sample qualitative health research

Use controlled vocabulary

Databases use controlled vocabulary to categorize each record stored. The terms they use are known as  thesaurus terms or subject headings .  The thesaurus terms vary for each database according to their indexing system.

For example, qualitative research is indexed in PubMed as "Qualitative Research" or "Nursing Methodology Research", while in CINAHL their subject heading "Qualitative Studies" is complemented by more detailed terms, including "Phenomenological Research" and "Grounded Theory".

Tutorials for searching subject headings

Use qualitative research filters

Qualitative research filters are pre-formulated search strategies that have been constructed by librarians to help you retrieve articles in databases that deal with qualitative research. You can use the filter and then combine the results with your subject.

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PubMed Topic Specific Queries

• Go to  http://www.ncbi.nlm.nih.gov/pubmed/
• Under PubMed Tools , click Topic Specific Queries
• In the left column, click   Health Services Research (HSR) Queries
• Enter your search topic
• Under Category select Qualitative Research  
• Go to PsychINFO database in Database Finder .
• Enter your topic in the search box.
• In right column, under Methodoly, MATHEMATICAL MODEL , select Qualitative study .
• Under Refine Search section on the left, limit further your search under Methodology drop down menu.

Modify your search strategy accordingly by using thesaurus terms, such as qualitative research, grounded theory, interviews, observation methods, etc.

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• Health Research

How to Design a Qualitative Health Research Study. Part 1: Design and Purposeful Sampling Considerations

• September 2019
• PROFESSIONI INFERMIERISTICHE 72(2):152-161
• 72(2):152-161

• Università degli Studi di Milano-Bicocca

• York University
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• Published: 21 November 2018

Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period

• Konstantina Vasileiou   ORCID: orcid.org/0000-0001-5047-3920 1 ,
• Julie Barnett 1 ,
• Susan Thorpe 2 &
• Terry Young 3  

BMC Medical Research Methodology volume  18 , Article number:  148 ( 2018 ) Cite this article

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Choosing a suitable sample size in qualitative research is an area of conceptual debate and practical uncertainty. That sample size principles, guidelines and tools have been developed to enable researchers to set, and justify the acceptability of, their sample size is an indication that the issue constitutes an important marker of the quality of qualitative research. Nevertheless, research shows that sample size sufficiency reporting is often poor, if not absent, across a range of disciplinary fields.

A systematic analysis of single-interview-per-participant designs within three health-related journals from the disciplines of psychology, sociology and medicine, over a 15-year period, was conducted to examine whether and how sample sizes were justified and how sample size was characterised and discussed by authors. Data pertinent to sample size were extracted and analysed using qualitative and quantitative analytic techniques.

Our findings demonstrate that provision of sample size justifications in qualitative health research is limited; is not contingent on the number of interviews; and relates to the journal of publication. Defence of sample size was most frequently supported across all three journals with reference to the principle of saturation and to pragmatic considerations. Qualitative sample sizes were predominantly – and often without justification – characterised as insufficient (i.e., ‘small’) and discussed in the context of study limitations. Sample size insufficiency was seen to threaten the validity and generalizability of studies’ results, with the latter being frequently conceived in nomothetic terms.

Conclusions

We recommend, firstly, that qualitative health researchers be more transparent about evaluations of their sample size sufficiency, situating these within broader and more encompassing assessments of data adequacy . Secondly, we invite researchers critically to consider how saturation parameters found in prior methodological studies and sample size community norms might best inform, and apply to, their own project and encourage that data adequacy is best appraised with reference to features that are intrinsic to the study at hand. Finally, those reviewing papers have a vital role in supporting and encouraging transparent study-specific reporting.

Peer Review reports

Sample adequacy in qualitative inquiry pertains to the appropriateness of the sample composition and size . It is an important consideration in evaluations of the quality and trustworthiness of much qualitative research [ 1 ] and is implicated – particularly for research that is situated within a post-positivist tradition and retains a degree of commitment to realist ontological premises – in appraisals of validity and generalizability [ 2 , 3 , 4 , 5 ].

Samples in qualitative research tend to be small in order to support the depth of case-oriented analysis that is fundamental to this mode of inquiry [ 5 ]. Additionally, qualitative samples are purposive, that is, selected by virtue of their capacity to provide richly-textured information, relevant to the phenomenon under investigation. As a result, purposive sampling [ 6 , 7 ] – as opposed to probability sampling employed in quantitative research – selects ‘information-rich’ cases [ 8 ]. Indeed, recent research demonstrates the greater efficiency of purposive sampling compared to random sampling in qualitative studies [ 9 ], supporting related assertions long put forward by qualitative methodologists.

Sample size in qualitative research has been the subject of enduring discussions [ 4 , 10 , 11 ]. Whilst the quantitative research community has established relatively straightforward statistics-based rules to set sample sizes precisely, the intricacies of qualitative sample size determination and assessment arise from the methodological, theoretical, epistemological, and ideological pluralism that characterises qualitative inquiry (for a discussion focused on the discipline of psychology see [ 12 ]). This mitigates against clear-cut guidelines, invariably applied. Despite these challenges, various conceptual developments have sought to address this issue, with guidance and principles [ 4 , 10 , 11 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ], and more recently, an evidence-based approach to sample size determination seeks to ground the discussion empirically [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].

Focusing on single-interview-per-participant qualitative designs, the present study aims to further contribute to the dialogue of sample size in qualitative research by offering empirical evidence around justification practices associated with sample size. We next review the existing conceptual and empirical literature on sample size determination.

Sample size in qualitative research: Conceptual developments and empirical investigations

Qualitative research experts argue that there is no straightforward answer to the question of ‘how many’ and that sample size is contingent on a number of factors relating to epistemological, methodological and practical issues [ 36 ]. Sandelowski [ 4 ] recommends that qualitative sample sizes are large enough to allow the unfolding of a ‘new and richly textured understanding’ of the phenomenon under study, but small enough so that the ‘deep, case-oriented analysis’ (p. 183) of qualitative data is not precluded. Morse [ 11 ] posits that the more useable data are collected from each person, the fewer participants are needed. She invites researchers to take into account parameters, such as the scope of study, the nature of topic (i.e. complexity, accessibility), the quality of data, and the study design. Indeed, the level of structure of questions in qualitative interviewing has been found to influence the richness of data generated [ 37 ], and so, requires attention; empirical research shows that open questions, which are asked later on in the interview, tend to produce richer data [ 37 ].

Beyond such guidance, specific numerical recommendations have also been proffered, often based on experts’ experience of qualitative research. For example, Green and Thorogood [ 38 ] maintain that the experience of most qualitative researchers conducting an interview-based study with a fairly specific research question is that little new information is generated after interviewing 20 people or so belonging to one analytically relevant participant ‘category’ (pp. 102–104). Ritchie et al. [ 39 ] suggest that studies employing individual interviews conduct no more than 50 interviews so that researchers are able to manage the complexity of the analytic task. Similarly, Britten [ 40 ] notes that large interview studies will often comprise of 50 to 60 people. Experts have also offered numerical guidelines tailored to different theoretical and methodological traditions and specific research approaches, e.g. grounded theory, phenomenology [ 11 , 41 ]. More recently, a quantitative tool was proposed [ 42 ] to support a priori sample size determination based on estimates of the prevalence of themes in the population. Nevertheless, this more formulaic approach raised criticisms relating to assumptions about the conceptual [ 43 ] and ontological status of ‘themes’ [ 44 ] and the linearity ascribed to the processes of sampling, data collection and data analysis [ 45 ].

In terms of principles, Lincoln and Guba [ 17 ] proposed that sample size determination be guided by the criterion of informational redundancy , that is, sampling can be terminated when no new information is elicited by sampling more units. Following the logic of informational comprehensiveness Malterud et al. [ 18 ] introduced the concept of information power as a pragmatic guiding principle, suggesting that the more information power the sample provides, the smaller the sample size needs to be, and vice versa.

Undoubtedly, the most widely used principle for determining sample size and evaluating its sufficiency is that of saturation . The notion of saturation originates in grounded theory [ 15 ] – a qualitative methodological approach explicitly concerned with empirically-derived theory development – and is inextricably linked to theoretical sampling. Theoretical sampling describes an iterative process of data collection, data analysis and theory development whereby data collection is governed by emerging theory rather than predefined characteristics of the population. Grounded theory saturation (often called theoretical saturation) concerns the theoretical categories – as opposed to data – that are being developed and becomes evident when ‘gathering fresh data no longer sparks new theoretical insights, nor reveals new properties of your core theoretical categories’ [ 46 p. 113]. Saturation in grounded theory, therefore, does not equate to the more common focus on data repetition and moves beyond a singular focus on sample size as the justification of sampling adequacy [ 46 , 47 ]. Sample size in grounded theory cannot be determined a priori as it is contingent on the evolving theoretical categories.

Saturation – often under the terms of ‘data’ or ‘thematic’ saturation – has diffused into several qualitative communities beyond its origins in grounded theory. Alongside the expansion of its meaning, being variously equated with ‘no new data’, ‘no new themes’, and ‘no new codes’, saturation has emerged as the ‘gold standard’ in qualitative inquiry [ 2 , 26 ]. Nevertheless, and as Morse [ 48 ] asserts, whilst saturation is the most frequently invoked ‘guarantee of qualitative rigor’, ‘it is the one we know least about’ (p. 587). Certainly researchers caution that saturation is less applicable to, or appropriate for, particular types of qualitative research (e.g. conversation analysis, [ 49 ]; phenomenological research, [ 50 ]) whilst others reject the concept altogether [ 19 , 51 ].

Methodological studies in this area aim to provide guidance about saturation and develop a practical application of processes that ‘operationalise’ and evidence saturation. Guest, Bunce, and Johnson [ 26 ] analysed 60 interviews and found that saturation of themes was reached by the twelfth interview. They noted that their sample was relatively homogeneous, their research aims focused, so studies of more heterogeneous samples and with a broader scope would be likely to need a larger size to achieve saturation. Extending the enquiry to multi-site, cross-cultural research, Hagaman and Wutich [ 28 ] showed that sample sizes of 20 to 40 interviews were required to achieve data saturation of meta-themes that cut across research sites. In a theory-driven content analysis, Francis et al. [ 25 ] reached data saturation at the 17th interview for all their pre-determined theoretical constructs. The authors further proposed two main principles upon which specification of saturation be based: (a) researchers should a priori specify an initial analysis sample (e.g. 10 interviews) which will be used for the first round of analysis and (b) a stopping criterion , that is, a number of interviews (e.g. 3) that needs to be further conducted, the analysis of which will not yield any new themes or ideas. For greater transparency, Francis et al. [ 25 ] recommend that researchers present cumulative frequency graphs supporting their judgment that saturation was achieved. A comparative method for themes saturation (CoMeTS) has also been suggested [ 23 ] whereby the findings of each new interview are compared with those that have already emerged and if it does not yield any new theme, the ‘saturated terrain’ is assumed to have been established. Because the order in which interviews are analysed can influence saturation thresholds depending on the richness of the data, Constantinou et al. [ 23 ] recommend reordering and re-analysing interviews to confirm saturation. Hennink, Kaiser and Marconi’s [ 29 ] methodological study sheds further light on the problem of specifying and demonstrating saturation. Their analysis of interview data showed that code saturation (i.e. the point at which no additional issues are identified) was achieved at 9 interviews, but meaning saturation (i.e. the point at which no further dimensions, nuances, or insights of issues are identified) required 16–24 interviews. Although breadth can be achieved relatively soon, especially for high-prevalence and concrete codes, depth requires additional data, especially for codes of a more conceptual nature.

Critiquing the concept of saturation, Nelson [ 19 ] proposes five conceptual depth criteria in grounded theory projects to assess the robustness of the developing theory: (a) theoretical concepts should be supported by a wide range of evidence drawn from the data; (b) be demonstrably part of a network of inter-connected concepts; (c) demonstrate subtlety; (d) resonate with existing literature; and (e) can be successfully submitted to tests of external validity.

Other work has sought to examine practices of sample size reporting and sufficiency assessment across a range of disciplinary fields and research domains, from nutrition [ 34 ] and health education [ 32 ], to education and the health sciences [ 22 , 27 ], information systems [ 30 ], organisation and workplace studies [ 33 ], human computer interaction [ 21 ], and accounting studies [ 24 ]. Others investigated PhD qualitative studies [ 31 ] and grounded theory studies [ 35 ]. Incomplete and imprecise sample size reporting is commonly pinpointed by these investigations whilst assessment and justifications of sample size sufficiency are even more sporadic.

Sobal [ 34 ] examined the sample size of qualitative studies published in the Journal of Nutrition Education over a period of 30 years. Studies that employed individual interviews ( n  = 30) had an average sample size of 45 individuals and none of these explicitly reported whether their sample size sought and/or attained saturation. A minority of articles discussed how sample-related limitations (with the latter most often concerning the type of sample, rather than the size) limited generalizability. A further systematic analysis [ 32 ] of health education research over 20 years demonstrated that interview-based studies averaged 104 participants (range 2 to 720 interviewees). However, 40% did not report the number of participants. An examination of 83 qualitative interview studies in leading information systems journals [ 30 ] indicated little defence of sample sizes on the basis of recommendations by qualitative methodologists, prior relevant work, or the criterion of saturation. Rather, sample size seemed to correlate with factors such as the journal of publication or the region of study (US vs Europe vs Asia). These results led the authors to call for more rigor in determining and reporting sample size in qualitative information systems research and to recommend optimal sample size ranges for grounded theory (i.e. 20–30 interviews) and single case (i.e. 15–30 interviews) projects.

Similarly, fewer than 10% of articles in organisation and workplace studies provided a sample size justification relating to existing recommendations by methodologists, prior relevant work, or saturation [ 33 ], whilst only 17% of focus groups studies in health-related journals provided an explanation of sample size (i.e. number of focus groups), with saturation being the most frequently invoked argument, followed by published sample size recommendations and practical reasons [ 22 ]. The notion of saturation was also invoked by 11 out of the 51 most highly cited studies that Guetterman [ 27 ] reviewed in the fields of education and health sciences, of which six were grounded theory studies, four phenomenological and one a narrative inquiry. Finally, analysing 641 interview-based articles in accounting, Dai et al. [ 24 ] called for more rigor since a significant minority of studies did not report precise sample size.

Despite increasing attention to rigor in qualitative research (e.g. [ 52 ]) and more extensive methodological and analytical disclosures that seek to validate qualitative work [ 24 ], sample size reporting and sufficiency assessment remain inconsistent and partial, if not absent, across a range of research domains.

Objectives of the present study

The present study sought to enrich existing systematic analyses of the customs and practices of sample size reporting and justification by focusing on qualitative research relating to health. Additionally, this study attempted to expand previous empirical investigations by examining how qualitative sample sizes are characterised and discussed in academic narratives. Qualitative health research is an inter-disciplinary field that due to its affiliation with medical sciences, often faces views and positions reflective of a quantitative ethos. Thus qualitative health research constitutes an emblematic case that may help to unfold underlying philosophical and methodological differences across the scientific community that are crystallised in considerations of sample size. The present research, therefore, incorporates a comparative element on the basis of three different disciplines engaging with qualitative health research: medicine, psychology, and sociology. We chose to focus our analysis on single-per-participant-interview designs as this not only presents a popular and widespread methodological choice in qualitative health research, but also as the method where consideration of sample size – defined as the number of interviewees – is particularly salient.

Study design

A structured search for articles reporting cross-sectional, interview-based qualitative studies was carried out and eligible reports were systematically reviewed and analysed employing both quantitative and qualitative analytic techniques.

We selected journals which (a) follow a peer review process, (b) are considered high quality and influential in their field as reflected in journal metrics, and (c) are receptive to, and publish, qualitative research (Additional File  1 presents the journals’ editorial positions in relation to qualitative research and sample considerations where available). Three health-related journals were chosen, each representing a different disciplinary field; the British Medical Journal (BMJ) representing medicine, the British Journal of Health Psychology (BJHP) representing psychology, and the Sociology of Health & Illness (SHI) representing sociology.

Search strategy to identify studies

Employing the search function of each individual journal, we used the terms ‘interview*’ AND ‘qualitative’ and limited the results to articles published between 1 January 2003 and 22 September 2017 (i.e. a 15-year review period).

Eligibility criteria

To be eligible for inclusion in the review, the article had to report a cross-sectional study design. Longitudinal studies were thus excluded whilst studies conducted within a broader research programme (e.g. interview studies nested in a trial, as part of a broader ethnography, as part of a longitudinal research) were included if they reported only single-time qualitative interviews. The method of data collection had to be individual, synchronous qualitative interviews (i.e. group interviews, structured interviews and e-mail interviews over a period of time were excluded), and the data had to be analysed qualitatively (i.e. studies that quantified their qualitative data were excluded). Mixed method studies and articles reporting more than one qualitative method of data collection (e.g. individual interviews and focus groups) were excluded. Figure  1 , a PRISMA flow diagram [ 53 ], shows the number of: articles obtained from the searches and screened; papers assessed for eligibility; and articles included in the review (Additional File  2 provides the full list of articles included in the review and their unique identifying code – e.g. BMJ01, BJHP02, SHI03). One review author (KV) assessed the eligibility of all papers identified from the searches. When in doubt, discussions about retaining or excluding articles were held between KV and JB in regular meetings, and decisions were jointly made.

PRISMA flow diagram

Data extraction and analysis

A data extraction form was developed (see Additional File  3 ) recording three areas of information: (a) information about the article (e.g. authors, title, journal, year of publication etc.); (b) information about the aims of the study, the sample size and any justification for this, the participant characteristics, the sampling technique and any sample-related observations or comments made by the authors; and (c) information about the method or technique(s) of data analysis, the number of researchers involved in the analysis, the potential use of software, and any discussion around epistemological considerations. The Abstract, Methods and Discussion (and/or Conclusion) sections of each article were examined by one author (KV) who extracted all the relevant information. This was directly copied from the articles and, when appropriate, comments, notes and initial thoughts were written down.

To examine the kinds of sample size justifications provided by articles, an inductive content analysis [ 54 ] was initially conducted. On the basis of this analysis, the categories that expressed qualitatively different sample size justifications were developed.

We also extracted or coded quantitative data regarding the following aspects:

Journal and year of publication

Number of interviews

Number of participants

Presence of sample size justification(s) (Yes/No)

Presence of a particular sample size justification category (Yes/No), and

Number of sample size justifications provided

Descriptive and inferential statistical analyses were used to explore these data.

A thematic analysis [ 55 ] was then performed on all scientific narratives that discussed or commented on the sample size of the study. These narratives were evident both in papers that justified their sample size and those that did not. To identify these narratives, in addition to the methods sections, the discussion sections of the reviewed articles were also examined and relevant data were extracted and analysed.

In total, 214 articles – 21 in the BMJ, 53 in the BJHP and 140 in the SHI – were eligible for inclusion in the review. Table  1 provides basic information about the sample sizes – measured in number of interviews – of the studies reviewed across the three journals. Figure  2 depicts the number of eligible articles published each year per journal.

The publication of qualitative studies in the BMJ was significantly reduced from 2012 onwards and this appears to coincide with the initiation of the BMJ Open to which qualitative studies were possibly directed.

Pairwise comparisons following a significant Kruskal-Wallis Footnote 2 test indicated that the studies published in the BJHP had significantly ( p  < .001) smaller samples sizes than those published either in the BMJ or the SHI. Sample sizes of BMJ and SHI articles did not differ significantly from each other.

Sample size justifications: Results from the quantitative and qualitative content analysis

Ten (47.6%) of the 21 BMJ studies, 26 (49.1%) of the 53 BJHP papers and 24 (17.1%) of the 140 SHI articles provided some sort of sample size justification. As shown in Table  2 , the majority of articles which justified their sample size provided one justification (70% of articles); fourteen studies (25%) provided two distinct justifications; one study (1.7%) gave three justifications and two studies (3.3%) expressed four distinct justifications.

There was no association between the number of interviews (i.e. sample size) conducted and the provision of a justification (rpb = .054, p  = .433). Within journals, Mann-Whitney tests indicated that sample sizes of ‘justifying’ and ‘non-justifying’ articles in the BMJ and SHI did not differ significantly from each other. In the BJHP, ‘justifying’ articles ( Mean rank  = 31.3) had significantly larger sample sizes than ‘non-justifying’ studies ( Mean rank  = 22.7; U = 237.000, p  < .05).

There was a significant association between the journal a paper was published in and the provision of a justification (χ 2 (2) = 23.83, p  < .001). BJHP studies provided a sample size justification significantly more often than would be expected ( z  = 2.9); SHI studies significantly less often ( z  = − 2.4). If an article was published in the BJHP, the odds of providing a justification were 4.8 times higher than if published in the SHI. Similarly if published in the BMJ, the odds of a study justifying its sample size were 4.5 times higher than in the SHI.

The qualitative content analysis of the scientific narratives identified eleven different sample size justifications. These are described below and illustrated with excerpts from relevant articles. By way of a summary, the frequency with which these were deployed across the three journals is indicated in Table  3 .

Saturation was the most commonly invoked principle (55.4% of all justifications) deployed by studies across all three journals to justify the sufficiency of their sample size. In the BMJ, two studies claimed that they achieved data saturation (BMJ17; BMJ18) and one article referred descriptively to achieving saturation without explicitly using the term (BMJ13). Interestingly, BMJ13 included data in the analysis beyond the point of saturation in search of ‘unusual/deviant observations’ and with a view to establishing findings consistency.

Thirty three women were approached to take part in the interview study. Twenty seven agreed and 21 (aged 21–64, median 40) were interviewed before data saturation was reached (one tape failure meant that 20 interviews were available for analysis). (BMJ17). No new topics were identified following analysis of approximately two thirds of the interviews; however, all interviews were coded in order to develop a better understanding of how characteristic the views and reported behaviours were, and also to collect further examples of unusual/deviant observations. (BMJ13).

Two articles reported pre-determining their sample size with a view to achieving data saturation (BMJ08 – see extract in section In line with existing research ; BMJ15 – see extract in section Pragmatic considerations ) without further specifying if this was achieved. One paper claimed theoretical saturation (BMJ06) conceived as being when “no further recurring themes emerging from the analysis” whilst another study argued that although the analytic categories were highly saturated, it was not possible to determine whether theoretical saturation had been achieved (BMJ04). One article (BMJ18) cited a reference to support its position on saturation.

In the BJHP, six articles claimed that they achieved data saturation (BJHP21; BJHP32; BJHP39; BJHP48; BJHP49; BJHP52) and one article stated that, given their sample size and the guidelines for achieving data saturation, it anticipated that saturation would be attained (BJHP50).

Recruitment continued until data saturation was reached, defined as the point at which no new themes emerged. (BJHP48). It has previously been recommended that qualitative studies require a minimum sample size of at least 12 to reach data saturation (Clarke & Braun, 2013; Fugard & Potts, 2014; Guest, Bunce, & Johnson, 2006) Therefore, a sample of 13 was deemed sufficient for the qualitative analysis and scale of this study. (BJHP50).

Two studies argued that they achieved thematic saturation (BJHP28 – see extract in section Sample size guidelines ; BJHP31) and one (BJHP30) article, explicitly concerned with theory development and deploying theoretical sampling, claimed both theoretical and data saturation.

The final sample size was determined by thematic saturation, the point at which new data appears to no longer contribute to the findings due to repetition of themes and comments by participants (Morse, 1995). At this point, data generation was terminated. (BJHP31).

Five studies argued that they achieved (BJHP05; BJHP33; BJHP40; BJHP13 – see extract in section Pragmatic considerations ) or anticipated (BJHP46) saturation without any further specification of the term. BJHP17 referred descriptively to a state of achieved saturation without specifically using the term. Saturation of coding , but not saturation of themes, was claimed to have been reached by one article (BJHP18). Two articles explicitly stated that they did not achieve saturation; instead claiming a level of theme completeness (BJHP27) or that themes being replicated (BJHP53) were arguments for sufficiency of their sample size.

Furthermore, data collection ceased on pragmatic grounds rather than at the point when saturation point was reached. Despite this, although nuances within sub-themes were still emerging towards the end of data analysis, the themes themselves were being replicated indicating a level of completeness. (BJHP27).

Finally, one article criticised and explicitly renounced the notion of data saturation claiming that, on the contrary, the criterion of theoretical sufficiency determined its sample size (BJHP16).

According to the original Grounded Theory texts, data collection should continue until there are no new discoveries ( i.e. , ‘data saturation’; Glaser & Strauss, 1967). However, recent revisions of this process have discussed how it is rare that data collection is an exhaustive process and researchers should rely on how well their data are able to create a sufficient theoretical account or ‘theoretical sufficiency’ (Dey, 1999). For this study, it was decided that theoretical sufficiency would guide recruitment, rather than looking for data saturation. (BJHP16).

Ten out of the 20 BJHP articles that employed the argument of saturation used one or more citations relating to this principle.

In the SHI, one article (SHI01) claimed that it achieved category saturation based on authors’ judgment.

This number was not fixed in advance, but was guided by the sampling strategy and the judgement, based on the analysis of the data, of the point at which ‘category saturation’ was achieved. (SHI01).

Three articles described a state of achieved saturation without using the term or specifying what sort of saturation they had achieved (i.e. data, theoretical, thematic saturation) (SHI04; SHI13; SHI30) whilst another four articles explicitly stated that they achieved saturation (SHI100; SHI125; SHI136; SHI137). Two papers stated that they achieved data saturation (SHI73 – see extract in section Sample size guidelines ; SHI113), two claimed theoretical saturation (SHI78; SHI115) and two referred to achieving thematic saturation (SHI87; SHI139) or to saturated themes (SHI29; SHI50).

Recruitment and analysis ceased once theoretical saturation was reached in the categories described below (Lincoln and Guba 1985). (SHI115). The respondents’ quotes drawn on below were chosen as representative, and illustrate saturated themes. (SHI50).

One article stated that thematic saturation was anticipated with its sample size (SHI94). Briefly referring to the difficulty in pinpointing achievement of theoretical saturation, SHI32 (see extract in section Richness and volume of data ) defended the sufficiency of its sample size on the basis of “the high degree of consensus [that] had begun to emerge among those interviewed”, suggesting that information from interviews was being replicated. Finally, SHI112 (see extract in section Further sampling to check findings consistency ) argued that it achieved saturation of discursive patterns . Seven of the 19 SHI articles cited references to support their position on saturation (see Additional File  4 for the full list of citations used by articles to support their position on saturation across the three journals).

Overall, it is clear that the concept of saturation encompassed a wide range of variants expressed in terms such as saturation, data saturation, thematic saturation, theoretical saturation, category saturation, saturation of coding, saturation of discursive themes, theme completeness. It is noteworthy, however, that although these various claims were sometimes supported with reference to the literature, they were not evidenced in relation to the study at hand.

Pragmatic considerations

The determination of sample size on the basis of pragmatic considerations was the second most frequently invoked argument (9.6% of all justifications) appearing in all three journals. In the BMJ, one article (BMJ15) appealed to pragmatic reasons, relating to time constraints and the difficulty to access certain study populations, to justify the determination of its sample size.

On the basis of the researchers’ previous experience and the literature, [30, 31] we estimated that recruitment of 15–20 patients at each site would achieve data saturation when data from each site were analysed separately. We set a target of seven to 10 caregivers per site because of time constraints and the anticipated difficulty of accessing caregivers at some home based care services. This gave a target sample of 75–100 patients and 35–50 caregivers overall. (BMJ15).

In the BJHP, four articles mentioned pragmatic considerations relating to time or financial constraints (BJHP27 – see extract in section Saturation ; BJHP53), the participant response rate (BJHP13), and the fixed (and thus limited) size of the participant pool from which interviewees were sampled (BJHP18).

We had aimed to continue interviewing until we had reached saturation, a point whereby further data collection would yield no further themes. In practice, the number of individuals volunteering to participate dictated when recruitment into the study ceased (15 young people, 15 parents). Nonetheless, by the last few interviews, significant repetition of concepts was occurring, suggesting ample sampling. (BJHP13).

Finally, three SHI articles explained their sample size with reference to practical aspects: time constraints and project manageability (SHI56), limited availability of respondents and project resources (SHI131), and time constraints (SHI113).

The size of the sample was largely determined by the availability of respondents and resources to complete the study. Its composition reflected, as far as practicable, our interest in how contextual factors (for example, gender relations and ethnicity) mediated the illness experience. (SHI131).

Qualities of the analysis

This sample size justification (8.4% of all justifications) was mainly employed by BJHP articles and referred to an intensive, idiographic and/or latently focused analysis, i.e. that moved beyond description. More specifically, six articles defended their sample size on the basis of an intensive analysis of transcripts and/or the idiographic focus of the study/analysis. Four of these papers (BJHP02; BJHP19; BJHP24; BJHP47) adopted an Interpretative Phenomenological Analysis (IPA) approach.

The current study employed a sample of 10 in keeping with the aim of exploring each participant’s account (Smith et al. , 1999). (BJHP19).

BJHP47 explicitly renounced the notion of saturation within an IPA approach. The other two BJHP articles conducted thematic analysis (BJHP34; BJHP38). The level of analysis – i.e. latent as opposed to a more superficial descriptive analysis – was also invoked as a justification by BJHP38 alongside the argument of an intensive analysis of individual transcripts

The resulting sample size was at the lower end of the range of sample sizes employed in thematic analysis (Braun & Clarke, 2013). This was in order to enable significant reflection, dialogue, and time on each transcript and was in line with the more latent level of analysis employed, to identify underlying ideas, rather than a more superficial descriptive analysis (Braun & Clarke, 2006). (BJHP38).

Finally, one BMJ paper (BMJ21) defended its sample size with reference to the complexity of the analytic task.

We stopped recruitment when we reached 30–35 interviews, owing to the depth and duration of interviews, richness of data, and complexity of the analytical task. (BMJ21).

Meet sampling requirements

Meeting sampling requirements (7.2% of all justifications) was another argument employed by two BMJ and four SHI articles to explain their sample size. Achieving maximum variation sampling in terms of specific interviewee characteristics determined and explained the sample size of two BMJ studies (BMJ02; BMJ16 – see extract in section Meet research design requirements ).

Recruitment continued until sampling frame requirements were met for diversity in age, sex, ethnicity, frequency of attendance, and health status. (BMJ02).

Regarding the SHI articles, two papers explained their numbers on the basis of their sampling strategy (SHI01- see extract in section Saturation ; SHI23) whilst sampling requirements that would help attain sample heterogeneity in terms of a particular characteristic of interest was cited by one paper (SHI127).

The combination of matching the recruitment sites for the quantitative research and the additional purposive criteria led to 104 phase 2 interviews (Internet (OLC): 21; Internet (FTF): 20); Gyms (FTF): 23; HIV testing (FTF): 20; HIV treatment (FTF): 20.) (SHI23). Of the fifty interviews conducted, thirty were translated from Spanish into English. These thirty, from which we draw our findings, were chosen for translation based on heterogeneity in depressive symptomology and educational attainment. (SHI127).

Finally, the pre-determination of sample size on the basis of sampling requirements was stated by one article though this was not used to justify the number of interviews (SHI10).

Sample size guidelines

Five BJHP articles (BJHP28; BJHP38 – see extract in section Qualities of the analysis ; BJHP46; BJHP47; BJHP50 – see extract in section Saturation ) and one SHI paper (SHI73) relied on citing existing sample size guidelines or norms within research traditions to determine and subsequently defend their sample size (7.2% of all justifications).

Sample size guidelines suggested a range between 20 and 30 interviews to be adequate (Creswell, 1998). Interviewer and note taker agreed that thematic saturation, the point at which no new concepts emerge from subsequent interviews (Patton, 2002), was achieved following completion of 20 interviews. (BJHP28). Interviewing continued until we deemed data saturation to have been reached (the point at which no new themes were emerging). Researchers have proposed 30 as an approximate or working number of interviews at which one could expect to be reaching theoretical saturation when using a semi-structured interview approach (Morse 2000), although this can vary depending on the heterogeneity of respondents interviewed and complexity of the issues explored. (SHI73).

In line with existing research

Sample sizes of published literature in the area of the subject matter under investigation (3.5% of all justifications) were used by 2 BMJ articles as guidance and a precedent for determining and defending their own sample size (BMJ08; BMJ15 – see extract in section Pragmatic considerations ).

We drew participants from a list of prisoners who were scheduled for release each week, sampling them until we reached the target of 35 cases, with a view to achieving data saturation within the scope of the study and sufficient follow-up interviews and in line with recent studies [8–10]. (BMJ08).

Similarly, BJHP38 (see extract in section Qualities of the analysis ) claimed that its sample size was within the range of sample sizes of published studies that use its analytic approach.

Richness and volume of data

BMJ21 (see extract in section Qualities of the analysis ) and SHI32 referred to the richness, detailed nature, and volume of data collected (2.3% of all justifications) to justify the sufficiency of their sample size.

Although there were more potential interviewees from those contacted by postcode selection, it was decided to stop recruitment after the 10th interview and focus on analysis of this sample. The material collected was considerable and, given the focused nature of the study, extremely detailed. Moreover, a high degree of consensus had begun to emerge among those interviewed, and while it is always difficult to judge at what point ‘theoretical saturation’ has been reached, or how many interviews would be required to uncover exception(s), it was felt the number was sufficient to satisfy the aims of this small in-depth investigation (Strauss and Corbin 1990). (SHI32).

Meet research design requirements

Determination of sample size so that it is in line with, and serves the requirements of, the research design (2.3% of all justifications) that the study adopted was another justification used by 2 BMJ papers (BMJ16; BMJ08 – see extract in section In line with existing research ).

We aimed for diverse, maximum variation samples [20] totalling 80 respondents from different social backgrounds and ethnic groups and those bereaved due to different types of suicide and traumatic death. We could have interviewed a smaller sample at different points in time (a qualitative longitudinal study) but chose instead to seek a broad range of experiences by interviewing those bereaved many years ago and others bereaved more recently; those bereaved in different circumstances and with different relations to the deceased; and people who lived in different parts of the UK; with different support systems and coroners’ procedures (see Tables 1 and 2 for more details). (BMJ16).

Researchers’ previous experience

The researchers’ previous experience (possibly referring to experience with qualitative research) was invoked by BMJ15 (see extract in section Pragmatic considerations ) as a justification for the determination of sample size.

Nature of study

One BJHP paper argued that the sample size was appropriate for the exploratory nature of the study (BJHP38).

A sample of eight participants was deemed appropriate because of the exploratory nature of this research and the focus on identifying underlying ideas about the topic. (BJHP38).

Further sampling to check findings consistency

Finally, SHI112 argued that once it had achieved saturation of discursive patterns, further sampling was decided and conducted to check for consistency of the findings.

Within each of the age-stratified groups, interviews were randomly sampled until saturation of discursive patterns was achieved. This resulted in a sample of 67 interviews. Once this sample had been analysed, one further interview from each age-stratified group was randomly chosen to check for consistency of the findings. Using this approach it was possible to more carefully explore children’s discourse about the ‘I’, agency, relationality and power in the thematic areas, revealing the subtle discursive variations described in this article. (SHI112).

Thematic analysis of passages discussing sample size

This analysis resulted in two overarching thematic areas; the first concerned the variation in the characterisation of sample size sufficiency, and the second related to the perceived threats deriving from sample size insufficiency.

Characterisations of sample size sufficiency

The analysis showed that there were three main characterisations of the sample size in the articles that provided relevant comments and discussion: (a) the vast majority of these qualitative studies ( n  = 42) considered their sample size as ‘small’ and this was seen and discussed as a limitation; only two articles viewed their small sample size as desirable and appropriate (b) a minority of articles ( n  = 4) proclaimed that their achieved sample size was ‘sufficient’; and (c) finally, a small group of studies ( n  = 5) characterised their sample size as ‘large’. Whilst achieving a ‘large’ sample size was sometimes viewed positively because it led to richer results, there were also occasions when a large sample size was problematic rather than desirable.

‘Small’ but why and for whom?

A number of articles which characterised their sample size as ‘small’ did so against an implicit or explicit quantitative framework of reference. Interestingly, three studies that claimed to have achieved data saturation or ‘theoretical sufficiency’ with their sample size, discussed or noted as a limitation in their discussion their ‘small’ sample size, raising the question of why, or for whom, the sample size was considered small given that the qualitative criterion of saturation had been satisfied.

The current study has a number of limitations. The sample size was small (n = 11) and, however, large enough for no new themes to emerge. (BJHP39). The study has two principal limitations. The first of these relates to the small number of respondents who took part in the study. (SHI73).

Other articles appeared to accept and acknowledge that their sample was flawed because of its small size (as well as other compositional ‘deficits’ e.g. non-representativeness, biases, self-selection) or anticipated that they might be criticized for their small sample size. It seemed that the imagined audience – perhaps reviewer or reader – was one inclined to hold the tenets of quantitative research, and certainly one to whom it was important to indicate the recognition that small samples were likely to be problematic. That one’s sample might be thought small was often construed as a limitation couched in a discourse of regret or apology.

Very occasionally, the articulation of the small size as a limitation was explicitly aligned against an espoused positivist framework and quantitative research.

This study has some limitations. Firstly, the 100 incidents sample represents a small number of the total number of serious incidents that occurs every year. 26 We sent out a nationwide invitation and do not know why more people did not volunteer for the study. Our lack of epidemiological knowledge about healthcare incidents, however, means that determining an appropriate sample size continues to be difficult. (BMJ20).

Indicative of an apparent oscillation of qualitative researchers between the different requirements and protocols demarcating the quantitative and qualitative worlds, there were a few instances of articles which briefly recognised their ‘small’ sample size as a limitation, but then defended their study on more qualitative grounds, such as their ability and success at capturing the complexity of experience and delving into the idiographic, and at generating particularly rich data.

This research, while limited in size, has sought to capture some of the complexity attached to men’s attitudes and experiences concerning incomes and material circumstances. (SHI35). Our numbers are small because negotiating access to social networks was slow and labour intensive, but our methods generated exceptionally rich data. (BMJ21). This study could be criticised for using a small and unrepresentative sample. Given that older adults have been ignored in the research concerning suntanning, fair-skinned older adults are the most likely to experience skin cancer, and women privilege appearance over health when it comes to sunbathing practices, our study offers depth and richness of data in a demographic group much in need of research attention. (SHI57).

‘Good enough’ sample sizes

Only four articles expressed some degree of confidence that their achieved sample size was sufficient. For example, SHI139, in line with the justification of thematic saturation that it offered, expressed trust in its sample size sufficiency despite the poor response rate. Similarly, BJHP04, which did not provide a sample size justification, argued that it targeted a larger sample size in order to eventually recruit a sufficient number of interviewees, due to anticipated low response rate.

Twenty-three people with type I diabetes from the target population of 133 ( i.e. 17.3%) consented to participate but four did not then respond to further contacts (total N = 19). The relatively low response rate was anticipated, due to the busy life-styles of young people in the age range, the geographical constraints, and the time required to participate in a semi-structured interview, so a larger target sample allowed a sufficient number of participants to be recruited. (BJHP04).

Two other articles (BJHP35; SHI32) linked the claimed sufficiency to the scope (i.e. ‘small, in-depth investigation’), aims and nature (i.e. ‘exploratory’) of their studies, thus anchoring their numbers to the particular context of their research. Nevertheless, claims of sample size sufficiency were sometimes undermined when they were juxtaposed with an acknowledgement that a larger sample size would be more scientifically productive.

Although our sample size was sufficient for this exploratory study, a more diverse sample including participants with lower socioeconomic status and more ethnic variation would be informative. A larger sample could also ensure inclusion of a more representative range of apps operating on a wider range of platforms. (BJHP35).

‘Large’ sample sizes - Promise or peril?

Three articles (BMJ13; BJHP05; BJHP48) which all provided the justification of saturation, characterised their sample size as ‘large’ and narrated this oversufficiency in positive terms as it allowed richer data and findings and enhanced the potential for generalisation. The type of generalisation aspired to (BJHP48) was not further specified however.

This study used rich data provided by a relatively large sample of expert informants on an important but under-researched topic. (BMJ13). Qualitative research provides a unique opportunity to understand a clinical problem from the patient’s perspective. This study had a large diverse sample, recruited through a range of locations and used in-depth interviews which enhance the richness and generalizability of the results. (BJHP48).

And whilst a ‘large’ sample size was endorsed and valued by some qualitative researchers, within the psychological tradition of IPA, a ‘large’ sample size was counter-normative and therefore needed to be justified. Four BJHP studies, all adopting IPA, expressed the appropriateness or desirability of ‘small’ sample sizes (BJHP41; BJHP45) or hastened to explain why they included a larger than typical sample size (BJHP32; BJHP47). For example, BJHP32 below provides a rationale for how an IPA study can accommodate a large sample size and how this was indeed suitable for the purposes of the particular research. To strengthen the explanation for choosing a non-normative sample size, previous IPA research citing a similar sample size approach is used as a precedent.

Small scale IPA studies allow in-depth analysis which would not be possible with larger samples (Smith et al. , 2009). (BJHP41). Although IPA generally involves intense scrutiny of a small number of transcripts, it was decided to recruit a larger diverse sample as this is the first qualitative study of this population in the United Kingdom (as far as we know) and we wanted to gain an overview. Indeed, Smith, Flowers, and Larkin (2009) agree that IPA is suitable for larger groups. However, the emphasis changes from an in-depth individualistic analysis to one in which common themes from shared experiences of a group of people can be elicited and used to understand the network of relationships between themes that emerge from the interviews. This large-scale format of IPA has been used by other researchers in the field of false-positive research. Baillie, Smith, Hewison, and Mason (2000) conducted an IPA study, with 24 participants, of ultrasound screening for chromosomal abnormality; they found that this larger number of participants enabled them to produce a more refined and cohesive account. (BJHP32).

The IPA articles found in the BJHP were the only instances where a ‘small’ sample size was advocated and a ‘large’ sample size problematized and defended. These IPA studies illustrate that the characterisation of sample size sufficiency can be a function of researchers’ theoretical and epistemological commitments rather than the result of an ‘objective’ sample size assessment.

Threats from sample size insufficiency

As shown above, the majority of articles that commented on their sample size, simultaneously characterized it as small and problematic. On those occasions that authors did not simply cite their ‘small’ sample size as a study limitation but rather continued and provided an account of how and why a small sample size was problematic, two important scientific qualities of the research seemed to be threatened: the generalizability and validity of results.

Generalizability

Those who characterised their sample as ‘small’ connected this to the limited potential for generalization of the results. Other features related to the sample – often some kind of compositional particularity – were also linked to limited potential for generalisation. Though not always explicitly articulated to what form of generalisation the articles referred to (see BJHP09), generalisation was mostly conceived in nomothetic terms, that is, it concerned the potential to draw inferences from the sample to the broader study population (‘representational generalisation’ – see BJHP31) and less often to other populations or cultures.

It must be noted that samples are small and whilst in both groups the majority of those women eligible participated, generalizability cannot be assumed. (BJHP09). The study’s limitations should be acknowledged: Data are presented from interviews with a relatively small group of participants, and thus, the views are not necessarily generalizable to all patients and clinicians. In particular, patients were only recruited from secondary care services where COFP diagnoses are typically confirmed. The sample therefore is unlikely to represent the full spectrum of patients, particularly those who are not referred to, or who have been discharged from dental services. (BJHP31).

Without explicitly using the term generalisation, two SHI articles noted how their ‘small’ sample size imposed limits on ‘the extent that we can extrapolate from these participants’ accounts’ (SHI114) or to the possibility ‘to draw far-reaching conclusions from the results’ (SHI124).

Interestingly, only a minority of articles alluded to, or invoked, a type of generalisation that is aligned with qualitative research, that is, idiographic generalisation (i.e. generalisation that can be made from and about cases [ 5 ]). These articles, all published in the discipline of sociology, defended their findings in terms of the possibility of drawing logical and conceptual inferences to other contexts and of generating understanding that has the potential to advance knowledge, despite their ‘small’ size. One article (SHI139) clearly contrasted nomothetic (statistical) generalisation to idiographic generalisation, arguing that the lack of statistical generalizability does not nullify the ability of qualitative research to still be relevant beyond the sample studied.

Further, these data do not need to be statistically generalisable for us to draw inferences that may advance medicalisation analyses (Charmaz 2014). These data may be seen as an opportunity to generate further hypotheses and are a unique application of the medicalisation framework. (SHI139). Although a small-scale qualitative study related to school counselling, this analysis can be usefully regarded as a case study of the successful utilisation of mental health-related resources by adolescents. As many of the issues explored are of relevance to mental health stigma more generally, it may also provide insights into adult engagement in services. It shows how a sociological analysis, which uses positioning theory to examine how people negotiate, partially accept and simultaneously resist stigmatisation in relation to mental health concerns, can contribute to an elucidation of the social processes and narrative constructions which may maintain as well as bridge the mental health service gap. (SHI103).

Only one article (SHI30) used the term transferability to argue for the potential of wider relevance of the results which was thought to be more the product of the composition of the sample (i.e. diverse sample), rather than the sample size.

The second major concern that arose from a ‘small’ sample size pertained to the internal validity of findings (i.e. here the term is used to denote the ‘truth’ or credibility of research findings). Authors expressed uncertainty about the degree of confidence in particular aspects or patterns of their results, primarily those that concerned some form of differentiation on the basis of relevant participant characteristics.

The information source preferred seemed to vary according to parents’ education; however, the sample size is too small to draw conclusions about such patterns. (SHI80). Although our numbers were too small to demonstrate gender differences with any certainty, it does seem that the biomedical and erotic scripts may be more common in the accounts of men and the relational script more common in the accounts of women. (SHI81).

In other instances, articles expressed uncertainty about whether their results accounted for the full spectrum and variation of the phenomenon under investigation. In other words, a ‘small’ sample size (alongside compositional ‘deficits’ such as a not statistically representative sample) was seen to threaten the ‘content validity’ of the results which in turn led to constructions of the study conclusions as tentative.

Data collection ceased on pragmatic grounds rather than when no new information appeared to be obtained ( i.e. , saturation point). As such, care should be taken not to overstate the findings. Whilst the themes from the initial interviews seemed to be replicated in the later interviews, further interviews may have identified additional themes or provided more nuanced explanations. (BJHP53). …it should be acknowledged that this study was based on a small sample of self-selected couples in enduring marriages who were not broadly representative of the population. Thus, participants may not be representative of couples that experience postnatal PTSD. It is therefore unlikely that all the key themes have been identified and explored. For example, couples who were excluded from the study because the male partner declined to participate may have been experiencing greater interpersonal difficulties. (BJHP03).

In other instances, articles attempted to preserve a degree of credibility of their results, despite the recognition that the sample size was ‘small’. Clarity and sharpness of emerging themes and alignment with previous relevant work were the arguments employed to warrant the validity of the results.

This study focused on British Chinese carers of patients with affective disorders, using a qualitative methodology to synthesise the sociocultural representations of illness within this community. Despite the small sample size, clear themes emerged from the narratives that were sufficient for this exploratory investigation. (SHI98).

The present study sought to examine how qualitative sample sizes in health-related research are characterised and justified. In line with previous studies [ 22 , 30 , 33 , 34 ] the findings demonstrate that reporting of sample size sufficiency is limited; just over 50% of articles in the BMJ and BJHP and 82% in the SHI did not provide any sample size justification. Providing a sample size justification was not related to the number of interviews conducted, but it was associated with the journal that the article was published in, indicating the influence of disciplinary or publishing norms, also reported in prior research [ 30 ]. This lack of transparency about sample size sufficiency is problematic given that most qualitative researchers would agree that it is an important marker of quality [ 56 , 57 ]. Moreover, and with the rise of qualitative research in social sciences, efforts to synthesise existing evidence and assess its quality are obstructed by poor reporting [ 58 , 59 ].

When authors justified their sample size, our findings indicate that sufficiency was mostly appraised with reference to features that were intrinsic to the study, in agreement with general advice on sample size determination [ 4 , 11 , 36 ]. The principle of saturation was the most commonly invoked argument [ 22 ] accounting for 55% of all justifications. A wide range of variants of saturation was evident corroborating the proliferation of the meaning of the term [ 49 ] and reflecting different underlying conceptualisations or models of saturation [ 20 ]. Nevertheless, claims of saturation were never substantiated in relation to procedures conducted in the study itself, endorsing similar observations in the literature [ 25 , 30 , 47 ]. Claims of saturation were sometimes supported with citations of other literature, suggesting a removal of the concept away from the characteristics of the study at hand. Pragmatic considerations, such as resource constraints or participant response rate and availability, was the second most frequently used argument accounting for approximately 10% of justifications and another 23% of justifications also represented intrinsic-to-the-study characteristics (i.e. qualities of the analysis, meeting sampling or research design requirements, richness and volume of the data obtained, nature of study, further sampling to check findings consistency).

Only, 12% of mentions of sample size justification pertained to arguments that were external to the study at hand, in the form of existing sample size guidelines and prior research that sets precedents. Whilst community norms and prior research can establish useful rules of thumb for estimating sample sizes [ 60 ] – and reveal what sizes are more likely to be acceptable within research communities – researchers should avoid adopting these norms uncritically, especially when such guidelines [e.g. 30 , 35 ], might be based on research that does not provide adequate evidence of sample size sufficiency. Similarly, whilst methodological research that seeks to demonstrate the achievement of saturation is invaluable since it explicates the parameters upon which saturation is contingent and indicates when a research project is likely to require a smaller or a larger sample [e.g. 29 ], specific numbers at which saturation was achieved within these projects cannot be routinely extrapolated for other projects. We concur with existing views [ 11 , 36 ] that the consideration of the characteristics of the study at hand, such as the epistemological and theoretical approach, the nature of the phenomenon under investigation, the aims and scope of the study, the quality and richness of data, or the researcher’s experience and skills of conducting qualitative research, should be the primary guide in determining sample size and assessing its sufficiency.

Moreover, although numbers in qualitative research are not unimportant [ 61 ], sample size should not be considered alone but be embedded in the more encompassing examination of data adequacy [ 56 , 57 ]. Erickson’s [ 62 ] dimensions of ‘evidentiary adequacy’ are useful here. He explains the concept in terms of adequate amounts of evidence, adequate variety in kinds of evidence, adequate interpretive status of evidence, adequate disconfirming evidence, and adequate discrepant case analysis. All dimensions might not be relevant across all qualitative research designs, but this illustrates the thickness of the concept of data adequacy, taking it beyond sample size.

The present research also demonstrated that sample sizes were commonly seen as ‘small’ and insufficient and discussed as limitation. Often unjustified (and in two cases incongruent with their own claims of saturation) these findings imply that sample size in qualitative health research is often adversely judged (or expected to be judged) against an implicit, yet omnipresent, quasi-quantitative standpoint. Indeed there were a few instances in our data where authors appeared, possibly in response to reviewers, to resist to some sort of quantification of their results. This implicit reference point became more apparent when authors discussed the threats deriving from an insufficient sample size. Whilst the concerns about internal validity might be legitimate to the extent that qualitative research projects, which are broadly related to realism, are set to examine phenomena in sufficient breadth and depth, the concerns around generalizability revealed a conceptualisation that is not compatible with purposive sampling. The limited potential for generalisation, as a result of a small sample size, was often discussed in nomothetic, statistical terms. Only occasionally was analytic or idiographic generalisation invoked to warrant the value of the study’s findings [ 5 , 17 ].

Strengths and limitations of the present study

We note, first, the limited number of health-related journals reviewed, so that only a ‘snapshot’ of qualitative health research has been captured. Examining additional disciplines (e.g. nursing sciences) as well as inter-disciplinary journals would add to the findings of this analysis. Nevertheless, our study is the first to provide some comparative insights on the basis of disciplines that are differently attached to the legacy of positivism and analysed literature published over a lengthy period of time (15 years). Guetterman [ 27 ] also examined health-related literature but this analysis was restricted to 26 most highly cited articles published over a period of five years whilst Carlsen and Glenton’s [ 22 ] study concentrated on focus groups health research. Moreover, although it was our intention to examine sample size justification in relation to the epistemological and theoretical positions of articles, this proved to be challenging largely due to absence of relevant information, or the difficulty into discerning clearly articles’ positions [ 63 ] and classifying them under specific approaches (e.g. studies often combined elements from different theoretical and epistemological traditions). We believe that such an analysis would yield useful insights as it links the methodological issue of sample size to the broader philosophical stance of the research. Despite these limitations, the analysis of the characterisation of sample size and of the threats seen to accrue from insufficient sample size, enriches our understanding of sample size (in)sufficiency argumentation by linking it to other features of the research. As the peer-review process becomes increasingly public, future research could usefully examine how reporting around sample size sufficiency and data adequacy might be influenced by the interactions between authors and reviewers.

The past decade has seen a growing appetite in qualitative research for an evidence-based approach to sample size determination and to evaluations of the sufficiency of sample size. Despite the conceptual and methodological developments in the area, the findings of the present study confirm previous studies in concluding that appraisals of sample size sufficiency are either absent or poorly substantiated. To ensure and maintain high quality research that will encourage greater appreciation of qualitative work in health-related sciences [ 64 ], we argue that qualitative researchers should be more transparent and thorough in their evaluation of sample size as part of their appraisal of data adequacy. We would encourage the practice of appraising sample size sufficiency with close reference to the study at hand and would thus caution against responding to the growing methodological research in this area with a decontextualised application of sample size numerical guidelines, norms and principles. Although researchers might find sample size community norms serve as useful rules of thumb, we recommend methodological knowledge is used to critically consider how saturation and other parameters that affect sample size sufficiency pertain to the specifics of the particular project. Those reviewing papers have a vital role in encouraging transparent study-specific reporting. The review process should support authors to exercise nuanced judgments in decisions about sample size determination in the context of the range of factors that influence sample size sufficiency and the specifics of a particular study. In light of the growing methodological evidence in the area, transparent presentation of such evidence-based judgement is crucial and in time should surely obviate the seemingly routine practice of citing the ‘small’ size of qualitative samples among the study limitations.

A non-parametric test of difference for independent samples was performed since the variable number of interviews violated assumptions of normality according to the standardized scores of skewness and kurtosis (BMJ: z skewness = 3.23, z kurtosis = 1.52; BJHP: z skewness = 4.73, z kurtosis = 4.85; SHI: z skewness = 12.04, z kurtosis = 21.72) and the Shapiro-Wilk test of normality ( p  < .001).

Abbreviations

British Journal of Health Psychology

British Medical Journal

Interpretative Phenomenological Analysis

Sociology of Health & Illness

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Acknowledgments

We would like to thank Dr. Paula Smith and Katharine Lee for their comments on a previous draft of this paper as well as Natalie Ann Mitchell and Meron Teferra for assisting us with data extraction.

This research was initially conceived of and partly conducted with financial support from the Multidisciplinary Assessment of Technology Centre for Healthcare (MATCH) programme (EP/F063822/1 and EP/G012393/1). The research continued and was completed independent of any support. The funding body did not have any role in the study design, the collection, analysis and interpretation of the data, in the writing of the paper, and in the decision to submit the manuscript for publication. The views expressed are those of the authors alone.

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JB and TY conceived the study; KV, JB, and TY designed the study; KV identified the articles and extracted the data; KV and JB assessed eligibility of articles; KV, JB, ST, and TY contributed to the analysis of the data, discussed the findings and early drafts of the paper; KV developed the final manuscript; KV, JB, ST, and TY read and approved the manuscript.

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Additional Files

Additional file 1:.

Editorial positions on qualitative research and sample considerations (where available). (DOCX 12 kb)

Additional File 2:

List of eligible articles included in the review ( N  = 214). (DOCX 38 kb)

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Data Extraction Form. (DOCX 15 kb)

Additional File 4:

Citations used by articles to support their position on saturation. (DOCX 14 kb)

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Vasileiou, K., Barnett, J., Thorpe, S. et al. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol 18 , 148 (2018). https://doi.org/10.1186/s12874-018-0594-7

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• P van Royen 2 ,
• 1 Lecturer in Medical Sociology, Department of Social Medicine, University of Bristol, Bristol BS8 2PR, UK
• 2 Professor of General Practice, Department of General Practice, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium
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There are no easy solutions to the problem of improving the quality of care. Research has shown how difficult it can be, but has failed to provide reliable and effective ways to change services and professional performance for the better. Much depends on the perspectives of users and the attitudes and behaviours of professionals in the context of their organisations and healthcare teams. Qualitative research offers a variety of methods for identifying what really matters to patients and carers, detecting obstacles to changing performance, and explaining why improvement does or does not occur. The use of such methods in future studies could lead to a better understanding of how to improve quality.

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Barriers and facilitators to uptake and use of oral pre-exposure prophylaxis in pregnant and postpartum women: a qualitative meta-synthesis

• Ying Liu 1 ,
• Liao Zhang 1 &
• Hong Chen 1  

BMC Public Health volume  24 , Article number:  1653 ( 2024 ) Cite this article

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Acute HIV infection during pregnancy and in the postpartum period increases the risk of vertical transmission. The World Health Organization (WHO) has recommended preexposure prophylaxis for pregnant and postpartum women at risk of acquiring HIV. However, there are significant gaps between the actual practice and the ideal goal of preexposure prophylaxis implementation among pregnant and postpartum women. Therefore, it is important to determine what influences women’s implementation of preexposure prophylaxis during pregnancy and in the postpartum period. This review aims to aggregate barriers and facilitators to preexposure prophylaxis implementation among pregnant and postpartum women.

A range of electronic databases, including PubMed, CINAHL Plus with Full Text, Embase, and Web of Science, were searched for potentially relevant qualitative studies. The search period extended from the establishment of the databases to March 16, 2023. This review used the ENTREQ (Enhancing transparency in reporting of qualitative research synthesis) statement to guide the design and reporting of qualitative synthesis. The methodological quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The JBI meta-aggregation method was applied for guiding the data extraction, and the JBI ConQual method was applied for guiding the evaluation of the level of evidence for the synthesis.

Of retrieved 2042 studies, 12 met the inclusion criteria. The total population sample included 447 participants, including 231 pregnant and postpartum women, 21 male partners, 75 healthcare providers (HCPs)/healthcare workers (HCWs), 18 policymakers, 37 mothers, and 65 women of childbearing age. A total of 149 findings with credibility ratings of “unequivocal” or “equivocal” were included in this meta-synthesis. Barriers and facilitators to preexposure prophylaxis implementation were coded into seven categories, including three facilitator categories: perceived benefits, maintaining relationships with partners, and external support, and four barriers: medication-related barriers, stigma, barriers at the level of providers and facilities, and biases in risk perception.

This systematic review and meta-synthesis aggregated the barriers and facilitators of preexposure prophylaxis implementation among pregnant and postpartum women. We aggregated several barriers to maternal preexposure prophylaxis implementation, including medication-related factors, stigma, barriers at the level of providers and facilities, and risk perception biases. Therefore, intervention measures for improving preexposure prophylaxis services can be developed based on these points.

PROSPERO Number

CRD42023412631.

Peer Review reports

Introduction

There were still an estimated 1.3 million new infections in 2022, and HIV remains a major global health issue [ 1 ]. Of those newly infected, approximately 42% are adolescent girls and women (age ≥ 15 years) [ 1 ]. Evidence has shown that pregnant and postpartum women are at up to 2 to 4 times higher risk of acquiring HIV than their nonpregnant and postpartum period [ 2 ]. Factors contributing to increased HIV susceptibility during pregnancy include increased innate and suppressed adaptive immunity, increased genital tract inflammation, alterations in vaginal microbiota, decreased vaginal epithelium integrity, and gross or microtrauma to the genital tract [ 2 , 3 ]. Furthermore, acute HIV infection during pregnancy and the postpartum period is an important reason of vertical transmission of HIV [ 4 , 5 ]. Among the causes of new HIV vertical transmission reported in 2020, acute maternal or breastfeeding infection accounted for 23% of the new vertical transmission [ 6 ]. Therefore, prevention of maternal HIV infection is crucial to eliminate vertical transmission and reduce the global HIV prevalence.

To prevent the HIV epidemic, a series of HIV biomedical interventions have been developed, including a so-called ‘test and treat’ combination, treatment as prevention, vaccination and oral pre-exposure prophylaxis (PrEP) [ 7 ]. PrEP is a highly effective biological prevention method for individuals at high risk of HIV [ 8 ]. The global adoption of PrEP has been on the rise, with over 90 countries approving it for HIV prevention by December 2022 [ 9 ]. The World Health Organization (WHO) has also recommended that PrEP is commenced for any individual at risk of HIV acquisition, including the use of PrEP for pregnant and postpartum women at risk of exposure to HIV [ 10 ]. Previous studies indicate that oral PrEP use before, during, and after pregnancy does not pose an increased risk of adverse pregnancy outcomes [ 11 , 12 , 13 ]. Despite these recommendations and several maternal health benefits, both knowledge and uptake of PrEP among pregnant and postpartum women still remain low [ 14 ]. PrEP counseling and services for cis-gender women, including those who are pregnant or postpartum, currently remain limited [ 15 ]. Even in regions with high HIV incidence, such as Africa, PrEP programs have primarily focused on men who have sex with men, and the delivery of PrEP to women during pregnancy and postpartum is still in its early stages [ 16 ].

While previous studies have investigated the experience and influencing factors of maternal oral PrEP from a single perspective, these isolated perspectives cannot comprehensively summarize the key factors affecting the implementation of maternal oral PrEP [ 17 , 18 ]. To date, researchers have not identified a published systematic review examining the factors influencing the implementation of maternal oral PrEP. Therefore, it is necessary to aggregate the barriers and contributing factors to the implementation of maternal oral PrEP from multiple perspectives. We then used a meta-aggregation approach to conduct a qualitative and systematic review of barriers and facilitators to oral PrEP in pregnant and postpartum women. Meta aggregation is grounded in the philosophic traditions of pragmatism and Husserlian transcendental phenomenology, and it is usually used to produce recommendations to guide practitioners and policymakers [ 19 ]. The purpose of this review is to aggregate the barriers and facilitators of maternal oral PrEP from multiple perspectives, and to provide intervention directions for future acceptance and implementation of oral PrEP for pregnant and postpartum women.

The protocol for this review was pre-registered with PROSPERO (PROSPERO, CRD42023412631) and followed the PRISMA and ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) conduct and reporting guidelines [ 20 , 21 ]. JBI’s meta-aggregation approach was used to guide the data extraction and synthesis, and the JBI ConQual approach was used to evaluate the evidence level of the synthesized findings [ 22 ]. This meta-synthesis of qualitative studies was conducted to aggregate barriers to and facilitators of oral PrEP among pregnant and postpartum women and to answer the following two questions: What are the barriers to oral PrEP use among pregnant and postpartum women? What factors can facilitate oral PrEP among pregnant and postpartum women?

Search strategy

We conducted searches across four databases: PubMed, CINAHL Plus with Full Text, Embase, and Web of Science. The search period extended from the establishment of the databases to March 16, 2023. The search strategies were the combination of medical subject headings (MeSH), title, abstract, keywords and Boolean operators (AND/OR/NOT). Key search terms were grouped into themes relating to HIV, oral PrEP, and qualitative study. To avoid omitting potentially relevant studies, we did not limit the participants or countries of the articles during the search process. The details of all search strategies we used are available in Supplementary Material 1 .

Eligibility criteria

The primary studies were selected following the PICoS format (participants, phenomenon of interest, context, and study design).

Studies were included if they met the following criteria:

Participants: All studies with an aim to qualitatively identify and report barriers and facilitators to oral PrEP in pregnant and postpartum women were eligible;

Phenomenon of interest: Potential barriers and facilitators to oral PrEP use among pregnant and postpartum women;

Context: We did not restrict background conditions for this review;

Study design: Qualitative research with no limitation of the methodology (i.e., phenomenology, ethnography or grounded theory method), and mixed-method studies were included if they offered clear qualitative analysis and the primary data could be extracted.

Exclusion criteria

The exclusion criteria included the following:

Review articles, conference abstracts, posters, books, and dissertations;

Studies that did not identify or discuss oral PrEP among pregnant and postpartum women;

Repeated publications;

Studies did not have available full texts, and.

Studies were not an English article.

Study selection

All retrieved articles were imported into the reference management program Endnote X9 and duplicates were removed. Two authors (Liu and Zhang) independently undertook the screening process, following the PRISMA guidelines (see Fig. 1). Two researchers (Liu and Zhang) independently screened the titles and abstracts of the studies following our inclusion criteria. Afterwards, the full text of potentially relevant studies was read to select eligible articles for inclusion in this review and meta-synthesis, and the reasons for excluded studies were classified in detail. Any disagreement in the selection process was discussed among two researchers or consultation with a third researcher (Chen) until agreement was reached.

Flow diagram of search strategy and study selection

Quality appraisal

The methodological quality of included studies was investigated via the Joanna Briggs Institute Critical Appraisal Checklist for critical and interpretive research [ 23 ]. This checklist consists of 10 items, each with four scoring criteria: “yes”, “no”, unclear or “not applicable”. If 60% of the items answered “yes”, the quality of the study was considered acceptable, 70–90% answered “yes” referred to good quality, and if 100% of the items answered “yes”, the quality of the study was high. A study was included if the item achieved a minimum of 60% “yes”. Two reviewers (Liu and Zhang) independently conducted the critical appraisal of each research synthesis selected. Moreover, discussions during a team meeting were held to resolve any disagreements.

Data extraction

Data extraction occurred in two phases. The first phase of data extraction was the extraction of general details of the study, which was conducted by the same two researchers using a pre-designed Excel spreadsheet. The following study characteristics and outcomes were extracted (1) basic study information (first author, publication year, country, research setting); (2) study design (research objectives, sample size, methods, sampling methods, data collection and analysis methods); (3) outcome measures. The second phase of data extraction is the extraction of findings. Findings were defined as verbatim extracts of the author’s analytical interpretation of the results or data. When extracting research results, levels of “credibility” should be assigned based on the reviewer’s assessment of the degree of fit or agreement between the data and the accompanying exemplar quotes. There are three levels of “credibility”. A finding was rated as “unequivocal” if the congruence of the finding and the illustration accompanied was beyond a reasonable doubt, as “equivocal” if a clear association between them was lacking, or as “unsupported” if the data did not support the findings. Only unequivocal and equivocal findings were included, and unsupported findings were not presented in the synthesis result [ 23 ]. The extracted information was validated by a third investigator (Chen), and any disagreements were discussed with a third researcher (Chen) until consensus was reached.

Data synthesis

JBI’s meta-aggregation approach was used to guide the data synthesis. This approach is grounded in the philosophic traditions of pragmatism and Husserlian transcendental phenomenology. It is a widely used method with the pragmatic aim of systematically reviewing qualitative research to generate synthesized findings that can be used to inform healthcare practice or policy, which is perfectly aligned with the purpose of this review [ 23 ]. The data synthesis was conducted using a three-stage process. First, extracting findings from the included studies (this is the second phase of the data extraction as well). Second, pooling the findings into new categories based on the similarity in meaning, and each category consisted of at least two findings. Third, developing one or more synthesized statements of at least two categories.

Quality appraisal of each synthesized finding

The JBI ConQual approach was used to evaluate the dependability and credibility of each synthesized finding [ 24 ]. Dependability was assessed using five items (items 2, 3, 4, 6, and 7) from the JBI critical appraisal checklist. Dependability was rated high if 4–5 items were appraised with “yes”, moderate if 2 to 3 items were appraised with “yes”, and low if 0–1 item was appraised with “yes”. Credibility is a rating of findings and illustrations (direct citations) in the studies. Credibility is evaluated as follows: unequivocal, equivocal, and unsupported. If most included studies in a synthesized finding had a dependability rating of high/moderate/low/, the dependability of the synthesized finding remained “high”/degraded 1 level/degraded 2 levels. The overall credibility of a synthesized finding remained “high” if it consisted of unequivocal findings, degraded 1 level if it consisted of a mixture of unequivocal and equivocal findings, degraded 2 levels if it consisted of equivocal findings, degraded 3 levels if it consisted of a mixture of equivocal and unsupported findings, and degraded 4 levels if it consisted of unsupported findings. The overall ConQual score was rated with “high”, “moderate”, “low”, and “very low”, started with “high” and was downgraded one level for every downgrade in the dependability and credibility scores.

Search results

The defined search strategy identified 3220 citations, of which 1178 articles were removed due to duplication, while 2042 potentially relevant studies were retained for further screening. Screening of titles and abstracts of remaining articles for their eligibility resulted in exclusion of 1914 obviously irrelevant records. The full texts of the remaining 128 studies were assessed for eligibility, leading to the exclusion of 116 studies that did not meet the inclusion criteria. Ultimately, 12 studies were critically appraised and included in the review. A flow diagram of the study selection process is provided in Fig.  1 .

Study characteristics

A total of 12 papers were included in the review [ 16 , 17 , 18 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. Of these 12 papers, four were described as descriptive qualitative studies, one was a mixed method study with thematic analysis of qualitative results, and the remaining seven qualitative research articles did not explicitly report the research methods. Among the 12 included studies, 11 studies conducted in Africa, with South Africa and Kenya being the most common; only one study addressed the perceptions and acceptance of oral PrEP among African American women. A total of 447 participants were enrolled in the studies, including 231 pregnant and postpartum women, 21 male partners, 75 healthcare providers (HCPs)/healthcare workers (HCWs), 18 policymakers, 37 mothers, and 65 women of childbearing age. The details of the included studies are shown in Table  1 .

Methodological quality

All studies had a clear statement of the research objectives and strong representation of the voices of participants in the studies, and had ethics approval from appropriate committees. Seven studies mentioned the location of the researcher culturally or theoretically [ 16 , 17 , 18 , 25 , 27 , 30 , 33 ]. Only five studies stated the influence of the researcher on the research [ 17 , 18 , 27 , 30 , 33 ]. The results of JBI-QARI assessment are shown in Table  2 .

Meta-aggregation

A total of 149 findings were extracted, and the barriers and facilitators to oral PrEP use were coded into seven categories, including three facilitators: perceived benefits, influence of partners with unknown serostatus, and external support, and the four barriers: medication-related barriers, stigma, barriers to the health care system, and biases in risk perception. The process of credibility evaluation and findings synthesis can be found in Supplementary Materials 2 and 3 .

Synthesized finding 1: The facilitators of oral PrEP implementation in pregnant and postpartum women

We identified three categories of facilitators of oral PrEP implementation: perceived benefits of oral PrEP, maintaining relationships with partners, and external support.

Perceived benefits of oral PrEP

Pregnant and postpartum women perceive the protective effects of oral PrEP for both pregnant and postpartum women and newborns which is a strong motivation to use oral PrEP, especially in serodiscordant couples [ 16 , 17 , 18 , 25 , 26 , 27 , 29 , 31 ]. The experience of taking oral PrEP during pregnancy and in the postpartum period and remaining HIV-free makes pregnant and postpartum women personally aware of the benefits of oral PrEP, which greatly facilitates the implementation of oral PrEP [ 34 ].

“I did not want to give birth to a child who has HIV…And, even though we used condoms, That was also another reason that motivated me to continue using Truvada [during pregnancy], that in case of anything, Truvada was going to help me during the pregnancy.” (26-year-old woman) [ 17 ].

Women can decide whether or not to initiate oral PrEP use, which gives them autonomy because there is no need to negotiate with their partner as with condom use. The use of oral PrEP reminds women of the importance of taking care of themselves and evoked their sense of responsibility and care for their life and self-worth [ 26 , 32 ].

Now when we have sex, we use condoms. Before I started PrEP, we weren’t using condoms. The pill (PrEP) encourages me to use condoms and to know that I will not end up getting infected (Woman 18–20 years) [ 26 ].

Maintaining relationships with partners

Oral PrEP is a good method to protect against HIV acquisition, particularly for HIV-negative individuals in HIV serodiscordant partnerships, those with multiple sexual partners, and those who believed their partners had ancillary partners [ 25 , 32 ]. When faced with HIV-serodiscordance, maternal initiation of oral PrEP is a way to maintain stability in their relationships and affirm their love and support for their HIV-Infected partner, which is an important facilitator of oral PrEP implementation [ 17 , 29 ]. Choosing oral PrEP can provide a woman with protection against transmission and make her feel safe when deciding to stay in the relationship.

“I was taking [PrEP] to motivate my husband to take ART. We set our medication time to be the same, so we take medicine together. I would take PrEP and he also takes ART and he would see that we are taking the drugs together.” (24-year-old woman) [ 17 ].

External support

Healthcare providers play an important role in promoting oral PrEP adherence [ 20 , 30 , 31 , 32 , 36 ]. Their attitudes toward oral PrEP significantly influence pregnant and postpartum women’s initiation and continuation of oral PrEP [ 17 , 18 , 26 , 27 , 32 ]. Healthcare workers’ active support and attention to maternal oral PrEP will promote the adherence of pregnant and postpartum women to use oral PrEP throughout pregnancy and postpartum, which greatly promotes the implementation of maternal oral PrEP [ 17 ].

“First the healthcare worker herself, the attitude of the healthcare worker, if I think it’s not a good idea, then it means I will talk less about it.”– PrEP-naïve nurse counsellor [ 33 ].

Encouragement and support from family, friends, and male partners are also important facilitators of sustained maternal oral PrEP use, especially support and encouragement from male partners [ 25 , 26 , 27 , 29 , 33 ]. Male partners play a major role in the acceptability, use, and compliance of oral PrEP [ 33 ]. The positive attitude and support of partners greatly improve the acceptance and compliance of maternal PrEP, which is also an important promoting factor for maternal oral PrEP [ 35 ]. In general, external support perceived by pregnant and postpartum women is a great facilitator for maternal oral PrEP.

“Like a woman who tells you she wants to take PrEP but wishes the husband would be there, she would have taken it.”– PrEP-experienced pharmacist [ 33 ].

“I would advise her to take [PrEP] whole-heartedly because the baby comes in contact with so many things in the womb, so you would find that you infect the baby. I would advise her to take it every day.”(Male partner, Zambia) [ 25 ].

Synthesized finding 2: The barriers to oral PrEP implementation in pregnant and postpartum women

Four categories emerged regarding the barriers to oral PrEP implementation: medication-related barriers, stigma, barriers at the level of providers and facilities, and biases in risk perception.

Medication-related barriers

Safety and side effects of oral PrEP were reported as barriers in most of the qualitative studies [ 16 , 17 , 25 , 27 , 28 , 30 , 31 , 32 ]. Pregnant and postpartum women may hesitate to take oral PrEP due to concerns about the safety of oral PrEP and the potential harm of side effects to the unborn baby and newborn. Women recognized that pregnancy symptoms and oral PrEP side effects were similar, making it challenging to distinguish between them and potentially leading to overreaction, which was seen as a potential barrier to continuing oral PrEP use during pregnancy [ 17 ].

“The pregnant woman carries a baby in her womb. You have to ask yourself, maybe this baby of mine that is still in the womb can get miscarried or die [because of taking PrEP]. Also with the woman who is breastfeeding. Maybe this child she is carrying, if she eats the drug, it can affect the baby, so they will have thoughts or concerns [about using PrEP]” (20-year-old woman) [ 17 ].

The adherence to daily pills was a big challenge of the oral PrEP implementation. Pregnant and postpartum women may frequently and intermittently forget to take their daily medication [ 29 , 30 , 33 ]. For example, a mobile lifestyle, such as leaving home, traveling, and moving, can make daily adherence to medication a challenge [ 16 , 30 ]. And medication itself is one of the barriers to maternal oral PrEP adherence. Pregnant and postpartum women may refuse to start and continue oral PrEP because the tablets are too large, they do not like taking them, or they have to take other medications simultaneously [ 16 , 30 ].

“I was traveling mostly. I would sometimes leave it [PrEP] at [my flat] and go to [my home]. I would be at my other place for maybe 4 days without taking it.” PrEP user, lower adherer, age 30 [ 16 ].

I don’t like pills, and I was also taking pills for the pregnancy. I thought these ones [PrEP] should wait because I was taking pills for the pregnancy…. I gave birth through a c-section [cesarean], so I stopped [PrEP]. I was taking pills for the operation, so I felt that they were too many. I put PrEP aside and focused on my baby and took the other pills, for the operation. (PID334, 29 years) [ 30 ].

A large proportion of qualitative studies have reported stigma as a barrier to maternal uptake of oral PrEP [ 16 , 18 , 27 , 29 , 30 , 31 , 32 , 33 ]. Misconceptions about oral PrEP are prevalent in the community, with most people not understanding the difference between oral PrEP and ARVs and perceiving people taking oral PrEP as HIV positive. Consequently, pregnant and postpartum women may refuse oral PrEP due to fear of being perceived as HIV positive [ 29 , 30 , 31 , 32 ]. Additionally, using oral PrEP could indirectly reveal the couple’s serodiscordant status. Fear of being branded as “reckless and irresponsible” for choosing to stay with partners living with HIV led women to keep their use of oral PrEP secret, which became a barrier to its utilization in pregnant and postpartum women [ 29 ].

“I cannot talk to anyone about it [PrEP] because people have different views about the drug. … yet in actual sense they have not bought the idea and even talk about you to other people telling them you are HIV positive” (under 20 years old, stable on PrEP, not pregnant). [ 32 ]

“The problem of sharing such things with others is that if I tell them, they will get to know that my husband has HIV… They will think I am reckless and irresponsible.” – Female, age 26, Low adherence (#102). [ 29 ]

Barriers at the level of providers and facilities

Lack of health care resources was seen as a barrier to maternal oral PrEP implementation, which comprised of lack of human resources, lack of financial resources [ 25 , 30 , 32 , 33 ]. For health care providers, maternal oral PrEP is complex and requires time spent counseling pregnant and postpartum women about the drug itself, risks, and adherence, increasing workload in an already overburdened clinical setting [ 33 ]. Not only that, but oral PrEP providers also described ambiguity in the definition of risk and lack of clarity on oral PrEP eligibility when prescribing oral PrEP, which is also a potential problem as a barrier to oral PrEP implementation [ 29 , 32 ].

… I haven’t reconnected with PrEP services because my baby and myself are no longer attending here in this clinic, I take my baby to a different facility for postnatal care and there hasn’t been any conversation about the PrEP service so I won’t know whether they offer it or not. (PID199, 28 years) [ 30 ].

Biases in risk perception

The majority of studies reported pregnant and postpartum women had insufficient knowledge of sexual health related to HIV self-risk perception [ 16 , 26 , 29 , 32 , 33 ]. HIV self-risk perception refers to the individual’s perception of the possibility of being infected with HIV based on knowledge and behavior [ 36 ]. Pregnant and postpartum women who are clinically at high risk of HIV infection perceive themselves to be at low or no risk, but in reality, a lack of knowledge about their partner’s HIV status, coupled with suspicion of partner infidelity and most women not using condoms during sex, puts most women at high risk of HIV infection [ 33 ]. The discordance between self-perceived and actual risk may pose a challenge to the implementation of maternal oral PrEP.

“The perception of the woman … Do they feel they are at risk? What kind of relationship do they have with their partner and especially about HIV because you see that perception is what will drive the appearance and what [will] drive their commitment to use of PrEP.”– PrEP-experienced community health worker [ 33 ].

“[W]hen you counsel somebody who is not sick, it’s difficult. Like . you are telling me you want to prevent and but am not sick so I ask, ‘Why do you want to give me medication and am not sick?”– PrEP-experienced nurse counsellor [ 33 ].

Quality appraisal of synthesized findings

The quality appraisal of the synthesized findings is presented in Table  3 . The overall ConQual score of all three synthesized findings was rated as “low”.

We conducted a qualitative meta-synthesis that included qualitative studies and a mix of studies reporting qualitative findings, aiming to uncover the barriers and facilitators that pregnant and postpartum women encounter when initiating and adhering to oral PrEP. Our findings indicate that several factors drive maternal oral PrEP use and adherence, including the perceived benefits of oral PrEP, maintaining relationships with partners and receiving external support. Notably, pregnant and postpartum women are highly motivated to initiate and consistently adhere to oral PrEP usage due to their desire to protect themselves from infection and give birth to an HIV-negative child. We also identified several challenges that participants encountered in initiating or consistently adhering to their oral PrEP regimen. These include concerns about drug safety and side effects, stigma surrounding oral PrEP use, provider-and-facility-level barriers, as well as biases in risk perception. Given the limited research on oral PrEP in pregnant and postpartum women, our findings may contribute to a deeper understanding of the barriers and facilitators to initiating and adhering to oral PrEP during pregnancy and in the postpartum period with high risk of infection, thereby providing support for future pregnant and postpartum women who receive oral PrEP.

Our findings indicated that perceived benefit was an important contributing factor to the implementation of maternal oral PrEP. Studies have shown that the benefits of protecting themselves and their babies from HIV infection are an attractive option for pregnant and postpartum women when explaining oral PrEP to women without knowledge or experience of oral PrEP [ 17 ]. In addition, multiple negative HIV testing results also make pregnant and postpartum women feel the benefits of oral PrEP and promote their adherence to oral PrEP [ 32 ]. Previous studies have shown that women are more motivated to address some health issues during pregnancy, and hence, motivation to take oral PrEP during pregnancy may be high, especially among high-risk women with unknown partner serologic status or HIV carriers [ 37 , 38 , 39 , 40 ]. To increase the perceived benefits of oral PrEP for pregnant and postpartum women, oral PrEP counseling should be offered to raise awareness of the advantages of oral PrEP for pregnant and postpartum women and increase their motivation to use this preventive measure [ 41 ].

Moreover, our finding of this systematic review was that external support had a large impact on promoting maternal oral PrEP implementation and adherence. A supportive environment, especially support from healthcare providers and partners, plays an important role in facilitating oral PrEP implementation [ 42 ].A positive and supportive attitude from these providers may significantly improve the implementation and compliance of PrEP for pregnant and postpartum women [ 17 , 18 ]. At the same time, disclosing PrEP use to family and friends and obtaining support from them may improve maternal PrEP adherence. Moreover, in the context of a patriarchal society, if the partner expresses a positive and supportive attitude towards the implementation of maternal PrEP, the maternal attitude towards PrEP may be more positive and the compliance may be higher [ 35 , 43 , 44 ]. A supportive environment may inspire maternal confidence in oral PrEP [ 29 ]. This provides an important entry point to address maternal oral PrEP implementation and adherence, for example, encompassing the involvement of their parents or partners in oral PrEP promotion and health education initiatives, extending beyond solely targeting pregnant and postpartum women [ 45 ].

This review found that certain characteristics of oral PrEP pills may be barriers to the implementation of maternal oral PrEP. Foremost among these are concerns about the safety and side-effect profile of oral PrEP. Pregnant and postpartum women faced the challenge of distinguishing between normal pregnancy symptoms and oral PrEP-related side effects. They were concerned that the observed side effects might be a danger sign for oral PrEP-exposed infants, which greatly reduced the willingness to use oral PrEP [ 46 , 47 ].Therefore, to alleviate maternal concerns about the side effects and safety of oral PrEP, medical providers should prioritize initiating early and frequent discussions with pregnant and postpartum women at high risk of HIV exposure, thoroughly explaining its safety profile, potential side effects, and providing informational support to enhance their awareness [ 48 ].

Furthermore, this review identified stigma against oral PrEP as a barrier to maternal oral PrEP implementation. Lack of knowledge about oral PrEP makes it difficult for the community to correctly distinguish between oral PrEP and antiviral therapy [ 49 ]. Pregnant and postpartum women may refuse oral PrEP for fear of being identified as HIV-positive individuals. Additionally, oral PrEP use may indirectly expose couples’ serodiscordant status, and the choice to stay with an HIV-infected partner for fear of being labeled “reckless and irresponsible” leads women to keep oral PrEP use secret, which may affect adherence [ 29 ]. According to the available literature, long-acting injectable PrEP has been found to potentially enhance adherence to HIV prevention measures among pregnant and postpartum women who face stigma associated with oral PrEP [ 50 ]. However, this approach should be complemented with additional strategies, encompassing community-based interventions that incorporate media and educational initiatives, as well as the active engagement of male partners in HIV prevention and education efforts [ 51 , 52 ].

Our study found that a heavy healthcare burden is also a barrier to maternal prevention. For maternal oral PrEP services to be implemented, additional resources at the facility level are needed to ensure effective delivery of prevention, which include additional funding for provider training (clinical and operational), oral PrEP-specific information, education, and communication materials for clinic attendees, effective ways to promote adherence, and more. In addition, due to the lack of guidelines for screening women for oral PrEP, many healthcare providers have gaps in knowledge regarding eligibility review and risk assessment, and they are uncertain how to assess oral PrEP eligibility for pregnant and postpartum women [ 33 ]. To address this gap, it is imperative to provide healthcare providers administering oral PrEP with comprehensive training on its safety, efficacy, and proper prescription methods for pregnant and postpartum women [ 53 ]. Moreover, the integration of oral PrEP services into routine ANC clinics presents a chance to alleviate the current medical strain. A recent study underscores the potential of this integration to not only mitigate HIV incidence among pregnant and postpartum women, significantly decreasing perinatal transmission of HIV, but also to influence the overall HIV incidence rates [ 54 ].

At the same time, our study also found that there was a significant discrepancy between the perceived risk of self-HIV infection and the actual risk, which was a barrier for maternal oral PrEP implementation. In a Kenyan study among adolescent girls and young women (AGYW), 43% of those with at least one risk factor for HIV acquisition who did not initiate oral PrEP because they did not perceive themselves to be at risk [ 55 ]. Self-perceived risk and actual risk are not always congruent, pregnant and postpartum women often underestimate their risk of HIV infection, which seriously hampers the implementation of maternal oral PrEP. Future interventions should prioritize counseling services that effectively guide pregnant and postpartum women to conduct HIV risk self-assessments, thereby enhancing their risk perception regarding oral PrEP [ 56 ]. However, how to align maternal risk perception with their actual risk is not fully understood, and this may require more research [ 56 ].

Potential limitations to this qualitative systematic review relate to the challenges in identifying all relevant studies. First, the search was completed on 16th March 2023, and studies completed after this date were not included in this review. Second, we only included studies published in English, which may suggest that potentially relevant studies conducted in countries where English is not the predominant language may be missed. Third, although the included studies were all of good quality, almost all the included studies did not report the statement locating the researcher culturally or theoretically and the influence of the researcher on the research, which may weaken the overall quality of the evidence.

Implications for future research and practice

To facilitate future oral PrEP implementation among pregnant and postpartum women and achieve the goal of eliminating mother-to-child transmission, future research and practice should:

Carry out health education activities and popularize oral PrEP knowledge to improve awareness and address oral PrEP-related social stigma.

Emphasize the important role of male partners in the implementation of maternal oral PrEP, we cannot ignore the positive impact of external support on pregnant and postpartum women and create a supportive environment for them.

Increase human resources and financial investment and eliminate structural barriers to obtaining oral PrEP.

Provide pregnant and postpartum women with choices of modalities for oral PrEP treatment.

This review integrated the barriers and facilitators to maternal oral PrEP implementation during pregnancy and in the postpartum period following the JBI’s meta-aggregation approach. The studies we reviewed identified several common barriers to oral PrEP implementation including medication-related barriers, stigma, barriers at the level of providers and facilities, and biases in risk perception. Future initiatives to address barriers to maternal oral PrEP access could be based on reference to our findings.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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This study was supported by the Sichuan Science and Technology Program. (Award ID: 2023YFS0045)

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YL, LZ, and HC contributed to the conception and design of the study and wrote the first draft of the manuscript. YL, LZ, and HC contributed to the literature search and screening, analysis, and interpretation. All authors contributed to manuscript revision and approved the submitted version.

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Liu, Y., Zhang, L. & Chen, H. Barriers and facilitators to uptake and use of oral pre-exposure prophylaxis in pregnant and postpartum women: a qualitative meta-synthesis. BMC Public Health 24 , 1653 (2024). https://doi.org/10.1186/s12889-024-19168-4

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Research Article

A qualitative content analysis of cannabis-related discussions on Reddit during the COVID-19 pandemic

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

Affiliation Department of Health Promotion and Behavioral Sciences, UTHealth Houston School of Public Health, Houston, Texas, United States of America

Affiliation Department of Public Health, Purdue University, West Lafayette, Indiana, United States of America

Roles Validation, Writing – review & editing

Affiliation School of Social Work, University of Minnesota-Twin Cities, Saint Paul, Minnesota, United States of America

Roles Conceptualization, Data curation, Writing – original draft, Writing – review & editing

Roles Conceptualization, Formal analysis, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

• Hannah Reygaerts, 
• Sidney Smith, 
• Lynette M. Renner, 
• Yumary Ruiz, 
• Laura M. Schwab-Reese

• Published: June 6, 2024
• https://doi.org/10.1371/journal.pone.0304336
• Reader Comments

Social media has become an increasingly important way to seek and share experiences, support, knowledge, and advice during the COVID-19 pandemic. Reddit, a pseudonymous social media platform, was one way that young people interacted during the pandemic. Our study goals were two-fold: (1) to categorize information sought and provided by users of r/saplings, a subreddit devoted to cannabis use and is often used by young people, and (2) to examine if conversations changed during the COVID-19 pandemic. We extracted 213 randomly selected posts and 2,546 related comments across four time periods (before the pandemic, during the first wave, summer, and next fall). We assessed the volume of posts and comments throughout our study period and conducted a qualitative content analysis. Quantitatively, the findings demonstrated an increase in the number of posts and comments throughout the study period. Given the substantial growth in subreddit activity throughout our study period, Reddit may play an increasingly important role in youth socialization related to cannabis. From the content analysis, we identified three major themes: how to acquire cannabis, how to use cannabis, and associated consequences. Reddit-users prioritized certain content in their posts at different stages of the pandemic. ‘Places to acquire’ and ‘future use’ were most common at the beginning of the pandemic, while the theme of ‘consequences’ and the topic of ‘tolerance’ became more prominent during the summer months. The comments to these posts were generally thorough and responsive to the post. Nearly all the information came from opinions or personal experiences. Firstly, our findings suggest that young people viewed Reddit as a viable outlet for conversations about cannabis. Secondly, due to the nature of the peer comments and lack of verifiable information being exchanged, misinformation may still circulate and inadvertently worsen the efforts to reduce cannabis-related harm. Interventions that provide understandable and accurate cannabis-related information in accessible formats may increase young people’s ability to access and practice harm reduction.

Citation: Reygaerts H, Smith S, Renner LM, Ruiz Y, Schwab-Reese LM (2024) A qualitative content analysis of cannabis-related discussions on Reddit during the COVID-19 pandemic. PLoS ONE 19(6): e0304336. https://doi.org/10.1371/journal.pone.0304336

Editor: Lakshit Jain, University of Connecticut Health Center: UConn Health, UNITED STATES

Received: August 1, 2023; Accepted: May 10, 2024; Published: June 6, 2024

Copyright: © 2024 Reygaerts et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Posts and comments are available at: https://doi.org/10.6084/m9.figshare.23654499.v1 .

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

For many people, the various COVID-19 safety measures and subsequent disruptions to daily life led to increased psychological distress (e.g., anxiety, depression) [ 1 – 9 ] and maladaptive coping behaviors (e.g., substance use) [ 10 – 12 ]. Some of the disruptions experienced by children and youth included social isolation, school closures, and loss of routine and healthy outlets [ 13 – 16 ]. In June 2020, approximately 25% of individuals aged 18–24 in the United States reported initiating or increasing substance use to cope with pandemic-related stress or emotions [ 10 ], which is consistent with prior research following man-made and natural emergencies in various populations [ 17 – 22 ].

Due to limited in-person social opportunities, many adolescents turned to social media to cope with feelings of loneliness and reconnect with like-minded individuals [ 23 – 25 ]. Social media offers a means to interact with others and to seek and share experiences, support, knowledge, and advice [ 26 , 27 ]. Specifically, pseudonymous media platforms allow users to control self-presentation and self-disclosure, reducing the likelihood of offline harm [ 27 , 28 ]. These features likely enhance users’ comfort when discussing sensitive topics, such as drug use and mental health [ 25 – 27 ]. Many users share their experiences via social media to seek support, while others ask for advice or share experiences to establish credibility [ 29 ]. Thus, these spaces provide a window into people’s experiences and perceptions of these topics [ 30 , 31 ].

Despite its popularity and users’ reliance on it for information and support, social media has been found to be a primary source of misinformation and unsubstantiated claims on health topics [ 32 ]. Recent policy changes in several countries, including the United States, have loosened restrictions on cannabis, making it easier to access and use. While cannabis-users report using it for fun and experimentation, individuals who are new to cannabis may want to use it for various other reasons, such as alleviating anxiety, depression, insomnia, or chronic pain [ 33 ]. These individuals may have a plethora of questions regarding the substance, ways to use it, dosing, and more. Because some negativity surrounding cannabis use persists regardless of policy changes [ 34 ], individuals may use pseudonymous social media platforms as a primary source to address their questions [ 35 ].

Even though cannabis use on its own is not directly associated with death [ 36 ], its use is associated with adverse health effects such as increased risk of cardiovascular disease mortality, reduced cognitive function, and increased neuropsychiatric effects, especially among those who are underage [ 37 , 38 ]. Furthermore, cannabis may also interact with other medications. As with any substance, it generates concerns such as driving under the influence and dependency. Cannabis use disorder is a particular concern among youth with mood disorders as it has been associated with heightened risk of nonfatal self-harm, homicide, death by unintentional overdose, and all-cause mortality [ 39 ]. The misinformation posted to social media may also perpetuate positive health claims about cannabis and the denial of associated dangers to cannabis use, which can further harm young people.

Reddit ( https://www.reddit.com/ ) is one social media platform used by young people. On Reddit, users create pseudonymous usernames and interact with others by creating or commenting on posts within topic-driven communities called “subreddits.” Researchers have utilized Reddit to understand users’ experiences with mental health and substance use [ 29 , 40 – 47 ]. Recently, several studies have demonstrated that subreddits without age restrictions (i.e., forums not specifically encouraging or forbidding minors) are a rich source of information and discussion on sobriety, harm reduction, and other substance use-related topics. For example, one recent study demonstrated that people experiencing substance use-related stigma seek support on Reddit [ 48 ]. Fentanyl, a synthetic opioid that increases the risk of overdose and mortality, is also commonly studied on Reddit. One study found that Reddit was used to discuss harm reduction strategies and anxieties related to fentanyl-contaminated oxycodone [ 48 , 49 ], while a second focused on a fentanyl-specific subreddit that found that quality of life impairment, polysubstance use, and tolerance/dependence/withdrawal were the most commonly discussed topics [ 50 ]. One study specifically focused on how Reddit could provide insight into the lived experiences of substance use during the pandemic [ 51 ]. They found across four substance use-related subreddits that pandemic-specific stressors, limited formal support, disruptions to coping strategies, and access to illicit and prescription drugs were commonly discussed [ 51 ].

Adolescents have been shown to post on mental health-related subreddits more often during the COVID-19 pandemic events compared to prior to these events [ 25 ]. However, few studies have focused on adolescents’ Reddit use for substance use information and help-seeking, and those that have were primarily focused on e-cigarette use [ 52 – 54 ]. Questions remain about what information young people seek pertaining to cannabis via Reddit and whether the type of information sought changed due to the COVID-19 pandemic.

Thus, we sought to understand if and how people use r/saplings, an adolescent-focused subreddit, to discuss cannabis. The study goals were two-fold: (1) to categorize information sought and provided by users of r/saplings and (2) to examine if r/sapling conversations changed during the COVID-19 pandemic. Because many in-person interactions were restricted throughout the COVID-19 pandemic, social media may play a more prominent role in young people’s cannabis-related socialization. Thus, this study may provide important insights into the type of information sought and provided by young people about cannabis. Further, we identify if these interactions changed throughout the pandemic, which may provide additional insights into how young people coped with pandemic-related stressors.

Material and methods

Data collection and sample.

In December 2020, we extracted all posts (N = 6,584) and comments (N = 63,269) from r/saplings from October 1, 2019, to October 31, 2020. We obtained our data using Pushshift API, a software interface that archives all posts and comments at the time of submission to Reddit [ 55 ]. We chose r/saplings due to its connection with the subreddit r/trees. r/trees is a large, active subreddit surrounding cannabis discussion. This subreddit enforces a set of rules to protect their community and includes a rule that prohibits posting by minors (18 years and younger) ( https://www.reddit.com/r/trees/ ) [ 56 ]. From r/trees’ Rules, minors are directed to post on r/saplings instead, a subreddit described as “a place to learn about cannabis use and culture” ( https://www.reddit.com/r/saplings/ ). It is estimated that r/saplings had 53,000 members in October 2019 and 62,000 members in October 2020, as listed on the r/saplings page.

To identify a feasible sample for content analysis, we randomly selected one post per day during four different times: 1) Pre-pandemic (October 1, 2019, to October 31, 2019, and February 1, 2020, to February 29, 2020) to capture posts prior to the pandemic; 2) First Wave (March 1, 2020, to April 30, 2020) to capture posts when lockdown was in place for most countries; 3) Summer (June 1, 2020, to July 31, 2020) to capture posts as lockdown orders were being lifted; and 4) Next School Year (October 1, 2020, to October 31, 2020) to capture posts when young people were returning to school with some COVID-19 safety measures implemented at many institutions. This timeframe was determined according to a couple of deciding factors. In 2020, most Reddit website traffic came from the United States (U.S.) [ 57 ]. Therefore, COVID-19 events as they unfolded in the U.S. and were reported by the World Health Organization (WHO) were used to pinpoint which months related to which phases of the pandemic [ 58 ]. Since not all major pandemic-related events happened within the same day for some countries, additional months were selected to capture possible variation.

Furthermore, we examined the conventional school schedules of the top ten countries that visited Reddit.com in 2020 to identify which months most often correspond to active school sessions. Since data was collected in December 2020, only October 2020 was selected for ‘Next School Year’, allowing for potential comparison between ‘Pre-pandemic’ and ‘Next School Year.’ This approach yielded a total of 213 posts and all related comments. Posts and comments removed by Reddit moderators or posters before data collection were not replaced.

Data analysis

First, we plotted the overall number of posts and comments made each month to identify how the number of posts and comments changed during our study period. Then, using the randomly selected dataset described in the Sample section, we conducted a qualitative content analysis using an adaptation of grounded theory to develop the codebook [ 59 ]. First, three coders (all of whom are co-authors) independently reviewed all content from the 213 posts and related comments ( n = 2,546) from r/saplings. Then, we discussed potential patterns during a second review, concentrating on recurring themes and areas of divergence across conversations to draft the initial codebook. After finalizing this draft, we applied the codes to 10% of the dataset and compared the results. We refined the codebook to increase intercoder reliability and ensure the representation of relevant materials. We repeated this process until we reached 90% agreement across all coders and then coded the entire dataset.

To analyze the coded materials, we conducted bivariate analyses to examine changes in the quantity and content of posts and comments across the four time periods. Although we considered applying statistical inference tests, the nuance within our coding structure created very small cell sizes, substantially reducing the tests’ power and interpretability. We also reviewed the materials within each code to identify representative quotes. We paraphrased these quotes, which is in line with ethical guidance and recent conventions when using Reddit data which are in place to reduce the risk of reverse identification [ 60 ].

Ethical issues

We only used publicly available information in this study and complied with the terms and conditions during data collection. Reddit is a pseudonymous platform, meaning individuals may be identified across time through usernames, but their true identity is unknown. The Purdue University Institutional Review Board determined this work was exempt from informed consent, which is consistent with generally accepted ethical guidelines [ 61 , 62 ].

The number of posts and comments on r/saplings increased substantially throughout the study period ( Fig 1 ). Posters generally sought advice about cannabis, although some shared their experiences or asked about the experiences of others ( Table 1 ). Eighty-five percent of comments were made by users other than the original poster or the user who created the initial post. Most comments contained detailed, relevant information or follow-up questions.

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https://doi.org/10.1371/journal.pone.0304336.g001

https://doi.org/10.1371/journal.pone.0304336.t001

We identified three broadly defined themes among posts: (1) how to acquire cannabis, (2) using cannabis, and (3) related consequences ( Table 2 ). Within the theme of ‘acquiring’, users posted content focused on people (e.g., dealers, friends, family), places (e.g., physical locations) (n = 31), and means (e.g., buying, receiving as a gift, stealing) for obtaining cannabis (n = 21), and few posters asked about growing cannabis. The majority of posts involved using cannabis (i.e., the ‘using’ theme) (n = 212), and many posters shared or asked for advice about past (n = 64) or future experiences (n = 83). They often wanted to know if their experiences while high were normal. Posters who recently began using or changed their method of use (e.g., changing from edibles to vaping) inquired about dosage and how to increase the intensity of their high. Others had questions about equipment, the appearance of cannabis, or tolerance. Additionally, some posters shared or asked advice on consequences (i.e., the ‘consequences’ theme), such as cannabis’s effects on health and safety, employment, eviction, or getting in trouble with parents at 48 posts out of 213. Health questions were often related to early age initiation or combining cannabis with prescription medication (e.g., anxiety medications). Sometimes, users specifically discussed how the pandemic was influencing their cannabis use (‘ my parents are staying home due to COVID-19 which sucks because I can’t smoke now )’. Pandemic-focused posts were most common in the conversations about acquiring cannabis (i.e., previously bought at school or public places), although they also came out in conversations about cannabis use.

https://doi.org/10.1371/journal.pone.0304336.t002

Users were responsive to posts, with an average of 12.0 ( sd = 20.2) comments per post. One post received over 200 comments, and only 25 (11.7%) posts received no comments. Generally, comments were thorough and responsive to the materials shared in the post. Most often, the comments were based on opinions or personal experiences. Although rare, some referenced or directed individuals to other sources (e.g., YouTube, websites); of these, only two comments referenced a credible source (e.g., public health department).

The types of posts and comments remained relatively stable over time (Tables 2 and 3 ). However, there were some meaningful changes. Almost 10% of pre-pandemic posts referenced growing cannabis, compared with less than 3% during other periods. Conversely, posts about possible sources and ways to acquire cannabis became far more common during the pandemic. This increase was especially noticeable between the pre-pandemic and first wave time points (e.g., 4 versus 12 posts for places to acquire, and 3 versus 8 posts for ways to acquire). Discussing places to acquire and future use was common across all periods but was particularly prominent during the first wave of the pandemic and the fall of 2020. Tolerance-related conversations were highest during the summer with six posts, and lowest during the first wave and the fall with 4 and 1 post. Consequences also became the focus among posts in the summer months.

https://doi.org/10.1371/journal.pone.0304336.t003

Our first aim was to categorize information sought and provided by Reddit users on r/saplings and identified three broadly defined themes among posts: (1) how to acquire cannabis, (2) using cannabis, and (3) related consequences ( Table 2 ). Throughout the study period, users discussed various aspects of acquiring, using cannabis, and consequences of using marijuana. Typically, they received detailed, on-topic responses to their questions, indicating a level of social support. Some of our findings in r/Saplings are similar to the work of Costello 29 on r/trees, a subreddit meant for older individuals and cannabis. Users tended to disclose various information about their Cannabis use (e.g., dosage, ways to use cannabis), and while they discussed ‘tolerance,’ we also did not encounter ‘addiction’ as a topic. Lastly, most comments included advice and instructions similar to r/trees. A proportion of comments were in the form of follow-up questions in order to tailor responses, though most of the advice and instruction came from personal experiences and opinions. While some banter was present, which was coded as ‘Other,’ commenters ultimately formed a sense of camaraderie by providing support in the comments. Other prior work has similarly demonstrated that young people use social media as an important source of information and support about sensitive topics [ 27 – 29 , 47 , 63 ]. Given the increase in subreddit activity and engagement, Reddit may play an increasingly important role in socialization related to cannabis.

Our second aim was to assess the impact of the COVID-19 on Reddit conversation topics and whether certain themes were prioritized. Places to Acquire, Ways to Acquire, Future use, and Equipment related topics rose in volume by the first wave of the pandemic compared to before the pandemic. At this time, only the theme of consequences remained the same, and the remaining topics declined in volume. ‘Places to acquire’ and ‘future use’ were most frequently discussed during the first wave. The first wave includes the timeframe in which stringent COVID-19 mitigation measures such as stay-at-home orders and closures were put in place. In addition, national data found that youth’s substance use declined during the pandemic. Therefore, our findings suggest that adolescents seemingly struggled to locate cannabis and find in-person resources, thus turning to social media platforms such as Reddit. Our work also supports this latter statement quantitively. The number of posts and comments on r/saplings increased during our study period, from before the COVID-19 pandemic until after its onset. This finding is consistent with prior research, which found increased social media use among youth during the pandemic [ 23 – 25 ]. Altogether, our findings suggest that users turned to social media, including Reddit, and viewed Reddit as a viable outlet for conversations and resource about cannabis.

The theme of Consequences and tolerance became much more prominent during the summer months. During this time, most posts focused on maximizing the pleasant experience while minimizing negative consequences. Although some explicitly framed the conversations around safety (e.g., medication interactions, safe dose), others discussed safety more implicitly (e.g., tolerance issues, avoiding panic attacks). Notably, as of early June, COVID-19 restrictions eased due to available testing, news on vaccination circulated, ‘bubble arrangements’ were endorsed, quarantine requirements were less stringent, and some countries opened their borders [ 64 , 65 ]. Even prior to the pandemic, our findings demonstrated that users wanted information and support on how to use cannabis safely.

Other studies have similarly demonstrated that social media is not only a valuable source of information but also provides support for harm reduction and recovery [ 66 , 67 ]. Nevertheless, r/saplings may not always be an adequate source of confirmable information on cannabis. Although several posts specifically asked for ‘experts,’ nearly all information provided was based on opinion or personal expertise, which could still have been rooted in misinformation regarding cannabis use. Most users provided support via leaving detailed and engaged comments, however, commenters without medical backgrounds may unintentionally spread misinformation (e.g., inaccurate medical information, provide information from unidentifiable online sources) and potentially leave detrimental opinions (e.g., original poster worried about drug interactions should ‘give it a try’ and ‘see what happens’). Thus, while there is still great value in lived peer experience within the realm of harm reduction [ 68 ], this type of information exchange may result in users not always receiving accurate and verifiable harm reduction information and may lead to worse unintended consequences. Interventions that provide understandable and accurate information in accessible formats may increase young people’s ability to access and consequently practice harm reduction strategies. Due to Reddit’s pseudonymous nature and format, it may be one possible tool in such interventions.

There are limitations to consider when interpreting our work. Reddit is pseudonymous, so we do not know who is using r/saplings or their demographic information. Additionally, even though directed to minors, users who are not minors can still post and comment on r/saplings. As such, our findings may not be confined to only represent posts and comments made by people aged 18 or younger. Further, as a qualitative content analysis, all posts and comments could not be incorporated. Although we randomly selected posts to increase the sample’s representativeness, computational analyses of all conversations may identify additional information. Another limitation is ‘chatbots’ and third-party influences, as both can manipulate online conversations and skew perceptions. However, their influence was limited in our data set since obvious bot-content was coded as ‘Other.’ Our data may still be subject to influence from individuals involved third parties promoting cannabis products. Despite these limitations, our work contributes to the small body of work about young people’s discussions about cannabis during COVID-19. Our findings suggest that young people want to reduce harms associated with cannabis use and may be open to harm reduction information if shared on platforms with like-minded individuals in an easily accessible format.

Acknowledgments

The study team would like to thank Dr. Jeremy Foote and Kendyl Griffith. Dr. Foote helped the team retrieve the Reddit post and comment data. Ms. Griffith helped with early drafts of the coding framework and literature review.

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The value of qualitative methods to public health research, policy and practice

Institute of Mental Health, University of Nottingham Faculty of Medicine and Health Sciences, Triumph Road, Nottingham NG7 2UH, UK

A O’Caithain

The University of Sheffield, Sheffield, UK

Sheffield Hallam University, Sheffield, UK

This article reviews the role and use of qualitative methods in public health research.

‘Signs of quality’ are introduced to help guide potential authors to publish their qualitative research in public health journals. We conclude that high-quality qualitative research offers insights that quantitative research cannot. It is time for all public health journals to recognise the value of qualitative research and increase the amount that they publish.

Introduction

In this article, we briefly review the role and use of qualitative methods in public health research and its significance for research, policy and practice. Historically, public health research has been largely dependent on quantitative research rooted in medical science. Qualitative research approaches, however, are able to provide the ‘lived experience’ perspective of patients, practitioners and the public on any aspect of public health.

To inform this article, we searched the most recent original research articles published in ten of the most widely cited public health journals in the world (generally those with the highest impact factor, including Perspectives in Public Health ). The list of journals can be found in Table 1 .

The methods used in 100 recently published original research articles in 10 public health journals

We examined 100 of the most recently published original research articles (10 from each journal up until May, 2021) to discover how many of these reported qualitative methods. The findings from this quick review can be found in Table 1 below. The review revealed that 85 articles reported quantitative methods, 11 reported mixed-methods, and only 4 reported qualitative methods. In our review, we deliberately did not include one public health journal, Critical Public Health because it specialises in publishing qualitative public health research studies. With only four qualitative research papers out of the most recent 100 public health original research articles published in the top journals, we have decided to publish this article first to encourage qualitative research practices in public health, second to highlight the value of qualitative research, third to briefly identify what makes ‘good qualitative research’ and finally to promote increased submissions of original qualitative research in this and other public health journals.

Reporting Qualitative Health Research

Qualitative research has its origins in Interpretivism. As such, it has been widely used in the social sciences, in contrast to the medical sciences that historically have largely embraced the positivist tradition. Typically, public health research has followed the positivist tradition although qualitative research methodology appears more often in public health journals than top medical journals. For example, a cursory examination of the Lancet indicates that it does not appear to publish any qualitative research and the British Medical Journal ( BMJ ) rarely does so. In 2016, the BMJ published an open letter from 76 senior academics from 11 countries inviting its editors to: ‘ … reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission ’. 1 Included in their support for qualitative research articles in the BMJ , they observe that many of the journal’s top papers have been qualitative studies. This letter has been cited 250 times in the literature, largely supportive of their views. In their reply to the letter, Editors of the BMJ acknowledge that: ‘ … we agree they can be valuable, and recognise that some research questions can only be answered by using qualitative methods ’. 2 In so much as we can tell to date, the BMJ has not changed its practice. Fortunately, published accounts of qualitative research in various other health disciplines flourishes, for example, there are now at least two health journals that are exclusively designed for this purpose ( Qualitative Health Research and International Journal of Qualitative Studies on Health and Well-being ).

The Value of Qualitative Health Research

The following quotation succinctly argues the need for qualitative research methods in public health:

Public health, we believe, needs both epidemiology and qualitative research. Without epidemiology we cannot answer questions about the prevalence of and association between health determinants and outcomes. Without qualitative enquiry, it is difficult to explain how individuals interpret health and illness in their everyday lives, or to understand the complex workings of the social, cultural and institutional systems that are central to our health and wellbeing. 3

In particular, given a situation with complex phenomena involving human experience and behaviour, quantitative research may equally excel in finding out ‘what and when?’, but qualitative research may equally be needed to find out ‘why, how and how come?’. Green and Britten 4 summarise the role of qualitative research in health, and we have adapted their key points to apply to public health:

• Qualitative methods can help bridge the gap between scientific evidence and public health policy and practice by investigating human perceptions and experiences.
• Recognising the limits of quantitative approaches and that different research questions require different kinds of research.
• Qualitative research findings provide rigorous and firsthand accounts of public health educational, promotional and clinical practices in everyday contexts.
• Qualitative research can be used to help inform individual health choices and health promotion initiatives within communities.

Doing High-Quality Qualitative Research

Quality is unlikely to be the only reason that so little qualitative research finds its way into public health journals; even research articles of the highest quality may be met with resistance from reviewers and editors. Nonetheless it is important to attend to quality. Articles using qualitative methods require the same rigour as articles reporting quantitative methods; however, the criteria for assessing rigour are different. When assessing qualitative articles, we need to remember that what is considered rigorous in the social sciences is not necessarily the same as what is considered rigorous in the medical sciences and vice versa. Either way, what is important is that public health journals publish high-quality research studies, whatever methodology is employed. The following quotation is helpful in focusing on the need for rigour in qualitative approaches to healthcare research:

The use of qualitative research in health care enables researchers to answer questions that may not be easily answered by quantitative methods. Moreover, it seeks to understand the phenomenon under study in the context of the culture or the setting in which it has been studied … (however this) … requires researchers in health care who attempt to use it, to have a thorough understanding of its theoretical basis, methodology and evaluation techniques. 5

As quoted above, Al-Busaidi, 5 asserts that qualitative health researchers need an appreciation of theory and methodologies and use of both in all research and evaluation studies. What is most important in any qualitative study is that the research question is clear and the method is appropriate to answer the research question. We can therefore begin to ask critical questions of any qualitative article submitted for publication in public health journals:

• Is the research question clear?
• Is the method appropriate for addressing the research question?
• Is there an explanation as to how and why this method is appropriate?
• What are the theories referred to in this study and how are these applied?
• Are these theories consistent throughout the study?
• Has the sample been critiqued to make readers aware of who is not included and how this might affect findings?
• Is the analysis grounded in the data?
• Does the analysis address questions of the data so that insights are identified that go beyond simply describing what participants have said?
• Are there clearly articulated implications for public health practice?

In addition to these fundamental questions, to help researchers report qualitative research, there are two frameworks that help to maintain standards for the conduct and reporting of the method. The first is COREQ (Consolidated criteria for reporting qualitative research). 6 This is a 32-point checklist of three domains: research team and reflexivity, study design and analysis and findings. The second is Standards for Reporting Qualitative Research (SRQR), 7 which is a 21-point check-list following the same format. Together, these are both useful tools for helping researchers think about what they need to consider when conducting qualitative research and for helping reviewers assess articles using qualitative methods. We are not suggesting that qualitative researchers should use these frameworks as tick-box checklists, although they may be used to enable researchers to think through important elements of qualitative research that may be otherwise overlooked. At the end of this article, we supply weblinks to enable the reader to inspect these two frameworks.

‘Signs of Quality’ for Reporting Qualitative Public Health Research

Rather than leave the reader baffled by frameworks and checklists, we propose a number of ‘signs of quality’ that we would expect to see when reviewing articles submitted to this or any other high-quality public health journal.

The research question is clearly identified and clearly related to public health policy or practice and the chosen method is appropriate for answering that question. A rationale is offered to justify the study and the methods used.

Ethical questions are considered, the study has been conducted and reported in an ethical manner, and ethical approval has been granted from a recognised ethics committee.

How the study was implemented needs to be reported as clearly as possible including: how access to participants was achieved, what questions were asked, and how the analysis was conducted.

The study needs to be both theoretically and practically consistent. For example, if the study claims to be narrative research, did the questions elicit stories and is narrative theory used in analysis?

Collaborative

In recent years, health services in many countries have embraced patient and public involvement and co-production in both research and practice. Such initiatives are designed to draw our attention to service users’ views, needs and desires. This agenda sits very well with qualitative research methodologies.

Contribution

Every research study needs to make a contribution to the body of knowledge concerning the subject under investigation. If there is theoretical and practical consistency throughout the study and it has been competently conducted and analysed, the reader should come away with a sense of learning something new on the topic. This insight should be easy for a reader to take away from each article and the easiest way to do this is to articulate it clearly in the conclusion in the abstract as well as the conclusion in the body of the paper. Conclusions of ‘it’s complex’ or ‘there were five issues affecting this phenomenon’ fail to offer useful insights. They may be a signal of an under-analysed study. It will be much more helpful to readers to state a single key issue that adds to the evidence base and that helps members of the population, policy-makers, or practitioners to understand the phenomenon under study or take action on it.

Examples of Good Qualitative Research from this Journal

In order to exemplify the principles, we espouse in this article, we refer to two recent articles published in Perspectives in Public Health that use qualitative methods. First, Lozano-Sufrategui et al. 8 aimed to ‘… understand the behaviour changes men who attended a weight loss programme engage in during weight maintenance … ’. To achieve this aim, the research team encouraged men on a weight loss programme to keep photo-diaries of themselves and to talk about their progress with the researchers. The research is innovative in its approach and uniquely reports the participants’ thoughts, feelings and behaviours. It highlights the importance of drawing on the diversity of methods that exist beyond face-to-face interviews. The second example is Eley et al. 9 who conducted interviews and focus groups in four countries in order to ‘ … explore school educators’ attitudes, behaviours and knowledge towards food hygiene, safety and education .’ Using this approach, they were able to explore individual and group views on this subject thus identifying not only the need for more educational resources but barriers and opportunities in the process. While reading these articles, it becomes immediately apparent that these studies were able to gain insight into the respective topics that quantitative methods could never achieve. What qualitative research facilitates is the human connection between interviewer and interviewee and in that process, together with the guarantee of confidentiality, people are able to speak in-depth about their experiences and perceptions, from which much can be learned. In these two examples, the qualitative findings give insights into the thoughts and feelings of the participants and enable a greater understanding of how the researchers were able to draw their conclusions from the research.

A review of top public health journals identified that the vast majority of research that is being currently published in high-ranking public health journals use quantitative methods. High-quality qualitative research offers insights that quantitative research cannot. It is time for all public health journals to recognise the value of qualitative research and increase the amount of high-quality qualitative research that they publish.

COREQ link :

http://cdn.elsevier.com/promis_misc/ISSM_COREQ_Checklist.pdf

SRQR link :

https://onlinelibrary.wiley.com/pb-assets/assets/15532712/SRQR_Checklist-1529502683197.pdf

Conflict of Interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

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

Contributor Information

T Stickley, Institute of Mental Health, University of Nottingham Faculty of Medicine and Health Sciences, Triumph Road, Nottingham NG7 2UH, UK.

A O’Caithain, The University of Sheffield, Sheffield, UK.

C Homer, Sheffield Hallam University, Sheffield, UK.

Qualitative Survey Questions with Some Examples

Understanding your customers’ experiences and perceptions is crucial for enhancing your products and services. While quantitative research provides numerical insights, qualitative survey questions dive deeper, exploring the “why” behind customer behaviors.

This article answers what qualitative research questions focus on, their applications, types, and the advantages and disadvantages of using them.

Qualitative vs. Quantitative Questions

Surveys can include both qualitative and quantitative questions. Quantitative questions yield numerical data, easily measured and statistically analyzed, like “How many times have you used our app this week?” or “On a scale of 1-10, how satisfied are you with our service?” This data is invaluable for spotting trends, measuring performance, and making data-driven decisions.

Qualitative research questions, however, seek to understand the underlying reasons, opinions, and motivations behind customer actions. They often start with “why,” “how,” or “what.” For instance, “What features do you find most useful in our app?” or “Can you describe a challenge you faced while using our service?”

Our Tip: A Balanced Approach

These qualitative survey questions examples provide richer, more detailed data, invaluable for customer experience (CX) professionals aiming to boost user satisfaction and loyalty. They uncover insights that quantitative data alone can’t, such as emotional responses and personal stories, revealing deeper customer needs and preferences.

A balanced approach, blending qualitative and quantitative research, typically yields the best results. Quantitative data highlights areas needing attention, while qualitative data explains why these issues exist and suggests potential solutions. This combination offers a comprehensive understanding of customer experiences, guiding more effective improvements and innovations.

When Should We Use Qualitative Research Questions?

Qualitative research questions are especially useful in various scenarios. By asking these “why” questions, you uncover insights that shape strategies, conduct market research, and enhance customer experiences.

Exploring Experiences:

Understand how customers interact with your product or service. For instance, “Can you describe your overall experience with our customer support ?” This type of question helps you focus on uncovering the nuances of customer interactions, highlighting what works well and what needs improvement.

Investigating Processes:

Gain insights into how customers use your product. For example, “Can you walk us through how you typically use our app?” This helps identify pain points in the user journey and opportunities to streamline processes.

Addressing Sensitive Topics:

Delve into issues that might be uncomfortable or nuanced, such as “How do you feel about the privacy features of our app?” A careful approach ensures respondents feel safe and respected while sharing their thoughts.

Understanding Change:

Comprehend shifts in customer behavior or preferences, like “Why did you decide to upgrade to our premium plan?” Understanding these reasons guides strategic decisions and product development.

Uncovering Motivations:

Discover what drives customer decisions. For instance, “What motivated you to choose our product over competitors?” This helps understand the unique value propositions that attract customers to your brand.

Identifying Expectations:

Determine what customers expect from your service or product. For example, “What features would you like to see in future updates?” Knowing these expectations helps prioritize developments to enhance satisfaction and loyalty.

Evaluating Impact:

Assess the impact of changes or new features. For instance, “How has the new dashboard improved your workflow?” This provides direct feedback on recent updates, helping measure their effectiveness.

Try Ready-To-Use CX Surveys

Patient Satisfaction Survey

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Service quality survey

Customer Needs Survey

Product Feedback Survey (NPS)

Types of Qualitative Research Questions – Examples

There are various types of qualitative research questions, each serving a distinct purpose. Here are some examples focused on customer experience and marketing:

Descriptive

Descriptive questions gather detailed information about specific aspects of your product or service, helping understand what customers notice and appreciate.

• “What specific design elements stand out in our app?”
• “What features do you find most helpful on our website?”
• “Which elements of our service do you value most, and why?”

These effective qualitative research questions uncover details often missed in broader surveys. Customers might highlight a feature’s simplicity or the aesthetic appeal of your app’s interface, offering actionable insights for your design team.

Predictive questions explore potential future behaviors or outcomes, helping anticipate customer needs and preferences for proactive improvements.

• “If we had a project management tool integration for our app, how often would you use it?”
• “How likely are you to recommend our service to a friend after using our new feature?”
• “What impact do you think adding live chat support would have on your overall satisfaction?”

Predictive questions gauge the potential success of new features or changes before implementation, allowing adjustments based on customer feedback and reducing the risk of investing in unwanted developments.

Experiential

Experiential questions focus on understanding customers’ personal experiences and emotions, providing insights into their journey and emotional responses at various touchpoints.

• “How would you describe your first impressions of our application?”
• “Can you share a time when our customer service exceeded your expectations?”
• “What emotions do you associate with using our product, and why?”

These questions help qualitative research methods identify emotional factors influencing customer satisfaction and loyalty, amplifying positive experiences and addressing negative ones to enhance overall perception.

Compar a tive

Comparative questions draw comparisons between different products, services, or experiences, helping understand your competitive position and identify areas for improvement.

• “Was the pricing clear and easy to understand compared to our competitors?”
• “How does our product compare to others you’ve used in terms of ease of use?”
• “In what ways do you think our service stands out from competitors?”

Comparative questions reveal strengths and weaknesses relative to competitors, guiding strategies to enhance unique selling points and address gaps in your offerings.

Process-oriented

Process-oriented questions explore the steps customers take when interacting with your product or service, identifying barriers and opportunities to optimize the customer journey.

• “What are your next steps when you encounter an issue with our product?”
• “How do you typically find information on our website?”
• “What process do you follow to decide to make a purchase on our platform?”

Each qualitative research question, together with its statistical analysis, provide insights into practical aspects of customer interactions, highlighting areas to streamline and make the UX more intuitive.

Advantages and Disadvantages of Using Qualitative Questions in Surveys

Qualitative methods in conducting online research have their strengths and weaknesses. Let’s take a brief look at them.

In-Depth Data Gathering:

Qualitative questions provide detailed insights into customer thoughts and feelings, helping understand the “why” behind their actions. This depth leads to more targeted and effective improvements.

Encouraging Customers to Speak Their Minds:

These questions invite open-ended responses, letting customers express their opinions and experiences in their own words. This uncovers insights that structured questions might miss, capturing the full range of customer sentiments.

Participant Engagement:

Qualitative questions make surveys more engaging, encouraging participants to spend more time providing thoughtful answers. Engaged participants offer richer data, leading to more valuable insights.

Flexibility in Responses:

Unlike quantitative questions, which limit answers to predefined options, qualitative questions let respondents answer in their own words. This flexibility reveals unexpected insights and nuances.

Contextual Understanding:

Qualitative responses include context that quantitative data lacks, providing a fuller picture of customer experiences and perceptions. This context is crucial for accurately interpreting feedback and making informed decisions.

Disadvantages

Sample Bias:

The open-ended nature of qualitative questions may attract responses from customers with strong opinions, potentially skewing the data. Ensure a diverse range of participants to mitigate this bias.

Privacy Issues:

Collecting detailed personal information can raise privacy concerns, requiring careful data handling to ensure confidentiality. Robust data protection measures are essential to maintain customer trust.

Time-Consuming Analysis:

Analyzing qualitative data is time-consuming, requiring a nuanced approach compared to quantitative data. This often involves coding responses, identifying themes, and interpreting meanings, which can be labor-intensive.

Subjectivity in Interpretation:

Qualitative data is inherently subjective, both in how respondents articulate their answers and in how researchers interpret them. Ensuring consistent, unbiased interpretation requires careful methodological rigor.

Limited Generalizability:

Qualitative data is detailed and specific, making it harder to generalize findings across a larger population. While valuable, these insights often need to be complemented with quantitative research to provide a broader perspective.

Good Qualitative Research Questions – Sum Up

Incorporating qualitative surveys into your research can unlock valuable insights that quantitative data alone can’t. By crafting and strategically using these questions, CX specialists can gain a deeper understanding of customer experiences, motivations, and preferences. Though challenges exist with qualitative data, its rich, detailed feedback is instrumental in shaping product and service strategies, enhancing customer satisfaction and loyalty.

Conducting qualitative research explore the nuanced aspects of CX in focus groups, laying the foundation for meaningful improvements. Whether you’re understanding customer behavior, addressing sensitive issues, or evaluating changes’ impact, qualitative questions offer the depth needed for informed decision-making. By balancing these with quantitative measures, you get a comprehensive view of your customers, enabling you to create more personalized, responsive, and effective CX strategies.

Tool For Quantitative and Qualitative Questions

As you choose qualitative research questions for your surveys, consider your research objective and your target audience’s unique contexts. Tailor questions to elicit detailed, thoughtful responses guiding your efforts to boost customer satisfaction and loyalty. Remember, the ultimate aim is to understand and meet your customers’ needs more effectively, fostering stronger relationships and driving long-term business success.

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Author: Dariusz Jaroń

Updated: 20 June 2024

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Drugs take nearly 300 lives every day. 1 To address the increasing number of overdose deaths related to both prescription opioids and illegal drugs, we created a website to educate people who use drugs about the dangers of illegally manufactured fentanyl, the risks and consequences of mixing drugs, the lifesaving power of naloxone, and the importance of reducing stigma around recovery and treatment options. Together, we can stop drug overdoses and save lives.

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Explore and download Stop Overdose and other educational materials on CDC's Overdose Resource Exchange .

• Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2021 on CDC WONDER Online Database, released in 2023. Data are from the Multiple Cause of Death Files, 2018-2021, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-expanded.html on Mar 5, 2024

Every day, drugs claim hundreds of lives. The Stop Overdose website educates drug users on fentanyl, naloxone, polysubstance use, and dealing with stigma.