qualitative research is important because

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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 September 5, 2024.

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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Qualitative Research: Characteristics, Design, Methods & Examples

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On This Page:

Qualitative research is a type of research methodology that focuses on gathering and analyzing non-numerical data to gain a deeper understanding of human behavior, experiences, and perspectives.

It aims to explore the “why” and “how” of a phenomenon rather than the “what,” “where,” and “when” typically addressed by quantitative research.

Unlike quantitative research, which focuses on gathering and analyzing numerical data for statistical analysis, qualitative research involves researchers interpreting data to identify themes, patterns, and meanings.

Qualitative research can be used to:

• Gain deep contextual understandings of the subjective social reality of individuals
• To answer questions about experience and meaning from the participant’s perspective
• To design hypotheses, theory must be researched using qualitative methods to determine what is important before research can begin. 

Examples of qualitative research questions include: 

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

Characteristics 

Naturalistic setting.

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

Naturalistic settings provide valuable contextual information to help researchers better understand and interpret the data they collect.

The environment, social interactions, and cultural factors can all influence behavior and experiences, and these elements are more easily observed in real-world settings.

Reality is socially constructed

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

The primacy of subject matter 

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

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

Variables are complex, interwoven, and difficult to measure

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

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

Emic (insider’s point of view)

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

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

Interpretive analysis

In qualitative research, interpretive analysis is crucial in making sense of the collected data.

This process involves examining the raw data, such as interview transcripts, field notes, or documents, and identifying the underlying themes, patterns, and meanings that emerge from the participants’ experiences and perspectives.

Collecting Qualitative Data

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

Observations

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

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

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

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

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

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

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

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

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

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

Focus groups 

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

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

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

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

Ethnography

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

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

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

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

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

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

Qualitative Data Analysis Methods

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

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

Grounded theory

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

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

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

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

Content analysis

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

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

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

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

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

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

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

Discourse analysis

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

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

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

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

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

Thematic analysis

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

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

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

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

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

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

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

Phases of Thematic Analysis

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

Template analysis

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

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

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

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

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

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

Frame analysis

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

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

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

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

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

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

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

Preventing Bias in Qualitative Research

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

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

Co-coding 

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

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

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

Member checking

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

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

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

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

Reflexivity in qualitative research

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

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

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

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

Reflexivity Example

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

Establishing Trustworthiness in Qualitative Research

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

1. Credibility in Qualitative Research

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

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

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

2. Transferability in Qualitative Research

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

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

3. Dependability in Qualitative Research

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

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

4. Confirmability in Qualitative Research

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

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

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

Audit Trails in Qualitative Research

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

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

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

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

Discovery of unexpected data

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

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

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

Flexibility

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

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

Naturalistic settings

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

Limitations

Time-consuming .

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

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

Subjectivity 

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

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

Limited generalizability

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

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

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

While individual qualitative studies are often limited in their generalizability due to factors such as sample size and context, metasynthesis enables researchers to synthesize findings from multiple studies, potentially leading to more generalizable conclusions.

By integrating findings from studies conducted in diverse settings and with different populations, metasynthesis can provide broader insights into the phenomenon of interest.

Extraneous variables

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

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

What sample size should qualitative research be?

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

Are surveys qualitative or quantitative?

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

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

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

What are the ethical considerations of qualitative research?

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

What is triangulation in qualitative research?

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

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

Why is qualitative research important?

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

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

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

What is coding data in qualitative research?

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

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

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

What is the difference between qualitative and quantitative research?

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

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

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

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

What is trustworthiness in qualitative research?

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

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

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

What is data saturation in qualitative research?

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

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

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

Why is sampling in qualitative research important?

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

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

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

What is narrative analysis?

Narrative analysis is a qualitative research method used to understand how individuals create stories from their personal experiences.

There is an emphasis on understanding the context in which a narrative is constructed, recognizing the influence of historical, cultural, and social factors on storytelling.

Researchers can use different methods together to explore a research question.

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalisability

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

• Labour-intensive

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

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

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

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

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

Focus Groups

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

Ethnographic Studies

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

Text Analysis

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

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

Process of Observation

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

Record Keeping

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

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

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

Qualitative Research Analysis Methods

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

Thematic Analysis

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

Content Analysis

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

Discourse Analysis

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

Grounded Theory Analysis

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

Narrative Analysis

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

Phenomenological Analysis

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

Comparative Analysis

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

Applications of Qualitative Research

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

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

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

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

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

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

Purpose of Qualitative Research

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

Qualitative research can serve multiple purposes, including:

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

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

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

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

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

Advantages of Qualitative Research

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

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

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

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

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• > Qualitative research: its value and applicability

Article contents

What questions are best answered using qualitative research, countering some misconceptions, in conclusion, qualitative research: its value and applicability.

Published online by Cambridge University Press:  02 January 2018

Qualitative research has a rich tradition in the study of human social behaviour and cultures. Its general aim is to develop concepts which help us to understand social phenomena in, wherever possible, natural rather than experimental settings, to gain an understanding of the experiences, perceptions and/or behaviours of individuals, and the meanings attached to them. The effective application of qualitative methods to other disciplines, including clinical, health service and education research, has a rapidly expanding and robust evidence base. Qualitative approaches have particular potential in psychiatry research, singularly and in combination with quantitative methods. This article outlines the nature and potential application of qualitative research as well as attempting to counter a number of misconceptions.

Qualitative research has a rich tradition in the social sciences. Since the late 19th century, researchers interested in studying the social behaviour and cultures of humankind have perceived limitations in trying to explain the phenomena they encounter in purely quantifiable, measurable terms. Anthropology, in its social and cultural forms, was one of the foremost disciplines in developing what would later be termed a qualitative approach, founded as it was on ethnographic studies which sought an understanding of the culture of people from other societies, often hitherto unknown and far removed in geography. Reference Bernard 1 Early researchers would spend extended periods of time living in societies, observing, noting and photographing the minutia of daily life, with the most committed often learning the language of peoples they observed, in the hope of gaining greater acceptance by them and a more detailed understanding of the cultural norms at play. All academic disciplines concerned with human and social behaviour, including anthropology, sociology and psychology, now make extensive use of qualitative research methods whose systematic application was first developed by these colonial-era social scientists.

Their methods, involving observation, participation and discussion of the individuals and groups being studied, as well as reading related textual and visual media and artefacts, form the bedrock of all qualitative social scientific inquiry. The general aim of qualitative research is thus to develop concepts which help us to understand social phenomena in, wherever possible, natural rather than experimental settings, to gain an understanding of the experiences, perceptions and/or behaviours of those studied, and the meanings attached to them. Reference Bryman 2 Researchers interested in finding out why people behave the way they do; how people are affected by events, how attitudes and opinions are formed; how and why cultures and practices have developed in the way they have, might well consider qualitative methods to answer their questions.

It is fair to say that clinical and health-related research is still dominated by quantitative methods, of which the randomised controlled trial, focused on hypothesis-testing through experiment controlled by randomisation, is perhaps the quintessential method. Qualitative approaches may seem obscure to the uninitiated when directly compared with the experimental, quantitative methods used in clinical research. There is increasing recognition among researchers in these fields, however, that qualitative methods such as observation, in-depth interviews, focus groups, consensus methods, case studies and the interpretation of texts can be more effective than quantitative approaches in exploring complex phenomena and as such are valuable additions to the methodological armoury available to them. Reference Denzin and Lincoln 3

In considering what kind of research questions are best answered using a qualitative approach, it is important to remember that, first and foremost, unlike quantitative research, inquiry conducted in the qualitative tradition seeks to answer the question ‘What?’ as opposed to ‘How often?’. Qualitative methods are designed to reveal what is going on by describing and interpreting phenomena; they do not attempt to measure how often an event or association occurs. Research conducted using qualitative methods is normally done with an intent to preserve the inherent complexities of human behaviour as opposed to assuming a reductive view of the subject in order to count and measure the occurrence of phenomena. Qualitative research normally takes an inductive approach, moving from observation to hypothesis rather than hypothesis-testing or deduction, although the latter is perfectly possible.

When conducting research in this tradition, the researcher should, if possible, avoid separating the stages of study design, data collection and analysis, but instead weave backwards and forwards between the raw data and the process of conceptualisation, thereby making sense of the data throughout the period of data collection. Although there are inevitable tensions among methodologists concerned with qualitative practice, there is broad consensus that a priori categories and concepts reflecting a researcher's own preconceptions should not be imposed on the process of data collection and analysis. The emphasis should be on capturing and interpreting research participants' true perceptions and/or behaviours.

Using combined approaches

The polarity between qualitative and quantitative research has been largely assuaged, to the benefit of all disciplines which now recognise the value, and compatibility, of both approaches. Indeed, there can be particular value in using quantitative methods in combination with qualitative methods. Reference Barbour 4 In the exploratory stages of a research project, qualitative methodology can be used to clarify or refine the research question, to aid conceptualisation and to generate a hypothesis. It can also help to identify the correct variables to be measured, as researchers have been known to measure before they fully understand the underlying issues pertaining to a study and, as a consequence, may not always target the most appropriate factors. Qualitative work can be valuable in the interpretation, qualification or illumination of quantitative research findings. This is particularly helpful when focusing on anomalous results, as they test the main hypothesis formulated. Qualitative methods can also be used in combination with quantitative methods to triangulate findings and support the validation process, for example, where three or more methods are used and the results compared for similarity (e.g. a survey, interviews and a period of observation in situ ).

‘There is little value in qualitative research findings because we cannot generalise from them’

Generalisability refers to the extent that the account can be applied to other people, times and settings other than those actually studied. A common criticism of qualitative research is that the results of a study are rarely, if ever, generalisable to a larger population because the sample groups are small and the participants are not chosen randomly. Such criticism fails to recognise the distinctiveness of qualitative research where sampling is concerned. In quantitative research, the intent is to secure a large random sample that is representative of the general population, with the purpose of eliminating individual variations, focusing on generalisations and thereby allowing for statistical inference of results that are applicable across an entire population. In qualitative research, generalisability is based on the assumption that it is valuable to begin to understand similar situations or people, rather than being representative of the target population. Qualitative research is rarely based on the use of random samples, so the kinds of reference to wider populations made on the basis of surveys cannot be used in qualitative analysis.

Qualitative researchers utilise purposive sampling, whereby research participants are selected deliberately to test a particular theoretical premise. The purpose of sampling here is not to identify a random subgroup of the general population from which statistically significant results can be extrapolated, but rather to identify, in a systematic way, individuals that possess relevant characteristics for the question being considered. Reference Strauss and Corbin 5 The researchers must instead ensure that any reference to people and settings beyond those in the study are justified, which is normally achieved by defining, in detail, the type of settings and people to whom the explanation or theory applies based on the identification of similar settings and people in the study. The intent is to permit a detailed examination of the phenomenon, resulting in a text-rich interpretation that can deepen our understanding and produce a plausible explanation of the phenomenon under study. The results are not intended to be statistically generalisable, although any theory they generate might well be.

‘Qualitative research cannot really claim reliability or validity’

In quantitative research, reliability is the extent to which different observers, or the same observers on different occasions, make the same observations or collect the same data about the same object of study. The changing nature of social phenomena scrutinised by qualitative researchers inevitably makes the possibility of the same kind of reliability problematic in their work. A number of alternative concepts to reliability have been developed by qualitative methodologists, however, known collectively as forms of trustworthiness. Reference Guba 6

One way to demonstrate trustworthiness is to present detailed evidence in the form of quotations from interviews and field notes, along with thick textual descriptions of episodes, events and settings. To be trustworthy, qualitative analysis should also be auditable, making it possible to retrace the steps leading to a certain interpretation or theory to check that no alternatives were left unexamined and that no researcher biases had any avoidable influence on the results. Usually, this involves the recording of information about who did what with the data and in what order so that the origin of interpretations can be retraced.

In general, within the research traditions of the natural sciences, findings are validated by their repeated replication, and if a second investigator cannot replicate the findings when they repeat the experiment then the original results are questioned. If no one else can replicate the original results then they are rejected as fatally flawed and therefore invalid. Natural scientists have developed a broad spectrum of procedures and study designs to ensure that experiments are dependable and that replication is possible. In the social sciences, particularly when using qualitative research methods, replication is rarely possible given that, when observed or questioned again, respondents will almost never say or do precisely the same things. Whether results have been successfully replicated is always a matter of interpretation. There are, however, procedures that, if followed, can significantly reduce the possibility of producing analyses that are partial or biased. Reference Altheide, Johnson, Denzin and Lincoln 7

Triangulation is one way of doing this. It essentially means combining multiple views, approaches or methods in an investigation to obtain a more accurate interpretation of the phenomena, thereby creating an analysis of greater depth and richness. As the process of analysing qualitative data normally involves some form of coding, whereby data are broken down into units of analysis, constant comparison can also be used. Constant comparison involves checking the consistency and accuracy of interpretations and especially the application of codes by constantly comparing one interpretation or code with others both of a similar sort and in other cases and settings. This in effect is a form of interrater reliability, involving multiple researchers or teams in the coding process so that it is possible to compare how they have coded the same passages and where there are areas of agreement and disagreement so that consensus can be reached about a code's definition, improving consistency and rigour. It is also good practice in qualitative analysis to look constantly for outliers – results that are out of line with your main findings or any which directly contradict what your explanations might predict, re-examining the data to try to find a way of explaining the atypical finding to produce a modified and more complex theory and explanation.

Qualitative research has been established for many decades in the social sciences and encompasses a valuable set of methodological tools for data collection, analysis and interpretation. Their effective application to other disciplines, including clinical, health service and education research, has a rapidly expanding and robust evidence base. The use of qualitative approaches to research in psychiatry has particular potential, singularly and in combination with quantitative methods. Reference Crabb and Chur-Hansen 8 When devising research questions in the specialty, careful thought should always be given to the most appropriate methodology, and consideration given to the great depth and richness of empirical evidence which a robust qualitative approach is able to provide.

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• DOI: https://doi.org/10.1192/pb.bp.113.042770

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• Volume 25, Issue 1
• Critical appraisal of qualitative research: necessity, partialities and the issue of bias
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• http://orcid.org/0000-0001-5660-8224 Veronika Williams ,
• Anne-Marie Boylan ,
• http://orcid.org/0000-0003-4597-1276 David Nunan
• Nuffield Department of Primary Care Health Sciences , University of Oxford, Radcliffe Observatory Quarter , Oxford , UK
• Correspondence to Dr Veronika Williams, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; veronika.williams{at}phc.ox.ac.uk

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• qualitative research

Introduction

Qualitative evidence allows researchers to analyse human experience and provides useful exploratory insights into experiential matters and meaning, often explaining the ‘how’ and ‘why’. As we have argued previously 1 , qualitative research has an important place within evidence-based healthcare, contributing to among other things policy on patient safety, 2 prescribing, 3 4 and understanding chronic illness. 5 Equally, it offers additional insight into quantitative studies, explaining contextual factors surrounding a successful intervention or why an intervention might have ‘failed’ or ‘succeeded’ where effect sizes cannot. It is for these reasons that the MRC strongly recommends including qualitative evaluations when developing and evaluating complex interventions. 6

Critical appraisal of qualitative research

Is it necessary.

Although the importance of qualitative research to improve health services and care is now increasingly widely supported (discussed in paper 1), the role of appraising the quality of qualitative health research is still debated. 8 10 Despite a large body of literature focusing on appraisal and rigour, 9 11–15 often referred to as ‘trustworthiness’ 16 in qualitative research, there remains debate about how to —and even whether to—critically appraise qualitative research. 8–10 17–19 However, if we are to make a case for qualitative research as integral to evidence-based healthcare, then any argument to omit a crucial element of evidence-based practice is difficult to justify. That being said, simply applying the standards of rigour used to appraise studies based on the positivist paradigm (Positivism depends on quantifiable observations to test hypotheses and assumes that the researcher is independent of the study. Research situated within a positivist paradigm isbased purely on facts and consider the world to be external and objective and is concerned with validity, reliability and generalisability as measures of rigour.) would be misplaced given the different epistemological underpinnings of the two types of data.

Given its scope and its place within health research, the robust and systematic appraisal of qualitative research to assess its trustworthiness is as paramount to its implementation in clinical practice as any other type of research. It is important to appraise different qualitative studies in relation to the specific methodology used because the methodological approach is linked to the ‘outcome’ of the research (eg, theory development, phenomenological understandings and credibility of findings). Moreover, appraisal needs to go beyond merely describing the specific details of the methods used (eg, how data were collected and analysed), with additional focus needed on the overarching research design and its appropriateness in accordance with the study remit and objectives.

Poorly conducted qualitative research has been described as ‘worthless, becomes fiction and loses its utility’. 20 However, without a deep understanding of concepts of quality in qualitative research or at least an appropriate means to assess its quality, good qualitative research also risks being dismissed, particularly in the context of evidence-based healthcare where end users may not be well versed in this paradigm.

How is appraisal currently performed?

Appraising the quality of qualitative research is not a new concept—there are a number of published appraisal tools, frameworks and checklists in existence. 21–23  An important and often overlooked point is the confusion between tools designed for appraising methodological quality and reporting guidelines designed to assess the quality of methods reporting. An example is the Consolidate Criteria for Reporting Qualitative Research (COREQ) 24 checklist, which was designed to provide standards for authors when reporting qualitative research but is often mistaken for a methods appraisal tool. 10

Broadly speaking there are two types of critical appraisal approaches for qualitative research: checklists and frameworks. Checklists have often been criticised for confusing quality in qualitative research with ‘technical fixes’ 21 25 , resulting in the erroneous prioritisation of particular aspects of methodological processes over others (eg, multiple coding and triangulation). It could be argued that a checklist approach adopts the positivist paradigm, where the focus is on objectively assessing ‘quality’ where the assumptions is that the researcher is independent of the research conducted. This may result in the application of quantitative understandings of bias in order to judge aspects of recruitment, sampling, data collection and analysis in qualitative research papers. One of the most widely used appraisal tools is the Critical Appraisal Skills Programme (CASP) 26 and along with the JBI QARI (Joanna Briggs Institute Qualitative Assessment and Assessment Instrument) 27 presents examples which tend to mimic the quantitative approach to appraisal. The CASP qualitative tool follows that of other CASP appraisal tools for quantitative research designs developed in the 1990s. The similarities are therefore unsurprising given the status of qualitative research at that time.

Frameworks focus on the overarching concepts of quality in qualitative research, including transparency, reflexivity, dependability and transferability (see box 1 ). 11–13 15 16 20 28 However, unless the reader is familiar with these concepts—their meaning and impact, and how to interpret them—they will have difficulty applying them when critically appraising a paper.

The main issue concerning currently available checklist and framework appraisal methods is that they take a broad brush approach to ‘qualitative’ research as whole, with few, if any, sufficiently differentiating between the different methodological approaches (eg, Grounded Theory, Interpretative Phenomenology, Discourse Analysis) nor different methods of data collection (interviewing, focus groups and observations). In this sense, it is akin to taking the entire field of ‘quantitative’ study designs and applying a single method or tool for their quality appraisal. In the case of qualitative research, checklists, therefore, offer only a blunt and arguably ineffective tool and potentially promote an incomplete understanding of good ‘quality’ in qualitative research. Likewise, current framework methods do not take into account how concepts differ in their application across the variety of qualitative approaches and, like checklists, they also do not differentiate between different qualitative methodologies.

On the need for specific appraisal tools

Current approaches to the appraisal of the methodological rigour of the differing types of qualitative research converge towards checklists or frameworks. More importantly, the current tools do not explicitly acknowledge the prejudices that may be present in the different types of qualitative research.

Concepts of rigour or trustworthiness within qualitative research 31

Transferability: the extent to which the presented study allows readers to make connections between the study’s data and wider community settings, ie, transfer conceptual findings to other contexts.

Credibility: extent to which a research account is believable and appropriate, particularly in relation to the stories told by participants and the interpretations made by the researcher.

Reflexivity: refers to the researchers’ engagement of continuous examination and explanation of how they have influenced a research project from choosing a research question to sampling, data collection, analysis and interpretation of data.

Transparency: making explicit the whole research process from sampling strategies, data collection to analysis. The rationale for decisions made is as important as the decisions themselves.

However, we often talk about these concepts in general terms, and it might be helpful to give some explicit examples of how the ‘technical processes’ affect these, for example, partialities related to:

Selection: recruiting participants via gatekeepers, such as healthcare professionals or clinicians, who may select them based on whether they believe them to be ‘good’ participants for interviews/focus groups.

Data collection: poor interview guide with closed questions which encourage yes/no answers and/leading questions.

Reflexivity and transparency: where researchers may focus their analysis on preconceived ideas rather than ground their analysis in the data and do not reflect on the impact of this in a transparent way.

The lack of tailored, method-specific appraisal tools has potentially contributed to the poor uptake and use of qualitative research for informing evidence-based decision making. To improve this situation, we propose the need for more robust quality appraisal tools that explicitly encompass both the core design aspects of all qualitative research (sampling/data collection/analysis) but also considered the specific partialities that can be presented with different methodological approaches. Such tools might draw on the strengths of current frameworks and checklists while providing users with sufficient understanding of concepts of rigour in relation to the different types of qualitative methods. We provide an outline of such tools in the third and final paper in this series.

As qualitative research becomes ever more embedded in health science research, and in order for that research to have better impact on healthcare decisions, we need to rethink critical appraisal and develop tools that allow differentiated evaluations of the myriad of qualitative methodological approaches rather than continuing to treat qualitative research as a single unified approach.

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• ↵ CASP (Critical Appraisal Skills Programme). date unknown . http://www.phru.nhs.uk/Pages/PHD/CASP.htm .
• ↵ The Joanna Briggs Institute . JBI QARI Critical appraisal checklist for interpretive & critical research . Adelaide : The Joanna Briggs Institute , 2014 .
• Stephens J ,

Contributors VW and DN: conceived the idea for this article. VW: wrote the first draft. AMB and DN: contributed to the final draft. All authors approve the submitted article.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Correction notice This article has been updated since its original publication to include a new reference (reference 1.)

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

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

Data visualization can be employed formatively, to aid your data analysis, or summatively, to present your findings. Many qualitative data analysis (QDA) software platforms, such as NVivo , feature search functionality and data visualization options within them to aid data analysis during the formative stages of your project.

For expert assistance creating data visualizations to present your research, Harvard Library offers Visualization Support . Get help and training with data visualization design and tools—such as Tableau—for the Harvard community. Workshops and one-on-one consultations are also available.

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

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

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

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

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

• Annual Reviews   Review articles sum up the latest research in many fields, including social sciences, biomedicine, life sciences, and physical sciences. These are timely collections of critical reviews written by leading scientists.  
• HOLLIS - search for resources on theories in your field   Modify this example search by entering the name of your field in place of "your discipline," then hit search.  
• Oxford Bibliographies   Written and reviewed by academic experts, every article in this database is an authoritative guide to the current scholarship in a variety of fields, containing original commentary and annotations.  
• ProQuest Dissertations & Theses (PQDT)   Indexes dissertations and masters' theses from most North American graduate schools as well as some European universities. Provides full text for most indexed dissertations from 1990-present.  
• Very Short Introductions   Launched by Oxford University Press in 1995, Very Short Introductions offer concise introductions to a diverse range of subjects from Climate to Consciousness, Game Theory to Ancient Warfare, Privacy to Islamic History, Economics to Literary Theory.
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• Volume 42 , pages 139–160, ( 2019 )

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

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What is Qualitative in Research

Unsettling definitions of qualitative research, what is “qualitative” in qualitative research why the answer does not matter but the question is important, explore related subjects.

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

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

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

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

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

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

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

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

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

Towards a Definition of Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Analysis – What is Qualitative Research?

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

Qualitative and Quantitative

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

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

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

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

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

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

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

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

Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

Grounded Theory

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

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

Defining Qualitative Research

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

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

Distinctions

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

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

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

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

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

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

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

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

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

Improved Understanding

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

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

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

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

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

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

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

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

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

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

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

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

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

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Acknowledgements

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

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Insights into maternal pertussis vaccination counselling: a qualitative study on perspectives and experiences among midwives and gynaecologists in the Netherlands

• Veja Widdershoven 1 , 2 ,
• Eveline C.H. van Eerd 1 ,
• Marije Pfeyffer 2 , 3 ,
• Liesse M.L. Vanderhoven 1 , 2 ,
• Amanja Verhaegh-Haasnoot 1 ,
• Rianne P. Reijs 2 , 3 &
• Christian J.P.A. Hoebe 1 , 2 , 4  

BMC Infectious Diseases volume  24 , Article number:  903 ( 2024 ) Cite this article

Metrics details

Healthcare professionals (HCPs) play a significant role in the decision-making process of pregnant women on maternal vaccinations. Whereas a high proportion of HCPs discuss maternal vaccinations with pregnant women, confidence in discussing maternal vaccinations is lacking and HCPs experience inadequate training to discuss maternal vaccinations with pregnant women. Furthermore, different practical barriers might influence the consultation process, such as lack of time. More studies on the barriers, as well as facilitators, to discussing maternal vaccinations is needed and will help us to better understand and support HCPs in discussing maternal vaccinations.

This qualitative study involved semi-structured interviews with fourteen HCPs working as midwives or gynaecologists in the Netherlands. An integrated theoretical approach was used to inform data collection and analysis. Thematic analysis was conducted using inductive and deductive approaches. This study followed the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines.

The thematic analysis of the data pointed to the following five themes of HCP counselling: the consultation process, attitude, perceived norm, perceived control and improvement ideas. Most HCPs follow a similar approach in maternal pertussis vaccination consultations, beginning by assessing clients’ understanding, providing basic information, and addressing questions. However, consultation timing and prioritization vary among HCPs. Challenges in consultations include client requests for clear advice, with HCPs trained to remain neutral, emphasizing client autonomy in decision-making. Most HCPs acknowledge the importance of their consultations in informing pregnant women about maternal pertussis vaccination.

Conclusions

This study offers a confirmation of the awareness of the pivotal role of HCPs in informing pregnant women about the maternal pertussis vaccination. HCPs stress the importance of neutral counselling, enabling pregnant women to make well-informed decisions independently. Because of upcoming vaccine hesitancy nowadays, HCPs must be equipped with the knowledge and confidence to navigate difficult conversations. Continuous education and training might help to increase HCPs’ confidence in handling difficult consultations. Additionally, making the information materials for pregnant women available in multiple languages and incorporating more visuals to enhance comprehension could support HCPs in reaching a broader group of pregnant women.

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Introduction

Maternal immunization is an effective strategy in preventing pregnant women and their newborns from severe diseases, like influenza and pertussis [ 1 , 2 , 3 ]. Previous studies have demonstrated the significant impact of maternal immunization, resulting in a 63% reduction in influenza cases and a 91% decrease in pertussis infections among young infants [ 4 , 5 ]. The Dutch National Immunization Program (NIP) introduced the maternal pertussis vaccination (MPV) in December 2019. This followed earlier implementations in the UK (2012), Australia (2015), Belgium (2013) and US (2012) [ 6 , 7 , 8 , 9 , 10 ]. In the Netherlands MPV is given by the Public Health Service (PHS) as part of Youth Health Care. Midwives and gynaecologists are expected to briefly discuss the possibility of MPV, handing out the national information leaflet and referring pregnant women to the website for more information and for making an appointment between 14 and 22 weeks of pregnancy. These healthcare professionals (HCPs) are not involved in actual vaccine delivery. Notwithstanding the recognized public and individual health advantages of MPV, the coverage among pregnant women is lower than anticipated; about 61% in the UK, 55% in the US and 64% in the Netherlands in 2022 [ 11 , 12 , 13 ]. Many pregnant women remain hesitant towards receiving the MPV, making the task of increasing acceptance a global challenge [ 14 , 15 , 16 ].

Studies investigating reasons related to MPV acceptance and refusal have shown that HCPs, mainly midwives and gynaecologists, play a significant role in the decision-making process of pregnant women [ 3 , 16 , 17 , 18 ]. Receiving a HCP recommendation is a main facilitator of increasing MPV acceptance, while absence of this recommendation increases vaccine hesitancy and is one of the main barriers reported among unvaccinated pregnant women [ 15 , 17 , 18 , 19 , 20 , 21 ]. In addition, inadequate knowledge is also a barrier to vaccination acceptance. Such as knowledge about the vaccine, for example their efficacy and availability, and knowledge about the diseases they prevent [ 17 , 18 ]. For many pregnant women this knowledge is only gained when the vaccination is discussed with a HCP [ 17 ]. In our previous questionnaire study among MPV acceptors and refusers in the Netherlands, 13% of MPV acceptors indicated that they did not know MPV existed until their midwife or obstetrician provided information about the vaccination. Moreover, 52% of MPV acceptors mentioned that they accepted MPV because of the information given by a HCP, underlying the importance of HCPs as a source of information for pregnant women [ 22 ]. During pregnancy, women have frequent contact with their midwife or gynaecologist and therefore information and recommendations about MPV can easily be given.

Although a high proportion of HCPs discuss maternal vaccinations with pregnant women, studies have suggested that they lack confidence in these discussions and often experience inadequate training for discussing maternal vaccinations with pregnant women [ 16 , 18 , 21 , 23 ]. In addition to insufficient training, lack of knowledge about the disease and the vaccines themselves is a significant barrier to discussing maternal vaccinations [ 23 , 24 ]. Several studies have identified that HCPs can possess negative attitudes towards maternal vaccinations, often due to doubts about the effectiveness and safety of administering vaccines during pregnancy. These doubts were found to be more prevalent among midwives compared to other HCPs [ 17 , 21 , 25 ]. Furthermore, various practical barriers have been cited. HCPs frequently experience uncertainties regarding who is responsible for informing pregnant women about maternal vaccinations. Additionally, a high workload and consequent lack of time significantly impact their ability to discuss maternal vaccinations adequately [ 18 , 21 , 23 , 26 ]. Concerns about reimbursement for the time spent discussing maternal vaccinations further complicates these interactions [ 18 ]. More research on both the barriers and facilitators of discussing maternal vaccinations is needed to better understand and support HCPs in discussing maternal vaccinations.

The Reasoned Action Approach (RAA) is used in this study to understand the behaviour of HCPs with regards to discussing maternal vaccinations. According to the RAA, behaviour is best predicted by the intention to perform that behaviour. The theory identifies three main determinants for explaining and predicting intention. First, the attitude a person has towards a particular behaviour. Second, the normative influence, which represents the perceived social pressure towards a particular behaviour. Third, a person’s perceived behavioural control, which reflects the belief in their skills and abilities to execute the behaviour. In addition to these determinants, the RAA emphasizes the significant influence of skills and environmental barriers a person may encounter in executing a particular behaviour [ 27 ]. This qualitative study explores the perspectives and experiences of midwives and gynaecologists in the Netherlands regarding MPV counselling through semi-structured interviews. The aim is to uncover barriers and facilitators that can eventually inform interventions to optimize maternal vaccination advice by HCPs and to increase maternal vaccination uptake.

Study design

To explore the perspectives of HCPs concerning MPV counselling, a theory-informed qualitative study was conducted involving semi-structured interviews. We assessed the perspectives of HCPs on MPV counselling partially by assessing determinants of the Reasoned Action Approach (RAA). The RAA aims to explain and predict behaviour, in our study MPV counselling, based on attitudes, perceived norms and perceived behavioural control [ 28 ]. Additionally, the RAA considers required skills or environmental barriers that influence whether someone’s intention is converted into behaviour. The COnsolidated criteria for REporting Qualitative research (COREQ) guidelines were followed for data reporting [ 29 ].

Participant selection

Participants were HCPs working as midwives or gynaecologists in the Netherlands. Some participants were recruited via a previous online cross-sectional questionnaire study [ 30 ] about MPV counselling. HCPs who indicated having interest in participating in an interview, received an invitation for the interview via e-mail. Invited participants were asked to recruit future participants among their co-workers, using the snowball principle. When HCPs were willing to participate, the interview was scheduled and an informed consent form was signed. Participants were recruited until data saturation was achieved.

Data collection

Semi-structured audio-recorded interviews with HCPs were conducted between February 2022 and February 2023. The interviews lasted approximately 30–40 min each and were conducted online or by telephone. Interviews were held by experienced interviewers: a female youth health care physician (MP) and a female PhD student (VW). Prior to the study, no relationship was established between the participants and the interviewers. At the beginning of the interview, the interviewers introduced themselves and the aim and purpose of this study were explained once more. Confidentiality of data was emphasised to minimize possible socially desirable answers.

Interviews were audio recorded, transcribed verbatim and anonymized. An interview guide consisting of several main themes was developed a priori. MP and VW developed this guide based on a previous questionnaire study among HCPs about MPV counselling using the theoretical framework developed by Visser et al. [ 31 ]. Questions asked in the current qualitative study were used to gain more in depth perspectives on MPV counselling and related perceived barriers and facilitators. Themes included were: consultation processes and practical implications (when and how MPV counselling takes place), attitudes towards MPV and MPV counselling, barriers and facilitators to MPV counselling, and improvement ideas. No pilot interview was conducted.

Data analysis

Interviews were transcribed verbatim in Dutch by an external transcription service company. The transcripts were imported into ATLAS.ti 23 software for qualitative analysis. A thematic analysis was performed, using the 15-point checklist of criteria for good thematic analysis developed by Braun and Clarke [ 28 ]. We used a hybrid process of inductive and deductive coding. An initial coding structure was developed by two researchers based on the RAA and themes from the interview guide (Fig.  1 ). In addition to the initial coding structure, emergent codes were added by using inductive coding. The coding process was conducted iteratively, persisting until no additional codes emerged. In addition, field notes were compared with transcripts to develop a deeper understanding of the interpretation of the data. The field notes helped to collect contextual data and identify meaningful, expressive phrases, body language, and emotions in interview passages during the process of coding. Thereby, our analysis focussed on both explicit and implicit dimensions of the qualitative data, providing a more nuanced and comprehensive analysis. Data analysis was performed by two independent researchers (EE and VW). Discrepancies during the coding process were discussed among the researchers until a consensus was reached.

Ethics statement

This study was approved by the Medical Ethical Committee of the University of Maastricht (METC 2020-2296-A-1).

In total, 79 HCPs were personally approached via e-mail or telephone. Of the invited HCPs, 14 one-time interviews (18%) were conducted over the course of the twelve month research period. The participants consisted of 10 midwifes and 4 gynaecologists from 5 different provinces in the Netherlands. The majority of them were female (93%, n  = 13).

Results will be described based on the coding tree (Fig.  1 ), starting with the overall consultation process, followed by attitude, perceived norm, perceived control and improvement ideas.

Coding tree based on the Reasoned Action Approach

Overall consultation process

Consultation approach.

The majority of HCPs expressed a similar approach to their consultation sessions. They often started by asking pregnant women, hereafter usually referred to as clients, about their prior understanding of MPV, followed by providing basic information and answering questions: “So I ask […] have you ever heard of the maternal pertussis vaccination? Do you know what it means? We also give them the flyer […] from the National Institute for Public Health and the Environment (RIVM). […] And then [I] write down a number they can call for [making the] appointment.” (P4 , midwife). Most HCPs used two common arguments during their consultations. First, they explain that the baby is protected against the harmful effects of a pertussis infection starting at birth as the baby receives antibodies from the mother. Second, this means that, in most cases, the newborn needs one vaccination less. A few HCPs provided limited information about MPV because they feel it is not their responsibility and they receive no extra time or money for discussing it: “I explain very little about this [MPV] […] because there is a discussion about who is responsible [for providing information].” (P11 , midwife).

At the end of the consultation, HCPs would hand out the RIVM flyer and explain how to make the appointment online. Notably, all HCPs indicated not distributing flyers in languages other than Dutch or English. In circumstances where there was a language barrier, HCPs referred their clients to the official RIVM website: “If I really have to , I refer to the RIVM [website] where the translation can be found , but I have not printed [the flyers] out myself […].” (P2 , midwife) . Two HCPs stated that they just referred clients to the website and did not hand out flyers, citing environmental concerns in one case.

Consultation timing

The vaccination consultation takes about 5 to 10 min on average, depending on the client’s prior knowledge and their questions or concerns. The timing of the consultation sessions differed substantially across the HCPs. The most often agreed-upon schedule was to do an initial consultation session and hand out the flyer in week 16, followed by a follow-up session in week 22 to address further questions and enquire about a possible vaccination appointment: “At 16 weeks we give the information about [the vaccine] , and then […] we’ll come back to that after those 22 weeks […].” (P8 , midwife). “And at 22 weeks we verify whether they have had enough information , whether it was clear and whether they want to know anything else about [the vaccine]. And we note in the [medical file] whether they have made an appointment.” (P12 , midwife). Some HCPs, however, reported initiating the conversation as late as week 22 or 24, while others already mentioned the vaccine during intake in week 12 and revisited the matter in week 20. Few HCPs only discussed MPV during one consultation, unless the client addresses MPV herself again in a next consultation.

Challenges during consultations

HCPs mentioned some challenges that they face during their consultations. For example, some HCPs mentioned experiencing a challenge when clients request a clear positive or negative advice whether they should accept MPV. However, most HCPs stated that they had been trained to remain neutral while counselling: “But they ask that [my opinion about MPV] very often. […] I always say , what I think , you do not think. […] And then I try to be like , but what do you think , why do you hesitate?” (P14 , gynaecologist) . Especially when clients were hesitant about MPV, many HCPs mentioned that they feel the importance to emphasize that the clients have their own choice to accept or reject MPV. HCPs would provide extra information if desired, but they never expressed their own preferences or choices: “We counsel neutrally. If people really have questions about the vaccination , you answer these questions. You hope that you have given all the information and that all the questions have been answered. Then it [the choice] is up to the parent , I think. […] We are not going to push them or say you must make a choice” (P4 , midwife). Next to the neutral counselling, two HCPs acknowledged the importance of providing additional information or using drawings when counselling clients with a lower level of educational attainment. One HCP mentioned that occasionally MPV is not discussed during consultations due to different priorities, especially in case of complicated pregnancies.

Attitude regarding their role

Overall, most HCPs acknowledged the importance of their consultation and information in the decision-making process of pregnant women. Some HCPs addressed that they think pregnant women do not know about MPV if HCPs are not discussing it: “I think it is important for pregnant women to know this [advantages MPV] , to be well informed.[…] You have to tell the pregnant woman [the existence of MPV] , because they do not know on their own.” (P1 , gynaecologist). They agree that only giving a flyer is not enough information and most of them mentioned the importance of repeating information about MPV: “[…]the power of repetition is important , I think. […]For example like folic acid , that [communication] was really high for a while and everybody started taking folic acid even before they were pregnant. But that [awareness] is decreasing now.” (P7 , midwife).

Several participants have highlighted that the higher the quality of information and the more positive the HCP is towards the vaccine, the higher the vaccine uptake among pregnant women: “what just appears from [previous research] is that the more positive the HCP is towards vaccinations , the greater the uptake. So , I just think this role [of doing the consultation] was made for us.” (P5 , gynaecologist). Nevertheless, the HCPs generally acknowledge the importance of pregnant women being free to make an informed choice about getting the MPV or not. One HCP reported that it is beneficial the obstetricians and gynaecologists are executing the consultations, as they are not working in an organization in favour of vaccinations, such as a Public Health Service (PHS): “We [gynaecologists and obstetricians] play an important role , because they [pregnant women] do not see us as a PHS in favour of vaccinations. They see us as a caregiver for their baby.” (P14 , gynaecologist).

Overall, HCPs reported minimal opposition or criticism from clients during the MPV counselling. However, some HCPs mentioned that vaccinations are a sensitive topic nowadays, making it more difficult to discuss MPV. Clients often discovered information online before the consultation and formed their opinion about MPV: “They [pregnant women] say that medication is not safe during pregnancy. But I happen to be the gynaecologist. I know that the vaccination is not bad. You should get this one [MPV].” (P9 , gynaecologist). Because HCPs want to keep a good relationship with the clients, they often gauge how the client thinks about MPV before providing any information. In addition, HCPs conversate more about maternal vaccinations such as COVID-19 and influenza vaccination.

Attitude regarding consultations

Timing and prioritizing of MPV consultations showed contrast between two groups of HCPs. Half of the HCPs expressed that counselling about MPV felt like a small effort that easily fits into their existing consultation time: “I think it is easy to do at the 16-week consultation , we have fifteen minutes. […] So [counselling about MPV] fits in nicely , because it is one of the topics to discuss.” (P4 , midwife). The other half often prioritized other tasks over vaccination counselling due to the extensive nature of parental care: „I already have so much in my consultation hours that I want to discuss” (P7 , midwife). Additionally, some HCPs felt dissatisfied about not being reimbursed for counselling MPV, while other HCPs considered counselling MPV to be minor in comparison to other responsibilities.

Perceived norm

Perceived norm mpv.

The majority of HCPs believed that most clients support and accept MPV. Even though HCPs know that some clients have a negative attitude towards MPV, have a fear of vaccinations, or have misconceptions about vaccinations (e.g. vaccination causes autism in children). Most HCPs reported that they do not encounter these clients during their consultations. However, some HCPs reported that MPV uptake might depend on the population (e.g. lower uptake in individuals with a lower level of educational attainment, and a lower socioeconomic status) and region. Several HCPs recognized that pregnant women based their decision on experiences and behaviour of family and friends (descriptive norm): “During my consultations they say: My friend and sisters also received that [MPV] , thus so do I [accept MPV].” (P7 , midwife) . Besides, nowadays more and more information about MPV and maternal vaccinations are available online and in magazines. One HCP indicated that 80% of pregnant women simply follow the recommendation of the government without further consideration (injunctive norm): “I think that 80% [of pregnant women] tend to accept MPV because it [MPV] is the recommendation of the government without further consideration. They just make an appointment.” (P3 , midwife).

Perceived norm consultations

While most HCPs have agreements within their medical office on when and how MPV will be discussed with the clients, there is uncertainty about whether these agreements are followed consistently across practitioners and healthcare settings (descriptive norm): “We all hand out the flyer during the intake. [But] I do not really know to what extent we will come back to it at 20 weeks. I do know that we once agreed to come back to it one more time , but that was [long ago] , so to what extent do [the others] still do that?” (P3 , midwife). Several HCPs understood that other HCPs might not have the same opinion about the MPV and might therefore counsel differently due to different underlying beliefs. One participant said that she believed that there is a big group of HCPs that is not in favour of doing the MPV consultations and is therefore not doing them (well).

A key theme was the idea that MPV should be counselled as neutral as possible, highlighting the positive and negatives aspects of MPV without sharing their personal opinion. Most HCPs follow the injunctive principle that pregnant women should have autonomy and make their own decisions about maternal vaccinations. One HCP also emphasized feeling responsible for the delivery of information about MPV (injunctive norm): “I feel like it is my responsibility to make sure they [pregnant women] are informed. […] If someone [pregnant woman] did not receive the MPV because she did not hear about it [MPV] , I would blame myself.” (P5 , gynaecologist).

Perceived control

Perceived autonomy.

A reoccurring topic was a lack of autonomy in establishing the terms and conditions of their engagement in MPV counselling. When MPV was newly introduced into the NIP, many HCPs felt that they were excluded from the discussions surrounding the implementation and only received information on the practicalities, leaving them with limited time to prepare. Midwives especially felt that this was yet another task that was imposed upon them without consulting them and without accompanying financial assistance: “[…] when it [MPV] was first introduced , everyone was like , something gets added again that we have to counsel about , [but] which we are not allowed to do [vaccinate] ourselves. So again , a longer consultation time that you have to schedule.” (P8 , midwife). Some HCPs indicated that they would prefer to give MPV themselves or being compensated for counselling MPV to increase the sense of urgency and responsibility: “And I do not really think [counselling the MPV] is my job […] I already have so much in my office hours that I want to discuss , […] But the moment you are also responsible for giving [the vaccine] yourself , I think that would make the counselling different.” (P7 , midwife).

Several HCPs expressed difficulties maintaining neutrality during MPV counselling, since the official advice from the government is to recommend the vaccine. HCPs were not allowed to express their own opinions about the decision to accept or reject MPV, which might limit them in choosing which information they provide.

Perceived capacity

Overall, HCPs feel competent in executing the consultation and answer frequently asked and basic questions. Yet, several HCPs expressed insecurities regarding answering difficult questions, e.g. about adjuvants in vaccines, or providing sufficient information when pregnant women are hesitant. Some HCPs found it easy to inform their clients that they would need to research the answer and will provide it at a later time: “[…] most questions are doable. Otherwise , I say [that] I’m going to look it up [and] then I will come back to you. So , in that sense , always sure [about my ability to answer question]. And if I do not know , I’ll just look [the answer] up.” (P4 , midwife). Some HCPs mentioned sending clients to the PHS for more information or counselling, however, they feel that the PHS does not answer the questions either: “[I] often notice that people ask questions , which […] I do not know the answer to either. [So] then I say , oh , just check with the PHS , because they are the ones giving the vaccination. But they [the PHS] often refer back to us because we should be doing the counselling.” (P3 , midwife). A few HCPs indicated that they do not know where to find more information and who to contact in case they have questions. Almost all HCPs expressed their wish for an extra training to refresh and update their knowledge about maternal vaccinations.

Improvement ideas

All HCPs provided some improvement ideas that can be summarized in three categories: (1) information material for pregnant women, (2) increasing knowledge of HCPs and (3) administration of MPV. First, many HCPs mentioned the importance of having more inclusive information materials available for pregnant women. For example, providing information on various channels including forums, social media and local television channels watched by non-native speakers or having written information available in more languages and using visuals elements to make the information easier to understand: “For example , for [information on] the NIPT (non-invasive prenatal testing) test [they use] very simple animations. Something like that would also be nice [for MPV]. Just also for the low literate , to whom visuals appeal more than linguistics.” (P5 , gynaecologist). Second, multiple HCPs mentioned introducing frequent training for HCPs to stay informed about MPV or other maternal vaccinations and to exchange practical examples: “[…] sometimes I think it would be good for us to repeat [our knowledge of MPV] again [to refresh our memory].” (P7 , midwife).

Third, the majority of HCPs expressed their willingness to administer MPV themselves. The advantages they cited included reduced waiting time for appointments, elimination of the need for transportation to other locations, and greater ease in scheduling, particularly for individuals with low health literacy or low socio-economic status: “I would like to give MPV myself. […] My assistant can make an appointment for you. There are no barriers , you do not have to make the appointment , you do not have to go somewhere else.” (P9 , gynaecologist). The disadvantages cited were: the large amount of administrative work and lacking the capacity to store the vaccination adequately in an official refrigerator with an expensive quality management system to secure the cold chain.

This study provides insights about HCPs’ perspectives and experiences concerning MPV counselling in the Netherlands. Our findings highlight that (1) HCPs are aware of their essential role in informing pregnant women about MPV, (2) HCPs stress the importance of neutral counselling, (3) HCPs express insecurities about providing accurate and comprehensive information, especially when faced with vaccine hesitant opinions, and (4) involvement of HCPs in the implementation process of MPV might increase the sense of urgency and responsibility.

Generally, midwives and gynaecologists have close relationships with their clients, establishing them as trusted sources of information [ 32 , 33 ]. Pregnant women tend to be receptive to information provided by midwives and gynaecologists, making both the content (covering the benefits and risks of MPV) and the manner of delivery (through discussion or informational handouts) crucial factors [ 22 , 34 ]. Multiple previous studies indicated a strong association between HCPs’ recommendation and MPV acceptance [ 33 , 34 , 35 ]. However, our study highlights that HCPs stress the importance of neutral counselling, enabling pregnant women to make well-informed decisions about MPV independently which contrasts with the clear positive advice by the government based on a high quality synthesis of evidence by the National Health Council. However, strong evidence implies that a recommendation by a HCP could increase maternal vaccination uptake [ 3 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Therefore, it might be beneficial to shift the role of the HCP from a neutral counselling role to a positive advisory role. However, for this new role to be effective, it is important to consider the cultural environment in which the HCP operates and to ensure that a strong HCP-client relationship remains a priority.

HCPs have observed that vaccination has become a sensitive topic, especially after the COVID-19 pandemic, they express the increased difficulty to discuss MPV without damaging the relationship with their clients. Moreover, vaccine hesitancy is on the rise, prompting individuals to seek information online, where a large amount of confusing disinformation is present, consequently leading to an expanding body of misconceptions [ 35 ]. Thus, competent HCPs play a key role to answer difficult questions and provide accurate information that is needed to inform pregnant women. Several HCPs in our study expressed insecurities about providing accurate and comprehensive information, especially when faced with vaccine hesitant opinions. Regular training on topics such as vaccine ingredients, vaccine effectiveness and common misconceptions, might help to increase HCPs’ confidence and give them tools to handle difficult consultations about MPV. Additionally, providing information materials through several channels in multiple languages and incorporating more visuals to enhance comprehension could support HCPs in reaching a broader spectrum of pregnant women, including those who do not speak the native language and those with lower levels educational attainment.

While the majority of HCPs expressed a positive attitude about the MPV and their role in the decision-making process of pregnant women, some HCPs believed that it is not their responsibility to discuss MPV, partly due to the absence of a financial compensation or having insufficient time. This is bothersome as in the Dutch system the HCP referral role to the vaccination institute is essential as no national pregnancy register exists and therefore no central invitation system is available as is the case for other national vaccination programme vaccines. This lack hampers the ability to directly invite individuals for vaccination appointments. Establishing such a registry could improve vaccination uptake, as it appears that not all pregnant clients currently receive the necessary vaccination information. Furthermore, several HCPs expressed a desire for greater participation in the implementation process of MPV. Midwives in particular expressed that choices about the implementation were made without consulting them. This finding was confirmed by another Dutch qualitative study that aimed to evaluate the implementation of MPV [ 36 ]. Similar challenges have been observed in other European studies on the integration of maternal vaccinations into routine care for pregnant women. HCPs were found to have difficulties incorporating (the discussion of) maternal vaccinations into their standard care practices and lacked the confidence and knowledge to effectively inform their clients. Uncertainties about who is responsible for informing pregnant women about maternal vaccinations were observed as well. It was found that strong institutional support is necessary to help HCPs implement maternal vaccinations in their routine care, with a clear designation of responsibility [ 37 , 38 ]. The absence of strong institutional support decreases the willingness, ability and sense of responsibility of HCPs to discuss MPV with pregnant women. Increasing engagement of stakeholders, such as HCPs, needs to be considered to decrease resistance to future guideline implementation [ 39 ]. More involvement in the implementation process of MPV might increase the sense of urgency and responsibility among HCPs and, thereby, increase the likelihood of HCPs prioritizing MPV counselling. Furthermore, a few HCPs provided limited information about MPV because they feel it is not their responsibility. As already mentioned in the introduction, the HCP is expected to briefly discuss the possibility of MPV, handing out the national information leaflet and referring pregnant women to the website for more information and for making an appointment between 14 and 22 weeks of pregnancy. It would be valuable to bring the guideline on the implementation of maternal vaccinations to the attention of gynaecologists and midwives in order to clarify their role and responsibilities in MPV counselling. In addition to involving HCPs in the decision-making processes surrounding MPV, compensating the professionals financially for their invested time could be beneficial for MPV uptake.

Strengths and limitations

This study exhibits both strengths and limitations. One significant strength lies in the diverse study population, encompassing midwives and gynaecologists residing in 5 distinct Dutch provinces, with both female and male participants. A second strength is the coding process, carried out by two independent researchers. A third strength is that our study population included HCPs whose personal opinions were critical towards maternal vaccination. One expressed these concerns by not accepting the MPV during her own pregnancy. However, there are limitations to consider. One limitation pertains to the potential for selection bias, as some participants had previously responded to a questionnaire and expressed interest in participating in follow-up research. Despite this sampling process, data saturation was confirmed, as no new insights emerged. Additionally, the interviews were conducted either online or by telephone which could have potentially hindered effective communication.

This study offers a confirmation of the awareness of the pivotal role of HCPs, particularly midwives and gynaecologists, in informing pregnant women about MPV who maintain close and trusted relationships with their clients. HCPs stress the importance of neutral counselling, enabling pregnant women to make well-informed decision independently. Shifting HCPs from neutral counselling to positive advising on MPV, could boost vaccination rates. However, discussions with pregnant women have become more complicated nowadays because of upcoming vaccine hesitancy. HCPs must be equipped with the knowledge and confidence to navigate difficult conversations, including addressing concerns about vaccine ingredients, effectiveness, and common misconceptions. HCPs express insecurities about providing accurate and comprehensive information. Regular education might help to increase HCPs’ confidence in handling difficult consultations. Additionally, information materials available in multiple languages and incorporating more visuals to enhance comprehension could support HCPs in reaching a broader group of pregnant women. Establishing a national registry for pregnant women, which can be used for direct MPV invitations could enhance vaccination rates. Furthermore, increasing engagement in the implementation process of future maternal vaccinations and providing financial compensation might increase HCPs sense of responsibility and the likelihood of prioritizing maternal vaccination counselling.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the fact that the data of this study contain potentially identifying and sensitive participant information and that publicly sharing the data would not be in accordance with participant’s consent obtained for this study but are available from the corresponding author on reasonable request.

Abbreviations

Healthcare professional

Consolidated criteria for REporting Qualitative research

maternal pertussis vaccination

National immunization program

Public Health Service

Reasoned Action Approach

National Institute for Public Health and the Environment

non-invasive prenatal testing

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Acknowledgements

We would like to thank all the participants for participating in this study and being so open in their interviews.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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VW, MP, RPR, AVH and CJPAH conceptualized and designed the study. VW and MP collected the data, VW and EE performed the data analysis, data interpretation and drafts of the manuscript. CJPAH and RPR supervised the study. All authors contributed to reviewing and editing of the manuscript and read and approved the final manuscript for submission.

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Widdershoven, V., van Eerd, E.C., Pfeyffer, M. et al. Insights into maternal pertussis vaccination counselling: a qualitative study on perspectives and experiences among midwives and gynaecologists in the Netherlands. BMC Infect Dis 24 , 903 (2024). https://doi.org/10.1186/s12879-024-09681-7

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Understanding medical students’ transition to and development in clerkship education: a qualitative study using grounded theory

• Hyo Jeong Lee   ORCID: orcid.org/0000-0001-8764-6610 1 ,
• Do-Hwan Kim   ORCID: orcid.org/0000-0003-4137-7130 1 &
• Ye Ji Kang   ORCID: orcid.org/0000-0003-1711-2394 2  

BMC Medical Education volume  24 , Article number:  910 ( 2024 ) Cite this article

Metrics details

Medical students perceive the transition to clerkship education as stressful and challenging and view themselves as novices during their rotation in clerkship education. The developmental perspective is thus important because the transition to clerkship supports rather than hinders growth. Accordingly, this study examines medical students’ transition to clerkship and their developmental features.

In-depth interviews were conducted with 18 medical students or graduates who had completed clerkships as medical students. Based on Straussian grounded theory, the collected data were analyzed in terms of the differences between pre- and post-clerkship education.

Our data analysis revealed five stages of the transition process: “anticipation and anxiety,” “reality check,” “seeking solutions,” “practical application,” and “transition and stability.” The core category, that is, “growing up from being students to being student doctors,” was driven by patients who perceived the participants as student doctors. Meanwhile, the participants recognized that having a solution that is agreed upon by colleagues was more important than knowing the correct answer. The participants undergoing the transition to clerkship showed developmental features divided into three categories: personal, social, and professional. Specifically, they attempted to balance clerkship and life through personal development, learned to navigate around the hospital and reduced tension through social development, and developed clinical competencies focused on efficiency through professional development.

Conclusions

This study explores the process of students’ transition to clerkship education and the developmental features that emerge during this period. The students were motivated by patients who perceived them as student doctors. Through the transition, they maintained a work-life balance and adapted to hospitals but developed an overly doctor-centered attitude by cultivating clinical competencies with a focus on efficiency. To develop them into medical professionals, it is essential to assist their transition and cultivate a patient-centered attitude.

Peer Review reports

The transition to clerkship education marks the first time that medical students will experience the role of being doctors and is an important stage for them to grow into doctors who think and act according to the values of their profession in clinical settings [ 1 , 2 ]. Students who have entered clerkship education move away from the systematic and structured medical school environment to a hospital setting where apprenticeship and experiential learning methods are common and students face a variety of tasks that are markedly different from those in the pre-clinical education period, including communication with patients and their families, cooperation with medical staff, and self-management [ 3 , 4 ]. In other words, the transition to clinical practice education involves understanding the context of the new environment, socializing to meet societal standards, and exerting considerable effort toward adapting to the complex environment [ 5 , 6 ].

The transition to clerkship is known to be a difficult period for medical students as they face stressful and challenging tasks as part of the undergraduate medical curricula [ 7 ]. Many students express concerns that their lack of clinical knowledge and skills could potentially harm patients [ 7 ]. In addition, the increased workload causes physical and mental fatigue, and students experience difficulties in self-management and time management [ 8 ]. Accordingly, universities offer a transition course to help students in their transition from pre-clinical to clinical education. Nevertheless, students struggle to adapt to the culture of medical teams, including interacting with supervisors, professors, residents, and interns; and learning how to work effectively [ 3 , 9 ]. Furthermore, students still perceive the transition as “disruptive” [ 10 ] and a “big leap” that needs to be overcome [ 9 ].

Examining the developmental perspective of the transition to clerkship education is crucial in medical education. The purpose of clerkship education is to provide students with hands-on clinical experience and to facilitate their development into proficient medical professionals. Despite its importance, current research primarily focuses on bridging the gap between pre-clerkship and clerkship education by enhancing students’ preparation while paying little attention to their developmental experiences during this transition [ 11 ]. Consequently, each new rotation often leaves students feeling like novices, impeding their progress and weakening their sense of direction [ 12 ]. This recurring sense of starting over can slow the transition process, potentially hindering overall growth [ 13 ].

Socialization during clerkship plays a crucial role in the formation of professional identities, which has a direct impact on care quality and patient outcomes. Students who develop a strong professional identity are more likely to be confident, communicate well, and understand their roles and responsibilities, which are essential to high-quality patient care [ 14 ]. However, recent studies have focused on students’ experiences in a single specialty without considering the temporal aspect, which limits the generalizability of the findings to students in other specialties [ 9 , 10 ]. Therefore, it is necessary to comprehensively understand the developmental processes across various specialties during the transition to clerkship. This understanding not only enhances the current state of clerkship education but also informs the development of targeted improvement strategies through an evaluation of educational outcomes and achievements.

In summary, the developmental perspective of the transition to clerkship education is vital. By emphasizing the growth experiences of students, we can optimize medical education to foster continuous development and the formation of professional identities during the transition phase, which in turn leads to improved patient care and academic success. Accordingly, our study aims to explore the transition process by evaluating not only medical students’ experience in their transition to clerkship education but also the developmental features they gain through the transition. Our research questions are as follows: First, how do medical students transition into clerkship education? Second, what developmental features do medical students cultivate as they transition to clerkship education?

Study design

This study utilized the Straussian Grounded Theory (Straussian GT) to deeply understand the process of transition to clerkship education for Korean medical students and to consider their development through this process. Straussian GT, developed by Strauss and Corbin, offers structured instructions for coding and analysis that include a literature review, allowing for a comprehensive examination of intricate social phenomena from multiple perspectives [ 15 ]. Unlike the classical GT by Glaser, which emphasizes emergent theory without pre-existing frameworks, the Straussian GT permits a more structured approach and integrates existing theoretical concepts into the analysis [ 16 ]. This methodology is particularly suitable for our study as it facilitates the exploration of the complex clerkship education environment, where students, supervisors, patients, and guardians coexist and interact. To capture the students’ vivid experiences of this education, we conducted semi-structured interviews. The entirety of this study followed COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines [ 17 ].

Study context

We conducted this study in the context of Korean medical schools. Traditionally, clerkship education in Korea is block clerkship, which lasts two years and begins in the fifth year of medical school. During that time, students work full time in hospitals and participate in clinical practice, notably rotating across specialties such as internal medicine, surgery, pediatrics, and psychiatry, for 2 to 12 weeks. Decisions regarding the order of rotation through various specialties and the grouping with peers are mainly made administratively, giving students minimal control over these decisions.

Data collection and participants

We recruited 18 participants who had at least 3 months of clerkship education as student doctors from two separate universities. We used purposeful sampling to select two knowledgeable and experienced individuals from the early research participants who could provide in-depth answers to the research problems. The initial plan was primarily to target third-year medical students who had recently entered clerkship education to ensure the vividness of their data. However, two pilot interviews revealed that, on average, the transition to clerkship education takes 3 to 6 months. Hence, we shifted to the selection of participants who had received clerkship education in at least two specialties, students in their final year of medical school, and graduates within a year of graduation. Given that numerous environmental influences could impair recall, we chose this one-year time limit to attract graduates with recent experience.

Data collection involved conducting semi-structured interviews to explore the experiences related to the transition to a clerkship in depth. The participants were asked about “expectations and concerns about clerkship education before it begins,” “overall encounters in the early stages of clerkship education,” and “features perceived to contribute to the successful transition to clerkship education.” The grounds for these factors are provided accordingly. The interviews were conducted over a span of two months, specifically between March and April 2023, with each interview lasting 50–90 min. Afterwards, we repeated the selection and recruitment of the next data collection targets using theoretical sampling, based on the theoretical concepts that emerged from the collected data [ 15 ]. We repeatedly performed sampling and analysis until we reached theoretical saturation, indicating the accumulation of appropriate data and the unnecessary need for additional data collection [ 18 ].

Data analysis and trustworthiness

The collected data were analyzed in terms of the transition process and the differences that emerged between pre- and post- clerkship education. The recorded interview file and the researcher’s notes were transcribed using Naver Clova Note. The data were then analyzed by grounded theory using the qualitative research software MAXQDA20 (VERBI GmbH, Berlin, Germany, 2019). All collected data were categorized into concepts that could represent ideas and phenomena through line-by-line analysis. Constant comparative methods were used as the data were collected and analyzed. These methods involve a continuous comparison of the phenomena, concepts, and categories being studied. They also help form theories by elaborating abstract categories through the clarification of similarities and differences and understanding of their relationships. After all the data were collected, each set was synthesized and analyzed within the entire framework.

The following strategies were used to ensure the validity and reliability of the data analysis [ 18 ]. First, while coding, we tried to systematically compare phenomena by comparing them with existing theories and literature. Using this technique, we attempted to grasp the attributes and dimensions that might have been missed in the data analysis process [ 15 ]. Second, expert reviews were conducted. In this study, one researcher with qualitative research experience and another who was familiar with the research subject and had expertise in related fields were asked to review the validity of the data and results. Third, we conducted a member check to enhance the trustworthiness of the study. We provided a summary of the preliminary findings to the participants, asking them to review and provide feedback on the accuracy of their views and experiences. This process ensured that the data analysis accurately reflected the participants’ perspectives, thereby strengthening the credibility and dependability of the results.

Ethics statement

This study was approved by the Institutional Review Board of Hanyang University (HYUIRB-202304-008-1). Before the interview, the participants were presented with a thorough explanation of the research purpose and interview content. They were then requested to sign a “Research Participation Consent Form,” and the interviews proceeded only after obtaining their consent.

We interviewed nine third-year medical students, seven fourth-year medical students, and two interns who were less than a year after graduation. They received clerkship training at two different universities. Table  1 provides their detailed demographic characteristics. According to the statements of the study participants, they went through five steps to become student doctors. Comparing themselves to their earlier selves, they observed significant changes and growth, ultimately reaching a transition where they could assume the role of student doctors. This data analysis divided the study’s results into two distinct parts: (1) the process of transitioning to clerkship education, and (2) the students’ developmental features through the transition.

Part 1. process of transition to clerkship education

The data analysis revealed the core category as “growing up from being students to being student doctors.” It also identified the five stages of the transition to clerkship education: “anticipation and anxiety,” “reality check,” “seeking solutions,” “practical application,” and “transition and stability.”

The first stage was “anticipation and anxiety.” The participants felt both excited and anxious before their clerkship education started. They looked forward to having more leisure time than they did during the pre-clinical period, but they were also nervous about getting to know new people. In particular, they were worried that they might unintentionally harm a patient because of their lack of expertise. Nevertheless, in the field, they expected vivid and rich learning.

The participants then entered the “reality check” stage as their clerkship education began. At this stage, the participants reported perplexing experiences that differed from their expectations. In an unfamiliar medical setting, the participants observed that even the professors could not focus and were puzzled about their position. Furthermore, they regarded themselves as “non-medical personnel” who were comparable to patients. However, actual patients did recognize them as medical staff, and this perception developed the participants’ sense of obligation but became a burden as well. Consequently, the participants understood that they needed qualifications beyond their student status to perform the role of doctors. To achieve these qualifications, they exerted effort to identify the competencies that they lacked.

The participants who identified their competencies entered the “seeking solutions” stage to explore the ways to improve them. The search for improvement measures was divided into the individual and group levels. First, at the individual level, the participants attempted to address a problem by going to the library to look for textbooks or by utilizing a database to find the original text. In addition, they used image training to alleviate their fear when confronted with an operating room or a patient and to raise the degree of preparation for responding flexibly to any situation. The participants progressively recovered their diminished confidence as a result of this approach. Meanwhile, they addressed problems that could not be solved by data search by closely observing the interaction between supervisors and members of the medical team. Furthermore, they attempted to observe and use their colleagues’ performance abilities.

The group level entails looking for someone who can solve a problem when a solution cannot be reached through individual effort. In this case, the participants frequently worked with their colleagues to address problems and would ask interns or residents. In some cases, they would ask for help from their supervisors, but such an approach is extremely rare. Therefore, the accuracy of a solution sought could not be verified easily. Nevertheless, the participants appreciated coming up with a solution that was agreed upon by their colleagues.

After completing the search for improvements, the research participants entered the fourth stage, “practical application,” and applied and practiced the measures sought in the previous phase in actual scenarios. At this stage, the participants reported striving to avoid stuttering when interacting with patients or using a forceful tone to give the impression of being a student doctor with expertise rather than an inexperienced student.

In the final stage, “transition and stability,” the participants repeated the process of identifying and executing improvements as well as developing their identities as student doctors. At this stage, the participants would have successfully transitioned to clerkship education and entered the stable phase.

The speed of the transition to clerkship education differed depending on the participants’ prior clerkship experience and the characteristics of the patients they met. Participants with more opportunities for clerkship and positive patient experiences (i.e., patients being receptive to student involvement) tended to transition more quickly. Conversely, participants with fewer engagement opportunities or negative patient experiences (i.e., patients were reluctant towards student involvement) took longer to transition. One participant described his experience as follows: “The patient I met when I started my internal medicine clerkship must have been upset. When I first spoke to him , I sensed it. I conducted the consultation as instructed by the professor , but the patient rejected me. After that , I was reluctant to conduct consultations. A few weeks later , during the hematologic oncology rotation , the professor’s educational goal was for us to conduct daily patient consultations and provide care like a doctor. I only went once , but this time , the patient was kind and cooperative instead of being difficult. Then I thought , “It’s okay; it’s worth trying.” After that , I consulted with patients more often until they were discharged. (Participant N)” The longer it took to reach the transition, the more they reverted to the second step, “reality check,” in a continuous process of seeking and applying solutions. Through this repetitive process, participants gradually moved beyond the student and established their identity as “student doctors,” a preliminary stage of medical practice.

In summary, the participants reported that their desire to manage the increasing responsibilities and burdens of clinical practice motivated their transition to clerkship education. They repeatedly identified problems and formulated and implemented improvement measures. As a result, they not only transitioned to clerkship education and acclimated to the educational environment, but also grew into student doctors. Figure  1 ; Table  2 present the specific contents and quotes for each step.

The process of transitioning to clerkship education

Part 2. students’ developmental features through transition

The second result pertained to the developmental features of students who have entered the transition and stability stages. These developmental features were divided into three categories: “personal,” “social,” and “professional.” Personal development involved balancing clerkship and life; “social development” included changes in relationships among members and adaptability to the medical environment; and “professional development” featured content on growing up as a student doctor and how to perform the role. They identified themselves in a way that matched their first appearance after being transferred to clerkship. The developmental features of the students who have entered the stable phase through the transition are discussed in the next section. Table  3 summarizes the contents and quotes.

Personal development

Securing personal time.

Securing personal time means that as the participants became accustomed to clerkship education, the time to prepare for clerkship became shorter, and the individual time increased in proportion. Specifically, they reported changes such as shortened time to read the handover or solve tasks such as case reports from 3 days to 3 h. This shortened time generated personal time, which was used for self-development or to completely rest or recharge by meeting friends.

Building resilience

Building resilience means being able to quickly forget the feelings they experienced while participating in clerkships. It was identified as one of the major features that contributed to the participants’ improved quality of life. One participant stated that when she was scolded by a professor, she was depressed all day, even after going home, but she was eventually able to overcome it quickly (Participant A). In a repeated clerkship environment, the participants were able to quickly overcome the distress caused by their mistakes and did not hold on to the negative emotions or shock that arose from situation.

Social development

Bridging the psychological gap with professors.

The participants who recognized that they had reached the transition mentioned that unlike before, the psychological gap between them and their professors had narrowed through clerkship education. To date, pre-clerkship lessons have been conducted in classrooms with more than 100 students. Hence, for the participants, their professors were like “lecturers,” and conversing with them and asking them questions were difficult. However, they acknowledged that the intimate engagement with professors softened their view of the latter. In particular, they began to view their professors not as authoritative and hierarchical creatures or as senior doctors with more knowledge but as humans who had emotions like them.

Adjusting to hospital life

The participants felt accustomed to hospital life as dressing and using hospital facilities became natural for them. They noted that wearing practical clothes such as gowns before their transition felt like borrowing someone else’s clothes, but at their current state, it was no longer awkward. Furthermore, they used to hesitate to go to the ward for water or to use the employees’ restaurant, but at this point, they could use these facilities naturally. One participant stated that he felt completely familiar with the hospital after seeing himself clearly providing directions to patients. Some participants said that hospital life was still awkward but that if it went as described above, they would feel totally adapted to and transition to clerkship education.

• Professional development

Developing a student doctor identity

The participants shifted from being “the same non-medical personnel” to forming relationships with patients as “student doctors” through the transition to clerkship education. Initially, the participants were anxious and hesitant when consulting and examining patients, but over time, they were able to play a role in understanding their patients’ status as student doctors.

Enhancing patient communication skills

One of the features of the transition was enhancing participants’ patient communication skills. Previously, most participants not only wrote and memorized patient consultation scripts but also rushed to ask questions about memorized topics rather than listening to them while interacting with patients. However, with enhanced communication skills, they no longer wrote scripts and were able to make eye contact with patients, talk with them, and freely think of follow-up questions based on patients’ responses. In fact, some participants said that they were indeed fearful during their first time, but through constant practice, their communication with patients became more enjoyable (Participant E).

Improving clinical efficiency

The participants gained clinical reasoning skills, particularly efficiency-oriented clinical abilities related to clinical consultations, as they transitioned to clerkship education. They became acquainted with the reasoning process of listening to symptoms and inferring diseases instead of thinking about likely symptoms based on the disease. They initially acted and responded attentively during physical examinations or consultations, taking into account their patients’ pain or condition. Over time, they learned to focus on conducting consultations swiftly and accurately rather than examining their patients’ emotions.

From a developmental point of view, this study explored how students form their professional identity as student doctors and what developmental characteristics they show through the transition to clerkship education. Based on the results, the transition process and the features that developed can be discussed in two ways.

Process of transition to clerkship

The participants’ transition process revealed significant growth into “student doctors.” This process involved five stages: anticipation and anxiety, reality check, seeking solutions, practical application, and transition and stability. This finding is significant in that it reveals the process by which students establish their professional identity. Previous studies have elucidated the process of adapting to an organization as a newcomer [ 19 ] and have also investigated factors or perceptions that influence this transition process, such as inadequate preparation [ 10 ]. Our research, however, uncovers the detailed stages through which students develop into student doctors via self-discovery and problem-solving.

Central to the transition process was the interaction with patients. The students were motivated by the patient, who recognized himself as a student doctor and attempted to establish an identity as one. For example, one participant reported feeling a great sense of responsibility when he saw the patient struggling emotionally during the initial practice and taking his role seriously. This is an experience-oriented curriculum in which clerkship education takes place through dynamic interactions between members within a systematic structure [ 20 ], and in particular, interactions with patients prove that students are important not only to acquire knowledge, skills, and attitudes based on learning experiences for individual patients in real situations but also to form their identity as doctors [ 21 ].

However, not all patient experiences lead to positive outcomes. Participants who interacted with patients willing to contribute to student education during clerkships were able to transition more quickly due to favorable responses and positive communication. Conversely, participants faced challenges in effectively communicating with patients who were unwilling to participate in student education, resulting in repeated attempts to identify and implement improvement measures that delayed the transition to clerkship education. Moreover, students often experience anxiety in clinical settings, such as patient consultations, due to a lack of clear understanding and readiness for their roles [ 22 ], and this insecurity is further exacerbated by inadequate supervision [ 23 ]. In the current medical environment, where expectations for quality medical services are growing, student participation is likely to face skepticism [ 24 , 25 ]. To prevent students from experiencing severe negative experiences in clerkship, professors should intervene appropriately to ensure patients accommodate students and help form a constructive learning community [ 26 , 27 , 28 ].

Another noteworthy observation is the students’ tendency to solve problems through discussions with colleagues rather than seeking help from professors. They valued having a common, agreed-upon solution as much as knowing the correct answer, and they perceived asking supervisors for help as something to avoid. We can discuss this behavior from a cultural perspective.

In Asian cultures, relationships play a significant role in influencing behavior [ 29 ]. Combined with the hierarchical and closed nature of medical groups, students may fear that making an unfavorable impression on a professor could adversely affect their future [ 30 ]. This hierarchical relationship extends beyond the university into their professional careers, emphasizing the importance of reputation management as perceived through the professor’s eyes [ 31 , 32 ]. As a result, students often felt burdened to maintain a professional appearance and were highly conscious of their evaluator-evaluatee relationship with their professors. Their perception of asking questions as annoying likely stemmed from this hesitation [ 3 , 8 , 33 ]. Consequently, this structure may deter students from interacting directly with professors, leading them to rely more on peer support.

While peer interactions can strengthen their relationships, there is a risk of students acquiring inaccurate information due to their lack of expertise and difficulty in discerning the validity and usefulness of medical evidence [ 34 ]. This can hinder the development of expertise and skills, ultimately impacting their professional identity as physicians [ 19 , 28 ]. Therefore, fostering an environment where students can actively communicate and challenge rigid cultural norms is crucial for effective medical education [ 10 , 35 ].

Students’ developmental features through transition

Students grew up balancing clerkship and life, adapting to the hospital environment, and developing efficient and professional clinical competencies during the transition to clerkship education. These developments improve students’ adaptability, which is an important factor in their effective performance as future healthcare professionals [ 1 , 4 , 11 ]. To date, research has focused on increasing readiness by exploring gaps in pre- and post-clinical practice training [ 10 , 11 ]. However, our work focuses on examining students’ features during the transition to clerkship education and discussing the implications.

First, personal development demonstrates how students constantly strive to balance practice and life during clinical practice. With the recent emphasis on the concept of work-life balance [ 36 ], students recognize clerkship as a kind of work and seek to flexibly cope with stress and improve their quality of life [ 37 ]. They use their leisure time and reduced time spent preparing for clerkship to recharge or meet friends, and they develop resilience to maintain psychological stability. This is crucial because healthcare settings frequently expose not only students but also medical staff to the risk of physical and mental fatigue and burnout [ 7 , 8 , 24 ]. Therefore, practicing self-management, such as time management and flexible coping with stress during the clerkship education, can also greatly benefit professional socialization [ 10 ].

Second, with regard to social development, the participants recognized adaptation to the hospital environment as a crucial factor for the transition to clerkship education. The participants gained confidence as members of the hospital by becoming acquainted with facilities and locations of the hospital. This result differs from those of previous studies that reported the lack of clinical knowledge and skills as the cause of difficult conversion [ 38 , 39 , 40 ]. Until now, the preparatory curriculum for the transition primarily focused on basic clinical skills, communication, physical examination, and other topics related to the national examination, resulting in relatively limited awareness and information about the hospital’s work environment [ 41 ]. It could have made the students feel that clinical practice education was a difficult process [ 9 , 10 ]. However, it is necessary to review the content composition of the transition course, as students require useful and practical tips for clinical practice training, such as detailed job descriptions, in addition to clinical knowledge [ 13 ].

Furthermore, the participants felt the professors were more humane and accessible, although they were still difficult, which reduced the psychological distance between them. This contributed to creating an environment where students can reduce tension in the hospital and move around without being overly conscious of their surroundings. For example, there were many students who were nervous to be polite when meeting professors, but the tension decreased as the psychological distance decreased. This allowed students to move confidently within the hospital, get the necessary information more easily, and adapt faster to the hospital’s facilities and environment.

Finally, students achieved professional development through the cultivation of clinical competencies with a focus on efficiency. Specifically, their professional development mainly consisted of clinical competencies that could be objectively identified. Some participants mentioned that they were able to reflect on the characteristics of a good doctor as perceived by patients, but many others mentioned the reduction in patient consultation time as a key factor in a successful transition. Participants, who initially focused on patients’ emotions such as pain, gradually came to understand symptoms through concise questions. They developed an attitude that was unaffected by patients’ emotions and experienced a sense of bonding with doctors as a result of these changes. The overly skill-centered clerkship education may have led the participants to adopt a doctor-centered attitude instead of a patient-centered one [ 42 , 43 ]. However, patient-centered healthcare is important because it not only contributes to improving patients’ health outcomes, increasing patient satisfaction, and strengthening the trust relationship between patients and their healthcare providers, but also enhances doctor’s the job satisfaction [ 44 ]. Therefore, clerkship education should be improved to cultivate doctors who can not only develop the capacity to objectively identify diseases but also empathize with patients and have a subjective perspective on diseases [ 5 ].

Implications for medical education

Based on the results of this study, we derive several practical implications for improving clerkship education.

Firstly, we suggest implementing a faculty development program that offers guidance on conducting clerkship education. Guiding students through the transition process and sharing their difficulties will help professors reflect on how to manage a clerkship and adopt a learner-centered perspective. These efforts will provide opportunities for students to experience clinical practice in a constructive environment with appropriate supervision.

Second, we propose changing the content of the transition course before students enter clerkship education. Providing practical information about the clerkship, including the hospital’s structure and system, as well as lectures related to medical knowledge or skills, will be helpful for a successful transition [ 9 , 10 ]. Additionally, similar to the faculty development program, including information on what students will experience after entering clerkship education will help reduce their initial confusion and increase their adaptability.

Finally, we suggest creating a clerkship environment that fosters patient-centered attitudes. To achieve this, involving patients as active partners or mentors can be considered. Patients’ active participation in education can enhance students’ understanding of diseases and patient experiences, as well as provide insights into the professional values expected by society from doctors [ 45 , 46 ]. Furthermore, it can be a useful strategy, as involving patients who explicitly agreed to participate in student education can reduce the student’s feelings of rejection and increase the patient’s satisfaction with their treatment [ 26 ].

Limitation and avenues for future research

The limitations of this study and suggestions for future studies are as follows: First, we observed that the participants reached the transition to clerkship education at varying speeds, but we did not analyze the specific causes and types in detail. Therefore, to further understand the factors affecting the transition and the steps involved, we propose a follow-up study to verify the causes and types by conducting additional interviews. Second, this study limited its scope to experiences in block-type clinical practice and did not investigate students’ experiences in longitudinal integrated clerkship or mixed clerkship education. Longitudinal integrated clerkship provides a unique learning environment in which students develop clinical competencies by establishing a longitudinal relationship with patients; therefore, block-type clinical practice and conversion experiences may differ [ 47 ]. Accordingly, examining students’ conversion experiences in various clinical practice education models can contribute significantly to improving the overall clerkship education. Nevertheless, this study is significant because it presents the process of students’ transition to clerkship education as well as the meaning of the features that develop through this transition.

This study explores the process of students’ transition to clerkship education and the developmental features that emerge during this period. The students, motivated by patients who perceive them as student doctors, navigate through this transition by repeatedly identifying their problems and implementing improvement plans. Throughout this process, they balance their personal lives with clinical work, adapt to the hospital environment, and develop efficient and professional clinical competencies. These developments improve their adaptability and readiness for future healthcare roles.

Data availability

The datasets of this article are available from the corresponding author on reasonable request.

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Conceptualization: Lee HJ. Data curation: Lee HJ. Formal analysis: Lee HJ, Kang YJ, and Kim DH. Investigation: Lee HJ, Kang YJ, and Kim DH. Methodology: Lee HJ, Kang YJ, Kim DH. Software: Lee HJ. Validation: Lee HJ, Kang YJ, and Kim DH. Writing - original draft: Lee HJ. Writing - review & editing: Lee HJ, Kang YJ, and Kim DH.

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Lee, H.J., Kim, DH. & Kang, Y.J. Understanding medical students’ transition to and development in clerkship education: a qualitative study using grounded theory. BMC Med Educ 24 , 910 (2024). https://doi.org/10.1186/s12909-024-05778-4

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Use and perception of risk: traditional medicines of Pakistani immigrants in Norway

• Saliha Khalid 1 ,
• Agnete Egilsdatter Kristoffersen 1 ,
• Lise-Merete Alpers 2 ,
• Christine Råheim Borge 3 ,
• Samera Azeem Qureshi 4 &
• Trine Stub 1  

BMC Complementary Medicine and Therapies volume  24 , Article number:  331 ( 2024 ) Cite this article

Metrics details

Pakistani immigrants are the largest non-Western ethnic minority group in Norway. Traditional medicines (TM) are extensively used in Pakistan, and studies show that ethnic minorities also use them to recover from illness after migration to the Western world. This study aims to explore Pakistani immigrants’ experiences and perceptions of risk regarding the use of TM to treat illnesses.

A qualitative study was conducted through in-depth interviews ( n  = 24) with Pakistani immigrants in Norway from February to March 2023. Participants were recruited through purposive and snowball sampling methods. The data was analyzed using Braun & Clarke’s reflexive thematic analysis (RTA) using Nvivo.

RTA revealed three main themes and six sub-themes. The main themes were: (a) House of knowledge, (b) Choosing the best possible approach for health restoration, and (c) Adverse effects of TM used. A total of 96 different TM were identified, including herbs, food items, animal products, minerals, herbal products, and ritual remedies. All participants used TM to restore health in acute and chronic diseases, and many used TM along with conventional medicines. The participants’ mothers were the primary source of knowledge about TM, and they passed it on to the next generation. They also frequently used religious knowledge to recover from illness. Although TM is considered safe because of its natural origin, some participants experienced adverse effects of TM, but none of them reported it to the health authorities.

The study helps to understand the experiences and perceptions of risk of Pakistani immigrants in Norway regarding traditional practices for treating health complaints. Public health policies to improve the health of these immigrants should consider the importance of TM in their lives. Further research is necessary to explore the safety and toxicity of those TM that are common in Pakistani households in Norway.

Peer Review reports

Migration has affected the Western world in various aspects, but its contribution to several healthcare challenges is a significant consequence [ 1 ]. The diverse cultural beliefs of the patients can hinder healthcare providers from holistically addressing the health complaints of the immigrant community [ 2 ]. As Norway has experienced substantial growth in immigration in recent decades, immigrants and their Norwegian-born children accounted for 20.8% of the population in 2024 [ 3 ]. One of the largest non-Western ethnic minority groups in Norway is the Pakistanis, with 23,569 immigrants and 18,662 born to immigrant parents in 2024 [ 4 ]. Most live in the capital city of Norway, Oslo, and the areas around it [ 4 ]. More than 50% of the Pakistani immigrants in Oslo report poor health as opposed to only one-fifth of ethnic Norwegians [ 5 ]. This is partly due to a higher rate of diabetes (14% vs. 2.6%) [ 5 ], psychological distress (22% vs. 9.9%) [ 5 ], and cardiovascular disease (acute myocardial infarction, 5.7% vs. 2.7%) [ 6 ]. It leads to more frequent general practitioners and medical specialists visits than ethnic Norwegians [ 7 ]. This cultural and ethnic diversity among healthcare seekers comes with variations in disease conditions [ 5 , 8 ], healthcare expectations [ 9 ], and patients’ beliefs [ 10 ]. Different ethnic groups use traditional medicine (TM) to manage illnesses in Norway [ 11 , 12 ]. TM is extensively used by more than half of the population in Pakistan [ 13 , 14 ], and research has demonstrated that Pakistanis continue using TM after emigration from Pakistan [ 1 , 15 ]. Therefore, knowledge about their traditional practices is needed to meet immigration-related healthcare challenges, as we know little about them [ 16 ].

In Pakistan, both private and public healthcare facilities are available [ 17 ]. The public sector is underutilized due to unequal resources in the population, lack of trained staff, lack of access, poor governance, etc. [ 18 , 19 , 20 , 21 ]. In this context and due to financial shortcomings, self-medication, self-care, herbal medicines, and TM are used by more than half of the population to restore health [ 13 , 14 , 22 ]. TM is known as “the knowledge , skills , and practices based on the theories , beliefs , and experiences indigenous to different cultures , whether explicable or not , used in the maintenance of health as well as in the prevention , diagnosis , improvement , or treatment of physical and mental illness” [ 23 ]. In Pakistan, TM is a part of the cultural heritage and is preferred by 51.7% of the Pakistani population today, of which 20% combine it with conventional medicine [ 24 , 25 ]. Tibb-e-Unani, homeopathy, mind-body medicine, and biologically based practices (home remedies, diet, and nutrition) are commonly used in Pakistan [ 24 , 26 ] for colds, coughs, gastrointestinal problems, etc [ 27 ].

As treating illnesses with TM and their self-administration is deeply embedded in Pakistani cultural heritage [ 28 ], research indicates that Pakistanis maintain the use of TM even after emigrating from Pakistan. Pakistani immigrants in England were found to associate certain foods with medicinal effects [ 29 ]. Other international studies show that Pakistani immigrants still use TM modalities in their new home country [ 1 , 15 , 30 ]. So, Pakistani immigrants may also widely use TM in Norway. Medical pluralism is a concept that explains why individuals resort to different modalities and treatments to pursue health in any community [ 31 ]. This leads to using conventional medicines and TM, even when these have mutually incompatible explanations for the illness [ 32 ].

One of the goals of the World Health Organization (WHO) Traditional Medicine Strategy 2014–2023 is to support the safe use of TM. Considering this, asking TM users about their perceptions of risk and experiences regarding such use is essential. Risks associated with healthcare intervention may be categorized as direct or indirect risks [ 33 ]. Direct risk includes harm from a medical intervention, procedure, product, or treatment, including negative interactions between conventional medicines and TM interventions like herbs and supplements. Direct risk is any adverse effects from using any herb, food item, supplement, or health-related practice [ 34 ]. Indirect risk is not directly related to a specific medicine or herb but harms the patient due to the treatment setting or practice in general [ 35 ], such as untrained health professionals, poor communication between healthcare professionals and patients, lack of authentic information, etc [ 33 , 35 ]. According to a systematic review of adverse drug reactions (ADR) in Norway [ 36 ], 250 out of 260 ADR reports of plant-based products submitted to RELIS (Manufacturer-independent drug information for healthcare professionals) were related to herbal dietary supplements [ 37 ]. Therefore, it is essential to consider the safety of herbal products before they are used and to record the experience-based knowledge of TM users about the safety of these TM.

Even though Hakonsen et al. found that 15% of first-generation Pakistani immigrants in Norway used herbal remedies and supplements bought or sent from Pakistan [ 16 ], we do not know what herbal remedies they use, why and how they use them, and their beliefs about such use. This knowledge about cultural beliefs and traditional practices can help healthcare providers better understand this patient community and address their health complaints holistically [ 2 ]. This better understanding can improve communication between immigrants and healthcare providers, finally leading to patient trust in the healthcare system [ 38 ]. This knowledge is also essential for patient safety and to avoid negative interactions between natural remedies and conventional medicines [ 39 ].

So, in this study, we will explore Pakistani immigrants’ experiences with using TM to treat illnesses. Emphasis was placed on exploring various modalities, such as food items, herbal remedies, and dietary supplements. Furthermore, we intended to delineate the perceived safety profile of these TM practices from the participants’ perspective (perceptions), thereby contributing to a nuanced understanding of the intersection between cultural practices and health within this community.

We used in-depth interviews to explore Pakistani immigrants’ experiences regarding TM use in Norway from February to March 2023. A qualitative research design helps understand the phenomena of sparse knowledge [ 40 ] and further generates a deep understanding of the informant’s knowledge, experiences, attitudes, and feelings [ 41 ]. In this study, we have used the COnsolidated criteria for REporting Qualitative research (COREQ) checklist [ 42 ].

Study area and setting

The study took place in Oslo, the capital of Norway, which is known for its significant investment in public health. Oslo is the most populated city in Norway, located on the country’s southern coast. Figure  1 shows Oslo’s location in Norway. In 2024, 34.7% of the population in Oslo corresponds to immigrants and their children, and 13.6% of them are from Asia [ 3 ]. Norway allocates substantial resources to healthcare, corresponding to 12.7% of mainland Norway’s Gross Domestic Product in 2022 [ 43 ]. The Norwegian healthcare system is predominantly financed by public funds and the government, which warrants low personal financing [ 44 ]. Conventional medicine is Norway’s officially approved medical system [ 45 , 46 ]. However, Traditional and Complementary Medicine (T&CM) is practiced outside the official healthcare system and is used by 62% of the population annually [ 47 ].

Map of Norway

Recruitment

Participants were recruited from patients in the outpatient department of a local hospital setting and their community. The inclusion criteria for the study participants were: (1) First-generation (born in Pakistan) or second-generation (born in Norway with both parents born in Pakistan) immigrants from Pakistan living in Norway, (2) first-hand experience of using TM, (3) ability to understand Urdu, Norwegian, or English, (4) For those recruited via hospital, the reason for admission to the hospital was not intoxication for suicidal purposes. The exclusion criteria were age under 18 years, mental impairment, and hospital inpatients. Purposive sampling [ 40 ] was used to recruit participants who visited the hospital’s medical unit ( n  = 6). An introduction letter describing the study was distributed to the hospital staff so that they could inform the patients about the study. The hospital staff also provided the patients with written information about the study in a patient information brochure (PIB). PIB was available in Norwegian, Urdu, and English. When a patient agreed to receive more information about the study, the first author received their contact information. She provided more in-depth information through a telephone call, including the reasons for doing the research, and scheduled a time for a personal interview. Six participants, all first-generation immigrants, were recruited through this method. These participants helped recruit other participants ( n  = 18) by snowball sampling [ 40 ]. The interviewer had no prior relationships with the study participants. One of the immigrants refused to participate in the study due to lack of time, but none of the participants dropped out.

Advisory group

A group of 5 voluntary individuals (1 male and four females), including first- and second-generation immigrants, contributed to ensure public involvement in the project. The group gave valuable feedback on the interview guide, patient information brochure’s content, design, and graphics; and supported translating the brochure into Urdu. This group was not involved in analyzing the data and drafting the manuscript. The members were not paid for this service and were not participants in the study.

Interview guide and training of the interviewer

An interview guide was developed based on existing literature with the help of experienced qualitative researchers in the research group, including TS, LMA, and SAQ, a female Pakistani immigrant researcher in Norway. After two pilot interviews, the interview guide was shortened. No changes have been made to the interview guide between the interviews.

The first author (SK) is a PhD student and a pharmacist from Pakistan. She was brought up in Pakistan and knows about Pakistani culture. AEK and TS listened to the two initial interview recordings in English. SAQ (researcher and co-author) participated in one of the face-to-face interviews in Urdu with SK. AEK, TS, and SAQ provided feedback about the interviewing method and follow-up probing questions. It helped to ensure reflexivity in the study, a process of critical reflection on the self as a researcher [ 40 , 48 ]. It helped SK to identify her blind spots where she could influence the interview. This input made her more aware of her position as a researcher and ensured that the information she collected aligned with the purpose of the study. (The interview guide is available as supplementary material)

Data collection

Twenty-four in-depth interviews lasted between 30 and 90 min and were conducted by the first author either face-to-face ( n  = 18) or online (audio) ( n  = 6). Although face-to-face communication may be more effective due to expressions and gestures, we gathered in-depth information in the online interviews due to cultural similarity and lack of language barrier between the participants and the interviewee. All the interviews were audio-recorded after the participant’s consent. The face-to-face interviews were conducted at the place of the participant’s choice: In a hotel ( n  = 3), library ( n  = 5), and private homes ( n  = 10) from February to March 2023 in Oslo. Seven out of 24 interviews were conducted in English, while the others were in Urdu. Two members of the research team, who are native Urdu speakers and fluent in English, contributed to the translation process. The first author translated and transcribed the interviews verbatim into English and read the transcripts several times to minimize errors. The translations were cross-checked by another team member and finalized after gaining a consensus. Data saturation was reached at 22 interviews, and two more interviews were conducted afterward to ensure we didn’t obtain any new information [ 40 ]. The first author took notes during the interviews. No repeated interviews were carried out.

Data analysis

Following the reflexive thematic analysis (RTA) method by Braun and Clarke, two authors (SK and TS) analyzed the interview transcripts [ 49 , 50 ]. RTA is a six-phase method including (1) familiarising with the data, (2) generating codes, (3) constructing themes, (4) reviewing potential themes, (5) defining and naming themes, and (6) producing the report [ 49 , 50 ]. SK and TS familiarised themselves with the data by reading and re-reading the transcripts and marking features of interest. Twenty-five codes were developed through an inductive orientation, which later merged into seven themes. These themes were defined and named multiple times before finalizing them. After discussions with the research team, themes with similar information were collapsed into three main themes. Six sub-themes were created to show diversity in the data. For example, the sub-theme, “Exchange of health practices between Pakistan and Norway,” was originally a theme named “exchange between different regions of the world” with two sub-themes: (1) Exchange of knowledge and (2) Exchange of entities. Later, we named it cross-cultural exchange, then cross-medical exchange, and finally, “Exchange of health practices between Pakistan and Norway.” At the end of the analysis, this theme was made a sub-theme under the theme, “Choosing the best possible approach for health restoration,” as it was the primary reason for this exchange. All the analysis steps in RTA were done iteratively, and this reflexive approach helped the investigators understand the data and name the themes better than in a linear process. To ensure the research results truly reflect reality (internal validity, credibility, and study triangulation), both SK and TS performed the data analysis [ 48 ], and the consolidated criteria for reporting qualitative studies were used [ 42 ]. Analysis was conducted using QSR-NVivo v10.0 software [ 51 ].

Ethical considerations

The study was approved by the Norwegian Centre for Research Data (reference number: 447080) as the Regional Committees for Medical and Health Research Ethics (REK 493745) decided that the study was not considered health research in Norway and, therefore, did not require approval from them. The participants were informed about the study’s purpose, method, and content and their rights as participants. It was emphasized that participation was voluntary and that they could withdraw without consequences. Verbal and written informed consent were obtained from the participants before recording the interview. Each participant received an identification (ID) number to ensure anonymity. The confidentiality of the participants was ensured by anonymizing the interview transcripts. We didn’t return the transcripts to the participants for comments/corrections, but one of the participants reviewed her transcript upon request and did not suggest any changes.

Demographics of the participants

A total of twenty-four participants (sixteen females and eight males) ranging from 21 to 80 years of age were interviewed (Table  1 ). Sixteen participants were first-generation Pakistani immigrants, and eight were second-generation immigrants. More than half of the participants were females. The mean age of 1st generation participants was 50 years and 29 years for the 2nd generation participants, respectively. All the 1st generation participants were married. Two 2nd generation participants were married, and others were single ( n  = 6). All participants were living with their families in Norway. Less than half of the participants were retired. Others were self-employed or students. Diabetes ( n  = 5), digestive problems ( n  = 8), and cardiovascular problems ( n  = 6) were the most frequently reported health complaints by the participants. The number of different TM modalities used by the participants ranged from 6 to 27, with a mean of 14 different TM modalities per participant. Table  1 shows the participants’ demographic data and the types of TM modalities they used.

The analysis of the interviews revealed three main themes: (a) House of Knowledge , (b) Choosing the best possible approach for health restoration , and (c) Adverse effects of TM use . We divided these themes into six sub-themes (see Table  2 for the Overview of themes and sub-themes). We did not recognize any pattern of differences between the views of 1st and 2nd generation immigrants.

House of knowledge

Under this theme, we explained the participants’ extensive knowledge of TM for specific illnesses. We gained insight into the use of TM while living in a family system and how family influenced TM use. We explored the importance and role of family in sickness and cure.

Influence of family in TM use

Most participants talked about the importance of family in the lives of immigrants when they were sick and how the family influenced their TM use. All the participants lived with their families in Norway and shared that the source of knowledge regarding TM is their home (mothers and grandmothers). Some of the participants expressed that the Pakistani family system influenced their lives in Norway. For instance, one participant (F16) explained it this way: The family system is very strong in Pakistan. If you live in a family , you learn these things automatically. They used to apply these things [TM] to you and your siblings , and their parents did the same with them. So , when you live in such a society , you learn these things from your family life. This quote explains how living with and observing the family helped the participants learn about TM. The participants’ belief in the healing power of TM and these learned behaviors reinforced the notion that TM could benefit their health because of living with the family. A second-generation participant (F23) who was a frequent user of TM with various health complaints stated: It is because of the environment we have at home. I was also always observing my parents , and they just took Paracetamol as a last resort. They always tried to recover their body using natural things. This explains how the family environment transferred one generation’s beliefs regarding TM to another.

There were also participants who mentioned that discussing with family members is essential when they experience mental or physical health complaints and deciding on TM to be used. A participant (F3) stated: As a family first , I take suggestions from my wife that I have this problem and ask what I should do now. So , I take her suggestions; whatever she recommends , like some medicine or any remedy , herb , kawa , then I take it. Another participant (F1) who received family care in the past stated: My family helped me so much during this time [with schizophrenia]. Everyone took great care of me at home and behaved very well with me. So, it shows how living with the family and family care provided physical, emotional, and mental support in illness. Some participants also stated that they always contacted their mothers when they experienced a health complaint because they were sure their mothers would suggest a remedy for every problem. F17 explained: I call my mother , and then , of course , she would bring out a remedy. So, trust in the family and receiving their help and solutions seemed important, even for adults. It shows the connection with the family, family care, and dependence on the traditional knowledge of the family to recover from the health complaints.

Knowledge about TM for specific illnesses

Participants shared their extensive knowledge about TM and how they use it for specific illnesses. The information they shared included common names of TM, preparation methods, dosage, adverse effects, and lifestyle advice. We identified 96 different TM modalities used for 44 different health complaints. Most reported TM modalities were medicinal plants, animal products, and food items, but the participants also reported using some minerals, ritual remedies, and commercial herbal preparations (Table  2 ). Generally, the women and participants with chronic illnesses used more TM modalities than the men and other participants. Table  3 shows TM used for various health complaints and the participant-reported adverse effects of TM. An extended list with more information about TM, including traditional names, English names, scientific names, preparation methods, dosage, adverse effects, and lifestyle advice, is available as supplementary material (additional file 1: Table  4 ).

Choosing the best possible approach for health restoration

Throughout this theme, the participants described how they chose the best possible option for restoring health while living in Norway and what factors govern this decision. They explained how living in Norway influenced their attitudes and behaviors toward health-seeking. Three subthemes were identified under this theme: health-seeking behavior for restoring health, reasons for using TM, and the exchange of health practices between Pakistan and Norway.

Health-seeking behavior for restoring health

We identified different health-seeking behaviors of the participants for restoring health in illness and their beliefs behind these behaviors. Many of the participants reported using both TM and conventional medicines to recover from health complaints. The decision about which modalities to use could depend on factors such as their belief in TM, the nature and severity of the illness, access to the healthcare system, the response from the healthcare providers, and the availability of TM at home. They also expressed that using TM was their first approach to any health complaint. However, two of the participants (F23, F20) stated that the approach they used to manage the illness depended on their problem. In addition, a couple of participants (F1, F13) mentioned that their first approach was using conventional medicines. Some participants suffering from chronic diseases expressed the importance of taking conventional medicines to maintain their quality of life.

A few participants preferred to use TM for minor illnesses but usually visited the conventional doctor in case of serious diseases. Various reasons were identified for this health-seeking behavior. Some participants believed that TM could cure the problem entirely with few adverse effects rather than eliminate the symptoms. F19 explained that keeping it natural positively helps your body because painkillers can have negative effects. What it [painkillers] can do is that the problem will be there , but your pain will not be there. But the problem can still be there , if you know what I mean . So, it depicts a strong belief in the healing power of TM. Some participants (F20, F21) used TM because of the Islamic faith that Allah created natural things that are better to use. It included the fact that the food items specified in the Quran and Hadees (teachings of the prophet) can cure the illness. A female respondent (F21) said: It’s more related to my belief in Islam , and I want to use the natural things which God gave us instead of all these chemically produced things [conventional medicine].

Another reason for using TM was the belief that the long-term use of conventional medicines is not suitable for the body. One of the participants (F14) managed her problem of chronic constipation through diet changes and household remedies because she found it better to avoid conventional medicine prescribed by her doctor. The difficulty in assessing the healthcare services in Norway was another reason for the preference for TM in illness. A female informant (F2) said: I have a lot of these things [TM] at home because here [in Norway] , it is very difficult to reach the doctor when you are sick. As they have a very long procedure , first you have to talk to the doctor , and then he will give you an appointment. Others preferred TM due to the low probability of getting conventional medicines from the healthcare system compared to Pakistan. All the participants who had children under five years of age reported frequent use of TM for their children, and they believed that it helped them. A worried mother (F15) of three small children who frequently suffered from seasonal allergies and infections stated: The doctor just gave her [child] paracetamol because there is no other medicine like cough syrup for a child in Norway who is under two years of age. Apart from paracetamol , the remedy I use is adding black pepper powder or nutmeg to honey and mace powder to honey and giving it to her. These quotes depict that barriers in assessing the Norwegian healthcare services contributed to using TM for themselves and their families.

Some participants (F13, F1) also preferred to use conventional medicines as a first choice, even for minor health complaints, as they wanted quick relief. In addition, some participants reported using conventional over-the-counter medications before accessing the Norwegian healthcare system and in the waiting time to see the doctor. F15 stated: I always want a quick solution. I always start with paracetamol for me and my daughter. I don’t visit the doctor immediately when the problem starts. The participants (F16, F5) revealed they were using more conventional medicines after migration because of the lack of TM in Norway. Regarding this, the participant (F16) stated: In Norway , it is difficult to get those things from which we do the remedies in Pakistan. So , I didn’t do anything. In short, although TM was the first choice to treat illness for most participants, several combined this with conventional medicine or entirely used conventional medicines due to the lack of availability of TM in Norway.

Reasons for using TM

We identified that the participants used TM often in combination with conventional medicine to manage acute and mild health complaints, chronic problems, adverse effects of conventional medicines, and undiagnosed health complaints. Participants reported using different herbal remedies, food items, and commercial herbal preparations for acute and mild health complaints such as flu, seasonal allergies, and gastrointestinal problems. Several participants (F15, F4, F23, F8, F14) mentioned that they preferred TM for minor complaints because the doctors in Norway usually don’t prescribe any medication for minor complaints (cold and viral infections).

The participants (F4, F6, F7, F2, F3) also expressed that they combined TM with conventional medicine for chronic conditions such as diabetes, arthritis, and cardiovascular problems. For instance (F2): Sometimes it happens , and you are taking medicine , but your sugar level is still not under control. Then , in this case , I use black cumin and fenugreek seeds , mix them in the water , and drink them. It makes the sugar level better . Another participant (F6) mentioned using TM to control her blood pressure after taking conventional medicines. She stated: I used to drink cold drinks after adding ice and psyllium husk to them. It lowers my blood pressure , and I also keep the seeds of black cardamom in my mouth. It is very effective.

Some participants (F10, F11, F4, F3) reported using TM to manage chronic problems after experiencing adverse effects of conventional medicines. A participant (F10) had gastric problems due to extensive use of conventional medicines, so she started using TM (turmeric and seeds drinks). She (F10) found that TM could improve her quality of life: That [turmeric drink] is so soothing , and I sleep like a baby , and I wake up without crying like a baby because it relieves my pain . Another participant (F11) mentioned that she didn’t use conventional medicines because they make her drowsy, while another one (F4) avoided them to sleep peacefully.

Two participants used TM to manage autoimmune diseases because they knew that conventional medicines couldn’t cure their problem, so they preferred to use various home remedies and ritual remedies to manage their condition. F5 reported using TM to treat stomach problems that his doctor was unable to diagnose after multiple medical tests. He stated: I had very severe burning in my stomach , and they (doctors) always said that everything was fine. But then my sister told me to add psyllium husk to milk at night and to drink it in the morning. I used it for just one week , and I don’t have any problem now after 30 years . These data demonstrate the extensive dependence of first and second-generation participants on TM use in various types of health complaints.

Exchange of health practices between Pakistan and Norway

Participants reported the exchange of TM, conventional medicines, food items, and knowledge regarding health and TM between Pakistan and Norway. Some participants developed medical practices that were a mix of traditional and conventional medical practices. It was also expressed that they learned how to take care of their health through diet, exercise, and hygiene while living in Norway, and they continued practicing this when they visited Pakistan. For instance, a participant (F19) avoided eating in restaurants in Pakistan because of hygiene problems. Another participant (F21) continued eating in restaurants in Pakistan after eating raw red onion (quercetin: anti-bacterial) before eating anything else. She reported that she never got sick from food after she started this practice. It shows how the participants practiced their new (Norwegian) and traditional (Pakistani) knowledge of health for their well-being.

Participants (F8, F15, S2, F6, F3, F24) contacted herbalists and traditional healers in Pakistan while living in Norway through some family member or when visiting Pakistan due to family recommendations and the belief in TM. Some participants searched for remedies on the internet when they experienced some health complaints (F10, F14, F2, F24). Participants also reported bringing TM from Pakistan, Sweden (F4), and Turkey (F5, S2) because they were not available in Norway. Others took conventional medicines (F9, F10) and food items from Norway (F7) to Pakistan, doubting the quality of medicines in Pakistan. Some participants (F10, F1) reported that the medicines available in Pakistan are not “ first-class medicines .” A participant (F1) with chronic illness explained it: It means true and false. In Pakistan , false medicines (author’s comment: low quality) are very common and have fewer effects . A participant (F7) who has been living in Norway for 35 years and has a gluten allergy always brings gluten-free flour to Pakistan as he can’t eat the flour available in Pakistan. These data depict how the exchange of TM and health practices between Pakistan and Norway occurred at different levels and contributed to practicing the best approach to health restoration.

Adverse effects of TM use

Under this theme, we explored the participants’ knowledge, experiences, and beliefs regarding the adverse effects of TM. Most of the participants were unaware of the adverse effects of TM and seemed confident that it could never happen. Few participants (F14, F21, F22) experienced minor adverse effects from honey, ginger, salt, and turmeric, such as an unpleasant taste or odor, bloating, and irritation (Table  3 ). However, one participant (F1) reported serious adverse effects. He experienced renal failure because of using TM recommended by a healer in Pakistan. He said that a religious healer advised him to eat sugar. He continued: It harmed me significantly , so I was close to the death point many times . He also reported a negative interaction of TM with conventional medicines in this way. It happened that they (TM) lowered my sugar level so much. My doctor told me this is the problem with these remedies and that other medicines also stopped working after using them. It depicts participants’ experiences regarding the adverse effects of TM and drug-herb interaction.

After experiencing adverse effects of TM, some participants (F1, F14) stopped using them, while others continued using the TM after changing their method of use and preparation. F14 stopped using honey and lemon because of the warm effect of honey on the body. She stated: By a warm effect , I mean that you feel a burning in your stomach . A participant (F21) had skin burns because of using concentrated lavender oil. She continued using it after mixing it with another oil. Two participants (F10, F4) reported allergic reactions (sore throat, breathing problems, and watery eyes) after eating almonds and figs. They continued using them after soaking the almonds and figs in water overnight and eating small portions of such food items as recommended by their healers. It led to no allergic reactions, according to the participants. It shows that participants had their ways of managing adverse effects, and many participants who experienced adverse effects continued using them despite experiencing these harms.

Some participants (F16, F12) were concerned about the adverse effects of TM before use. They used Google to search the pros and cons of TM, but none reported using scientific sources for this purpose. One participant (F12), the mother of two children, mentioned that she used to search on Google for remedies that were considered safe for her children. She believed that because of this counterchecking, her children never experienced any adverse effects of TM.

Participants believe that natural is always safe and effective

Most participants considered TM safe because they believed “Natural is always safe.” They said they never experienced any adverse effects of TM because of their natural origin and lack of chemicals. F11 argued: Because these are all natural things , they don’t have any adverse effects. Another participant (F5) said: These things don’t have any adverse effects. They don’t have any chemicals , and chemicals are responsible for the adverse effects. Because of a firm belief in TM’s healing power and effectiveness, most participants shared that they did not countercheck the information about TM before using it. A female participant (F15) shared that she didn’t seek information before using TM because of her beliefs. She stated: Because these are remedies that have been used in our houses for centuries , we firmly believe they are correct. It shows that participants’ information-seeking before using TM was dependent on the patient’s beliefs regarding the safety of TM. These beliefs and perceptions may be understood as indirect risks of TM modalities.

In this paper, we have revealed three themes: (a) House of Knowledge , (b) Choosing the best possible approach for health restoration , and (c) Adverse effects of TM used , along with six sub-themes. The participants interviewed were heterogeneous and varied significantly based on sociodemographic profiles; however, common themes developed from these interviews. The participants mentioned the influence of family in TM use and their dependence on the traditional knowledge of mothers to recover from illness. Participants also combined TM and conventional medicine practices to treat illnesses and adversities. TM was used for managing acute and chronic diseases, and modalities like herbs, food items, and supplements were commonly used. Most of the participants believed that TM modalities were safe because of their natural origin, even though some also experienced adverse effects.

This study revealed the influence of family in TM use and that mothers were the significant caregivers (and source of information) for the whole family regarding medical routines and illness. Getting medical advice from the older woman of the family is also common in other cultures [ 52 ] and aligns with other studies [ 1 , 15 , 53 ]. These studies highlight the differences in gender roles due to traditional and cultural norms. For instance, it was reported that the use of TM was recommended by family (usually mother) or friends [ 13 ]. Another qualitative study, including 63 participants, also revealed the role of the family in decision-making about illness [ 54 ]. In our study, some of the participants reported inquiring their mothers about preparing the herbal remedies, thus indicating the influence of family in TM use. So, despite Norway’s efficient healthcare system, seeking advice from family members about illness is transferred with the family to the new country from one generation to another, making the whole family frequently use TM.

Our findings of herbs used for adversity (cinnamon , cloves , carom seeds , black cumin seeds , ginger , etc.) are in accordance with findings among Pakistani immigrants in other European countries like Denmark and the UK [ 1 , 15 ]. These herbs are also extensively used for the same medical indications in Pakistan [ 25 , 55 , 56 , 57 , 58 ] and other countries [ 59 ]. Some herbal products (Carmina, Khamira, lal-sherbet, and hajmola) have not been reported in other studies among Pakistani immigrants in Europe before, even though they are commonly used in Pakistan. Our finding that the female participants and those with chronic illnesses used more TM modalities than the men and other participants aligns with other studies [ 1 , 15 ].

While exploring the health-seeking behavior of the participants, we found out that the majority preferred to use TM for minor illnesses. This aligns with another focus group study about the use of herbal medicines [ 60 ]. Following family traditions, positive attitudes and beliefs, avoiding the side effects of conventional medicine, and dissatisfaction with the healthcare system were the common reasons behind TM use that we identified and are following other studies [ 60 , 61 , 62 ]. Another important reason was the belief that TM treats the cause of illness rather than just alleviating the symptoms. It aligns with another study on Pakistani immigrants in Scotland [ 30 ]. It was also revealed that the participants managed health complaints by combining TM and conventional medicines. This behavior can be explained by the concept of medical pluralism. The concept describes how people resort to different types of medical systems for one illness due to cultural and societal influences [ 53 ]. This concept has been extensively used in studies focusing on the immigrants’ use of various types of medical practices in adversity [ 1 , 63 , 64 , 65 ].

However, when people migrate to a place with a different culture, changes are observed in their behaviors, attitudes, values, stress, coping, and cultural identity [ 66 , 67 ]. This process is called acculturation [ 67 ] and is a psychological course of adjustment to a new culture by the immigrant [ 68 ]. Participants in this study combined TM, conventional medicines, and practices learned in Norway to restore health, showing some extent of acculturation and integration. It is essential to consider that the transfer of this medical knowledge goes both ways. The participants practiced Pakistani traditions in Norway and took Norwegian medicinal knowledge and modalities (hygiene rules, food items, and medicines) to Pakistan. It can be explained by the bi-dimensional model of acculturation, which means practicing some of the previous knowledge and the new knowledge learned after the migration [ 67 ]. Other studies on Pakistani immigrants in Norway also showed some extent of acculturation regarding food habits [ 69 ], body mass index [ 70 ], and the prevalence of modern health worries [ 71 ].

Adverse effects of TM used

Participants in the present study experienced some adverse effects (direct risk) of TM and didn’t report them to the health authorities (RELIS Manufacturer-independent drug information for healthcare professionals). Research shows that many herbal medicines from the Middle East and Asia contain various heavy metals, including lead, cadmium, mercury, etc., that can be hazardous for users [ 72 , 73 , 74 ]. Some medicinal plants the participants used have potentially toxic effects, e.g., psyllium husk and licorice (part of herbal supplements) [ 75 ]. Research has also shown the use of these plants among Pakistani immigrants in other parts of the world [ 1 , 15 ]. It is, therefore, crucial to improve this population’s knowledge of these hazards [ 76 ].

In the herbal industry, lack of adherence to good manufacturing practices, adulteration, poor regulatory measures, and lack of quality control are common [ 77 ]. There is no worldwide consensus on how to adopt the standards for herbal drugs compared to conventional medicine [ 77 ]. Contamination of herbal medicines is a global problem [ 78 ], and research has revealed the presence of pathogenic bacteria [ 79 ] and fungal contamination [ 80 ] in various medicinal plants available in Pakistan. It may be due to poor storage, handling conditions, and transport [ 80 ]. Some herbal preparations used by the participants were bought from Pakistan. It can lead to the transfer of contaminated herbs from an unregulated market in Pakistan to Norway and can pose severe adverse effects for the users. So, research on herbal toxicology [ 81 ], standardization [ 82 ], and pharmacovigilance [ 83 ] of herbal medicines is essential and warranted.

In our study, most participants believed that TM is always safe because of its natural origin [ 84 ]. This learned behavior and robust belief system could be an indirect risk that hindered them from making good health choices. Participants showed a lack of knowledge about drug-herb interaction. This finding aligns with another qualitative study that explored women’s views on herbal medicine [ 85 ]. Another indirect risk is the lack of accurate and comprehensive labeling of herbal medicines regarding their harms and benefits [ 86 ]. Getting information about TM from the internet (social media and Google) using non-scientific sources was revealed. It aligns with another study [ 35 ] showing information variability as a common indirect risk. Usually, such information has misleading claims about effect and safety. It can be more risky for communities with low health literacy [ 35 ], which is the case with Pakistani immigrants. Without adequate skills to critically evaluate the information, there is less chance of identifying false claims about TM. A qualitative study exploring the role of evidence for patients highlighted that patients do not value scientific information about complementary medicines to the same extent as doctors do [ 87 ]. Therefore, it is a matter of concern to be considered in TM safety and risk debates.

A recent health literacy survey on immigrants in Norway revealed that they experience difficulties accessing information about disease treatment [ 88 ]. Lack of available information and access to conventional healthcare information is an indirect risk that may lead to immigrants extensively using TM. One of the reasons for using TM was the difficulty in getting medicines from their family physician. In Pakistan, medicines are used extensively for minor health complaints, and almost all conventional medications, such as antibiotics, are accessible without prescription [ 13 ]. After migration, the participants found it challenging to cope with diseases without any prescribed medicine, so they may use TM more frequently in this scenario. We emphasize that these direct and indirect risks can lead to severe consequences. It is, therefore, essential to consider them and promote measures to reduce such risks.

Strengths and limitations

To the best of our knowledge, this is the first study that addressed the use of TM by Pakistani immigrants living in Norway. This study’s strength lies in research methods and user involvement. The use of qualitative methodology enabled us to capture the holistic view of the participants about TM [ 41 ]. User involvement helped us gain insight into the topic from the perspective of immigrants at different phases. Including members with and without medical backgrounds in the user involvement group enabled us to cover both perspectives. Open-ended questions ensured the exploration of the phenomena of interest at a deeper level. Due to information-rich participants, we obtained rich data and reached saturation after 22 interviews. Feedback from the research team on the pilot interviews helped identify the first author’s influence on the interview. She took notes during the interviews to write her views and to ensure reflexivity [ 48 ]. The detailed description of the study area, setting, participants, and the sampling and recruitment process of the participants warrant the transferability of the study findings to another setting [ 48 ]. Both the first author and the last authors read the interviews separately before starting the development of themes and agreeing on the results to ensure validity and minimize researcher subjectivity [ 48 ].

The results of this research should be interpreted considering its limitations. All the participants were interviewed once, and there was unequal distribution of participants based on gender. Future studies on the topic should consider gender balance. We asked the participants about their past experiences regarding the use of TM, so there is a possibility of recall bias. As the interviewee (SK) shared the same Pakistani culture, it may have impacted her reflexivity (the process of the researcher’s critical reflection on himself as a researcher considering assumptions, emotional reactions, expectations, and unconscious responses) despite taking appropriate measures of triangulation and feedback from the research team [ 48 ]. As qualitative research targets a specific population [ 40 ], it is essential to conduct further studies based on the type of illnesses and other parameters.

Implications for practice and research

Knowledge from this study can help healthcare providers understand Norwegian Pakistani patients’ choices and preferences in illness. Due to the extensive use of TM by this community, it is essential to ask immigrant patients about the TM they use. Promoting research assessing the safety of medicinal plants before the effect is necessary [ 89 ]. The participants showed sparse awareness about the safety of TM and drug-herb interactions, so it is crucial to improve this community’s knowledge about this aspect. The study results show that Pakistani immigrants use TM for various types of illnesses, so there is a need to have a closer look at the TM used by this population for the diseases that are prevalent in this community. Conducting such studies on other immigrant populations in Norway is essential to gather information about their traditional practices.

This study explores the experiences of TM use and perceptions of risk regarding these practices among Pakistani immigrants in Norway. The influence of family and various reasons for using TM are explored. All participants reported using TM to restore health for different diseases, alone or combined with conventional medicines. Public health strategies to improve immigrant health should consider the perceptions of immigrants regarding the use of TM. Although TM was considered safe, adverse effects were experienced and not reported to the health authorities. Further research is necessary regarding the safety and toxicity of TM, which are extensively used in Pakistani households in Norway.

Data availability

All data generated or analyzed during this study are included in this published article.

Abbreviations

Traditional Medicine

Reflexive thematic analysis

Traditional and Complementary Medicine

World Health Organization

Adverse Drug Reactions

Identification

Patient information brochure

COnsolidated criteria for REporting Qualitative research

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Acknowledgements

We express our gratitude to all the study participants for giving their time and sharing their knowledge.

Open access funding provided by UiT The Arctic University of Norway (incl University Hospital of North Norway). This research was funded by the National Research Centre for Complementary and Alternative Medicine (NAFKAM) at the Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Norway. The Open-access funding was provided by UiT The Arctic University of Norway.

Open access funding provided by UiT The Arctic University of Norway (incl University Hospital of North Norway)

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AK conception; CRB recruitment of the participants from the hospital; SK and SAQ data collection; SK and TS, data analysis; SK, TS, and AK interpretation of data; SK & TS drafted the manuscript; SK, LMA, SAQ, AK, CRB, and TS revised the manuscript. All authors have read and approved the manuscript.

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Supplementary Material 1: Description. Table 4 shows the traditional and scientific names of traditional medicines, their preparation method, purpose of use, dosage, lifestyle advice, and adverse effects

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Khalid, S., Kristoffersen, A.E., Alpers, LM. et al. Use and perception of risk: traditional medicines of Pakistani immigrants in Norway. BMC Complement Med Ther 24 , 331 (2024). https://doi.org/10.1186/s12906-024-04620-0

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Validity, reliability, and generalizability in qualitative research

Lawrence leung.

1 Department of Family Medicine, Queen's University, Kingston, Ontario, Canada

2 Centre of Studies in Primary Care, Queen's University, Kingston, Ontario, Canada

In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative research, qualitative research as a whole has been constantly critiqued, if not disparaged, by the lack of consensus for assessing its quality and robustness. This article illustrates with five published studies how qualitative research can impact and reshape the discipline of primary care, spiraling out from clinic-based health screening to community-based disease monitoring, evaluation of out-of-hours triage services to provincial psychiatric care pathways model and finally, national legislation of core measures for children's healthcare insurance. Fundamental concepts of validity, reliability, and generalizability as applicable to qualitative research are then addressed with an update on the current views and controversies.

Nature of Qualitative Research versus Quantitative Research

The essence of qualitative research is to make sense of and recognize patterns among words in order to build up a meaningful picture without compromising its richness and dimensionality. Like quantitative research, the qualitative research aims to seek answers for questions of “how, where, when who and why” with a perspective to build a theory or refute an existing theory. Unlike quantitative research which deals primarily with numerical data and their statistical interpretations under a reductionist, logical and strictly objective paradigm, qualitative research handles nonnumerical information and their phenomenological interpretation, which inextricably tie in with human senses and subjectivity. While human emotions and perspectives from both subjects and researchers are considered undesirable biases confounding results in quantitative research, the same elements are considered essential and inevitable, if not treasurable, in qualitative research as they invariable add extra dimensions and colors to enrich the corpus of findings. However, the issue of subjectivity and contextual ramifications has fueled incessant controversies regarding yardsticks for quality and trustworthiness of qualitative research results for healthcare.

Impact of Qualitative Research upon Primary Care

In many ways, qualitative research contributes significantly, if not more so than quantitative research, to the field of primary care at various levels. Five qualitative studies are chosen to illustrate how various methodologies of qualitative research helped in advancing primary healthcare, from novel monitoring of chronic obstructive pulmonary disease (COPD) via mobile-health technology,[ 1 ] informed decision for colorectal cancer screening,[ 2 ] triaging out-of-hours GP services,[ 3 ] evaluating care pathways for community psychiatry[ 4 ] and finally prioritization of healthcare initiatives for legislation purposes at national levels.[ 5 ] With the recent advances of information technology and mobile connecting device, self-monitoring and management of chronic diseases via tele-health technology may seem beneficial to both the patient and healthcare provider. Recruiting COPD patients who were given tele-health devices that monitored lung functions, Williams et al. [ 1 ] conducted phone interviews and analyzed their transcripts via a grounded theory approach, identified themes which enabled them to conclude that such mobile-health setup and application helped to engage patients with better adherence to treatment and overall improvement in mood. Such positive findings were in contrast to previous studies, which opined that elderly patients were often challenged by operating computer tablets,[ 6 ] or, conversing with the tele-health software.[ 7 ] To explore the content of recommendations for colorectal cancer screening given out by family physicians, Wackerbarth, et al. [ 2 ] conducted semi-structure interviews with subsequent content analysis and found that most physicians delivered information to enrich patient knowledge with little regard to patients’ true understanding, ideas, and preferences in the matter. These findings suggested room for improvement for family physicians to better engage their patients in recommending preventative care. Faced with various models of out-of-hours triage services for GP consultations, Egbunike et al. [ 3 ] conducted thematic analysis on semi-structured telephone interviews with patients and doctors in various urban, rural and mixed settings. They found that the efficiency of triage services remained a prime concern from both users and providers, among issues of access to doctors and unfulfilled/mismatched expectations from users, which could arouse dissatisfaction and legal implications. In UK, a care pathways model for community psychiatry had been introduced but its benefits were unclear. Khandaker et al. [ 4 ] hence conducted a qualitative study using semi-structure interviews with medical staff and other stakeholders; adopting a grounded-theory approach, major themes emerged which included improved equality of access, more focused logistics, increased work throughput and better accountability for community psychiatry provided under the care pathway model. Finally, at the US national level, Mangione-Smith et al. [ 5 ] employed a modified Delphi method to gather consensus from a panel of nominators which were recognized experts and stakeholders in their disciplines, and identified a core set of quality measures for children's healthcare under the Medicaid and Children's Health Insurance Program. These core measures were made transparent for public opinion and later passed on for full legislation, hence illustrating the impact of qualitative research upon social welfare and policy improvement.

Overall Criteria for Quality in Qualitative Research

Given the diverse genera and forms of qualitative research, there is no consensus for assessing any piece of qualitative research work. Various approaches have been suggested, the two leading schools of thoughts being the school of Dixon-Woods et al. [ 8 ] which emphasizes on methodology, and that of Lincoln et al. [ 9 ] which stresses the rigor of interpretation of results. By identifying commonalities of qualitative research, Dixon-Woods produced a checklist of questions for assessing clarity and appropriateness of the research question; the description and appropriateness for sampling, data collection and data analysis; levels of support and evidence for claims; coherence between data, interpretation and conclusions, and finally level of contribution of the paper. These criteria foster the 10 questions for the Critical Appraisal Skills Program checklist for qualitative studies.[ 10 ] However, these methodology-weighted criteria may not do justice to qualitative studies that differ in epistemological and philosophical paradigms,[ 11 , 12 ] one classic example will be positivistic versus interpretivistic.[ 13 ] Equally, without a robust methodological layout, rigorous interpretation of results advocated by Lincoln et al. [ 9 ] will not be good either. Meyrick[ 14 ] argued from a different angle and proposed fulfillment of the dual core criteria of “transparency” and “systematicity” for good quality qualitative research. In brief, every step of the research logistics (from theory formation, design of study, sampling, data acquisition and analysis to results and conclusions) has to be validated if it is transparent or systematic enough. In this manner, both the research process and results can be assured of high rigor and robustness.[ 14 ] Finally, Kitto et al. [ 15 ] epitomized six criteria for assessing overall quality of qualitative research: (i) Clarification and justification, (ii) procedural rigor, (iii) sample representativeness, (iv) interpretative rigor, (v) reflexive and evaluative rigor and (vi) transferability/generalizability, which also double as evaluative landmarks for manuscript review to the Medical Journal of Australia. Same for quantitative research, quality for qualitative research can be assessed in terms of validity, reliability, and generalizability.

Validity in qualitative research means “appropriateness” of the tools, processes, and data. Whether the research question is valid for the desired outcome, the choice of methodology is appropriate for answering the research question, the design is valid for the methodology, the sampling and data analysis is appropriate, and finally the results and conclusions are valid for the sample and context. In assessing validity of qualitative research, the challenge can start from the ontology and epistemology of the issue being studied, e.g. the concept of “individual” is seen differently between humanistic and positive psychologists due to differing philosophical perspectives:[ 16 ] Where humanistic psychologists believe “individual” is a product of existential awareness and social interaction, positive psychologists think the “individual” exists side-by-side with formation of any human being. Set off in different pathways, qualitative research regarding the individual's wellbeing will be concluded with varying validity. Choice of methodology must enable detection of findings/phenomena in the appropriate context for it to be valid, with due regard to culturally and contextually variable. For sampling, procedures and methods must be appropriate for the research paradigm and be distinctive between systematic,[ 17 ] purposeful[ 18 ] or theoretical (adaptive) sampling[ 19 , 20 ] where the systematic sampling has no a priori theory, purposeful sampling often has a certain aim or framework and theoretical sampling is molded by the ongoing process of data collection and theory in evolution. For data extraction and analysis, several methods were adopted to enhance validity, including 1 st tier triangulation (of researchers) and 2 nd tier triangulation (of resources and theories),[ 17 , 21 ] well-documented audit trail of materials and processes,[ 22 , 23 , 24 ] multidimensional analysis as concept- or case-orientated[ 25 , 26 ] and respondent verification.[ 21 , 27 ]

Reliability

In quantitative research, reliability refers to exact replicability of the processes and the results. In qualitative research with diverse paradigms, such definition of reliability is challenging and epistemologically counter-intuitive. Hence, the essence of reliability for qualitative research lies with consistency.[ 24 , 28 ] A margin of variability for results is tolerated in qualitative research provided the methodology and epistemological logistics consistently yield data that are ontologically similar but may differ in richness and ambience within similar dimensions. Silverman[ 29 ] proposed five approaches in enhancing the reliability of process and results: Refutational analysis, constant data comparison, comprehensive data use, inclusive of the deviant case and use of tables. As data were extracted from the original sources, researchers must verify their accuracy in terms of form and context with constant comparison,[ 27 ] either alone or with peers (a form of triangulation).[ 30 ] The scope and analysis of data included should be as comprehensive and inclusive with reference to quantitative aspects if possible.[ 30 ] Adopting the Popperian dictum of falsifiability as essence of truth and science, attempted to refute the qualitative data and analytes should be performed to assess reliability.[ 31 ]

Generalizability

Most qualitative research studies, if not all, are meant to study a specific issue or phenomenon in a certain population or ethnic group, of a focused locality in a particular context, hence generalizability of qualitative research findings is usually not an expected attribute. However, with rising trend of knowledge synthesis from qualitative research via meta-synthesis, meta-narrative or meta-ethnography, evaluation of generalizability becomes pertinent. A pragmatic approach to assessing generalizability for qualitative studies is to adopt same criteria for validity: That is, use of systematic sampling, triangulation and constant comparison, proper audit and documentation, and multi-dimensional theory.[ 17 ] However, some researchers espouse the approach of analytical generalization[ 32 ] where one judges the extent to which the findings in one study can be generalized to another under similar theoretical, and the proximal similarity model, where generalizability of one study to another is judged by similarities between the time, place, people and other social contexts.[ 33 ] Thus said, Zimmer[ 34 ] questioned the suitability of meta-synthesis in view of the basic tenets of grounded theory,[ 35 ] phenomenology[ 36 ] and ethnography.[ 37 ] He concluded that any valid meta-synthesis must retain the other two goals of theory development and higher-level abstraction while in search of generalizability, and must be executed as a third level interpretation using Gadamer's concepts of the hermeneutic circle,[ 38 , 39 ] dialogic process[ 38 ] and fusion of horizons.[ 39 ] Finally, Toye et al. [ 40 ] reported the practicality of using “conceptual clarity” and “interpretative rigor” as intuitive criteria for assessing quality in meta-ethnography, which somehow echoed Rolfe's controversial aesthetic theory of research reports.[ 41 ]

Food for Thought

Despite various measures to enhance or ensure quality of qualitative studies, some researchers opined from a purist ontological and epistemological angle that qualitative research is not a unified, but ipso facto diverse field,[ 8 ] hence any attempt to synthesize or appraise different studies under one system is impossible and conceptually wrong. Barbour argued from a philosophical angle that these special measures or “technical fixes” (like purposive sampling, multiple-coding, triangulation, and respondent validation) can never confer the rigor as conceived.[ 11 ] In extremis, Rolfe et al. opined from the field of nursing research, that any set of formal criteria used to judge the quality of qualitative research are futile and without validity, and suggested that any qualitative report should be judged by the form it is written (aesthetic) and not by the contents (epistemic).[ 41 ] Rolfe's novel view is rebutted by Porter,[ 42 ] who argued via logical premises that two of Rolfe's fundamental statements were flawed: (i) “The content of research report is determined by their forms” may not be a fact, and (ii) that research appraisal being “subject to individual judgment based on insight and experience” will mean those without sufficient experience of performing research will be unable to judge adequately – hence an elitist's principle. From a realism standpoint, Porter then proposes multiple and open approaches for validity in qualitative research that incorporate parallel perspectives[ 43 , 44 ] and diversification of meanings.[ 44 ] Any work of qualitative research, when read by the readers, is always a two-way interactive process, such that validity and quality has to be judged by the receiving end too and not by the researcher end alone.

In summary, the three gold criteria of validity, reliability and generalizability apply in principle to assess quality for both quantitative and qualitative research, what differs will be the nature and type of processes that ontologically and epistemologically distinguish between the two.

Source of Support: Nil.

Conflict of Interest: None declared.

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Controlling dengue among vulnerable populations in Brazil

When Dr Vanessa Cruvinel started her career in public health, she could never have dreamt that she’d be working in Latin America’s largest open waste site, trying to improve the health of one of the most vulnerable populations in Brazil.      

Until recently, Estrutural City in Brasilia had the largest open waste site in Latin America. While the site was closed in 2018 and many waste pickers are now employed in indoor waste sorting facilities, extreme poverty of people living in this area still contributes to the transmission of diseases, particularly dengue. As of April 2024,  Brazil is the country with the highest number of cases in the world , with 6.3 million suspected dengue cases, more than 80% of cases globally reported to WHO.

“This community in Estrutural City, initially formed by waste pickers 60 years ago and which now has 35 000 inhabitants, is more vulnerable than the other poor communities in Brazil,” Dr Cruvinel, a professor at the Public Health School of the University of Brasilia, said in a recent  presentation to TDR’s Joint Coordinating Board.

Inadequate sanitation services contributes to the transmission of dengue. Photos courtesy of Vanessa Cruvinel.

TDR in 2020 published a conceptual framework covering the essential elements of successful multisectoral collaborations. TDR has been supporting research teams in Africa and Latin America that have been implementing the multisectoral approach.  

Dr Marcos Obara and Dr Cruvinel have been leading the research team in Brazil. With technical and financial support from TDR, the team conducted research to develop public health solutions to reduce the incidence of dengue infection in Estrutural City, the poorest region in Brasilia, through the participation of three sectors having an impact on health: sanitation, urban services and education.  

In Estrutural City, the lack of adequate sanitation contributes to the growth of dengue-carrying mosquitoes. Although the study’s qualitative survey showed that many inhabitants knew how to prevent the spread of dengue by using special water storage tanks and removing trash from breeding sites, because of extreme poverty they could not afford to change their behaviour. Over 70% of inhabitants had had dengue at some point in their lives.

Dr Cruvinel noted some key preliminary findings and actions taken to address them:   

• Due to close living conditions, mobile waste disposal units cannot access houses to collect rubbish. For 7000 people, only five waste disposal sites are available, which means waste is often left in ditches. The Government of Brasilia’s Urban Cleaning Service is now implementing educational efforts to focus on correct waste disposal. And Dr Cruvinel’s team has donated trash cans to households as well as water tanks used by schools.
• An indoor waste sorting building has been provided so less waste is left in open areas, near living accommodations. 
• The study group installed 150 stations with the larvicide Pyriproxyfen. In areas of high incidence of dengue, this has helped to reduce the number of dengue cases by killing mosquito larvae. The Secretariat of Health of Brasilia now intends to implement this strategy of mosquito-disseminated larvicide in the areas of high incidence of dengue.

The partnership with the sanitation department and urban services was essential to give more strength to the programme, and the partnership with the education sector for adults and children empowered the population with knowledge on protection measures. 

Dr Cruvinel said that one of the most important steps they took as researchers was to listen to the community: “We met with the waste pickers, the community leaders, those working in education as well as the parents of the children in kindergarten, even the children. We knew how important it was to listen to the people directly affected to understand how they suffer. This helped us develop our research methodology. Without doing this, we couldn’t have helped reduce dengue rates in their community.”    

While the study is still ongoing, there has been a 64% reduction of dengue cases in Estrutural City between 2022 and 2023. This outcome is likely linked to the dissemination of the larvicide  Pyriproxyfen, Dr Cruvinel said.

Dr Cruvinel and her team are now sharing their experiences with other countries, including in West Africa.   

Watch the full presentation by Dr Cruvinel to TDR’s Joint Coordinating Board

More on the multisectoral approach to controlling vector-borne diseases