured interviews

In-depth, semi-structured interviews were conducted by one researcher (ZB, a female postdoctoral researcher with experience of qualitative research) between August 2022 and January 2023. Interviews were conducted remotely ( via Zoom) or in-person (face-to-face) depending on participant preference. The semi-structured interview topic guide (see Item 2 , Supplementary File for the complete interview guide) was developed based on three pilot interviews (not included in the final participant numbers) and was informed by findings from previous studies conducted by the research team [ 23 , 24 ], as well as the lived-experiences of patient champions involved in this study (AB and RB). Areas explored included: participants’ perspectives on, and approaches to, deprescribing; when and how they might deprescribe; the role of carers and family members within this process; and exploration of gaps around deprescribing decision-making.

Data analysis

All semi-structured interviews were audio-recorded to enable data analysis. The audio files were encrypted and transcribed verbatim by an external transcription company; audio files were uploaded to an encrypted, password-protected site and immediately following confirmation of accurate transcription were deleted. All interview data were anonymised at the point of transcription and all transcripts were checked for accuracy and correctness by ZB and CLR (a researcher with expertise in qualitative research). Participants did not provide comment on the transcripts, nor feedback on results.

Following reflexive thematic analysis processes, as defined by Braun and Clarke [ 25 , 26 ], the principle of constant comparison guided an iterative process of data collection and analysis. Reflexive thematic analysis was performed by two researchers (CLR and AR-B, a researcher with expertise in conducting qualitative research) to analyse the interview data. Close and detailed reading of the transcripts allowed the researchers to familiarise themselves with the data. Initial descriptive codes were identified in a systematic manner across the data; these were then sorted into common coding patterns, which enabled the development of analytic themes from the data. The themes were reviewed, refined and named once coherent and distinctive. Two authors (AR-B and CLR) performed the data analysis through discussion and, if agreement was not reached, by consensus with the other members of the research team (AT, AH and CE, with expertise in palliative care and qualitative research). Post-interview field notes enhanced this reflective process. NVivo (version 12) software was used to facilitate data management. The research team were in agreement that data sufficiency and information power [ 27 , 28 ] occurred after 18 semi-structured interviews and thus, study recruitment stopped following interview number 20; recurring similarity within participant responses, with no new concepts discussed, guided this decision. To ensure confidentiality when using direct participant quotes, non-identifiable pseudonyms are used throughout the research (e.g., Participant 1 and Participant 2 etc.)

Ethical approval

This study was granted ethical approval by the UK National Health Service (NHS) Health Research Authority (reference 305394, date approved: 08.04.2022, South Birmingham REC). Research governance was followed in accordance with Newcastle University and NHS Trust research policies at study sites.

Participant demographics

Twenty participants were recruited and interviewed for this study (participant demographics are described in Table  1 ). Of the twenty participants interviewed; 7 described their job role as a medical consultant working within various settings in the UK (including palliative medicine and respiratory medicine), 6 participants were nurses providing palliative and end-of-life care to patients across primary or secondary care settings, 4 were specialist pharmacists working across a range of disciplines, including frailty and heart failure, and 3 participants were general practitioners (GPs). Nineteen participants self-reported their ethnicity as White British and one participant identified as British Asian. Twelve of the 20 participants were aged between 40 and 50 years and the mean time qualified in their respective roles was 17 years (SD ± 8.5 years). Five interviews were conducted using video software (Zoom ® , n  = 5), while the rest were carried out in-person ( n  = 15). Interviews ranged from 27 to 62 min. There were no refusals to partake, participant dropouts or repeat interviews.

From the interviews, many participants described the importance of deprescribing decision-making, and that it should be a considered, proactive, and planned process. To achieve this, three themes and subsequent sub-themes were developed from the data (Fig.  1 ); these focused on: (1) professional attitudes, competency and responsibility towards deprescribing; (2) changing the culture of deprescribing and (3) involving the patient and family/caregivers in deprescribing decision-making. Note the use of arrows in the figure to visually represent the interplay between the themes, and their sub-themes, as part of the bigger picture of achieving proactive deprescribing.

Themes developed to support the delivery of deprescribing as a proactive process, rather than a reactive consequence for patients in receipt of palliative care

Theme 1: Professional attitudes, competency and responsibility towards deprescribing

Taking ownership of the deprescribing decision.

Participants across all healthcare professional roles shared beliefs that deprescribing was potentially a positive process; however, a number of challenges and concerns were raised, which seemed to influence whether deprescribing was undertaken, or not. The first of these related to taking ownership of the process, and ultimately, the decision-making. A number of participants described a lack of clarity around “whose job is it to do deprescribing?” (Participant 15). In turn, participants discussed feeling “like I don’t want to be treading on other people’s toes” by making decisions about stopping medicines, particularly when patients are receiving care from “a big multidisciplinary team” (Participant 10).

“One of the big barriers I see is ownership… There’s a sense that “I don’t want to touch the rheumatology drugs” or “they’re under the heart failure team so I don’t want to touch any of that” … having some sense professionally , as a cohesive profession about who does it – I think we need to get to that place” (Participant 15 , Medical Consultant).

In efforts to take responsibility for deprescribing practices, participants acknowledged that certain healthcare settings may be better suited to make decisions about deprescribing. Two participants proposed making use of multidisciplinary team meetings as an approach to deprescribing decision-making in collaboration with members of the wider care team. One participant stated: “I would always do (deprescribing) in collaboration with , I guess what we’d call , the parent team” , indicating the connection that may be required between specialist palliative care services and other clinical specialities (Participant 12). While another participant highlighted “the beauty of palliative care specialities (for having) an easily accessible multidisciplinary team with a doctor , a specialist nurse , a physio , an OT (occupational therapist) … you can sit round the table and make those decisions and offer advice” (Participant 13). Several participants also emphasised general practice or “care offered by teams based in the community” as preferable settings to make decisions for deprescribing (Participant 1). For example, one participant working within secondary care shared a preference for community-based healthcare professionals to take ownership of deprescribing processes as they can “go into somebody’s home , where they (the patient) will feel more comfortable… in an environment where they feel safe so that open communication can be a bit easier” (Participant 1). The same participant indicated this preference for community-based ownership compared with conversations occurring “if they (the patient) were on a ward setting” (Participant 1). This was echoed by a Nurse Specialist who suggested deprescribing decision making “needs to be done in a calmer environment when you’ve got the time to have those discussions” (Participant 12).

Recognising the challenges associated with deprescribing decisions

Participants recognised the challenges that healthcare professionals face when making decisions around deprescribing medicines for patients in receipt of palliative care. One such challenge related to healthcare professionals’ fear and uncertainty about the repercussions of stopping medications. For example, the hesitancy “of stopping medications because it is not always clear what the outcome of that is going to be” for their patients (Participant 2).

“I think they’re scared of stopping an aspirin and then someone having a stroke… or stopping a NOAC (non-vitamin K oral anticoagulant) and their AF (atrial fibrillation) being uncontrolled and causing a stroke. I think they’re scared of the consequences” (Participant 13 , Specialist Pharmacist).

Several participants suggested that this fear may relate to a lack of formal education on deprescribing for healthcare professionals during their training years with one participant stating “F1 (foundation year 1) doctors are scared of doing deprescribing because it feels like a big responsibility , and that’s scary” (Participant 13). Other participants noted caution amongst medical healthcare professionals when it came to deprescribing, and postulated that causes of this could be due to a lack of exposure in training and the lack of normalisation of the process as part of their scope of practice. One participant stated that “if they (medics) learnt about it as undergraduates , like anything , the more you do it , the easier it becomes and the more confident you feel in doing it” (Participant 3) and another suggested “it will take a little time to become a normal thing for prescribers to do more confidently” (Participant 13).

Theme 2: changing the culture of deprescribing

Establishing the culture of deprescribing, by starting from the start.

Healthcare professionals shared views around better establishing the culture of deprescribing within clinical practice. They highlighted perspectives around the importance of “starting to think that way from the start” (Participant 11) at the point of prescribing a medication. Participants felt that this change to prescribing culture may also prompt patients to normalise “medicines aren’t always needed to be a forever thing” (Participant 14).

“When you prescribe something… historically people are just like , I’ve written it up and here you go and off you go. But I think maybe just having a real explanation of it… even saying there might come a point where you might want to think about stopping it” (Participant 14 , General Practitioner).

A key aspect within establishing a culture of deprescribing centred on participant’s views of the ‘best times’ to have conversations around stopping or reducing medication. One participant discussed a common trend seen in their clinical experience where conversations often happen too late in a patient’s clinical trajectory. They described feeling “ like it ends up being , if a patient is just really unwell… it’s probably then when [deprescribing] really starts being thought about” (Participant 14). Another participant working in palliative care, echoed these views and stated “by the time I’ve got involved as a palliative care nurse , it can be too late for some of these conversations. It would be nice if somebody would at least start them earlier on” (Participant 12). Despite recognising the importance of this, the ‘optimal’ timing of these conversations was not identified by participants; instead, they placed emphasis that having conversations around deprescribing should be guided according to a person’s individualised care needs. One proposed timeframe was at the point of “ an annual medication review for everyone in respect of what you’re diagnosing and treating” (Participant 12) and then “continually , as and when” thereafter (Participant 11).

Educating and empowering patients

Alongside the need for healthcare professionals to begin establishing the culture of deprescribing, it was also recognised that patient education and empowerment to make decisions around deprescribing was vital. Participants viewed deprescribing as a process ideally underpinned by shared decision-making, which should be “collaborative… we should say (to the patient) “look , in a medical opinion , we could do this , but what do you think?” I think should be a proper open discussion” (Participant 3). In order to achieve this collaboration, participants recognised the need to “give patients information in a way that they a) want and b) understand” so that they feel valued and “feel a true part of the conversation” (Participant 13). One palliative medicine consultant acknowledged the importance of patient empowerment when it came to changing the culture around deprescribing; they viewed medicines education and psychological support as vital tools to achieve supportive deprescribing and understood the worry that may accompany people having to think - and make decisions - about potentially stopping medications.

“It’s probably the first time they’ve been asked , “What does this drug really mean to you? Would it worry you if you had to stop it? What do you think it’s doing for you?” Those are quite big conversations.” (Participant 15 , Medical Consultant) .

Theme 3: involving patients (and others) in deprescribing decision-making

Acknowledging the priorities of patients, alongside others involved in their care.

Healthcare professionals recognised the need to involve patients closely in conversations and decisions around deprescribing, particularly taking into consideration their priorities when it comes to medication. A number of participants reflected on the importance of individualisation and tailoring deprescribing conversations to each specific person, rather than adopting a ‘one size fits all’ approach. One participant reflected on focusing on an individual’s preferences about taking medications, recognising that there may be discrepancies between their own clinical judgement about the necessity of a medication and the desire of a person to take it; they felt it important to voice both sides of the conversation and help the patient make an informed choice about deprescribing. From this, the importance of establishing the priorities of the patient was considered essential in deprescribing decision-making.

“Focusing on what we know what is important for that person… if somebody turned around to me and said , “I’m terrified of dying of a stroke , is it alright if I keep taking the statins?” the answer would be “absolutely yes” , and saying , “Well , what are your priorities in your remaining weeks , months , years of life , and what would you like us to focus on as healthcare professionals?” (Participant 4 , Medical Consultant).

Taking time to understand what influences a patient to take their medications was recognised by participants. It appeared important to appreciate that some patients may not want to make any changes with their medication at the point of an initial deprescribing conversation taking place; it was recognised that this may change over time, with fluctuations in their symptoms, disease trajectory, prognosis or even shifts in a person’s preferences or priorities around their care.

Whilst it was important to have a patient voice present in those discussions, healthcare professionals also recognised the importance of acknowledging priorities of others involved in their care, such as family, friends and caregivers. Healthcare professionals acknowledged the day-to-day input that family and carers have with their loved one’s medication, and reported it was vital to have their input into overall deprescribing decisions. One participant discussed the importance of “pre-planning” discussions about deprescribing with relatives, and having these conversations at an early enough stage “when there’s less tightened emotions to give them (relative) a chance to think and input into decisions about medicines , at a pace that is suitable for all parties” (Participant 3).

Participants reflected on the challenges that can sometimes present when making decisions about deprescribing if medication priorities differ between the patient and family member(s). One participant shared an example “where the patient wants to carry on with some medication but the family thought “I don’t think you need that – it’s making you too drowsy”” (Participant 14). They went on to further postulate the implications that continuation of a medication may have for the carer “or family member who feels like “well because you’re more drowsy , I’ve got to come and help you with this and that”” (Participant 14). Another participant discussed the commonality of conflicts between patients and family members when it concerns the trajectory of life-limiting illnesses. Specifically, if a carer or relative “hasn’t accepted that the person is dying , and me coming in and talking about stopping all these meds they’ve been on for years – that’s often the thing that really brings it home to them” (Participant 8).

Reflections on language used to establish shared conversations around deprescribing

Another participant reflected on the influence that language can have when establishing and shaping shared conversations with patients around deprescribing. They reflected on common phrasing used when prescribing and commencing new medicines, believing that often “the message we give as professionals is “once you’re on it , you’re on it forever”. I get why we do that for compliance , concordance … but maybe we need a bit of “this will be reviewed annually and we might change it” phrasing built in” (Participant 15). In doing so, it was deemed helpful to establish and share expectations between the prescriber and the patient relating to the intention and duration of each medication, whilst also involving patient perspectives in the ongoing review process.

Another participant shared an example where language used when starting a medication was a barrier to deprescribing in a specialist palliative care setting. They reflected on how often it is communicated by prescribers: ”never stop this medicine” or “this medicine is so important” that (when discussing deprescribing with one patient) … he just kind of thought as soon as he stopped it , he would die” (Participant 17). Reflections in language were also noted by other participants, specifically when describing successful deprescribing episodes as consultations that are framed in a way to minimise (or avoid) patient fear and/or concern. They recommended using shared language that aligned with “trialling without” a particular medication, as opposed to “stopping it” (Participant 5), so that the patient felt they could have input as an equal partner in the deprescribing decision-making process.

“It’s the framing of how you’re doing it – “we’ll put this to one side. I’m not stopping it , we’ll put it to one side. If you feel any different , you can put the medicine straight back up” (Participant 5 , Medical Consultant).

Another participant picked up on the influence of language when discussing deprescribing medication for patients with life-limiting illnesses. In particular, the importance of gently introducing deprescribing concepts that “explain we’re not giving up on them” and “emphasising that we’re on a journey together and they’re not being left high and dry” (Participant 9).

A further participant reflected on the importance of language and terms used to establish a relationship of trust between the healthcare professional and the patient, prior to making a deprescribing decision. For example, to help establish such a relationship they flatten the hierarchy between the patient and themselves, in a bid to “ feel that they (patients) can ask things to me that maybe they otherwise won’t” (Participant 10). In doing so, the participant felt the dynamic of the consultation was one of shared decision-making, rather than a “traditional consultation” with a paternalistic approach. Other participants alluded to the power and value of forming relationships between the patient and the prescriber where “trust needs to be at the centre … if they don’t know they can trust you , they might not be comfortable (with deprescribing decisions) … until you’ve built up that rapport” (Participant 1).

By exploring the perspectives of healthcare professionals, this study builds on previous evidence by exploring the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context. This study collated the perspectives from a range of healthcare professional groups working with responsibility for prescribing medication in a palliative care context – a specialist patient cohort, which has previously been under-reported in the deprescribing literature, as well as healthcare research more broadly. A consistent finding across all interviews was that the decision-making to underpin deprescribing approaches should be considered, planned, and done proactively as part of ongoing clinical care, rather than as a separate reactive process as a consequence of a patient’s illness or development of an adverse drug reaction. This was a unique finding from this work, which encompassed elements of professional responsibility and attitudes, alongside a need to change the culture in which prescribing and deprescribing are recognised as similar entities when it comes to safe and effective medicines use. Another unique learning point centres on the use of shared language within deprescribing conversations; framing decision-making consultations with terminology that reflects shared, equal conversations may prove more inclusive and balanced. As well, patient empowerment and person-centred approaches were deemed essential components of deprescribing decision-making; whereby the priorities of patients and others (such as family members or carers) are recognised and included as part of the deprescribing process.

Echoing previous studies in the wider deprescribing literature [ 29 , 30 , 31 ], healthcare professionals interviewed as part of this study acknowledged the value of forming and establishing trust with patients prior to deprescribing conversations taking place. Indeed, given the emotions that accompany a life-limiting illness, once a positive patient-healthcare professional relationship was formed, participants perceived it was easier to broach the subject of deprescribing. It is not clear from this research if patients perceive all healthcare professionals as the same, but findings in the wider literature suggest that older adults have greater trust in certain healthcare professionals, such as medical doctors, compared to others, like pharmacists [ 30 , 32 , 33 , 34 ]. Further building on elements of trust within deprescribing practices, participants discussed the underpinning uncertainty or fear that is experienced from a healthcare professional standpoint when a decision is made whether to deprescribe. Specifically, participants reported a lack of education built within their professional undergraduate and/or postgraduate training about how to approach deprescribing. In keeping with this study, these findings have been reported by prescribers working in a range of healthcare specialities including mental health [ 35 ], geriatric medicine [ 36 , 37 , 38 ] and wider primary care services [ 39 , 40 ]. In recognition of the inconsistent and non-standardised implementation of deprescribing within undergraduate education, a curricular framework for approaches to deprescribing has been proposed [ 41 ]. In this, recommendations were made aiming to improve the previously reported low prescriber self-efficacy and self-confidence when it comes to deprescribing [ 42 , 43 , 44 , 45 , 46 , 47 ] – something which future research may seek to evaluate, specifically within specialist patient cohorts like people accessing palliative care services.

Findings in this study echoed the value of building and maintaining interdisciplinary relationships between healthcare professional groups when approaching deprescribing as part of a multi-disciplinary team [ 38 , 48 , 49 ]. As well as this, the significance of shared collaborative conversations between clinicians, patients, and family members or carers was also echoed [ 17 ]. Much focus within previous studies has rightly placed patient preferences of deprescribing at the centre [ 50 , 51 , 52 ], however, future research may wish to further explore the dynamics and interplay between the preferences of others involved in a person’s care. Considering the role that carers and family members play in supporting people in receipt of palliative care [ 53 , 54 , 55 , 56 ], a greater understanding of shared patient-relative-clinician triad discussions about deprescribing would be useful to explore.

Another important study finding was the importance of the language used to have shared deprescribing conversations and the language used by healthcare professionals. Studies in wider healthcare literature have previously alluded to the complexity of conversations about end-of-life care and life-limiting illness [ 57 ], as well as the challenges of initiating discussions about medicines during periods of clinical deterioration or changes in disease trajectory [ 58 ]. Findings from this work show the importance of aligning language with shared expectations and shared decisions between the prescriber and the patient, specifically relating to the intended duration and rationale for each prescribed medication. A recent study by Green et al. [ 59 ] recommended suggestions for patient-preferred language that clinicians could use when communicating deprescribing decisions amongst older adults; findings from this and other studies [ 60 , 61 ] could be transferable to this work, in particular recognition of framing deprescribing decisions around an individual’s priorities and goals [ 59 ].

Whilst we believe our results are robust and have important implications for the way in which healthcare professionals approach deprescribing decision-making, we do acknowledge that the majority of our sample was limited to practice within the North East of England thus, the experience of our participants was that of, predominantly, White British females. Including the voices of healthcare professionals from other ethnic groups may have brought previously unheard considerations to the forefront, which may impact or influence deprescribing processes in minoritised groups – given the growing diversity of the patient population within the UK, this warrants further investigation in a bid to ensure cultural competence is embedded within deprescribing decision-making.

There remains a need to develop interventions to promote deprescribing decision-making for patients accessing palliative care services. In particular, there are still gaps in knowledge concerning the needs and challenges of patients and their family members or carers in this context, especially when it comes to the prescribing and deprescribing of medications as an overall component of care. Future research approaches should seek to further explore the steps within shared decision-making of deprescribing to understand how future interventions could best support this process. To achieve this, co-design methodology could be used to collectively combine the views of all people involved in the deprescribing process, including people with lived experience of receiving palliative care, their family members or carers, as well as healthcare professionals. By exploring the perspectives of healthcare professionals with responsibility for prescribing medication, this qualitative study addressed the first steps of this process and could be used to support future co-design work in this area.

This study sought to further explore the perspectives of healthcare professionals with responsibility for making deprescribing decisions with people accessing palliative care services. A diverse range of healthcare professionals identified the importance of supporting deprescribing decision-making so it becomes a proactive process, using shared language, rather than a reactive consequence, within a person’s care journey. The identified themes included professional attitudes, competency and responsibility towards deprescribing decision-making; changing the culture of deprescribing; and, the importance of involving patients and their family/caregivers in deprescribing decision-making. Future work should explore how healthcare professionals, patients and their family can best be supported in the shared decision-making processes of deprescribing.

Data availability

Data is provided within the manuscript or supplementary information files.

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Acknowledgements

Acknowledgement is given to the healthcare professionals who were participants in this study – without their support, the study would not have been possible. Also, thanks are given to the wider PONDER team - Dr. Lisa Baker, Dr. Ellie Bond, and Dr. Rachel Quibell.

This project is funded by the National Institute for Health and Care Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number Award ID: NIHR202283). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. In addition, authors AT, AH and BH are part-funded by the NIHR Newcastle Patient Safety Research Collaboration (PSRC).

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Z.B. led on the day-to-day running of the project and data collection. A.T. oversaw the running of this project as Principal Investigator and provided project management expertise. A.R-B. and C.L.R. led on data interpretation and analysis and writing of this manuscript. C.E. provided methodological expertise on data collection, interpretation, and analysis. J.J., J.E., B.H., A.H. provided topic input, interpretation and analysis. J.E. supported the recruitment of participants. A.B. and R.B. contributed in their appointment as patient champions with lived-experience and ensured appropriateness and sensitivity throughout the entire research process. All authors read, provided comments on, and approved the final manuscript.

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Robinson-Barella, A., Richardson, C.L., Bayley, Z. et al. “ Starting to think that way from the start” : approaching deprescribing decision-making for people accessing palliative care - a qualitative exploration of healthcare professionals views. BMC Palliat Care 23 , 221 (2024). https://doi.org/10.1186/s12904-024-01523-2

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• Jennifer O’Loughlin 2 , 3 &
• Marie-Pierre Sylvestre 2 , 3  

BMC Public Health volume  24 , Article number:  2434 ( 2024 ) Cite this article

Metrics details

Young adults face unique vulnerabilities during major life disruptions like the COVID-19 pandemic. The pandemic contributed to increases in mental health challenges and substance use among young adults. This study explores the experiences of young adults who increased their cannabis use during the pandemic.

Participants were recruited from the Nicotine Dependence in Teens (NDIT) study, and qualitative data were collected through semi-structured interviews conducted via Zoom. A total of 25 participants (ages 33–34) reporting increased cannabis use during the pandemic were included. Thematic analysis and gender-based analysis was employed to extract key themes.

Five themes emerged: (1) No disruption in cannabis use; (2) Cannabis use to manage declines in mental health; (3) Cannabis use to break up pandemic boredom; (4) Cannabis use as an expression of freedom; (5) Cannabis use as “another way to chill out.”

Conclusions

This research provides valuable perspectives on how major life disruptions, like the COVID-19 pandemic, influence cannabis use among young adults. The findings offer guidance for public health initiatives and highlight avenues for further investigation.

Peer Review reports

Introduction

The COVID-19 pandemic represented a major life disruption with unexpected changes to family dynamics (e.g., everyone at home), routines (e.g., school and extracurricular facilities closed), socialization (e.g., closure of restaurants and cancellation of social events), and employment (e.g., working at home and job loss) [ 1 , 2 ]. Because young adults are in a transitional life stage and often in the process of establishing themselves in these areas, they were particularly vulnerable to these disruptions, [ 3 ] and were among those most vulnerable to increasing substance use and mental health challenges in response to pandemic-induced distress [ 4 , 5 ]. A global cross-sectional survey of 1,653 participants ages 18–82 found that younger adults (age 18–34 years) were more vulnerable to pandemic-related stress, anxiety, and depression than older age groups [ 6 ].

Some evidence suggests that pandemic-related distress could have prompted increases in cannabis use to alleviate these negative effects [ 1 , 7 , 8 ]. For example, the Canadian Cannabis Survey in 2021 reported that 29% of Canadian cannabis users increased their cannabis use during the pandemic, which users attributed to boredom, stress, anxiety, lack of a regular schedule, and loneliness [ 9 ]. This appears to be especially true among young adults. According to a recent longitudinal study of changes in substance use before and during the pandemic, cannabis was the only substance that showed an increase in initiation and an increase in weekly/daily use among young adults age 30. [ 10 ] The experiences of young adults who increased their cannabis use during the pandemic to contextualize these numbers, however, remain unexplored.

There is emerging evidence that gender influences cannabis use. According to a systematic review, males are more likely to conform to “male typicality”, and are at higher risk of increased use during young adulthood than females [ 11 ]. In addition, gendered norms play different roles, with some protective of substance use (e.g., women are nurturing) and others conducive to substance use (e.g., women are relational) [ 11 ], lending to the conclusion that more more research is needed to understand the role of gender in cannabis use specifically. Some research has explored the role of gender in cannabis use during the pandemic. Compared to men, women reported greater increases in cannabis use to manage mental health challenges during the pandemic [ 12 , 13 , 14 , 15 ]. This may be due to women reporting higher rates of mental health issues during the pandemic compared to men [ 16 ]. Understanding the experiences of women and men during the pandemic is needed to unpack the relationship between gender and increased cannabis use during the pandemic.

Because cannabis was legalized in Canada in 2018, the pandemic paralleled rapid expansion of the cannabis market in cannabinoid composition (i.e., THC and CBD), potency of cannabis products, and delivery formats (e.g., inhalation, oral, topical) ( 17 – 18 ), which prompted an increase in cannabis use among young adults in particular [ 18 , 19 , 20 ]. Because most provinces and jurisdictions in Canada deemed cannabis retailers an essential service during the pandemic, [ 9 ] retailers were able to adapt by offering curbside pickup or online sales to reduce in-person interactions [ 21 ]. Understanding how such changes impacted cannabis use during the pandemic needs exploration.

Thus, there are numerous gaps in our understanding of cannabis use experiences among young adults during the pandemic. In this study, we addressed these gaps in an exploratory qualitative study of young adults who increased their cannabis use during the pandemic. Our objectives were to: (i) describe the cannabis use experiences of young adults during the pandemic; and (ii) investigate gender differences in their cannabis use experiences. Understanding these experiences is critical to informing the development of effective interventions to reduce the harms of cannabis use, particularly during major life disruptions.

Context – NDIT study

Participants were recruited from the Nicotine Dependence in Teens (NDIT) study, an ongoing investigation of 1294 participants recruited in 1999–2000 at ages 12–13 (grade 7 students). NDIT initially aimed to investigate the natural course and determinants of cigarette smoking and nicotine dependence in adolescence, [ 22 ] but quantitative data collection expanded to encompass use of other substances, lifestyle behaviours, genetics, anthropometrics measures, psychosocial factors, and mental health. Between 1999 and 2005 when participants (ages 12–17) were in high school, they completed self-report questionnaires every 3 months in a total of 20 data collection cycles. After high school, five additional data collection cycles have taken place to date (i.e., cycle 21 in 2007-08 at mean age 20.4 (SD = 0.8); cycle 22 in 2010-12 at mean age 24.0 (0.7); cycle 23 in 2017–2020 at mean age 30.6 (1.0); cycle 24 in 2020 -21 during the COVID-19 pandemic at mean age 33.6 (0.8) ; and cycle 25 at mean age 35.2 (0.61).

NDIT was approved by ethics committees at the Montreal Department of Public Health, McGill University and Centre hospitalier de l’Université de Montréal (2007–2384, 2017–6895, ND06.087). Parents/guardians provided written informed consent at baseline and participants, all of whom had attained legal age, provided consent post-high school.

Data collection

Participants who reported any increase in cannabis use in the past year during cycle 24 were eligible to participate in this qualitative study. From July to September 2021, a purposive sample of eligible English- and French-speaking males and females were invited to participate in 60-minute semi-structured interviews conducted via Zoom by AA and GF. During these interviews, participants were asked about how the pandemic influenced their mental health and health behaviors, including cannabis use. Herein, we present data on cannabis use during the pandemic among these young adults. These data are based on seven interview questions, including type, frequency, and context of use during the pandemic, reasons for use during the pandemic, and perceived positive and negative impacts of the pandemic on cannabis use.

Data analysis

All interviews were audio-recorded and transcribed by a third party. All transcripts were reviewed by research assistants for accuracy and then anonymized. We disaggregated the data by gender and analyzed the data using Braun and Clark’s thematic analysis approach [ 23 , 24 ], which comprises of six phases (familiarisation, initial code generation, theme generation, theme review, theme confirmation, and reporting). We positioned our analysis within a constructivist epistemology and interpretive/subjectivist ontology, meaning that the themes were developed through communication with the participants and through interpretations by the researchers. For phase one (familiarisation with the data), three researchers (GF, LS, and AA) read the transcripts and collaboratively iterated on what they were seeing in coding meetings. For phase two (initial code generation), we employed Nvivo qualitative data analysis software to generate descriptive codes for responses to the interview questions. For example, if a participant mentioned using cannabis to treat heightened anxiety during the pandemic, we created a broad code of “mental health” and then a sub-code of “anxiety”. One researcher (LS) then coded the transcripts for women, and another (AA) coded the transcripts for men (so that gender-based influences on cannabis experiences could be identified). During phase three (theme generation), after all transcripts were coded, we engaged in collaborative theme development meetings, wherein we discussed what meaning was shared across the entire sample and what meaning was unique to women or men as a collective, or even to individual participants. We did this iteratively until we established meaning saturation and no new themes emerged when reviewing the coded data. During phase four (theme review), we collaboratively iterated on the themes to ensure that nuances were appropriately captured. For phase five (naming themes), we discussed and generated a thematic framework to capture the themes and their relationships to each other.

The credibility of the study is established through content and methodological expertise among the study team members, and through the development of a codebook. The dependability of the study is ensured through a data analysis audit trail that we kept track of via research team reviews and summaries of transcripts, use of collaborative coding, and use of Nvivo data analysis software. The confirmability of the study findings is ensured through the frequent team meetings that were held to discuss and confirm consensus of the meaning of the findings throughout data analysis. The transferability of the study findings is enhanced through the robust sample size included in this study, with equal representation of males and females.

A total of 25 participants were included in this study (Table  1 ). Participants were all age 33 or 34, and just over half were female. All female participants identified as women and all male participants identified as men. All participants reported using cannabis daily or weekly in the past year. Most had more than high-school education in both female and male samples (91.7% and 84.6% respectively), and a household income above $50,000, which was slightly higher among males at 74.9% compared to 53.9%. Except for one, all participants were born in Canada. More female participants reported living alone (46.2%), being unemployed (38.5%), and having a history of a mental health diagnosis (53.8%). More male participants reported past year substance use of any kind compared to females. More females scored higher on depressive and anxiety symptoms than males.

Qualitative themes

Our findings revealed five themes that capture the influence of the pandemic on young adult cannabis use including: (1) no disruption in cannabis use; (2) cannabis use to manage declines in mental health; (3) cannabis use to break up pandemic boredom; (4) cannabis use as an expression of freedom; and (5) cannabis use as “another way to chill out”. Gender-specific findings in relation to these themes were identified.

No disruption in cannabis use

Men reported cannabis use as a more regular day-to-day activity than females. Thus, men were particularly vocal about experiencing little or no disruption in their use due to pandemic restrictions and lockdowns. Men reported that access to cannabis during the pandemic was not only unhindered, but became even easier. In addition to cannabis stores being considered an essential service in Quebec and allowed to remain open, these outlets quickly adapted to alternative and convenient modes of delivery, such as home delivery. Men reported enhanced accessibility as a major facilitating factor for use during the pandemic:

I mean already there was the accessibility. That’s one issue, that you can just go to the store and pick it up at any time. And it’s essential so it doesn’t close, while everything else does. (male, 1070001) ‘Cause if you ordered before 1:00 PM on their website, you would get it that evening. So I would literally like order it during the day and then at night, I’d order Uber Eats and my food and my weed would just get delivered to my door [laughs]. It was like “The future is here and it’s great”! [laughs] So yeah, that definitely contributed to like the more, easier access to it, like I didn’t even have to go to the store and have to deal with waiting in line, waiting in a huge line. Uh… and then going in the store, wearing a mask, all that stuff. (male, 115003)

Cannabis to manage declines in mental health

Participants frequently reported an increase in cannabis use during the pandemic because they struggled with heightened anxiety and stress in response to the impacts of the pandemic including job loss, working from home, having no childcare, and the overall stress of lockdowns:

Maybe [I used] a little bit more in terms of the anxiety that was coming up. So maybe I had a lot more bad nights during the pandemic than I would have had if there had been no pandemic. (female, 2580010) First time [I used cannabis] was just like curiosity and just kind of for fun. And the second time was COVID. That is actually the reason. (male, 80002)

Cannabis use to cope during the pandemic was particularly prevalent among women who were mothers. Women spoke to decreases in their mental health due to job-related stress combined with increased childcare responsibilities. They often described feeling out of control, and using cannabis was a way to cope with that feeling:

The biggest stressors for me were like the kids being home the whole time, or like for that stretch from March till the end of August of last year. And my work situation, just really feeling completely out of control. (female, 350001)

Many women, however, emphasized that they were using cannabis as an alternative to managing their mental health symptoms rather than to get high. Women with children made sure to emphasize that they did not use it in front of their children:

Well, a lot of times it’s when I have my kids my stress level is really, really high. So, around like 6 o’clock, I can’t take it anymore, so I go and smoke like three four puffs in the garage. (female, 1860010)

In addition, several women reported that endorsement by their doctor was important to their decision-making and comfort in using cannabis to treat their mental health symptoms:

[My Dr.] was like: “That’s good… if you can find something … to not be on Ativan every day instead.” (female, 1660001).

Cannabis as a way to break up pandemic boredom

Participants described feelings of boredom during the pandemic, which was largely blamed on their inability to engage in their usual day-to-day activities (e.g., going to work, gyms, or restaurants; socializing; participating in extracurricular activities). As a result, they described cannabis use as a tool that enabled them to face boredom and provided a means to entertain oneself during lockdowns and stay-at-home orders:

I think, it’s really just boredom, during the pandemic, not [laughs]-not having any action, like, it’s-it’s just that, basically. It wasn’t like, “Oh, my God, I’m sad right now, I want to like forget about it.” No, it was just like, “This is boring! Let’s try some things to like get a little buzz, a little effect.” (female, 720006).

In this vein, participants described using cannabis as something that became popular amongst a variety of social circles during the pandemic. They explained that all the new compositions (e.g., THC/CBD) and formats (e.g., edibles) of cannabis that were made widely available following the legalization of cannabis in Canada, prompted them to try new modes of consumption and new products because there was a sense among participants that cannabis was more acceptable and that everyone was trying it and discussing it:

During the pandemic, there was this new trend with candy. And I saw some very serious people - well, not very serious, but you know, very functional people, I mean, who work, who do, uh… who were talking to me about it, like, “Oh yeah, it’s really cool. It helps you relax.” So I tried it. I ordered a bottle-uh, a bottle-uh yeah, that’s right, a little bottle of candy. And yeah [laughs]! I thought it was like chill to try like at night. I was like, “Ah, this is cool! You know it’s relaxing.” Then I was taking something too that was- there was more- what do you call it? CBD… (female, 720006).

Cannabis use was also used to maintain social routines to combat pandemic boredom. One participant described smoking cannabis during video chats as a way to keep up his social connections:

So it was still kind of a social thing ‘cause I would be smoking in my room while my friends were on video calls, also smoking weed. So it’s like almost like we were doing the same thing that we were doing before, so it was– there was a little bit of social element. But again, it was only like once a week, but I was still smoking every day. (male, 1150003)

Cannabis use as an expression of freedom

Some participants, especially women, described cannabis use as an expression of freedom from the lockdowns. Nearly all participants reported first trying cannabis during adolescence. Therefore, using cannabis during the pandemic was paralleled with memories of when they were young and free. They described feeling like teenagers again, and wanting to be a bit wild when they felt so inhibited by the lockdowns. Some described using during lockdowns with others in their bubble, while others described using when there were breaks in the lockdowns at social gatherings as a way to celebrate:

We had gone out one night, and I felt like a teenager again. One of my friends had some edibles in the freezer, so me and my friends were like, “let’s try it”. (female, 710001) Uh, well I think, uh, there’s a kind of feeling like, “We got our freedom back”, you know. I must have been feeling a bit wild there you know like “anything goes” [laughs]! (female, 2090010)

“Another way to chill out”

Many participants reported using cannabis as a way of winding down from their hectic days, often referred to as an alternative to winding down with a glass of wine:

Oh I guess– I guess when I was using it, I was just kind of thinking…this is another way I can chill out. Like, can I do this or can I replace this with a glass of red wine, kind of thing? (female, 450003)

Some participants talked about how their alcohol consumption increased during the pandemic. They concluded that cannabis was a better alternative since they did not suffer from the side effects of excessive consumption like they did with alcohol (e.g., hangover):

Because initially…in the pandemic, it was more like let’s have drinks every night and that I feel has more of an effect on my state the following day, with a hangover, or it triggers a migraine. So I avoid that with cannabis. Which is I guess the lesser of two evils. (female, 350001)

While women reported using cannabis to wind down usually after tasks were completed and kids asleep, men often reported using cannabis earlier in the evening and as something to help them connect and feel more present with their family:

Like I don’t smoke a lot, you know I’d be like two or three puffs – and it really helps me to calm down and be present with my kids. (male, 420002)

Further, some women reported smoking cannabis as a way to connect with their husband or partner while they were winding down from the day. In fact, several women reported that they only started using it because their partner was using it:

Like I think for… in terms of smoking it, it just became… it was occasionally something to do cause my husband’s smoking it and… it was a nice way to like wind down in the evening kind of thing…it was enjoyable to do when it was… warm at night and we could sit outside and we would talk and we could you know smoke a little bit and chat and stuff like that. (female, 1660001)

Main findings

This study examined contextual factors that influenced cannabis use among young adults who reported an increase in cannabis use during a major life disruption, the COVID-19 pandemic. Themes in this study revealed that this disruption was associated with uninterrupted access to cannabis, a way to manage mental health, something that helped them manage boredom, something that reminded them of when they were young and free, and as another way to wind down. The findings also revealed some gender-based differences in use, whereby women expressed childcare and job-related strain as a key factor in increasing cannabis use. In addition, women were adamant about not exposing their children to cannabis, not using it to get high, and receiving their doctor’s approval to use cannabis to manage mental health symptoms. Finally, some women reported smoking cannabis (versus using oils or edibles) as a way to connect with their male partner.

Similar to other studies [ 8 , 27 , 28 ] young adults in this study reported increasing use to help them cope throughout the pandemic. For example, Clendennen et al. [ 27 ] found that increases in stress and symptoms of anxiety and depression predicted increases in cannabis use among young adults during the pandemic. Noteworthy in our study was the strain that mothers experienced. This may be due, in part, to the fact that childcare fell primarily on women during the pandemic [ 29 ]. According to a survey in the United States, compared to fathers, mothers reported that they were more likely to face professional hurdles, reduce their work hours, face difficulties in getting work done, and shoulder most of the caregiving burden [ 30 ]. The experiences of mothers in this study suggest a disproportionate impact of the pandemic on them regarding childcare, which could be attributed to normative gender-based roles (e.g., women are caregivers) that appeared to naturally fall into place when supports for women and working mothers (e.g., daycare) were no longer available. Our findings thus confirm that the lack of much needed targeted relief for mothers (e.g., social support, employment support) is an area for development.

Supportive of other studies, [ 31 ] young adults reported that cannabis use helped ease boredom during the pandemic. With limited opportunities for socialization, and the inability to engage in recreational activities that were part of their typical routine (e.g., going to the gym), young adults in this study used cannabis to break free and remedy their boredom. This method of coping with boredom raises concerns about the long-term impacts of the pandemic on substance use in general, including cannabis use behavior. It also raises questions about how young adults adapt to disruptions over time and if the increase in use in response to boredom was temporary. Regardless, these findings underscore the importance of recreational and social outlets for the young adult population.

The pandemic followed legalization of cannabis in Canada in 2018 closely [ 21 ], with new cannabis formats and potency options more readily available during the pandemic. This may have contributed to participants likening their cannabis use during the pandemic to their first use as teenagers, whereby new product options offered renewed novelty and excitement around cannabis. Similar to other studies [ 32 , 33 ], the effects of the pandemic on nostalgia for the “good old days” was expressed through engaging in activities that reminded participants of times when they were young and free (e.g., listening to music). Although there is evidence that nostalgia is protective of mental health and that it promoted happiness during the pandemic [ 34 , 35 ], the effects of cannabis use as a nostalgic activity needs more investigation.

The influence of gender on differential use and perceptions of cannabis was noteworthy. In particular, women appeared to be attuned to stigmatization associated with their use, emphasizing that they would not use around their children, were using it primarily to ease mental health symptoms rather than to get high, were more likely to use formats that did not produce smoke (e.g., oils and edibles), and reported that their doctor’s approval was important to them. Despite that legalization of cannabis has somewhat normalized cannabis use, social norms that associate cannabis use with masculinity problematizes cannabis use among women [ 36 ]. In an analysis of cannabis stigmas, Reid [ 37 ] cautioned against claims of normalization of cannabis use since qualitative accounts reveal increasing evidence that social stigmas are intersecting with particular groups who typically experience inequality, including women. Our qualitative findings underscore women’s accounts that reflect a desire to resist stigmatization of their use.

It was also interesting how cannabis use among men influenced uptake among their female partners. Women reported joining their partner in using cannabis as a way to connect and spend time together. Researchers examining heterosexual couples found that joint cannabis use appears to strengthen relationship functioning in the short term [ 38 ]. However, there is a gap in the literature regarding the impact of cannabis use among couples in the long term, as well as among couples whereby one partner started using cannabis because of the other partner.

Implications and future research

This study has implications for public health and future research. In relation to public health, the findings pinpoint actions that can be considered to support young adults through major life disruptions, like the COVID-19 pandemic. For example, promoting social and extracurricular outlets for young adults (e.g., discounts on camping or park passes), supporting mothers with childcare costs and relief (e.g., funding, space), creating supports in the context of job insecurity (e.g., lobby for government grants that could be activated during a global pandemic), and ensuring that doctors are educated on the effects of cannabis use should be a priority. Additionally, promoting healthy outlets to express nostalgia (e.g., through music or activities) may also be a productive way to promote resilience and happiness through challenging disruptions. In relation to future research, understanding the temporality of increased cannabis use during the pandemic, the potential benefits and pitfalls of using cannabis as a nostalgic activity, and the influence of partners on cannabis use are all areas which will benefit from future research.

Strengths and limitations

A strength of this study is that it is one of the first to explore how the pandemic influenced cannabis use among young adults through the voices of young adults. Another strength is the sample size and representation of women and men. As a result, a novel contribution of this study is an exploration of gender differences in the experience of cannabis use during the pandemic. A strength is also that the sample was drawn from a large pool of young adults in Quebec, Canada. Finally, the findings provide helpful directions for future research, and directions for public health advocates to consider when supporting young adults during major life disruptions, such as the pandemic.

Limitations include that this study involved a Quebec sample and Quebec had different rules around COVID-19 than other provinces, possibly limiting transferability of the findings. Another limitation is that the interviews were conducted in the summer of 2021, such that the full impact of the pandemic may not have been captured. However, the interviews were conducted after the lockdown, which represented a critical timeline during the pandemic. In addition, pandemic regulations during the summer, and access to the outdoors due to the weather, may have influenced participants’ cannabis use. Usage patterns and perceptions on cannabis use may have shifted after this time point (e.g., some users may have decided to quit or commit to a decrease in use). Finally, we did not measure the level of increase in cannabis use in this study sample.

This study examined how a major life disruption, the COVID-19 pandemic, influenced cannabis use among young adults. Our findings reveal the contextualized experiences of young women and men in navigating such a disruption and how it impacted their cannabis use. Young adults found that they did not experience any disruption in their ability to access cannabis, and they described increasing their use due to mental health struggles, feeling bored, as an expression of freedom during restrictions, and as a way to relax. These findings have important public health implications and identify key areas for future research.

Data availability

“Data can be accessed by completing a data access form, which is available on the Nicotine Dependence in Teens website (www.nditstudy.ca), and will then need to be submitted to the NDIT principal investigator, Dr. Jennifer O’Loughlin ([email protected]). “.

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Acknowledgements

The authors would like to acknowledge the participants for their time and contributions.

The NDIT study was supported by the Canadian Cancer Society (grant numbers 010271, 017435, 704031) and the Canadian Institutes of Health Research (grant number 451832, 477288). LS is supported by a Canadian Cancer Society Emerging Scholar Award (grant number 707156). MPS is supported by Salary Awards from The Fonds de Recherche du Québec - Santé. JOL held a Tier 1 Canada Research Chair from 2004 to 2021. JK held a Doctoral Scholarship from the Québec Order of Nurses (Ordre des infirmières et infirmiers du Québec) from 2019 to 2022.

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Laura L. Struik

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Alexia Armasu, Teodora Riglea, Jodi Kalubi, Mounia Naja, Jennifer O’Loughlin & Marie-Pierre Sylvestre

Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC, Canada

Genevieve Fortin, Teodora Riglea, Jodi Kalubi, Olivier Ferlatte, Jennifer O’Loughlin & Marie-Pierre Sylvestre

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Contributions

L.S. conducted data analysis and wrote the main manuscript text. A.A. conducted data collection and analysis. G.F., J.K., and M-P.S. conducted data collection. O.F. supported data analysis. M.N. assisted with NDIT data cleaning. T.R. analyzed and prepared the demographic table. J.O. oversaw the study and provided access to NDIT. M-P.S. conceptualized the study. All authors contributed to and reviewed the manuscript.

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Correspondence to Laura L. Struik .

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Struik, L.L., Armasu, A., Fortin, G. et al. A qualitative study of experiences among young adults who increased their cannabis use during the COVID-19 pandemic. BMC Public Health 24 , 2434 (2024). https://doi.org/10.1186/s12889-024-19886-9

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Received : 21 December 2023

Accepted : 26 August 2024

Published : 06 September 2024

DOI : https://doi.org/10.1186/s12889-024-19886-9

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