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Criteria for Good Qualitative Research: A Comprehensive Review

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• Volume 31 , pages 679–689, ( 2022 )

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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• Calvin Moorley 1 ,
• Xabi Cathala 2
• 1 Nursing Research and Diversity in Care, School of Health and Social Care , London South Bank University , London , UK
• 2 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

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Introduction

In order to make a decision about implementing evidence into practice, nurses need to be able to critically appraise research. Nurses also have a professional responsibility to maintain up-to-date practice. 1 This paper provides a guide on how to critically appraise a qualitative research paper.

What is qualitative research?

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Useful terms

Some of the qualitative approaches used in nursing research include grounded theory, phenomenology, ethnography, case study (can lend itself to mixed methods) and narrative analysis. The data collection methods used in qualitative research include in depth interviews, focus groups, observations and stories in the form of diaries or other documents. 3

Authenticity

Title, keywords, authors and abstract.

In a previous paper, we discussed how the title, keywords, authors’ positions and affiliations and abstract can influence the authenticity and readability of quantitative research papers, 4 the same applies to qualitative research. However, other areas such as the purpose of the study and the research question, theoretical and conceptual frameworks, sampling and methodology also need consideration when appraising a qualitative paper.

Purpose and question

The topic under investigation in the study should be guided by a clear research question or a statement of the problem or purpose. An example of a statement can be seen in table 2 . Unlike most quantitative studies, qualitative research does not seek to test a hypothesis. The research statement should be specific to the problem and should be reflected in the design. This will inform the reader of what will be studied and justify the purpose of the study. 5

Example of research question and problem statement

An appropriate literature review should have been conducted and summarised in the paper. It should be linked to the subject, using peer-reviewed primary research which is up to date. We suggest papers with a age limit of 5–8 years excluding original work. The literature review should give the reader a balanced view on what has been written on the subject. It is worth noting that for some qualitative approaches some literature reviews are conducted after the data collection to minimise bias, for example, in grounded theory studies. In phenomenological studies, the review sometimes occurs after the data analysis. If this is the case, the author(s) should make this clear.

Theoretical and conceptual frameworks

Most authors use the terms theoretical and conceptual frameworks interchangeably. Usually, a theoretical framework is used when research is underpinned by one theory that aims to help predict, explain and understand the topic investigated. A theoretical framework is the blueprint that can hold or scaffold a study’s theory. Conceptual frameworks are based on concepts from various theories and findings which help to guide the research. 6 It is the researcher’s understanding of how different variables are connected in the study, for example, the literature review and research question. Theoretical and conceptual frameworks connect the researcher to existing knowledge and these are used in a study to help to explain and understand what is being investigated. A framework is the design or map for a study. When you are appraising a qualitative paper, you should be able to see how the framework helped with (1) providing a rationale and (2) the development of research questions or statements. 7 You should be able to identify how the framework, research question, purpose and literature review all complement each other.

There remains an ongoing debate in relation to what an appropriate sample size should be for a qualitative study. We hold the view that qualitative research does not seek to power and a sample size can be as small as one (eg, a single case study) or any number above one (a grounded theory study) providing that it is appropriate and answers the research problem. Shorten and Moorley 8 explain that three main types of sampling exist in qualitative research: (1) convenience (2) judgement or (3) theoretical. In the paper , the sample size should be stated and a rationale for how it was decided should be clear.

Methodology

Qualitative research encompasses a variety of methods and designs. Based on the chosen method or design, the findings may be reported in a variety of different formats. Table 3 provides the main qualitative approaches used in nursing with a short description.

Different qualitative approaches

The authors should make it clear why they are using a qualitative methodology and the chosen theoretical approach or framework. The paper should provide details of participant inclusion and exclusion criteria as well as recruitment sites where the sample was drawn from, for example, urban, rural, hospital inpatient or community. Methods of data collection should be identified and be appropriate for the research statement/question.

Data collection

Overall there should be a clear trail of data collection. The paper should explain when and how the study was advertised, participants were recruited and consented. it should also state when and where the data collection took place. Data collection methods include interviews, this can be structured or unstructured and in depth one to one or group. 9 Group interviews are often referred to as focus group interviews these are often voice recorded and transcribed verbatim. It should be clear if these were conducted face to face, telephone or any other type of media used. Table 3 includes some data collection methods. Other collection methods not included in table 3 examples are observation, diaries, video recording, photographs, documents or objects (artefacts). The schedule of questions for interview or the protocol for non-interview data collection should be provided, available or discussed in the paper. Some authors may use the term ‘recruitment ended once data saturation was reached’. This simply mean that the researchers were not gaining any new information at subsequent interviews, so they stopped data collection.

The data collection section should include details of the ethical approval gained to carry out the study. For example, the strategies used to gain participants’ consent to take part in the study. The authors should make clear if any ethical issues arose and how these were resolved or managed.

The approach to data analysis (see ref  10 ) needs to be clearly articulated, for example, was there more than one person responsible for analysing the data? How were any discrepancies in findings resolved? An audit trail of how the data were analysed including its management should be documented. If member checking was used this should also be reported. This level of transparency contributes to the trustworthiness and credibility of qualitative research. Some researchers provide a diagram of how they approached data analysis to demonstrate the rigour applied ( figure 1 ).

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Example of data analysis diagram.

Validity and rigour

The study’s validity is reliant on the statement of the question/problem, theoretical/conceptual framework, design, method, sample and data analysis. When critiquing qualitative research, these elements will help you to determine the study’s reliability. Noble and Smith 11 explain that validity is the integrity of data methods applied and that findings should accurately reflect the data. Rigour should acknowledge the researcher’s role and involvement as well as any biases. Essentially it should focus on truth value, consistency and neutrality and applicability. 11 The authors should discuss if they used triangulation (see table 2 ) to develop the best possible understanding of the phenomena.

Themes and interpretations and implications for practice

In qualitative research no hypothesis is tested, therefore, there is no specific result. Instead, qualitative findings are often reported in themes based on the data analysed. The findings should be clearly linked to, and reflect, the data. This contributes to the soundness of the research. 11 The researchers should make it clear how they arrived at the interpretations of the findings. The theoretical or conceptual framework used should be discussed aiding the rigour of the study. The implications of the findings need to be made clear and where appropriate their applicability or transferability should be identified. 12

Discussions, recommendations and conclusions

The discussion should relate to the research findings as the authors seek to make connections with the literature reviewed earlier in the paper to contextualise their work. A strong discussion will connect the research aims and objectives to the findings and will be supported with literature if possible. A paper that seeks to influence nursing practice will have a recommendations section for clinical practice and research. A good conclusion will focus on the findings and discussion of the phenomena investigated.

Qualitative research has much to offer nursing and healthcare, in terms of understanding patients’ experience of illness, treatment and recovery, it can also help to understand better areas of healthcare practice. However, it must be done with rigour and this paper provides some guidance for appraising such research. To help you critique a qualitative research paper some guidance is provided in table 4 .

Some guidance for critiquing qualitative research

• ↵ Nursing and Midwifery Council . The code: Standard of conduct, performance and ethics for nurses and midwives . 2015 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21 Aug 18 ).
• Barrett D ,
• Cathala X ,
• Shorten A ,

Patient consent for publication Not required.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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

https://doi.org/10.1136/bmjebm-2018-111132

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• qualitative research

Introduction

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

Critical appraisal of qualitative research

Is it necessary.

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

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

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

How is appraisal currently performed?

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

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

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

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

On the need for specific appraisal tools

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

Concepts of rigour or trustworthiness within qualitative research 31

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

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

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

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

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

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

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

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

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

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

• Williams V ,
• Boylan AM ,
• Lingard L ,
• Orser B , et al
• Brawn R , et al
• Van Royen P ,
• Vermeire E , et al
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• Sainsbury P ,
• ↵ CASP (Critical Appraisal Skills Programme). date unknown . http://www.phru.nhs.uk/Pages/PHD/CASP.htm .
• ↵ The Joanna Briggs Institute . JBI QARI Critical appraisal checklist for interpretive & critical research . Adelaide : The Joanna Briggs Institute , 2014 .
• Stephens J ,

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

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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

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How to critique qualitative research articles

Affiliation.

• 1 Hamilton Psychiatric Hospital, Ontario.
• PMID: 10603806

The critique of qualitative research requires the use of different standards and criteria than are used for quantitative research. The great diversity of available qualitative methods can make evaluation or critical appraisal difficult for consumers of research who are less familiar with these methods. The current paper suggests that the following guidelines be used when a qualitative research paper is being examined: the topic must be appropriate for qualitative enquiry; the specific qualitative research method chosen must "fit"; the literature reviewed should be consistent with the method chosen; there should be ample description of informants or participants, context, and researcher; appropriate methods for information gathering and information analysis should be employed; the conclusions should be sound; and, the research must have some importance and relevance.

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Qualitative Research: Data Collection, Analysis, and Management

Introduction.

In an earlier paper, 1 we presented an introduction to using qualitative research methods in pharmacy practice. In this article, we review some principles of the collection, analysis, and management of qualitative data to help pharmacists interested in doing research in their practice to continue their learning in this area. Qualitative research can help researchers to access the thoughts and feelings of research participants, which can enable development of an understanding of the meaning that people ascribe to their experiences. Whereas quantitative research methods can be used to determine how many people undertake particular behaviours, qualitative methods can help researchers to understand how and why such behaviours take place. Within the context of pharmacy practice research, qualitative approaches have been used to examine a diverse array of topics, including the perceptions of key stakeholders regarding prescribing by pharmacists and the postgraduation employment experiences of young pharmacists (see “Further Reading” section at the end of this article).

In the previous paper, 1 we outlined 3 commonly used methodologies: ethnography 2 , grounded theory 3 , and phenomenology. 4 Briefly, ethnography involves researchers using direct observation to study participants in their “real life” environment, sometimes over extended periods. Grounded theory and its later modified versions (e.g., Strauss and Corbin 5 ) use face-to-face interviews and interactions such as focus groups to explore a particular research phenomenon and may help in clarifying a less-well-understood problem, situation, or context. Phenomenology shares some features with grounded theory (such as an exploration of participants’ behaviour) and uses similar techniques to collect data, but it focuses on understanding how human beings experience their world. It gives researchers the opportunity to put themselves in another person’s shoes and to understand the subjective experiences of participants. 6 Some researchers use qualitative methodologies but adopt a different standpoint, and an example of this appears in the work of Thurston and others, 7 discussed later in this paper.

Qualitative work requires reflection on the part of researchers, both before and during the research process, as a way of providing context and understanding for readers. When being reflexive, researchers should not try to simply ignore or avoid their own biases (as this would likely be impossible); instead, reflexivity requires researchers to reflect upon and clearly articulate their position and subjectivities (world view, perspectives, biases), so that readers can better understand the filters through which questions were asked, data were gathered and analyzed, and findings were reported. From this perspective, bias and subjectivity are not inherently negative but they are unavoidable; as a result, it is best that they be articulated up-front in a manner that is clear and coherent for readers.

THE PARTICIPANT’S VIEWPOINT

What qualitative study seeks to convey is why people have thoughts and feelings that might affect the way they behave. Such study may occur in any number of contexts, but here, we focus on pharmacy practice and the way people behave with regard to medicines use (e.g., to understand patients’ reasons for nonadherence with medication therapy or to explore physicians’ resistance to pharmacists’ clinical suggestions). As we suggested in our earlier article, 1 an important point about qualitative research is that there is no attempt to generalize the findings to a wider population. Qualitative research is used to gain insights into people’s feelings and thoughts, which may provide the basis for a future stand-alone qualitative study or may help researchers to map out survey instruments for use in a quantitative study. It is also possible to use different types of research in the same study, an approach known as “mixed methods” research, and further reading on this topic may be found at the end of this paper.

The role of the researcher in qualitative research is to attempt to access the thoughts and feelings of study participants. This is not an easy task, as it involves asking people to talk about things that may be very personal to them. Sometimes the experiences being explored are fresh in the participant’s mind, whereas on other occasions reliving past experiences may be difficult. However the data are being collected, a primary responsibility of the researcher is to safeguard participants and their data. Mechanisms for such safeguarding must be clearly articulated to participants and must be approved by a relevant research ethics review board before the research begins. Researchers and practitioners new to qualitative research should seek advice from an experienced qualitative researcher before embarking on their project.

DATA COLLECTION

Whatever philosophical standpoint the researcher is taking and whatever the data collection method (e.g., focus group, one-to-one interviews), the process will involve the generation of large amounts of data. In addition to the variety of study methodologies available, there are also different ways of making a record of what is said and done during an interview or focus group, such as taking handwritten notes or video-recording. If the researcher is audio- or video-recording data collection, then the recordings must be transcribed verbatim before data analysis can begin. As a rough guide, it can take an experienced researcher/transcriber 8 hours to transcribe one 45-minute audio-recorded interview, a process than will generate 20–30 pages of written dialogue.

Many researchers will also maintain a folder of “field notes” to complement audio-taped interviews. Field notes allow the researcher to maintain and comment upon impressions, environmental contexts, behaviours, and nonverbal cues that may not be adequately captured through the audio-recording; they are typically handwritten in a small notebook at the same time the interview takes place. Field notes can provide important context to the interpretation of audio-taped data and can help remind the researcher of situational factors that may be important during data analysis. Such notes need not be formal, but they should be maintained and secured in a similar manner to audio tapes and transcripts, as they contain sensitive information and are relevant to the research. For more information about collecting qualitative data, please see the “Further Reading” section at the end of this paper.

DATA ANALYSIS AND MANAGEMENT

If, as suggested earlier, doing qualitative research is about putting oneself in another person’s shoes and seeing the world from that person’s perspective, the most important part of data analysis and management is to be true to the participants. It is their voices that the researcher is trying to hear, so that they can be interpreted and reported on for others to read and learn from. To illustrate this point, consider the anonymized transcript excerpt presented in Appendix 1 , which is taken from a research interview conducted by one of the authors (J.S.). We refer to this excerpt throughout the remainder of this paper to illustrate how data can be managed, analyzed, and presented.

Interpretation of Data

Interpretation of the data will depend on the theoretical standpoint taken by researchers. For example, the title of the research report by Thurston and others, 7 “Discordant indigenous and provider frames explain challenges in improving access to arthritis care: a qualitative study using constructivist grounded theory,” indicates at least 2 theoretical standpoints. The first is the culture of the indigenous population of Canada and the place of this population in society, and the second is the social constructivist theory used in the constructivist grounded theory method. With regard to the first standpoint, it can be surmised that, to have decided to conduct the research, the researchers must have felt that there was anecdotal evidence of differences in access to arthritis care for patients from indigenous and non-indigenous backgrounds. With regard to the second standpoint, it can be surmised that the researchers used social constructivist theory because it assumes that behaviour is socially constructed; in other words, people do things because of the expectations of those in their personal world or in the wider society in which they live. (Please see the “Further Reading” section for resources providing more information about social constructivist theory and reflexivity.) Thus, these 2 standpoints (and there may have been others relevant to the research of Thurston and others 7 ) will have affected the way in which these researchers interpreted the experiences of the indigenous population participants and those providing their care. Another standpoint is feminist standpoint theory which, among other things, focuses on marginalized groups in society. Such theories are helpful to researchers, as they enable us to think about things from a different perspective. Being aware of the standpoints you are taking in your own research is one of the foundations of qualitative work. Without such awareness, it is easy to slip into interpreting other people’s narratives from your own viewpoint, rather than that of the participants.

To analyze the example in Appendix 1 , we will adopt a phenomenological approach because we want to understand how the participant experienced the illness and we want to try to see the experience from that person’s perspective. It is important for the researcher to reflect upon and articulate his or her starting point for such analysis; for example, in the example, the coder could reflect upon her own experience as a female of a majority ethnocultural group who has lived within middle class and upper middle class settings. This personal history therefore forms the filter through which the data will be examined. This filter does not diminish the quality or significance of the analysis, since every researcher has his or her own filters; however, by explicitly stating and acknowledging what these filters are, the researcher makes it easer for readers to contextualize the work.

Transcribing and Checking

For the purposes of this paper it is assumed that interviews or focus groups have been audio-recorded. As mentioned above, transcribing is an arduous process, even for the most experienced transcribers, but it must be done to convert the spoken word to the written word to facilitate analysis. For anyone new to conducting qualitative research, it is beneficial to transcribe at least one interview and one focus group. It is only by doing this that researchers realize how difficult the task is, and this realization affects their expectations when asking others to transcribe. If the research project has sufficient funding, then a professional transcriber can be hired to do the work. If this is the case, then it is a good idea to sit down with the transcriber, if possible, and talk through the research and what the participants were talking about. This background knowledge for the transcriber is especially important in research in which people are using jargon or medical terms (as in pharmacy practice). Involving your transcriber in this way makes the work both easier and more rewarding, as he or she will feel part of the team. Transcription editing software is also available, but it is expensive. For example, ELAN (more formally known as EUDICO Linguistic Annotator, developed at the Technical University of Berlin) 8 is a tool that can help keep data organized by linking media and data files (particularly valuable if, for example, video-taping of interviews is complemented by transcriptions). It can also be helpful in searching complex data sets. Products such as ELAN do not actually automatically transcribe interviews or complete analyses, and they do require some time and effort to learn; nonetheless, for some research applications, it may be a valuable to consider such software tools.

All audio recordings should be transcribed verbatim, regardless of how intelligible the transcript may be when it is read back. Lines of text should be numbered. Once the transcription is complete, the researcher should read it while listening to the recording and do the following: correct any spelling or other errors; anonymize the transcript so that the participant cannot be identified from anything that is said (e.g., names, places, significant events); insert notations for pauses, laughter, looks of discomfort; insert any punctuation, such as commas and full stops (periods) (see Appendix 1 for examples of inserted punctuation), and include any other contextual information that might have affected the participant (e.g., temperature or comfort of the room).

Dealing with the transcription of a focus group is slightly more difficult, as multiple voices are involved. One way of transcribing such data is to “tag” each voice (e.g., Voice A, Voice B). In addition, the focus group will usually have 2 facilitators, whose respective roles will help in making sense of the data. While one facilitator guides participants through the topic, the other can make notes about context and group dynamics. More information about group dynamics and focus groups can be found in resources listed in the “Further Reading” section.

Reading between the Lines

During the process outlined above, the researcher can begin to get a feel for the participant’s experience of the phenomenon in question and can start to think about things that could be pursued in subsequent interviews or focus groups (if appropriate). In this way, one participant’s narrative informs the next, and the researcher can continue to interview until nothing new is being heard or, as it says in the text books, “saturation is reached”. While continuing with the processes of coding and theming (described in the next 2 sections), it is important to consider not just what the person is saying but also what they are not saying. For example, is a lengthy pause an indication that the participant is finding the subject difficult, or is the person simply deciding what to say? The aim of the whole process from data collection to presentation is to tell the participants’ stories using exemplars from their own narratives, thus grounding the research findings in the participants’ lived experiences.

Smith 9 suggested a qualitative research method known as interpretative phenomenological analysis, which has 2 basic tenets: first, that it is rooted in phenomenology, attempting to understand the meaning that individuals ascribe to their lived experiences, and second, that the researcher must attempt to interpret this meaning in the context of the research. That the researcher has some knowledge and expertise in the subject of the research means that he or she can have considerable scope in interpreting the participant’s experiences. Larkin and others 10 discussed the importance of not just providing a description of what participants say. Rather, interpretative phenomenological analysis is about getting underneath what a person is saying to try to truly understand the world from his or her perspective.

Once all of the research interviews have been transcribed and checked, it is time to begin coding. Field notes compiled during an interview can be a useful complementary source of information to facilitate this process, as the gap in time between an interview, transcribing, and coding can result in memory bias regarding nonverbal or environmental context issues that may affect interpretation of data.

Coding refers to the identification of topics, issues, similarities, and differences that are revealed through the participants’ narratives and interpreted by the researcher. This process enables the researcher to begin to understand the world from each participant’s perspective. Coding can be done by hand on a hard copy of the transcript, by making notes in the margin or by highlighting and naming sections of text. More commonly, researchers use qualitative research software (e.g., NVivo, QSR International Pty Ltd; www.qsrinternational.com/products_nvivo.aspx ) to help manage their transcriptions. It is advised that researchers undertake a formal course in the use of such software or seek supervision from a researcher experienced in these tools.

Returning to Appendix 1 and reading from lines 8–11, a code for this section might be “diagnosis of mental health condition”, but this would just be a description of what the participant is talking about at that point. If we read a little more deeply, we can ask ourselves how the participant might have come to feel that the doctor assumed he or she was aware of the diagnosis or indeed that they had only just been told the diagnosis. There are a number of pauses in the narrative that might suggest the participant is finding it difficult to recall that experience. Later in the text, the participant says “nobody asked me any questions about my life” (line 19). This could be coded simply as “health care professionals’ consultation skills”, but that would not reflect how the participant must have felt never to be asked anything about his or her personal life, about the participant as a human being. At the end of this excerpt, the participant just trails off, recalling that no-one showed any interest, which makes for very moving reading. For practitioners in pharmacy, it might also be pertinent to explore the participant’s experience of akathisia and why this was left untreated for 20 years.

One of the questions that arises about qualitative research relates to the reliability of the interpretation and representation of the participants’ narratives. There are no statistical tests that can be used to check reliability and validity as there are in quantitative research. However, work by Lincoln and Guba 11 suggests that there are other ways to “establish confidence in the ‘truth’ of the findings” (p. 218). They call this confidence “trustworthiness” and suggest that there are 4 criteria of trustworthiness: credibility (confidence in the “truth” of the findings), transferability (showing that the findings have applicability in other contexts), dependability (showing that the findings are consistent and could be repeated), and confirmability (the extent to which the findings of a study are shaped by the respondents and not researcher bias, motivation, or interest).

One way of establishing the “credibility” of the coding is to ask another researcher to code the same transcript and then to discuss any similarities and differences in the 2 resulting sets of codes. This simple act can result in revisions to the codes and can help to clarify and confirm the research findings.

Theming refers to the drawing together of codes from one or more transcripts to present the findings of qualitative research in a coherent and meaningful way. For example, there may be examples across participants’ narratives of the way in which they were treated in hospital, such as “not being listened to” or “lack of interest in personal experiences” (see Appendix 1 ). These may be drawn together as a theme running through the narratives that could be named “the patient’s experience of hospital care”. The importance of going through this process is that at its conclusion, it will be possible to present the data from the interviews using quotations from the individual transcripts to illustrate the source of the researchers’ interpretations. Thus, when the findings are organized for presentation, each theme can become the heading of a section in the report or presentation. Underneath each theme will be the codes, examples from the transcripts, and the researcher’s own interpretation of what the themes mean. Implications for real life (e.g., the treatment of people with chronic mental health problems) should also be given.

DATA SYNTHESIS

In this final section of this paper, we describe some ways of drawing together or “synthesizing” research findings to represent, as faithfully as possible, the meaning that participants ascribe to their life experiences. This synthesis is the aim of the final stage of qualitative research. For most readers, the synthesis of data presented by the researcher is of crucial significance—this is usually where “the story” of the participants can be distilled, summarized, and told in a manner that is both respectful to those participants and meaningful to readers. There are a number of ways in which researchers can synthesize and present their findings, but any conclusions drawn by the researchers must be supported by direct quotations from the participants. In this way, it is made clear to the reader that the themes under discussion have emerged from the participants’ interviews and not the mind of the researcher. The work of Latif and others 12 gives an example of how qualitative research findings might be presented.

Planning and Writing the Report

As has been suggested above, if researchers code and theme their material appropriately, they will naturally find the headings for sections of their report. Qualitative researchers tend to report “findings” rather than “results”, as the latter term typically implies that the data have come from a quantitative source. The final presentation of the research will usually be in the form of a report or a paper and so should follow accepted academic guidelines. In particular, the article should begin with an introduction, including a literature review and rationale for the research. There should be a section on the chosen methodology and a brief discussion about why qualitative methodology was most appropriate for the study question and why one particular methodology (e.g., interpretative phenomenological analysis rather than grounded theory) was selected to guide the research. The method itself should then be described, including ethics approval, choice of participants, mode of recruitment, and method of data collection (e.g., semistructured interviews or focus groups), followed by the research findings, which will be the main body of the report or paper. The findings should be written as if a story is being told; as such, it is not necessary to have a lengthy discussion section at the end. This is because much of the discussion will take place around the participants’ quotes, such that all that is needed to close the report or paper is a summary, limitations of the research, and the implications that the research has for practice. As stated earlier, it is not the intention of qualitative research to allow the findings to be generalized, and therefore this is not, in itself, a limitation.

Planning out the way that findings are to be presented is helpful. It is useful to insert the headings of the sections (the themes) and then make a note of the codes that exemplify the thoughts and feelings of your participants. It is generally advisable to put in the quotations that you want to use for each theme, using each quotation only once. After all this is done, the telling of the story can begin as you give your voice to the experiences of the participants, writing around their quotations. Do not be afraid to draw assumptions from the participants’ narratives, as this is necessary to give an in-depth account of the phenomena in question. Discuss these assumptions, drawing on your participants’ words to support you as you move from one code to another and from one theme to the next. Finally, as appropriate, it is possible to include examples from literature or policy documents that add support for your findings. As an exercise, you may wish to code and theme the sample excerpt in Appendix 1 and tell the participant’s story in your own way. Further reading about “doing” qualitative research can be found at the end of this paper.

CONCLUSIONS

Qualitative research can help researchers to access the thoughts and feelings of research participants, which can enable development of an understanding of the meaning that people ascribe to their experiences. It can be used in pharmacy practice research to explore how patients feel about their health and their treatment. Qualitative research has been used by pharmacists to explore a variety of questions and problems (see the “Further Reading” section for examples). An understanding of these issues can help pharmacists and other health care professionals to tailor health care to match the individual needs of patients and to develop a concordant relationship. Doing qualitative research is not easy and may require a complete rethink of how research is conducted, particularly for researchers who are more familiar with quantitative approaches. There are many ways of conducting qualitative research, and this paper has covered some of the practical issues regarding data collection, analysis, and management. Further reading around the subject will be essential to truly understand this method of accessing peoples’ thoughts and feelings to enable researchers to tell participants’ stories.

Appendix 1. Excerpt from a sample transcript

The participant (age late 50s) had suffered from a chronic mental health illness for 30 years. The participant had become a “revolving door patient,” someone who is frequently in and out of hospital. As the participant talked about past experiences, the researcher asked:

• What was treatment like 30 years ago?
• Umm—well it was pretty much they could do what they wanted with you because I was put into the er, the er kind of system er, I was just on
• endless section threes.
• Really…
• But what I didn’t realize until later was that if you haven’t actually posed a threat to someone or yourself they can’t really do that but I didn’t know
• that. So wh-when I first went into hospital they put me on the forensic ward ’cause they said, “We don’t think you’ll stay here we think you’ll just
• run-run away.” So they put me then onto the acute admissions ward and – er – I can remember one of the first things I recall when I got onto that
• ward was sitting down with a er a Dr XXX. He had a book this thick [gestures] and on each page it was like three questions and he went through
• all these questions and I answered all these questions. So we’re there for I don’t maybe two hours doing all that and he asked me he said “well
• when did somebody tell you then that you have schizophrenia” I said “well nobody’s told me that” so he seemed very surprised but nobody had
• actually [pause] whe-when I first went up there under police escort erm the senior kind of consultants people I’d been to where I was staying and
• ermm so er [pause] I . . . the, I can remember the very first night that I was there and given this injection in this muscle here [gestures] and just
• having dreadful side effects the next day I woke up [pause]
• . . . and I suffered that akathesia I swear to you, every minute of every day for about 20 years.
• Oh how awful.
• And that side of it just makes life impossible so the care on the wards [pause] umm I don’t know it’s kind of, it’s kind of hard to put into words
• [pause]. Because I’m not saying they were sort of like not friendly or interested but then nobody ever seemed to want to talk about your life [pause]
• nobody asked me any questions about my life. The only questions that came into was they asked me if I’d be a volunteer for these student exams
• and things and I said “yeah” so all the questions were like “oh what jobs have you done,” er about your relationships and things and er but
• nobody actually sat down and had a talk and showed some interest in you as a person you were just there basically [pause] um labelled and you
• know there was there was [pause] but umm [pause] yeah . . .

This article is the 10th in the CJHP Research Primer Series, an initiative of the CJHP Editorial Board and the CSHP Research Committee. The planned 2-year series is intended to appeal to relatively inexperienced researchers, with the goal of building research capacity among practising pharmacists. The articles, presenting simple but rigorous guidance to encourage and support novice researchers, are being solicited from authors with appropriate expertise.

Previous articles in this series:

Bond CM. The research jigsaw: how to get started. Can J Hosp Pharm . 2014;67(1):28–30.

Tully MP. Research: articulating questions, generating hypotheses, and choosing study designs. Can J Hosp Pharm . 2014;67(1):31–4.

Loewen P. Ethical issues in pharmacy practice research: an introductory guide. Can J Hosp Pharm. 2014;67(2):133–7.

Tsuyuki RT. Designing pharmacy practice research trials. Can J Hosp Pharm . 2014;67(3):226–9.

Bresee LC. An introduction to developing surveys for pharmacy practice research. Can J Hosp Pharm . 2014;67(4):286–91.

Gamble JM. An introduction to the fundamentals of cohort and case–control studies. Can J Hosp Pharm . 2014;67(5):366–72.

Austin Z, Sutton J. Qualitative research: getting started. C an J Hosp Pharm . 2014;67(6):436–40.

Houle S. An introduction to the fundamentals of randomized controlled trials in pharmacy research. Can J Hosp Pharm . 2014; 68(1):28–32.

Charrois TL. Systematic reviews: What do you need to know to get started? Can J Hosp Pharm . 2014;68(2):144–8.

Competing interests: None declared.

Further Reading

Examples of qualitative research in pharmacy practice.

• Farrell B, Pottie K, Woodend K, Yao V, Dolovich L, Kennie N, et al. Shifts in expectations: evaluating physicians’ perceptions as pharmacists integrated into family practice. J Interprof Care. 2010; 24 (1):80–9. [ PubMed ] [ Google Scholar ]
• Gregory P, Austin Z. Postgraduation employment experiences of new pharmacists in Ontario in 2012–2013. Can Pharm J. 2014; 147 (5):290–9. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Marks PZ, Jennnings B, Farrell B, Kennie-Kaulbach N, Jorgenson D, Pearson-Sharpe J, et al. “I gained a skill and a change in attitude”: a case study describing how an online continuing professional education course for pharmacists supported achievement of its transfer to practice outcomes. Can J Univ Contin Educ. 2014; 40 (2):1–18. [ Google Scholar ]
• Nair KM, Dolovich L, Brazil K, Raina P. It’s all about relationships: a qualitative study of health researchers’ perspectives on interdisciplinary research. BMC Health Serv Res. 2008; 8 :110. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pojskic N, MacKeigan L, Boon H, Austin Z. Initial perceptions of key stakeholders in Ontario regarding independent prescriptive authority for pharmacists. Res Soc Adm Pharm. 2014; 10 (2):341–54. [ PubMed ] [ Google Scholar ]

Qualitative Research in General

• Breakwell GM, Hammond S, Fife-Schaw C. Research methods in psychology. Thousand Oaks (CA): Sage Publications; 1995. [ Google Scholar ]
• Given LM. 100 questions (and answers) about qualitative research. Thousand Oaks (CA): Sage Publications; 2015. [ Google Scholar ]
• Miles B, Huberman AM. Qualitative data analysis. Thousand Oaks (CA): Sage Publications; 2009. [ Google Scholar ]
• Patton M. Qualitative research and evaluation methods. Thousand Oaks (CA): Sage Publications; 2002. [ Google Scholar ]
• Willig C. Introducing qualitative research in psychology. Buckingham (UK): Open University Press; 2001. [ Google Scholar ]

Group Dynamics in Focus Groups

• Farnsworth J, Boon B. Analysing group dynamics within the focus group. Qual Res. 2010; 10 (5):605–24. [ Google Scholar ]

Social Constructivism

• Social constructivism. Berkeley (CA): University of California, Berkeley, Berkeley Graduate Division, Graduate Student Instruction Teaching & Resource Center; [cited 2015 June 4]. Available from: http://gsi.berkeley.edu/gsi-guide-contents/learning-theory-research/social-constructivism/ [ Google Scholar ]

Mixed Methods

• Creswell J. Research design: qualitative, quantitative, and mixed methods approaches. Thousand Oaks (CA): Sage Publications; 2009. [ Google Scholar ]

Collecting Qualitative Data

• Arksey H, Knight P. Interviewing for social scientists: an introductory resource with examples. Thousand Oaks (CA): Sage Publications; 1999. [ Google Scholar ]
• Guest G, Namey EE, Mitchel ML. Collecting qualitative data: a field manual for applied research. Thousand Oaks (CA): Sage Publications; 2013. [ Google Scholar ]

Constructivist Grounded Theory

• Charmaz K. Grounded theory: objectivist and constructivist methods. In: Denzin N, Lincoln Y, editors. Handbook of qualitative research. 2nd ed. Thousand Oaks (CA): Sage Publications; 2000. pp. 509–35. [ Google Scholar ]

How to Critique Qualitative Research Articles

• Cheryl Forchuk
• Jacqueline Roberts

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Corporate activities that influence population health: A scoping review and qualitative synthesis to develop the HEALTH-CORP typology

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Introduction: The concept of the commercial determinants of health (CDH) is used to study the actions (and associated structures) of commercial entities that influence population health and health equity. The aim of this study was to develop a typology that describes the diverse set of activities through which corporations influence population health and health equity across industries. Methods: We conducted a scoping review of articles using CDH terms (n=116) that discuss corporate activities that can influence population health and health equity across 16 industries. We used the qualitative constant comparison method to build a typology called the Corporate Influences on Population Health (HEALTH-CORP) typology. Results: The HEALTH-CORP typology identifies 70 corporate activities that can influence health across industries and categorizes them into seven domains of corporate influence (e.g., political practices, employment practices). We present a model that situates these domains based on their proximity to health outcomes and identify five population groups (e.g., workers, local communities) to consider when evaluating corporate health impacts. Discussion: The HEALTH-CORP typology facilitates an understanding of the diverse set of corporate activities that can influence population health and the population groups affected by these activities. We discuss the utility of these contributions in terms of identifying interventions to address the CDH and advancing efforts to measure and monitor the CDH. We also leverage our findings to identify key gaps in CDH literature and suggest avenues for future research.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

Raquel Burgess was supported by a Doctoral Foreign Study Award provided by the Canadian Institutes of Health Research at the time this research was conducted. Funding was provided by the Yale School of Public Health and the Yale Graduate Student Assembly to present this work at the American Public Health Association Annual Meeting in 2022.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

The data for this study are published academic articles which are available from the respective publishers (see Supplementary Material, Appendix 2 for the characteristics of included articles). In addition, we uploaded the following files to Open Science Framework (DOI 10.17605/OSF.IO/TG9S7) to support data availability: 1) a .csv file containing a list of the articles that underwent title and abstract screening in our study and the respective screening decisions that were assigned, and 2) .ris files containing the citations to the respective articles and the assigned screening decisions, which can be uploaded into a reference manager. Interested parties can contact the corresponding author for additional information.

https://osf.io/tg9s7/

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• Published: 02 April 2022

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

• Nicholas C. Coombs 1 ,
• Duncan G. Campbell 2 &
• James Caringi 1  

BMC Health Services Research volume  22 , Article number:  438 ( 2022 ) Cite this article

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Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Peer Review reports

Unequal access to healthcare services is an important element of health disparities in the United States [ 1 ], and there remains much about access that is not fully understood. The lack of understanding is attributable, in part, to the lack of uniformity in how access is defined and evaluated, and the extent to which access is often oversimplified in research [ 2 ]. Subsequently, attempts to address population-level barriers to healthcare access are insufficient, and access remains an unresolved, complex health challenge [ 3 , 4 , 5 ]. This paper presents a study that aims to explore some of the less well studied barriers to healthcare access, particularly those that influence healthcare acceptability and appropriateness.

In truth, healthcare access entails a complicated calculus that combines characteristics of individuals, their households, and their social and physical environments with characteristics of healthcare delivery systems, organizations, and healthcare providers. For one to fully ‘access’ healthcare, they must have the means to identify their healthcare needs and have available to them care providers and the facilities where they work. Further, patients must then reach, obtain, and use the healthcare services in order to have their healthcare needs fulfilled. Levesque and colleagues critically examined access conceptualizations in 2013 and synthesized all ways in which access to healthcare was previously characterized; Levesque et al. proposed five dimensions of access: approachability, acceptability, availability, affordability and appropriateness [ 2 ]. These refer to the ability to perceive, seek, reach, pay for, and engage in services, respectively.

According to Levesque et al.’s framework, the five dimensions combine to facilitate access to care or serve as barriers. Approachability indicates that people facing health needs understand that healthcare services exist and might be helpful. Acceptability represents whether patients see healthcare services as consistent or inconsistent with their own social and cultural values and worldviews. Availability indicates that healthcare services are reached both physically and in a timely manner. Affordability simplifies one’s capacity to pay for healthcare services without compromising basic necessities, and finally, appropriateness represents the fit between healthcare services and a patient’s specific healthcare needs [ 2 ]. This study focused on the acceptability and appropriateness dimensions of access.

Before the novel coronavirus (SARS-CoV-2; COVID-19) pandemic, approximately 13.3% of adults in the US did not have a usual source of healthcare [ 6 ]. Millions more did not utilize services regularly, and close to two-thirds reported that they would be debilitated by an unexpected medical bill [ 7 , 8 , 9 ]. Findings like these emphasized a fragility in the financial security of the American population [ 10 ]. These concerns were exacerbated by the pandemic when a sudden surge in unemployment increased un- and under-insurance rates [ 11 ]. Indeed, employer-sponsored insurance covers close to half of Americans’ total cost of illness [ 12 ]. Unemployment linked to COVID-19 cut off the lone outlet to healthcare access for many. Health-related financial concerns expanded beyond individuals, as healthcare organizations were unequipped to manage a simultaneous increase in demand for specialized healthcare services and a steep drop off for routine revenue-generating healthcare services [ 13 ]. These consequences of the COVID-19 pandemic all put additional, unexpected pressure on an already fragmented US healthcare system.

Other structural barriers to healthcare access exist in relation to the rural–urban divide. Less than 10% of US healthcare resources are located in rural areas where approximately 20% of the American population resides [ 14 ]. In a country with substantially fewer providers per capita compared to many other developed countries, persons in rural areas experience uniquely pressing healthcare provider shortages [ 15 , 16 ]. Rural inhabitants also tend to have lower household income, higher rates of un- or under-insurance, and more difficulty with travel to healthcare clinics than urban dwellers [ 17 ]. Subsequently, persons in rural communities use healthcare services at lower rates, and potentially preventable hospitalizations are more prevalent [ 18 ]. This disparity often leads rural residents to use services primarily for more urgent needs and less so for routine care [ 19 , 20 , 21 ].

The differences in how rural and urban healthcare systems function warranted a federal initiative to focus exclusively on rural health priorities and serve as counterpart to Healthy People objectives [ 22 ]. The rural determinants of health, a more specific expression of general social determinants, add issues of geography and topography to the well-documented social, economic and political factors that influence all Americans’ access to healthcare [ 23 ]. As a result, access is consistently regarded as a top priority in rural areas, and many research efforts have explored the intersection between access and rurality, namely within its less understood dimensions (acceptability and appropriateness) [ 22 ].

Acceptability-related barriers to care

Acceptability represents the dimension of healthcare access that affects a patient’s ability to seek healthcare, particularly linked to one’s professional values, norms and culture [ 2 ]. Access to health information is an influential factor for acceptable healthcare and is essential to promote and maintain a healthy population [ 24 ]. According to the Centers for Disease Control and Prevention, health literacy or a high ‘health IQ’ is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others, which impacts healthcare use and system navigation [ 25 ]. The literature indicates that lower levels of health literacy contribute to health disparities among rural populations [ 26 , 27 , 28 ]. Evidence points to a need for effective health communication between healthcare organizations and patients to improve health literacy [ 24 ]. However, little research has been done in this area, particularly as it relates to technologically-based interventions to disseminate health information [ 29 ].

Stigma, an undesirable position of perceived diminished status in an individual’s social position, is another challenge that influences healthcare acceptability [ 30 ]. Those who may experience stigma fear negative social consequences in relation to care seeking. They are more likely to delay seeking care, especially among ethnic minority populations [ 31 , 32 ]. Social media presents opportunities for the dissemination of misleading medical information; this runs further risk for stigma [ 33 ]. Stigma is difficult to undo, but research has shown that developing a positive relationship with a healthcare provider or organization can work to reduce stigma among patients, thus promoting healthcare acceptability [ 34 ].

A provider’s attempts to engage patients and empower them to be active decision-makers regarding their treatment has also been shown to improve healthcare acceptability. One study found that patients with heart disease who completed a daily diary of weight and self-assessment of symptoms, per correspondence with their provider, had better care outcomes than those who did not [ 35 ]. Engaging with household family members and involved community healers also mitigates barriers to care, emphasizing the importance of a team-based approach that extends beyond those who typically provide healthcare services [ 36 , 37 ]. One study, for instance, explored how individuals closest to a pregnant woman affect the woman’s decision to seek maternity care; partners, female relatives, and community health-workers were among the most influential in promoting negative views, all of which reduced a woman’s likelihood to access care [ 38 ].

Appropriateness-related barriers to care

Appropriateness marks the dimension of healthcare access that affects a patient’s ability to engage, and according to Levesque et al., is of relevance once all other dimensions (the ability to perceive, seek, reach and pay for) are achieved [ 2 ]. The ability to engage in healthcare is influenced by a patient’s level of empowerment, adherence to information, and support received by their healthcare provider. Thus, barriers to healthcare access that relate to appropriateness are often those that indicate a breakdown in communication between a patient with their healthcare provider. Such breakdown can involve a patient experiencing miscommunication, confrontation, and/or a discrepancy between their provider’s goals and their own goals for healthcare. Appropriateness represents a dimension of healthcare access that is widely acknowledged as an area in need of improvement, which indicates a need to rethink how healthcare providers and organizations can adapt to serve the healthcare needs of their communities [ 39 ]. This is especially true for rural, ethnic minority populations, which disproportionately experience an abundance of other barriers to healthcare access. Culturally appropriate care is especially important for members of minority populations [ 40 , 41 , 42 ]. Ultimately, patients value a patient-provider relationship characterized by a welcoming, non-judgmental atmosphere [ 43 , 44 ]. In rural settings especially, level of trust and familiarity are common factors that affect service utilization [ 45 ]. Evidence suggests that kind treatment by a healthcare provider who promotes patient-centered care can have a greater overall effect on a patient’s experience than a provider’s degree of medical knowledge or use of modern equipment [ 46 ]. Of course, investing the time needed to nurture close and caring interpersonal connections is particularly difficult in under-resourced, time-pressured rural health systems [ 47 , 48 ].

The most effective way to evaluate access to healthcare largely depends on which dimensions are explored. For instance, a population-based survey can be used to measure the barrier of healthcare affordability. Survey questions can inquire directly about health insurance coverage, care-related financial burden, concern about healthcare costs, and the feared financial impacts of illness and/or disability. Many national organizations have employed such surveys to measure affordability-related barriers to healthcare. For example, a question may ask explicitly about financial concerns: ‘If you get sick or have an accident, how worried are you that you will not be able to pay your medical bills?’ [ 49 ]. Approachability and availability dimensions of access are also studied using quantitative analysis of survey questions, such as ‘Is there a place that you usually go to when you are sick or need advice about your health?’ or ‘Have you ever delayed getting medical care because you couldn’t get through on the telephone?’ In contrast, the remaining two dimensions–acceptability and appropriateness–require a qualitative approach, as the social and cultural factors that determine a patient’s likelihood of accepting aspects of the services that are to be received (acceptability) and the fit between those services and the patient’s specific healthcare needs (appropriateness) can be more abstract [ 50 , 51 ]. In social science, qualitative methods are appropriate to generate knowledge of what social events mean to individuals and how those individuals interact within them; these methods allow for an exploration of depth rather than breadth [ 52 , 53 ]. Qualitative methods, therefore, are appropriate tools for understanding the depth of healthcare providers’ experiences in the inherently social context of seeking and engaging in healthcare.

In sum, acceptability- and appropriateness-related barriers to healthcare access are multi-layered, complex and abundant. Ensuring access becomes even more challenging if structural barriers to access are factored in. In this study, we aimed to explore barriers to healthcare access among persons in Montana, a historically underserved, under-resourced, rural region of the US. Montana is the fourth largest and third least densely populated state in the country; more than 80% of Montana counties are classified as non-core (the lowest level of urban/rural classification), and over 90% are designated as health professional shortage areas [ 54 , 55 ]. Qualitative methods supported our inquiry to explore barriers to healthcare access related to acceptability and appropriateness.

Participants

Qualitative methods were utilized for this interpretive, exploratory study because knowledge regarding barriers to healthcare access within Montana’s rural health systems is limited. We chose Montana healthcare providers, rather than patients, as the population of interest so we may explore barriers to healthcare access from the perspective of those who serve many persons in rural settings. Inclusion criteria required study participants to provide direct healthcare to patients at least one-half of their time. We defined ‘provider’ as a healthcare organization employee with clinical decision-making power and the qualifications to develop or revise patients’ treatment plans. In an attempt to capture a group of providers with diverse experience, we included providers across several types and specialties. These included advanced practice registered nurses (APRNs), physicians (MDs and DOs), and physician assistants (PAs) who worked in critical care medicine, emergency medicine, family medicine, hospital medicine, internal medicine, pain medicine, palliative medicine, pediatrics, psychiatry, and urgent care medicine. We also included licensed clinical social workers (LCSWs) and clinical psychologists who specialize in behavioral healthcare provision.

Recruitment and Data Collection

We recruited participants via email using a snowball sampling approach [ 56 ]. We opted for this approach because of its effectiveness in time-pressured contexts, such as the COVID-19 pandemic, which has made healthcare provider populations hard to reach [ 57 ]. Considering additional constraints with the pandemic and the rural nature of Montana, interviews were administered virtually via Zoom video or telephone conferencing with Zoom’s audio recording function enabled. All interviews were conducted by the first author between January and September 2021. The average length of interviews was 50 min, ranging from 35 to 70 min. There were occasional challenges experienced during interviews (poor cell phone reception from participants, dropped calls), in which case the interviewer remained on the line until adequate communication was resumed. All interviews were included for analysis and transcribed verbatim into NVivo Version 12 software. All qualitative data were saved and stored on a password-protected University of Montana server. Hard-copy field notes were securely stored in a locked office on the university’s main campus.

Data analysis included a deductive followed by an inductive approach. This dual analysis adheres to Levesque’s framework for qualitative methods, which is discussed in the Definition of Analytic Domains sub-section below. Original synthesis of the literature informed the development of our initial deductive codebook. The deductive approach was derived from a theory-driven hypothesis, which consisted of synthesizing previous research findings regarding acceptability- and appropriateness-related barriers to care. Although the locations, patient populations and specific type of healthcare services varied by study in the existing literature, several recurring barriers to healthcare access were identified. We then operationalized three analytic domains based on these findings: cultural considerations, patient-provider communication, and provider-provider communication. These domains were chosen for two reasons: 1) the terms ‘culture’ and ‘communication’ were the most frequently documented characteristics across the studies examined, and 2) they each align closely with the acceptability and appropriateness dimensions of access to healthcare, respectively. In addition, ‘culture’ is included in the definition of acceptability and ‘communication’ is a quintessential aspect of appropriateness. These domains guided the deductive portion of our analysis, which facilitated the development of an interview guide used for this study.

Interviews were semi-structured to allow broad interpretations from participants and expand the open-ended characterization of study findings. Data were analyzed through a flexible coding approach proposed by Deterding and Waters [ 58 ]. Qualitative content analysis was used, a method particularly beneficial for analyzing large amounts of qualitative data collected through interviews that offers possibility of quantifying categories to identify emerging themes [ 52 , 59 ]. After fifty percent of data were analyzed, we used an inductive approach as a formative check and repeated until data saturation, or the point at which no new information was gathered in interviews [ 60 ]. At each point of inductive analysis, interview questions were added, removed, or revised in consideration of findings gathered [ 61 ]. The Standards for Reporting Qualitative Research (SRQR) was used for reporting all qualitative data for this study [ 62 ]. The first and third authors served as primary and secondary analysts of the qualitative data and collaborated to triangulate these findings. An audit approach was employed, which consisted of coding completed by the first author and then reviewed by the third author. After analyses were complete, member checks ensured credibility and trustworthiness of findings [ 63 ]. Member checks consisted of contacting each study participant to explain the study’s findings; one-third of participants responded and confirmed all findings. All study procedures were reviewed and approved by the Human Subjects Committee of the authors’ institution’s Institutional Review Board.

Definitions of Analytic Domains

Cultural considerations.

Western health systems often fail to consider aspects of patients’ cultural perspectives and histories. This can manifest in the form of a providers’ lack of cultural humility. Cultural humility is a process of preventing imposition of one’s worldview and cultural beliefs on others and recognizing that everyone’s conception of the world is valid. Humility cultivates sensitive approaches in treating patients [ 64 ]. A lack of cultural humility impedes the delivery of acceptable and appropriate healthcare [ 65 ], which can involve low empathy or respect for patients, or dismissal of culture and traditions as superstitions that interfere with standard treatments [ 66 , 67 ]. Ensuring cultural humility among all healthcare employees is a step toward optimal healthcare delivery. Cultural humility is often accomplished through training that can be tailored to particular cultural- or gender-specific populations [ 68 , 69 ]. Since cultural identities and humility have been marked as factors that can heavily influence patients’ access to care, cultural considerations composed our first analytic domain. To assess this domain, we asked participants how they address the unique needs of their patients, how they react when they observe a cultural behavior or attitude from a patient that may not directly align with their treatment plan, and if they have received any multicultural training or training on cultural considerations in their current role.

Patient-provider communication

Other barriers to healthcare access can be linked to ineffective patient-provider communication. Patients who do not feel involved in healthcare decisions are less likely to adhere to treatment recommendations [ 70 ]. Patients who experience communication difficulties with providers may feel coerced, which generates disempowerment and leads patients to employ more covert ways of engagement [ 71 , 72 ]. Language barriers can further compromise communication and hinder outcomes or patient progress [ 73 , 74 ]. Any miscommunication between a patient and provider can affect one’s access to healthcare, namely affecting appropriateness-related barriers. For these reasons, patient-provider communication composed our second analytic domain. We asked participants to highlight the challenges they experience when communicating with their patients, how those complications are addressed, and how communication strategies inform confidentiality in their practice. Confidentiality is a core ethical principle in healthcare, especially in rural areas that have smaller, interconnected patient populations [ 75 ].

Provider-Provider Communication

A patient’s journey through the healthcare system necessitates sufficient correspondence between patients, primary, and secondary providers after discharge and care encounters [ 76 ]. Inter-provider and patient-provider communication are areas of healthcare that are acknowledged to have some gaps. Inconsistent mechanisms for follow up communication with patients in primary care have been documented and emphasized as a concern among those with chronic illness who require close monitoring [ 68 , 77 ]. Similar inconsistencies exist between providers, which can lead to unclear care goals, extended hospital stays, and increased medical costs [ 78 ]. For these reasons, provider-provider communication composed our third analytic domain. We asked participants to describe the approaches they take to streamline communication after a patient’s hospital visit, the methods they use to ensure collaborative communication between primary or secondary providers, and where communication challenges exist.

Healthcare provider characteristics

Our sample included 12 providers: four in family medicine (1 MD, 1 DO, 1 PA & 1 APRN), three in pediatrics (2 MD with specialty in hospital medicine & 1 DO), three in palliative medicine (2 MDs & 1 APRN with specialty in wound care), one in critical care medicine (DO with specialty in pediatric pulmonology) and one in behavioral health (1 LCSW with specialty in trauma). Our participants averaged 9 years (range 2–15) as a healthcare provider; most reported more than 5 years in their current professional role. The diversity of participants extended to their patient populations as well, with each participant reporting a unique distribution of age, race and level of medical complexity among their patients. Most participants reported that a portion of their patients travel up to five hours, sometimes across county- or state-lines, to receive care.

Theme 1: A friction exists between aspects of patients’ rural identities and healthcare systems

Our participants comprised a collection of medical professions and reported variability among health-related reasons their patients seek care. However, most participants acknowledged similar characteristics that influence their patients’ challenges to healthcare access. These identified factors formed categories from which the first theme emerged. There exists a great deal of ‘rugged individualism’ among Montanans, which reflects a self-sufficient and self-reliant way of life. Stoicism marked a primary factor to characterize this quality. One participant explained:

True Montanans are difficult to treat medically because they tend to be a tough group. They don’t see doctors. They don’t want to go, and they don’t want to be sick. That’s an aspect of Montana that makes health culture a little bit difficult.

Another participant echoed this finding by stating:

The backwoods Montana range guy who has an identity of being strong and independent probably doesn’t seek out a lot of medical care or take a lot of medications. Their sense of vitality, independence and identity really come from being able to take care and rely on themselves. When that is threatened, that’s going to create a unique experience of illness.

Similar responses were shared by all twelve participants; stoicism seemed to be heavily embedded in many patient populations in Montana and serves as a key determinant of healthcare acceptability. There are additional factors, however, that may interact with stoicism but are multiply determined. Stigma is an example of this, presented in this context as one’s concern about judgement by the healthcare system. Respondents were openly critical of this perception of the healthcare system as it was widely discussed in interviews. One participant stated:

There is a real perception of a punitive nature in the medical community, particularly if I observe a health issue other than the primary reason for one’s hospital visit, whether that may be predicated on medical neglect, delay of care, or something that may warrant a report to social services. For many of the patients and families I see, it’s not a positive experience and one that is sometimes an uphill barrier that I work hard to circumnavigate.

Analysis of these factors suggest that low use of healthcare services may link to several characteristics, including access problems. Separately, a patient’s perceived stigma from healthcare providers may also impact a patient’s willingness to receive services. One participant put it best by stating

Sometimes, families assume that I didn’t want to see them because they will come in for follow up to meet with me but end up meeting with another provider, which is frustrating because I want to maintain patients on my panel but available time and resource occasionally limits me from doing so. It could be really hard adapting to those needs on the fly, but it’s an honest miss.

When a patient arrives for a healthcare visit and experiences this frustration, it may elicit a patient’s perceptions of neglect or disorganization. This ‘honest miss’ may, in turn, exacerbate other acceptable-related barriers to care.

Theme 2: Facilitating access to healthcare requires application of and respect for cultural differences

The biomedical model is the standard of care utilized in Western medicine [ 79 , 80 ]. However, the US comprises people with diverse social and cultural identities that may not directly align with Western conceptions of health and wellness. Approximately 11.5% of the Montana population falls within an ethnic minority group. 6.4% are of American Indian or Alaska Native origin, 0.5% are of Black or African American origin, 0.8% are of Asian origin and 3.8% are of multiple or other origins. [ 81 ]. Cultural insensitivity is acknowledged in health services research as an active deterrent for appropriate healthcare delivery [ 65 ]. Participants for this study were asked how they react when a patient brings up a cultural attitude or behavior that may impact the proposed treatment plan. Eight participants noted a necessity for humility when this occurs. One participant conceptualized this by stating:

When this happens, I learn about individuals and a way of life that is different to the way I grew up. There is a lot of beauty and health in a non-patriarchal, non-dominating, non-sexist framework, and when we can engage in such, it is really expansive for my own learning process.

The participants who expressed humility emphasized that it is best to work in tandem with their patient, congruently. Especially for those with contrasting worldviews, a provider and a patient working as a team poses an opportunity to develop trust. Without it, a patient can easily fall out of the system, further hindering their ability to access healthcare services in the future. One participant stated:

The approach that ends up being successful for a lot of patients is when we understand their modalities, and they have a sense we understand those things. We have to show understanding and they have to trust. From there, we can make recommendations to help get them there, not decisions for them to obey, rather views based on our experiences and understanding of medicine.

Curiosity was another reaction noted by a handful of participants. One participant said:

I believe patients and their caregivers can be engaged and loving in different ways that don’t always follow the prescribed approach in the ways I’ve been trained, but that doesn’t necessarily mean that they are detrimental. I love what I do, and I love learning new things or new approaches, but I also love being surprised. My style of medicine is not to predict peoples’ lives, rather to empower and support what makes life meaningful for them.

Participants mentioned several other characteristics that they use in practice to prevent cultural insensitivity and support a collaborative approach to healthcare. Table 1 lists these facilitating characteristics and quotes to explain the substance of their benefit.

Consensus among participants indicated that the use of these protective factors to promote cultural sensitivity and apply them in practice is not standardized. When asked, all but two participants said they had not received any culturally-based training since beginning their practice. Instead, they referred to developing skills through “on the job training” or “off the cuff learning.” The general way of medicine, one participant remarked, was to “throw you to the fire.” This suggested that use of standardized cultural humility training modules for healthcare providers was not common practice. Many attributed this to time constraints.

Individual efforts to gain culturally appropriate skills or enhance cultural humility were mentioned, however. For example, three participants reported that they attended medical conferences to discuss cultural challenges within medicine, one participant sought out cultural education within their organization, and another was invited by Native American community members to engage in traditional peace ceremonies. Participants described these additional efforts as uncommon and outside the parameters of a provider’s job responsibilities, as they require time commitments without compensation.

Additionally, eight participants said they share their personal contact information with patients so they may call them directly for medical needs. The conditions and frequency with which this is done was variable and more common among providers in specialized areas of medicine or those who described having a manageable patient panel. All who reported that they shared their personal contact information described it as an aspect of rural health service delivery that is atypical in other, non-rural healthcare systems.

Theme 3: Communication between healthcare providers is systematically fragmented

Healthcare is complex and multi-disciplinary, and patients’ treatment is rarely overseen by a single provider [ 82 ]. The array of provider types and specialties is vast, as is the range of responsibilities ascribed to providers. Thus, open communication among providers both within and between healthcare systems is vital for the success of collaborative healthcare [ 83 ]. Without effective communication achieved between healthcare providers, the appropriate delivery of healthcare services may be become compromised. Our participants noted that they face multiple challenges that complicate communication with other providers. Miscommunication between departments, often implicating the Emergency Department (ED), was a recurring point noted among participants. One participant who is a primary care physician said:

If one of my patients goes to the ER, I don’t always get the notes. They’re supposed to send them to the patient’s primary care doc. The same thing happens with general admissions, but again, I often find out from somebody else that my patient was admitted to the hospital.

This failure to communicate can negatively impact the patient, particularly if time sensitivity or medical complexity is essential to treatment. A patient’s primary care physician is the most accurate source of their medical history; without an effective way to obtain and synthesize a patient’s health information, there may be increased risk of medical error. One participant in a specialty field stated:

One of the biggest barriers I see is obtaining a concise description of a patient’s history and needs. You can imagine if you’re a mom and you’ve got a complicated kid. You head to the ER. The ER doc looks at you with really wide eyes, not knowing how to get information about your child that’s really important.

This concern was highlighted with a specific example from a different participant:

I have been unable to troubleshoot instances when I send people to the ER with a pretty clear indication for admission, and then they’re sent home. For instance, I had an older fellow with pretty severe chronic kidney disease. He presented to another practitioner in my office with shortness of breath and swelling and appeared to have newly onset decompensated heart failure. When I figured this out, I sent him to the ER, called and gave my report. The patient later came back for follow up to find out not only that they had not been admitted but they lost no weight with outpatient dialysis . I feel like a real opportunity was missed to try to optimize the care of the patient simply because there was poor communication between myself and the ER. This poor guy… He ended up going to the ER four times before he got admitted for COVID-19.

In some cases, communication breakdown was reported as the sole cause of a poor outcome. When communication is effective, each essential member of the healthcare team is engaged and collaborating with the same information. Some participants called this process ‘rounds’ when a regularly scheduled meeting is staged between a group of providers to ensure access to accurate patient information. Accurate communication may also help build trust and improve a patient’s experience. In contrast, ineffective communication can result in poor clarity regarding providers’ responsibilities or lost information. Appropriate delivery of healthcare considers the fit between providers and a patient’s specific healthcare needs; the factors noted here suggest that provider-provider miscommunication can adversely affect this dimension of healthcare access.

Another important mechanism of communication is the sharing of electronic medical records (EMRs), a process that continues to shift with technological advances. Innovation is still recent enough, however, for several of our study participants to be able to recall a time when paper charts were standard. Widespread adoption and embrace of the improvements inherent in electronic medical records expanded in the late 2000’s [ 84 ]. EMRs vastly improved the ability to retain, organize, safeguard, and transfer health information. Every participant highlighted EMRs at one point or another and often did so with an underlying sense of anger or frustration. Systematic issues and problems with EMRs were discussed. One participant provided historical context to such records:

Years back, the government aimed to buy an electronic medical record system, whichever was the best, and a number of companies created their own. Each were a reasonable system, so they all got their checks and now we have four completely separate operating systems that do not talk to each other. The idea was to make a router or some type of relay that can share information back and forth. There was no money in that though, so of course, no one did anything about it. Depending on what hospital, clinic or agency you work for, you will most likely work within one of these systems. It was a great idea; it just didn’t get finished.

Seven participants confirmed these points and their impacts on making coordination more difficult, relying on outdated communication strategies more often than not. Many noted this even occurs between facilities within the same city and in separate small metropolitan areas across the state. One participant said:

If my hospital decides to contract with one EMR and the hospital across town contracts with another, correspondence between these hospitals goes back to traditional faxing. As a provider, you’re just taking a ‘fingered crossed’ approach hoping that the fax worked, is picked up, was put in the appropriate inbox and was actually looked at. Information acquisition and making sure it’s timely are unforeseen between EMRs.

Participants reported an “astronomic” number of daily faxes and telephone calls to complete the communication EMRs were initially designed to handle. These challenges are even more burdensome if a patient moves from out of town or out of state; obtaining their medical records was repeatedly referred to as a “chore” so onerous that it often remains undone. Another recurring concern brought up by participants regarded accuracy within EMRs to lend a false sense of security. They are not frequently updated, not designed to be family-centered and not set up to do anything automatically. One participant highlighted these limitations by stating:

I was very proud of a change I made in our EMR system [EPIC], even though it was one I never should have had to make. I was getting very upset because I would find out from my nursing assistant who read the obituary that one of my patients had died. There was a real problem with the way the EMR was notifying PCP’s, so I got an EPIC-level automated notification built into our EMR so that any time a patient died, their status would be changed to deceased and a notification would be sent to their PCP. It’s just really awful to find out a week later that your patient died, especially when you know these people and their families really well. It’s not good care to have blind follow up.

Whether it be a physical or electronic miscommunication between healthcare providers, the appropriate delivery of healthcare can be called to question

Theme 4: Time and resource constraints disproportionately harm rural health systems

Several measures of system capacity suggest the healthcare system in the US is under-resourced. There are fewer physicians and hospital beds per capita compared to most comparable countries, and the growth of healthcare provider populations has stagnated over time [ 15 ]. Rural areas, in particular, are subject to resource limitations [ 16 ]. All participants discussed provider shortages in detail. They described how shortages impact time allocation in their day-to-day operations. Tasks like patient intakes, critical assessments, and recovering information from EMRs take time, of which most participants claimed to not have enough of. There was also a consensus in having inadequate time to spend on medically complex cases. Time pressures were reported to subsequently influence quality of care. One participant stated:

With the constant pace of medicine, time is not on your side. A provider cannot always participate in an enriching dialogue with their patients, so rather than listen and learn, we are often coerced into the mindset of ‘getting through’ this patient so we can move on. This echoes for patient education during discharge, making the whole process more arduous than it otherwise could be if time and resources were not as sparse.

Depending on provider type, specialty, and the size of patient panels, four participants said they have the luxury of extending patient visits to 40 + minutes. Any flexibility with patient visits was regarded as just that: a luxury. Very few providers described the ability to coordinate their schedules as such. This led some study participants to limit the number of patients they serve. One participant said:

We simply don’t have enough clinicians, which is a shame because these people are really skilled, exceptional, brilliant providers but are performing way below their capacity. Because of this, I have a smaller case load so I can engage in a level of care that I feel is in the best interest of my patients. Everything is a tradeoff. Time has to be sacrificed at one point or another. This compromise sets our system up to do ‘ok’ work, not great work.

Of course, managing an overly large number of patients with high complexity is challenging. Especially while enduring the burden of a persisting global pandemic, participants reflected that the general outlook of administering healthcare in the US is to “do more with less.” This often forces providers to delegate responsibilities, which participants noted has potential downsides. One participant described how delegating patient care can cause problems.

Very often will a patient schedule a follow up that needs to happen within a certain time frame, but I am unable to see them myself. So, they are then placed with one of my mid-level providers. However, if additional health issues are introduced, which often happens, there is a high-risk of bounce-back or need to return once again to the hospital. It’s an inefficient vetting process that falls to people who may not have specific training in the labs and imaging that are often included in follow up visits. Unfortunately, it’s a forlorn hope to have a primary care physician be able to attend all levels of a patient’s care.

Several participants described how time constraints stretch all healthcare staff thin and complicate patient care. This was particularly important among participants who reported having a patient panel exceeding 1000. There were some participants, however, who praised the relationships they have with their nurse practitioners and physician’s assistants and mark transparency as the most effective way to coordinate care. Collectively, these clinical relationships were built over long standing periods of time, a disadvantage to providers at the start of their medical career. All but one participant with over a decade of clinical experience mentioned the usefulness of these relationships. The factors discussed in Theme 4 are directly linked to the Availability dimension of access to healthcare. A patient’s ability to reach care is subject to the capacity of their healthcare provider(s). Additionally, further analysis suggests these factors also link to the Appropriateness dimension because the quality of patient-provider relationships may be negatively impacted if a provider’s time is compromised.

Theme 5: Profits are prioritized over addressing barriers to healthcare access in the US.

The US healthcare system functions partially for-profit in the public and private sectors. The federal government provides funding for national programs such as Medicare, but a majority of Americans access healthcare through private employer plans [ 85 ]. As a result, uninsurance rates influence healthcare access. Though the rate of the uninsured has dropped over the last decade through expansion of the Affordable Care Act, it remains above 8 percent [ 86 ]. Historically, there has been ethical criticism in the literature of a for-profit system as it is said to exacerbate healthcare disparities and constitute unfair competition against nonprofit institutions. Specifically, the US healthcare system treats healthcare as a commodity instead of a right, enables organizational controls that adversely affect patient-provider relationships, undermines medical education, and constitutes a medical-industrial complex that threatens influence on healthcare-related public policy [ 87 ]. Though unprompted by the interviewer, participants raised many of these concerns. One participant shared their views on how priorities stand in their practice:

A lot of the higher-ups in the healthcare system where I work see each patient visit as a number. It’s not that they don’t have the capacity to think beyond that, but that’s what their role is, making sure we’re profitable. That’s part of why our healthcare system in the US is as broken as it is. It’s accentuated focus on financially and capitalistically driven factors versus understanding all these other barriers to care.

Eight participants echoed a similar concept, that addressing barriers to healthcare access in their organizations is largely complicated because so much attention is directed on matters that have nothing to do with patients. A few other participants supported this by alluding to a “cherry-picking” process by which those at the top of the hierarchy devote their attention to the easiest tasks. One participant shared an experience where contrasting work demands between administrators and front-line clinical providers produces adverse effects:

We had a new administrator in our hospital. I had been really frustrated with the lack of cultural awareness and curiosity from our other leaders in the past, so I offered to meet and take them on a tour of the reservation. This was meant to introduce them to kids, families and Tribal leaders who live in the area and their interface with healthcare. They declined, which I thought was disappointing and eye-opening.

Analysis of these factors suggest that those who work directly with patients understand patient needs better than those who serve in management roles. This same participant went on to suggest an ulterior motive for a push towards telemedicine, as administrators primarily highlight the benefit of billing for virtual visits instead of the nature of the visits themselves.

This study explored barriers and facilitators to healthcare access from the perspective of rural healthcare providers in Montana. Our qualitative analysis uncovered five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. Themes 2 and 3 were directly supported by earlier qualitative studies that applied Levesque’s framework, specifically regarding healthcare providers’ poor interpersonal quality and lack of collaboration with other providers that are suspected to result from a lack of provider training [ 67 , 70 ]. This ties back to the importance of cultural humility, which many previous culture-based trainings have referred to as cultural competence. Cultural competence is achieved through a plethora of trainings designed to expose providers to different cultures’ beliefs and values but induces risk of stereotyping and stigmatizing a patient’s views. Therefore, cultural humility is the preferred idea, by which providers reflect and gain open-ended appreciation for a patient’s culture [ 88 ].

Implications for Practice

Perhaps the most substantial takeaway is how embedded rugged individualism is within rural patient populations and how difficult that makes the delivery of care in rural health systems. We heard from participants that stoicism and perceptions of stigma within the system contribute to this, but other resulting factors may be influential at the provider- and organizational-levels. Stoicism and perceived stigma both appear to arise, in part, from an understandable knowledge gap regarding the care system. For instance, healthcare providers understand the relations between primary and secondary care, but many patients may perceive both concepts as elements of a single healthcare system [ 89 ]. Any issue experienced by a patient when tasked to see both a primary and secondary provider may result in a patient becoming confused [ 90 ]. This may also overlap with our third theme, as a disjointed means of communication between healthcare providers can exacerbate patients’ negative experiences. One consideration to improve this is to incorporate telehealth programs into an existing referral framework to reduce unnecessary interfacility transfers; telehealth programs have proven effective in rural and remote settings [ 91 ].

In fact, telehealth has been rolled out in a variety of virtual platforms throughout its evolution, its innovation matched with continued technological advancement. Simply put, telehealth allows health service delivery from a distance; it allows knowledge and practice of clinical care to be in a different space than a patient. Because of this, a primary benefit of telehealth is its impact on improving patient-centered outcomes among those living in rural areas. For instance, text messaging technology improves early infant diagnosis, adherence to recommended diagnostic testing, and participant engagement in lifestyle change interventions [ 92 , 93 , 94 ]. More sophisticated interventions have found their way into smartphone-based technology, some of which are accessible even without an internet connection [ 95 , 96 ]. Internet accessibility is important because a number of study participants noted internet connectivity as a barrier for patients who live in low resource communities. Videoconferencing is another function of telehealth that has delivered a variety of health services, including those which are mental health-specific [ 97 ], and mobile health clinics have been used in rural, hard-to-reach settings to show the delivery of quality healthcare is both feasible and acceptable [ 98 , 99 , 100 ]. While telehealth has potential to reduce a number of healthcare access barriers, it may not always address the most pressing healthcare needs [ 101 ]. However, telehealth does serve as a viable, cost-effective alternative for rural populations with limited physical access to specialized services [ 102 ]. With time and resource limitations acknowledged as a key theme in our study, an emphasis on expanding telehealth services is encouraged as it will likely have significant involvement on advancing healthcare in the future, especially as the COVID-19 pandemic persists [ 103 ].

Implications for Policy

One could argue that most of the areas of fragmentation in the US healthcare system can be linked to the very philosophy on which it is based: an emphasis on profits as highest priority. Americans are, therefore, forced to navigate a health service system that does not work solely in their best interests. It is not surprising to observe lower rates of healthcare usage in rural areas, which may be a result from rural persons’ negative views of the US healthcare system or a perception that the system does not exist to support wellness. These perceptions may interact with ‘rugged individualism’ to squelch rural residents’ engagement in healthcare. Many of the providers we interviewed for this study appeared to understand this and strived to improve their patients’ experiences and outcomes. Though these efforts are admirable, they may not characterize all providers who serve in rural areas of the US. From a policy standpoint, it is important to recognize these expansive efforts from providers. If incentives were offered to encourage maximum efforts be made, it may lessen burden due to physician burnout and fatigue. Of course, there is no easy fix to the persisting limit of time and resources for providers, problems that require workforce expansion. Ultimately, though, the current structure of the US healthcare system is failing rural America and doing little to help the practice of rural healthcare providers.

Implications for Future Research

It is important for future health systems research efforts to consider issues that arise from both individual- and system-level access barriers and where the two intersect. Oftentimes, challenges that appear linked to a patient or provider may actually stem from an overarching system failure. If failures are critically and properly addressed, we may refine our understanding of what we can do in our professional spaces to improve care as practitioners, workforce developers, researchers and advocates. This qualitative study was exploratory in nature. It represents a step forward in knowledge generation regarding challenges in access to healthcare for rural Americans. Although mental health did not come up by design in this study, future efforts exploring barriers to healthcare access in rural systems should focus on access to mental healthcare. In many rural areas, Montana included, rates of suicide, substance use and other mental health disorders are highly prevalent. These characteristics should be part of the overall discussion of access to healthcare in rural areas. Optimally, barriers to healthcare access should continue to be explored through qualitative and mixed study designs to honor its multi-dimensional stature.

Strengths and Limitations

It is important to note first that this study interviewed healthcare providers instead of patients, which served as both a strength and limitation. Healthcare providers were able to draw on numerous patient-provider experiences, enabling an account of the aggregate which would have been impossible for a patient population. However, accounts of healthcare providers’ perceptions of barriers to healthcare access for their patients may differ from patients’ specific views. Future research should examine acceptability- and appropriateness-related barriers to healthcare access in patient populations. Second, study participants were recruited through convenience sampling methods, so results may be biased towards healthcare providers who are more invested in addressing barriers to healthcare access. Particularly, the providers interviewed for this study represented a subset who go beyond expectations of their job descriptions by engaging with their communities and spending additional uncompensated time with their patients. It is likely that a provider who exhibits these behavioral traits is more likely to participate in research aimed at addressing barriers to healthcare access. Third, the inability to conduct face-to-face interviews for our qualitative study may have posed an additional limitation. It is possible, for example, that in-person interviews might have resulted in increased rapport with study participants. Notwithstanding this possibility, the remote interview format was necessary to accommodate health risks to the ongoing COVID-19 pandemic. Ultimately, given our qualitative approach, results from our study cannot be generalizable to all rural providers’ views or other rural health systems. In addition, no causality can be inferred regarding the influence of aspects of rurality on access. The purpose of this exploratory qualitative study was to probe research questions for future efforts. We also acknowledge the authors’ roles in the research, also known as reflexivity. The first author was the only author who administered interviews and had no prior relationships with all but one study participant. Assumptions and pre-dispositions to interview content by the first author were regularly addressed throughout data analysis to maintain study integrity. This was achieved by conducting analysis by unique interview question, rather than by unique participant, and recoding the numerical order of participants for each question. Our commitment to rigorous qualitative methods was a strength for the study for multiple reasons. Conducting member checks with participants ensured trustworthiness of findings. Continuing data collection to data saturation ensured dependability of findings, which was achieved after 10 interviews and confirmed after 2 additional interviews. We further recognize the heterogeneity in our sample of participants, which helped generate variability in responses. To remain consistent with appropriate means of presenting results in qualitative research however, we shared minimal demographic information about our study participants to ensure confidentiality.

The divide between urban and rural health stretches beyond a disproportionate allocation of resources. Rural health systems serve a more complicated and hard-to-reach patient population. They lack sufficient numbers of providers to meet population health needs. These disparities impact collaboration between patients and providers as well as the delivery of acceptable and appropriate healthcare. The marker of rurality complicates the already cumbersome challenge of administering acceptable and appropriate healthcare and impediments stemming from rurality require continued monitoring to improve patient experiences and outcomes. Our qualitative study explored rural healthcare providers’ views on some of the social, cultural, and programmatic factors that influence access to healthcare among their patient populations. We identified five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. This study provides implications that may shift the landscape of a healthcare provider’s approach to delivering healthcare. Further exploration is required to understand the effects these characteristics have on measurable patient-centered outcomes in rural areas.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to individual privacy could be compromised but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate.

All study procedures and methods were carried out in accordance with relevant guidelines and regulations from the World Medical Association Declaration of Helsinki. Ethics approval was given by exempt review from the Institutional Review Board (IRB) at the University of Montana (IRB Protocol No.: 186–20). Participants received oral and written information about the study prior to interview, which allowed them to provide informed consent for the interviews to be recorded and used for qualitative research purposes. No ethical concerns were experienced in this study pertaining to human subjects.

Consent for publication.

The participants consented to the publication of de-identified material from the interviews.

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This research was supported by the Center for Biomedical Research Excellence award (P20GM130418) from the National Institute of General Medical Sciences of the National Institute of Health. The first author was also supported by the University of Montana Burnham Population Health Fellowship. We would like to thank Dr. Christopher Dietrich, Dr. Jennifer Robohm and Dr. Eric Arzubi for their contributions on determining inclusion criteria for the healthcare provider population used for this study.

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

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Coombs, N.C., Campbell, D.G. & Caringi, J. A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res 22 , 438 (2022). https://doi.org/10.1186/s12913-022-07829-2

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Acceptability, values, and preferences of older people for chronic low back pain management; a qualitative evidence synthesis

• Heather Ames 1 ,
• Christine Hillestad Hestevik 1 &
• Andrew M. Briggs 2 , 3  

BMC Geriatrics volume  24 , Article number:  24 ( 2024 ) Cite this article

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Chronic primary low back pain (CPLBP) and other musculoskeletal conditions represent a sizable attribution to the global burden of disability, with rates greatest in older age. There are multiple and varied interventions for CPLBP, delivered by a wide range of health and care workers. However, it is not known if these are acceptable to or align with the values and preferences of care recipients. The objective of this synthesis was to understand the key factors influencing the acceptability of, and values and preferences for, interventions/care for CPLBP from the perspective of people over 60 and their caregivers.

We searched MEDLINE, CINAHL and OpenAlex, for eligible studies from inception until April 2022. We included studies that used qualitative methods for data collection and analysis; explored the perceptions and experiences of older people and their caregivers about interventions to treat CPLBP; from any setting globally. We conducted a best fit framework synthesis using a framework developed specifically for this review. We assessed our certainty in the findings using GRADE-CERQual.

All 22 included studies represented older people’s experiences and had representation across a range of geographies and economic contexts. No studies were identified on caregivers. Older people living with CPLBP express values and preferences for their care that relate to therapeutic encounters and the importance of therapeutic alliance, irrespective of the type of treatment, choice of intervention, and intervention delivery modalities. Older people with CPLBP value therapeutic encounters that validate, legitimise, and respect their pain experience, consider their context holistically, prioritise their needs and preferences, adopt a person-centred and tailored approach to care, and are supported by interprofessional communication. Older people valued care that provided benefit to them, included interventions beyond analgesic medicines alone and was financially and geographically accessible.

Conclusions

These findings provide critical context to the implementation of clinical guidelines into practice, particularly related to how care providers interact with older people and how components of care are delivered, their location and their cost. Further research is needed focusing on low- and middle-income settings, vulnerable populations, and caregivers.

Peer Review reports

Low back pain (LBP) and other musculoskeletal conditions represent a sizable contribution to the global burden of disability [ 1 , 2 , 3 , 4 , 5 ]. While the prevalence and impact of LBP are relevant across the life-course, global estimates for prevalence and disability show rates to be greatest in older age. The high prevalence of LBP in older people accounts for frequent care seeking for LBP [ 6 ], particularly among older adults experiencing recurrent LBP [ 7 ]. The number of older people experiencing and seeking care for LBP is expected to increase due to population ageing and an increasing prevalence of risk factors for noncommunicable diseases [ 8 ]. Despite this, intervention trials and clinical guidelines for LBP disproportionately underrepresent older people [ 9 , 10 ], potentially leaving an important knowledge gap for optimal care of LBP in older people.

Clinical management of LBP is characterized by multiple and varied interventions, delivered by a wide range of health and care workers [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ]. In many contexts the interventions delivered may not be aligned with best evidence leading to unwarranted care variation and potential harm. Further, interventions may not be aligned with the values, preferences and acceptability attitudes among care recipients (and/or their carers), substantiating the need for global guidelines in this area [ 21 ]. Importantly, values and preferences of older people likely differ to younger adults. From the perspective of healthy ageing, carers are an essential workforce for supporting functional ability in older people and enabling ageing in place. The perspectives of carers are therefore critical to ensure care planning and delivery for any health condition experienced by an older people is feasible and acceptable and does not negatively impact on the quality of life of the carer [ 22 , 23 ] . For example, recent work has also identified the need to sample perspectives of carers related to delivery of care for people living with chronic pain [ 24 ].

In response to this context and the priority to support healthy ageing, the World Health Organization (WHO) initiated the development of standard clinical guideline for the non-surgical management of chronic primary LBP (CPLBP) in adults, including older people, in primary and community care settings in 2020 [ 21 ]. The guidelines were published in December 2023 [ 25 ].

This qualitative evidence synthesis was commissioned in parallel to several systematic reviews of evidence of benefits and harms of prioritized interventions for the Guideline, synthesized from randomized controlled trials (RCTs) [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ]. These interventions were broad in scope, intensity and setting for delivery (reflected in the inclusion criteria for this synthesis). The aim of all the interventions is to improve health and wellbeing outcomes for people living with CPLBP. However, it is important to explore how this broad variation in interventions is perceived and experienced by older people with CPLBP and/or their caregivers (formal or informal, family members). Are some interventions more accepted than others? Are there differences between the interventions and/or access to them related to equity (gender, culture, place of residence, socio economic status) or setting (geographic or health care setting)? These important context questions can only be comprehensively answered using qualitative research methods. These contextual data are intended to support the development of the WHO guideline and complement additional perspectives brought to the development process by other stakeholders involved in the guideline development, consistent with WHO guideline development methods [ 45 ].

It is important to consider people’s preferences around interventions when formulating and implementing clinical management guidelines. In this paper we use the concept of person-centred care, in order to encompass a broader perspective than those related to being a patient. We have adopted the definition of person-centred care that is used in the WHO Guideline, that is “Person-centred care means eliciting an individual’s values, preferences and priorities: once expressed, they should guide all aspects of that person’s health care, supporting their personalized health and life goals” [ 46 , 47 ].

An intervention may be proven effective but if it is not accepted by people living with the condition (and/or their carers) or they feel it causes burden or harm, it will not be adopted. An important step in a WHO guidelines development process is to consider what people living with CPLBP and their caregivers find acceptable? Feasible? Valued? [ 45 ] For example, there is a need to understand preferences and perspectives concerning accessibility, availability, affordability, perceived quality, burden [time, distance, frequency of visits], stigma, duration of therapeutic effect, person/patient’s role (passive or active role), immediacy of treatment effect, configuration of the care team– single practitioner or team approach, influence on comorbid health conditions, and symptoms related to the treatment. Some of these dimensions of value, preference and acceptability have been identified as previously as important to decision-making around treatments among older adults with osteoarthritis [ 48 ]. To date there has been some research conducted that considers people’s preferences for treatment for CPLBP [ 49 , 50 , 51 , 52 , 53 , 54 , 55 ]. However, to our knowledge, there has been no synthesis of primary qualitative research exploring the key factors influencing the implementation, uptake, and experience of interventions designed to manage CPLBP from the perspective of people aged over 60 and their caregivers.

The objective of this qualitative evidence synthesis (QES) was to understand the key factors influencing the acceptability of, and values and preferences/perspectives for, interventions/care for CPLBP from the perspective of people over 60 and their caregivers. The purpose of the QES was to inform the development of the WHO guideline [ 25 ].

This QES followed the best practice as described by the Cochrane collaboration in their handbook [ 56 , 57 ]. The protocol was registered on PROSPERO at inception ( https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=328469 ).

We included primary studies with qualitative study designs. We included mixed-methods studies when it was possible to extract the data that were collected and analysed using qualitative methods. The inclusion criteria are described in Table  1 .

We searched in two databases (MEDLINE and CINAHL powered by Ovid) (April 28, 2022) and supplemented the search with a search in an open-source dataset, OpenAlex [ 59 , 60 ] (May 3, 2022) through the EPPI-Reviewer platform [ 59 ]. We also screened the references of the included studies. Finally, we asked members of the WHO Guideline Development Group to recommend any relevant research they were aware of.

To maximise efficiency of the study selection process, we used the machine learning function “priority screening” in the systematic review software EPPI-reviewer [ 61 ].

Two review authors (HA and CHH) independently assessed eligibility of the titles and abstracts. We retrieved the full text of all the papers identified as potentially relevant. Two authors (HA and CHH) then assessed the eligibility of these papers independently. Discrepancies in decisions were resolved by discussion among the authors.

Data extraction was performed using a data extraction form designed specifically for this review. One author performed the data extraction and a second author checked for accuracy against the source paper and any discordances were resolved through consensus discussion. We extracted the following information from the studies; author, year of publication, geographic setting, description of context, data collection methods (sampling, collection, and analysis), description of participants covering the aspects named in the inclusion table (see Table 1 ) and if ethics approval was given for the study.

We assessed the methodological limitations of the included studies using a list of domains iteratively developed by the Cochrane EPOC group [ 62 , 63 , 64 , 65 ]. We did not exclude studies based on our assessment of methodological limitations but used the information about methodological limitations to assess our confidence in the review findings.

We analysed the data by conducting a best fit framework synthesis [ 66 , 67 , 68 , 69 ]. Best fit framework synthesis is a qualitative synthesis method that blends deductive and inductive synthesis and analysis processes. As part of the synthesis method, review authors identify a conceptual framework that fits at least 50% of the data. After data extraction, data that does not fit within the framework is further analysed in order to develop a new framework that includes all of the data. We used the themes identified in the scoping review on older adults’ perceptions and experiences of integrated care by Lawless et al. [ 70 ], a conceptual framework from Chua et al. on choosing interventions for hip or knee osteoarthritis [ 48 ] as well as the PROGRESS Plus framework that addresses issues related to equity [ 71 ] to generate an a priori theoretical framework. We chose these frameworks as they were relevant to the topic we were exploring and expected to cover at least 50% of the data. The PROGRESS+ framework [ 71 ] was added to address the specific needs of the WHO guidelines process around equity, gender and human rights. HA moved the extracted data into the framework and CHH checked the data. We then analysed the data within each framework section and developed our findings. Relevant data that did not fit into the framework were analysed thematically. We used a thematic analysis approach as described by Miles and Huberman [ 72 ] as referred to in Carroll 2013 [ 66 ] in their paper on best fit framework synthesis. New themes were generated based on our interpretation of the evidence and constant comparison of the new themes across the included studies. In accordance with best fit framework synthesis methods, we inductively expanded the a priori framework to include a section on person-centred care and communication to reflect the breadth of all our findings.

Findings were then organized according to the domains defined in the WHO Handbook for Guideline Development that inform the determination of a recommendation, derived from qualitative evidence, including values and preferences, resource implications, equity and human rights, acceptability and feasibility (See Table  2 ).

Finally, we assessed our confidence in the findings using GRADE-CERQual [ 73 ]. We present detailed descriptions of our confidence assessment in Evidence Profile(s) [ 74 ].

In each section we present the summary of findings table and a summary of the main points discussed in the findings. For specific findings and our confidence in them please refer to Tables  4 - 9 (Summary of Qualitative Evidence Tables).

Review author reflexivity

Neither Heather Ames (HA), Christine Hillestad Hestevik (CHH) or Andrew Briggs (AMB) have reached the age of 60, so we do not understand the lived experience of being an older adult. HA is a previous elite athlete who has experience with chronic musculoskeletal pain and interventions due to injury and AMB has experience of chronic musculoskeletal pain. Both HA and AMB’s parents are over 60, have experienced chronic pain and have discussed their treatments with them. All authors support an evidence-based medicine approach to care. AMB is a clinician, researcher, and health systems professional in the field of chronic musculoskeletal pain. CHH does not have personal experience with chronic musculoskeletal pain or treatment interventions. She did her PhD on healthcare provided to older people from the perspectives of older persons, their family caregivers and healthcare professionals and has some experience with older persons experiences with encounters when in need of healthcare. These prior experiences, particularly a lived experience of chronic musculoskeletal pain, lead us to believe in the difficulties older people are facing. It also felt like the topics that were being raised were familiar from the perspective of personal and research experience.

From a yield of 1878 unique citations, 22 studies were included in this review, reflected in 24 reports. See Fig.  1 for the study selection process. For a description of the included studies see Table  3 .

Study selection flowchart

The included studies were conducted in the United States ( n  = 8) [ 53 , 54 , 78 , 90 , 91 , 93 , 94 , 96 ], United Kingdom ( n  = 3) [ 77 , 79 , 92 ], Germany ( n  = 2) [ 85 , 86 ], Sweden ( n  = 2) [ 75 , 87 ], Australia ( n  = 2) [ 84 , 88 , 89 ], Canada ( n  = 1) [ 80 ], Chile ( n  = 1) [ 95 ], Brazil ( n  = 1) [ 76 ], and Nigeria ( n  = 2) [ 81 , 82 , 83 ]. One study focused on Aboriginal Australians, a vulnerable population [ 88 , 89 ]. In 14 of the studies all participants were aged 60 or older [ 53 , 54 , 77 , 80 , 84 , 85 , 86 , 87 , 90 , 91 , 93 , 94 , 95 , 96 ]. In five, the mean or median age of the participants were 60 or older [ 75 , 76 , 78 , 79 , 92 ]. Three studies were included under the inclusion criteria for age for a low or middle-income country or identified vulnerable population [ 75 , 81 , 82 , 83 , 88 , 89 ]. In these studies, the age of the participants ranged from 26 to 72 years, but we only used disaggregated results from participants aged 40 or above.

In 16 of the studies, the participants were community-dwelling older adults [ 53 , 54 , 76 , 77 , 78 , 80 , 81 , 82 , 83 , 87 , 88 , 89 , 90 , 91 , 93 , 94 , 95 , 96 ]. Three of the studies were conducted in a primary health care setting but the residence of the participants was not discussed [ 75 , 85 , 86 ]. In three studies, the setting was unclear so we could not define the residence of the participants [ 79 , 84 , 92 ]. Nine of the studies were nested in a trial or a larger feasibility study [ 53 , 54 , 84 , 86 , 90 , 91 , 92 , 93 , 94 ].

We did not identify any studies that explored the perceptions or experiences of caregivers (formal or informal, family members).

Acceptability, values, and preferences

Since there was a large overlap in evidence related to values and preferences and acceptability, the findings are presented pooled. Values and preferences extended to interactions with health care providers, interventions for CPLBP and the modes of care delivery for CPLBP. Sixteen studies from 11 countries contributed to these findings (USA, Germany, Australia, United Kingdom, England, Scotland, Canada, Nigeria, Sweden, Brazil, and Chile). Participants in nine studies were all over 60 [ 54 , 77 , 80 , 85 , 87 , 91 , 93 , 95 , 96 ]. Four studies had participants with a mean or average age of 60 or older [ 75 , 76 , 79 , 92 ] and four studies were from LMICs or vulnerable populations [ 76 , 81 , 82 , 83 , 88 , 89 ] of which three were included based on a lowered age threshold [ 81 , 82 , 83 , 88 , 89 ]. In 13 of the studies most of the participants were women (53–83%) [ 54 , 75 , 76 , 77 , 79 , 80 , 81 , 82 , 85 , 87 , 91 , 93 , 95 , 96 ]. In two studies [ 83 , 92 ] there was an equal distribution of men and women. In one study most participants were men (52–66% men) [ 88 , 89 ].

Interactions with health care providers

Most participants wanted their health care providers to collaborate and work together to provide holistic care for their CPLBP. There was a preference among participants for providers who were respectful, caring, person-centred, collaborative, open to discussing treatment options and provided individualized care. They preferred health care providers who recognized them and their pain as individual and unique. This type of care allowed them to feel safe and feel they had meaningful relationships. When this was lacking, they could feel frustrated, vulnerable and experience a sense of aloneness (high confidence) [ 75 , 79 , 83 , 88 , 89 , 91 , 93 , 95 , 96 ].

Participants generally emphasized the care should be person-centred and provide continuity. They also identified a preference for a collaborative communication style which meant involving the older person in discussions about diagnosis and treatment options and viewing them as the expert on their own body (low confidence) [ 77 , 79 , 80 , 88 , 91 ].

Participants wanted collaboration and communication across their care teams to ensure co-ordinated care delivery and avoid duplication in care or diagnostics (moderate confidence) [ 75 , 88 , 91 ]. Some participants felt that they often received conflicting advice or information from health care providers. Participants valued receiving a diagnosis as this influenced their treatment decisions. The way the diagnosis was communicated could also shape their beliefs and responses to pain (moderate confidence) [ 76 , 79 , 81 , 83 , 85 , 89 , 91 , 92 , 95 ]. Some participants expressed dissatisfaction with health care providers for being unwilling to discuss treatment options other than medication (low confidence) [ 75 , 93 , 96 ]. The summary of findings is presented in Table  4 .

Values and preferences for CPLBP interventions in older people

Participants had clear values and preferences for how they chose a specific treatment for CPLBP. A choice of treatment could be influenced by previous experiences. Participants valued treatments that they viewed as effective, beneficial, and credible and fit them as individuals (high confidence) [ 53 , 54 , 79 , 80 , 81 , 82 , 84 , 85 , 86 , 87 , 93 , 95 , 96 ].

Most participants used and valued medication for its ability to provide short-term pain relief. However, many participants did not like the side effects associated with medications or the way the medication(s) made them feel (moderate confidence) [ 53 , 78 , 79 , 91 , 93 , 96 ]. Many also feared addiction, especially in relation to opioid analgesics. In some cases, participants adjusted or stopped medication without consulting their health care provider because of fears of adverse events (moderate confidence) [ 53 , 79 , 91 , 96 , 97 ].

Mindfulness and meditation encouraged participants to examine, assess, understand, and accept their pain rather than avoid it. Participants were able to use mindfulness and meditation for pain management and coping to varying degrees (moderate confidence) [ 54 , 90 , 94 ]. The summary of the findings is presented in Table  5 .

Format of interventions and educational materials for CPLBP in older people

Participants discussed their experiences with, and views of, organized and unorganized physical therapies and activities. Specific physical interventions were rarely mentioned. For many participants, physical activity was an important aspect of coping with their CPLBP. Many participants preferred a group format for physical exercises as it facilitated social support, collaboration and encouraged increased attendance (moderate confidence) [ 54 , 79 , 80 , 81 , 82 , 85 ]. Some participants also expressed preferences for educational material for physical interventions which had drawings and descriptions of the exercises. This made them more comprehensible, easier to follow and helpful for present and future reference (low confidence) [ 79 , 81 , 82 , 85 , 86 ].

Peer support interventions appeared to be acceptable and valued by some older people. They were seen as an acceptable way of gaining support and sharing information or advice. Participants mostly viewed peer support as feasible as it could be delivered through several different modalities (for example, face to face, in groups or online) that would fit individual preferences and lifestyles. However, it was clear that peer support was difficult to find and access in some settings, although appeared to be valued as a component of overall self-management of a CPLBP experience (low confidence) [ 77 , 78 , 80 , 92 , 96 ] [ 77 , 78 , 80 , 92 , 96 ].. The summary of the findings is presented in Table  6 .

Cost/resources related to CPLBP care in older people

Seven studies from five countries contributed to these findings (USA, Australia, England, Nigeria, and Sweden). Participants in three studies were all over 60 [ 53 , 84 , 91 ], two studies had participants with a mean or average age of 60 or older [ 75 , 79 ] and two studies were from LMICs or vulnerable populations of which both were included based on a lowered age threshold [ 83 , 88 , 89 ]. In five of the studies most of the participants where women (55–100%) [ 53 , 75 , 79 , 84 , 91 ]. In one study there was an equal distribution between men and women [ 83 ]. In one study most participants were men (66%) [ 88 , 89 ].

We found that cost and resources could be a barrier to accessing care for CPLBP for some participants. High costs (financial, time and travel) could render treatments inaccessible to participants or acts as a deterrent (moderate confidence) [ 53 , 79 , 83 , 91 ]. Many also preferred health care providers near where they lived to minimise travel burden. However, some participants were willing to travel if a trusted or favoured provider relocated, or they wanted to explore new treatment options. Others chose to find a new practitioner closer to them in this situation (moderate confidence) [ 53 , 75 , 79 , 83 , 84 , 88 , 91 ]. The summary of the findings is presented in Table  7 .

Feasibility

Twelve studies from eight countries contributed to these findings (USA, Canada, UK, Australia, England, Scotland, Nigeria, Chile). Participants in seven studies were all over 60 [ 53 , 77 , 80 , 84 , 91 , 95 , 96 ]. Three studies had participants with a mean or average age of 60 or older [ 78 , 79 , 92 ] and two studies were from LMICs or vulnerable populations of which both were included based on a lowered age threshold [ 81 , 82 , 83 ]. In 10 of the studies most of the participants where women (62–100%) [ 53 , 77 , 78 , 79 , 80 , 81 , 82 , 84 , 91 , 95 , 96 ]. In two studies there was about an equal distribution between men and women [ 83 , 92 ].

Some participants found information about treatments difficult to access and wanted help finding it or navigating the information from a health or care worker or through a peer support system. They felt that this could help them make decisions (low confidence) [ 78 , 79 , 84 , 92 , 96 ].

Physical activity and/or exercise was used a part of a self-management strategy for many participants. Activities such as swimming and walking were often mentioned as being done in their own time and when it fit their schedule. Some participants adopted physical exercise, assistive products, or alternative forms of treatment to supplement the conventional treatments they were receiving or when they felt “conventional treatments” failed. However, some did not inform their health care providers about their self-management strategies or changes they had made (moderate confidence). The summary of findings is presented in Table  8 .

Equity and human rights

Seven studies from six countries contributed to this finding (USA, Canada, UK, England, Scotland, and Sweden, Brazil). Participants in four studies were all over 60 [ 77 , 80 , 91 , 93 ] and three studies had participants with a mean or average age of 60 or older [ 75 , 79 , 92 ]. In six of the studies most of the participants were women [ 75 , 77 , 79 , 80 , 91 , 93 ]. In one study there was an equal distribution of men and women [ 92 ].

Some participants perceived age-related stigma or bias when accessing healthcare for their CPLBP. They reported feeling that they were treated differently, dismissed, or discriminated against because of their age. They felt they were not taken seriously. This perceived stigma could deter them from seeking further treatment. However, in other cases participants believed that they were taken more seriously as they aged (Low confidence). The summary of the finding is presented in Table  9 .

Additions to the framework

To incorporate all the data we analysed we expanded the framework to include a section we labelled person centred care.

Main findings

Based on this synthesis of qualitative evidence derived from more than 650 older participants across 22 studies with representation across a range of geographies and economic contexts, we identified that older people living with CPLBP express values and preferences for their care that relate to therapeutic encounters and the importance of therapeutic alliance, irrespective of the type of treatment offered or delivered, choice of intervention, and intervention delivery modalities. Older people with CPLBP value therapeutic encounters that validate, legitimise, and respect their pain experience; that consider their context holistically and prioritise their needs and preferences; that adopt a person-focused and tailored approach to care; and that are supported by interprofessional communication. Older people value care that provides benefit to them, that includes a suite of interventions beyond analgesic medicines alone, and that is financially and geographically accessible. These findings provide critical context to service delivery models for older people; formulation of recommendations for guidelines that relate to older people; and service considerations for the implementation of clinical guidelines into practice, particularly related to how health care workers interact with older people, with attention to potential age-related bias, and how components of care are delivered.

Person-centred care for older adults living with CPLBP

Many older people felt that healthcare providers did not legitimise their pain and that pain was deprioritised relative to other health conditions. Musculoskeletal pain, including CPLBP, is a common experience in older people [ 98 , 99 ] and a very frequent co-morbidity with other noncommunicable diseases [ 100 ]. Therefore, pain assessment is a key component of the WHO Integrated Care for Older People (ICOPE) assessment and care pathway [ 101 ]. Comorbidities more strongly associated with mortality or acute health declines can make it difficult for health professionals to prioritise symptoms of CPLBP in time-limited clinical encounters. There seems to be a difference between patient and care provider priorities when it comes to pain management and our findings point to the need to legitimise and respond to pain as this clearly is a priority for older people, consistent with recently reported evidence [ 55 ]. Our findings point to the importance of the therapeutic relationship and communication between older people and care providers to understand the impact of, and preference for, CPLBP care. Older people also experienced issues linked to equity during the therapeutic encounter. These could be expressed through ageism and stigma associated with CPLBP. Being told to ‘just live with it’, or the idea that CPLBP was an inevitable part of ageing were common and suggest a potential age-related bias among healthcare providers. Being aware of potential clinician bias related to chronic pain in older people is important, since ageism is associated with poorer health outcomes, particularly in low resource settings [ 102 ].

The needs and priorities of older people may well differ to younger adults (e.g. return to work, taking care of dependents, intensity of everyday activities or sport may be less important for older people). There are previous findings of the perceived needs of adult groups with CPLBP [ 103 , 104 ]. Consistent with other reviews among adults, we identified that older people value clear and consistent information, a clear diagnosis, prognosis, and a communication style that is meaningful and avoids jargon [ 105 ]. Communication that emphasises disability or impairments can be unhelpful to fostering pain self-efficacy, contribute to fear, unhelpful care seeking and further compound disability [ 106 , 107 , 108 , 109 ], which will foster healthy ageing. Rather, providing empowering and positive communication that is validating, helping to make sense of pain and the likelihood of a positive prognosis, providing cognitive reassurance and clear information about benefits and harms of interventions (in particular, medicines) can support shared decision-making, positive behaviour change towards effective self-management, and better engagement in meaningful activities [ 110 ]; all important for supporting healthy ageing.

We identified a preference for integrated and coordinated CPLBP care across care providers and facilities, consistent with the WHO ICOPE model [ 101 ]. This includes holistic care planning with comprehensive assessments and care plans aligned with the person’s values, priorities and preferences concerning their care. The older person should be involved with decision-making and goal-setting from the the start of their care journey. The care should be regular and include sustained follow-up, with integration and communication across different levels of care. This approach to care can help to avoid unnecessary treatments, polypharmacy and other potential harms [ 47 , 110 ]. Our findings about fears of side effects, dependency and medicine withdrawal or non-adherence also points to the need for clinicians to take time to explain risk-benefits of different medicines so that older people understand what medicines are for and how to use them safely.

Values and preferences were largely agnostic to intervention modality, other than values relating to medicines, where specific issues related to fear of adverse events were observed. Although analgesic medicines were considered important for CPLBP care, older people preferred care packages that extend beyond analgesia so that care is more holistic and considers safety (e.g. issues of dependency for opioid analgesics) and that were meaningful and personally enjoyable – such as social benefits of group exercise. Recent evidence points to the importance of considering pharmacologic and non-pharmacologic therapies for CPLBP care, consistent with the experiences, values and preferences of older people [ 97 ]. Other evidence highlights care needs also extend beyond biomedical domains [ 24 , 103 ]. Specifcally, tailoring components of care that addresses pain, emotional and social wellbeing, consistent with WHO ICOPE [ 101 ] model for improving functional ability, is important.

Implementing and delivering care for older people living with CPLBP

When developing, implementing, and delivering interventions for older people who experience functional disability related to musculoskeletal pain (or other co-morbidities), consideration of economic, social, and cultural contexts is critical. Many experienced financial and geographic barriers to care. Access to care that is expensive (or not included in UHC or insurance rebates), that requires travel, or accessing buildings that are not adapted for people experiencing functional disability can be problematic. This threat is more severe for those living in poverty without access to healthcare or who cannot afford to access healthcare near them, such as in low-resource settings. This lack of access may lead to worse outcomes for older people living in these settings, widening inequities in access to health care and health outcomes. Services also need to consider the user’s social context [ 111 ]. If not taken into account, pain care is likely to be inequitable and inaccessible. Support needs to go beyond the purely biomedical (especially focusing on medication) and encompass interventions that address peer support and socialization as well as issues around acceptability and stigma. Interventions should be tailored to local contexts to increase social and cultural approval. Some of the interventions included in this synthesis, such as exercise, were stigmatized in some settings [ 81 , 82 , 83 ]. Other research has also found that stigma can be associated with gender [ 112 ] or with interventions targeted at older people [ 113 ].

Older people also wanted support for the implementation of interventions such as guidance on how to perform exercises in the form of drawings and text. None of the studies we included talked about digital supports except for those related to peer support where digital meetings were discussed. While some formative evidence exists around the role of digital technologies to support healthy ageing [ 114 , 115 , 116 ], further research is required to understand users’ perspectives, benefits and harms in different contexts and among different population groups. Other research has also shown the acceptability of peer support in older adults with CPLBP [ 117 ]. Research on older people has found that they access digital tools but may face barriers such as physical mobility, sight and hearing impairment and low digital literacy when trying to use them [ 118 , 119 , 120 ]. Studies examining the use of digital tools for interventions for low back pain not limited to older people have found that users value models that are easily understandable, provide an opening to further communication with health care providers, family and colleagues and can provide prompts, reassurance, ongoing support and interaction with other users [ 121 , 122 ].

These empirical findings hold direct relevance to the formulation of recommendations in guidelines and implementation of recommended care within service models and local care pathways. In this context, the current QES has informed the development of the WHO Guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings  [ 25 ]. Without consideration of the fundamental EtD factors (Table 2 ) and the evidence underpinning each when formulating recommendations for guidelines or implementation plans for service models, as presented in our QES, care recipients (and in some cases, care providers) may not accept or be able to access care, manifesting as an enduring disease burden and inequity in health outcomes. The QES findings, when coupled with evidence for benefit, harm, cost effectiveness and implementation feasibility and lived experience perspectives that contribute to co-creation of solutions (care recommendations, service models, care pathways) that are more likely to be implemented, sustainable and acceptable [ 123 ]. Indeed, consideration of qualitative evidence anchored to EtD domains is common practice for WHO guidelines [ 45 ].

Implications for research

There was a clear lack of research from low- and middle-income settings as well as vulnerable populations in all settings. Most of the included studies explored the perceptions of community dwelling older adults. More research on the experiences of older adults living in residential care or other settings could help to broaden our understanding. Very few of the studies explored perceptions of specific interventions. Most looked at treatment across interventions and participants did not differentiate between interventions in the same way a health care provider would. For example, participants viewed the visit to the physiotherapist as the intervention whereas health care providers would view each of the treatments received as individual interventions. One topic not frequently discussed in the included studies was cost and out of pocket expenses. This may be because several studies were conducted as part of a trial where participants did not pay to access the intervention. Cost was also rarely discussed in studies taking place in publicly funded health care systems. Understanding affordability of care, willingness to pay and inequities in access to care due to cost will be important in planning implementation of health services for CPLBP care for older people. Further research is also needed on the perspectives and experiences of caregivers as there were no studies identified that explored this topic of interest.

Implications for practice

The questions that form our implications for practice are derived from our findings with moderate or high confidence. They may help health system or program managers to plan, implement or manage interventions for CPLBP. It is important to consider local contextual factors including gender, age, cultural group, and education when implementing interventions.

Is the burden to access services low (financial, time and travel)? Have issues related to burden and equity of access been considered?

When planning, implementing, or managing an intervention for CPLBP or communicating with people over 60 with CPLBP:

◦ have participants values and preferences been explored and taken into consideration?

◦ are participants informed about the physical exercise or physical supports available to them?

When communicating with adults over 60 with CPLBP, have values and preferences been considered, regarding:

◦ communication, cultural preferences, and health care provider collaboration?

◦ receiving a diagnosis and preferences for information?

When prescribing medication, do health care workers provide open and honest communication with their patients about medications, the risk of side effects, and the risk of dependency, inviting them to return with concerns and informing of the importance of working together to manage their medications?

Older people with CPLBP value therapeutic encounters that legitimise and respect their pain experience, that consider their context holistically and prioritises their needs and preferences, that is tailored, and that is supported by interprofessional communication. Older people value care that provides benefit, that includes interventions beyond analgesic medicines alone, and that is financially and geographically accessible. These findings provide critical context to the implementation of clinical guidelines and service models into practice, particularly related to how care providers interact with older people and how components of care are delivered and their accessibility.

Availability of data and materials

All the studies in this synthesis are published and available. The data that is in each finding is available in an interactive Summary of Qualitative Findings table. For access to this tool please send an email to the corresponding author.

Abbreviations

Chronic primary low back pain

• Low back pain
• Qualitative evidence synthesis

Randomised controlled trial

Universal health coverage

Integrated care for older people

World health organization

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Acknowledgements

We would like to acknowledge our search specialist Elisabet Hafstad for her expertise in developing and conducting the search for this synthesis.

Open access funding provided by Norwegian Institute of Public Health (FHI) This synthesis was commissioned and funded by the WHO to contribute to a guidelines process. The lead authors (HA and CHH) discussed the synthesis objectives and inclusion criteria with the commissioner. HA and CHH independently conducted the synthesis and came to the findings.

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All authors conceptualised the synthesis and wrote the protocol. HA and CHH conducted the search, study selection, analysis, and decision on findings. AMB was not involved in data extraction or synthesis. AMB acted as a subject expert during the synthesis process and connecting the findings of the synthesis to the broader field. All authors were involved in drafting this manuscript.

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HA is an anthropologist and health systems research who has been working with qualitative evidence synthesis since 2013. She is a senior researcher at the Norwegian Institute of Public Health and an Associate convener with the Cochrane Qualitative and Implementation Methods Group.

CHH is a health systems researcher with a speciality within nutrition. She has been working with qualitative evidence synthesis since 2018. She is a senior advisor at the Norwegian Institute of Public Health where she specialises in conducting systematic reviews.

AMB is a consultant to the WHO, supporting the development of the WHO Guideline on chronic primary low back pain in adults. He is also a health systems and services researcher and practicing physiotherapist.

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Supplementary Information

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Search strategy.

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Machine learning plan.

Additional file 3.

Excluded full text studies with reason.

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Evidence profile table.

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Final adapted framework.

Additional file 6.

ENTREQ Checklist.

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Ames, H., Hestevik, C.H. & Briggs, A.M. Acceptability, values, and preferences of older people for chronic low back pain management; a qualitative evidence synthesis. BMC Geriatr 24 , 24 (2024). https://doi.org/10.1186/s12877-023-04608-4

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Evidence synthesis – Indigenous people’s experiences of primary health care in Canada: a qualitative systematic review

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Geneveave Barbo, RN, MN, MClSc Author reference footnote 1 ; Sharmin Alam, MA Author reference footnote 2

https://doi.org/10.24095/hpcdp.44.4.01

This article has been peer reviewed.

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Research article  by Barbo G et al. in the HPCDP Journal licensed under a  Creative Commons Attribution 4.0 International License

Geneveave Barbo, College of Nursing, University of Saskatchewan, Health Science Building - 1A10, Box 6, 107 Wiggins Road, Saskatoon, SK  S7N 5E5; Tel: 306-966-6221; Email: [email protected]

Barbo G, Alam S. Indigenous people’s experiences of primary health care in Canada: a qualitative systematic review. Health Promot Chronic Dis Prev Can. 2024;44(4):131-51. https://doi.org/10.24095/hpcdp.44.4.01

Introduction: Indigenous people in Canada encounter negative treatment when accessing primary health care ( PHC ). Despite several qualitative accounts of these experiences, there still has not been a qualitative review conducted on this topic. In this qualitative systematic review, we aimed to explore Indigenous people’s experiences in Canada with PHC services, determine urban versus rural or remote differences and identify recommendations for quality improvement.

Methods: This review was guided by the Joanna Briggs Institute’s methodology for systematic reviews of qualitative evidence. MEDLINE, CINAHL , PubMed, PsycInfo, Embase and Web of Science as well as grey literature and ancestry sources were used to identify relevant articles. Ancestry sources were obtained through reviewing the reference lists of all included articles and determining the ones that potentially met the eligibility criteria. Two independent reviewers conducted the initial and full text screening, data extraction and quality assessment. Once all data were gathered, they were synthesized following the meta-aggregation approach (PROSPERO CRD 42020192353).

Results: The search yielded a total of 2503 articles from the academic databases and 12 articles from the grey literature and ancestry sources. Overall, 22 articles were included in this review. Three major synthesized findings were revealed—satisfactory experiences, discriminatory attitudes and systemic challenges faced by Indigenous patients—along with one synthesized finding on their specific recommendations.

Conclusion: Indigenous people value safe, accessible and respectful care. The discrimination and racism they face negatively affect their overall health and well-being. Hence, it is crucial that changes in health care practice, structures and policy development as well as systemic transformation be implemented immediately.

Keywords : Indigenous people, primary health care, health services accessibility, systematic review, Canada

• This is the first qualitative systematic review to explore the experiences of Indigenous people with primary health care services across Canada.
• Following Joanna Briggs Institute’s systematic reviews of qualitative evidence methodology, this review included six academic databases as well as grey literature and ancestry sources.
• The experiences of Indigenous people accessing primary health care in Canada have been described as supportive and respectful in some cases, but also heavily included discriminatory attitudes and systemic challenges.
• Indigenous people living in rural or remote communities reported greater concern about privacy, confidentiality and accessibility compared to those residing in urban locations.

Introduction

The 1946 Constitution of the World Health Organization ( WHO ) established that every human being has the fundamental right to the highest attainable standard of health. Footnote 1 Nevertheless, to this day, health inequities continue to exist worldwide. Footnote 2 Health inequities are systematic differences in the health status of various population groups caused by unequal distribution of social determinants of health that further disadvantage those who are already socially vulnerable. Footnote 2 Footnote 3 The WHO and other public health advocates assert the importance of investing in primary health care ( PHC ) as a means of addressing health inequities within countries. Footnote 4 Footnote 5

In Canada, PHC services have been offered to all eligible residents through the universal public health coverage, also known as Medicare. Footnote 6 Medicare is governed by the 1984 Canada Health Act , which ensures the delivery of health care services (including PHC ) and adherence to the five core principles of public administration, comprehensiveness, universality, portability and accessibility. Footnote 7 In 2000, a PHC reform was agreed upon and launched by the federal, provincial and territorial governments, with the primary goal of improving service access, service quality and health equity as well as responsiveness to patients’ and communities’ needs. Footnote 6 Footnote 8 Yet, PHC access and quality issues continue to persist, particularly for socially marginalized populations, such as in the case of Indigenous Peoples Footnote 9 Footnote 10 Social marginalization is often defined as social exclusion due to a lack of power, resources and status that leads to limited opportunity or accessibility. Footnote 11  

Numerous studies have highlighted barriers faced by Indigenous people who reside in urban and rural or remote locations when accessing PHC services, such as discrimination, racism, lack of culturally safe care and inaccessible care. Footnote 12 Footnote 13 Footnote 14 Footnote 15 Despite several qualitative accounts of these negative experiences, a deep search of the literature indicates that there still has not been a qualitative review conducted on this topic. Addressing this literature gap may assist policy makers, health care managers and professionals, and researchers in identifying key areas for improving PHC access and quality across Canada.

Accordingly, we aimed to explore the following research questions:

• What are the experiences and perspectives of Indigenous people with PHC services in Canada?
• How do these experiences and perspectives differ when comparing PHC services provided in urban versus rural or remote settings?
• What are the recommendations of Indigenous people to improve the quality of PHC services delivered in Canada?

Protocol and registration

This systematic review is registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42020192353).

Eligibility criteria and search strategy

Our review was guided by Joanna Briggs Institute ( JBI ) methodology for systematic reviews of qualitative evidence; Footnote 16 the detailed protocol has been described elsewhere. Footnote 17 English and French qualitative and mixed-methods articles were considered for inclusion if they focussed on first- or second-hand experiences of Indigenous people in Canada when receiving PHC services. There were no restrictions with respect to publication year or research participants’ age, gender, medical condition or geographical location.

A preliminary search of CINAHL and PubMed was conducted to identify keywords and terms relevant to the research questions. A complete search strategy was then developed and tailored to each selected database: MEDLINE, CINAHL , PubMed, PsycInfo, Embase and Web of Science ( Table 1 ). Grey literature was also searched on Google Scholar, Bielefeld Academic Search Engine, ProQuest Dissertations and Theses and other relevant websites (e.g. Native Health Database and National Collaborating Centre for Indigenous Health). Furthermore, the reference list of each included article was examined to identify any additional studies for the review in order to obtain ancestry sources.

Study selection

Following the search, all identified citations were uploaded on Rayyan. Footnote 18 Next, two authors (GB and SA) independently screened the articles’ titles and abstracts against the inclusion criteria. They then independently examined selected articles in full. Reasons for excluding certain articles were noted, and no major discrepancy arose between the two reviewers; hence, the assistance of a third reviewer was not needed. Once all included articles were identified, they performed an independent quality assessment using JBI ’s Critical Appraisal Checklist for Qualitative Research. Footnote 19

Data extraction and synthesis

All pertinent data from the included studies were then retrieved using the JBI data extraction tool. Footnote 16 The extracted data included information on the studies’ methodology, approach to analysis, phenomena of interest, geographical location, participant characteristics, findings and illustrations. These data were then synthesized following JBI ’s meta-aggregation approach; the findings and illustrations were aggregated into categories and further grouped together to create a comprehensive set of synthesized findings. Finally, consistent with Munn et al., Footnote 20 these synthesized findings were assigned a ConQual score to demonstrate their dependability and credibility.

The search yielded a total of 2503 articles from the academic databases and 12 articles from the grey literature and ancestry searches. Overall, 22 articles were included in this review.

Figure 1 illustrates the PRISMA flow diagram of the search results and study selection process. Footnote 21 The methodological quality of all included articles was moderate to high; therefore, no studies were excluded following their appraisal ( Table 2 ).

Characteristics of included studies

The detailed characteristics of the included studies are presented in Table 3 . Articles were published between 2001 and 2020. Various qualitative approaches were used in these studies. These approaches included participatory research design, Footnote 12 Footnote 22 Footnote 23 Footnote 24 Footnote 25 Footnote 26 Footnote 27 Indigenous methodologies, Footnote 13 Footnote 15 Footnote 24 Footnote 28 Footnote 29 Footnote 30 Footnote 31 ethnography, Footnote 25 Footnote 27 Footnote 32 Footnote 33 phenomenology, Footnote 34 Footnote 35 case study, Footnote 14 Footnote 36 qualitative description, Footnote 12 Footnote 37 grounded theory Footnote 38 and mixed methods. Footnote 39 Eleven out of 22 studies represented experiences from major Canadian metropolitan areas, including Calgary, Footnote 25 Footnote 38 Edmonton, Footnote 37 Ottawa, Footnote 23 Toronto, Footnote 29 Footnote 30 Footnote 34 Vancouver Footnote 15 Footnote 28 and Winnipeg, Footnote 13 Footnote 31 while 10 studies were conducted in rural or remote communities within the provinces of British Columbia, Footnote 26 Footnote 27 Footnote 39 Manitoba, Footnote 33 Nova Scotia, Footnote 12 Footnote 24 Ontario Footnote 24 and Quebec Footnote 14 and within the Canadian territories of Nunavut Footnote 22 and Northwest Territories. Footnote 32 Finally, one article included findings from multiple provinces and locations, with participants from urban southern and rural Alberta, urban northern and remote northern Ontario, and rural British Columbia. Footnote 35 The categorization of urban versus rural or remote settings was based on the study setting as defined by the authors as well as by the population density; urban areas are characterized as having at least 400 people per square kilometre, and the opposite is true (< 400/km 2 ) for rural or remote regions. Footnote 40  

Research participants of included studies were from First Nations, Métis and Inuit background, and overall were between the ages of 16 and 79 years. Their reasons for seeking PHC and their pre-existing medical conditions also varied (e.g. cancer, arthritis, diabetes, cardiovascular disease, human immunodeficiency virus and mental health disorders).

Synthesized findings

Table 4 presents an overview of the individual findings of our review. Three major synthesized findings emerged from these, pertaining to our first and second research questions, and another one arose for the third research question. Table 5 is a summary of findings containing each synthesized finding’s level of dependability and credibility, as well as ConQual score (which rates confidence in the quality of evidence from reviews of qualitative research) to help their evaluation and integration into education, practice and policy.

Synthesized finding one: supportive and respectful experiences

Synthesized finding one demonstrates that certain experiences of Indigenous people when receiving PHC were considered supportive and respectful. This metasynthesis was developed from four categories that included 15 findings. Some First Nations, Métis and Inuit participants expressed that they had supportive and respectful encounters with PHC providers, as they felt safe, secure, listened to and freely able to express themselves without judgment. This finding was affirmed by one of the First Nations and Métis participants living in an urban location as she described her prenatal care: “My G.P. is just a fantastic doctor because he sits there and actually listens to his patients. He respects that they know as much about what’s going on with their body as he probably does, if not more.” Footnote 31 ,p 165 Another First Nations woman residing in a remote community echoed this positive experience:

When my husband died, my [family] doctor phoned me to tell me to come in to talk with him and see if I was okay and talk about things that happened … and he explained it to me really softly; things like this happen. He was really caring. And that was the best thing that ever happened to me was him phoning me on his own to tell me that. Footnote 32 ,p.140

Participants also greatly appreciated when PHC providers were supportive, accessible and offered as much time as needed to address all of their concerns; similar experiences were described by those residing in urban, rural and remote areas. Having access to dependable information and providers made a significant difference for many of the participants. Many First Nations women in rural communities said that their community health nurses were “always there” to assist them with their health needs. Footnote 12

Moreover, Indigenous participants from urban, rural and remote locations valued health care providers demonstrating respect towards them, their family and their cultural identity. Providers were expected to exhibit culturally sensitive care and to have had training and to possess knowledge about Indigenous history, traditions, customs and challenges. When these qualities were present, PHC providers were perceived to be more helpful and genuine. Overall, across all settings—urban, remote and rural—instances of supportive and respectful PHC were experienced by First Nations, Métis and Inuit participants.

Synthesized finding two: discriminatory attitudes and maltreatment

Synthesized finding two reveals that Indigenous people experienced various forms of discrimination and maltreatment that most often resulted in them not receiving adequate and quality primary health care; thus, many adopted strategies to cope with such challenges. Six categories and 58 findings were represented in this metasynthesis.

There were numerous accounts in which participants shared their experiences of health care providers making comments or exhibiting behaviours based on discrimination. First Nations, Métis and Inuit patients in urban and rural or remote areas were immediately assumed to have tobacco and drug addiction, to be intoxicated by alcohol, to have abusive partners, to mistreat their children, or any combination of these, without any actual justification or evidence of such claims. Footnote 13 Footnote 14 Footnote 15 Footnote 25 Footnote 34 Footnote 38 As reported by an aggravated Inuit participant from a remote community, “I arrived at the clinic and the first thing the doctor asked me is if I’m a smoker. Is that normal? It’s as if she assumed that because I’m Inuit I’m a smoker. I don’t think that is fair.” Footnote 14 ,p.293 A First Nations woman in an urban setting also commented, “Oh I wouldn’t get the proper care if I needed it, like if I was in pain. They thought I’d be there just to get high.” Footnote 34 ,p.122

These negative stereotypes automatically formed the basis of the care that Indigenous people received even though they did not necessarily apply to the specific situation of each patient. Consequently, these patients were generally dismissed, turned away and unable to receive the proper medical care they required, leading to severe complications or even death. Footnote 32

Such situations were experienced in urban, rural and remote locations. As reported by a participant in Goodman et al.:

I reached out on my right side and it really hurt. I went to a DTES [Downtown Eastside] clinic to the doctor and she told me to walk it off. I went to sleep and woke up and thought I was dying—big pain in my chest. I collapsed a lung. I think she thought I wanted painkillers, but I was really hurt. Footnote 15 ,p.90

Another First Nations participant reported in Fontaine et al.:

I lost [a family member]. He did drink a lot. And anyway, he got sick and every time he went to the Nursing Station, the nurse in charge there told him, he said, “Oh, you have a severe hangover,” without checking him. And he went about three, I know three times for sure, whether the fourth time, I can’t remember. But anyway, they kept chasing him home, “There’s nothing wrong with you. You’re just ... quit drinking, get, you’re ... hung over,” you know. Anyway, he died one night in ... his home. Footnote 13 ,p.5

Besides the deliberate omission of quality care, some Indigenous patients also sensed that certain PHC providers had discriminatory attitudes towards Indigenous people. In some cases, as soon as First Nations, Métis and Inuit participants from both urban and rural or remote locations entered a clinic, they instantly felt unwelcomed and judged, based on how the health providers and staff looked at and talked to them. This was further extended in their subsequent interactions, as explained by one frustrated participant in Goodman et al.:

So [the nurse] showed me how to [inject], but she was so mean about it. She was not accommodating. She said I should know how to do it myself. They treated me like crap, and I know it was because I was Native. We all know because of the look—there’s a look. When you need the medical care, we put up with it. We shouldn’t have to. We bleed the same way, we birth the same way. We have no choice … Footnote 15 ,p.89

Some participants in urban as well as rural or remote areas thought that the negative attitudes and judgments of PHC providers may have stemmed from their lack of understanding or disregard for Indigenous life experiences, history, background and socioeconomic and political circumstances, Footnote 23 Footnote 25 Footnote 37 but this was particularly emphasized by individuals living in rural or remote communities. There were instances in which First Nations women living on-reserve, who were required to travel to the city due to the unavailability of specialized services or diagnostic tools in their communities, were constantly fined for being late or missing their appointments in the city, even though the primary reasons for missing the appointments were that they were not able to afford a phone, or that there were traffic delays resulting from travelling a long distance. Footnote 32 As Browne and Fiske reported, “The embarrassment associated with being late or with being asked to pay the cancellation fine when they lacked the money shaped women’s experiences and left women with the sense that they were being blamed for circumstances beyond their control.” Footnote 32 ,p.138

As a result of these various negative interactions with PHC providers and the health care system, numerous Indigenous patients learned to cope by deciding not to disclose their cultural identity and medical history, presenting themselves to look more credible, or simply avoiding seeking care. Certain participants in Goodman et al., Footnote 15 Monchalin et al. Footnote 30 and Oelke Footnote 25 divulged having omitted sharing their Indigenous background and certain aspects of their medical history to PHC providers, as they believed that this information would not be beneficial for their care, and worse, might only lead to discriminatory acts. Others chose to dress or behave differently in front of PHC providers to gain respect. Footnote 32 Indeed, one First Nations participant living in a remote community elaborated in Browne and Fiske:

It seemed like any time I go to a doctor I would have to be well dressed. I have to be on my best behaviour and talking and I have to sound educated to get any kind of respect…. If I was sicker than a dog and if I didn’t want to talk and I didn’t care how I sounded or whatever, I’d get treated … like lower than low. But if I was dressed appropriately and spoke really well, like I usually do, then I’d get treated differently…. But why do I have to try harder to get any kind of respect? You know, why do I have to explain? Footnote 32 ,p.135

In certain cases, Indigenous patients delayed seeking care as long as possible to prevent being subjected to traumatic and discriminatory experiences. Footnote 15 Footnote 25 They sought health care only when their illness or symptoms had become serious, and they were left with no choice. Footnote 15 Footnote 25 Many participants from both urban and rural or remote regions admitted to distrusting PHC providers. Footnote 13 Footnote 24 Footnote 26 Footnote 34 However, Inuit and First Nations patients residing in rural or remote communities expressed significant concerns about whether providers were adequately protecting their privacy and confidentiality. Footnote 14 Footnote 22 Footnote 24

When comparing the PHC experiences of First Nations, Métis and Inuit participants in urban and rural or remote settings, we found very limited differences. As demonstrated above, similar to Indigenous patients living in urban areas, rural or remote participants also faced discriminatory attitudes and dismissive and judgmental care, forcing them to develop strategies for coping with such maltreatment. One particular geographical difference, however, was the fear of privacy and confidentiality breach. Although one participant in the study by Bucharski et al., Footnote 37 which included First Nations and Métis women in an urban setting, expressed their concern about privacy and confidentiality, multiple First Nations, Métis and Inuit participants in rural or remote locations highlighted this fear. This concern may be more significant for residents of close-knit, small communities, as are often found in rural or remote locations. For these participants, PHC providers who were not considered “locals” were at times preferred, since they did not know anyone from the community and/or they would only be temporarily working in the community. Footnote 14

Synthesized finding three: structural and practice issues

Synthesized finding three highlights issues related to the PHC system’s structure and practices that led Indigenous people to experience inaccessible and incomplete care. Four categories and 32 findings formed the basis of this metasynthesis.

Our review found that major shortages of PHC providers existed across Canada. As a result, the Indigenous patients in the studies we reviewed who lived in both urban and rural or remote settings experienced lack of continuity of care, inaccessibility, short visits and inadequate health teaching and promotion. Many First Nations and Métis people who lived in cities did not have a family doctor; hence, they most often opted to visit walk-in clinics where various physicians rotate to cover the hours, and patients did not necessarily see the same physician during all their visits. Footnote 25 Footnote 35 Establishing a therapeutic physician–patient relationship may be impossible in such brief encounters. This issue was even more problematic in rural and remote communities, where the transiency of PHC providers is prominent, and their recruitment and retention are challenging. Footnote 22 Footnote 27 Footnote 32 Footnote 35 Some First Nations and Métis participants in Jacklin et al. “felt that once doctors gain experience, ‘they want more money here, and if they don’t get it, they quit and move on.’” Footnote 35 ,pp.109-110

Additionally, Inuit and First Nations patients who lived in rural or remote regions could not easily access certain medical care and preventive services. Footnote 12 Footnote 14 Footnote 34 Footnote 39 Minimal or no time was dedicated to health teaching or promotion, especially in a manner that was culturally appropriate. Footnote 14 Indeed, as one of the Inuit participants in Fraser and Nadeau confirmed,

If I was diabetic, for example, I would need information, what can I eat and what can I not. My Grandmother, they did not give her any ideas what she can eat and what she cannot do…. They need to have examples, recipes, and take less salt and sugar. And, how to make bannock. Like when you make spaghetti, use the whole wheat spaghetti. All those nutrition information. People need encouragement. Footnote 14 ,p.292

Though health promotion materials, such as brochures and videos, may be available, First Nations and Métis participants in Oekle Footnote 25 further highlighted the absence of culturally adapted verbal and visual teachings. One participant reported, “The prevention services that are available for First Nations are what’s ever in the hype for the White crowd. So if it’s a White problem, a White prevention problem, those are what’s available.” Footnote 25 ,p.147 Also, visits of First Nations and Métis patients with PHC providers in metropolitan, rural and remote areas were commonly described as “rushed,” there being “never enough time,” “a race to fit as much patients as possible” and “similar to an assembly line.” Footnote 23 Footnote 31 Footnote 33 Footnote 35 For this reason, many felt that their needs and concerns were not entirely addressed. Footnote 33 Footnote 35

In regard to other geographical considerations, despite the differences of PHC services offered in urban and rural or remote settings, PHC structure and practices in all three settings similarly affected the accessibility of care experienced by Indigenous people. For instance, in rural or remote locations, hospitals and specialized care did not necessarily exist. PHC providers within these settings therefore generally assumed an expanded role to offer additional services to community; however, this had its limits, as certain diagnostic tools and specialists were only available in the major cities. Footnote 12 Footnote 14 In urban areas, First Nations and Métis people encountered comparable accessibility challenges, including the lack of PHC services for children and youth, and mental health support. Footnote 25

Synthesized finding four: recommendations

Synthesized finding four focussed on Indigenous patients’ recommendations for greater emphasis on culturally sensitive empathic care, recruitment of Indigenous PHC providers, accessibility and health teaching and promotion. This last metasynthesis was created from five categories and 25 findings.

Numerous First Nations, Métis and Inuit participants emphasized the importance of cultural sensitivity and empathy, indicating that it is paramount that all PHC providers and staff are familiar with Indigenous history and practices. Footnote 34 Footnote 33 Footnote 37 They expressed the idea that only through education would providers and staff start to be empathic and respectful towards Indigenous peoples. Footnote 13 Footnote 37 Besides provider–patient interactions, cultural sensitivity could also be conveyed in the design of the physical spaces where PHC services are delivered. Participants suggested that incorporating Indigenous symbols or art onto the walls of the clinic could provide a more welcoming environment for patients. Footnote 29

Participants also suggested that greater funding should be allocated to recruiting PHC providers and staff, particularly those with an Indigenous background. Footnote 12 Footnote 23 Footnote 25 Footnote 34 Footnote 35 Footnote 36 As one participant explained, “I just think they need to have more Native doctors and nurses ... for Aboriginal peoples to feel comfortable ... or people that are experienced in Aboriginal culture. It would be nice to have our own Aboriginal people running it.” Footnote 23 ,p.83

Furthermore, there is a great need to enhance health teaching and promotion in all PHC settings. Footnote 14 Footnote 25 Footnote 33 Footnote 35 Health teaching and promotion must also appropriately consider the cultural context and challenges of Indigenous peoples for these to be perceived as beneficial. Footnote 25

Lastly, when geographical differences between urban and rural or remote settings were examined, minor nuances were noticed. Although recommendations for culturally sensitive empathic care, recruitment of Indigenous PHC providers, improved accessibility and health education were common across First Nations, Métis and Inuit participants from urban and rural or remote regions, certain recommendations were given more emphasis within one particular setting. For example, the need for culturally sensitive empathic care and recruitment of Indigenous PHC providers was pointed out more by First Nations and Métis participants residing in the urban areas than those in rural or remote communities, who mostly emphasized suggestions for accessibility and health teaching and promotion.

The purpose of this qualitative systematic review was to explore Indigenous people’s experiences in Canada with PHC services, determine urban versus rural or remote differences and identify recommendations for quality improvement. Three major synthesized findings were revealed—supportive and respectful experiences, discriminatory attitudes and systemic challenges faced by Indigenous patients—along with one synthesized finding on their specific recommendations.

The conflicting PHC experiences of First Nations, Métis and Inuit participants, wherein instances of supportive and respectful interactions were revealed while discriminatory attitudes and systemic barriers simultaneously exist, attest to the multifaceted complexity of the situation. The interplay between systemic, institutional and interpersonal factors may have influenced these conflicting PHC experiences. The historical and intergenerational traumas of colonization, forced assimilation and residential schools continue to leave a lasting effect on the health care system, contributing to systemic discrimination that is ingrained within Canada’s health care policies and structures. The policies and structures of the health care system often reflect historical biases and stereotypes rooted in the colonial era and the legacy of residential schools. These biases manifest in policies that fail to adequately address the unique health challenges faced by Indigenous populations, resulting in unequal access to health care resources and services.

Additionally, there is limited Indigenous representation in health care policy making and leadership. This absence of perspective leads to a health care system that often does not fully understand or prioritize the health needs of Indigenous communities, further alienating them from the system. Although at the institutional level some organizations have invested in cultural sensitivity and antiracism training for health care providers, which can result in more positive experiences for Indigenous patients, individual health care providers within these organizations may still hold conscious or unconscious biases against Indigenous peoples, which can negatively affect the quality of care received.

In sum, the disparity in PHC experiences among Indigenous communities arises from a multifaceted set of conditions that operate at various levels. While systemic issues such as discrimination and racism can lead to negative experiences, targeted interventions and personal relationships can sometimes result in positive interactions. Therefore, efforts to improve PHC health care for Indigenous people in Canada need to be comprehensive, multipronged and culturally sensitive to effectively address this complex situation.

Indigenous people in this review valued safe, accessible and respectful care, aligning with their basic human rights as outlined in the United Nations Declaration on the Rights of Indigenous Peoples Footnote 41 and the Truth and Reconciliation Commission ( TRC ) of Canada’s calls to action. Footnote 42 Canadian governments and other sectors are nowhere near fulfilling these calls to action, Footnote 43 particularly in the domain of health. At the current pace, completing all the calls to action will take until 2065. Footnote 43 This shortcoming is particularly evident in our review; significant findings from most of the included articles illustrated considerable discrimination, racism and maltreatment of Indigenous peoples. Synthesized findings two and three echoed these unjust experiences that Indigenous patients had to face (and potentially continue to face).

The discrimination and racism faced by the Indigenous people in this review negatively affected their overall health and well-being. While accessing PHC , they often felt uncomfortable and judged due to providers’ negative stereotypes of Indigenous people. These attitudes, along with dismissive care and maltreatment, caused Indigenous people in the studies reviewed to avoid seeking care, exacerbating medical symptoms and potentially leading to severe complications or death.

Similar findings in other studies show that past experiences of discrimination and racism made Indigenous people more likely to avoid medical assistance, contributing to unfavourable health outcomes. Footnote 3 Footnote 44 The life expectancy of Indigenous people is five years less than that of the general population. Footnote 3 Additionally, the prevalence of infectious diseases, chronic conditions and mental health disorders as well as infant mortality rates among Indigenous populations in Canada are significantly higher compared to non-Indigenous Canadians. Footnote 3 These disparities were further exacerbated during the pandemic, particularly for Indigenous people in rural and remote communities, who contracted COVID-19 at rates three to four times the national average—rising to seven and eight times in some weeks. Footnote 45

In this review, First Nations, Métis and Inuit participants living in rural or remote locations were also more likely to experience maltreatment and dismissive care as well as issues with privacy, confidentiality and accessibility. Footnote 1 Footnote 12 Footnote 13 Footnote 14 Footnote 15 Footnote 22 Footnote 24 Footnote 34 These particular issues could be attributed to the close-knit nature of small communities and the structural barriers associated with the lack of health care infrastructure within these areas. Even though we identified 10 studies of rural and remote regions, there were still limited findings on Indigenous people’s PHC experiences in such regions, which prevented a deeper analysis of geographical considerations. The inclusion of participants from diverse geographical settings, however, adds another layer of complexity and richness to the findings, as it allows for a more nuanced understanding of how location may impact health care experiences. Hence, more research on PHC experiences of Indigenous peoples living in rural or remote communities is required to comprehensively understand the challenges they encounter.

Overall, the synthesized findings of this review emphasize the urgent need to address longstanding discrimination and racism, while also advocating for the implementation of sustainable changes to prevent further endangerment of Indigenous lives in Canada.

Recommendations

Indigenous patients have highlighted numerous problems with PHC services, leading to calls for changes in health care practice, structures and policy development. This includes emphasizing Indigenous culture in training, improving cross-cultural communication and prioritizing education to reduce negative experiences, all of which are in line with the TRC calls to action numbers 23 and 24. Footnote 42 Footnote 46 Despite an increase in cultural competency and antiracism training, Footnote 47 there is still a need to increase the methodological rigour and standardization of such training, as well as to examine their long-term effects while stressing Indigenous community partnerships. Footnote 46 Footnote 48 Health care providers should also practise some form of self-reflection, such as journalling or meditation, to examine personal biases. Footnote 49 This approach, aligned with cultural humility principles, teaches providers to defer to clients as experts in their own culture, creating a safer, nonjudgmental environment with the voices of Indigenous patients at its forefront. Footnote 49

However, the focus of change should not be solely on health care practice and providers. Systemic transformation, including more funding and support for Indigenous communities, must happen concurrently in order to establish meaningful traction towards better patient care. There is a nationwide shortage of Indigenous PHC providers and staff that requires immediate attention. As emphasized in the TRC calls to action, “We call upon all levels of government to increase the number of Aboriginal professionals working in the health-care field [and to] ensure the retention of Aboriginal health care providers in Aboriginal communities…” Footnote 42 ,p.164 These key actors are critical in all sectors of society, from frontline and academia to research and policy development. Footnote 49 At this point, the inclusion of Indigenous people across all sectors should be the norm, and not merely an afterthought.

Strengths and limitations

This is the first qualitative review exploring Indigenous people’s experiences with PHC services across Canada, serving as a valuable guide for policy makers and health care providers to identify target areas for improvement. Only by incorporating the voices of service users into health policies and interventions will the PHC and health care system as a whole deliver services that truly and meaningfully meet patients’ and communities’ needs. However, a limitation of qualitative review stems from the pooling of findings that are context-dependent, thus potentially reducing the emphasis on important contextual factors. Nevertheless, through our use of the chosen methodology (i.e. meta-aggregation), the traditions of qualitative research were maintained, preserving the context of each study and aggregating findings into a combined whole. Footnote 16 This strengthens the review’s findings, making them more appropriate for guiding policy makers and health care providers.

Despite some supportive and respectful encounters with PHC providers, the majority of the experiences of Indigenous peoples were inadequate, unjust and filled with discriminatory attitudes and behaviours. Certainly, more work needs to be done before Canada meets all five core principles of the Canada Health Act . Footnote 7 These principles are the basis of our health care system and should be applicable to all Canadians, irrespective of their age, gender, race and cultural background. Footnote 7 Therefore, it is the duty of Canadian governments, other sectors and citizens to ensure that Indigenous people receive the health care they deserve.

Acknowledgements

We acknowledge Ms. Anita Kiafar for her ideas and feedback during the initial conceptualization phase of this systematic review. While not involved in the writing, her input during discussions was appreciated.

This research did not receive any funding.

Conflicts of interest

The authors declare there are no conflicts of interest.

Authors’ contributions and statement

• GB, SA—conceptualization.
• GB, SA—formal analysis.
• GB—project administration.
• GB, SA—visualization.
• GB—writing—original draft.
• GB, SA—review & editing.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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