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Speaker 1: Validity and reliability are probably among the most confusing and frustrating terms when it comes to qualitative research. There are so many definitions and so many discussions and so many alternative terms have been put forward, so it doesn't really help to understand what validity is and how we can ensure that our findings are valid or how we can increase these findings' validity. So in this video, I'll take you through six steps to increase the validity of your qualitative findings. In quantitative research, validity and reliability are quite straightforward terms. So reliability refers to replicability and consistency of certain measurements and validity to whether this measurement is measuring what it's supposed to measure. So it's quite straightforward. But think about qualitative research. Can we really talk about consistency of our instruments? Imagine that you're interviewing the same person twice and asking the same questions. Even though you're asking the same questions, this person is not likely to give you exactly the same answers. So for this reason, reliability doesn't really refer to qualitative research. It's not that relevant. And usually, people discuss validity rather than reliability of qualitative studies. And validity of qualitative research is usually discussed in terms of three common threads to validity, which are three different types of bias. Respondent bias, researcher bias, and reactivity. So respondent bias refers to a situation where your participants are not giving you honest responses for any reason. They may feel that the topic is threatening to their self-esteem, for example, or they may simply try to please you and give you the answers they think you are looking for. Researcher bias refers to the influence of your previous knowledge and assumptions on your study, which may be a very dangerous and a very risky factor in your study. I've talked about the role of assumptions quite a lot in my other videos and in my blog. And finally, reactivity refers to the role of you as a researcher and your influence, your physical presence in the research situation, and its possible influence on the data, on what the participants say, and so on and so forth. And in order to minimize the potential influence of these three types of bias on your study, Robson suggests the following six strategies to deal with threats to validity. Prolonged involvement refers to you as a researcher being involved in the research situation in your participants' environment, which is likely to result in the increase in the level of trust between you and your participants. This in turn is likely to reduce the risk of respondent bias and reactivity as you generate this common trust. However, it is likely to increase the risk of researcher bias because you and your participants are likely to generate some set of common assumptions. And as I said, assumptions may be a very dangerous thing for your research. Triangulation is such a broad topic and I'm sure that you've at least heard about it before, if not read about it. Triangulation may refer to many things, including triangulation of data, so when you collect different kinds of data, triangulation of methodology, when you have, for example, mixed methods research, or triangulation of theory, where you're comparing what's emerging from your data to previous existing theories. In any case, triangulation is likely to reduce all kinds of threats to validity, so just remember that it's always good to consider triangulating these different aspects of your study. Peer debriefing refers to any input or feedback from other people. This may happen during internal events, such as seminars or workshops in your university, or external, such as conferences. In any case, the feedback and quite likely criticism that you'll receive from other people helps you become more objective and helps you see and become aware of certain limitations of your study. And this is likely to reduce researcher's bias, so again, researcher's bias which was about your previous assumptions and your previous knowledge. So you're becoming more objective and more aware of how your study may be improved. Member checking may mean a couple of things, but in essence it refers to the practice of seeking clarification with your participants. So asking them to clarify certain things before you actually jump into conclusions and describe your interpretation of that data. So it may be simply keeping in touch with your participants, sending them a text message or an email, and asking them whether what you think they meant when they said something in the interview is actually what they meant. Another practice is to send them interview transcripts. So to send them the whole transcript and ask them to delete or change things or add things to that transcript. And finally, you have a method called validation interview, which is all about member checking. So it's basically a whole interview which serves the purpose of this clarification that I discussed. So after you've conducted the first run of analysis after the interview, you conduct another interview and you just ask your participants about your interpretations and about anything that was not clear to you. Negative case analysis is one of my favorite things to do. And I talk extensively about it in my self-study course on how to analyze qualitative data. But basically what it involves is analyzing these cases or data sets that do not match the rest of the data, do not match the trends or patterns that emerge in the rest of the data. And although you may feel tempted to ignore these cases, you may fear that they will ruin your data or your findings, quite often they tell you more about the rest of the data than these actual other cases themselves. So negative cases highlight not just how this one case is different from the rest of the data, but they actually highlight the similarities between the rest of the data. So this is a very, very valuable and important thing to do. And finally, keeping an audit trail means that you keep a record of all the activities involved in your research. So all the audio recordings, your methodological decisions, your researcher diary, your coding book, just having all of this available so you can, for example, demonstrate it to somebody. So again, this way you become really transparent and the validity of your findings cannot really be argued. Importantly, don't worry about having to apply all these strategies in your study. Firstly, some of them are almost natural, like peer debriefing. So as a student, it's very likely that you will receive feedback, you will talk to other people about your study, you will receive feedback and criticism. So you don't really have to worry about consciously applying it as a strategy. And secondly, you can choose some of these strategies, a combination of these strategies. You don't really have to apply every single one on the list. However, it is important to think about validity and it's very important to talk about it in your study. So if you demonstrate that you are thinking about validity and you demonstrate what exactly you did to increase this validity, it will be a major, major advantage to you and to your study.

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HSED 704 Advanced Qualitative Research (3 credits)

Offered by: Health Sciences Education ( Faculty of Medicine and Health Sciences )

Administered by: Graduate Studies

HSED : Review various philosophical and theoretical perspectives that underpin schools of qualitative inquiry and identify perspectives relevant to coherent and rigorous research design; identify consequences for validity of particular methodological choices from the range of forms that each particular methodology takes; explore theoretical perspectives relevant to their research interests; investigate implications for the design and appraisal of qualitative research in health and social care; defensible knowledge claims from a qualitative research perspective; consider approaches to representing and writing and qualitative research; and specialized terminology in the field.

Terms: Winter 2025

Instructors: Kinsella, Elizabeth Anne; Molinaro, Monica (Winter)

Prerequisite: Permission of the instructor.

Must have completed an introduction to a qualitative research course.

Priority given to Institute of Health Sciences Education students.

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Nursing: Quantitative vs. Qualitative?

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Facilitators and barriers to initiating and completing tuberculosis preventive treatment among children and adolescents living with HIV in Uganda: a qualitative study of adolescents, caretakers and health workers

• Pauline Mary Amuge 1 ,
• Denis Ndekezi 2 ,
• Moses Mugerwa 1 ,
• Dickson Bbuye 1 ,
• Diana Antonia Rutebarika 3 ,
• Lubega Kizza 4 ,
• Christine Namugwanya 1 ,
• Angella Baita 1 ,
• Peter James Elyanu 1 ,
• Patricia Nahirya Ntege 1 ,
• Dithan Kiragga 1 ,
• Carol Birungi 4 ,
• Adeodata Rukyalekere Kekitiinwa 1 ,
• Agnes Kiragga 5 ,
• Moorine Peninah Sekadde 6 ,
• Nicole-Austin Salazar 7 ,
• Anna Maria Mandalakas 8 &
• Philippa Musoke 9  

AIDS Research and Therapy volume  21 , Article number:  59 ( 2024 ) Cite this article

Metrics details

Introduction

People living with HIV (PLHIV) have a 20-fold risk of tuberculosis (TB) disease compared to HIV-negative people. In 2021, the uptake of TB preventive treatment among the children and adolescents living with HIV at the Baylor-Uganda HIV clinic was 45%, which was below the national target of 90%. Minimal evidence documents the enablers and barriers to TB preventive treatment (TPT) initiation and completion among children and adolescents living with HIV(CALHIV). We explored the facilitators and barriers to TPT initiation and completion among CALHIV among adolescents aged 10-19years and caretakers of children below 18years.

We conducted a qualitative study from February 2022 to March 2023, at three paediatric and adolescent HIV treatment centers in Uganda. In-depth interviews were conducted at TPT initiation and after completion for purposively selected health workers, adolescents aged 10–19 years living with HIV, and caretakers of children aged below 18years.

The desire to avoid TB disease, previous TB treatment, encouragement from family members, and ministry of health policies emerged as key facilitators for the children and adolescents to initiate TPT. Barriers to TPT initiation included; TB and HIV-related stigma, busy carer and adolescent work schedules, reduced social support from parents and family, history of drug side effects, high pill burden and fatigue, and perception of not being ill. TPT completion was enabled by combined TPT and ART refill visits, delivery of ART and TPT within the community, and continuous education and counseling from health workers. Reported barriers to TPT completion included TB and HIV-related stigma, long waiting time. Non-disclosure of HIV status by caretakers to CALHIV and fear of side effects was cited by health workers as a barrier to starting TPT. Facilitators of TPT initiation and completion reported by healthcare workers included patient and caretaker health education, counselling about benefits of TPT and risk of TB disease, having same appointment for TPT and ART refill to reduce patient waiting time, adolescent-friendly services, and appointment reminder phone calls.

The facilitators and barriers of TPT initiation and completion among CALHIV span from individual, to health system and structural factors. Health education about benefits of TPT and risk of TB, social support, adolescent-friendly services, and joint appointments for TPT and ART refill are major facilitators of TPT initiation and completion among CALHIV in Uganda.

Globally, 10.6 million people fell ill with tuberculosis (TB) in 2022, of which 12% were children below 15 years of age, and 23% reported in Africa [ 1 ]. People living with HIV (PLHIV) accounted for a disproportionate 6.7% of the TB cases and TB-HIV co-infection rates greater than 50% persist in numerous countries [ 1 ]. Out of the 1.6 million TB related deaths that occurred in 2021, 187,000 were among PLHIV, with 11% among children living with HIV [ 1 ].

Following TB exposure, PLHIV have a 20-fold increased life-time risk of progressing to TB disease, and up to 15% annual risk of TB disease, compared to the general population [ 2 ]. There is evidence that TB preventive treatment (TPT) in combination with anti-retroviral therapy (ART), reduces the risk of TB disease by up to 90% [ 3 , 4 ]. During the period 2018–2021, 10.6 million PLHIV received TPT globally, which was more than the targeted 6 million PLHIV. Nevertheless, there is minimal global data reporting TPT completion rates.

Uganda is one of the 30 countries categorized as high TB and TB/HIV burden by the World Health Organization (WHO) [ 1 ], with 74,799 TB patients reported in 2022, of which 32% were HIV-co-infected, and 12% were children below 15years of age [ 1 ]. Following three nation-wide TPT uptake campaigns led by the Ugandan ministry of health, 88.8% of the eligible PLHIV received TPT [ 5 ]. In Ugandan public health facilities, only 17% PLHIV initiated TPT out of the 93% who were eligible for TPT, with only 58% completing the full TPT course [ 6 ]. Some of the documented challenges contributing to such gaps in TPT uptake among PLHIV include; hesitancy of health workers to prescribe TPT for fear of promoting drug resistance, interrupted TPT supply, patients’ fear of additional pill burden and side-effects [ 6 ]. Non-completion of TPT was also associated with ART non-adherence, ART regime switch, and patient representation among adult PLHIV in rural Uganda [ 7 ]. Effective implementation of TPT, through addressing identified barriers and enhancing the facilitators of TPT [ 8 ], is key in reducing the burden of TB disease among PLHIV and bridging the TPT uptake and completion gaps [ 9 , 10 , 11 ]. However, there is limited data on TPT completion especially among PLHIV who are concurrently on ART. Therefore, it is important to understand the multi-faceted barriers and facilitators of initiating and completing TPT among the PLHIV. These may be related to the different healthcare system components such as; the clients or community, health policies, leadership and governance, drugs and logistics management, clinical information systems, service delivery, health workforce and financing [ 12 ]. Individual factors reported to facilitate TPT uptake and delivery among PLHIV in Tanzania include; alignment of ART and TPT visits, and TPT-related education and counseling. In South Africa, individual facilitators of TPT completion among PLHIV included; knowledge about TB and TPT, acceptance of one’s HIV status, having social support in the community and at the health facility, and desire for health preservation [ 13 ]. Individual barriers to TPT uptake and delivery included; perceived or previous experience of side effects, HIV stigma, pill burden, negative cultural and religious values, misunderstanding of TPT’s preventive role, financial burden of transport to the clinic and lost wages, and ineffective communication with the health workers [ 13 , 14 , 15 ].

Health care worker facilitators of TPT initiation among PLHIV include; comprehensive and collective planning, and supervision, presence of guidelines, TB-HIV training, positive attitude and being knowledgeable about TPT, known benefit of TPT, and effective health worker communication [ 8 , 13 , 16 ]. Health care worker and health system barriers to TPT delivery and uptake include; fear for isoniazid resistance due to interrupted drug supply, poor knowledge and attitude, misunderstanding about timing of TPT initiation, shortage of skilled health workers, variable TB screening practices and responsibilities, drug shortage [ 10 ], and contradicting guidelines from TB programs and HIV care programs [ 14 , 17 , 18 , 19 ]. In South Africa, lack of fidelity to national TPT guidelines was a barrier among health workers to initiation of TPT for PLHIV [ 20 ]. Absence of parental risk perception was reported as a barrier to TPT uptake among children in TB endemic areas [ 21 ]. Most of the documented facilitators and barriers to TPT initiation and completion are among adults, with limited reports for children, adolescents and their care takers.

Therefore, we conducted a qualitative study to explore the perceived and experienced barriers and facilitators to TPT initiation and completion among Ugandan children and adolescents living with HIV (CALHIV).

Theoretical orientation

A growing body of literature illustrates that health outcomes are progressively influenced by the environments within which individuals thrive and less by individual behaviors [ 22 ]. We therefore adopted the social ecological model (SEM) as a theoretical framework for analysis (see Fig.  1 below). The social-ecological model (SEM) of health promotion by McLeroy and colleagues states that health behaviour and promotion are interrelated and occur around multiple levels in the individual, interpersonal, institutional, community, and policy levels [ 23 ] This multifaceted perspective is important to understand and explicate barriers and facilitators of TPT initiation and completion among children and adolescents living with HIV, caregivers, and health care workers. The first level refers to individual factors that facilitate or inhibit a person’s choices, including personal stigma, limited knowledge about the prevention treatment, financial constraints and drug characteristics. The second level is interpersonal or network influences. An individual’s relationship with their closest caretakers, and family members influences their uptake and completion of preventative treatments. The third level is community perspectives, as children, caregivers and health care workers are influenced by community-held mass awareness campaigns community drug delivery services and community misconception about prevention treatments. The fourth level refers to health system (institutional) influences, including busy, unapproachable health care workers, limited access to the right treatment and the long waits. The final level refers to structural influences including the accessibility of the information and services related to TB.

Illustration of the SEM framework showing the interrelations at various levels

Study design and data collection methods

This qualitative study was part of a prospective cohort study conducted from February 2022 to March 2023; where CALHIV and their care takers were offered to choose either facility-based or community-based initiation and delivery of TPT. This was part of the differentiated TPT delivery among CALHIV in Uganda (COMBAT TB study).

Study setting

The study was conducted at three high-volume paediatric and adolescent HIV treatment clinics; Baylor College of Medicine Children’s Foundation-Uganda (Baylor-Uganda) center of excellence (COE) HIV clinic located in Mulago Hospital Kampala, Joint Clinical Research Center (JCRC) located in Lubowa, and the Makerere Joint AIDS Program (MJAP) ISS Clinic located on Mulago Hill in Kampala. The Baylor-Uganda clinic located about 4 km from the Kampala city center, provides comprehensive HIV care services for more than 4000 CALHIV out of more than 8000 PLHIV in care at the clinic. The JCRC Lubowa HIV clinic located in Wakiso district, 11 km from Kampala, and it provides comprehensive HIV care services to 1300 CALHIV out of 15,000 PLHIV in care. The MJAP ISS clinic located on Mulago Hill in Kampala, provides comprehensive HIV care services to 612 adolescents out of over 17,000 PLHIV in care. The three clinics run from Monday to Friday as one-stop-centers for care and research on HIV, TB and other HIV-related conditions. The HIV and TB care is provided by multi-disciplinary teams which include counselors, community health workers, peer educators, nurses, pharmacy staff, doctors and laboratory staff. The clients receive HIV prevention services, ART, TB preventive treatment and TB treatment. There is also screening and treatment of other opportunistic infections and non-communicable conditions like mental health issues, hypertension, and diabetes. The services are provided at the health facilities or within the community, based on the national HIV and TB treatment and prevention guidelines.

The CALHIV were screened for TB using the WHO-recommended TB symptom screening tool at every clinic visit. Individuals with TB symptoms completed a clinical evaluation, and TB diagnostic tests, such as Xpert MTB/RIF ultra, urine TB lipoarabinomannan (TB-LAM) for those with CD4 count < 200cells/ul, and chest X-ray. Patients diagnosed with TB then start TB treatment.

Individuals who were assessed as not having TB were considered eligible for TPT, such as; PLHIV above one year of age with no evidence of TB disease, PLHIV who are close contacts of TB patients, and PLHIV who have recently completed a full course of TB treatment. The ministry of health supplied the study sites with TPT drugs; initially isoniazid taken daily for six (6) months, and later rolled-out once weekly isoniazid and rifapentine for three months. The TPT is dispensed with pyridoxine, to prevent peripheral neuropathy, a common side-effect of isoniazid. Individuals who developed mild or moderate side effects, were usually advised to continue with the TPT while the side-effects were managed. If any individuals developed severe side effects, the TPT was withheld to first manage the side effects.

Individuals who initiated TPT within the differentiated delivery approach, had follow-up done via phone calls at two weeks and four weeks after TPT initiation. Follow-up was done at 3months after TPT initiation, and thereafter every three-months at the clinic or within the community to identify and manage side-effects, screen for TB symptoms, and assess adherence to the TPT and ART.

TB screening and diagnostic tests were done for participants with TB symptoms after starting TPT. Participants diagnosed with TB disease before completion of their full TPT course had their TPT stopped and TB treatment started. Adolescents living with HIV were eligible for the study if they were aged 10–19 years, initiating TPT, and completed or did not complete the full dose of TPT. Care takers were eligible for the study if their children aged < 18years living with HIV were initiating TPT, completed or did not complete the full dose of TPT and were willing to provide written informed consent. Health care workers were eligible if they were actively involved in providing TPT and willing to provide written informed consent.

Purposive sampling was done to select eligible health workers, adolescents aged 10-19years and parents or care takers of children who were eligible to start TPT.

During selection of adolescents and care takers, selection was done to try and achieve representation from; the three clinics, with almost equal numbers of; males and females, and age categories (10-14years, 15-19years), TPT completion status (completed, did not complete, missed doses or lost to follow-up), facility-based or community-based delivery models, and ART status (initiating ART or ART-experienced).

The health care workers in this study were involved in screening the children and adolescents for TB, assessing TPT eligibility, prescribing TPT, monitoring individuals on TPT, and providing TB-HIV counseling and guidance according to the national TB and leprosy control guidelines (24). Among the health workers, efforts were made to select equal numbers of males and females, and fair representation by different cadres (nurses, clinical officers, doctors, pharmacists).

Data collection procedure

A semi-structured interview guide was used for each category to obtain in-depth descriptions and valuable insights about the barriers and facilitators to TPT initiation and completion from the three categories of participants.

During the TPT initiation visits, qualitative in-depth interviews (IDIs) were conducted face to-face by an experienced male social scientist (DN), using the piloted interview guide for the data collection process. Interviews lasted between 30 and 45 min. Field notes were also made after each data collection session. Participants were recruited through purposive sampling with the help of the study nurse (CN) at three HIV clinics between June 2022 and August 2023. The IDIs were carried out with the CALHIV, Caretakers/parents and health workers. All the IDIs were held in a conducive place that was safe, neutral and with minimal distractions for the participants and the researcher. This place was either suggested by the interviewee or preset by the interviewer at the participating HIV clinics. Data collection was conducted in a language preferred by the participant, either English or Luganda. The interviewer (DN) took time at the outset of the discussions to develop a rapport with participants, acknowledging the sensitivity of the topic and creating a safe space for them to share their thoughts and experiences. Participants were fully informed about the purpose and objectives of the study, and they provided their informed consent to participate, indicating their understanding and agreement with the research goals and procedures. Approximately four months into the TPT study, participants were approached to participate in the second phase of IDIs for TPT completion.

Sample size

During TPT initiation, thirty (30) IDIs were carried out with the caretakers/parents and children ( N  = 30; 10 health workers, 10 CALHIV, and 10 Caretakers/parents). After TPT completion, interviews were conducted with 10 care takers, and 10 CALHIV. Participants were purposively sampled to represent those CALHIV who completed and those who did not complete or defaulted their TPT dose. The interview guide explored both the facilitators and the barriers for the TPT initiation and completion.

Data management and analysis

In-depth interviews were audio recorded, transcribed verbatim, and then translated into English for a hybrid approach of inductive and deductive thematic analysis [ 22 ] by two researchers (DN and PMA) experienced in qualitative methodology. The initial deductive coding was based on the five levels of the Social Ecological Model (SEM) in Fig.  1 above, and inductive coding was used to explore other themes that were not covered by the SEM. Three transcripts were initially selected and read through for familiarization and coded manually by DN. To ensure coding consistency, the developed codes were shared with the study principal investigator PMA to facilitate collaborative thematic analyses throughout [ 23 ]. All transcripts were imported into NVivo 14 and coded using the refined codebook by DN and PMA. The transcripts were not returned to the participants. The data was organized into pre-defined key themes outlined by the levels of the SEM. A framework approach using SEM was used for data analysis [ 25 ]. Themes and sub-themes were continually reviewed and refined to capture emerging new codes. Quotes were captured to highlight thematic areas and increase our understanding of the context. The methods and results were aligned to the consolidated criteria for reporting qualitative research (CORE-Q) [ 26 ].

A total of 50 IDIs were conducted for the selected participants (health workers ( N  = 10), adolescents ( N  = 10), care takers ( n  = 10) until saturation of content was achieved. Table  1 below summarises the demographic characteristics of the study participants.

Facilitators to initiation and completion of TPT among adolescents and children

From the IDIs, we found the following facilitators at individual level. Participants perceiving themselves as being at risk of contracting TB was a key facilitator to initiate and complete TPT. In addition, some care takers highlighted that the TPT will also help the child to have a good life without TB, but if she acquires TB and yet is already HIV positive, the child may be severally affected.

“Apart from the fact that it will help me to prevent TB, it will help me not to get TB and am assured that I will not get TB because TB is very risky, inconvenient and I will protect others because I know I am at a very high risk. So by taking the drugs, at least I know am protecting someone in case I get it, am protecting a family member, a sibling, a sister”. Male Adolescent 15 years.

Further analysis revealed that care takers and participants who were once diagnosed with TB and recovered narrated their agony and the experience of treating TB which they noted that they would not want to experience again. The experience they had with TB disease compelled them to initiate and complete their TPT dose.

“Another reason why I accepted my child to start on TPT is because my child has ever suffered from TB, and given that now we have the drugs for preventing it, I had no reason to resist it. I was afraid the child might acquire it again”. Female carer of 10-year-old adolescent.

The desire to remain free from TB emerged as a facilitator to initiating and completing TPT. The TPT was perceived as a breakthrough strategy to prevent acquisition of TB.

“Since I had an experience of a person with TB that I told you about, I didn’t want to wait until he is affected as it did to the other one I saw. So that forced me to ensure that the dose is completed”. Female caretaker of 14-year-old adolescent.

At the interpersonal level, support, care and encouragement from family, supervision from the caretakers also emerged as important facilitators to initiate and complete TPT. The participants remarked that receiving care and support (reminders) from immediate family encouraged them to complete their treatment.

“Like at home, there is my mother who always reminds me to take my drugs. That helped me to always take my drugs in time”. Female Adolescent, 18 years.

Community level facilitators included guidance and counseling, comprehensive information, mass awareness and sensitization about TPT. Participants mentioned that receiving adequate information and sensitization was helpful for their decision to initiate TPT. Participants reported that they received information from the health workers on how the child should take the medicine and how the treatment works to prevent the disease, something that encouraged most of them to start their children on treatment.

“The encouragement I got from doctors helped me to give treatment to my child for TB treatment which also made it easy for me to start him on TPT. I believe by the time the dose is completed the child will be okay. Doctors also sensitized us about the possible side effects of the drugs and they follow up with phone calls”.  Female care taker for a 7-year old child.

It emerged that information about the TPT made available by the health workers, with opportunities to discuss the treatment with the doctors, and making it known in the community, enabled the care givers to allow TPT to be given to their children and adolescents.

“When people are aware, it makes the services easy to access. Many people talk about other things on TVs and radios but they don’t take about TB. We have to tell people TB is real and a killer disease. You can also inform them in case someone sees the symptoms they should be screened for TB”. Medical doctor 01.

At the institutional and organizational level, participants preferred to have convenient services as a facilitator for the initiation and completion of the treatment. This was in terms of having TPT appointments scheduled on the same days of ART refill so that they can have all the drugs on the same appointment as this will reduce the time spent at the clinic and cost of repeat visits.

“The other issue is integrating those TPT refills with their usual clinic visits and community services so that they can readily receive the drugs at times without even wasting much time and transport to come to the clinic”. Medical doctor 02.

Among the healthcare providers, it emerged that many young people preferred to have the drugs taken to them so that they don’t have any excuses of not coming to the clinic for treatment.

“Also initiating TPT delivery models that reduce the transport costs and avoid missing clinical appointments and doses. Also to make sure their drugs are delivered before they are out of stock”. Nursing officer 01.

Besides the convenient services, health workers recognized mechanisms of following up the patients initiated on TPT or reminding them when to take their treatment as facilitator for the completion of TPT.

“We need to make mechanisms of follow ups when you put someone on TPT, you have to check on them to see how they are doing sometimes when you tell them to take the drug on Sunday it means they will even shift the ARVs to the same date”. Epidemiologist 01.

Health workers also cited frequent and friendly communication with children and caretakers in terms of the health talks at the clinic, calling the patients through the mobile phones and receive their feedback.

“Another thing is when you relate with children they bring out their challenges where you share and help them out. Smoothly they can cooperate and complete the six months’ TB preventive treatment". Study counsellor 01. “With the care takers, it is just a matter of explaining to them. It will not be hard for them if they have understood the importance of TPT and even the challenges will be less. The information should be explained in a way which is understood.” TB community linkage facilitator 01.

At the structural level, what emerged was having national policies and good performance indicators at the health facilities that are developed to create demand for the TPT among CALHIV has a great advantage and facilitates TPT uptake.

“Demand creation, tasking health workers. We have our weekly performance review and TPT is among the many indicators we track. Ministry of health asks us how many people are on TPT which helps the health worker to improve on performance and this will facilitate the uptake of TPT”. Medical officer 01.

Regular auditing and identifying the challenges and weaknesses at the facilitate level in relation to the prescription of the treatment emerged as a key facilitator for the uptake of TPT among CALHIV.

“We have reached that level where we appreciate if you find your health workers are not performing well, sit down as a unit and ask yourself on the weaknesses. If you planned to start 56 participants on TPT this week what happened, open the file and do file audits. You will discover interesting things other than patients missed to come or ask the pharmacist why were you not prescribing the drugs when there was even an alert”. Epidemiologist 02.

The following themes emerged as barriers to TPT initiation and completion at patient-level, structural, community and interpersonal levels.

We found the following individual-level barriers to TPT initiation and completion. One of the emerging barriers to initiate or complete their TPT was the stigma associated with taking TB or HIV drugs. The fear of being seen taking many pills on a daily basis was cited as affecting their emotional well-being and mental health.

“Stigma will always be there and I think it’s a reason why so many kids out there fear. Personally before, I didn’t have any problem taking my medicine. So when the stigma started I stopped taking medicine, I stopped caring, it really caused me a lot of mental damage and trauma”. Male Adolescent 18 years.

Where there is limited privacy, taking the treatment would be difficult. Participants also mentioned that they would fail to come for their HIV clinic appointments, for fear of being identified as HIV patients or TB patients.

“…the main challenge is the stigma of HIV which is a leading factor in the community. Some of them fail to come for their appointments because of stigma. They don’t want to be identified as HIV or TB-positive”. Medical officer 03.

The fear of drug-related side effects was reported as a key barrier to starting TPT. Participants expressed their fear of taking TPT treatment for fear of side effects based on their past experiences with different drugs. At TPT completion, experience of side-effects like dizziness and nausea emerged as barriers to TPT completion.

“It would make me feel nausea or feel like vomiting, headache and dizziness. Me I decided not to take them anymore… I even didn’t tell anyone”. Male adolescent, 12 years old.

High pill burden coupled with poor drug adherence also emerged as key barriers reported by the participants, especially if the child was also on ART regimens.

“Another issue is about the pill burden because these are people who are already on ARVs and then they are added more pills for TB so it becomes a lot for them”. Nursing officer 3. “The biggest barrier is adherence because it’s still a challenge to even those that are HIV negative. There are clients who are not used to taking treatment and if the treatment is for six months there will be a challenge of commitment to take the drugs every day.” Medical officer 03.

Among the caretakers, it emerged that pill fatigue created by taking tablets when a person is not sick with TB, caused many adolescents to miss their doses and some did not complete, even though they reported taking the drugs when it is not true.

“Some children fear taking drugs and time comes when the child is tired and no longer wants to take the medicine. … the child can pretend to be taking the medicine when it is not true because the child got tired of taking the drugs”. Female Caretaker of 8-year-old child. “That the medicine was a lot, and the child got tired of it, so she didn’t complete. “Sometimes she could say, “it is just for prevention, I will not take it”. The fact that the child didn’t have TB, she could not care at all”. Female caretaker of 15 years adolescent.

Caretakers expressed the discomfort of children taking pills with a bad smell, big size, unpleasant color and poorly packaged. Participants said that a pill with no smell, small size and attractive packaging would be easier to swallow.

“One, the smell of the medication might not be really good to the child, the pill size can be too big, you even see and say ooh! Female caretaker to 13-year-old adolescent.

It emerged that some adolescents and their caretakers are “ engaged in demanding jobs that may not allow time to collect their medication or they may forget to take it ”. Community Health linkage officer 01.

Forgetting to take the additional drugs also emerged as hinderance to complete the TPT.

“…when you work a lot and do not get time, because you are not used to it like ARVs, the busy schedule can also cause you from not taking the drugs. Male adolescent-18 years. “She is so forgetful. You always have to ask her whether she has taken the medicine. If you are not around, I just know she has not taken and that’s why she didn’t complete”. Female caretaker to a 16year-old adolescent.

At the interpersonal level, the change of caretakers and lack of support mainly from parents also emerged as key barriers to the completion of TPT.

“Some of them like children depend on their caretakers and sometimes we experience changes of the caretakers”. Nursing officer 04.

Among female caregivers, denial or restrictions by the husbands to come to the clinic for refills, also emerged as a barrier for TPT completion among their children

“For those that are married, their husbands don’t allow them to come to the clinic since it was not on the program”. Female caretaker 14 years child.

Financial constraints and lack of food contributed to delay in TPT initiation and failure to complete the treatment. Caretakers expressed concerns that certain medications require a specific diet to be effective, but they struggled to provide the necessary nutritional support, particularly for their school-aged children, which in turn impacted their ability to adhere to treatment regimens, as highlighted by one adolescent’s experience

“Ok the major challenge I faced at school is sometimes I don’t take medicine because I have not eaten. I know the medicine is very strong and I know it will affect my stomach. It will affect me so if am to take it on an empty stomach it wouldn’t be possible. So sometimes I just don’t take it because I know it will cause me effects”. Female Adolescent 18 years.

Failure of the caretakers to disclose HIV status to the children was cited as a barrier of children to initiate and take TPT treatment. One health worker noted that most mothers at home have never disclosed the reason why their children take these drugs daily, and when the husband is around they cannot take their drugs.

“There is also no disclosure especially to the children. So you find when the child doesn’t take the drugs because they do not understand why they are taking the drugs”. Medical doctor 04.

This has also been a challenge to trace TB contacts in families where the patient has never disclosed to the family members and as a result, children in these families miss the opportunity to take the TPT treatment.

“Disclosure is the problem when families have not yet disclosed, and someone comes down with TB. It is difficult to conduct contact tracing, for example on what ground are you asking the family about TB. So it is hard”. Epidemiologist 02.

At the community level, misconception about TPT and Community stigma associated to TB were some of the barriers identified. Further analysis revealed that some adolescents are so inquisitive about drugs and the intended benefit of taking the drugs. However, many are confused with the different sources of information about the benefits of the drugs. In addition, they did not understand how it could work to prevent infection. For example, there was a misconception about the dangers of taking medication when you are well. Some perceived that the government would introduce these treatments as a gateway to reducing their life span.

“Adolescents are very inquisitive. They keep questioning depending on the different sources of information they receive. So some of the questions are like, “don’t you think these are the drugs that stimulate our TB?” Most of them have those questions and I don’t know whether it’s propaganda now they keep saying “the government or the health facilities are trying to make us fall sick quickly and we even google some of these drugs kill the cells that could have protected our bodies”. This affects their TPT drug adherence”. Medical officer 02.

Participants also reported that there was stigma related to TB disease at health facilities and in the communities where patients reside. The situation worsens especially for adolescents in schools where students fail to take their medication until their next appointment because of the stigma from their fellow peers.

“Students may stigmatize you, which at times makes you not to take the drugs or hide it from them that you are not taking the drugs”. Female adolescent 18 years. “Yes, because they disturb you, they say that one is a TB patient, and they talk a lot. This caused me to miss the refill days”. Female adolescent 14 years.

At the institution level, the long waiting-time at the clinic emerged as a barrier to completing TPT. Participants revealed that they preferred quick access to services without having to spend long hours in queues waiting to receive the treatment.

“It’s just embarrassing, it’s just too much. The long waiting really makes me feel like opting out. That’s the truth I can tell you”. Female care takers to a 13-year-old adolescent. “I come early and leave late. That issue made it hard for me. Sometimes I tell her to go by herself but then I remember that she will not give in her complaints. Sometimes we missed coming”. Female caretaker to a 12-year-old adolescent.

Participants were concerned about the attitude of health workers when they are seeking services. This was viewed as a major barrier because they thought if the health workers are rude to the clients, they might not find it conducive to collect their treatment. This was echoed by some health workers who shared the experience that when patients are mistreated, they fail to come back until they are followed up.

“You may find when the person has failed to come on a clinic visit because he was mistreated by a nurse and has not been listened to. Then the person concludes by saying I will not come back”. When it comes to the next appointment, they don’t come back”. Medical officer 05.

Health care workers forgetting to prescribe the drugs at refill visits emerged as one of the barriers to TPT completion.

“Also to the prescribers, someone might have taken TPT like for three months and when they report back, the prescriber forgets to give the refill to add up the six months. So, a patient ends up missing the three months and restart the treatment again”. Medical officer 01.

Health care workers also commented that health facilities may lack essential medicines, and clients are advised to buy from private pharmacies which hinders completion.

At the structural level, participants reported that if the clinic was not within easy reach, they found it a problem to pick their drug refills. This required them to travel long distances with costly transport.

“Transport also affects us, there is a time when you have to come and get treatment but when you don’t have money and that’s why some people fail to come”. Female care giver to 12-year-old adolescent.

This qualitative study explored the perceived, and experienced facilitators, and barriers to TPT initiation and completion among children and adolescents living with HIV, as reported by the Ugandan health workers, adolescents, and care takers of children.

Parental support and supervision, perceived risk of TB disease, and previous experiences of TB treatment were reported by adolescents and care takers of children as the major facilitators of TPT initiation and completion. Similar to a Kenyan study by S. Ngugi et al. [ 15 ], this study found that provision of adequate information about TPT benefits and dosing by health workers, family and community support, and experience of treating children with TB were highlighted by care takers as facilitators that enabled their children to initiate and complete TPT. Social support is very key in determining TPT initiation and completion among CALHIV, calling for integration of psychosocial support in TPT programs.

Facilitators of TPT initiation and completion highlight the need to provide adolescent friendly services and integrated TB and HIV services to facilitate initiation and completion of TPT among adolescents living with HIV [ 8 ]. Adolescent friendly services should be accessible, acceptable, appropriate and delivered in safe and respectful environment by supportive healthcare providers (27, 28). These include promotive, preventive, curative, and referral health services (28).

The barriers to TPT initiation and completion reported by adolescents included; TB or HIV-related stigma, busy work schedules of the adolescents and care takers, reduced social support from parents and family, previous experience of side effects from other drugs, pill burden and fatigue when that are not sick, financial constraints to travel to the clinic, and lack of food to take with the medicines. The roll-out of shorter TPT regimens is very timely [ 9 ], and will most likely address concerns of pill burden and fatigue among CALHIV who are already receiving daily ART.

Although care takers identified barriers to TPT initiation and completion that were similar to those reported by the adolescents, care takers additionally reported barriers such as; pill size, burden and odour, misconception and misinformation about the benefits and duration of the TPT, long distances to the health facilities, and rude health workers. It is important to provide regular adherence support from TPT initiation to facilitate completion, and therefore the efficacious benefits of TPT.

In contrast to the study by Teklay G et al. [ 18 ], health workers did not report fear of creating isoniazid resistance as a barrier to TPT initiation among CALHIV. Barriers cited by health workers included; TB and HIV-related stigma, undisclosed HIV status to the CALHIV, misconceptions that TPT puts their life at risk, fear of side effects, missed opportunities due to forgetting by health workers, poor attitude of health workers towards the adolescents, long waiting hours, change of care takers, and lack of parental or social support. These are closely related to the contextual barriers reported by Nyarubamba R. F et al. in Tanzania [ 14 ], and Lai J et al. in Ethiopia [ 16 ]. Drug stock outs in some facilities were reported as barriers, similar to a study among health workers in Ethiopia [ 18 ].

Limitations

The purposively selected sample is not widely representative of the CALHIV and their care takers in high TB burden countries. Therefore, transferability of these results in other settings may vary based on; the social-ecological models used to assess patient perceptions, TB disease burden, patient/family education and support initiatives within the healthcare system. There were limited numbers of participants who did not complete TPT, limiting the depth of lived experiences about barriers to TPT completion among CALHIV. This study did not explore the perspectives of policy makers in TB care, as these are also important to guide concerted efforts to improve TPT uptake and completion among CALHIV. There was no quantitative data for triangulation with the qualitative results.

The in-depth interviews were conducted at TPT initiation and after TPT completion. This minimised recall bias. This enabled deeper understanding of both perceived and experienced facilitators and barriers to TPT initiation and completion among CALHIV.

The facilitators and barriers of TPT initiation and completion among CALHIV are diverse, spanning from individual factors to healthcare system and structural factors. Educating patients about the benefits of TPT and the need to reduce the risk of TB, facilitates TPT initiation and completion among CALHIV. Availability of social support, adolescent-friendly services, and integration of TPT refills into ART refill visits are also major facilitators of TPT initiation and completion among CALHIV.

TB and HIV-related stigma, high pill burden of TPT in addition to ART, non-disclosure of HIV status of the children and adolescents, lack of parental support, transport difficulties, and misconceptions about TPT side effects, were the major barriers to initiation and completion among these CALHIV. Therefore, it is important to implement patient-centered TB and TPT services for CALHIV and their caretakers, so as to improve TPT initiation and completion, ultimately, reducing TB burden in this high-risk population.

Recommendations

Provision of clear information about TPT and TB, psychosocial and adherence support, adolescent-friendly TB-HIV services, and integration of TPT delivery into ART delivery models, are promising strategies to improve the uptake and completion of TPT among children and adolescents living with HIV in high TB-HIV burden settings like Uganda. TPT completion is likely where services are offered within a family-centered approaches to enhance psychosocial support for adherence. We recommend integrating TPT delivery into existing ART delivery approaches, at health facility and community level, to enhance uptake and completion of TPT among CALHIV.

Data availability

The data that support the findings of this study are available on request from the corresponding author Dr Pauline Mary Amuge (PMA) [email protected], and the institutional representative [email protected] This is to ensure that the data is shared within the provisions of the protocol approved by the Makerere University School of Medicine research and ethics committee, as it was aimed to accomplish specified study objectives.

Abbreviations

Assisted Partner Notification

Anti-retroviral therapy

Anti-retroviral drugs

Children and Adolescents Living with HIV

Severe Acute Respiratory Syndrome due to Corona Virus-19

Differentiated Service Delivery

Differentiated Service Delivery Models

Human Immune-deficiency Virus

3months course of Isoniazid and Rifapentine

3months course of Isoniazid and Rifampicin

Integrated community case management

Isoniazid (isonicotinylhydrazide)

Isoniazid Preventive Therapy

Interrupted time series

Latent Tuberculosis Infection

Ministry of Health

National Drug Authority

National Tuberculosis and Leprosy control Program

Bacteriologically Confirmed Pulmonary Tuberculosis

Clinically Diagnosed Pulmonary Tuberculosis

People Living with HIV

Pulmonary Tuberculosis

• Tuberculosis

Tuberculosis Preventive Treatment

Village Health Team

World Health Organisation

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Acknowledgements

Baylor College of Medicine Children’s Foundation-Uganda: Henry Balwa, Susan Tukamuhebwa, Rachel Namuddu Kikabi, Florence Namuli, Kizito David, Wasswa George, Rogers Nizeyimana, Geofrey Musoba, Alex Tekakwo, Brenda Nakabuye, David Mpagi. Joint Clinical Research Center (JCRC) Lubowa: Flavia Nakato, Joan Nangiya, Henry Mugerwa, Drollah Ssebagala. Makerere Joint AIDS Program (MJAP) Mulago ISS Clinic Kampala Uganda: Douglas Musimbago, Fred Semitala.

This work was supported by the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) grant programme at the International AIDS Society (IAS), through the CIPHER Research grant awarded to PA for the period 1st November 2021 to 31st October 2023, for a project titled “Differentiated delivery of tuberculosis preventive treatment (TPT) within existing health facility and community HIV care models to improve TPT uptake and completion among children and adolescents living with HIV in Uganda following the COVID-19 pandemic.”

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Contributions

PMA conceived the original concept. The funding was secured by PMA, PJE, PNN, ARK, AK, AMM, PM. The study was designed by PMA, PJE, MSP, AG, NAS, AMM, PM. Data was curated by PMA, DN, AB, DB, MM, CB, LK and CN. The data was analysed by DN and PMA. The project was co-ordinated by PMA, DN, MM, DB, DAR, and CB. The project technical advisors and mentors were; PJE, AK, ARK, AMM, NAS, MSP, AMM, PM. The original manuscript draft and responses to all author comments were written by PMA and DN. All authors reviewed and edited the original manuscript draft before submission. PMA and DN addressed all comments, and revised the manuscript. All authors reviewed and approved the final manuscript for publication.

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Correspondence to Pauline Mary Amuge .

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Written informed consent was obtained before data collection from participants aged ≥ 18 years, and parents/carers of children under 18years. Written informed assent was obtained from children aged 8years to under 18 years. All data were stored on encrypted computers. Filed notes and signed participant-informed consent forms were kept in a locked drawer at the study site. Participants’ names were not recorded anywhere during data collection. Each participant was given a unique identifying number to ensure confidentiality. The research teams did not include any identifying information that could have harmful consequences for the participants. Ethical approval was granted by the Makerere University school of medicine Research and Ethics Committee (17th June 2020, REF 2020 − 127), and the Uganda National Council for Science and Technology (12th November 2020; HS768ES).

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Amuge, P.M., Ndekezi, D., Mugerwa, M. et al. Facilitators and barriers to initiating and completing tuberculosis preventive treatment among children and adolescents living with HIV in Uganda: a qualitative study of adolescents, caretakers and health workers. AIDS Res Ther 21 , 59 (2024). https://doi.org/10.1186/s12981-024-00643-2

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Implementation of health-promoting retail initiatives in the Healthier Choices in Supermarkets Study—qualitative perspectives from a feasibility study

• Katrine Sidenius Duus   ORCID: orcid.org/0000-0002-1630-3132 1 ,
• Tine Tjørnhøj-Thomsen   ORCID: orcid.org/0000-0003-3621-6682 1 &
• Rikke Fredenslund Krølner   ORCID: orcid.org/0000-0002-4928-4310 1  

BMC Medicine volume  22 , Article number:  349 ( 2024 ) Cite this article

Metrics details

Improving food environments like supermarkets has the potential to affect customers’ health positively. Scholars suggest researchers and retailers collaborate closely on implementing and testing such health-promoting interventions, but knowledge of the implementation of such interventions is limited. We explore the implementation of four health-promoting food retail initiatives selected and developed by a partnership between a research institution, a large retail group, and a non-governmental organisation.

The four initiatives included downsizing of bags for pick’n’ mix sweets and soda bottles at the check-out registers, shelf tags promoting healthier breakfast cereal options, and replacing a complimentary bun with a banana offered to children. The initiatives were implemented for 6 weeks (or longer if the store manager allowed it) in one store in Copenhagen, Denmark. Data were collected through observations, informal interviews with customers, and semi-structured interviews with retailers. We conducted a thematic analysis of transcripts and field notes inspired by process evaluation concepts and included quantitative summaries of selected data.

Two out of four initiatives were not implemented as intended. The implementation was delayed due to delivery issues, which also resulted in soda bottles not being downsized as intended. The maintenance of the shelf tags decreased over time. Retailers expressed different levels of acceptability towards the initiatives, with a preference for the complimentary banana for children. This was also the only initiative noticed by customers with both positive and negative responses. Barriers and facilitators of implementation fell into three themes: Health is not the number one priority, general capacity of retailers, and influence of customers and other stakeholders on store operation.

Conclusions

The retailers’ interests, priorities, and general capacity influenced the initiative implementation. Retailers’ acceptability of the initiatives was mixed despite their involvement in the pre-intervention phase. Our study also suggests that customer responses towards health-promoting initiatives, as well as cooperation with suppliers and manufacturers in the development phase, may be determining to successful implementation. Future studies should explore strategies to facilitate implementation, which can be applied prior to and during the intervention.

Peer Review reports

What we eat affects our health and well-being [ 1 ]. Diet is associated with obesity, cancers [ 2 ], and mental well-being [ 3 ], and a healthy diet has been associated with lower all-cause mortality [ 4 ]. One important factor in improving diet is to create a food environment that supports a healthy diet [ 5 , 6 ]. In modern societies, such as Denmark, supermarkets are the main source of food [ 7 ]. Supermarkets therefore hold a significant influence on what food we buy and potentially also eat [ 7 , 8 , 9 ]. Studies report associations between the concentration of supermarkets and overweight and obesity in the neighbourhood [ 10 ] and between the healthfulness of supermarkets and people’s diets [ 11 , 12 ]. Moreover, unhealthy food and beverage products are promoted more often than healthy products and beverages in, for example, supermarkets [ 9 , 13 , 14 ]. This indicates a need to explore how and if it is possible to implement health promotion initiatives in supermarkets and whether customers respond to such initiatives as intended.

Studies show that health-promoting interventions in supermarkets can affect customers to purchase more healthy products [ 7 , 9 , 15 , 16 , 17 ]. Reviews and a meta-analysis have concluded that the most effective initiative in supermarket settings is price changes—the evidence points to the positive effects of reduced prices to increase the purchase of healthier products, especially fruit and vegetables [ 7 , 17 ]. Even though price reductions seem to be effective, they seem more challenging to implement due to retailers’ drive for profit and low preference for financing such price cuts [ 7 , 18 ]. There is some evidence that nudges in terms of product information and positioning, as well as altering the number of available products, can impact what products are being purchased [ 15 , 16 ]. However, the quality of this evidence is low. Overall, most of the studies that have explored the effect of interventions in supermarkets have been conducted in the USA and other high-income countries [ 15 , 16 ], in controlled settings, or applied a weak study design, such as non-randomised studies [ 16 , 17 ]. To our knowledge, only a few studies have been conducted in Denmark [ 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. These studies represent different designs and types of interventions: reformulation of private-label products to reduce calorie content [ 24 ], informational claims to promote low-salt foods [ 23 ], nudges via signs to promote sales of fruit and vegetables [ 22 ], positioning (shelf-space management) of dairy products [ 20 ], replacement of sugar confectionery with fruit and healthy snacks at the checkout [ 19 ], discount on fruit and vegetables combined with space management [ 25 ] and structural changes in supermarkets and education of supermarket employees as part of a multicomponent intervention [ 21 ] (the three latter studies are reporting from the same project). All but one study [ 23 ] found an effect of the applied intervention strategies, although mostly small or modest. This calls for more studies in real-life settings and investigations of why some interventions have the desired effect while others do not. Lack of effect may be explained by 1) customers not noticing or finding the initiatives relevant [ 19 , 23 ], 2) customers buying other products instead of or additionally to promoted intervention products [ 20 , 24 ], 3) the shelf organising effect [ 20 ], or 4) theory fail in regards to customer behaviour [ 22 ].

Several studies have explored facilitators and barriers to the implementation of health-promoting interventions in supermarkets. Reviews show that implementation is supported if the retailer is receptive to innovation, feels responsible for community health, and receives financial support or subsidies [ 26 ]. Furthermore, implementation is supported if the intervention provides the retailers with knowledge of health promotion and business skills [ 26 , 27 ]. Other facilitators include compatibility with context and customers’ needs, positive customer responses to the initiative, the prospect of improved public image, establishment of partnerships, low retailer effort requirements, and increased profit or sales [ 26 , 27 ]. Health-promoting interventions in supermarkets are hindered by high customer demand for unhealthy products and lower demand for healthy products, constraints of store infrastructure, challenges in product supply, high staff turnover, and lack of time [ 26 , 27 ]. Other barriers are doubt regarding changing customers’ behaviour, poor communication between collaborators [ 26 ], high running costs, and risk of spoilage [ 26 , 27 ].

Middle et al. [ 26 ] conclude that the underlying mechanism of barriers and facilitators of implementation is the (mis)alignment of retailers’ and intervention researchers’ interests. The authors, therefore, suggest a close collaboration between intervention researchers and retailers to work towards an alignment of interests and resolving or avoiding misalignment, which is supported by Gupta et al. [ 27 ]. However, knowledge of how such collaborative efforts affect the implementation of healthy food retail interventions is warranted.

The aim of this study is to explore the implementation, acceptability, and feasibility of four different health-promoting food retail initiatives to increase customers’ purchase of healthy food and beverages, which were selected and developed together with food retailers: 1) Promotion of healthier breakfast cereals and products using shelf tags, 2) downsizing of sodas sold at the checkout desks, 3) downsizing of bags for the pick’n’ mix sweets, 4) replacement of a complimentary bun for children with a banana. The study has three research objectives:

To document the implementation and sustainment of the initiatives over time

To explore the retailers’ and customers’ responses to and acceptability of the initiatives

To investigate barriers and facilitators of implementation and sustainment of the initiatives.

Setting and the initiatives

This study was conducted in Denmark during 2020 and 2021, 2 years that involved two major societal events, first the coronavirus disease pandemic and later the start of the Russia-Ukraine war. Both events heavily influenced the circumstances of everyday life including opportunities for conducting research and running businesses. The specific influences on this study will be unfolded later in the findings and discussion sections.

In this study, we collaborated with the retailer Salling Group, which holds 34.2% of the market share of grocery retailers in Denmark [ 28 ]. Salling Group is owned by the Salling Foundations and has no shareholders—all profits go to reinvestment in the business and donations to sports (amateur and professional), charity, education, and research. Salling Group owns three national supermarket chains: føtex, Netto and Bilka, alongside other businesses. For the feasibility test, we collaborated with føtex, which owns over 100 stores all over Denmark, including 23 stores called føtex food. føtex (except føtex food) offers both groceries and many different non-food products (e.g. textiles, cosmetics, toys, electronics, and home accessories).

The initiatives were selected and developed by a partnership, including a group of researchers at the National Institute of Public Health, University of Southern Denmark, consultants from the Danish Cancer Society, and employees at the Corporate Social Responsibility (CSR) department in Salling Group, the marketing department at føtex, and two store managers (hereafter referred collectively to as ‘the retailers’) over approximately 2 years. The process involved in-person meetings, desk research (the use of existing material [ 29 ]), visits to the test store, and a prototype test of three suggested initiatives. The researchers initiated the collaboration and were responsible for designing the research study and data collection and analyses. The retailers hosted the site of the feasibility test, contributed to the selection and development of initiatives and co-managed the practical part of the study. The Danish Cancer Society was recruited by the research project to develop the initiatives. A detailed description of the collaboration and development process is reported elsewhere (Duus et al.  unpublished ).

The feasibility test ended up including four initiatives: 1) Promotion of healthier breakfast cereals and products using shelf tags, 2) downsizing of soda sold at the checkout desks, 3) downsizing of bags for the pick’n’ mix sweets, 4) replacement of a complimentary bun for children with a banana (suggested by the retailers). The initiatives were based on a compromise between the willingness of the retailers and the interest and ideas of the remaining partners rather than on what the literature suggests are the most effective strategies (Duus et al.  unpublished ). Detailed descriptions of the initiatives and the rationale behind them are found in Table 1 .

The prototype test showed that 1) It was important to have a sign informing the customers about the initiative that offered a free banana to children instead of the usual free bun to create a better understanding of the changed offer; 2) Promotional shelf tags needed weekly maintenance as some would fall off; 3) It was difficult to sustain an initiative promoting ready-to-serve salads and ready-to-cook vegetables next to different fresh meats, as it met resistance among the staff due to being an additional task and led to more product waste (Customers did not expect to find these products next to the meat and therefore might not notice them). The learnings from the prototype test led to modifications of the implementation plan and the discard of the latter initiative. The prototype test also made us aware of how quickly the selection of food offered and the layout of the store changed over time, which the researcher, therefore, paid extra attention to during subsequent data collection. Moreover, the researcher made sure to update the list of products that should have a shelf tag a few weeks before the implementation to include new products offered.

The føtex marketing department developed a script to inform the staff at the test store about the feasibility test, explaining and showing each initiative and the aim of the study overall. This was sent to the store manager after being reviewed by the researchers. The store manager was responsible for informing all relevant staff about the implementation and maintenance of the initiatives. The føtex marketing department also made sure to inform the relevant suppliers. Employees at the test store and brand staff from a brewery (who stock the coolers at the check-out desks) implemented the initiatives in the store. The research group did not correct or maintain the initiatives in the store after they were launched; however, the researchers monitored it and reported back to the retailers, either at meetings or by email.

Overall study design

The four initiatives were implemented in the test store for 6 weeks (or longer if the store manager allowed it) starting in September 2021. A føtex store in central Copenhagen (the capital city of Denmark) was chosen as the test store. This decision was made for pragmatic reasons, as the research institute is based in Copenhagen, and based on Salling Group’s decision as it offered their new store layout, which all stores were in the process of being converted to (it was the same store as where the prototype test was conducted).

We designed a qualitative study involving participant observations and interviews to evaluate the feasibility of the initiatives. The methods were designed to explore the partnership and collaboration (the aim of another publication [Duus et al. Unpublished ]), as well as the implementation of the initiatives [ 30 ]. In the design of this study, we were inspired by McGill et al.'s (2020) two-phase framework of qualitative process evaluation from a complex systems perspective. This framework suggests an evaluation that looks at changes over time, starting with phase 1, the static system description and hypothesis generation about how the system might change when the intervention is introduced, followed by phase 2, an adaptive evaluation approach to the system undergoing change which follows emerging findings [ 31 ].

Data collection

In-store observations.

During October and November 2020, we mapped the store layout and customer flow in the test store as part of the static system description. Over 3 weeks, three research assistants performed 12 participant observations of 1005 min in total. The observations followed an observation guide which covered 1) the physical setting (e.g. the layout, placement of products, signs, and pictures); 2) the people (e.g. who are the customers? Are people shopping alone or together with others? How do they move around the store? What are the staff doing?) and 3) short interviews with customers (if possible) about their shopping at the particular store, and their thoughts about the layout of the store. The research teams’ access to the store was approved by the store manager, and research assistants wore a key chain with a sign showing their name and affiliation during the observations. During this data collection period, it was made mandatory to use face masks in supermarkets due to the coronavirus disease pandemic. As the implementation was delayed to approximately 1 year after this static description was completed, one participant observation in the test store was performed at the end of August 2021, just before initiative implementation, to document any major changes in the store layout and selection. Key lessons from these observations about the test supermarket and customers’ behaviour in the store included knowledge on 1) the route around the store, 2) the different times spent at the store, 3) interactions with objects (e.g. products and phones), 4) interactions with children, 5) behaviour of the staff, and 6) sensory impression (Additional file 1). These lessons informed our following data generation and assisted in contextualising our analysis.

The first author monitored the implementation process through participant observations of status meetings ( n  = 2) and correspondence via email and phone with the store manager and the contact person at føtex. In-store participant observations were conducted during and after the feasibility test period, September 2021–May 2022 ( n  = 25 ~ 1795 min in total; see Additional file 2). These observations focused on documenting the presence of the initiatives as well as customers’ and staff’s responses to the initiatives. Access to the store was once again approved by the store manager, and the researcher wore a key chain. During the participant observations in-store, we conducted informal interviews with customers (see Additional file 2 for examples of questions), which lasted a maximum of 5 min each. The first author would approach people and ask if they were interested in answering a brief question. She introduced herself by her first name, where she worked and explained she was doing a research project about shopping patterns. The participant observations were documented by taking notes and photos. Handwritten notes were digitalised and written down at the first chance after leaving the store.

Qualitative interviews

Between November 2021 and February 2023, the first author conducted four semi-structured interviews with retailers ( n  = 3) who had been involved in the study (Table 2 ) to explore their views on the initiatives and the implementation process. Interview guides were used in all interviews alongside different prompts (e.g. timelines and documents). Interview guides were tailored to each participant’s specific role and involvement in the development and implementation of the initiatives. Besides questions related to the initiatives and the implementation effort, the guides included questions about the informants’ background and motivation for the project (personally and professionally), their view on their role and scope for action (individually and organisationally) and their perception of the collaboration with the other organisations. After the participants’ consent was given verbally right before the interview, the interviews were recorded and later transcribed verbatim.

To explore the level of implementation (research objective I), all field notes and photos taken during and after the feasibility test were reviewed to assess whether the initiatives were present and to what degree (e.g. x out of x possible tags).

To explore the perception of the initiatives among employees and customers (research objective II) and identify barriers and facilitators for implementing the initiatives (research objective III), we followed a thematic analysis inspired by Braun and Clarke [ 32 ]. Firstly, field notes and interview transcripts were read thoroughly and openly coded, by writing keywords in the margin of the material, with a focus on the two research objectives. After initial coding, the codes were summarised into broader themes, by writing them into a document with short descriptions and revised according to data excerpts and the full empirical material. The themes drew on the process evaluation concepts: acceptability, responsiveness [ 30 ], motivation, general capacity to implement [ 33 ] and commercial viability [ 34 ]. Lastly, the themes were named, and the final analysis was written up.

We have structured the presentation of study findings as follows: Firstly, we present the implementation of the initiatives overall. Secondly, we present the implementation of each initiative, customers’ responses to them, and the retailers’ perspectives. Lastly, we present the overall facilitators and barriers to the implementation of the initiatives.

Implementation of the initiatives

The implementation of the initiatives was challenged. Firstly, we found that not all the preparations for the implementation were finished in time for the scheduled day. On the scheduled day, the retailer decided to push back the implementation by 1 week. The main reasons were that there had been some misunderstandings around the ordering of the smaller sodas. It was informed that the smaller soda would be a 330 ml can instead of the 375 ml bottle at the price of DKK 10.00 (~ 1.3 euros). The 500 ml bottle usually sold at the coolers cost DKK 16.00 (~ 2.2 euros). The Danish Cancer Society and the research group had two concerns about this: 1) the use of a can instead of a bottle would make the interpretation of the results very difficult, as the bottle and the can have two different functions to the customer—with the can, the product would be consumed all at once, whereas the bottle with the screw lid could be saved for later after it had been open; 2) the price was too low—the price per litre would be lower on the smaller sodas than it had been on those replaced. No changes were made despite these concerns.

Secondly, just days before the implementation, the retailers informed the other partners that they would stick with cans for the test of smaller-sized sodas and that they would now be 250 ml. They acknowledged that both the size and the packing were not optimal but that the optimal 375 ml in a bottle was just not possible. Additionally, they informed the researchers that they could no longer find the new bags produced for the pick’n’mix sweet display.

These challenges led to a delay of the implementation of the initiatives by 1 week, but also a staggered implementation, where the initiatives were implemented when ready (the soda initiative 2 weeks later and the bags for pick’n’ mix sweets 8 weeks later). The retailers agreed to push back the end day correspondingly, upholding the 6 weeks of implementation. Table 3 shows an overview of the implementation of the four initiatives according to the day and week of the feasibility test period.

Smaller product sizes of sodas at the checkout desk

As seen from Table  3 , we did observe the implementation of a smaller product size of the targeted sodas in all coolers, besides the one at the bakery, in the week leading up to the agreed date. We hereafter observed a full implementation of 250 ml cans during the first 2 weeks of implementation. During the third week and the beginning of the fourth week, we observed a mix of 250 and 330 ml cans or only 330 ml cans. The store manager explained that this was probably due to non-delivering from the supplier. At the end of the fourth week and for the last 2 weeks, we observed a full implementation of 250 ml cans. As the targeted size of the initiative was a 375 ml bottle, the initiative was not implemented as intended. After the 6-week feasibility test period, we observed that the smaller 250 ml cans were available in all coolers for at least eight more weeks. As expected, the presentation of the coolers fluctuated over the period. On days of stocking (Monday, Wednesday, and Friday), the coolers would look neat and full, while they would appear more empty or messy on other days.

Customer responsiveness

We observed very few customers who bought any products from the coolers, and we did not get to talk to any customers about the initiative. However, the observations in the store showed no distinct change in customers’ behaviour around the coolers nor expressions of discontent or excitement with the initiative. In an interview with the store manager, he explained that he believed customers had not noticed the change.

Retailer perspectives

The store manager was positive about the initiative, but from his perspective, the decision to implement it should be made at the procurement level and by the suppliers. However, he did have an opinion on how to implement it. The price needed to be fair according to the product it replaced. Moreover, he drew attention to the fact that it was the supplier’s personnel who stocked the products rather than his own. The store manager was, therefore, not surprised that the employees at the store had little to say about the initiative. føtex’s representative (B) was also positive about the initiative and expressed in the interview that the chain would be willing to implement it—if they found it to be the ‘right thing’ to do. However, the representative also emphasised the importance of agreeing with the suppliers, which is a time-consuming process and ‘not done in just six months’.

Shelf tags for breakfast cereal products

From the first day of the implementation, some tags were missing, and one tag was consistently misplaced (Table  3 ). During the first 3 weeks, 10% ( n  = 3) of the tags were missing. This portion progressively increased to 23% until the end of the fifth week. In the sixth week, the portion decreased at first to 16% but decreased again and ended at 26%. In the weeks after the implementation period, the tags stayed present but slowly came off. Approximately 6 months later, three (10%) of the tags were still present. We observed throughout the feasibility test that the presentation of the area varied, which is to be expected in a busy supermarket. At times, the area looked messy; boxes would block access to some products, products would be sold out, some would change packaging, and new products would be introduced to the selection.

When we asked customers about the tags, we learned that they had been unaware of them and that some believed that it was not something they would use—some did not know the meaning of the labels on the tags, while others did not find the labels relevant for them.

[The tags] don’t matter. My wife is pretty health conscious, so we don’t use those, let alone know with such a thing as breakfast cereal. (Male customer)

From our observations of the behaviour of the customers in the breakfast products and cereals department, we find two interesting groups: Those who shop alone and those who shop together with others (primarily children). These groups seem to practice different behaviours.

Among those who do their grocery shopping by themselves, we find two subgroups: 1) those who have planned or know exactly what they want to buy, and 2) those who decide at the store. For the first sub-group, we observed that some showed this by practising a behaviour where they would walk quickly and purposefully towards the shelves and quickly pick up a product. Others would look determined to find a specific product, as the fieldnote excerpt illustrates:

A woman stands looking at the muesli. She first grabs an orange bag on the bottom shelf, then a more yellow one next door and puts the first one back on the shelf. She inspects the bag she took. She starts to look around the shelves more and reaches for a bag that has a pinker look on the top shelf. She puts it back and reaches into the space next to it, where there are a few bags at the very back, but she has difficulty reaching them. A man comes by, notices the woman, and offers to help her. The woman indicates a yes, and the man reaches up and grabs a bag ‘that's the one!’ says the woman as the man hands her the bag.

Another example was a man who kept looking back and forth between some muesli and granola products and his phone before he eventually chose a product. It is unknown whether the man was looking at a specific note, a text request from his family, or a picture on his phone, yet what was on his phone seemed to determine the product he bought. Overall, this group seemed very unlikely to be influenced by the tags, as they had made their choice already before they entered the store.

For the second sub-group, those who seemed to make their decision in the store, we observed that some would just stop and glance at the products without choosing one before moving on with their shopping. Others would look more randomly at the selection than those described above, walk back and forth in the aisle, compare different products and read the info on the back of the products.

For those who shopped together with others (most often children), we observed that when adults shopped with children, the choices of the child and the choices of the adult often conflicted. In one example of a child and a woman who looked at breakfast cereal products, the child was initially allowed to pick a product and asked for different chocolate variants, which all featured cartoon figures; however, the woman rejected all of the child’s choices. In the interaction, the child was met with demands from the woman regarding the attributes of the products: they could not contain chocolate or sugar. In the end, it was the woman who chose a product based on her experience of the child’s preferences and her criteria. In similar situations, we did observe an attempt at compromising between the adult’s and the child’s criteria, which was explained by this woman:

I ask them [woman and boy aged about 10] what they look for when choosing breakfast cereals. The woman looks at the boy and says, ‘Well, what are we looking for?’. The boy does not answer but looks at her and me and smiles. The woman herself replies, ‘Something we can agree on. Something he likes but is not too unhealthy, either’. I ask her what she considers unhealthy. She waffles for a bit and then replies, ‘Yes, but he wants that Lions cereal, for example, and I don’t want him to have that. So something that’s not de facto sweets’. She takes the box of granola that they have chosen [Paulún's blueberry/lemon granola] out of the basket, looks at it and says, ‘So we chose this one. There's probably also a lot of fructose and caramelised stuff in it, but yeah.’

This illustrates the high impact children had on the choices of breakfast products, but also how the parents tried to control and negotiate the final choice.

Retailer perspective

The store manager had little faith in the effectiveness of the shelf tags:

The thing about tagging cereals, I don't think that makes the slightest difference. The reason why I’m sceptical in that regard is that it’s a mixture of what I do on a daily basis. It’s especially the behavioural patterns of our customers, but also how I act as a customer myself to a degree. I don't think shelf tags with the whole grain label or anything like that; in my experience it hasn’t changed things much. (Store manager)

His view on the effect of the initiative was in line with our observations of the customers in the store. Furthermore, the store manager explained that it was difficult to maintain the initiative, as it was not part of the employees’ daily routine. This was also the argument of why the tags lingered after the test period—it was just not part of the usual protocol either to hang them up or take them down. This perspective was shared by the føtex representative (B), who also highlighted the cost of this maintenance.

Contrary to the store managers’ sceptics, the føtex representative (B) was more positive about the initiative:

I think it’s a good initiative. We work a lot with tags and labels in general. [...] I think making it transparent to the consumer is really interesting because there’s nothing wrong with buying a box of Nesquick cereal every once in a while. At least we should not claim it’s the wrong thing to do. But you just have to be clear about what you’re buying, and I think those labels help with that. (føtex representative (B))

She explained that the initiative was highly compatible with their usual strategies. However, she also explained in the interview that a barrier to using shelf tags to promote the buying of certain products was that the chain was trying to reduce the printed material they used in their stores as part of their CSR strategy and to reduce costs.

Replacement of the complimentary bun for children with a banana

The complimentary banana was fully implemented in the feasibility test period except for 1 day of observation, where the signs were not visible (Table  3 ). The initiative also remained available and present by the sign for at least 10 weeks after the implementation period. Furthermore, the store manager informed the researcher that they would continue to provide bananas for customers requesting this as an act of customer service. From the observations, we do find that the presentation of the initiative changed throughout the period. At first, the bananas were placed in a cardboard box on the display counter, which was later replaced with a nicer-looking basket. The number of bananas and their colour also fluctuated during the different days, which would be expected due to the delivery of the bananas and how often they are restocked. However, compared to the buns, we never observed that the bananas were not available, making it a reliable offer no matter the time of the day.

We observed two ways (1 and 2) that the complimentary offer for children was brought up: 1) A customer would ask for the ‘bun for children’, or 2) the staff would offer the complimentary banana to buying customers. In the first way 1), we saw two responses from the staff (a and b) and the customers (i and ii): (a) The customer would be offered the bun with no mention of the banana, or (b) the staff would inform the customer that they no longer offered buns but that they offered a banana instead. The customers had two primary responses to this message: (i) The customer rejected the offer and decided to buy a bun or another item instead. The child was often included in this decision. (ii) The customer accepted the offer and received the banana. In some cases, the child did not accept the offer and the customer compensated for this response by buying a bun or another product for the child. In the second way 2), in which the staff offered the banana spontaneously, the customers almost always reacted positively and accepted the offer.

The following excerpt illustrates why some customers rejected the offer:

A woman with a child of about 1-year-old in a stroller walks up to the bakery and asks for a children's bun. The child has already noticed the buns from the moment they arrive and sits, pointing at the buns through the glass window and babbling. The shop assistant says that there are no children's buns but bananas and points to the sign. The woman replies, ‘I’d like to buy a bun, then’. The assistant takes the bun and enters it into the till, while the woman says, ‘Bananas are so messy’. The assistant smiles and says, ‘Well yeah, I'll pass that on’. The woman replies, ‘It's just that the banana is rather a bother, and the assistant replies, ‘But I think we’ll be offering [the buns] again eventually’.

Thus, adults rejected the offer because eating a banana was a messier process than eating a bun. During meetings and interviews, the retailer also highlighted this as the main reason for rejections of the offer, especially among those with younger children. Another reason for rejection was that the parents did not appreciate the offer nor perceived a need to offer their children a banana instead of a bun.

This initiative was the most successful and interesting one in the eyes of the store manager.

I’d like to highlight the banana for kids, which is clearly the initiative I found most customers were pleased with. (Store manager)

Many customers responded positively to the new offer, which was emphasised as a marker of success. It was also the reason why the initiative continued after the 6-week period, and the store manager explained that they would continue to give bananas to those who asked for them.

The following excerpt illustrates what the bun meant to føtex and the chain’s relationship with its customers.

The children's bun has been around for donkey’s years, and it’s become ingrained in parents and kids alike that you can get them in føtex. So, we’re quite interested in learning how many people would actually, if presented with the alternative, choose something else, like, for example, the banana. I’m quite surprised by that – we can't track it, unfortunately – but off the top of my head, up to 40 to 50 percent actually choose the banana. I find that very interesting. (føtex representative (B))

Thus, it came as a surprise that the initiative was so well received. However, despite the positive experiences with the initiative, the retailers also commented on the cost. They highlighted that the banana was more expensive than the bun, and if it should be an option offered in all stores, then it would have to be prioritised at the executive level as an additional expenditure. In this case, the banana would only be an alternative to the bun and not a replacement. This was rationalised by the retailers’ attitude of not making choices on behalf of the customers.

Smaller bags for pick’n’ mix sweets

This initiative was not implemented until 8 weeks after the initial implementation date. It was fully implemented for five out of the six weeks; during the third week, we observed that the old, larger bags had been hung in front of the new smaller bags. At 2 weeks and four and a half months after the feasibility test, the smaller bags could still be found behind the larger bags—however, it is unlikely that these would have been used, as the obvious choice would have been the bag at the very front. As described for the other areas, this also fluctuated in its presentation and stocking.

We did not get any direct reactions from customers on the smaller bag. However, our observations showed that different strategies were used to decide the amount of candy among customers who bought pick’n’mix sweets. Some showed signs of visually assessing the amount of sweets in the bag, which were the customers we would expect to influence. We often observed this strategy among adults with children, where it was the adult who would visually assess the amount and communicate to the child when they had picked enough.

Those with very young children would walk alongside the child and select the sweets for them, and some adults would encourage the choice of the child by pointing out different variants and commenting on the appearance of the sweets.

Other strategies were to mix according to a pre-defined number of pieces or volume:

A boy of about 10 and a girl of about 8 come over and mix sweets. They repeatedly weigh the bag while doing so. A woman comes over, and the girl says, ‘Hello mummy!’ The woman says, ‘Don’t forget to weigh it’. She then grabs a bag herself and begins to mix sweets. The boy asks the girl, ‘Did you weigh it?’. The girl walks over to the scales and says, ‘I think I’ve got enough’. However, she does not close the bag, and she begins to walk around somewhat restlessly, then says, ‘I don’t know what to pick. I’m still [a few] grammes short’.

An interesting aspect of the situation above is that the girl expressed that she was satisfied with what she had chosen, but she felt that she had to meet the prespecified weight and, therefore, tried to find more sweets to put in her bag. Such strategies undermine the mechanism which the initiative was trying to influence.

Overall, the retailers were positive about this initiative. The føtex representative (B) highlighted that this initiative was interesting as it was a stealth initiative, compared to the initiatives with the sodas, and would change the behaviour of the customers without them noticing. In her opinion, this was not a problem, as people paid per gram.

The store manager had a clear demand for the implementation; it should be easy for both the staff and customers to use. This perspective was backed up by a føtex representative (B) who said:

If there’s something that doesn’t work for us, it’s... if it doesn’t work for our customers, that’s what we need to solve first. (føtex representative (B))

This shows how one success criterion of the retailers is customer satisfaction, which we elaborate on later (See: Influence of customers and other stakeholders on store operation).

The initiative was very delayed, and one reason was that it was challenging to create a new bag that would work in the store. This resulted in the order of many different bags in large quantities due to the agreements with the suppliers, which had been very costly for the retailer.

The føtex representative (B) also reflected on what the potential evidence of an effect would mean to the retailer:

Then we’ll have to wait and see if people buy fewer sweets. And of course, this is something that we must take into account because it’s no secret that part of being a responsible business is to make a profit. And if we sell fewer sweets, then we make less money. (føtex representative (B))

This shows how health and financial profit were seen as opposites and how the success of the initiative would not necessarily lead to it being viewed favourably, as it would negatively affect their profit. Any implementation in the chain would, therefore, have to be a strategic decision.

Facilitators and barriers

In the sections above, we have focused on the four specific initiatives. In the following, we will present analytical findings that go across the initiatives and elucidate what facilitated and hampered the implementation of the initiatives overall. We have organised our findings under three headings: Health is not the number one priority; General capacity of the retailer; and Influence of customers and other stakeholders on store operation.

Health is not the number one priority

In this section, we present the retailers’ motivation for and interest in engaging in the project and working with health and health promotion and what drives and/or curbs this motivation. In our understanding of motivation, we draw on Scaccia et al. [ 33 ] and view motivation as incentives and disincentives that contribute to the desirability of using an initiative focusing on health.

We find that the retailers expressed motivation for working with health and health promotion, which at first seemed to be based on interest. The retailer representatives explained how they personally were interested in health and wanted to learn more, but also that the organisation had an interest in health, especially among children and young people, and wanted to contribute to health-preventing activities, for example, by financially supporting local sports clubs. According to one retailer representative, this was because physical activity and healthy eating promote happier customers, as well as happy employees. The argument points to retailers’ focus on customer satisfaction (see: Influence of customers and other stakeholders on store operation). The focus on the customers relates to another factor of motivation: Working with health was also seen as a relative advantage in that customers increasingly demand healthier products and alternatives. Lastly, we found that the motivation for working with health was a feeling of obligation due to the view of having a social responsibility:

I would say, in purely business and commercial terms, we are, indeed, a commercial business that was created to make money. There’s no ignoring that (laughs). So, of course, this is our main KPI [key performance indicator]. But that being said, we also agree that we have a social responsibility because we are as big as we are. We make a lot of foodstuffs available to the Danes, as do many of our colleagues in our industry, so there is no doubt that we have a role to play in terms of what we make available. (føtex representative (A))

According to the excerpt, this obligation was rooted in the size of the organisation and, thereby, the major influence on people’s selection of food products. However, the excerpt also highlighted that health was not their first priority, which was profit. This point has been repeatedly mentioned among retailers, which reinforces its validity; they were a business and had to gain profit to keep running their operation, which presented limits for what could be implemented. The store manager even expressed how he perceived the running of a supermarket and promotion of public health as incompatible goals and something he had never seen an example of in a real-life supermarket.

However, from the interviews with the retailers and our fieldwork, it seemed that this was not completely black and white, as the retailers were willing to give up their profit in some cases. An example is the hiding of tobacco products in all Salling Groups’ supermarket chains, which they voluntarily implemented in 2018, which led to a significant decrease in profit from tobacco products.

After all, the Salling Group pioneered this with tobacco products. I'm proud of that, but I also think it’s the right thing to do. My personal opinion is that it was the absolutely correct move they chose to make, by making it harder to market a product that is obviously bad for my health. We’re not there with pick‘n’mix sweets just yet, in that we would claim they’re bad for your health, but the mindset in terms of; that is, upholding the mindset when it comes to cigarettes is something that we, as an industry, can easily support in close cooperation with, among others, yourselves [researchers] and the industry. (Store manager)

Risk seemed to be the driver. If the retailer was convinced that the risk was real or big enough, then they were willing to give up some of their profits because it was the ‘right thing to do’, and they would have the courage and power to do so. It was mentioned by all three informants that they did not believe in bans, limitations or hiding of products, as this interfered with the customer’s freedom of choice. This viewpoint was a barrier to the implementation of all initiatives that used strategies that would minimise or reduce the availability of a product. Yet, as with the tobacco products, we found other examples where this restriction of choice was justified by the retailer. One example was that the føtex chain only sold organic bananas. From a sign in the store, this was because:

‘we want to avoid the spray agent chlorpyrifos. Among other things, it is suspected of harming the development of children and foetuses. We can’t live with that suspicion and therefore you can only buy organic bananas in the future’

As with the cigarettes, the argument here was the health risks. In the interview with the store manager about restricting choices, animal welfare and political reasons (e.g. Russia’s warfare against Ukraine) were mentioned as other arguments for doing so.

So, despite an immediate motivation for working with health, the retailer also expressed how other interests and priorities may hinder and set aside the work with health.

General capacity of the retailer

This section presents our findings relating to the general capacity of the retailer in the form of resources, organisational size, and culture. General capacity is understood as the readiness or ability to implement any new initiative [ 33 ].

Through the interviews with the føtex representative (B) and working together with the retailer during the project, we have found that the retailer seemed to be used to and willing to implement new initiatives. In this current study, they accounted for all expenses related to the development of materials for the test and were also willing to risk some of their profit for a short period of time. The føtex representative (B) highlighted this high level of available resources several times in the interview:

I have some leverage, so when we do something, we don’t do it by halves. What I find most motivating, and I can say that with complete peace of mind, is that if the Salling Group says they’re going to do something, or if føtex says they’re going to do something or says they want to win this particular battle, then we win it, and then we do it to the full. [...] So when we say, for example, with this health project, that ‘we want to work with health,’ then we do want to work with health, and we’re going to make a difference in health, too. (føtex representative (B))

In this excerpt, she expressed that the mere size of the company allowed them to push any agenda if they wanted to. However, this also underlines that this capacity is dependent on the retailer’s willingness, a willingness that was not in favour of many of the initiatives that the researcher, based on the literature, thought would have the greatest effect.

Even though the size of the company came with many available resources, the retailer also explained how the size of the company had worked against the project in several ways:

What I think made it difficult for us to get through with some of these things let's just take the sodas, in that case, we have a private label collaborator who has production facilities, and when they press the ‘Salling sodas’ button, it doesn't just spew out a few thousand bottles, but millions. So saying ‘can't we just try to reduce the size and give it a try.’ It's a giant setup, so it’s not possible to do that at a whim. You’d need to get a whole or half chain on board that can help sell such volumes because otherwise, the costs would go through the roof. (føtex representative (A))

What this excerpt explains is that even changes that appeared small would take tremendous effort and be very costly, due to the size of the organisation.

Another challenge of the implementation was embedded in the retailers’ organisational culture. Føtex representative (B) explained in the interview that conflicting goals between employees made it difficult and time-consuming when implementing new initiatives. Another barrier to implementing the initiatives was high staff turnover at the retailer. In an interview with a føtex representative, she explained that people often shifted around different positions in the organisation, which ended in the project falling between two stools, leading to misunderstandings of agreements and changes in attitudes towards the initiatives.

In summary, we find that the retailers could, in some respects, have a strong general capacity to implement new initiatives by having available resources and being used to implement new initiatives. Regardless, this study shows that this was not utilised due to a lack of willingness. Moreover, we find that the size and organisational culture of the retailer hampered the implementation of the initiatives.

Influence of customers and other stakeholders on store operation

The last section reports on the influence of customers on the retailer’s willingness to implement the initiatives, and the influence of other stakeholders, especially producers, on what can be implemented.

We found that the customer’s reactions and attitudes were determining to the retailer when implementing any new initiative, as indicated in the sections above. According to the retailer, the customer was the focus when designing the layout of the store:

We are in very close dialogue with our clients, we do quantitative surveys and we do focus groups, we do in-depth interviews. And in that context, we're trying to understand, when you're shopping, how do you go about it. Is it easy for you to find the items you are looking for? And based on the responses, we try to adapt our stores to make things easy for our customers. (føtex representative (A))

The same representative also mentioned that she thought it would have been a strength of the project to have conducted interviews with the customers as a part of the development process, emphasising the weight they put on the customer’s attitudes. The retailers highlighted the importance of customer satisfaction and convenience in their shopping experience as a barrier to implementing certain initiatives, such as changing the placement of products. However, these same factors have also proven to be facilitators for other initiatives, such as the tags for breakfast products and the complimentary banana for children, as demonstrated above.

Another important stakeholder for the supermarkets was the suppliers of their products. Others were government actors (e.g. the Danish Veterinary and Food Administration). For both downsizing initiatives, the suppliers of the products (sodas and bags for sweets) were key to the success of their implementation. In an interview with the store manager, he explained the huge role some of these suppliers have in the daily operation of the store and the chain.

After all, we’ve got a chain agreement that our head office has made with the breweries. I don’t get to decide which items are in our refrigerators. [...] The tricky thing is that we’re not only dealing with føtex or the Salling Group. We also have to do with some other, equally large companies that are also just coming in. Plus, I have people here X times a week to service their particular area. [...] [Another thing] that proved tricky, as far as I recall, was that the alternatives offered, people felt strongly about those because the breweries made some strategic choices, and because of those, some of the items that we might be able to stock, they didn't want to sell those. (Store manager)

This excerpt illustrates how suppliers like the breweries, as shown earlier, influenced the implementation and affected the decisions made by the retailer.

This section indicates that even though the retailer is convinced that a given initiative would be interesting to implement in their supermarket, the suppliers often must agree as well, and finally, the customers must also welcome it.

In this study, we have explored the implementation, acceptability, and feasibility of four different health-promoting food retail initiatives aimed at customers in a real-life supermarket setting, using different qualitative methods. We found that (i) Two initiatives (downsizing of bags for the pick’n’ mix sweets and the complimentary banana for children) were implemented to a high degree, yet delivery issues caused delays according to the planned date, especially for the bags. The downsizing of soda bottles was not implemented as intended; the size and packaging deviated from the original plan due to delivery failure. Moreover, the implementation decreased over the feasibility test for the initiative with shelf tags, as it took more continuous maintenance. For all initiatives, we found that they lingered after the feasibility test; however, only the banana for children was somewhat sustained for a period to accommodate customer demand. (ii) The retailers expressed different levels of acceptability towards the initiatives, and different representatives sometimes also showed different levels of acceptability towards the same initiative, such as the tags on the breakfast products. The most well-received initiative was the banana for children, which is somewhat unsurprising, as it was the retailers themselves that suggested including this initiative. Additionally, the positive response from the customers that they got supported the retailers’ positive attitude towards the initiative. We also found that many customers responded well to this initiative; however, we also observed a group that did not accept the initiative and preferred the bun over the banana. For the remaining initiatives, customers did not seem to notice them. Yet, we did observe customer behaviours that would probably work against the suggested mechanisms of some of the initiatives. (iii) In general, we describe three themes of barriers and facilitators that influence the implementation and possible sustainment of the initiatives: Health is not the number one priority, General capacity of the retailer, and Influence of customers and other stakeholders on store operation. Firstly, we found the retailers were motivated to work with health, both from a personal and professional perspective. The motivation was rooted in a feeling of social responsibility as well as health initiatives being viewed as a relative advantage, due to demand and making customers happier. Still, other priorities, such as profit and maintaining customers’ ‘free choice’, challenged the motivation to implement such initiatives. Secondly, the retailer showed a high level of available resources, which supported their general capacity to implement the initiatives; however, the large size of the organisation and its culture proved to be barriers to the implementation. Lastly, the analysis showed that the influence of both customers and other stakeholders was crucial to the implementation, both in terms of what is possible and what the retailers would be interested in and prioritise.

Our findings are similar to those of others [ 26 , 35 ]. Winkler et al. [ 35 ] found that even though supermarket actors found health-promoting initiatives meaningful to engage in, their engagement was challenged by a business mindset, practical routines, and structural requirements. Thus, despite the involvement of retailers in the development, selection and implementation of the initiatives, studies suggest that healthy food retail initiatives still encounter some fundamental barriers towards the implementation, such as the economical aspect or the view on customers’ free choice. However, our results also indicate that it might be possible to persuade food retailers to remove products or restrict choices if the evidence or arguments of it being the right thing to do are sufficiently strong, as with organic bananas or tobacco products. This has also been the case of another retailer in Denmark, which has decided that all their stores should be tobacco and nicotine-free by the end of 2028 to reduce the number of smokers [ 36 ]. Another solution is to identify win–win initiatives, as the complimentary banana for children was somewhat an example of (if we consider the banana as a healthier alternative) and which other studies have found as well [ 35 , 37 ].

Even though the four initiatives were implemented (yet two not as intended) in this study, and we found them to be somewhat acceptable to the retailers, we must still highlight that these initiatives represent a very small portion of the initiatives first suggested and entail several compromises from what the researchers had initially planned (Duus et al. Unpublished ). Moreover, the customer’s responses to the initiatives were mixed, and in some cases, their behaviour indicated that the initiatives would have little effect. Compared with studies testing similar initiatives, we find that 1) Shelf tags alone were found unlikely to change food purchases [ 38 ] and are likely to contribute to disparities in food purchases as not all customers know nutrition labels or have the literacy to read and understand them [ 39 ]. 2) Smaller bags for pick’n’ mix sweets could be successfully implemented and, based on results from another study, might be able to decrease the volume of sweets sold [ 40 ]. Moreover, others have also shown that customers are willing to buy smaller product options [ 41 ]. Taken together, this suggests that voluntary engagement with researchers might not suffice to make changes that would improve the supermarket environment as opted for to support population health. This view has also been suggested by Winkler et al. [ 35 ], and in the Lancet series on commercial determinants of health, an even more critical perspective on engagements with commercial actors as food retailers is presented [ 42 , 43 ]. Here they warn against how commercial actors use partnerships with researchers, among others, as a tool to improve their reputation and credibility [ 42 ].

In our collaborative process with the retailer, we experienced many challenges. We did not accomplish aligning retailers’ and researchers’ interests as scholars have suggested being the prerequisite of implementing healthy food retail interventions in supermarkets [ 26 , 27 ]. This underlines the importance of the pre-intervention phase, as described by Hawe, Shiell, and Riley [ 44 ], which is fundamental to a successful implementation. During the pre-intervention phase, the establishment of relationships between different people or agencies often occurs, and these relationships may play a crucial role in the implementation and the explanation of why some work and others do not [ 44 ]. In line with this, another study has suggested exploring what implementation strategies might promote the uptake of evidence-based interventions among food retailers [ 45 ]. They found that contrary to many other studies, the intervention in their study was compatible with the interest of the store managers to which it was presented—these store managers had a strong feeling of social responsibility towards the communities they operated in [ 45 ].

Strength and limitations

The investigation of the feasibility test was strengthened by using different methods, process evaluation concepts, and a broad view including both the delivery and presentation of the initiatives as well as customer and retailer perspectives. We primarily got the retailer perspective from a strategic level, yet we had planned on conducting focus group interviews with staff at the test store to get perspectives from an operational level on the initiatives and the implementation process. However, no staff wanted to participate in an interview. The store manager explained that this probably was due to three things: 1) They had no interest in the study, or they were tired of the study, 2) the recruitment was done too late (approximately 2 months after the feasibility test period), and 3) the staff was overworked as a result of understaffing due to the coronavirus disease pandemic. Future studies aim also to analyse sales data in order to evaluate whether any changes in sales of the products we intervened on occurred. However, with the available data, we will not be able to analyse whether the initiatives change people’s eating patterns or whether they influence people differently in terms of their socioeconomic factors or other characteristics.

A thorough needs assessment [ 46 ] among supermarket customers to test the initiative’s assumptions and their food purchase patterns would have strengthened the study. However, this was not possible within the timeframe and funding scheme, so the development drew primarily on existing knowledge and the experience of the retailer and the Danish Cancer Society. Furthermore, the store visits conducted in the store during the development of the initiative also provided a few customer perspectives, which led to the exclusion of some ideas (Duus et al.  unpublished ).

Furthermore, we learned two methodological lessons from the in-store observations: 1) All observers were met by the feeling of being ‘in the way’ and a need to be in almost constant movement to not interfere with the order in the store. The observers were met with a feeling of self-awareness and a need to legitimise their presence at the store by wearing a sticker on their shirts saying ‘visitor’ or their university identification card. These feelings were amplified by the governmental advice of social distancing and the requirement to wear face masks in grocery stores, introduced during the period of observations. 2) Concerning this, the observers also found it challenging to approach customers for the short interviews due to the feeling of invading people’s private space, hence only five were conducted. This was especially challenging when wearing face masks, as it was impossible to produce and read non-verbal signals (e.g. smiles), and difficult to hear what people were saying.

Implications for future studies and practice

This study presents an investigation of the implementation of healthy food retail initiatives for supermarkets that have been developed and selected together with retailers as suggested by the literature. It suggests that the implementation of such initiatives is possible and—to some degree—high. Yet, the quality of the initiatives was rather low, and some were not implemented as intended. Moreover, we still present some of the same barriers and limitations as former studies that have not implemented collaborative strategies in the pre-intervention phase. Some of this may be due to challenges such as a high staff turnover at the retailer and a lack of a shared understanding, as shown in another study (Duus et al. unpublished ). Future studies must explore this further.

Lessons for future studies are to identify initiatives that customers appreciate, as this is important to retailers. Underlining a needs assessment as an important first step in intervention development [ 30 , 46 ]. Furthermore, future studies should involve a broader range of stakeholders, including manufacturers and suppliers, in the development of the initiatives, as they have significant power over what can be implemented. Future studies would also benefit from identifying and testing implementation strategies that can facilitate the implementation of this type of intervention in this setting.

We performed a qualitative investigation of the implementation, acceptability, and feasibility of four different healthy food retail initiatives aimed at customers in a real-life supermarket setting, which had been developed and selected together with retailers. Only two of the four initiatives were implemented as intended, and the perspectives of retailers and customers were mixed or unclear. Altogether, the study highlights the challenges of implementing healthy retail food initiatives despite early involvement of retailers in the selection and design of those initiatives. Adding to the challenges of implementation, the initiatives also represent a compromise between the interests of the researcher and the retailers and do not represent what the literature suggests as the most effective strategies. A compromise made to uphold the partnership and complete the funded research project. Future studies should further examine the impact and pitfalls of including retailers (or other commercial actors) in the development and selection of healthy food retail initiatives and try to identify successful implementation strategies facilitating implementation.

Availability of data and materials

The data generated and analysed during the current study are not publicly available due to their sensitive and confidential nature but are available from the corresponding author upon reasonable request.

Abbreviations

Corporate Social Responsibility

Key Performance Indicator

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Acknowledgements

We want to thank all the participating retail group and supermarket staff members involved in this project and the implementation process. We appreciate the time and effort you have dedicated to this project and your openness. Furthermore, we want to acknowledge the customers who took the time to share their opinions with us during their daily grocery shopping.

We acknowledge Johanne Aviaja Rosing, Louise Ayoe Sparvath Brautsch, and Carl Johannes Middelboe for their assistance in conducting the pre- and post-intervention observations.

Open access funding provided by University of Southern Denmark This study is funded by the Danish Cancer Society, grant no.: R274-A16920. The first author (Katrine Sidenius Duus) has also received a Faculty Scholarship from the Faculty of Health Sciences at the University of Southern Denmark to support the completion of her PhD thesis, which this study is part of.

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KSD, RFK, and TTT contributed to the funding acquisition, study conception and design. Data generation and analyses were performed by KSD. The first draft of the manuscript was written by KSD. RFK and TTT commented on previous versions of the manuscript and contributed in writing the final manuscript. KSD wrote up the final manuscript. All authors read and approved the final manuscript.

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This study has been approved by SDU Research & Innovation Organization (notification no. 11.136). All informants who participated in interviews received written and verbal information about the aim, that participation was voluntary and that their information would be used for research purposes only and treated with confidentiality. By participating, consent for their data to be used for research was given. Data from the observation and documents were handled confidentially and with caution to protect sensitive information that could identify individuals.

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Duus, K.S., Tjørnhøj-Thomsen, T. & Krølner, R.F. Implementation of health-promoting retail initiatives in the Healthier Choices in Supermarkets Study—qualitative perspectives from a feasibility study. BMC Med 22 , 349 (2024). https://doi.org/10.1186/s12916-024-03561-2

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What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalizability

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

• Labor-intensive

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

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

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

Research bias

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

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

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

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

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

Focus Groups

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

Ethnographic Studies

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

Text Analysis

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

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

Process of Observation

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

Record Keeping

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

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

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

Qualitative Research Analysis Methods

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

Thematic Analysis

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

Content Analysis

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

Discourse Analysis

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

Grounded Theory Analysis

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

Narrative Analysis

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

Phenomenological Analysis

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

Comparative Analysis

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

Applications of Qualitative Research

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

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

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

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

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

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

Purpose of Qualitative Research

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

Qualitative research can serve multiple purposes, including:

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

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

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

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

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

Advantages of Qualitative Research

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

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

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

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

Also see Research Methods

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

Prevent plagiarism, run a free check.

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalisability

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

• Labour-intensive

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

Cite this Scribbr article

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Bhandari, P. (2023, January 30). What Is Qualitative Research? | Methods & Examples. Scribbr. Retrieved 2 September 2024, from https://www.scribbr.co.uk/research-methods/introduction-to-qualitative-research/

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What is qualitative research?

Quantitative vs qualitative research, approaches to qualitative research, qualitative data types and category types, disadvantages of qualitative research, how to use qualitative research to your business’s advantage, 6 steps to conducting good qualitative research, how do you arrange qualitative data for analysis, qualitative data analysis, how qualtrics products can enhance & simplify the qualitative research process, try qualtrics for free, your ultimate guide to qualitative research (with methods and examples).

31 min read You may be already using qualitative research and want to check your understanding, or you may be starting from the beginning. Learn about qualitative research methods and how you can best use them for maximum effect.

Qualitative research is a research method that collects non-numerical data. Typically, it goes beyond the information that quantitative research provides (which we will cover below) because it is used to gain an understanding of underlying reasons, opinions, and motivations.

Qualitative research methods focus on the thoughts, feelings, reasons, motivations, and values of a participant, to understand why people act in the way they do .

In this way, qualitative research can be described as naturalistic research, looking at naturally-occurring social events within natural settings. So, qualitative researchers would describe their part in social research as the ‘vehicle’ for collecting the qualitative research data.

Qualitative researchers discovered this by looking at primary and secondary sources where data is represented in non-numerical form. This can include collecting qualitative research data types like quotes, symbols, images, and written testimonials.

These data types tell qualitative researchers subjective information. While these aren’t facts in themselves, conclusions can be interpreted out of qualitative that can help to provide valuable context.

Because of this, qualitative research is typically viewed as explanatory in nature and is often used in social research, as this gives a window into the behavior and actions of people.

It can be a good research approach for health services research or clinical research projects.

Free eBook: The qualitative research design handbook

In order to compare qualitative and quantitative research methods, let’s explore what quantitative research is first, before exploring how it differs from qualitative research.

Quantitative research

Quantitative research is the research method of collecting quantitative research data – data that can be converted into numbers or numerical data, which can be easily quantified, compared, and analyzed .

Quantitative research methods deal with primary and secondary sources where data is represented in numerical form. This can include closed-question poll results, statistics, and census information or demographic data.

Quantitative research data tends to be used when researchers are interested in understanding a particular moment in time and examining data sets over time to find trends and patterns.

The difference between quantitative and qualitative research methodology

While qualitative research is defined as data that supplies non-numerical information, quantitative research focuses on numerical data.

In general, if you’re interested in measuring something or testing a hypothesis, use quantitative research methods. If you want to explore ideas, thoughts, and meanings, use qualitative research methods.

Where both qualitative and quantitative methods are not used, qualitative researchers will find that using one without the other leaves you with missing answers.

For example, if a retail company wants to understand whether a new product line of shoes will perform well in the target market:

• Qualitative research methods could be used with a sample of target customers, which would provide subjective reasons why they’d be likely to purchase or not purchase the shoes, while
• Quantitative research methods into the historical customer sales information on shoe-related products would provide insights into the sales performance, and likely future performance of the new product range.

There are five approaches to qualitative research methods:

• Grounded theory: Grounded theory relates to where qualitative researchers come to a stronger hypothesis through induction, all throughout the process of collecting qualitative research data and forming connections. After an initial question to get started, qualitative researchers delve into information that is grouped into ideas or codes, which grow and develop into larger categories, as the qualitative research goes on. At the end of the qualitative research, the researcher may have a completely different hypothesis, based on evidence and inquiry, as well as the initial question.
• Ethnographic research : Ethnographic research is where researchers embed themselves into the environment of the participant or group in order to understand the culture and context of activities and behavior. This is dependent on the involvement of the researcher, and can be subject to researcher interpretation bias and participant observer bias . However, it remains a great way to allow researchers to experience a different ‘world’.
• Action research: With the action research process, both researchers and participants work together to make a change. This can be through taking action, researching and reflecting on the outcomes. Through collaboration, the collective comes to a result, though the way both groups interact and how they affect each other gives insights into their critical thinking skills.
• Phenomenological research: Researchers seek to understand the meaning of an event or behavior phenomenon by describing and interpreting participant’s life experiences. This qualitative research process understands that people create their own structured reality (‘the social construction of reality’), based on their past experiences. So, by viewing the way people intentionally live their lives, we’re able to see the experiential meaning behind why they live as they do.
• Narrative research: Narrative research, or narrative inquiry, is where researchers examine the way stories are told by participants, and how they explain their experiences, as a way of explaining the meaning behind their life choices and events. This qualitative research can arise from using journals, conversational stories, autobiographies or letters, as a few narrative research examples. The narrative is subjective to the participant, so we’re able to understand their views from what they’ve documented/spoken.

Qualitative research methods can use structured research instruments for data collection, like:

Surveys for individual views

A survey is a simple-to-create and easy-to-distribute qualitative research method, which helps gather information from large groups of participants quickly. Traditionally, paper-based surveys can now be made online, so costs can stay quite low.

Qualitative research questions tend to be open questions that ask for more information and provide a text box to allow for unconstrained comments.

Examples include:

• Asking participants to keep a written or a video diary for a period of time to document their feelings and thoughts
• In-Home-Usage tests: Buyers use your product for a period of time and report their experience

Surveys for group consensus (Delphi survey)

A Delphi survey may be used as a way to bring together participants and gain a consensus view over several rounds of questions. It differs from traditional surveys where results go to the researcher only. Instead, results go to participants as well, so they can reflect and consider all responses before another round of questions are submitted.

This can be useful to do as it can help researchers see what variance is among the group of participants and see the process of how consensus was reached.

• Asking participants to act as a fake jury for a trial and revealing parts of the case over several rounds to see how opinions change. At the end, the fake jury must make a unanimous decision about the defendant on trial.
• Asking participants to comment on the versions of a product being developed, as the changes are made and their feedback is taken onboard. At the end, participants must decide whether the product is ready to launch.

Semi-structured interviews

Interviews are a great way to connect with participants, though they require time from the research team to set up and conduct, especially if they’re done face-to-face.

Researchers may also have issues connecting with participants in different geographical regions. The researcher uses a set of predefined open-ended questions, though more ad-hoc questions can be asked depending on participant answers.

• Conducting a phone interview with participants to run through their feedback on a product. During the conversation, researchers can go ‘off-script’ and ask more probing questions for clarification or build on the insights.

Focus groups

Participants are brought together into a group, where a particular topic is discussed. It is researcher-led and usually occurs in-person in a mutually accessible location, to allow for easy communication between participants in focus groups.

In focus groups , the researcher uses a set of predefined open-ended questions, though more ad-hoc questions can be asked depending on participant answers.

• Asking participants to do UX tests, which are interface usability tests to show how easily users can complete certain tasks

Direct observation

This is a form of ethnographic research where researchers will observe participants’ behavior in a naturalistic environment. This can be great for understanding the actions in the culture and context of a participant’s setting.

This qualitative research method is prone to researcher bias as it is the researcher that must interpret the actions and reactions of participants. Their findings can be impacted by their own beliefs, values, and inferences.

• Embedding yourself in the location of your buyers to understand how a product would perform against the values and norms of that society

One-to-one interviews

One-to-one interviews are one of the most commonly used data collection instruments for qualitative research questions, mainly because of their approach. The interviewer or the researcher collects data directly from the interviewee one-to-one. The interview method may be informal and unstructured – conversational. The open-ended questions are mostly asked spontaneously, with the interviewer letting the interview flow dictate the questions to be asked.

Record keeping

This method uses existing reliable documents and similar sources of information as the data source. This data can be used in new research. It is similar to going to a library. There, one can go over books and other reference material to collect relevant data that can be used in the research.

Process of observation

In this data collection method, the researcher immerses themselves in the setting where their respondents are, keeps a keen eye on the participants, and takes notes. This is known as the process of observation.

Besides taking notes, other documentation methods, such as video and audio recording, photography, and similar methods, can be used.

Longitudinal studies

This data collection method is repeatedly performed on the same data source over an extended period. It is an observational research method that goes on for a few years and sometimes can go on for even decades. Such data collection methods aim to find correlations through empirical studies of subjects with common traits.

Case studies

This method gathers data from an in-depth analysis of case studies. The versatility of this method is demonstrated in how this method can be used to analyze both simple and complex subjects. The strength of this method is how judiciously it uses a combination of one or more qualitative methods to draw inferences.

What is data coding in qualitative research?

Data coding in qualitative research involves a systematic process of organizing and interpreting collected data. This process is crucial for identifying patterns and themes within complex data sets. Here’s how it works:

• Data Collection : Initially, researchers gather data through various methods such as interviews, focus groups, and observations. The raw data often includes transcriptions of conversations, notes, or multimedia recordings.
• Initial Coding : Once data is collected, researchers begin the initial coding phase. They break down the data into manageable segments and assign codes—short phrases or words that summarize each piece of information. This step is often referred to as open coding.
• Categorization : Next, researchers categorize the codes into broader themes or concepts. This helps in organizing the data and identifying major patterns. These themes can be linked to theoretical frameworks or emerging patterns from the data itself.
• Review and Refinement : The coding process is iterative, meaning researchers continuously review and refine their codes and categories. They may merge similar codes, adjust categories, or add new codes as deeper understanding develops.
• Thematic Analysis : Finally, researchers perform a thematic analysis to draw meaningful conclusions from the data. They explore how the identified themes relate to the research questions and objectives, providing insights and answering key queries.

Methods and tools for coding

• Manual Coding : Involves using highlighters, sticky notes, and physical organization methods.
• Software Tools : Programs like NVivo, ATLAS.ti, and MAXQDA streamline the coding process, allowing researchers to handle large volumes of data efficiently.

Data coding transforms raw qualitative data into structured information, making it essential for deriving actionable insights and achieving research objectives.

Qualitative research methods often deliver information in the following qualitative research data types:

• Written testimonials

Through contextual analysis of the information, researchers can assign participants to category types:

• Social class
• Political alignment
• Most likely to purchase a product
• Their preferred training learning style

Why is qualitative data important?

Qualitative data plays a pivotal role in understanding the nuances of human behavior and emotions. Unlike quantitative data, which deals with numbers and hard statistics, qualitative data captures the vivid tapestry of opinions, experiences, and motivations.

Understanding emotions and perceptions

One primary reason qualitative data is crucial is its ability to reveal the emotions and perceptions of individuals. This type of data goes beyond mere numbers to provide insights into how people feel and think. For example, understanding consumer sentiments can help businesses tailor their products and services to meet customer needs more effectively.

Rich context and insights

Qualitative analysis dives deep into textual data, uncovering rich context and subtle patterns that might be missed with quantitative methods alone. This kind of data provides comprehensive insights by examining the intricate details of user feedback, interviews, or focus group discussions. For instance, companies like IBM and Nielsen use qualitative data to gain a deeper understanding of market trends and consumer preferences.

Forming research parameters

Researchers use qualitative data to establish parameters for broader studies. By identifying recurring themes and traits, they can design more targeted and effective surveys and experiments. This initial qualitative phase is essential in ensuring that subsequent quantitative research is grounded in real-world observations.

Solving complex problems

In market research, qualitative data is invaluable for solving complex problems. It enables researchers to decode the language of their consumers, identifying pain points and areas for improvement. Brands like Coca-Cola and P&G frequently rely on qualitative insights to refine their marketing strategies and enhance customer satisfaction.

In sum, qualitative data is essential for its ability to capture the depth and complexity of human experiences. It provides the contextual groundwork needed to make informed decisions, understand consumer behavior, and ultimately drive successful outcomes in various fields.

How do you organize qualitative data?

Organizing qualitative data is crucial to extract meaningful insights efficiently. Here’s a step-by-step guide to help you streamline the process:

1. Align with research objectives

Start by revisiting your research objectives. Clarifying the core questions you aim to answer can guide you in structuring your data. Create a table or spreadsheet where these objectives are clearly laid out.

2. Categorize the data

Sort your data based on themes or categories relevant to your research objectives. Use different coding techniques to label each piece of information. Tools like NVivo or Atlas.ti can help in coding and categorizing qualitative data effectively.

3. Use visual aids

Visualizing data can make patterns more apparent. Consider using charts, graphs, or mind maps to represent your categorized data. Applications like Microsoft Excel or Tableau are excellent for creating visual representations.

4. Develop a index system

Create an index system to keep track of where each piece of information fits within your categories. This can be as simple as a detailed index in a Word document or a more complex system within your data analysis software.

5. Summary tables

Develop summary tables that distill large amounts of information into key points. These tables should reflect the core themes and subthemes you’ve identified, making it easier to draw conclusions.

6. Avoid unnecessary data

Don’t fall into the trap of hoarding unorganized or irrelevant information. Regularly review your data to ensure it aligns with your research goals. Trim any redundant or extraneous data to maintain clarity and focus.

By following these steps, you can turn your raw qualitative data into an organized, insightful resource that directly supports your research objectives.

Advantages of qualitative research

• Useful for complex situations: Qualitative research on its own is great when dealing with complex issues, however, providing background context using quantitative facts can give a richer and wider understanding of a topic. In these cases, quantitative research may not be enough.
• A window into the ‘why’: Qualitative research can give you a window into the deeper meaning behind a participant’s answer. It can help you uncover the larger ‘why’ that can’t always be seen by analyzing numerical data.
• Can help improve customer experiences: In service industries where customers are crucial, like in private health services, gaining information about a customer’s experience through health research studies can indicate areas where services can be improved.
• You need to ask the right question: Doing qualitative research may require you to consider what the right question is to uncover the underlying thinking behind a behavior. This may need probing questions to go further, which may suit a focus group or face-to-face interview setting better.
• Results are interpreted: As qualitative research data is written, spoken, and often nuanced, interpreting the data results can be difficult as they come in non-numerical formats. This might make it harder to know if you can accept or reject your hypothesis.
• More bias: There are lower levels of control to qualitative research methods, as they can be subject to biases like confirmation bias, researcher bias, and observation bias. This can have a knock-on effect on the validity and truthfulness of the qualitative research data results.

Qualitative methods help improve your products and marketing in many different ways:

• Understand the emotional connections to your brand
• Identify obstacles to purchase
• Uncover doubts and confusion about your messaging
• Find missing product features
• Improve the usability of your website, app, or chatbot experience
• Learn about how consumers talk about your product
• See how buyers compare your brand to others in the competitive set
• Learn how an organization’s employees evaluate and select vendors

Businesses can benefit from qualitative research by using it to understand the meaning behind data types. There are several steps to this:

• Define your problem or interest area: What do you observe is happening and is it frequent? Identify the data type/s you’re observing.
• Create a hypothesis: Ask yourself what could be the causes for the situation with those qualitative research data types.
• Plan your qualitative research: Use structured qualitative research instruments like surveys, focus groups, or interviews to ask questions that test your hypothesis.
• Data Collection: Collect qualitative research data and understand what your data types are telling you. Once data is collected on different types over long time periods, you can analyze it and give insights into changing attitudes and language patterns.
• Data analysis: Does your information support your hypothesis? (You may need to redo the qualitative research with other variables to see if the results improve)
• Effectively present the qualitative research data: Communicate the results in a clear and concise way to help other people understand the findings.

Transcribing and organizing your qualitative data is crucial for robust analysis. Follow these steps to ensure your data is systematically arranged and ready for interpretation.

1. Transcribe your sata

Converting your gathered information into a textual format is the first step. This involves:

• Listening to audio recordings: Jot down every nuance and detail.
• Reading through notes: Ensure all handwritten or typed notes are coherent and complete.

2. Choose a suitable format

Once transcribed, your data needs to be formatted for ease of analysis. You have several options:

• Spreadsheets: Tools like Microsoft Excel or Google Sheets allow for easy sorting and categorization.
• Specialized software: Consider using computer-assisted qualitative data analysis software (CAQDAS) such as NVivo, ATLAS.ti, or MAXQDA to handle large volumes of data efficiently.

3. Organize by themes

Begin to identify patterns or themes in your data. This method, often called coding, involves:

• Highlighting Key Points: Use different colors or symbols to mark recurring ideas.
• Creating Categories: Group similar themes together to form a coherent structure.

4. Label and store

Finally, label and store your data meticulously to ensure easy retrieval and reference. Label:

• Files and Documents: With clear titles and dates.
• Sections within Documents: With headings and subheadings to distinguish different themes and patterns.

By following these systematic steps, you can convert raw qualitative data into a structured format ready for comprehensive analysis.

Evaluating qualitative research can be tough when there are several analytics platforms to manage and lots of subjective data sources to compare.

Qualtrics provides a number of qualitative research analysis tools, like Text iQ, powered by Qualtrics iQ , provides powerful machine learning and native language processing to help you discover patterns and trends in text.

This also provides you with:

• Sentiment analysis — a technique to help identify the underlying sentiment (say positive, neutral, and/or negative) in qualitative research text responses
• Topic detection/categorisation — this technique is the grouping or bucketing of similar themes that can are relevant for the business & the industry (e.g., ‘Food quality,’ ‘Staff efficiency,’ or ‘Product availability’)

Validating your qualitative data

Validating data is one of the crucial steps of qualitative data analysis for successful research. Since data is quintessential for research, ensuring that the data is not flawed is imperative. Please note that data validation is not just one step in this analysis; it is a recurring step that needs to be followed throughout the research process.

There are two sides to validating data:

• Ensuring that the methods used are designed to produce accurate data.
• The extent to which the methods consistently produce accurate data over time.

Incorporating these validation steps ensures that the qualitative data you gather through tools like Text iQ is both reliable and accurate, providing a solid foundation for your research conclusions.

What are the approaches to qualitative data analysis?

Qualitative data analysis can be tackled using two main approaches: the deductive approach and the inductive approach. Each method offers unique benefits and caters to different research needs.

Deductive approach

The deductive approach involves analyzing qualitative data within a pre-established framework. Typically, researchers use predefined questions to guide their analysis, making it a structured and straightforward process. This method is particularly useful when researchers have a clear hypothesis or a reasonable expectation of the data they will gather.

Advantages :

• Quick and efficient
• Suitable for studies with known variables

Disadvantages :

• Limited flexibility
• May not uncover unexpected insights

Inductive approach

Contrastingly, the inductive approach is characterized by its flexibility and open-ended nature. Rather than starting with a set structure, researchers use this approach to let patterns and themes emerge naturally from the data. This method is time-consuming but thorough, making it ideal for exploratory research where little is known about the phenomenon under study.

• High flexibility
• Uncovers insights that may not be immediately obvious
• Time-intensive
• Requires rigorous interpretation skills

Both approaches have their merits and can be chosen based on the objectives of your research. By understanding the key differences between the deductive and inductive methods, you can select the approach that best suits your analytical needs.

What is the inductive approach to qualitative data analysis?

The inductive approach to qualitative data analysis is a flexible and explorative method. Unlike approaches that follow a fixed framework, the inductive approach builds theories and patterns from the data itself. Here’s a closer look:

• No fixed framework: This method does not rely on predetermined structures or strict guidelines. Instead, it allows patterns and themes to naturally emerge from the data.
• Exploratory nature: Often used when little is known about the research phenomenon, this approach helps researchers unearth new insights without preconceptions.
• Time-consuming but thorough: Due to its comprehensive nature, the inductive approach can be more time-intensive. Researchers meticulously examine data to uncover meaningful connections and build a deep understanding of the subject matter.
• Flexible and adaptive: This approach is particularly useful in dynamic research environments where the subject matter is complex or not well understood.

In essence, the inductive approach is about letting the data lead the research, allowing for the discovery of unexpected insights and a more nuanced understanding of the studied phenomena.

The deductive approach to qualitative data analysis is a method where researchers begin with a predefined structure or framework to guide their examination of data. Essentially, this means they start with specific questions or hypotheses in mind, which helps in directing the analysis process.

Key elements of the deductive approach:

• Researchers have a clear idea of what they are looking for based on prior knowledge or theories.
• This structured framework acts as a guide throughout the analysis.
• Specific questions are developed beforehand.
• These questions help in filtering and categorizing the data effectively.
• The deductive method is typically faster and more straightforward.
• It is particularly useful when researchers anticipate certain types of responses or patterns from their sample population.

In summary, the deductive approach involves using existing theories and structured queries to systematically analyze qualitative data, making the process efficient and focused.

How to conclude the qualitative data analysis process

Concluding your qualitative data analysis involves presenting your findings in a structured report that stakeholders can readily understand and utilize.

Start by describing your methodology . Detail the specific methods you employed during your research, including how you gathered and analyzed data. This helps readers appreciate the rigor of your process.

Next, highlight both the strengths and limitations of your study. Discuss what worked well and areas that posed challenges, providing a balanced view that showcases the robustness of your research while acknowledging potential shortcomings.

Following this, present your key findings and insights . Summarize the main conclusions drawn from your data, ensuring clarity and conciseness. Use bullet points or numbered lists to enhance readability where appropriate.

Moreover, offer suggestions or inferences based on your findings. Identify actionable recommendations or indicate future research areas that emerged from your study.

Finally, emphasize the importance of the synergy between analytics and reporting . Analytics uncover valuable insights, but it’s the reporting that effectively communicates these insights to stakeholders, enabling informed decision-making.

Even in today’s data-obsessed marketplace, qualitative data is valuable – maybe even more so because it helps you establish an authentic human connection to your customers. If qualitative research doesn’t play a role to inform your product and marketing strategy, your decisions aren’t as effective as they could be.

The Qualtrics XM system gives you an all-in-one, integrated solution to help you all the way through conducting qualitative research. From survey creation and data collection to textual analysis and data reporting, it can help all your internal teams gain insights from your subjective and categorical data.

Qualitative methods are catered through templates or advanced survey designs. While you can manually collect data and conduct data analysis in a spreadsheet program, this solution helps you automate the process of qualitative research, saving you time and administration work.

Using computational techniques helps you to avoid human errors, and participant results come in are already incorporated into the analysis in real-time.

Our key tools, Text IQ™ and Driver IQ™ make analyzing subjective and categorical data easy and simple. Choose to highlight key findings based on topic, sentiment, or frequency. The choice is yours.

Some examples of your workspace in action, using drag and drop to create fast data visualizations quickly:

Related resources

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

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The SAGE Handbook of Qualitative Research

• Norman K. Denzin - University of Illinois, Urbana - Champaign, USA
• Yvonna S. Lincoln - Texas A&M University, USA
• Description

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

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• New contributors offer 19 completely new chapter topics , including indigenous methodologies, methodologies in an age of new technologies, queer/quare theory, ethnodrama, data and its problematics, triangulation, collaborative inquiry, digital ethnography, the global audit culture, and much more.
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• Discussions on a wide range of methods expand the reader's repertoire of methodologies, enlarging the range of data that can be brought to bear on social and educational issues. 

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Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

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Qualitative Research : Definition

Qualitative research is the naturalistic study of social meanings and processes, using interviews, observations, and the analysis of texts and images.  In contrast to quantitative researchers, whose statistical methods enable broad generalizations about populations (for example, comparisons of the percentages of U.S. demographic groups who vote in particular ways), qualitative researchers use in-depth studies of the social world to analyze how and why groups think and act in particular ways (for instance, case studies of the experiences that shape political views).   

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What is Qualitative in Qualitative Research

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• Published: 27 February 2019
• Volume 42 , pages 139–160, ( 2019 )

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

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

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

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

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

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

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

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

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

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

Towards a Definition of Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Analysis – What is Qualitative Research?

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

Qualitative and Quantitative

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

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

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

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

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

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

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

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

Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

Grounded Theory

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

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

Defining Qualitative Research

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

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

Distinctions

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

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

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

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

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

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

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

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

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

Improved Understanding

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

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

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

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

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

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

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

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

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

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

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

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

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

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Acknowledgements

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

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Aspers, P., Corte, U. What is Qualitative in Qualitative Research. Qual Sociol 42 , 139–160 (2019). https://doi.org/10.1007/s11133-019-9413-7

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