conclusion chapter 5 qualitative research

How To Write The Results/Findings Chapter

For qualitative studies (dissertations & theses).

By: Jenna Crossley (PhD Cand). Expert Reviewed By: Dr. Eunice Rautenbach | August 2021

So, you’ve collected and analysed your qualitative data, and it’s time to write up your results chapter – exciting! But where do you start? In this post, we’ll guide you through the qualitative results chapter (also called the findings chapter), step by step.  

Overview: Qualitative Results Chapter

• What (exactly) the qualitative results chapter is
• What to include in your results chapter
• How to write up your results chapter
• A few tips and tricks to help you along the way

What exactly is the results chapter?

The results chapter in a dissertation or thesis (or any formal academic research piece) is where you objectively and neutrally present the findings of your qualitative analysis (or analyses if you used multiple qualitative analysis methods ). This chapter can sometimes be combined with the discussion chapter (where you interpret the data and discuss its meaning), depending on your university’s preference.  We’ll treat the two chapters as separate, as that’s the most common approach.

In contrast to a quantitative results chapter that presents numbers and statistics, a qualitative results chapter presents data primarily in the form of words . But this doesn’t mean that a qualitative study can’t have quantitative elements – you could, for example, present the number of times a theme or topic pops up in your data, depending on the analysis method(s) you adopt.

Adding a quantitative element to your study can add some rigour, which strengthens your results by providing more evidence for your claims. This is particularly common when using qualitative content analysis. Keep in mind though that qualitative research aims to achieve depth, richness and identify nuances , so don’t get tunnel vision by focusing on the numbers. They’re just cream on top in a qualitative analysis.

So, to recap, the results chapter is where you objectively present the findings of your analysis, without interpreting them (you’ll save that for the discussion chapter). With that out the way, let’s take a look at what you should include in your results chapter.

What should you include in the results chapter?

As we’ve mentioned, your qualitative results chapter should purely present and describe your results , not interpret them in relation to the existing literature or your research questions . Any speculations or discussion about the implications of your findings should be reserved for your discussion chapter.

In your results chapter, you’ll want to talk about your analysis findings and whether or not they support your hypotheses (if you have any). Naturally, the exact contents of your results chapter will depend on which qualitative analysis method (or methods) you use. For example, if you were to use thematic analysis, you’d detail the themes identified in your analysis, using extracts from the transcripts or text to support your claims.

While you do need to present your analysis findings in some detail, you should avoid dumping large amounts of raw data in this chapter. Instead, focus on presenting the key findings and using a handful of select quotes or text extracts to support each finding . The reams of data and analysis can be relegated to your appendices.

While it’s tempting to include every last detail you found in your qualitative analysis, it is important to make sure that you report only that which is relevant to your research aims, objectives and research questions .  Always keep these three components, as well as your hypotheses (if you have any) front of mind when writing the chapter and use them as a filter to decide what’s relevant and what’s not.

Need a helping hand?

How do I write the results chapter?

Now that we’ve covered the basics, it’s time to look at how to structure your chapter. Broadly speaking, the results chapter needs to contain three core components – the introduction, the body and the concluding summary. Let’s take a look at each of these.

Section 1: Introduction

The first step is to craft a brief introduction to the chapter. This intro is vital as it provides some context for your findings. In your introduction, you should begin by reiterating your problem statement and research questions and highlight the purpose of your research . Make sure that you spell this out for the reader so that the rest of your chapter is well contextualised.

The next step is to briefly outline the structure of your results chapter. In other words, explain what’s included in the chapter and what the reader can expect. In the results chapter, you want to tell a story that is coherent, flows logically, and is easy to follow , so make sure that you plan your structure out well and convey that structure (at a high level), so that your reader is well oriented.

The introduction section shouldn’t be lengthy. Two or three short paragraphs should be more than adequate. It is merely an introduction and overview, not a summary of the chapter.

Pro Tip – To help you structure your chapter, it can be useful to set up an initial draft with (sub)section headings so that you’re able to easily (re)arrange parts of your chapter. This will also help your reader to follow your results and give your chapter some coherence.  Be sure to use level-based heading styles (e.g. Heading 1, 2, 3 styles) to help the reader differentiate between levels visually. You can find these options in Word (example below).

Section 2: Body

Before we get started on what to include in the body of your chapter, it’s vital to remember that a results section should be completely objective and descriptive, not interpretive . So, be careful not to use words such as, “suggests” or “implies”, as these usually accompany some form of interpretation – that’s reserved for your discussion chapter.

The structure of your body section is very important , so make sure that you plan it out well. When planning out your qualitative results chapter, create sections and subsections so that you can maintain the flow of the story you’re trying to tell. Be sure to systematically and consistently describe each portion of results. Try to adopt a standardised structure for each portion so that you achieve a high level of consistency throughout the chapter.

For qualitative studies, results chapters tend to be structured according to themes , which makes it easier for readers to follow. However, keep in mind that not all results chapters have to be structured in this manner. For example, if you’re conducting a longitudinal study, you may want to structure your chapter chronologically. Similarly, you might structure this chapter based on your theoretical framework . The exact structure of your chapter will depend on the nature of your study , especially your research questions.

As you work through the body of your chapter, make sure that you use quotes to substantiate every one of your claims . You can present these quotes in italics to differentiate them from your own words. A general rule of thumb is to use at least two pieces of evidence per claim, and these should be linked directly to your data. Also, remember that you need to include all relevant results , not just the ones that support your assumptions or initial leanings.

In addition to including quotes, you can also link your claims to the data by using appendices , which you should reference throughout your text. When you reference, make sure that you include both the name/number of the appendix , as well as the line(s) from which you drew your data.

As referencing styles can vary greatly, be sure to look up the appendix referencing conventions of your university’s prescribed style (e.g. APA , Harvard, etc) and keep this consistent throughout your chapter.

Section 3: Concluding summary

The concluding summary is very important because it summarises your key findings and lays the foundation for the discussion chapter . Keep in mind that some readers may skip directly to this section (from the introduction section), so make sure that it can be read and understood well in isolation.

In this section, you need to remind the reader of the key findings. That is, the results that directly relate to your research questions and that you will build upon in your discussion chapter. Remember, your reader has digested a lot of information in this chapter, so you need to use this section to remind them of the most important takeaways.

Importantly, the concluding summary should not present any new information and should only describe what you’ve already presented in your chapter. Keep it concise – you’re not summarising the whole chapter, just the essentials.

Tips and tricks for an A-grade results chapter

Now that you’ve got a clear picture of what the qualitative results chapter is all about, here are some quick tips and reminders to help you craft a high-quality chapter:

• Your results chapter should be written in the past tense . You’ve done the work already, so you want to tell the reader what you found , not what you are currently finding .
• Make sure that you review your work multiple times and check that every claim is adequately backed up by evidence . Aim for at least two examples per claim, and make use of an appendix to reference these.
• When writing up your results, make sure that you stick to only what is relevant . Don’t waste time on data that are not relevant to your research objectives and research questions.
• Use headings and subheadings to create an intuitive, easy to follow piece of writing. Make use of Microsoft Word’s “heading styles” and be sure to use them consistently.
• When referring to numerical data, tables and figures can provide a useful visual aid. When using these, make sure that they can be read and understood independent of your body text (i.e. that they can stand-alone). To this end, use clear, concise labels for each of your tables or figures and make use of colours to code indicate differences or hierarchy.
• Similarly, when you’re writing up your chapter, it can be useful to highlight topics and themes in different colours . This can help you to differentiate between your data if you get a bit overwhelmed and will also help you to ensure that your results flow logically and coherently.

If you have any questions, leave a comment below and we’ll do our best to help. If you’d like 1-on-1 help with your results chapter (or any chapter of your dissertation or thesis), check out our private dissertation coaching service here or book a free initial consultation to discuss how we can help you.

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This post is part of our dissertation mini-course, which covers everything you need to get started with your dissertation, thesis or research project. 

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20 Comments

This was extremely helpful. Thanks a lot guys

Hi, thanks for the great research support platform created by the gradcoach team!

I wanted to ask- While “suggests” or “implies” are interpretive terms, what terms could we use for the results chapter? Could you share some examples of descriptive terms?

I think that instead of saying, ‘The data suggested, or The data implied,’ you can say, ‘The Data showed or revealed, or illustrated or outlined’…If interview data, you may say Jane Doe illuminated or elaborated, or Jane Doe described… or Jane Doe expressed or stated.

I found this article very useful. Thank you very much for the outstanding work you are doing.

What if i have 3 different interviewees answering the same interview questions? Should i then present the results in form of the table with the division on the 3 perspectives or rather give a results in form of the text and highlight who said what?

I think this tabular representation of results is a great idea. I am doing it too along with the text. Thanks

That was helpful was struggling to separate the discussion from the findings

this was very useful, Thank you.

Very helpful, I am confident to write my results chapter now.

It is so helpful! It is a good job. Thank you very much!

Very useful, well explained. Many thanks.

Hello, I appreciate the way you provided a supportive comments about qualitative results presenting tips

I loved this! It explains everything needed, and it has helped me better organize my thoughts. What words should I not use while writing my results section, other than subjective ones.

Thanks a lot, it is really helpful

Thank you so much dear, i really appropriate your nice explanations about this.

Thank you so much for this! I was wondering if anyone could help with how to prproperly integrate quotations (Excerpts) from interviews in the finding chapter in a qualitative research. Please GradCoach, address this issue and provide examples.

what if I’m not doing any interviews myself and all the information is coming from case studies that have already done the research.

Very helpful thank you.

This was very helpful as I was wondering how to structure this part of my dissertation, to include the quotes… Thanks for this explanation

This is very helpful, thanks! I am required to write up my results chapters with the discussion in each of them – any tips and tricks for this strategy?

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• Chapter Five: Qualitative Methods (Part 1)

Every day you are confronted with the need to understand research methodology. In your work life, you are asked to compile and process data. Whether you are researching leadership techniques or analyzing sales statistics, you must be able to interpret the data you encounter. There is an everyday utility to qualitative techniques such as observation or interviewing. Imagine yourself as a new member of an organization. What are the informal rules of the organization? What is the culture of this work environment? Are there expectations other than the ones provided in the job description or by the supervisor? Over time, with keen observation and interview skills, a new organization member can uncover the answers to these and other questions. So, while the information contained in this section approaches qualitative methodologies from a scholarly perspective, the skills and techniques identified herein will help you understand human social action in a variety of situations.

• Chapter One: Introduction
• Chapter Two: Understanding the distinctions among research methods
• Chapter Three: Ethical research, writing, and creative work
• Chapter Four: Quantitative Methods (Part 1)
• Chapter Four: Quantitative Methods (Part 2 - Doing Your Study)
• Chapter Four: Quantitative Methods (Part 3 - Making Sense of Your Study)
• Chapter Five: Qualitative Data (Part 2)
• Chapter Six: Critical / Rhetorical Methods (Part 1)
• Chapter Six: Critical / Rhetorical Methods (Part 2)
• Chapter Seven: Presenting Your Results

One of the goals of quantitative research is to produce generalized knowledge about a communication event or phenomenon. Quantitative researchers ground their investigations in the scientific method in order to control or manipulate variables, reduce or eliminate researcher bias, and discover verifiable patterns of human behavior. The goals of quantitative research are to explain, predict, and control behavior. Qualitative research, in contrast, seeks to develop subjective understanding of communication phenomena. Rather than the experimental designs and survey instruments of quantitative researchers, qualitative researchers often seek to collect data in natural settings and rely on observations of and interviews with research participants to create data, which is not designed to produce quantifiable and generalizable results, but rather to produce in-depth understanding specific to particular situations. Although noticeably different from quantitative and rhetorical research designs, qualitative research methods are a popular and vital approach to the identification, understanding, and analysis of human interaction. In this chapter, we discuss the fundamental assumptions, philosophical traditions and salient attributes of qualitative research.

The Qualitative Worldview

Individuals engaged in qualitative research approach their projects from a different perspective than quantitative and rhetorical researchers. Even though all researchers share an interest in accurately reflecting social reality and in crafting an intellectual argument that is built on the foundations of valid data collection and observation, several assumptions are specific to qualitative research. Understanding these assumptions can help you better determine whether you need to use qualitative methods for the particular study in which you are interested.

Assumptions of Qualitative Research

Our knowledge of social reality is based on subjective interpretation.  Qualitative researchers assume that due to our limited perception and our individual experiences, our understanding of social reality is necessarily subjective. Due to this, qualitative researchers reject the realist worldview that postulates an objective, measurable reality. Instead, reality is a social construction, given life through  intersubjective  agreement – that is, the contours of reality are defined by general agreement between humans in the society. Another way to think of this is that reality isn't completely  objective  – existing externally from humans, but  subjective  – existing in the interpretations of humans. Concepts such as love, democracy, and friendship are difficult to quantify, and are often the result of negotiated understandings between pairs or groups of people. Therefore, for qualitative researchers, it is important to understand how individuals and groups subjectively understand their experiences.

Subjectivity, in regards to qualitative research, manifests itself in two ways. On one hand, there is the recognition that the participants in the research have their own unique way of interpreting and understanding events and their own social actions. For example, a researcher studying leadership would recognize that research participants, whether they are CEOs or workers, coaches or players, preachers or congregation members, have their own unique perspective on leadership. In order to fully understand leadership, a qualitative researcher would need to consider all, or at least as many as possible, of the various subjective understandings of leadership.

On the other hand, the researcher recognizes that he or she is the primary data collection instrument, and her or his subjectivity affects the study. Rather than utilizing a survey, specifically designed to reduce bias and maintain objectivity, a qualitative researcher, whether through observation or interviewing, filters all of the data through his or her own understanding. In this way, a qualitative researcher must recognize his or her subjectivity regarding the collection and analysis of data.

Research proceeds inductively . Induction is the process of moving from a series of specific observations to a general conclusion or theory. Unlike quantitative research, which often proceeds deductively from a general premise or theory to specific examples, qualitative research, through the gathering of subjective interpretations, seeks to develop general understanding through the analysis of the collected data.

For example, it is unlikely that qualitative research will begin with a theory, such as Inoculation Theory (a theory concerning how people resist persuasion), and then through experimental or survey designs, seek to validate and support the theory. In fact, it is quite the opposite. Qualitative researchers, interested in how people resist persuasion, might begin by asking participants for accounts of times when they have successfully resisted persuasive attempts. Qualitative researchers deliberately avoid beginning with the conclusion. After collecting these individual accounts from participants, researchers analyze the data in order to identify situational rules that then facilitate understanding of social action.

The goal of qualitative research is  understanding . Nineteenth century German philosopher Wilhelm Dilthey (2010), articulating the difference between the natural and the social sciences, stated that the former sought causes and effects while the latter sought  verstehen . Simply put,  verstehen  means understanding. One of the founders of sociology, Max Weber, elaborated on Dilthey’s work and stated that the purpose and method of the social sciences should be  verstehen . Weber (1962) believed that it was not possible to fully predict human social action. Therefore, rather than attempting to predict and control human behavior, qualitative social scientists should seek to understand social action. It is important to recognize that human social action varies immensely, and it would be difficult to identify social actions that are likely to be consistent from one person to the next and across a variety of circumstances. For example, humans would have a wide range of responses to an embrace from an acquaintance, an insult, slapstick humor, physical violence, or being ignored.

Researchers emphasize credibility, rather than validity/reliability . Many qualitative researchers use the word credibility rather than validity or reliability. This is not to say that qualitative researchers do not desire validity, but rather to recognize that currently validity and reliability are synonymous with the quantitative approach to research. The use of the term  credibility  is a deliberate choice and refers to the veracity and accuracy of the data collected. Essentially, qualitative researchers are creating an argument—an argument which claims that the conclusions derived from the qualitative research are an accurate reflection of social reality. For example, if a U.S. Senator were giving a speech, we might ask whether or not the speaker is credible and whether or not the information presented in the speech is credible. In much the same way, we might evaluate qualitative research by asking whether or not the researcher and the argument presented in the research are credible.

Knowledge is created through intersubjective agreement . Qualitative researchers believe that knowledge is built through intersubjective agreement. For example, a researcher investigating friendship development among college students realizes that his or her study is only one piece of the puzzle and that a similar study would likely reveal new elements or focus on different characteristics of friendship. It is through the sharing of this body of knowledge that understanding is built. In fact, it is the very process of how research participants collectively construct multiple understandings in which the researcher is interested. Participants define and construct understanding intersubjectively and researchers document this process, enter their findings into the public record through publication, and then jointly construct meaning with other researchers, other participants, and other publications. Participants then become co-researchers with the researcher. This process results in an intersubjective, rather than an objective, understanding of the social world.     

The social setting or context is an important element in understanding any communication interaction . Qualitative researchers believe that context is integral to understanding communication. Research often takes place within the natural setting of the participants. For example, a researcher conducting an ethnography of college wrestling would observe the participants at practice, meetings, and competitions, etc.—paying careful attention to the characteristics of the setting. So, why is the context so important? In the case of a wrestling ethnography, many contextual factors aid our understanding of the group. Is the coach new or a seasoned veteran? Does the program have a stellar reputation or is it struggling for respectability? Does the team have 15 members or 45? Does the program have a state-of-the-art practice facility? All of these distinctions can help facilitate the researcher’s understanding of a group in a way that differs from quantitative research involving a survey of 200 wrestlers.

The values of the researcher cannot be completely separated from the research . Qualitative research is a subjective endeavor. A researcher relies on his or her ability to accurately interpret the available data in order to make a valid argument regarding the phenomena under investigation. Because the researcher is the data collection instrument and the values of the researcher are present during the interpretation, extra effort must be made to ensure that the biases of the researcher do not diminish the quality of the interpretation.

In life, it is obvious that people often see what they want to see. If a politician is giving a speech, it is likely that supporters will interpret elements of the speech in a manner that is entirely different from the way that detractors interpret those same elements. Because of this, it is important that researchers recognize and acknowledge the role that their values play in the interpretation of the data and to ensure that their conclusions are built on fully substantiated and supported claims.

In summary, qualitative assumptions include:

• Knowledge of social reality is based on subjective interpretation;
• Research proceeds inductively;
• The goal of qualitative research is understanding;
• Researchers emphasize credibility;
• Knowledge is created through intersubjective agreement;
• The social setting or context is an important element in understanding any communication interaction; and
• The values of the researcher cannot be completely separated from the research.

These assumptions represent the worldview shared by qualitative researchers. Ultimately, decisions regarding methodology rest on the types of questions that the researcher wants to answer. If your goal is to  understand  a particular communication phenomenon in depth, qualitative methods are a good research choice for you.

The Traditions of Qualitative Research

While quantitative research has the firmly established tradition of the scientific method, qualitative research locates its roots in a variety of philosophical strains. Cultural studies, critical theory, ethnomethodology, and others have all contributed to the theoretical traditions of qualitative methodology. However, the three traditions to be discussed here are hermeneutics, phenomenology, and symbolic interactionism.

Hermeneutics

According to Schwandt (2001),  hermeneutics  refers “to the art, theory, and philosophy of interpreting the meaning of an object” (p. 115). The “object” under examination can take a variety of forms: a Black-Eyed Peas song, a conversation between friends, a commercial for the latest iPhone, or a Presidential State of the Union Address. Hermeneutists call these objects “texts,” and they serve as the data for a hermeneutic study. The process of interpreting meaning makes hermeneutic analysis so fundamental to qualitative research. This process goes beyond the  translation  of a text and involves an effort to  interpret  the text. We are engaged in the process of interpretation every day. For example, lawyers, judges, and politicians are constantly in the process of interpreting laws. An ongoing discussion in the United States is whether or not the Bill of Rights is a “living, breathing document,” thus necessitating new interpretation, or is an unchanging document that means the same today as it did upon its ratification in 1791.

Hermeneutics, or interpretation, as a scholarly practice traces its roots to ancient Greek society. However, it is in the area of biblical scholarship that the more recent foundation of hermeneutics rests. Biblical scholars must not only translate ancient religious documents, but must interpret them for a new time period. For example, during the Protestant Reformation, new interpretations of biblical passages strengthened the Protestant cause while shifting away from Roman Catholic interpretations of the text. This process of interpretation is important because it acknowledges that texts must be reevaluated and re-interpreted in order to ascertain applicability and relevance.

Modern hermeneutics, as developed by Dilthey (2010), Gadamer (1976), and Ricoeur (1981), moved hermeneutic analysis beyond the study of ancient texts to include the range of “texts” that we consider for analysis today. Texts can include a near limitless range of social actions—transcripts from an interview, a movie, Congressional proceedings, a commercial, etc. In order to properly understand a text, the interpreter must have an understanding of not only the text, but of the cultural and historical epoch from which it originates. What do we know about the whole of the text? What do we know about the author or authors of the text? What do we know about the time period in which the text was created? Remember, the charge for a hermeneutic researcher is to interpret the text, and the goal of the hermeneutic researcher is understanding. Scholars in this tradition believe that one cannot fully understand a text until one understands the range of forces involved in the creation of the text. In this tradition, the emphasis is on the relationship among the text, author, context, and the researcher.

Phenomenology

While the centrality of interpretation in hermeneutic scholarship marks an approach that is clearly divergent from quantitative research with its scientific method roots, it is with phenomenology that we see a deliberate rejection of quantitative social science and its focus on an objective, measurable reality. Phenomenologists deny the existence of a reality that exists independent of our perceptions. 

Phenomenology originated with the work of Edmund Husserl (1990) as he sought to develop a way of objectively studying subjective experiences. Husserl focused on understanding events or phenomena by understanding how people consciously experience those events or phenomena. Husserl’s form of phenomenology, known as  transcendental phenomenology , included carefully cataloguing all of the attributes of an item, such as democracy, and then bracketing, or setting aside, those attributes of democracy that are completely subjective—byproducts of culture and the perceptions of the person conducting the analysis. Therefore, if a researcher wanted to understand a concept such as  democracy , he or she would identify all of the essential characteristics of democracy. Husserl would then advocate that those items on our list of essential characteristics of democracy that are culturally situated (for example, there are aspects of current U.S. democracy that differ from how other countries define democracy) be bracketed or set aside. By removing our cultural assumptions from the list through the process of bracketing, we are left with those items that seem universally, rather than contextually, valid—the essential characteristics of democracy.

While Husserl was interested in bracketing out the culturally based characteristics of a phenomenon, his student, Alfred Schutz (1967), found that the cultural variations that manifest in individual interpretation of experiences are the most interesting facets of the phenomenon. Therefore, Schutz’s  social phenomenology  emphasizes the subjective interpretation of everyday experiences. According to Schutz, these types of localized understandings are represented by people’s values, beliefs, etc. He called these typifications. In summary, while Husserl encouraged us to set aside our biases, Schutz asked us to consider how and why our biases develop.

Phenomenology focuses on  intersubjectivity . One way to understand the phenomenological concept of intersubjectivity is to imagine a group of researchers independently studying a previously undiscovered tropical island. One researcher, who is able to study the island via helicopter, is able to chronicle those island characteristics viewable from the air. Another researcher studies the island from a submarine and is able to describe the island characteristics viewable from this undersea vantage point. Finally, a third researcher is able to walk around the island and study it from within, and is able to see the island from a different perspective than either the aerial or nautical researcher. When the three researchers get together to share their findings, they identify those areas where their data overlaps—thereby revealing the essential characteristics of the island and achieving an intersubjective understanding. This does not mean that the observations unique to each researcher are invalid, just that it is never fully possible for others to experience the world in exactly the same manner as someone else and that the process of understanding a phenomenon is a process that is both ongoing and contingent. In distinguishing between the phenomenological approaches of Husserl and Schutz, Husserl would focus on where the researchers overlap, while Schutz would be more interested in the unique observations of each of the researchers.

Stewart and Mickunas (1990), after noting the lack of consensus in defining phenomenology, stated, “one can characterize phenomenological philosophy as centering on the following basic themes: a return to the traditional tasks of philosophy, the search for a philosophy without presuppositions, the intentionality of consciousness, and the refusal of the subject-object dichotomy” (p. 5). In summary, phenomenology contributes to qualitative research with its recognition of subjective experiences and its goal of intersubjective meaning construction. Quantitative researchers use sophisticated surveys as measuring devices. In qualitative research, the researcher is the data collection device.

Symbolic Interactionism

The third tradition influencing modern qualitative scholarship is Symbolic Interactionism. The aim for researchers in this tradition is to ascertain how meaning develops. Humans use symbols (words, phrases, images, nonverbal gestures, etc.) to interact with one another. How is it that people are able to agree on common understandings for these symbols? According to Symbolic Interactionists like Mead and Blumer (1986), the cultural meanings that people attach to symbols develop through their interactions with members of their social network, mediated images in their environment, and social context in a larger sense. Through these shared symbolic understandings, people are able to make sense and interpret their experiences.

Symbolic Interactionism focuses on the interplay among mind, self, and society.  Mind  includes individual human thoughts, while  self  considers interaction with others.  Society  provides the context in which meaning is made possible. What each know, their stock of knowledge, is shaped by their experiences and their interactions within a societal network, and knowledge, in turn, impacts the societal network.

Even though people often successfully share meanings, it is important to remember that meanings are constantly under negotiation. While most might share a collective interpretation of the essential characteristics of a dog, the meanings of other terms, like  liberal  or  conservative , are constantly under negotiation. Your own political orientation, the political orientation of your social group, and the political orientation of your family members all shape your understanding of these terms. Additionally, other factors such as how distinct media outlets define liberal or conservative or how you feel about specific politicians influence and guide how you conceptualize these terms.    Over the course of the evolution of Symbolic Interactionism, key components developed to further explain the results of interaction among social groups. Significant symbols and significant others are two examples of essential characteristics of this approach to human social action.  Significant symbols  are those, that when used, elicit understanding among the social group. For example, others might interpret the use of an image of an eagle or an American flag pin on your lapel as representative of your patriotism. The term  significant others  refers to those whom most shape a person’s understanding of cultural symbols.

Consider a concept such as corporate branding—where a corporation hopes to build a specific connection between a symbol representing their company and their target audience. For example, Nike wants customers and athletes to immediately connect the swoosh on their logo with quality or performance. However, it is important to remember the roles social groups play in people’s interpretation of significant symbols like the Nike swoosh. Some, due to Nike’s lawsuits, might associate the swoosh with unfair labor practices or poor working conditions. This example serves to further demonstrate that cultural understandings are always contingent.

If one considers that these three philosophical traditions represent the foundation of qualitative research, the individual pillars of the foundation reveal themselves. From hermeneutics comes the centrality of interpretation and the identification of texts (in all their myriad forms) as fundamental elements of scholarly analysis. From phenomenology comes the recognition that everything a person understands about reality is filtered through her or his own individual perceptions and that we should strive for intersubjective understandings of reality. Finally, from symbolic interactionism comes the realization that how people experience reality is shaped by the shared symbolic meanings that arise from their social network, cultural group, or philosophical standpoint. All three of these foundations reject a realist ontology; that is, the idea that there is a single objective reality that we can know independent of our subjective interpretation. Elements from nearly all of the assumptions of qualitative research, interpretation, textual artifacts, subjective understanding, and contextual shaping  can be traced back to these pillars.

Attributes of Qualitative Research

Before proceeding to an in-depth examination of specific steps for initiating and conducting a qualitative research project, there are a few general attributes and elements of qualitative research to consider. In this section, the authors discuss the primacy of observation as an essential attribute for a qualitative researcher, the types of questions posed by researchers, the different forms of data common to qualitative research, the varieties of sampling, and ways to improve the accuracy of your qualitative findings.

Observation

Having established the relationship between subjectivity and qualitative research and having established that the qualitative researcher, unlike the quantitative researcher, is the primary data collection instrument, it is necessary to consider one of the primary means of data collection in qualitative research: observation. It is common in qualitative research for researchers to immerse themselves in the social environment under investigation. People naturally engage in the process of observation every day—seeing what the weather is like, paying attention to what friends or professors are saying, or attending a meeting with a campus organization. However, systematic, scholarly observation differs from casual observation.

One way to think of how qualitative observation differs from casual observation is to consider playing a game of Texas Hold ‘Em poker. When you get together and play with your friends for skittles or peanuts, you may or may not pay enough attention to see if your opponents are bluffing. Now imagine that you are playing Texas Hold ‘Em on ESPN for ten million dollars. Under those circumstances it is critical that players are able to read the behaviors of others and also have a high awareness of their own behaviors. This is similar to the characteristics of a scholarly observer. When conducting observations for research purposes, researchers need to be able to sort through, process, and accurately capture the variety of stimuli occurring simultaneously in the environment. Additionally, researchers need to be cognizant of their own interpersonal behaviors and consider how they are impacting those in the environment.

Observation plays a very specific role in  ethnography,  which is when the researcher immerses him or herself into the culture or group being investigated. It also takes a keen eye for observation when conducting focus groups or interviews. Oftentimes, during the early stages of a research project, the researcher might rely on observation to get a preliminary sense of the communication context of the research participants. In general, the observation continuum looks like this:

While the explanation of each type of observation is fairly straightforward, it is worth exploring how each differs from the other. When a researcher takes on the role of  complete observer , he or she is usually not already a member of the group under observation. When we study a group as an outsider, we call this adopting an  etic  perspective . Simply put, it would be difficult to carry out our day-to-day responsibilities as a group member and focus extensively on capturing detailed notes of our observations of the group. Consider a student on the campus of who is having difficulty understanding why the student organization in which he or she is a member (e.g., the Chess Club) is having trouble functioning effectively. This student might identify successful student organizations with the intent of sitting in as an observer in order to try to determine what those groups do that contributes to their success. The student might select a public relations student organization and attend several meetings, not with the intention of joining, but with the intention of identifying the social actions that help make the PR group a successful organization. By carefully and successfully documenting the procedures and activities of the public relations organization, the observer might be able to integrate these behaviors into her or his own organization.

On the other side of the continuum is the  complete participant , someone who is already a member of the organization that he or she wants to study. Imagine again that you are the president of the Chess Club, and you want to improve the functioning of your student organization. Because you are the president and have all of the responsibilities associated with that position, it would be very difficult to take time off from your regular duties to take extensive field notes about the Chess Club’s organizational procedures. When you study an organization from an insider’s perspective, as you are in this example, it is called taking an  emic  perspective . In this case, the complete participant wants to carry out his or her routine responsibilities and then, after the meeting, attempt to write detailed notes describing the activities and experiences of the meeting.

Before discussing the two perspectives that mark the middle areas of the continuum, it is necessary to highlight three salient points regarding differences between taking an  etic  perspective or an  emic  perspective.

• Although complete observers may bring a fresh set of eyes and be able to focus exclusively on the act of observing, they may find that access is limited and acceptance of their presence is not guaranteed.
• Although complete participants have the advantage of understanding the history, rituals, and jargon of the organization, their pre-existing biases may greatly cloud their interpretation of events.
• Both types of observers must pay considerable attention to the concept of trust—complete observers, if the participants are aware of his or her presence, may have difficulty gaining the trust of the group and getting them to behave as they naturally would (consider the Hawthorne effect that states that people behave artificially when they know that they are being observed). Complete participants may begin with the trust of the participants, but will likely find themselves navigating a difficult path, particularly if they become aware of behaviors and activities that portray some members of the group in a negative light.

So what is the difference between an observer-as-participant and a participant-as-observer? A few years ago, a colleague was doing an ethnographic study of the emergency room in a large hospital. She had no training in the medical profession. She received permission to conduct observations and interviews over the course of several months. She began the study as a complete observer. However, over the course of her ethnographic study, she had multiple experiences that caused her to shift from complete observer to an observer-as-participant role. On one occasion, due to shortages on the staff, she was asked to hold a patient’s leg in place in order for the doctor to attempt to set the broken leg prior to putting it in a cast. Needless to say, the colleague was not expecting to play any kind of active role in the hospital emergency room other than active observation. So, an observer as participant is when an individual maintains the primary role of observation, but on occasion is asked to participate. Another example is when other professors visit your classroom in order to observe and evaluate your professor or teaching assistant. In this case the primary role is the observation, but in some circumstances the observers find themselves participating in class activities such as discussion or role-playing. Now imagine that you are a nurse in an emergency room who has been asked by administration to document communication patterns in the emergency room and recommend improvements. The participant-as-observer still has the primary responsibility of being a nurse in the emergency room, but he or she might also have specific time in meetings or every hour or so to document and reflect on observations. In this way she/he fulfills the primary role of nurse, but also is able to allocate time to observation and analysis on the side.

It is important to determine which observation role is best suited for your research. You must consider whether you are an insider or an outsider for the organization. You must then determine if you will be taking a covert (undercover) role or a more overt (out in the open) role. Regardless of the type of observation in which the researcher engages, specific and systematic expectations for data gathering and analysis govern your research. The role that you take impacts the type of data that you are able to collect.

Research Questions, Seldom Hypotheses

Qualitative research proceeds inductively—beginning with a specific group or a specific question and then gathering data in order to lead to a general explanation or perhaps even a theory. Qualitative researchers are seldom engaged in testing existing theory in the same sense that quantitative researchers are. Therefore, qualitative research relies on broad research questions asking “how” or “what” rather than testable hypotheses that make clear predictions. Consider the following sample research questions from three different qualitative studies.

RQ1: In what ways are employees’ constructions of mistreatment in the workplace muted or privileged?  RQ2: What are the processes that silence or encourage discussion of mistreatment by employees? (Meares, Oetzel, Torres, Derkacs, & Ginossar, 2004, p. 9)

RQ1: What are the components of high self-esteem for the women in the study? RQ2: How do they say they manage the construction and maintenance of high self-esteem in their lives? (DeFrancisco & Chatham-Carpenter, 2000, p. 77)

RQ1: How do disabled organizational members experience and negotiate organizational assimilation? (Cohen & Avanzino, 2010, p. 278)

While these three qualitative studies clearly follow the pattern of asking “how” or “what” questions, it is important to remember that, in general, there is more flexibility regarding the normative presentation of qualitative research. In some cases, such as the research of Wong and Goodwin (2009), because there was already an existing body of evidence on which to base their research, they proffered hypotheses with their qualitative study on marital satisfaction. Their hypotheses included:

H1: Bonding and the interactions between the spouses would be more important in individuals’ evaluation of marital relationships in modernized societies where independence is valued. H2: Relationships with other family members would be more important in the evaluation of marital relationships in societies where interdependence is valued. H3: Financial security would be a more important factor in marital satisfaction in less modernized settings. (Wong & Goodwin, 2009, p. 1014)

Wong and Goodwin gathered their data through in-depth qualitative interviews, but due to the large body of existing scholarship on marital satisfaction, they were confident in presenting hypotheses. However, it is necessary to point out that while hypotheses in qualitative research may exist, they are rare.

To further demonstrate the variation in qualitative research, some research studies may eschew research questions altogether. In these cases there is often a research purpose stated prior to describing the methods, but this purpose may take the form of a tentative statement rather than a research question. For example, Weinstein (2007) used field observations, interviews, and written documents to explore how inner city youths used writing (poetry, lyrics, etc.) to negotiate gender and sexual identity. She states, “I hope to contribute to the ongoing work done by researchers on adolescents’ and young adults’ uses of written and oral composition to find workable identities in the midst of multiple and shifting social contexts” (Weinstein, 2007, p. 30). In another case, Hundley and Shyles (2010) studied teenagers’ perceptions of technology and, rather than asking a research question, they simply stated, “this research continues the line of inquiry by listening to teenagers and gaining a perspective on what they think about emerging digital technologies and the functions various devices serve in their lives” (p. 418).

Thus, variation exists regarding the presentation of research goals in qualitative research. Goals may range from general purpose statements to specific research questions. Although hypotheses are rare, and research questions and research statements are more typical in qualitative research, one must remember that regardless of the approach, the methodology must be in the service of the overall research purpose.

Types of Data in Qualitative Research

The data for qualitative research takes many forms. Interviews and focus groups provide responses to carefully designed questions. Observation and ethnography provide detailed notes of the research setting. Participant responses or observation events may range from brief, specific responses to detailed, descriptive stories. A truly extensive ethnography, for example, might combine detailed field notes, descriptive stories, and specific responses to field interview questions. Stories, field notes, and interview/focus group responses are all valid forms of qualitative research data.

Stories.  Some qualitative techniques, such as narrative analysis, seek to elicit stories from the research participants, while in other cases, like interviews or focus groups, stories may arise naturally over the course of the research. Fisher (1984) said that it is natural for humans to communicate using stories. It is not hard to imagine the range of situations in which stories may either be elicited or arise spontaneously. Imagine an interview question where the researcher asks, “tell me about a time when you experienced conflict with a co-worker?” Or, consider doing research on U.S. wedding rehearsal dinner rituals. One can imagine the richness of the stories naturally arising in that setting. Qualitative research offers details and descriptions that are richer and more in-depth than quantitative research—the collecting of stories is a perfect way to capture the richness of our social activity.

Field notes . Whether one is observing a focus group, an emergency room, or the proceedings of a student organization meeting, field notes are a necessary tool for capturing the social activity as it unfolds. If the researcher is conducting an ethnography, and is involved in the act of cultural immersion, the observational field notes provide the data for the study. Field notes are a record of the activities of the participants of a study. The field notes are a written log of the researcher’s observations. Perhaps you like to go to the mall and watch the people as they come and go. Even with a good memory it is doubtful that you would be able to remember more than one or two interesting points if asked about it the next day. It is for this reason that detailed field notes, which describe the setting and participants in real time, are the best way of documenting a researcher’s time in the social environment.

For an ethnographer, the field notes are the data that allow the researcher to develop a credible argument in the final report. For a researcher observing a focus group, field notes enable the researcher to note the physical setting of the focus group or to chart how interaction proceeds over the course of the focus group. One of the most common ways to set up your field notes is to divide your page from top to bottom down the middle. On the left side of the page, the researcher should include specific observations, while on the right side of the page, the researcher should include tentative questions or concepts or future ideas. It is always important to also include the date, time, and location of the observation—and perhaps even a map of the research setting.

A good student activity is to select a location—the union, a class, a restaurant, etc.—and practice taking your own field notes. Just spend 30 minutes observing the location and see how accurately you are able to capture the setting and the ongoing interaction among the participants.

Consider the following example of field notes from observation of a graduate class:

In-depth interviews & focus groups.  Quite a bit of qualitative data is neither collected using field notes nor involves a detailed story. Much of the data follows the natural give and take of everyday conversation. Whenever possible, an audio recorder is a useful tool for capturing participant responses to interview questions. Open-ended responses that are not as extensive as a detailed story are very common in qualitative data. If brief, closed-ended responses are the type of data you need, you probably want to consider a quantitative survey. However, if you are interested in understanding how and why participants engage in certain activities or adopt certain values, qualitative interviewing will likely provide you with the type of data you need.

Stories, field notes, interview and focus group responses, and field notes are three common forms of data in qualitative research. All researchers are interested in producing the most accurate and valid conclusions from their data. Prior to and during the research process, there are choices the researcher can make to strengthen his or her results. The choices are rooted in a process called  triangulation , which means you may choose multiple ways to collect data or multiple methods to explore the answer to your research question/s (Denzin, 2006).

Sampling Characteristics

Selecting the participants for a qualitative study often relies on a very deliberate process. Whereas quantitative research improves its accuracy through random sampling that is representative of the population to which it seeks to extend its results, qualitative research, with its emphasis on context and focus on understanding, will generally use a  purposive  non-random sampling strategy, rather than a random, sampling process. Once again, the fact that qualitative research proceeds inductively (starting with a specific group or setting), rather than deductively, reinforces the necessity of purposive sampling practices. If a researcher wants to observe and understand the communication practices at a large retail store, he or she would purposely select a retail store as the setting for the study. According to Schwandt (2001), qualitative samples “are chosen not for their representativeness but for their relevance to the research question, analytical framework, and explanation or account being developed in the research” (p. 232). 

Another characteristic of qualitative research samples concerns sample size. Because qualitative research focuses on understanding rather than generalizations, the size of the sample is typically much smaller than a sample for a quantitative survey. For example, consider the amount of time it takes to set up, conduct, and transcribe ten average length interviews compared to an on-line survey that automatically compiles the data and uploads it into a statistical program. Also, if a researcher wants to study the large retail store with many departments, it is easy to imagine the amount of time necessary to complete a thorough ethnography. Even if the researcher only chooses to focus on a single department within a retail store, observing different shifts and different workers would take a considerable investment of time. Qualitative samples are both purposefully selected, to meet the research objective, and deliberately small, to be manageable for the researcher.

The Importance of Triangulation

All researchers seek to produce an accurate or credible account of the phenomenon under investigation. Researchers have a variety of options to improve the credibility of their studies. Triangulation is the process of using two or more types of evidence to provide a more clear and accurate interpretation of the data. Triangulation takes multiple forms from researcher triangulation to data triangulation. The basic premise behind triangulation is that if the multiple data sources converge, validity/credibility has been enhanced. We will briefly discuss several of the more popular forms of triangulation.

Multiple methodologies . This type of triangulation involves the researcher or researchers using multiple techniques to gather the data. Suppose that a researcher wants to study the communication practices of a local restaurant. One of the ways that the researcher might collect data is by interviewing the employees of the restaurant. The results of the interviews might paint a very accurate picture of restaurant activities. However, the researcher might also want to observe the restaurant as the social actors engage in their day-to-day activities. The idea behind triangulation is that the data collected from the interviews and the data collected from the observations of the restaurant, when combined, paint a more complete and accurate picture of the restaurant than either one of the methods alone. Of course, a researcher could also include a third method, focus groups, in an effort to corroborate the conclusions drawn from the interviews and the observations. Using multiple methodologies for triangulation does not have to be limited to qualitative methods. For example, it is very common for a researcher to conduct interviews in order to gain a basic understanding of a concept and then use that information to create quantitative surveys to distribute to a larger sample. The goal is to create the most credible interpretation of the data, and triangulation of methods is one way to improve the accuracy of a study.

Multiple researchers . This type of triangulation involves multiple researchers gathering data on the same subject. In the example regarding the ethnographic study of a retail establishment, it is easy to see how a research team would have an easier time collecting observations than an individual researcher would. It is not just that multiple researchers can spread out and cover more ground, thereby creating a more fully realized picture of the organization, but also that multiple researchers increase the chance of accurately capturing all of the activities occurring when viewing the same event. Think of all of the activities going on during a typical organizational meeting—multiple researchers would be able to capture a fuller spectrum of social activity in less time than just one researcher. Additionally, multiple researchers contribute to the development of intersubjective understanding. Multiple researchers can mitigate some of the biases of each researcher, helping to avoid reaching a premature conclusion or being overly subjective.

There are other forms of triangulation, such as multiple research settings (observing at different times or in different places) or multiple disciplinary approaches (one observer versed in organizational communication and another versed in organizational behavior). These forms of triangulation are not mutually exclusive; researchers can combine, and often do combine, a variety of these approaches.

General Strengths and Weaknesses of Qualitative Research

Perhaps the greatest strength of qualitative research is the sheer amount of depth it can bring to our understanding of social action. Qualitative data can capture many of the complexities of human interaction that are unable to be uncovered through a quantitative survey. Because it proceeds inductively, it is both strong at discovering new phenomena and at generating theories of human behavior. Qualitative data collection often occurs in the participants’ natural environment, improving the ecological validity of the study. As long as the researchers are able to overcome the Hawthorne effect, the data collected should reflect actual behaviors in ways that self-reported surveys or laboratory studies are unable to reflect. Finally, qualitative researchers allow the participants to tell their own stories rather than reducing the stories to numbers.

Qualitative research also has obvious weaknesses because the researcher is the data collection instrument, so the quality of the data is only as good as the researcher. Has the researcher collected enough data to paint an accurate picture? Has the researcher attempted to minimize individual bias to the fullest extent? These concerns represent just a few of the problems that could result from the subjective nature of qualitative research. Qualitative research is not good for generalizing results to a larger population and it is not good for examining causal relationships. There is also a considerable investment of time associated with this type of research.

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Chapter 5: Conclusion, Interpretation and Discussion

Introduction.

The following chapter concludes this report. A summary of the research is presented, and findings of the study are discussed and interpreted. The significance of this research in the immediate context of El Gallo and in the field of low-income housing is examined. Recommendations for further research end the chapter.

The scope of the following conclusions is limited to the context and historical characteristics of El Gallo. Thus, applied to other situations, these conclusions may yield incorrect assumptions. Still, these conclusions are relevant to the process of dwelling evolution in progressive development projects.

5.1 Summary of Research

This study observed the process of dwelling evolution in progressive development projects. The literature review was concentrated on the process of progressive development occurring in planned sponsored projects. It was found that, based on observations of the informal settlement process, progressive development under different contextual conditions was not questioned, and its benefits were taken for granted. Studies in the area were reduced to the period of improvement up to the time when the dwelling was physically consolidated. Longer term evaluation of progressive development projects were not found.

Research was undertaken on a 27-year-old progressive development project in Venezuela. The intention was to observe the process of dwelling evolution and the kind of housing that was being produced under progressive urban development projects on a long-term basis. The case study showed dwellings built with different initial levels of user-participation. Dwelling evolution was observed in a survey sample using parameters relevant to the case study (i.e., area increase, dwelling spatial growth and plot occupation, and changes in the functional structure).

Survey dwellings followed identifiable patterns of evolution in size, spatial structure and use-layout. Patterns were affected by aspects of the surrounding context and by aspects inherent to characteristics of the initial dwelling. Consequently, different dwelling groups showed different processes of progressive development.

5.2 Discussion and Interpretation of Findings.

As progressive developments, dwellings at El Gallo were able to adopt new and diverse roles along their whole process of evolution. In this section, relevant issues of the process of dwelling evolution observed at El Gallo are discussed. The first concerns the role of the non-permanent structure in the context of El Gallo as a sponsored progressive development project. The second comments on the process of dwelling evolution that followed the construction of the permanent structure.

In principle, non-permanent structures at El Gallo were similar to ranchos built in informal settlements. Ranchos at El Gallo served as primary shelters while more basic household priorities were met (i.e., services and infrastructure were provided, sources of income were found and generated, and even a favourable social environment was developed among neighbours). However, the majority of tin shacks were neither considerably increased nor upgraded with better materials even when they were used for long periods of time. This fact, together with the sudden change in the pace of development caused by the construction of a very complete permanent dwelling and subsequent removal of the rancho, had no connection with the gradual process of shack replacement observed in invasion settlements of Ciudad Guayana during this study (Portela, M. 1992). Neither did this process have a relationship with the system of "piecemeal construction" described by several housing researchers as characteristic of low-income dwellers.

The shanties were... housing in process of improvement. In particular the piecemeal system of building afforded great advantages to those who, like most of the poor in developing societies, have great variations in income from month to month (Peattie L. 1982:132).

Under El Gallo conditions of land security, ranchos did not show consolidation, and revealed their transient character because they were eventually substituted by permanent structures. The non-permanent structure revealed the primary household's aspiration for a minimum satisfactory habitable area. However, besides basic shelter during the initial stage, ranchos served to the purposes of capital accumulation that eventually allowed households to buy a basic unit according to official standards, or building a bigger, more complete first permanent structure. The size of ranchos reflected households' aspirations for the permanent dwelling, that is,smaller ranchos were substituted by basic units of the housing programs. Instead larger ranchos were substituted by large self-produced dwellings.

It is difficult to ascertain why ranchos were removed when they could have been kept as part of the dwelling, as in fact did a minority of households (2 cases). Is a fact that the temporary materials of ranchos contributed to their deterioration that ended with the total removal of the rancho. However, an idea that may have contributed to the demolition of the rancho was the household's adoption of the planner's belief that ranchos were a bad but necessary step on the way to obtaining permanent housing. Thus, once the permanent dwelling was built, the price households paid to gain credibility (i.e., that this stage was reached) was the demolition of the rancho itself. This interpretation can be specially true for Ciudad Guayana, where dwellings of certain quality such as those of El Gallo were seen as "casas" or houses. Instead, structures of similar quality in the hills of cities such as Caracas were still considered ranchos. In the long run, informal settlements obtained the largest benefits from this process because they gained far more official tolerance and social credibility (i.e., that shacks were actually temporary means of residence towards good-quality housing).

Those who lived in smaller ranchos improved their spatial conditions by moving to the small basic dwellings. Those who occupied bigger ranchos built bigger dwellings by themselves. Still, some households built their dwellings without going through the rancho stage. Self-produced dwellings followed the formal models either to gain the government's credibility of user commitment to build "good" government-like housing, or because households believed so. Imitation of the formal models, however, varied according to the builder's interpretation. For instance, the pattern of the detached dwelling was adopted, but often one of the side yards was reduced to a physical separation between the dwelling and the plot separation wall. More effective interpretations involved enlarging the front porch or using the central circulation axis to allow easy extension in the future.

The building approach of the permanent structure influenced the process of evolution that followed. Basic units built by the housing agencies had a compact, complete layout with higher standards of construction; however, aspects of the design, such as internal dimensions, were inadequate for household criteria, and the layout was not well adapted. Dwellings built according to provided plans and specificationshad similar problems, but households enlarged spaces and modified layouts when they were building the units. The level of construction standards was also reduced since the lateral façades of some dwellings were unfinished. Dwellings built totally by self-help means were the largest permanent structures. Aspects of the design of the first permanent structure allowed easy extension of the dwelling towards open areas of the plot. More user participation was reflected in straight-forward processes of evolution without internal modifications, and fewer stages to reach the current houseform.

5.3 Significance of the Study

While this study acknowledges again the effectiveness of progressive development in the housing system, it shows how dwelling evolution in progressive development projects can have different characteristics produced by internal and external interventions. Usually, projects are designed and launched to reproduce certain desirable outcomes and meet specific expectations. However, conditions prevailing in these projects and sometimes strategies that are introduced to "improve," "speed up" or make more "efficient" the process of evolution can affect the outcome in many different ways. This study showed how contextual characteristics of El Gallo, as well as the design and level of user participation in the initial permanent dwelling, affected successive stages of progressive development. However, it is important to recognize that are other issues beyond the spatial aspects that are intrinsically related with the evolution of the dwellings and that were not included within the scope of these particular research (i.e., household's changes in income, size, and age or gender structure).

The findings at El Gallo add modestly to the body of knowledge of literature on progressive development. Progressive Urban Development Units, UMUPs , have been the main housing strategy in Ciudad Guayana these last years, and they are likely to keep being used. Simple facts such as knowing the characteristics of the additions and modifications that households make to their dwellings over time can be the basis for more assertive actions supporting or enforcing progressive development activities. Understanding the process of dwelling evolution in low-income developments would be an effective way to help the process that, in the case of Ciudad Guayana, zonings and bylaws have been unable to regulate.

5.4 Recommendations for Further Research

Long term assessments are particularly constrained by the availability and reliability of recorded data. The frequency, and often the methodology, in which censuses and surveys are made do not always suit the purposes of this kind of research. Household interviews are very important, but they may become troubled by informant's limited memories and the continuity of the household in the dwelling. Aerial documentation, if available, represents one of the most reliable sources to observe physical change. Nevertheless, a careful and detailed process of observation of aerial data becomes very time consuming. For similar studies, a first phase in which the housing diversity is identified in the aerial data according to the selected criteria, would allow to reduce the number of detailed survey samples needed, thus considerably reducing the time of data collection.

In the context of Ciudad Guayana, further studies of the non-permanent dwelling in recent UMUPs would reveal new insights into the function of these structures in progressive development projects. This would be essential especially if any kind of initial aid is to be provided. On the other hand, following the growth of progressive developments is necessary if services and infrastructure are, as they are now, the responsibility of the local government. Identifying the producers of physical evolution -- i.e., the drivers and catalysts of change -- would be an important step for further research. An interesting step within this trend could be to ascertain the extent in which other household processes -- family growth, income increase and economic stability, household aging, changes in the household composition (single- to multi- family), etc., affect the process of dwelling evolution.

In the context of low-income housing, the process of progressive development needs further understanding. As in Ciudad Guayana, progressive development is likely to be the main housing strategy for other developing countries in the near future. Local authorities would do well to follow the evolution of settlements and to identify real household needs, and the consequences of public and/or private interventions in low-income settlements. Perhaps the most important learning of this study is that the experience of El Gallo acknowledges again the dynamic participation of the low-income households under different conditions, and still leaves wide room for a positive participation for the many other actors in the evolving urban entity.

. Notes for Chapter V

1 Dodge reports that some settlers of Ciudad Guayana kept the rancho and rented it to poorer families (Dodge,C. 1968:220). This attitude has been more common in other progressive development projects. The Dandora site and services also encouraged the construction of temporary shacks while the permanent dwelling was built. However, non-permanent structures remained to be rented or used as storage areas even after the permanent dwelling was built (McCarney, P.L. 1987:90).

Department and University Information

Minimum cost housing group.

Thesis Writing: What to Write in Chapter 5

Table of contents, introduction.

This article tells what a budding researcher must include in Chapter 5-the Summary. It also includes the tense of the verb and the semantic markers, which are predominantly used in writing the summary, conclusions, and recommendations.

For others, writing Chapter 5 is the easiest part of thesis writing, but there are groups of students who would like to know more about it. If you are one of them, this article on how to write chapter 5 of your thesis is purposely written for you.

What to Write in Chapter 5

1. write the summary.

Your summary in Chapter 5 may include:

• objectives of the study.
• statement of the problem.
• respondents.
• sampling procedures.
• method/s of research employed.
• statistical treatment/s applied, or hypotheses tested, if there is any; and

If you notice, all the parts mentioned above are already included in your Chapters 1- 4. So, the challenge is on how you are going to write and present it in Chapter 5 briefly.

First, you must go directly to the point of highlighting the main points. There is no need to explain the details thoroughly. You must avoid copying and pasting what you have written in the previous chapters. Just KISS (keep it short and simple)!

Then, write sentences in  simple past  and always use  passive voice  construction rather than the active voice. You must also be familiar with the different semantic markers.

When I was enrolled in Academic Writing in my master’s degree, I learned that there are semantic markers which can be used in order not to repeat the same words or phrases such as  additionally, also, further, in addition to, moreover, contrary to, with regard to, as regards, however, finally, during the past ___ years, from 1996 to 2006, after 10 years, as shown in, as presented in, consequently, nevertheless, in fact, on the other hand, subsequently and nonetheless.

Next, you may use the following guide questions to check that you have not missed anything in writing the summary:

• What is the objective of the study?;
• Who/what is the focus of the study?;
• Where and when was the investigation conducted?;
• What method of research was used?;
• How were the research data gathered?;
• How were the respondents chosen?;
• What were the statistical tools applied to treat the collected data?; and
• Based on the data presented and analyzed, what findings can you summarize?

Finally, organize the summary of the results of your study according to the way the questions are sequenced in the statement of the problem.

2. Write the Conclusion or Conclusions

Once you have written the summary in Chapter 5, draw out a conclusion from each finding or result. It can be done per question, or you may arrange the questions per topic or sub-topic if there is any. But if your research is quantitative, answer the research question directly and tell if the hypothesis is rejected or accepted based on the findings.

As to grammar, make sure that you use the  present tense of the verb  because it comprises a general statement of the theory or the principle newly derived from the present study. So, don’t be confused because, in your summary, you use past tense, while in conclusion; you use the present tense.

3. Write the Recommendations

The recommendations must contain practical suggestions that will improve the situation or solve the problem investigated in the study.

First, it must be logical, specific, attainable, and relevant. Second, it should be addressed to persons, organizations, or agencies directly concerned with the issues or to those who can immediately implement the recommended solutions. Third, present another topic which is very relevant to the present study that can be further investigated by future researchers.

But never recommend anything that is not part of your study or not being mentioned in your findings.

First, it must be logical, specific, attainable, and relevant. Second, it should be addressed to persons, organizations, or agencies directly concerned with the issues or to those who can immediately implement the recommended solutions. Third, present another topic that is very relevant to the present study that can be further investigated by future researchers.

Recommend nothing that is not part of your research or not being mentioned in your findings.

However, there are universities, especially in the Philippines, that require a specific thesis format to be followed by students. Thus, as a student, you must conform to the prescribed form of your college or university.

Nordquist, R. n.d. Imperative Mood. Retrieved July 29, 2014, from https://www.thoughtco.com/imperative-mood-grammar-1691151

© 2014 July 29 M. G. Alvior | Updated 2024 January 10

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Three Tips on How to Write a Good Statistical Question

5 ways on how to generate ideas even when you are not inspired, analyzing the macro and microstructures of editorial texts, about the author, mary g. alvior, phd.

Dr. Mary Gillesania Alvior has PhD in Curriculum Development from West Visayas State University. She earned her Master of Arts in Teaching English from De La Salle University, Manila as Commission on Higher Education (CHED) scholar. As academic advisor, she helps learners succeed in their academic careers by providing them the necessary skills and tips in order to survive in this wobbling financial environment. In 2014, she got involved in the establishment of a language institute in the Middle East, particularly in the use of Common European Framework of Reference for Languages (CEFR). Then she went to Thailand and became a lecturer in the international college and handled English and Graduate Education courses. From 2017 to 2021, she became the Focal Person for the Establishment of a Medical School, Director of Curriculum and Instructional Materials Development Office (CIMDO), Head of BAC Secretariat, Quality Management System (QMS) Leader, and TWG member of the Procurement for Medical Equipment. Currently, she is the coordinator of the Project Management Committee for the Establishment of the Medical School. In spite of numerous tasks, she is into data privacy, quality management system, and space industry.

100 Comments

can you please make a summary about “Centella Asiatica with virgin Coconut Oil as Ointment”?

I am still having problem in organizing my summary and conclusion (my topic is dress code in public schools. to be more specific, at the Voinjama Public School. Can you help me with a sample?

This is very helpful especially the grammar part. It really jumped start my writing effort… really want to finish my study with style.

I just pray you are okay. Thanks for responding to the questions, I have also learnt a lot.

Hello, Daryl. Thank you so much. About your request, I will find time to write about it. I got so busy the past months.

Precise and direct to the point ,, Thanks maam Mary.

Thanks very much for this all importing information on how to write chapter five in thesis writing. It gives me more insight as to how to develop the chapter five perfectly.

Hello maam my PhD research purely a qualitative study on community based organization of slum ..i used 3 tool case study , participant observation and FGDs to analyse role, impact, challenge and aspiration of CBOs . i used tabular form (matrix to analyse ) did not use any software..

PLEASE HELP/GUIDE ME WHAT SHOULD I WRITE in my Chapter 5 .. your help is very much crucial as i have to submit thesis this weekend KULDEEP

I’m so sorry, Kuldeep. I wish you are done with your doctorate research. It is been a year then. I got sick and had a lot of work to do. God bless!

Hello ma’am, can I ask about in what part the recommendation in chapter 1 reflect the recommendation in chapter5? Thanks.

Sorry, Aly. This is very late. Take your statement of the problem. the results for the statement of the problem will be the basis for your recommendation.

You are welcome, Prince. God bless to your research endeavor.

Thank you very much very insightful.

Eric, you are welcome. I wish you are able to finish your work.

how to write a recommendation, my title is common causes of financial problem. Hope you can help me…

Hello, Jolven. Your recommendation must be based on your findings. So, if that is your title, and you found that the common causes are the ——-, then write a recommendation based on the causes.

Thanks a lot, Mimimi.

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How to Write a Thesis or Dissertation Conclusion

Published on September 6, 2022 by Tegan George and Shona McCombes. Revised on November 20, 2023.

The conclusion is the very last part of your thesis or dissertation . It should be concise and engaging, leaving your reader with a clear understanding of your main findings, as well as the answer to your research question .

In it, you should:

• Clearly state the answer to your main research question
• Summarize and reflect on your research process
• Make recommendations for future work on your thesis or dissertation topic
• Show what new knowledge you have contributed to your field
• Wrap up your thesis or dissertation

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Table of contents

Discussion vs. conclusion, how long should your conclusion be, step 1: answer your research question, step 2: summarize and reflect on your research, step 3: make future recommendations, step 4: emphasize your contributions to your field, step 5: wrap up your thesis or dissertation, full conclusion example, conclusion checklist, other interesting articles, frequently asked questions about conclusion sections.

While your conclusion contains similar elements to your discussion section , they are not the same thing.

Your conclusion should be shorter and more general than your discussion. Instead of repeating literature from your literature review , discussing specific research results , or interpreting your data in detail, concentrate on making broad statements that sum up the most important insights of your research.

As a rule of thumb, your conclusion should not introduce new data, interpretations, or arguments.

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Depending on whether you are writing a thesis or dissertation, your length will vary. Generally, a conclusion should make up around 5–7% of your overall word count.

An empirical scientific study will often have a short conclusion, concisely stating the main findings and recommendations for future research. A humanities dissertation topic or systematic review , on the other hand, might require more space to conclude its analysis, tying all the previous sections together in an overall argument.

Your conclusion should begin with the main question that your thesis or dissertation aimed to address. This is your final chance to show that you’ve done what you set out to do, so make sure to formulate a clear, concise answer.

• Don’t repeat a list of all the results that you already discussed
• Do synthesize them into a final takeaway that the reader will remember.

An empirical thesis or dissertation conclusion may begin like this:

A case study –based thesis or dissertation conclusion may begin like this:

In the second example, the research aim is not directly restated, but rather added implicitly to the statement. To avoid repeating yourself, it is helpful to reformulate your aims and questions into an overall statement of what you did and how you did it.

Your conclusion is an opportunity to remind your reader why you took the approach you did, what you expected to find, and how well the results matched your expectations.

To avoid repetition , consider writing more reflectively here, rather than just writing a summary of each preceding section. Consider mentioning the effectiveness of your methodology , or perhaps any new questions or unexpected insights that arose in the process.

You can also mention any limitations of your research, but only if you haven’t already included these in the discussion. Don’t dwell on them at length, though—focus on the positives of your work.

• While x limits the generalizability of the results, this approach provides new insight into y .
• This research clearly illustrates x , but it also raises the question of y .

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You may already have made a few recommendations for future research in your discussion section, but the conclusion is a good place to elaborate and look ahead, considering the implications of your findings in both theoretical and practical terms.

• Based on these conclusions, practitioners should consider …
• To better understand the implications of these results, future studies could address …
• Further research is needed to determine the causes of/effects of/relationship between …

When making recommendations for further research, be sure not to undermine your own work. Relatedly, while future studies might confirm, build on, or enrich your conclusions, they shouldn’t be required for your argument to feel complete. Your work should stand alone on its own merits.

Just as you should avoid too much self-criticism, you should also avoid exaggerating the applicability of your research. If you’re making recommendations for policy, business, or other practical implementations, it’s generally best to frame them as “shoulds” rather than “musts.” All in all, the purpose of academic research is to inform, explain, and explore—not to demand.

Make sure your reader is left with a strong impression of what your research has contributed to the state of your field.

Some strategies to achieve this include:

• Returning to your problem statement to explain how your research helps solve the problem
• Referring back to the literature review and showing how you have addressed a gap in knowledge
• Discussing how your findings confirm or challenge an existing theory or assumption

Again, avoid simply repeating what you’ve already covered in the discussion in your conclusion. Instead, pick out the most important points and sum them up succinctly, situating your project in a broader context.

The end is near! Once you’ve finished writing your conclusion, it’s time to wrap up your thesis or dissertation with a few final steps:

• It’s a good idea to write your abstract next, while the research is still fresh in your mind.
• Next, make sure your reference list is complete and correctly formatted. To speed up the process, you can use our free APA citation generator .
• Once you’ve added any appendices , you can create a table of contents and title page .
• Finally, read through the whole document again to make sure your thesis is clearly written and free from language errors. You can proofread it yourself , ask a friend, or consider Scribbr’s proofreading and editing service .

Here is an example of how you can write your conclusion section. Notice how it includes everything mentioned above:

V. Conclusion

The current research aimed to identify acoustic speech characteristics which mark the beginning of an exacerbation in COPD patients.

The central questions for this research were as follows: 1. Which acoustic measures extracted from read speech differ between COPD speakers in stable condition and healthy speakers? 2. In what ways does the speech of COPD patients during an exacerbation differ from speech of COPD patients during stable periods?

All recordings were aligned using a script. Subsequently, they were manually annotated to indicate respiratory actions such as inhaling and exhaling. The recordings of 9 stable COPD patients reading aloud were then compared with the recordings of 5 healthy control subjects reading aloud. The results showed a significant effect of condition on the number of in- and exhalations per syllable, the number of non-linguistic in- and exhalations per syllable, and the ratio of voiced and silence intervals. The number of in- and exhalations per syllable and the number of non-linguistic in- and exhalations per syllable were higher for COPD patients than for healthy controls, which confirmed both hypotheses.

However, the higher ratio of voiced and silence intervals for COPD patients compared to healthy controls was not in line with the hypotheses. This unpredicted result might have been caused by the different reading materials or recording procedures for both groups, or by a difference in reading skills. Moreover, there was a trend regarding the effect of condition on the number of syllables per breath group. The number of syllables per breath group was higher for healthy controls than for COPD patients, which was in line with the hypothesis. There was no effect of condition on pitch, intensity, center of gravity, pitch variability, speaking rate, or articulation rate.

This research has shown that the speech of COPD patients in exacerbation differs from the speech of COPD patients in stable condition. This might have potential for the detection of exacerbations. However, sustained vowels rarely occur in spontaneous speech. Therefore, the last two outcome measures might have greater potential for the detection of beginning exacerbations, but further research on the different outcome measures and their potential for the detection of exacerbations is needed due to the limitations of the current study.

Checklist: Conclusion

I have clearly and concisely answered the main research question .

I have summarized my overall argument or key takeaways.

I have mentioned any important limitations of the research.

I have given relevant recommendations .

I have clearly explained what my research has contributed to my field.

I have  not introduced any new data or arguments.

You've written a great conclusion! Use the other checklists to further improve your dissertation.

If you want to know more about AI for academic writing, AI tools, or research bias, make sure to check out some of our other articles with explanations and examples or go directly to our tools!

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In a thesis or dissertation, the discussion is an in-depth exploration of the results, going into detail about the meaning of your findings and citing relevant sources to put them in context.

The conclusion is more shorter and more general: it concisely answers your main research question and makes recommendations based on your overall findings.

While it may be tempting to present new arguments or evidence in your thesis or disseration conclusion , especially if you have a particularly striking argument you’d like to finish your analysis with, you shouldn’t. Theses and dissertations follow a more formal structure than this.

All your findings and arguments should be presented in the body of the text (more specifically in the discussion section and results section .) The conclusion is meant to summarize and reflect on the evidence and arguments you have already presented, not introduce new ones.

For a stronger dissertation conclusion , avoid including:

• Important evidence or analysis that wasn’t mentioned in the discussion section and results section
• Generic concluding phrases (e.g. “In conclusion …”)
• Weak statements that undermine your argument (e.g., “There are good points on both sides of this issue.”)

Your conclusion should leave the reader with a strong, decisive impression of your work.

The conclusion of your thesis or dissertation shouldn’t take up more than 5–7% of your overall word count.

The conclusion of your thesis or dissertation should include the following:

• A restatement of your research question
• A summary of your key arguments and/or results
• A short discussion of the implications of your research

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George, T. & McCombes, S. (2023, November 20). How to Write a Thesis or Dissertation Conclusion. Scribbr. Retrieved April 15, 2024, from https://www.scribbr.com/dissertation/write-conclusion/

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Chapter 5 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

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Chapter 21. Conclusion: The Value of Qualitative Research

Qualitative research is engaging research, in the best sense of the word.

A few of the meanings of engage = to attract or hold by influence or power; to hold the attention of; to induce to participate; to enter into contest with; to bring together or interlock; to deal with at length; to pledge oneself; to begin and carry on an enterprise; to take part or participate; to come together; engaged = to be actively involved in or committed; to greatly interest; to be embedded with. ( Merriam-Webster Unabridged Dictionary )

There really is no “cookbook” for conducting qualitative research. Each study is unique because the social world is rich and full of wonders, and those of us who are curious about it have our own position in that world and our own understandings and experiences we bring with us when we seek to explore it. And yet even though our reports may be subjective, we can do what we can to make them honest and intelligible to everyone else. Learning how to do that is learning how to be a qualitative researcher rather than simply an amateur observer. Helping you understand that and getting you ready for doing so have been the goal of this book.

According to Lareau ( 2021:36 ), excellent qualitative work must include all the following elements: a clear contribution to new knowledge, a succinct assessment of previous literature that shows the holes in the literature, a research question that can be answered with the data in hand, a breadth and depth in the data collection, a clear exposition of the results, a deep analysis that links the evidence to the interpretation, an acknowledgment of disconfirming evidence, a discussion that uses the case as a springboard to reflect on more general concerns, and a full discussion of implications for ideas and practices. The emphasis on rigor, the clear contribution to new knowledge, and the reflection on more general concerns place qualitative research within the “scientific” camp vis-à-vis the “humanistic inquiry” camp of pure description or ideographic approaches. The attention to previous literature and filling the holes in what we know about a phenomenon or case or situation set qualitative research apart from otherwise excellent journalism, which makes no pretensions of writing to or for a larger body of knowledge.

In the magnificently engaging untextbook Rocking Qualitative Social Science , Ashley Rubin ( 2021 ) notes, “Rigorous research does not have to be rigid” ( 3 ). I agree with her claim that there are many ways to get to the top of the mountain, and you can have fun doing so. An ardent rock climber, Rubin calls her approach the Dirtbagger approach, a way of climbing the mountain that is creative, flexible, and definitely outside proscribed methods. Here are eleven lessons offered by Rubin in paraphrase form with commentary and direct quotes noted:

• There is no right way to do qualitative social science, “and people should choose the approach that works for them, for the particular project at hand, given whatever constraints and opportunities are happening in their life at the time. ( 252 )”
• Disagreements about what is proper qualitative research are distracting and misleading.
• Even though research questions are very important, they can and most likely will change during data collection or even data analysis—don’t worry about this.
• Your findings will have a bigger impact if you’ve connected them to previous literature; this shows that you are part of the larger conversation. This “anchor” can be a policy issue or a theoretical debate in the literature, but it need not be either. Sometimes what we do is really novel (but rarely—so always poke around and check before proceeding as if you are inventing the wheel).
• Although there are some rules you really must follow when designing your study (e.g., how to obtain informed consent, defining a sample), unexpected things often happen in the course of data collection that make a mockery of your original plans. Be flexible.
• Sometimes you have chosen a topic for some reason you can’t yet articulate to yourself—the subject or site just calls to you in some way. That’s fine. But you will still need to justify your choice in some way (hint: see number 4 above).
• Pay close attention to your sample: “Think about what you are leaving out, what your data allow you to observe, and what you can do to fill in some of those blanks” (252).  And when you can’t fill them in, be honest about this when writing about the limitations of your study.
• Even if you are doing interviews, archival research, focus groups, or any other method of data collection that does not actually require “going into the field,” you can still approach your work as fieldwork. This means taking fieldnotes or memos about what you are observing and how you are reacting and processing those observations or interviews or interactions or documents. Remember that you yourself are the instrument of data collection, so keep a reflective eye on yourself throughout.
• Memo, memo, memo. There is no magic about how data become findings. It takes a lot of work, a lot of reflection, a lot of writing. Analytic memos are the helpful bridge between all that raw data and the presented findings.
• Rubin strongly rejects the idea that qualitative research cannot make causal claims. I would agree, but only to a point. We don’t make the kinds of predictive causal claims you see in quantitative research, and it can confuse you and lead you down some unpromising paths if you think you can. That said, qualitative research can help demonstrate the causal mechanisms by which something happens. Qualitative research is also helpful in exploring alternative explanations and counterfactuals. If you want to know more about qualitative research and causality, I encourage you to read chapter 10 of Rubin’s text.
• Some people are still skeptical about the value of qualitative research because they don’t understand the rigor required of it and confuse it with journalism or even fiction writing. You are just going to have to deal with this—maybe even people sitting on your committee are going to question your research. So be prepared to defend qualitative research by knowing the common misconceptions and criticisms and how to respond to them. We’ve talked a bit about these in chapter 20, and I also encourage you to read chapter 10 of Rubin’s text for more.

Hopefully, by the time you have reached the end of this book, you will have done a bit of your own qualitative research—maybe you’ve conducted an interview or practiced taking fieldnotes. You may have read some examples of excellent qualitative research and have (hopefully!) come to appreciate the value of this approach. This is a good time, then, to take a step back and think about the ways that qualitative research is valuable, distinct and different from both quantitative methods and humanistic (nonscientific) inquiry.

Researcher Note

Why do you employ qualitative research methods in your area of study?

Across all Western countries, we can observe a strong statistical relationship between young people’s educational attainment and their parent’s level of education. If you have at least one parent who went to university, your own chances of going to and graduating from university are much higher compared to not having university-educated parents. Why this happens is much less clear… This is where qualitative research becomes important: to help us get a clearer understanding of the dynamics that lead to this observed statistical relationship.

In my own research, I go a step further and look at young men and women who have crossed this barrier: they have become the first in their family to go to university. I am interested in finding out why and how first-in-family university students made it to university and how being at university is experienced. In-depth interviews allow me to learn about hopes, aspirations, fears, struggles, resilience and success. Interviews give participants an opportunity to tell their stories in their own words while also validating their experiences.

I often ask the young people I interview what being in my studies means to them. As one of my participants told me, it is good to know that “people like me are worth studying.” I cannot think of a better way to explain why qualitative research is important.

-Wolfgang Lehman, author of Education and Society: Canadian Perspectives

For me personally, the real value of the qualitative approach is that it helps me address the concerns I have about the social world—how people make sense of their lives, how they create strategies to deal with unfair circumstances or systems of oppression, and why they are motivated to act in some situations but not others. Surveys and other forms of large impersonal data collection simply do not allow me to get at these concerns. I appreciate other forms of research for other kinds of questions. This ecumenical approach has served me well in my own career as a sociologist—I’ve used surveys of students to help me describe classed pathways through college and into the workforce, supplemented by interviews and focus groups that help me explain and understand the patterns uncovered by quantitative methods ( Hurst 2019 ). My goal for this book has not been to convince you to become a qualitative researcher exclusively but rather to understand and appreciate its value under the right circumstances (e.g., with the right questions and concerns).

In the same way that we would not use a screwdriver to hammer a nail into the wall, we don’t want to misuse the tools we have at hand. Nor should we critique the screwdriver for its failure to do the hammer’s job. Qualitative research is not about generating predictions or demonstrating causality. We can never statistically generalize our findings from a small sample of people in a particular context to the world at large. But that doesn’t mean we can’t generate better understandings of how the world works, despite “small” samples. Excellent qualitative research does a great job describing (whether through “thick description” or illustrative quotes) a phenomenon, case, or setting and generates deeper insight into the social world through the development of new concepts or identification of patterns and relationships that were previously unknown to us. The two components—accurate description and theoretical insight—are generated together through the iterative process of data analysis, which itself is based on a solid foundation of data collection. And along the way, we can have some fun and meet some interesting people!

Supplement: Twenty Great (engaging, insightful) Books Based on Qualitative Research

Armstrong, Elizabeth A. and Laura T. Hamilton. 2015. Paying for the Party: How College Maintains Inequality . Cambridge: Harvard University Press.

Bourgois, Phillipe and Jeffrey Schonberg. 2009. Righteous Dopefiend . Berkeley, CA: University of California Press.

DiTomaso, Nancy. 2013. The American Non-dilemma: Racial Inequality without Racism . Thousand Oaks, CA; SAGE.

Ehrenreich, Barbara. 2010. Nickel and Dimed: On (Not) Getting By in America . New York: Metropolitan Books.

Fine, Gary Alan. 2018. Talking Art: The Culture of Practice and the Practice of Culture in MFA Education . Chicago: University of Chicago Press.

Ghodsee, Kristen Rogheh. 2011. Lost in Transition: Ethnographies of Everyday Life after Communism . Durham, NC: Duke University Press.

Gowan, Teresa. 2010. Hobos, Hustlers, and Backsliders: Homeless in San Francisco . Minneapolis: University of Minnesota Press.

Graeber, David. 2013. The Democracy Project: A History, a Crisis, a Movement . New York: Spiegel & Grau.

Grazian, David. 2015. American Zoo: A Sociological Safari . Princeton, NJ: Princeton University Press.

Hartigan, John. 1999. Racial Situations: Class Predicaments of Whiteness in Detroit . Princeton, N.J.: Princeton University Press.

Ho, Karen Zouwen. 2009. Liquidated: An Ethnography of Wall Street. Durham, NC: Duke University Press.

Hochschild, Arlie Russell. 2018. Strangers in Their Own Land: Anger and Mourning on the American Right . New York: New Press.

Lamont, Michèle. 1994. Money, Morals, and Manners: The Culture of the French and the American Upper-Middle Class . Chicago: University of Chicago Press.

Lareau, Annette. 2011. Unequal Childhoods: Class, Race, and Family Life. 2nd ed with an Update a Decade Later. Berkeley, CA: University of California Press.

Leondar-Wright, Betsy. 2014. Missing Class: Strengthening Social Movement Groups by Seeing Class Cultures . Ithaca, NY: ILR Press.

Macleod, Jay. 2008. Ain’t No Makin’ It: Aspirations and Attainment in a Low-Income Neighborhood . 3rd ed. New York: Routledge.

Newman, Katherine T. 2000. No Shame in My Game: The Working Poor in the Inner City . 3rd ed. New York: Vintage Press.

Sherman, Rachel. 2006. Class Acts: Service and Inequality in Luxury Hotels . Berkeley: University of California Press.

Streib, Jessi. 2015. The Power of the Past: Understanding Cross-Class Marriages . Oxford: Oxford University Press.

Stuber, Jenny M. 2011. Inside the College Gates: How Class and Culture Matter in Higher Education . Lanham, Md.: Lexington Books.

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

• Open access
• Published: 10 April 2024

“So at least now I know how to deal with things myself, what I can do if it gets really bad again”—experiences with a long-term cross-sectoral advocacy care and case management for severe multiple sclerosis: a qualitative study

• Anne Müller   ORCID: orcid.org/0000-0002-2456-2492 1 ,
• Fabian Hebben   ORCID: orcid.org/0009-0003-6401-3433 1 ,
• Kim Dillen 1 ,
• Veronika Dunkl 1 ,
• Yasemin Goereci 2 ,
• Raymond Voltz 1 , 3 , 4 ,
• Peter Löcherbach 5 ,
• Clemens Warnke   ORCID: orcid.org/0000-0002-3510-9255 2 &
• Heidrun Golla   ORCID: orcid.org/0000-0002-4403-630X 1

on behalf of the COCOS-MS trial group represented by Martin Hellmich

BMC Health Services Research volume  24 , Article number:  453 ( 2024 ) Cite this article

143 Accesses

Metrics details

Persons with severe Multiple Sclerosis (PwsMS) face complex needs and daily limitations that make it challenging to receive optimal care. The implementation and coordination of health care, social services, and support in financial affairs can be particularly time consuming and burdensome for both PwsMS and caregivers. Care and case management (CCM) helps ensure optimal individual care as well as care at a higher-level. The goal of the current qualitative study was to determine the experiences of PwsMS, caregivers and health care specialists (HCSs) with the CCM.

In the current qualitative sub study, as part of a larger trial, in-depth semi-structured interviews with PwsMS, caregivers and HCSs who had been in contact with the CCM were conducted between 02/2022 and 01/2023. Data was transcribed, pseudonymized, tested for saturation and analyzed using structuring content analysis according to Kuckartz. Sociodemographic and interview characteristics were analyzed descriptively.

Thirteen PwsMS, 12 caregivers and 10 HCSs completed interviews. Main categories of CCM functions were derived deductively: (1) gatekeeper function, (2) broker function, (3) advocacy function, (4) outlook on CCM in standard care. Subcategories were then derived inductively from the interview material. 852 segments were coded. Participants appreciated the CCM as a continuous and objective contact person, a person of trust (92 codes), a competent source of information and advice (on MS) (68 codes) and comprehensive cross-insurance support (128 codes), relieving and supporting PwsMS, their caregivers and HCSs (67 codes).

Conclusions

Through the cross-sectoral continuous support in health-related, social, financial and everyday bureaucratic matters, the CCM provides comprehensive and overriding support and relief for PwsMS, caregivers and HCSs. This intervention bears the potential to be fine-tuned and applied to similar complex patient groups.

Trial registration

The study was approved by the Ethics Committee of the University of Cologne (#20–1436), registered at the German Register for Clinical Studies (DRKS00022771) and in accordance with the Declaration of Helsinki.

Peer Review reports

Introduction

Multiple sclerosis (MS) is the most frequent and incurable chronic inflammatory and degenerative disease of the central nervous system (CNS). Illness awareness and the number of specialized MS clinics have increased since the 1990s, paralleled by the increased availability of disease-modifying therapies [ 1 ]. There are attempts in the literature for the definition of severe MS [ 2 , 3 ]. These include a high EDSS (Expanded disability Status Scale [ 4 ]) of ≥ 6, which we took into account in our study. There are also other factors to consider, such as a highly active disease course with complex therapies that are associated with side effects. These persons are (still) less disabled, but may feel overwhelmed with regard to therapy, side effects and risk monitoring of therapies [ 5 , 6 ].

Persons with severe MS (PwsMS) develop individual disease trajectories marked by a spectrum of heterogeneous symptoms, functional limitations, and uncertainties [ 7 , 8 ] manifesting individually and unpredictably [ 9 ]. This variability can lead to irreversible physical and mental impairment culminating in complex needs and daily challenges, particularly for those with progressive and severe MS [ 5 , 10 , 11 ]. Such challenges span the spectrum from reorganizing biographical continuity and organizing care and everyday live, to monitoring disease-specific therapies and integrating palliative and hospice care [ 5 , 10 ]. Moreover, severe MS exerts a profound of social and economic impact [ 9 , 12 , 13 , 14 ]. PwsMS and their caregivers (defined in this manuscript as relatives or closely related individuals directly involved in patients’ care) often find themselves grappling with overwhelming challenges. The process of organizing and coordinating optimal care becomes demanding, as they contend with the perceived unmanageability of searching for, implementing and coordinating health care and social services [ 5 , 15 , 16 , 17 ].

Case management (CM) proved to have a positive effect on patients with neurological disorders and/or patients with palliative care needs [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ]. However, a focus on severe MS has been missed so far Case managers primarily function as: (1) gatekeeper involving the allocation of necessary and available resources to a case, ensuring the equitable distribution of resources; as (2) broker assisting clients in pursuing their interests, requiring negotiation to provide individualized assistance that aligns as closely as possible with individual needs and (3) advocate working to enhance clients’ individual autonomy, to advocate for essential care offers, and to identify gaps in care [ 25 , 26 , 27 , 28 , 29 ].

Difficulties in understanding, acting, and making decisions regarding health care-related aspects (health literacy) poses a significant challenge for 54% of the German population [ 30 ]. Additionally acting on a superordinate level as an overarching link, a care and case management (CCM) tries to reduce disintegration in the social and health care system [ 31 , 32 ]. Our hypothesis is that a CCM allows PwsMS and their caregivers to regain time and resources outside of disease management and to facilitate the recovery and establishment of biographical continuity that might be disrupted due to severe MS [ 33 , 34 ].

Health care specialists (HCSs) often perceive their work with numerous time and economic constraints, especially when treating complex and severely ill individuals like PwsMS and often have concerns about being blamed by patients when expectations could not be met [ 35 , 36 ]. Our hypothesis is that the CCM will help to reduce time constraints and free up resources for specialized tasks.

To the best of our knowledge there is no long-term cross-sectoral and outreaching authority or service dedicated to assisting in the organization and coordination of the complex care concerns of PwsMS within the framework of standard care addressing needs in health, social, financial, every day and bureaucratic aspects. While some studies have attempted to design and test care programs for persons with MS (PwMS), severely affected individuals were often not included [ 37 , 38 , 39 ]. They often remain overlooked by existing health and social care structures [ 5 , 9 , 15 ].

The COCOS-MS trial developed and applied a long-term cross-sectoral CCM intervention consisting of weekly telephone contacts and monthly re-assessments with PwsMS and caregivers, aiming to provide optimal care. Their problems, resources and (unmet) needs were assessed holistically including physical health, mental health, self-sufficiency and social situation and participation. Based on assessed (unmet) needs, individual care plans with individual actions and goals were developed and constantly adapted during the CCM intervention. Contacts with HCSs were established to ensure optimal care. The CCM intervention was structured through and documented in a CCM manual designed for the trial [ 40 , 41 ].

Our aim was to find out how PwsMS, caregivers and HCSs experienced the cross-sectoral long-term, outreaching patient advocacy CCM.

This study is part of a larger phase II, randomized, controlled clinical trial “Communication, Coordination and Security for people with severe Multiple Sclerosis (COCOS-MS)” [ 41 ]. This explorative clinical trial, employing a mixed-method design, incorporates a qualitative study component with PwsMS, caregivers and HCSs to enrich the findings of the quantitative data. This manuscript focuses on the qualitative data collected between February 2022 and January 2023, following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [ 42 ].

Research team

Three trained authors AM, KD and FH (AM, female, research associate, M.A. degree in Rehabilitation Sciences; KD, female, researcher, Dr. rer. medic.; FH, male, research assistant, B.Sc. degree in Health Care Management), who had no prior relationship with patients, caregivers or HCSs conducted qualitative interviews. A research team, consisting of clinical experts and health services researchers, discussed the development of the interview guides and the finalized category system.

Theoretical framework

Interview data was analyzed with the structuring content analysis according to Kuckartz. This method enables a deductive structuring of interview material, as well as the integration of new aspects found in the interview material through the inductive addition of categories in an iterative analysis process [ 43 ].

Sociodemographic and interview characteristics were analyzed descriptively (mean, median, range, SD). PwsMS, caregivers and HCSs were contacted by the authors AM, KD or FH via telephone or e-mail after providing full written informed consent. Participants had the option to choose between online interviews conducted via the GoToMeeting 10.19.0® Software or face-to-face. Peasgood et al. (2023) found no significant differences in understanding questions, engagement or concentration between face-to-face and online interviews [ 44 , 45 ]. Digital assessments were familiar to participants due to pandemic-related adjustments within the trial.

Out of 14 PwsMS and 14 caregivers who were approached to participate in interviews, three declined to complete interviews, resulting in 13 PwsMS (5 male, 8 female) and 12 caregiver (7 male, 5 female) interviews, respectively (see Fig.  1 ). Thirty-one HCSs were contacted of whom ten (2 male, 8 female) agreed to be interviewed (see Fig.  2 ).

Flowchart of PwsMS and caregiver participation in the intervention group of the COCOS-MS trial. Patients could participate with and without a respective caregiver taking part in the trial. Therefore, number of caregivers does not correspond to patients. For detailed inclusion criteria see also Table  1 in Golla et al. [ 41 ]

Flowchart of HCSs interview participation

Setting and data collection

Interviews were carried out where participants preferred, e.g. at home, workplace, online, and no third person being present. In total, we conducted 35 interviews whereof 7 interviews face-to-face (3 PwsMS, 3 caregivers, 1 HCS).

The research team developed a topic guide which was meticulously discussed with research and clinical staff to enhance credibility. It included relevant aspects for the evaluation of the CCM (see Tables  1 and 2 , for detailed topic guides see Supplementary Material ). Patient and caregiver characteristics (covering age, sex, marital status, living situation, EDSS (patients only), subgroup) were collected during the first assessment of the COCOS-MS trial and HCSs characteristics (age, sex, profession) as well as interview information (length and setting) were collected during the interviews. The interview guides developed for this study addressed consistent aspects both for PwsMS and caregivers (see Supplementary Material ):

For HCSs it contained the following guides:

Probing questions were asked to get more specific and in-depth information. Interviews were carried out once and recorded using a recording device or the recording function of the GoToMeeting 10.19.0® Software. Data were pseudonymized (including sensitive information, such as personal names, dates of birth, or addresses), audio files were safely stored in a data protection folder. The interview duration ranged from 11 to 56 min (mean: 23.9 min, SD: 11.1 min). Interviews were continued until we found that data saturation was reached. Audio recordings were transcribed verbatim by an external source and not returned to participants.

Data analysis

Two coders (AM, FH) coded the interviews. Initially, the first author (AM) thoroughly reviewed the transcripts to gain a sense of the interview material. Using the topic guide and literature, she deductively developed a category system based on the primary functions of CM [ 25 , 26 , 27 , 28 , 29 ]. Three interviews were coded repeatedly for piloting, and inductive subcategories were added when new themes emerged in the interview material. This category system proved suitable for the interview material. The second coder (FH) familiarized himself with the interview material and category system. Both coders (AM, FH) independently coded all interviews, engaging in discussions and adjusting codes iteratively. The finalized category system was discussed and consolidated in a research workshop and within the COCOS-MS trial group and finally we reached an intercoder agreement of 90% between the two coders AM and FH, computed by the MAXQDA Standard 2022® software.

We analyzed sociodemographic and interview characteristics using IBM SPSS Statistics 27® and Excel 2016®. Transcripts were managed and analyzed using MAXQDA Standard 2022®.

Participants were provided with oral and written information about the trial and gave written informed consent. Ethical approvals were obtained from the Ethics Committee of the University of Cologne (#20–1436). The trial is registered in the German Register for Clinical Studies (DRKS) (DRKS00022771) and is conducted under the Declaration of Helsinki.

Characteristics of participants and interviews

PwsMS participating in an interview were mainly German (84.6%), had a mean EDSS of 6.8 (range: 6–8) and MS for 13.5 years (median: 14; SD: 8.1). For detailed characteristics see Table  3 .

Most of the interviewed caregivers (9 caregivers) were the partners of the PwsMS with whom they lived in the same household. For further details see Table  3 .

HCSs involved in the study comprised various professions, including MS-nurse (3), neurologist (2), general physician with further training in palliative care (1), physician with further training in palliative care and pain therapist (1), housing counselling service (1), outpatient nursing service manager (1), participation counselling service (1).

Structuring qualitative content analysis

The experiences of PwsMS, caregivers and HCSs were a priori deductively assigned to four main categories: (1) gatekeeper function, (2) broker function, (3) advocacy function [ 25 , 26 , 27 , 28 , 29 ] and (4) Outlook on CCM in standard care, whereas the subcategories were developed inductively (see Fig.  3 ).

Category system including main and subcategories of the qualitative thematic content analysis

The most extensive category, housing the highest number of codes and subcodes, was the “ Outlook on CCM in standard care ” (281 codes). Following this, the category “ Advocacy Function ” contained 261 codes. The “ Broker Function ” (150 codes) and the “ Gatekeeper Function ” (160 codes) constituted two smaller categories. The majority of codes was identified in the caregivers’ interviews, followed by those of PwsMS (see Table  4 ). Illustrative quotes for each category and subcategory can be found in Table  5 .

Persons with severe multiple sclerosis

In the gatekeeper function (59 codes), PwsMS particularly valued the CCM as a continuous contact person . They appreciated the CCM as a person of trust who was reliably accessible throughout the intervention period. This aspect, with 41 codes, held significant importance for PwsMS.

Within the broker function (44 codes), establishing contact was most important for PwsMS (22 codes). This involved the CCM as successfully connecting PwsMS and caregivers with physicians and therapists, as well as coordinating and arranging medical appointments, which were highly valued. Assistance in authority and health and social insurance matters (10 codes) was another subcategory, where the CCM encompassed support in communication with health insurance companies, such as improving the level of care, assisting with retirement pension applications, and facilitating rehabilitation program applications. Optimized care (12 codes) resulted in improved living conditions and the provision of assistive devices through the CCM intervention.

The advocacy function (103 codes) emerged as the most critical aspect for PwsMS, representing the core of the category system. PwsMS experienced multidimensional, comprehensive, cross-insurance system support from the CCM. This category, with 43 statements, was the largest within all subcategories. PwsMS described the CCM as addressing their concerns, providing help, and assisting with the challenges posed by the illness in everyday life. The second-largest subcategory, regaining, maintaining and supporting autonomy (25 codes), highlighted the CCM’s role in supporting self-sufficiency and independence. Reviving personal wellbeing (17 codes) involved PwsMSs’ needs of regaining positive feelings, improved quality of life, and a sense of support and acceptance, which could be improved by the CCM. Temporal relief (18 codes) was reported, with the CCM intervention taking over or reducing tasks.

Within the outlook on CCM in standard care (84 codes), eight subcategories were identified. Communications was described as friendly and open (9 codes), with the setting of communication (29 codes) including the frequency of contacts deemed appropriate by the interviewed PwsMS, who preferred face-to-face contact over virtual or telephone interactions. Improvement suggestions for CCM (10 codes) predominantly revolved around the desire for the continuation of the CCM beyond the trial, expressing intense satisfaction with the CCM contact person and program. PwsMS rarely wished for better cooperation with the CCM. With respect to limitations (7 codes), PwsMS distinguished between individual limitations (e.g. when not feeling ready for using a wheelchair) and overriding structural limitations (e.g. unsuccessful search for an accessible apartment despite CCM support). Some PwsMS mentioned needing the CCM earlier in the course of the disease and believed it would beneficial for anyone with a chronic illness (6 codes).

In the gatekeeper function (75 codes), caregivers highly valued the CCM as a continuous contact partner (33 codes). More frequently than among the PwsMS interviewed, caregivers valued the CCM as a source of consultation/ information on essential individual subjects (42 codes). The need for basic information about the illness, its potential course, treatment and therapy options, possible supportive equipment, and basic medical advice/ information could be met by the CCM.

Within the broker function (63 codes), caregivers primarily experienced the subcategory establish contacts (24 codes). They found the CCM as helpful in establishing and managing contact with physicians, therapists and especially with health insurance companies. In the subcategory assistance in authority and health and social insurance matters (22 codes), caregivers highlighted similar aspects as the PwsMS interviewed. However, there was a particular emphasis on assistance with patients' retirement matters. Caregivers also valued the optimization of patients’ care and living environment (17 codes) in various life areas during the CCM intervention, including improved access to assistive devices, home modification, and involvement of a household support and/ or nursing services.

The advocacy function, with 115 codes, was by far the broadest category . The subcategory multidimensional, comprehensive, cross-insurance system support represented the largest subcategory of caregivers, with 70 statements. In summary, caregivers felt supported by the CCM in all domains of life. Regaining, maintaining and supporting autonomy (11 codes) and reviving personal wellbeing (8 codes) in the form of an improved quality of life played a role not only for patients but also for caregivers, albeit to a lower extend. Caregivers experienced temporal relief (26 codes) as the CCM undertook a wide range of organizational tasks, freeing up more needed resources for their own interests.

For the Outlook on CCM in standard care , caregivers provided various suggestions (81 codes). Similar to PwsMS, caregivers felt that setting (home based face-to-face, telephone, virtual) and frequency of contact were appropriate (10 codes, communication setting ) and communications (7 codes) were recognized as open and friendly. However, to avoid conflicts between caregiver and PwsMS, caregivers preferred meeting the CCM separately from the PwsMS in the future. Some caregivers wished the CCM to specify all services it might offer at the beginning, while others emphasized not wanting this. Like PwsMS, caregivers criticized the CCM intervention being (trial-related) limited to one year, regardless of whether further support was needed or processes being incomplete (13 codes, improvement suggestions ). After the CCM intervention time had expired, the continuous contact person and assistance were missed and new problems had arisen and had to be managed with their own resources again (9 codes, effects of CCM discontinuation ), which was perceived as an exhausting or unsolvable endeavor. Caregivers identified analogous limitations (8 codes), both individual and structural. However, the largest subcategory, was the experienced potential of CCM (27 codes), reflected in extremely high satisfaction with the CCM intervention. Like PwsMS, caregivers regarded severe chronically ill persons in general as target groups for a CCM (7 codes) and would implement it even earlier, starting from the time of diagnosis. They considered a CCM to be particularly helpful for patients without caregivers or for caregivers with limited (time) resources, as it was true for most caregivers.

Health care specialists

In the gatekeeper function (26 codes) HCSs particularly valued the CCM as a continuous contact partner (18 codes). They primarily described their valuable collaboration with the CCM, emphasizing professional exchange between the CCM and HCSs.

Within the broker function (43 codes), the CCM was seen as a connecting link between patients and HCSs, frequently establishing contacts (18 codes). This not only improved optimal care on an individual patient level (case management) but also at a higher, superordinate care level (care management). HCSs appreciated the optimized care and living environment (18 codes) for PwsMS, including improved medical and therapeutic access and the introduction of new assistive devices. The CCM was also recognized as providing assistance in authority and health and social matters (7 codes) for PwsMS and their caregivers.

In the advocacy function (43 codes), HCSs primarily reported temporal relief through CCM intervention (23 codes). They experienced this relief, especially as the CCM provided multidimensional, comprehensive, and cross-insurance system support (15 codes) for PwsMS and their caregivers. Through this support, HCSs felt relieved from time intensive responsibilities that may not fall within their area of expertise, freeing up more time resources for their actual professional tasks.

The largest category within the HCSs interviews was the outlook on CCM in standard care (116 codes). In the largest subcategory, HCSs made suggestions for further patient groups who could benefit (38 codes) from a CCM. Chronic neurological diseases like neurodegenerative diseases (e.g. amyotrophic lateral sclerosis), typical and atypical Parkinson syndromes were mentioned. HCSs considered the enrollment of the CCM directly after the diagnosis of these complex chronic diseases. Additionally, chronic progressive diseases in general or oncological diseases, which may also run chronically, were regarded worthwhile for this approach. HCSs also provided suggestions regarding improvement (21 codes). They wished e.g. for information or contact when patients were enrolled to the CCM, regular updates, exchange and collaborative effort. On the other hand, HCSs reported, that their suggestions for improvement would hardly be feasible due to their limited time resources. Similar to patients and caregivers, HCSs experienced structural limits (13 codes), which a CCM could not exceed due to overriding structural limitations (e.g. insufficient supply of (household) aids, lack of outreach services like psychotherapists, and long processing times on health and pension insurers' side). HCSs were also asked about their opinions on financial resources (14 codes) of a CCM in standard care. All interviewed HCSs agreed that CCM would initially cause more costs for health and social insurers, but they were convinced of cost savings in the long run. HCSs particularly perceived the potential of the CCM (20 codes) through the feedback of PwsMS, highlighting the trustful relationship enabling individualized help for PwsMS and their caregivers.

Persons with severe multiple sclerosis and their caregivers

The long-term cross-sectoral CCM intervention implemented in the COCOS-MS trial addressed significant unmet needs of PwsMS and their caregivers which previous research revealed as burdensome and hardly or even not possible to improve without assistance [ 5 , 6 , 9 , 10 , 33 , 35 , 46 ]. Notably, the CCM service met the need for a reliable, continuous contact partner, guiding patients through the complexities of regulations, authorities and the insurance system. Both, PwsMS and their caregivers highly valued the professional, objective perspective provided by the CCM, recognizing it as a source of relief, support and improved care in line with previous studies [ 37 , 47 ]. Caregivers emphasized the CCM’s competence in offering concrete assistance and information on caregiving and the fundamentals of MS, including bureaucratic, authority and insurances matters. On the other hand, PwsMS particularly appreciated the CCMs external reflective and advisory function, along with empathic social support tailored to their individual concerns. Above all, the continuous partnership of trust, available irrespective of the care sector, was a key aspect that both PwsMS and their caregivers highlighted. This consistent support was identified as one of the main components in the care of PwsMS in previous studies [ 5 , 33 , 35 ].

As the health literacy is inadequate or problematic for 54% of the German population and disintegration in the health and social care system is high [ 30 , 31 , 32 ], the CCM approach serves to enhance health literacy and reduce disintegration of PwsMS and their caregivers by providing cross-insurance navigational guidance in the German health and social insurance sector on a superordinate level. Simultaneously PwsMS and caregivers experienced relief and gained more (time) resources for all areas of life outside of the disease and its management, including own interests and establishing biographical continuity. This empowerment enables patients to find a sense of purpose beyond their illness, regain autonomy, and enhance social participation, reducing the feeling of being a burden to those closest to them. Such feelings are often experienced as burdensome and shameful by PwsMS [ 6 , 48 , 49 , 50 ]. Finding a sense of purpose beyond the illness also contributes to caregivers perceiving their loved ones not primarily as patient but as individuals outside of the disease, reinforcing valuable relationships such as partners, siblings, or children, strengthening emotional bonds. These factors are also highly relevant and well-documented in a suicide-preventive context, as the suicide rate is higher in persons diagnosed with neurological disorders [ 19 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ] and the feeling of being a burden to others, loss of autonomy, and perceived loss of dignity are significant factors in patients with severe chronic neurological diseases for suicide [ 50 , 57 ].

The temporal relief experienced by the CCM was particularly significant for HCSs and did not only improve the satisfaction of HCSs but also removed unfulfilled expectations and concerns about being blamed by patients when expectations could not be met, which previous studied elaborated [ 35 , 36 ]. Moreover, the CCM alleviated the burden on HCSs by addressing patients’ concerns, allowing them to focus on their own medical responsibilities. This aspect probably reduced the dissatisfaction that arises when HCSs are expected to address issues beyond their medical expertise, such as assistive devices, health and social insurance, and the organization and coordination of supplementary therapies, appointments, and contacts [ 35 , 36 , 61 ]. Consequently, the CCM reduced difficulties of HCSs treating persons with neurological or chronical illnesses, which previous research identified as problematic.

HCSs perceive their work as increasingly condensed with numerous time and economic constraints, especially when treating complex and severely ill individuals like PwsMS [ 36 ]. This constraint was mentioned by HCSs in the interviews and was one of the main reasons why they were hesitant to participate in interviews and may also be an explanation for a shorter interview duration than initially planned in the interview guides. The CCM’s overarching navigational competence in the health and social insurance system was particularly valued by HCSs. The complex and often small-scale specialties in the health and social care system are not easily manageable or well-known even for HCSs, and dealing with them can exceed their skills and time capacities [ 61 ]. The CCM played a crucial role in keeping (temporal) resources available for what HCSs are professionally trained and qualified to work on. However, there remains a challenge in finding solutions to the dilemma faced by HCSs regarding their wish to be informed about CCM procedures and linked with each other, while also managing the strain of additional requests and contact with the CCM due to limited (time) resources [ 62 ]. Hudon et al. (2023) suggest that optimizing time resources and improving exchange could involve meetings, information sharing via fax, e-mail, secure online platforms, or, prospectively, within the electronic patient record (EPR). The implementation of an EPR has shown promise in improving the quality of health care and time resources, when properly implemented [ 63 , 64 ]. The challenge lies ineffective information exchange between HCSs and CCM for optimal patient care. The prospect of time saving in the long run and at best for a financial incentive, e.g., when anchoring in the Social Security Code, will help best to win over the HCSs.If this crucial factor can be resolved, there is a chance that HCSs will thoroughly accept the CCM as an important pillar, benefiting not only PwsMS but also other complex patient groups, especially those with long-term neurological or complex oncological conditions that might run chronically.

Care and case management and implications for the health care system

The results of our study suggest that the cross-sectoral long-term advocacy CCM in the COCOS-MS trial, with continuous personal contacts at short intervals and constant reevaluation of needs, problems, resources and goals, is highly valued by PwsMS, caregivers, and HCSs. The trial addresses several key aspects that may have been overlooked in previous studies which have shown great potential for the integration of case management [ 17 , 47 , 62 , 65 , 66 ]. However, they often excluded the overriding care management, missed those patient groups with special severity and complexity who might struggle to reach social and health care structures independently or the interventions were not intended for long-term [ 22 , 37 ]. Our results indicate that the CCM intervention had a positive impact on PwsMS and caregivers as HCSs experienced them with benefits such as increased invigoration, reduced demands, and enhanced self-confidence. However, there was a notable loss experienced by PwsMS and caregivers after the completion of the CCM intervention, even if they had stabilized during the intervention period. The experiences of optimized social and health care for the addressed population, both at an individual and superordinate care level, support the integration of this service into standard care. Beyond the quantitatively measurable outcomes and economic considerations reported elsewhere [ 16 , 20 , 21 ], our results emphasize the importance of regaining control, self-efficacy, self-worth, dignity, autonomy, and social participation. These aspects are highlighted as preventive measures in suicidal contexts, which is particularly relevant for individuals with severe and complex illnesses [ 19 , 50 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ]. Our findings further emphasize the societal responsibilities to offer individuals with severe and complex illnesses the opportunity to regain control and meaningful aspects of life, irrespective of purely economic considerations. This underscores the need for a comprehensive evaluation that not only takes into account quantitative measures but also the qualitative aspects of well-being and quality of life when making recommendations of a CCM in standard care.

The study by J. Y. Joo and Huber (2019) highlighted that CM interventions aligned with the standards of the Case Management Society of America varied in duration, ranging from 1 month to 15.9 years, and implemented in community- or hospital-based settings. However, they noted a limitation in understanding how CM processes unfold [ 67 ]. In contrast, our trial addressed this criticism by providing transparent explanations of the CCM process, which also extends to a superordinate care management [ 40 , 41 ]. Our CCM manual [ 40 ] outlines a standardized and structured procedure for measuring and reevaluating individual resources, problems, and unmet needs on predefined dimensions. It also identifies goals and actions at reducing unmet needs and improving the individual resources of PwsMS and caregivers. Importantly, the CCM manual demonstrates that the CCM process can be structured and standardized, while accounting for the unique aspects of each individual’s serious illness, disease courses, complex needs, available resources, and environmental conditions. Furthermore, the adaptability of the CCM manual to other complex chronically ill patient groups suggests the potential for a standardized approach in various health care settings. This standardized procedure allows for consistency in assessing and addressing the individual needs of patients, ensuring that the CCM process remains flexible while maintaining a structured and goal-oriented framework.

The discussion about the disintegration in the social and health care system and the increasing specialization dates back to 2009 [ 31 , 32 ]. Three strategies were identified to address this issue: (a) “driver-minimizing” [Treiberminimierende], (b) “effect-modifying” [Effektmodifizierende] and (c) “disintegration-impact-minimizing” [Desintegrationsfolgenminimierende] strategies. “Driver-minimizing strategies” involve comprehensive and radical changes within the existing health and social care system, requiring political and social pursuit. “Disintegration-impact-minimizing strategies” are strategies like quality management or tele-monitoring, which are limited in scope and effectiveness. “Effect-modifying strategies”, to which CCM belongs, acknowledges the segmentation within the system but aims to overcome it through cooperative, communicative, and integrative measures. CCM, being an “effect-modifying strategy”, operates the “integrated segmentation model” [Integrierte Segmentierung] rather than the “general contractor model” [Generalunternehmer-Modell] or “total service provider model” [Gesamtdienstleister-Modell] [ 31 , 32 ]. In this model, the advantage lies in providing an overarching and coordinating service to link different HCSs and services cross-sectorally. The superordinate care management aspect of the CCM plays a crucial role in identifying gaps in care, which is essential for future development strategies within the health and social care system. It aims to find or develop (regional) alternatives to ensure optimal care [ 17 , 23 , 24 , 68 , 69 ], using regional services of existing health and social care structures. Therefore, superordinate care management within the CCM process is decisive for reducing disintegration in the system.

Strengths and limitations

The qualitative study results of the explorative COCOS-MS clinical trial, which employed an integrated mixed-method design, provide valuable insights into the individual experiences of three leading stakeholders: PwsMS, caregivers and HCSs with a long-term cross-sectoral CCM. In addition to in-depth interviews, patient and caregiver reported outcome measurements were utilized and will be reported elsewhere. The qualitative study’s strengths include the inclusion of patients who, due to the severity of their condition (e.g. EDSS mean: 6.8, range: 6–8, highly active MS), age (mean: 53.9 years, range: 36–73 years) family constellations, are often underrepresented in research studies and often get lost in existing social and health care structures. The study population is specific to the wider district region of Cologne, but the broad inclusion criteria make it representative of severe MS in Germany. The methodological approach of a deductive and inductive structuring content analysis made it possible to include new findings into an existing theoretical framework.

However, the study acknowledges some limitations. While efforts were made to include more HCSs, time constraints on their side limited the number of interviews conducted and might have biased the results. Some professions are underrepresented in the interviews. Complex symptoms (e.g. fatigue, ability to concentrate), medical or therapeutic appointments and organization of the everyday live may have been reasons for the patients’ and caregivers’ interviews lasting shorter than initially planned.

The provision of functions of a CCM, might have pre-structured the answers of the participants.

At current, there is no support system for PwsMS, their caregivers and HCSs that addresses their complex and unmet needs comprehensively and continuously. There are rare qualitative insights of the three important stakeholders: PwsMS, caregivers and HCSs in one analysis about a supporting service like a CCM. In response to this gap, we developed and implemented a long-term cross-sectoral advocacy CCM and analyzed it qualitatively. PwsMS, their caregivers and HCSs expressed positive experiences, perceiving the CCM as a source of relief and support that improved care across various aspects of life. For patients, the CCM intervention resulted in enhanced autonomy, reviving of personal wellbeing and new established contacts with HCSs. Caregivers reported a reduced organizational burden and felt better informed, and HCSs experienced primarily temporal relief, allowing them to concentrate on their core professional responsibilities. At a higher level of care, the study suggests that the CCM contributed to a reduction in disintegration within the social and health care system.

The feedback from participants is seen as valuable for adapting the CCM intervention and the CCM manual for follow-up studies, involving further complex patient groups such as neurological long-term diseases apart from MS and tailoring the duration of the intervention depending on the complexity of evolving demands.

Availability of data and materials

Generated and/or analyzed datasets of participants are available from the corresponding author on reasonable request to protect participants. Preliminary partial results have been presented as a poster during the EAPC World Congress in June 2023 and the abstract has been published in the corresponding abstract booklet [ 70 ].

Abbreviations

Amyotrophic lateral sclerosis

• Care and case management

Case management

Central nervous system

Communication, Coordination and security for people with multiple sclerosis

Consolidated criteria for reporting qualitative research

German register for clinical studies

Extended disability status scale

Electronic patient record

Quality of life

Multiple sclerosis

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Acknowledgements

We would like to thank all the patients, caregivers and health care specialists who volunteered their time to participate in an interview and the trial, Carola Janßen for transcribing the interviews, Fiona Brown for translating the illustrative quotes and Beatrix Münzberg, Kerstin Weiß and Monika Höveler for data collection in the quantitative study part.

COCOS-MS Trial Group

Anne Müller 1 , Fabian Hebben 1 , Kim Dillen 1 , Veronika Dunkl 1 , Yasemin Goereci 2 , Raymond Voltz 1,3,4 , Peter Löcherbach 5 , Clemens Warnke 2 , Heidrun Golla 1 , Dirk Müller 6 , Dorthe Hobus 1 , Eckhard Bonmann 7 , Franziska Schwartzkopff 8 , Gereon Nelles 9 , Gundula Palmbach 8 , Herbert Temmes 10 , Isabel Franke 1 , Judith Haas 10 , Julia Strupp 1 , Kathrin Gerbershagen 7 , Laura Becker-Peters 8 , Lothar Burghaus 11 , Martin Hellmich 12 , Martin Paus 8 , Solveig Ungeheuer 1 , Sophia Kochs 1 , Stephanie Stock 6 , Thomas Joist 13 , Volker Limmroth 14

1 Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany

2 Department of Neurology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany

3 Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), University of Cologne, Cologne, Germany

4 Center for Health Services Research (ZVFK), University of Cologne, Cologne, Germany

5 German Society of Care and Case Management e.V. (DGCC), Münster, Germany

6 Institute for Health Economics and Clinical Epidemiology (IGKE), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany

7 Department of Neurology, Klinikum Köln, Cologne, Germany

8 Clinical Trials Centre Cologne (CTCC), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany

9 NeuroMed Campus, MedCampus Hohenlind, Cologne, Germany

10 German Multiple Sclerosis Society Federal Association (DMSG), Hannover, Germany

11 Department of Neurology, Heilig Geist-Krankenhaus Köln, Cologne, Germany

12 Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany

13 Academic Teaching Practice, University of Cologne, Cologne, Germany

14 Department of Neurology, Klinikum Köln-Merheim, Cologne, Germany

Open Access funding enabled and organized by Projekt DEAL. This work was supported by the Innovation Funds of the Federal Joint Committee (G-BA), grant number: 01VSF19029.

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Anne Müller, Fabian Hebben, Kim Dillen, Veronika Dunkl, Raymond Voltz & Heidrun Golla

Department of Neurology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany

Yasemin Goereci & Clemens Warnke

Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), University of Cologne, Cologne, Germany

Raymond Voltz

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• Anne Müller
• , Fabian Hebben
• , Kim Dillen
• , Veronika Dunkl
• , Yasemin Goereci
• , Raymond Voltz
• , Peter Löcherbach
• , Clemens Warnke
• , Heidrun Golla
• , Dirk Müller
• , Dorthe Hobus
• , Eckhard Bonmann
• , Franziska Schwartzkopff
• , Gereon Nelles
• , Gundula Palmbach
• , Herbert Temmes
• , Isabel Franke
• , Judith Haas
• , Julia Strupp
• , Kathrin Gerbershagen
• , Laura Becker-Peters
• , Lothar Burghaus
• , Martin Hellmich
• , Martin Paus
• , Solveig Ungeheuer
• , Sophia Kochs
• , Stephanie Stock
• , Thomas Joist
•  & Volker Limmroth

Contributions

HG, KD, CW designed the trial. HG, KD obtained ethical approvals. HG, KD developed the interview guidelines with help of the CCM (SU). AM was responsible for collecting qualitative data, developing the code system, coding, analysis of the data and writing the first draft of the manuscript, thoroughly revised and partly rewritten by HG. FH supported in collecting qualitative data, coding and analysis of the interviews. KD supported in collecting qualitative data. AM, FH, KD, VD, YG, RV, PL, CW, HG discussed and con-solidated the finalized category system. AM, FH, KD, VD, YG, RV, PL, CW, HG read and commented on the manuscript and agreed to the final version.

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Ethics approval and consent to participate.

Participants were provided with oral and written information about the trial and provided written informed consent. Ethical approval was obtained from the Ethics Committee of the University of Cologne (#20–1436). The trial is registered in the German Register for Clinical Studies (DRKS) (DRKS00022771) and is conducted under the Declaration of Helsinki.

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Competing interests.

Clemens Warnke has received institutional support from Novartis, Alexion, Sanofi Genzyme, Janssen, Biogen, Merck and Roche. The other authors declare that they have no competing interests.

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Müller, A., Hebben, F., Dillen, K. et al. “So at least now I know how to deal with things myself, what I can do if it gets really bad again”—experiences with a long-term cross-sectoral advocacy care and case management for severe multiple sclerosis: a qualitative study. BMC Health Serv Res 24 , 453 (2024). https://doi.org/10.1186/s12913-024-10851-1

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How would you describe a mentally healthy college student based on Chinese culture? A qualitative research from the perspective of college students

• Mingjia Guo 1 ,
• Xiaoming Jia 1 &
• Wenqian Wang 1  

BMC Psychology volume  12 , Article number:  207 ( 2024 ) Cite this article

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Promoting college students’ mental health remains a significant concern, necessitating a clear understanding of what constitutes good mental health. Variations in the conceptualizations of mental health across cultures, typically derived from academic and authoritative perspectives, have overlooked insights from laypeople. This study aims to investigate the characteristics of mentally healthy college students within Chinese cultural contexts, emphasizing perspectives provided by college students themselves.

Undergraduates with self-reported mental health scores ≥ 7 were randomly selected for in-depth interviews. The sample ( N  = 17, 59% female) had a mean age of 20.82 ± 1.33 years and represented diverse regions, backgrounds, and academic fields. Thematic analysis was used in the analysis of the qualitative data, involving initial coding to identify 168 manifestations of mental health among college students, followed by categorizing them into 18 characteristics through focused coding. These characteristics were then organized into five themes via core coding. The Delphi method was utilized to validate the themes with 3 experts, ensuring the trustworthiness of the final findings.

Eighteen characteristics of mentally healthy college students emerged from the interviews, categorized into 5 themes: (1)Value Pursuit (i.e. Having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time.); (2)Life Attitude (i.e. Staying positive and having the ability and quality to cope with hardships.); (3)Interpersonal Ideals (i.e., Showing filial respect to parents appropriately.); (4)Behavior Ability(i.e., Studying diligently and learning well.); and (5)Self-cultivation (i.e., Possessing good qualities advocated by Confucianism, Buddhism, and Taoism coexist harmoniously.). Most of these characteristics directly reflect traditional Chinese culture or culture that has changed with the times. At the same time, some are a reflection of modern Chinese new culture.

Conclusions

On the whole, the characteristics of mentally healthy college students are diverse and with rich connotations, focusing on the individual’s relationship with the country, family, and others, and are good expressions of Chinese cultural features, such as the balance of Yin and Yang, the coexistence of Confucianism, Buddhism, and Taoism, and highlight moral attributes. In essence, these traits hold profound importance in advancing the mental health of Chinese college students.

Peer Review reports

The period of undergraduate study is vital for individual development, physical and mental growth, knowledge reserve, and health literacy development. For undergraduate students, they are in the process of transitioning from late adolescence to early adulthood, navigating various physical, psychological, and social changes [ 1 ]. After entering the university, undergraduates, especially first-year students, are prone to various maladaptation problems due to changes in their living and learning environments [ 2 ]. Notably, a recent nationwide survey of 48,789 undergraduate students from 31 provinces and cities of China showed that 24.17% of undergraduates were at risk of depression, and 49.58% were at risk of anxiety [ 3 ].

Some studies have shown that these psychological problems are related to culture. As a Chinese proverb goes, “Nothing is more important than learning.” Before university, Chinese students focused solely on their studies, with their parents managing all aspects of life [ 4 ]. Consequently, they may lack the ability to independently resolve problems, particularly when confronted with many challenges in university life, often feeling helpless. Furthermore, admission to university is considered an honor to ancestors and a source of pride for parents in Chinese culture [ 5 ]. Attaining good grades and securing an ideal career post-graduation are seen as ways for college students to fulfill their filial duties, like supporting their parents, thus imposing familial and communal pressures.

Cultural influences also play a role in the mental health of college students. Wang et al. (2016) investigated how traditional Chinese philosophies—such as relationship harmony (advocated by Confucianism), dialectical coping (from Taoism), and non-attachment (rooted in Buddhism)—impact college students’ mental health. Their research demonstrated these philosophies’ negative correlation with psychological distress and negative emotions while displaying positive correlations with self-esteem, positive emotions, meaning of life, and happiness [ 6 ]. Another study indicated that Chinese college students scoring higher in Zhongyong thinking exhibit lower anxiety and depressive symptoms, along with higher self-esteem and life satisfaction, versus those with lower scores [ 7 ].

Since culture and mental health are mutually embedded [ 8 ], different cultures may interpret the same things differently. For instance, in Western cultures, pursuing a college education is often viewed as an individual pursuit, whereas in collectivist China, but in China, higher education is commonly sought to elevate social status and offer enhanced financial support to parents, such as securing a comfortable retirement home. In times of conflict, individuals in Chinese society tend to adopt the principle of “taking a step back and yielding vastness and spaciousness to others” [ 9 ], prioritizing long-term harmony over immediate gains by favoring conflict avoidance over confrontation. The values of “harmony is precious” and the practice of “forbearance” are revered in China, whereas in Western societies, it may be considered unhealthy, with individuals opting for direct expression of discontent [ 10 ].

In China, only 8% of the population hold bachelor’s degrees [ 11 ], and college students are seen as the nation’s hope and future [ 12 ], underscoring a heightened focus on their mental health. To enhance the mental health of Chinese college students effectively, it is imperative to grasp the cultural nuances defining mental health across various contexts.

Mental health has always been a focus in the field of psychology. Researchers from diverse backgrounds have extensively investigated mental health within various cultural frameworks. This includes the development of nuanced interpretations and pertinent theories regarding mental health across different cultural settings [ 13 , 14 ]. Moreover, scholars have localized measurement tools through meticulous adaptations [ 1 , 15 , 16 , 17 ] and delved into understanding the impact mechanisms between mental health and its associated determinants [ 18 , 19 ]. In terms of the connotation of mental health, aside from the various approaches of counseling and psychotherapy have their interpretations and definitions of mental health, various organizations and scholars have also put forward different perspectives of mental health from multifaceted viewpoints, clearly demonstrating the impact of culture.

According to the Concise Encyclopaedia Britannica, mental health is defined as “the state of optimal functioning of the individual psyche within the limits of its own and environmental conditions, but not as an absolute state of perfection” [ 20 ]. Meeks and Heit describe mental health as “the ability to perceive and express one’s emotions and state of mind; mental health is the ability to accept reality as it is” [ 21 ]. Meanwhile, Ryan and Deci propose that mental health involves “the ability to feel effective and agile, e.g., to have full self-fulfillment” [ 22 ]. The World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can make a contribution to his or her community” [ 23 ]. These definitions illustrate how Western culture emphasizes individual capabilities, states of being, and overall well-being, focusing on fulfilling potential, fostering self-esteem, and reflecting a culture centered on the individual.

In the Dictionary of Psychology (Chinese version), mental health was defined as “a good state in which the individual’s mental state (e.g., general adaptability, soundness of personality) remains normal or at a good level, and in which harmony is maintained within the self (e.g., self-awareness, self-control, self-experience) and between the self and the environment” [ 24 ]. According to Zhang and Yang, mental health contains objective and subjective components [ 25 ]. An individual’s mental health is mainly expressed by the relationship between the individual and others in a group, so it contains social meaning. Hu suggests that mental health is about “following one’s heart and not exceeding the rules,” which has both its individual (developmental and autonomous) and social (adaptive and normative) aspects [ 26 ]. Yip defines mental health as a direction that suggests self-discipline and obedience to social order to maintain inner balance and external harmony with others [ 27 ]. Specifically, individuals can maintain this balance and harmony across three levels: personal, interpersonal, and moral/ethical. These definitions underscore Chinese scholars’ emphasis on the social aspects of the individual in conjunction with the proper functioning of mental faculties. They highlight Chinese culture’s focus on harmony, interpersonal relationships, societal connections, and moral/ethical considerations.

In summary, concepts and understandings of mental health are closely tied to culture [ 28 ], reflecting that the connotations of mental health defined by different cultural contexts can vary to some extent. Then, how is mental health related to culture? The theory of sociocultural models (TSCM) provides a perspective on the interaction between culture and the individual mind [ 29 ].

The primary thesis of the theory of sociocultural models (TSCM) is that the human mind and culture mutually constitute each other. During continued interactions, individuals internalize the social culture into their psychological realities to regulate their actions and interactions. Conversely, community members will externalize the psychological reality through enactment and instantiation, creating new social cultures through social interactions and co-construction with the existing social culture. The dialectical interactions of these two aspects constitute the mechanism of the sociocultural regulation of human actions and the construction of the sociocultural reality [ 29 ]. Consequently, social culture dictates varying expectations for mental health standards, while the characteristics associated with mental health are also culturally rooted and reflect social culture. Simultaneously, societal depictions of mentally healthy individuals contribute to the evolution of novel cultural norms in a reciprocal manner.

The Chinese culture has a long history of rich mental health concepts deeply rooted in philosophies such as Confucianism, Buddhism, and Taoism. Confucianism seeks to go into the society( Rushi ), i.e., “To ordain conscience for Heaven and Earth, to secure life and fortune for the populace, to carry on lost teachings of ancient sages, to build peace for posterity” (Zhang Zai: Heng Qu Yi Shuo ). When encountering setbacks, Confucianism advocates being adaptable to circumstances and maintaining mental health by being resilient and motivated. Taoism seeks to transcend the world( Chaoshi ) and advocates “letting go.”When encountering difficulties, people maintain mental health by going with the flow and doing what they should do. The philosophy also underscores the importance of balancing Yin and Yang, enabling individuals to perceive challenges holistically by acknowledging both positive and negative aspects. Buddhism seeks to jump out of the material world( Chushi ) and advocate “being free of worried thoughts” when encountering difficulties. As Hui Neng(the Sixth Patriarch of Zen) said in the Tan Jing, “Since everything is naught, where can dust gather?” Individuals can cope better with difficulties if they have a mindset that looks down on gains and losses and that everything is nothingness.

Popular anecdotes and proverbs in Chinese culture also dictate criteria for individuals’ mental health. For instance, the “Three Feet of Space” tale narrates an incident from ancient China where the Guo family faced a boundary dispute with their neighbor during house construction. Upon hearing of this issue, patriarch Guo Pu wisely proposed, “Sending letters a thousand miles just for a wall; why not give him three feet?” This led to the Guo family’s compromise, and finally, both families conceded three feet of space from their walls. This narrative underscores the cultural emphasis on fostering interpersonal harmony through mutual accommodation, viewing discordant relationships as signs of poor mental health.

Contemporary scholars have also endeavored to directly integrate key concepts from Chinese traditional culture into psychological counseling and therapy. Yang and his colleagues(2002) [ 30 ] created Taoist Cognitive Therapy to facilitate cognitive restructuring in psychologically distressed individuals by directly applying the 32 characteristics of the Taoist principle of health, that is: “Benefit without harm, but not disputing; abstinent contentment with little selfishness and desire; under the knowledge and the place, let gentleness overcome rigidity; recover the original simplicity, let it be.” Liu(2023) posits that “unity of universe and human” in Chinese culture is a core idea of mental health [ 31 ]. He pointed out that the psychological phenomenon corresponding to this concept is psychological nothingness. By fusing modern psychotherapy with the concept of “unity of universe and human,” Liu developed the technique of “Moving symptom’s symbol to nothingness” to fulfill the healing role of Chinese culture. These endeavors establish a robust framework for comprehending mental health through the lens of Chinese cultural perspectives.

Over the years, numerous scholars have delved into the attributes of mentally healthy college students. Prominent among these is Wang and Zhang’s widely recognized framework, which outlines eight characteristics drawing from personal experience: understanding and accepting oneself; accepting others and dealing well with them; facing reality squarely and accepting it; loving life and enjoying work; being able to coordinate and control emotions and being in a good state of mind; having a complete and harmonious personality; having normal intelligence; and having age-appropriate mental behavior [ 32 ]. However, this work has predominantly focused on psychological cognition, emotion, and intention, with limited consideration of the cultural context, particularly the influence of Chinese culture on mental health.

Subsequently, scholars such as Zeng and Lei, incorporating social, ethical, and moral perspectives, proposed a culturally nuanced framework emphasizing four main traits in mentally healthy college students: positive and controllable emotions, good moral values, comfortable coping with schoolwork, and healthy social interaction [ 33 ]. While valuable, this perspective primarily mirrors researchers’ subjective experiences and authority-driven viewpoints. It neglects insights from laypeople, omits identification of the aspects of Chinese culture showcasing characteristics of mentally healthy college students, and lacks differentiation between mentally healthy college students and other demographic groups. Consequently, there is a demand for exploring innovative methodologies to scrutinize the attributes of mentally healthy college students, particularly focusing on characteristics within Chinese culture.

Currently, there are various research paradigms for the study of mental health. Jiang (2004) categorized them and concluded that there are two main principles in evaluating mental health: the majority principle and the elite principle [ 34 ]. The majority principle refers to a research paradigm that selects research subjects through large samples and measures whether individuals deviate from the norm through the principle of statistical normal distribution [ 35 ]. An example is applying the Chinese version of Symptom Checklist-90 (SCL-90), one of the most often used self-report symptom inventories to measure the mental health of college students, and individuals scoring exceeding the norm were considered abnormal [ 36 ].

The elite principle refers to a research paradigm that focuses on elite samples, namely a small number of relatively outstanding individuals in the whole population who are at the tip of one side of the normal distribution, and primarily employs qualitative research methods to derive research findings [ 35 ]. For example, Maslow researched some great people in Western history( i.e., self-actualized people) using qualitative research methods such as biographical analysis, depicted 15 characteristics of self-actualized people, that is, “more efficient perception of reality and more comfortable relations with it,” “acceptance (self, others, nature),” “spontaneity; simplicity; naturalness,” “problem centering,” “the quality of detachment; the need for privacy,” “continued freshness of appreciation,” “autonomy; independence of culture and environment; will; active agents,” “the mystic experience: the peak experience,” “gemeinschaftsgefuhl,” “interpersonal relations,” “the democratic character structure,” “discrimination between means and ends, between good and evil,” “philosophical, unhostile sense of humor,” “creativeness,” “resistance to enculturation; the transcendence of any particular culture” [ 37 ].

Maslow’s findings profoundly influenced research on mental health definitions, standards, and interventions. While some researchers have embraced the characteristics of self-actualized people as an ideal standard of mental health [ 38 ], others have leveraged these characteristics by focusing on exceptional psychological qualities rather than normative behavioral performance [ 39 ], and many of these characteristics have been used as ideal indicators of mental health for the promotion of mental health among college students [ 40 ]. Additionally, these characteristics and the conditions that promote or inhibit self-actualization are also applied in methods and paths of healthy human development [ 41 ]. Furthermore, specific characteristics such as a “philosophical, unhostile sense of humor” have been directly applied by researchers to enhance humor quality among college students facing stress and embarrassment, aiming to uphold their mental well-being [ 42 ].

Despite significant value in both theory and practice, Maslow’s study is based on the Western culture and is not aimed at a specific group of college students. Consequently, its direct relevance to enhancing the mental well-being of Chinese college students may be limited, necessitating further investigation into mental health within the framework of Chinese culture. Nonetheless, Maslow’s study of the elite samples of self-actualized people also provides a new research paradigm for mental health research, which has greatly inspired this study.

In the past, most studies on the mental health of college students used quantitative studies based on the majority principle. While some qualitative studies inquiries delved into the characteristics of mentally healthy college students, these studies often focused on specific subgroups like those who experienced being left behind [ 43 ] or childhood trauma [ 44 ]. A gap exists in the mental health characteristics based on the Chinese culture of college students who are the elite samples, i.e., those who exhibit very good mental health. By utilizing the elite principle paradigm, researchers can gain insights into and depict the mental health characteristics of college students within the context of Chinese culture, with the ultimate aim of delineating the mental health characteristics of college students specific to this cultural framework.

This study will apply the elite principle to examine college students with very good mental health. Through a distinctly Chinese cultural lens, this research aims to delineate what mentally healthy college students look like and what characteristics they show. By focusing on college students’ personal experiences and Chinese culture, this study positions college students as knowledge generators, employing a qualitative research approach to uncover the characteristics of mentally healthy college students. The objective is to achieve a new understanding of college students’ mental health based on Chinese culture and provide a theoretical basis for new mental health standards and a reference for promoting, cultivating, and intervening in college students’ mental health.

In this study, mental health refers to the good psychological state of an individual. College students refer to the group of students who are receiving professional higher education. Chinese culture refers to the culture created by the Chinese over thousands of years of development, from ancient times to the present [ 45 ].

The study applied a participatory, exploratory, qualitative design. Qualitative methods are suitable for exploring the meaning of phenomena or life events to the interviewees and their inherent experiences from the subjectivity of the interviewees [ 46 ]. It also emphasizes the participants as a generator of knowledge and the acquisition of significant experiences from the participants [ 47 ]. Thus, it can help researchers to gain a deeper understanding of community members in a specific cultural-historical context. Moreover, qualitative methods hold particular promise for prioritizing participants’ voices, and they contribute to understanding human interaction with the environment in development and helping researchers build and expand new concepts and theories in specific cultural-historical contexts [ 48 ]. This study used semi-structured individual in-depth interviews to explore the characteristics of mentally healthy college students based on Chinese culture. Moreover, the procedure of the study is shown in Fig.  1 .

The procedure of the study

The development of the interview outline

The qualitative data for this study was collected through semi-structured interviews. Interviews serve as a tool to help reveal and understand participants’ perspectives and experiences. The interview outline for this study was based on the theory of sociocultural models [ 29 ], focusing on how the interviewed college students understood Chinese culture and which cultures were internalized as characteristics of mentally healthy college students.

The interview outline in the pre-interview includes questions such as “What do you think is mental health? What do you think a ‘mentally healthy’ college student is like? You can use yourself or your classmates as examples.” “What do you think is Chinese culture? What is your understanding of Chinese culture?” “What do you think is related to college students’ mental health in Chinese culture?” (Appendix 1 ).

Participant recruitment and selection

The selection criteria for the participants were: i) undergraduate students enrolled in colleges; ii) having a very good psychological status, with a self-assessment of mental health of 7 or more (out of 10); and iii) self-assessment anxiety/depression scores within the normal range.

The study recruited participants through postings in contact groups and forums among different colleges. Undergraduates who satisfied the selection criteria volunteered to participate in the study. At the time of self-referral, enrolled students rated their mental health with the term “Out of ten, how would you rate your mental health?” as well as filled out self-rated anxiety and depression scales [ 49 , 50 ].

The reasons for considering selection criteria are as follows. Firstly, the research objective is to identify the mental health characteristics of college students with good mental health. Therefore, following the elite principle and referencing Maslow’s self-actualization research paradigm [ 37 ], we have chosen exceptionally mentally healthy college students as elite samples for study. Given that statistical analysis commonly regards the top 27% as the criterion for high-score groups [ 51 , 52 ], a score of 7 out of 10 indicates high mental health levels. Consequently, the study interviewed college students scoring at least 7 points. Secondly, to eliminate individuals with significant biases in the self-assessment of mental health and those potentially experiencing psychological issues, we utilized scores from self-rating scales for depression and anxiety to exclude possible candidates with underlying psychological disorders.

Eventually, 17 college students who met the criteria were selected for interviews in this study. The selection of participants considered factors that might influence college students to develop different understandings of Chinese cultures, such as upbringing, family environment, and educational experiences. The total number of participants was determined based on thematic saturation, i.e., no significant themes emerged with new respondents [ 53 , 54 ]. Finally, 17 undergraduate students volunteered to participate in the formal interviews, and the self-reported mental health score of the interviewees was 8.11(SD = 0.90) (out of 10). Among the participants, seven were male, and ten were female. Their ages ranged from 19 to 23 years old (mean age = 20.82, SD = 1.33 years), five interviewees were from Double World-Class Project Universities in China, and 5 were first-year students, two sophomores, eight juniors, and two seniors. Participants came from different regions of China; 4 grew up in north China, 1 in northwest China, 2 in southwest China, 2 in south China, 1 in east China, and 7 in central China; 1 from an ethnic minority. 65% were from urban areas, and 29% had no siblings. Additional information on parents’ education level and occupation is shown in Table  1 .

After the interviews, participants were thanked for their participation and contribution and were offered 30 RMB (about 4 dollars) for participating.

The finalization of the interview outline

Before the formal interviews, three college students (one male and two female) who met the selection criteria were pre-interviewed, and the interview outline was adjusted based on the pre-interviews. Specifically, the researchers adjusted ambiguous expressions. For example, in the pre-interview, the researchers found that if they asked the interviewees, “What do you think is related to college students’ mental health in Chinese culture?” They answered how Chinese culture affects college students’ mental health rather than the characteristics of mentally healthy college students based on Chinese culture. Therefore, we adjusted the question to “What a ‘mentally healthy’ college student is like based on Chinese culture? You can take yourself or your classmates as an example” to obtain the characteristics of mental health that reflect Chinese culture. A formal interview outline was eventually formed (Appendix 2 ).

Data collection and analysis

The qualitative data was collected through in-depth personal interviews with eligible college students. Each interview lasted between 50- 100 min and was conducted by the researcher (MG), who possessed a doctoral background in psychology, had received training in qualitative research methods, and had three years of experience working in mental health education in universities. All participants signed informed consent forms prior to the interviews. In total, 1252 min of interviews were conducted with 17 participants, which were then manually transcribed by MG, resulting in 289,000 words of interview transcripts.

To accurately ascertain the true meaning expressed by the participants, this study employed manual analysis within the research team to code and analyze the interview transcripts word by word and sentence by sentence. Under the guidance of XJ (a clinical and counseling psychology professor), the research team completed all data analysis work. In addition to MG and WW, the team members included two doctoral students who are also full-time university psychological counselors and two master’s students specializing in mental health education.

The data analysis was conducted using thematic analysis [ 55 ]. The steps are as follows: first, the researcher transcribed each of the digitally recorded interviews, immersed within the data, and repeatedly read through the 289,000-word interview transcripts. Second, researchers identified meaningful texts and created open codes. Each meaningful sentence was marked with a “code number,” totaling 1,889. The study used “F” to represent female interviewees and “M” for male participants. The first number represents the interview orders of interviewees; the second number represents the order of the meaningful statements in the interview. For example, “M5-40” represents the 40th word, sentence, or paragraph spoken by the fifth male interviewee. Third, after contemplating the open codes repeatedly, 168 manifestations of mentally healthy college students were derived through initial coding. These manifestations were then summarized to establish 18 characteristics of psychologically healthy university students via focused coding. Subsequently, these 18 characteristics were further classified through core coding to derive five main themes. Fourth, we checked the themes and adjusted their structure until they met internal homogeneity and external heterogeneity criteria. Fifth, we defined and named the themes; 18 characteristics were obtained and coded into five themes.

The Delphi expert evaluation

Subsequently, three experts were invited to assess the appropriateness of naming, defining, and classifying the identified 18 characteristics and five themes above. These experts are professors in clinical and counseling psychology from institutions such as Beijing University of Chinese Medicine, with in-depth research in Chinese culture and mental health. They have published numerous related monographs and academic papers, such as “When Psychological Counseling Meets Traditional Culture” and “Mind Operations in Meditation.”

The evaluation comprised two rounds. The first round involved a focused group interview where the three experts individually reviewed each theme, characteristic, and original interview data, offering suggestions for revision. They generally approved of the theme divisions and most characteristics, with two main modifications: 1) the integration and categorization of specific characteristics, such as the initial characteristic “Having a pleasant disposition,” which was deemed by experts to contribute to a comfortable interpersonal state and thus was incorporated into “Interpersonal harmony and comfort.” 2) Adjustments to specific nomenclature, such as refining “Showing filial respect to parents” to “Showing filial respect to parents appropriately” to better emphasize the nuance of the characteristic.

The revised results were resent to the three experts for a second round of evaluation, leading to a consensus with no further modifications suggested, thus finalizing the research findings.

The trustworthiness of the data

Trustworthiness was achieved in several ways.

First, to minimize personal biases to the greatest extent possible, the researchers continuously reflect at each stage of the research project, remaining attentive to the influence of their own experiences and biases throughout all research and analysis phases. For instance, MG utilized a reflective journal [ 56 ] to document personal perspectives after each interview, consistently reminding herself to avoid preconceived notions.

Second, the selection of participants considered factors that might influence college students to develop different understandings of Chinese cultures to ensure the diversity of the participants. And, the total number of participants was determined based on thematic saturation [ 53 , 54 ]. In this study, after interviewing the F8(the 14th interviewee), no new significant themes emerged. Then, three more interviews were conducted (F9, F10, M7), and no significant themes emerged with the new respondents.

Third, the research performed investigator triangulation [ 57 ]. Independent researchers completed comparative analyses of individual findings, organized regular research team meetings to compare the analyses, and identified relevant themes. Moreover, XJ frequently reviewed interviews conducted by MG, her reactions to interviews, and the formulation of results. All the researchers discussed the coding and the corresponding original text until a consensus was obtained to bolster the study’s credibility and dependability.

Fourth, external audits are conducted to foster the accuracy or validity of a research study [ 57 ]. The research invited three experts above who have made achievements in Chinese culture and mental health to assess the appropriateness of naming, defining, and classifying the characteristics and themes in order to enhance the reliability of research findings.

College students’ understanding of Chinese culture

The interviewees’ understanding of Chinese culture was focused on the following four main aspects, and the participant’s identifier follows quotations.

Firstly, Chinese culture is undoubtedly distinct from other countries. For example, F1 believes that “Chinese culture is not just some fixed dynasties in history, or language, or what some literati or educators or some people said, it refers to some patterns of behavior or some ideas that distinguish people from other countries” (F1-66) and is unique to China (M3-110).

Secondly, Chinese culture includes both traditional and modern Chinese new cultures (e.g., revolutionary spirit, M2-95, M4-151, M7-85). Moreover, it is argued that Chinese culture is the essence of what has been left behind through history, including all aspects that have been handed down from ancient times to the present (M1-99; M5-128), and that it is a continuous transmission (F2-72, F4-92, F5-170, F7-137; F9-181; M6-132) and a fusion of the old and the new (F7-142). Chinese culture is implicitly formed and constantly influences and permeates everyone or their lives (F3-134; F7-138; M1-102; M3-111).

Thirdly, Chinese culture is a macro concept, encompassing both intangible and physical aspects. Intangible aspects include thoughts, spirits, and qualities (M2-95, M4-151, M5-131). The physical component includes not only literary works such as poetry (as perceived by all respondents) but also Chinese language and writing (Chinese characters, F2-75; oracle bone inscriptions, F9-184; calligraphy, F2-77, F5-170, F8-94), architecture (F3-148; F10-98), costume (F3-141; F10-101), and folkloric performances (drama, F2 -74; shadow puppets, F5-168; martial arts, F7-141), gastronomy (M5-132), art (painting, F8-93; paper-cutting, M1-100, M2-96, F5-169; china, M2-97; F2-75), traditional festivals and customs (M3-107; F3-138; F5-166; F7-140; F0-97. M7-87) and many others.

Fourthly, some important historical and modern figures mainly reflect Chinese culture’s ideological and spiritual aspects. For example, the famous statesman and literary figure Wen Tianxiang of the late Southern Song dynasty, whose poems “Everyone must die; let me but leave a loyal heart shining in the pages of history books” showed the interviewees his righteousness (M4-122), resilient, his moral integrity (F6-77), and his fearlessness in dedicating his life to his country (M2-72). There is also Zhou Enlai’s ambitious pursuit of “Reading for the rise of China” (M4-62), Mao Zedong’s sense of family and country and the importance he attached to learning (M5-43), and Qian Xuesen’s strict demands on himself during his research (M4-126). The interviewees also made many references to literary figures, such as Li Bai, a poet of the Tang dynasty, whom several interviewees mentioned for his free and ease in the face of frustration (M2-92, M6-30), and his ability to show his spontaneous side in life and learn things spontaneously(M5-54). As well as the ambition of Du Fu showed in his poem “When you are standing on the peak, you are on top of the world” (M5-36), and his sense of responsibility (M1-91, F3-56) reflected in his other poem, “To Emperor Yao and Shun, and to make the customs simple again” (M1-91, F3-56). They also talked about Su Shi’s open-mindedness (F8-79; M6-9) and cheerfulness (M5-29) in the face of adversity, who is a famous poet, calligrapher, gourmet, and hydraulic expert in the Northern Song Dynasty; and also the inner peace(M6-15) and indifference (F3-53) of Tao Yuanming (a famous idyllic poet in the Eastern Jin Dynasty) from his poem “I pick fence side asters at will; carefree I see the southern hill,” and so on.

In addition, the spirit of Chinese culture is also reflected in some allusions and some historical events in ancient and modern times, for example, “Mencius’ mother moves her home three times to better her son’s education” (F1-60), “Che Yin makes use of the light of fireflies or the reflected light by the snow to study” and “Kuang Heng dug a small hole on the wall in order to get some light from the neighbor’s house to read books” (F1-61; F8-34). These allusions convey the importance of studying hard even when conditions are limited. Also, the revolutionary spirit of the May Fourth Movement shows that young people are not afraid of sacrifice (M4-29), and the New Democratic and Industrial Revolution embodied the unity of the Chinese people (M7-91).

Characteristics of mentally healthy college students based on Chinese culture

There are eighteen characteristics of mentally healthy college students based on participants’ understanding of Chinese culture as described above, which is coded into five core themes: (1) value pursuit, (2) life attitude, (3) interpersonal ideal, (4) behavior ability, and (5) self-cultivation. It can be seen that the vast majority of the mental health characteristics reflect traditional Chinese culture, which is constantly being passed down and changed, with the remainder reflecting the influence of modern Chinese culture. The five themes and corresponding characteristics are shown in Table  2 . The results are presented below, and the participant’s identifier follows quotations.

Value pursuit

Value pursuit refers to an individual’s understanding and practice of life ideals and beliefs after integrating social consciousness, such as worldview, life view, and values. Participants described that mentally healthy college students based on Chinese culture have strong beliefs and goal pursuits of contributing to the motherland. They exhibit profound loyalty towards their motherland, viewing its service as their sacred duty, and are steadfast in their resolve to contribute through bold exploration, even in the face of daunting challenges or the prospect of personal sacrifice. This theme directly reflects the Chinese Confucian culture of “Self-cultivation is the starting point of several steps moving outward. The next step is managing family affairs, followed by governing the state. The final step is moving to provide peace and sound governance to all under heaven” and “To be the first in the country to worry about the affairs of the state and the last to enjoy oneself.” The following three subthemes were identified regarding students’ value pursuit.

(1) Loving their motherland and identifying with their culture

First and foremost, mentally healthy college students love their country and are firmly convinced that they want to identify with it. Twelve interviewees emphasize that mentally healthy college students should embody love for their country, cultural identification, and a profound sense of belonging and national pride. On the one hand, they are patriotic and loyal to their motherland and have high moral characters. For example, one participant said, “ like the patriotism in Yue Fei (a famous military man, strategist, calligrapher, poet, and national hero in Chinese history, and was the first of the Four generals rebuilding the Song dynasty). His patriotism and loyalty are also what a mentally healthy college student should have ” (#M6-54).

On the other hand, they identify with the country, nation, and culture from the heart and are proud of the motherland. Another participant said, “ Mentally healthy college students should have a real sense of cultural identity. Furthermore, a Chinese should identify with the traditional Chinese culture …… ” (#F3-110).

(2) Having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time

In addition, mentally healthy college students have a firm sense of mission and responsibility to the motherland. Ten interviewees assert that mentally healthy college students should exhibit a sense of national responsibility, ambitious aspirations, and a readiness to devote themselves to their homeland wholeheartedly. Mentally healthy college students should have ambitious ambitions. As M1-75 said: “ ‘To ordain conscience for Heaven and Earth, to secure life and fortune for the populace, to carry on lost teachings of ancient sages, to build peace for posterity’ (Zhang Zai: Heng Qu Yi Shuo), which can also reflect the looks of a mentally healthy college student. ”

The most important thing is to be willing to contribute to their motherland, even at the expense of oneself. Another participant said, “ Mentally healthy college students do not think about personal gains and losses too much but put their country and nation before themselves, ……, ‘Death is not my concern should it benefit the country. How can I pick and choose for my loss or gains?’ (Lin Zexu) …… ” (#M7-22).

(3) Daring to criticize, explore, and innovate

At the same time, mentally healthy college students have the quest and conviction to keep climbing to the top. Sixteen interviewees believe that mentally healthy college students are enterprising, daring to criticize, explore, and innovate to contribute to their country’s development. Mentally healthy college students are active, enterprising, and have goals and plans. One participant said, “ I think mentally healthy college students should have goals and plans for themselves ” (#M6-3). They also have critical thinking and exploratory spirit and will keep innovating. As F7 said, “ If you are a mentally healthy college student, you also need some innovative spirit to break through …… ” (#F7-59). Also, they are willing to explore and contribute to the country’s development, as M4 said: “ Mentally healthy college students should be like Qian Xuesen (also known as Tsien Hsue-she), who has a strong spirit of patriotism. He devoted himself to scientific research, and after countless attempts and explorations, he finally launched the first atomic bomb for China …… ” (#M4-124).

Life Attitude

Life attitude is an individual’s understanding and reaction to things that happen in daily life. Participants highlighted that maintaining a positive, optimistic, dialectical, and open-minded stance towards setbacks and challenges is a key characteristic of mentally healthy college students. This theme directly reflects Chinese culture: “Someday, with my sail piercing the clouds, I will mount the wind, break the waves, and traverse the vast, rolling sea.” and “It is blessed to suffer losses.” The following four subthemes regarding students’ life attitudes were identified.

(1) Loving life and being positive

Mentally healthy college students hold positive attitudes about life. Fourteen interviewees believe that mentally healthy college students exhibit optimistic attitudes toward life. Mentally healthy college students approach life optimistically, viewing it as brimming with hope. As F9 mentioned, “ I think I am mentally healthy because I am quite positive and optimistic about life, and I will face it positively even if there are some bad things ” (#F9-149). Moreover, they love life and experience life from their heart, “ I think mentally healthy college students can live a good life. Particularly, they can still maintain a love for life, have something they want to do, have the energy to fight or to live. ” (#M2-2). They always think life is full of meaning. As F1 said, “ I think some of the cases (of mental ill health) are because they have lost hope in life and do not want to do anything ” (#F1-47).

(2) Staying positive and having the ability and quality to cope with hardships

Mentally healthy college students possess a positive attitude towards suffering and setbacks. All interviewees believe that mentally healthy college students have a positive view and the qualities of coping with suffering when facing life difficulties. They will not shy away from adversity; instead, they proactively address issues, surmount obstacles, and manage them with composure. When facing difficulties or setbacks, mentally healthy college students maintain constructive beliefs. As one participant said: “ ‘Just as heaven keeps moving forward vigorously, a man of virtue should strive continuously to strengthen himself’ (The Change of Book). And ‘When Heaven intends to confer a great responsibility upon a person, it first visits his mind and will with suffering, toils his sinews and bones, subjects his body to hunger, exposes him to poverty and confounds his projects. Through this, his mind is stimulated, his nature strengthened, and his inadequacies repaired’ (Mencius). A mentally healthy college student should be like as described in these statements. ” (#F9-25).

They also exhibit the qualities to cope with hardships, such as striving continuously to strengthen themselves, being indomitable, resilient, enterprising, and so on. “ I think indomitable also reflects the self-control mentioned earlier, that is, they will not give up even after experiencing more difficulties ” (#M4-136).

Furthermore, they can analyze and resolve problems amid adversity and challenges, effectively overcoming them. “ For a long time, when my friends and I encounter setbacks, crises, or challenges, I always use this phrase to encourage myself and others to handle it calmly, ‘to be unchanged in front of the collapse of the mountain Tai, and to face danger without being surprised when it suddenly comes in front of you.’ ” (#M7-6).

(3) Being flexible and dialectical

Mentally healthy college students have a dialectical attitude towards life. Ten interviewees noted that mentally healthy college students demonstrate critical thinking skills by approaching situations objectively, comprehensively, and dialectically. These dialectical concepts, attitudes, and behaviors when facing negative things in life are also characteristics of mentally healthy college students. One participant said, “ Mentally healthy college students should be as objective and comprehensive as possible when dealing with things ” (#F3-118). They do not dwell on the present and have a positive attitude toward the future, “ There are plenty of fish in the sea. Do not miss the whole forest because of a tree. Even if you are sad about a breakup, do not cling to the past, but try to live a new life ” (#M7-12).

Furthermore, they think dialectically and believe that all sufferings have its reward. As F1 said: “ A saying goes that ‘Someday This Pain Will Be Useful to You,’ which means that it is not always bad to suffer Loss; think long term. For example, one may sometimes feel that their interests are being threatened in interpersonal relationships. However, if they are particularly concerned about this, it will make them uncomfortable, while if they are generous or forgiving, their heart will become more open ” (#F1-24).

(4) Being inclusive and broad-minded

Mentally healthy college students have an open-minded attitude toward life. Sixteen interviewees believe mentally healthy college students are tolerant, broad-minded, and open-minded. Both for themselves and others, mentally healthy college students hold tolerant attitudes. A participant said, “ I may lack a little tolerance for others because I am always strict with myself, so I may sometimes be strict with others. So, from this point of view, I think my mental health level needs to be further improved ” (#M2-79). They are broad-minded (“ Be magnanimous, as the saying goes, ‘A prime minister’s mind should be broad enough for poling a boat,’ which is a sign of college students’ mental health, advising people to look at whatever things a little more openly ”, #F6-34).

Moreover, even in the face of life’s misfortunes, they are also very liberal and open-minded, able to accept them openly. As M6 mentioned, “ One should also have positive and healthy perceptions. Su Shi, a famous poet, calligrapher, gourmet, and hydraulic expert in the Northern Song Dynasty, openly accepted the fact that he was deprived of his official position. Instead of being depressed daily, he lived an easy and interesting life, free and relaxed ” (#M6-9).

Interpersonal ideal

Interpersonal ideals refer to the pursuit and aspiration of individuals to achieve the best in interpersonal communication and good relationships. According to these interviewees, the characteristics of mentally healthy college students can be divided into general and specific interpersonal relationships. Regarding general interpersonal relationships, mentally healthy college students are friendly and kind, and their interactions with others are harmonious and comfortable. When navigating specific relationships like those with parents, they are filial but have rational thinking; in terms of friendship and romantic partnerships, they pursue ideal and pure relationships. This theme is a direct reflection of Chinese culture: “benevolence,” “harmony is precious,” “The relations between men of virtue are plain like water,” “filial piety,” and so on. The following four subthemes were identified regarding students’ interpersonal ideals.

1） Being benevolent and kind

Mentally healthy college students are benevolent and kind in their interactions with others. Thirteen interviewees believe mentally healthy college students are kind-hearted, compassionate, sincere, caring, and helping others without discrimination. Mentally healthy college students are benevolent and have compassion for others; as M7 mentioned, “ When I met beggars on the road, …… whether they are pretending or be, I am always willing to give them some money…… ” (#M7-54). They are kind-hearted (“ I think a person should be at least kind-hearted; he may have that kind of empathy inside, have that kind of emotion for either other people or animals, ……, and have a softer heart, which also reflects the mental health of college students ,” #F6-45). They treat people gently and friendly (“ Laozi and Confucius look gentler than others, I feel that this characteristic in them also indicates the mental health of college students ,” #M3-73).

Furthermore, they are helpful and kind to others. As one participant said, “ Imagine this: You’re in a crowd, and a bike tumbles to the ground. Everyone is looking around, unsure of what happened. Now, you’re caught in a bind: Should you lend a hand or stay back to avoid being wrongly accused? Despite the chance of misunderstanding, I feel it’s crucial to step up and help. Ignoring the situation just doesn’t sit right with me—it goes against everything I believe in. ” (#F5-161).

2） Interpersonal harmony and comfort

Mentally healthy college students have a harmonious and comfortable interpersonal state. All interviewees agree that mentally healthy college students exhibit pleasant character and interpersonal adeptness, adhere to fundamental Chinese cultural values, and maintain a more harmonious and comfortable relational environment compared to their peers. Mentally healthy college students experience interpersonal harmony and comfort; one interviewee said, “ A mentally healthy college student has better interpersonal relationships, ……and has a comfortable social state ” (#F1-17). In interpersonal interaction, they prioritize harmony (“ I quite agree with the saying ‘Peace is of paramount importance. Since we are studying together, it is important to take care of each other and try to understand each other ”, #M3-49). Besides, they have good interpersonal interactions (“ ones’ mental health, I think, also shows more in whether they can deal with interpersonal relationships with people around them, …… whatever kind of people may meet, they can deal with the relationship well ”, #F6-9).

Moreover, they appreciate others (“ If other people have gained a certain amount of academic achievement, …… if he is (mentally) healthy, he may be happy for others’ success, achievement ”, #M7-33). Also, they can resolve conflicts or contradictions in interpersonal relationships (“ There is no perfect person; for example, if they cause harm to others, they can recognize their mistakes and apologize timely and honestly ,” #M6-101).

Furthermore, they follow many guidelines to create a harmonious and comfortable interpersonal state. As F3 mentioned, “ I think, when it comes to some unimportant things, it is important not to bother others like that…… one should have the sense of proportion ” (#F3-39).

3） Having a soul mate

Mentally healthy college students seek to have a soul mate in specific friendships or romantic partnerships. Nine interviewees suggest that mentally healthy college students possess the ability and quality to communicate and empathize with others on a deep spiritual level and form corresponding friendships or romantic relationships. Whether in friendship or romantic relationships, mentally healthy college students have the correct attitude toward interaction, as F8 said, “ For example, Zeng Gong and Wang Anshi (both politicians of the Northern Song Dynasty), …… They become good friends for life not based on interests, but on their appreciation of each other, and the same values, which I think mental health of college students should always be ” (#F8-67).

They emphasize the spiritual level of communication more than pursuing each other’s company. They have a more high-quality and pure relationship, in friendship or romantic relationships. As F6 said: “ ‘The friendship of a noble person is as pure as water.’ (Chuang-Tzu). Put simply, relationships should be genuine and straightforward, free from fame-seeking or ulterior motives; Just like the story of Boya and Ziqi, mentally healthy students might find a companion who truly gets them, connecting on a spiritual and empathetic level…… ” (#F6-38). It is the same with romantic relationships, as M6 mentioned, “ When you read the poem of Su Shi, for example, ‘Ten years parted, one living, one dead; Not thinking; Yet never forgetting; A thousand Li from her lonely grave; I have nowhere to tell my grief……’ The affection between him and his wife is so deep that it is enviable ” (#M6-42).

4） Showing filial respect to parents appropriately

Mentally healthy college students have rational conceptions of filial piety towards their parents and appropriate, respectful behavior. Eleven interviewees believe mentally healthy college students are filial and rational in their interactions with their parents. Mentally healthy college students show filial piety to their parents appropriately. On the one hand, they practice filial piety by accompanying their parents, communicating more with them, caring for them, repaying them, and so on. As F5 mentioned, “ ‘Our bodies—to every hair and bit of skin—are received by us from our parents’ (Xiao Jing). Mentally healthy college students are grateful and respectful, often care for their parents, and spend more time with them ” (#F5-109).

On the other hand, they also have rational thinking rather than unprincipled obedience regarding filial piety’s “cognition” aspect. As one participant said, “ Not just any kind of filial piety, that is, you should have your thinking and judgment…… ” (#F3-105). Another participant said, “ Proper filial piety is an aspect of college students’ mental health, not that they are obedient to their parents. When they disagree with parents, they can communicate more with parents and let themselves be understood ” (#M5-102).

Behavior ability

Behavior ability refers to the ability of an individual to behave appropriately. According to these interviewees, mentally healthy college students have a variety of behavioral abilities, such as adapting to different environments, learning well, and regulating their emotions. This theme directly reflects the Chinese culture: “Those who obey heaven survive, and those who defy heaven perish,” “learn without thinking is reckless, think without learning is dangerous,” and “When joy, anger, sorrow, and happiness are not yet expressed as a response to other things, they are in a state of balance. When they are expressed in words and deeds by the rites, harmony is achieved. “The following three subthemes were identified regarding students’ behavior ability.

(1) Adapting to the environment

Mentally healthy college students can adapt to the environment. Seven interviewees believe that mentally healthy college students can adapt to different environments. Adaptability is reflected on the one hand in the interpersonal aspects (“ There is also the adaptation to the university environment. Mentally healthy college students can integrate into groups and clubs, and actively participate in club activities ”, #F2-16). Also, they can adapt to different environments (“ I think social adaptability is quite important…… I went to work part-time this summer, but I feel that I have just been exposed to it ”, #F9-10). Moreover, they also show adaptability to adversity (“ I think mentally healthy college students also can adapt to adversity…… ”, #M5-70).

(2) Studying diligently and learning well

Mentally healthy college students can learn well. Thirteen interviewees suggest that mentally healthy college students exhibit a positive learning attitude, take ownership of their learning, maintain a continuous learning process, and demonstrate good study habits. They learn earnestly and diligently and have good learning attitudes (“ College students with good mental health will keep learning, have the initiative to learn, down-to-earth. Moreover, if they work by fits and starts (Cao Xueqin: The Dream of Red Mansions), there will not be a good result ”, #F5-64).

They also actively take responsibility for learning. As F10 said, “ Responsibility is fundamental. The primary task for students is studying. One should stay in one’s lane ” (#F10-83). Besides, they are good at learning (“ I think Lu Xun, who gave up medicine to pursue literature, …… has a powerful ability to learn ”, #F9-71). In addition, they study diligently and accumulate knowledge. As M2 mentioned, “ Since I have to prepare for the entrance examination, I have to memorize words and take lessons every day. That is, ‘But unless you pile up little steps, you can never journey a thousand li; unless you pile up tiny streams, you can never make a river or a sea.’ (Hsun-Tzu: Encouraging Learning), …… I realized that what I do daily is important ”, #M2-93).

(3) Being emotionally appropriate and can regulate emotions

Mentally healthy college students can regulate and manage their emotions. Nine interviewees posit that mentally healthy students display emotional appropriateness and stability, promptly and effectively managing their emotions. Emotions are often regarded as the signal light of mental health. Thus, mentally healthy college students are emotionally appropriate and relatively stable, “ A mentally healthy college student should be emotionally stable, …… ‘The master was mild, and yet dignified; majestic, and yet not fierce; respectful, and yet easy’ (The Analects). One should have a suitable emotion in which state ” (#F3-78).

Moreover, when encountering adverse events, they have the ability to regulate their emotions. As one participant mentioned, “ A mentally healthy college student can control his emotions and regulate his emotions ” (#F6-1). At the same time, they can adjust themselves in appropriate and healthy ways in time, “ when he meets some bad things, he can just communicate with others, exercise…… instead of drinking or even hurting himself ” (#F8-10).

Self-cultivation

Self-cultivation refers to the inner quality or state an individual constantly improves or achieves through long-term efforts and cultivation. According to the interviewees, mentally healthy college students advocate the continuous improvement of self-cultivation. They try to possess many excellent qualities of Confucianism, Buddhism, and Taoism and perfect them daily by having clear and objective self-knowledge and constantly reflecting on themselves to improve their cultivation. This is a direct reflection of the Chinese culture of “no end to learning” and “Seeing the virtuous and thinking of the wise, seeing the unwise and introspecting”, and so on. The following four subthemes regarding students’ self-cultivation were identified.

(1) Having an objective, positive perception of oneself and can accept one’s mediocrity

The constant improvement of mentally healthy college students’ self-cultivation first requires a clear perception of oneself. Eleven interviewees believe mentally healthy college students have a positive, comprehensive, and clear understanding of themselves. They know their strengths and weaknesses and can accept their mediocre and weak sides, “ For example, an Olympic weightlifter, he can only lift 50 pounds, but he had to go lift 100 pounds…… A mentally healthy person should clearly understand themselves and do according to one’s abilities… ”, #F8-33). They also have a positive view of themselves, “ ‘All things in their being are good for something’ (Li Bai: Invitation to Wine); one should not think too lightly of themselves when disillusioned. They can certainly play their usefulness in life, cannot improperly belittle oneself ” (#F9-35). Furthermore, they can also accept their mediocrity and weakness, “ I think there is also a significant point, which is to accept their mediocrity gradually…… ” (#F1-8).

(2) Being confident and also modest

The constant improvement of mentally healthy college students’ self-cultivation also requires an objective perception of oneself. Thirteen interviewees believe that mentally healthy college students are confident and able to stick to what they believe is correct while also being modest. According to a participant, mentally healthy college students believe in themselves, “ This point of believing in oneself in Qian Xuesen is probably also what a mentally healthy college student should have…… ”, #M4-128). They are assertive and can stand firm on their ideas (“ When faced with two choices, mentally healthy college students listen to others’ opinions and at the same time stick to their ow n,” #F4-77). At the same time, they are also modest (“ A saying goes that, ‘Modesty helps one go forward, whereas conceit makes one lag.’ In my opinion, mentally healthy students may not be so proud of themselves……”, #F5-36). Furthermore, they are not overly confident or modest (“Both confidence and modesty in a mentally healthy college student are appropriate and balanced, that is, I think it is necessary to be confident but also modest……, ” #F7-109).

(3) Focusing on introspection and contemplation to align with the sages

Mentally healthy college students improve themselves through constant introspection. Ten interviewees believe mentally healthy college students focus on introspection and are strict with themselves. They constantly check the gaps to seek progress and expand their horizon. Specifically, mentally healthy college students often reflect on themselves (“ ‘I daily examine myself on three points……’ (The Analects) which I think reflects the mental health of college students, that is, whether you are doing your best in the team…… ”, F2-35). They are also strict with themselves, “ As the sayings go, ‘You cannot expect a better world without cleaning your room first,’ although Du Fu (a famous poet of the Tang Dynasty) is said to be very talented, if one cannot do small things well, like cleaning the house, he can do nothing else well ” (#M5-52).

Moreover, they make constant progress and look to the virtuous, “ ‘When you see a person of virtue and capability, you should think of emulating and equaling the person; when you see a person of low caliber, you should reflect on your weak points’ (The Analects). Mentally healthy people also constantly learn from the strengths of others and reflect on their weaknesses ” (#M2-34).

(4) Possessing good qualities advocated by Confucianism, Buddhism, and Taoism, which coexist harmoniously

The highest level of self-cultivation for mentally healthy college students is to possess many good qualities of Confucianism, Buddhism, and Taoism, which together become the characteristics of mentally healthy college students. Sixteen interviewees suggest that mentally healthy college students exhibit strong moral characteristics and virtues from Confucianism, Buddhism, and Taoism, all coexisting harmoniously. Mentally healthy college students have the excellent qualities of Taoism, such as being calm and bland, indifferent to fame and fortune, and peaceful and happy. As the participants said, “ This sense of ordinariness, which I think may also be a necessity for mental health…… ” (#F7- 34); “ Mentally healthy college students are calm and relaxed, take the rough with the smooth; they have confidence in themselves and take it easy ” (#M7-35).

Moreover, they have the excellent virtues of Confucianism, such as benevolence, righteousness, rites, wisdom, and good faith. As F3 said, “ Mentally healthy college students must be good in these virtues, like ‘loyalty, filial piety, rites, wisdom, good faith, and courage’…… ” (#F3-90). Another participant mentioned, “ After comparing so many fictional characters, it is hard for me to use words to describe him (Qiao Feng), …… very filial and loyal, very righteous, …… doing things very fairly, … … ”, #M6-59).

Besides, they also obtain the main qualities of Buddhism, such as gratitude and kindness (“ ‘Moral character can be built by accumulating goodness’ (Hsun-Tzu: Encouraging Learning). A mentally healthy college student does good deeds, such as attending activities as a volunteer…… ” #F2-30). As F9 said, “ Also, mentally healthy college students often remember others’ kindness and are grateful, and then be nice to others, as the saying goes, ‘You throw a peach to me, I give you a white jade for friendship.’ (The Book of Songs) ”, #F9 -112).

The study identified five themes and 18 characteristics of mentally healthy college students within Chinese culture. These characteristics are deeply rooted in Chinese traditions, highlighting yin-yang balance and moral cultivation. They related closely to college students’ identity, learning stage, and age. Contrasting with characteristics of other cultural backgrounds, they showcase the impact of Chinese culture on college students, validating and expanding the theory of sociocultural models.

Comparison with previous studies

Firstly, compared to existing research on the characteristics of mentally healthy college students, this study presents novel findings and unique insights. Consistent with other related studies rooted in Chinese culture, both this study and previous research accentuate that the characteristics of mentally healthy college students encompass facets such as self-awareness, interpersonal relationships, emotional regulation, and positive learning traits. For instance, Wang (1992) posited that mentally healthy college students exhibit characteristics focusing on self-awareness, interpersonal adeptness, and emotional regulation [ 32 ]. Similarly, Zeng (2021) described the characteristics of mentally healthy college students, highlighting their emotional state, academic performance, and interpersonal skills [ 33 ].

Some characteristics revealed in our study diverge from those proposed in prior research concerning their specific connotations. Taking emotional regulation as an example, the research of Zeng (2021) and Wang (1992) primarily emphasized affirming positive emotions. They depicted mentally healthy college students as “positively emotional and controllable” or “possess the capacity to coordinate and manage emotions effectively, sustaining a positive mood.” In contrast, the characteristic identified in this study of “being emotionally appropriate and can regulate emotions” not only encompasses positive emotions but also includes negative feelings, emphasizing the timely and moderate expression of both. This directly reflects the Confucian concept of “Zhongyong” (doctrine of the mean) in Chinese culture, which advocates for moderation in all things, whether positive or negative. Therefore, it is evident that college students’ mental health is closely intertwined with the concept of moderation. Individuals can achieve mental health in various aspects by expressing emotions moderately, whether positive or negative.

Furthermore, this study has identified characteristics not previously mentioned by Chinese scholars, such as “showing filial respect to parents appropriately.” Filial piety is a unique social behavior within Chinese culture, embodying a comprehensive and intricate ethical framework [ 58 ]. Chinese society dramatically emphasizes family values, where treating parents well and acknowledging their upbringing is paramount. Therefore, if one is not filial, one cannot be said to be mentally healthy. However, with the evolution of societal norms, the essence of filial piety has transformed. Recent research reveals that contemporary society no longer adheres to traditional interpretations of filial piety solely through obedience to parents [ 59 ]. This shift signifies that mentally healthy college students now approach filial piety differently, manifesting altered perspectives, attitudes, and behaviors toward this concept. In ancient China, departing from one’s hometown to pursue education and personal growth was discouraged, as staying by one’s parents’ side was deemed the epitome of filial piety. As Confucius stated, “While the father and mother are living, do not wander afar” ( The Analects ). However, today, individuals are encouraged to venture afar to contribute meaningfully to their country and society [ 60 ]. As a result, modern manifestations of filial piety among mentally healthy college students involve not just reverence, care, and support for their parents but also underscore the significance of preserving autonomy and independence while fulfilling their familial duties.

Secondly, upon comparing our findings with research from other cultural backgrounds, it becomes apparent that our results diverge significantly from those of Western culture but align closely with research outcomes from Africa and Asia.

In the West, the understanding of mental health emphasizes enhancing personal belonging, satisfaction, and well-being, which is very different from Chinese culture, which emphasizes self-sacrifice and self-elimination [ 61 ]. Although this study was conducted in a qualitative study of a group of college students in very good mental health, a research perspective similar to Maslow’s research on self-actualizers, there were significant differences in the specific characteristics of these healthy individuals in different cultures. In particular, this study did not address the characteristics of self-actualizers noted by Maslow, such as “the mystic experience: the peak experience” and “philosophical, unhostile sense of humor,” which emphasize excellent personal features. The characteristics identified from this study emphasize individuals’ relationships with the country and family. Such as “loving their motherland and identifying with their culture,” “having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time,” and “Showing filial respect to parents appropriately.” These characteristics are the direct expression of Chinese culture in terms of devoting oneself to the country and being filial to parents, which were not found in the results of Maslow’s study.

On the other hand, this study aligns more closely with research findings from African and Asian cultural backgrounds. For example, in the view of caregivers in Africa and Asia, mentally healthy individuals are people who contribute to the community and spend an enjoyable time in groups [ 28 ]. Thus, college students with good mental health can meet precise requirements at different levels: the individual and others, the individual and the family, and the individual and the nation, which is more of a relationship-oriented “big self” [ 62 ].

Thirdly, this research’s findings correspond with certain facets of the 24 character strengths and 6 virtues outlined in positive psychology, yet they also reveal disparities in specific aspects.

With the burgeoning of the positive psychology movement, some researchers have suggested that people with good mental health are not articulated merely as the absence of mental illness but as people who possess positive qualities, such as being highly resilient and well-being [ 63 ]. Seligman and colleagues summarized 6 virtues and 24 character strengths contributing to a good life [ 64 ], which have garnered wide attention. A point of convergence is that some positive psychological qualities emphasized by the characteristics identified in this study align with those highlighted in positive psychology. For instance, the characteristic of “being benevolent and kind” identified in this study emphasizes that mentally healthy college students are compassionate and kind. Similarly, one of the 6 virtues in positive psychology is humanity, which also focuses on kindness.

Nonetheless, notable distinctions exist between this study and the character strengths or virtues proposed by positive psychology. Firstly, in terms of the connotation of similar qualities, there are variations between the two. For example, the quality of “modesty” as a traditional Chinese virtue holds different implications than the Western perspective on “humility.” Modesty in Chinese culture carries much richer connotations than in the West, and core characteristics such as being open-minded, down-to-earth, and striving for improvement are unique to Chinese culture [ 65 ]. Additionally, while positive psychology views humility as an important but standalone character strength, this study found that mentally healthy college students are “being confident and also modest,” with modesty and confidence blending and coexisting harmoniously. This aligns with the encouragement of self-esteem, confidence, and self-improvement among the younger generation in China in recent years [ 66 ]. However, Chinese people still highly value modesty as a virtue while simultaneously emphasizing confidence. These seemingly contradictory qualities of confidence and modesty are valued, reflecting the dynamic balance of “yin and yang” in Chinese culture [ 67 ].

More importantly, this study has uncovered additional positive qualities beyond the 24 character strengths, such as “being inclusive and broad-minded”.These qualities carry strong moral attributes; in other words, possessing these moral qualities is essential for mental health. Confucianism emphasizes social morality, self-cultivation, and the development of a gentleman-like sage personality [ 68 ]. Self-cultivation is the basis for the ethical construction of family and society to perfect the ideal personality of governing the state and pacifying the world. The concept of “sageliness within and kingliness without” underscores this philosophy [ 69 ]. The characteristic “being inclusive and broad-minded” implies that mentally healthy college students exhibit tolerant and open-minded attitudes, embracing the principles of “Harmony, but Not Uniformity” and “The sea admits hundreds of rivers for its capacity to hold”(Chinese idioms) when encountering diverse viewpoints or adversity. Therefore, a mentally healthy college student possesses virtues such as tolerance and open-mindedness, showcasing solid moral values. In essence, college students’ mental health is intertwined with their moral attributes. A mentally healthy individual must embody essential moral qualities, which serve as markers of their overall well-being. Acknowledging the significance of moral virtues in defining and nurturing mental health among college students is crucial.

Validation and extension to the theory of sociocultural models

Firstly, this study validates the theory of sociocultural models. On one hand, this study confirms how culture influences individual psychology as proposed in the theory of sociocultural models. In this study, psychological entities represent the characteristics of mentally healthy college students that guide their thoughts, behaviors, and attitudes. According to the findings of this study, Chinese traditional culture plays a significant role in shaping these characteristics. For example, the patriotic sentiments of important historical figures such as Wen Tianxiang and Yue Fei, as well as the thoughts of traditional Chinese culture such as “Death is not my concern should it benefit the country. How can I pick and choose for my loss or gains?” (Lin Zexu: Two poems for family members on the way to the garrison ”) and “To ordain conscience for Heaven and Earth, to secure life and fortune for the populace, to carry on lost teachings of ancient sages, to build peace for posterity’ (Zhang Zai: Heng Qu Yi Shuo ) are internalized in the characteristics of “Having a sense of responsibility and mission and being willing to dedicate oneself to the country at any time.” The country cultivates college students as pillars of talent, and Confucianism teaches “To be the first in the country to worry about the affairs of the state and the last to enjoy oneself.” (Fan Zhongyan: The Yueyang Tower ). Thus, studying is not only for personal development but also for a sense of responsibility and contribution to the country, which arguably demonstrates the mental health characteristics of the specific group of college students with distinct traditional Chinese cultural connotations. Such findings align with the theory of sociocultural models, emphasizing how people internalize societal culture into their psychological entities to regulate their psychological activities.

On the other hand, this study validates how individual psychology externalizes and promotes the generation of new culture as proposed in the theory of sociocultural models. During China’s modernization, people have realized that only by daring to break through the shackles of existing ideas and exploring innovative development opportunities can the country move forward and develop sustainably. Many people have overcome difficulties and carried out the revolution, construction, and innovation in constructing Chinese socialism. Their love for the country and their sense of mission made them always meet the challenges of national reconstruction with high morale and perseverance [ 70 ]. Especially since the reform and opening-up, people’s minds have been fundamentally liberated, and the spring of scientific and technological progress has been ushered in. Their precious spiritual wealth, such as the characteristic of “daring to criticize, explore, and innovate,” has facilitated the development of new cultures like Chinese revolutionary and socialist cultures in modern times. Such findings align with the theory of sociocultural models, highlighting how group members externalize their psychological entities and transform them into new social cultures through social interactions and co-construction with existing social cultures.

Secondly, this study expands the content of the theory of sociocultural models. Due to a lack of specific pathways depicting the interaction between culture and psychology in the theory of sociocultural models, this study found that the significant carriers of interaction between culture and individual psychology are the spiritual world presented by historical and modern figures mentioned by the interviewees, as well as tangible worlds such as Chinese characters, poetry, martial arts, and art. These aspects of Chinese culture are internalized by college students as part of their psychological entities, guiding their words and actions and also shaping their perception of mental health. Conversely, the psychological entities of college students, such as the emergence of new concepts like “daring to criticize, explore, and innovate” in the construction of a new China, are transformed into emerging cultures, such as Chinese socialist culture through the role of figures like Qian Xuesen and stories as carriers.

Strengths, limitations, and future research

This study possesses several strengths. Firstly, it is the first attempt to systematically explore the characteristics of college students’ mental health entirely based on Chinese culture. The 18 identified characteristics directly convey or reflect aspects of Chinese culture, significantly enriching the comprehension of college students’ mental well-being within the context of Chinese culture. Secondly, the study adheres to the elite principle research paradigm by using elite samples as participants. Consequently, the outcomes comprehensively delineate the characteristics of mentally healthy college students possessing an excellent psychological state rooted in Chinese culture. These findings not only provide an ideal model for nurturing mental health among college students but also engender fresh insights into mental well-being, culminating in a novel benchmark for mental health standards. Thirdly, this study delves into the unique characteristics of mentally healthy college students within Chinese culture from the students’ firsthand experiences. In contrast, prior scholars predominantly offered personal opinions on the characteristics of mentally healthy individuals based on their experiences, lacking the direct perspectives of college students.

This study also has some limitations. As a qualitative study, the nature of this research inherently limits the applications of its conclusions. Focused primarily on college students, generalizing the findings to other groups in China (such as civil servants) may be constrained. Moreover, this study exclusively examines Chinese college students without conducting cross-cultural research. The absence of direct comparative studies fails to highlight variations in mentally healthy characteristics across diverse cultures. For instance, the absence of a comparative study between Chinese and students from other cultures (such as American college students) hindered exploration into the distinctive characteristics and differences of mentally healthy college students from varying cultures. Consequently, extrapolating the results of this study to other cultural contexts also has its limitations. Despite some similarities between Chinese culture and certain cultures in Asia and Africa, direct inferences also have significant constraints.

Furthermore, in terms of understanding culture, there is no conclusive definition of what culture is and what Chinese culture is. Scholars have put forward many understandings and definitions of Chinese culture from different perspectives. Understanding and defining Chinese culture are still in the exploratory stage, which challenges this study. The researcher’s understanding and mastery of existing relevant knowledge are somewhat limited regarding the formation of research results and the depth of analysis and discussion.

Future research could consider the following aspects. Firstly, a comparative study of the characteristics of mentally healthy people in different cultural groups can be conducted. Since individualistic/collectivistic cultures influence Americans and Chinese to be more expressive of private selves/collective selves, and religious cultures also influence individual self-esteem [ 71 ] and form religious selves [ 72 ]. Therefore, some comparative studies with students from different cultural backgrounds can be conducted in the future. For example, a comparative study with three groups of college students from the United States, China, and India can be considered to compare whether there are differences in the characteristics of mentally healthy college students from different cultures. Secondly, some quantitative studies can be considered. For example, future research could refine specific characteristics identified in the study, like “being flexible and dialectical,” for more specific operational definitions and develop a scale to measure the mental health of different groups to validate how these characteristics are manifested in university students or other groups so that more further research could be conducted using this new scale, which may help facilitate replication of the findings. Thirdly, based on continuous learning and accumulation of Chinese culture, future research can do in-depth excavation and exploration of the manifestation and nature of these mental health characteristics. For example, future research could select the characteristics reflecting the culture of filial piety or Zhongyong culture and explore how these cultures change and develop into mental health characteristics with the development of science and technology, the change of social structure, and the collision of Chinese and Western cultures, which may also be of great significance.

Practical implications

The Chinese culture has rich treasure resources and cultivated Chinese character traits, characteristics, and lifestyles. The results of this study show that many attitudes, ideas, and behaviors espoused by Chinese culture are manifestations of mental health. In particular, this study found the characteristics of mentally healthy college students based on Chinese culture, which is culturally applicable and more suitable for promoting the mental health of Chinese college students and can provide essential references and bases for mental health education and clinical practice.

On the one hand, this study can provide an overall theoretical framework for developing mental health courses for college students. Mental health courses are the most important and direct form of mental health education for college students in China, and they are also the primary way to improve the psychological quality of college students. The Ministry of Education requires colleges and universities to offer mandatory public courses on mental health for undergraduate students [ 73 ]. However, current mental health courses for Chinese college students rely mainly on Western mental health-related definitions, theories, and techniques for delivery [ 74 , 75 ]. The five themes and 18 characteristics discovered in this study are systematic, providing a comprehensive and systematic theoretical basis for college students’ mental health courses.

In particular, the five themes discovered in this study—values pursuit, life attitude, interpersonal ideals, behavioral ability, and self-cultivation—can be employed as the central pillars for teaching and setting objectives in a college student mental health course rooted in Chinese culture. Furthermore, the 18 identified characteristics can form each lesson’s fundamental content and learning goals, establishing a comprehensive framework. For instance, the characteristics “being confident and also modest” can be one of the key topics under the theme of “self-cultivation.” By comparing Western views of mental health (focused on confidence) with Chinese beliefs (valuing both confidence and modesty) and blending students’ self-awareness with Chinese cultural insights, the course can delve into the importance of confidence and modesty in Chinese culture. Strategies for cultivating these characteristics can be discussed, shedding light on the unique aspects of mental health development among college students within Chinese cultural contexts.

Secondly, this research offers valuable insights for fostering healthy personalities among college students in psychological counseling methods from the perspective of Chinese culture. On the one hand, this study has a guiding significance for setting goals in psychological counseling. Psychological counseling has traditionally emphasized decreasing negative emotions and boosting positive ones. Nevertheless, this study serves as a reminder for counselors to reassess this counseling objective. Throughout the counseling process, counselors should not only focus on diminishing negative emotions but also be wary of potential complications stemming from excessive positive emotions, stressing the importance of a moderate expression of positive and negative emotions.

On the other hand, the discoveries of this study could serve as a wellspring of inspiration for crafting indigenous approaches to psychological counseling. This research reveals that mentally healthy college students possess the characteristic “possessing good qualities advocated by Confucianism, Buddhism, and Taoism coexist harmoniously.” Within Chinese culture, the symbiotic interplay among Confucianism, Buddhism, and Taoism stands out as a cornerstone [ 76 ], where these philosophies coexist compatibly and mutually influence each other in shaping Chinese characters [ 77 ]. Future scholars might devise counseling methodologies rooted in the principle of harmonious coexistence found within Confucianism, Buddhism, and Taoism, potentially empowering individuals to bolster their mental health through these culturally embedded psychological counseling approaches.

This study explores the characteristics of mental health of college students with good psychological states from the perspective of Chinese culture and finds 18 characteristics, based on which five themes are formed: value pursuit, life attitude, interpersonal ideal, behavior ability, and self-cultivation. The 18 characteristics are typical of Chinese culture or its features, focusing on multi-level relationships with others, parents, and the country. They are also typical of Chinese culture with moral attributes, an emphasis on self-cultivation, a balance of Yin and Yang, and the coexistence of Confucianism, Buddhism, and Taoism. These findings help enrich the research on culture and mental health, highlight the Chinese cultural connotations of mental health, and help form an ideal standard of mental health for college students. Findings can serve as a theoretical foundation for improving the mental well-being of Chinese college students, act as a guiding light for enhancing students’ mental health, and be integrated directly into the mental health curriculum as course content. Mental health education activities based on these findings can help promote, maintain, and cultivate college students’ mental health literacy and healthy personalities to fulfill their potential and become the pillars of the nation.

Availability of data and materials

The datasets for this study are not readily available because they consist of interview data, for which confidentiality cannot be safeguarded. Therefore, the data will not be made available. Requests to access the datasets should be directed to XJ, [email protected].

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Acknowledgements

We appreciate Professor Tianjun Liu from Beijing University of Chinese Medicine, Professor Jianjun Zhu, and Professor Ming Li from Beijing Forestry University for their support in assessing the appropriateness of naming, defining, and classifying the 18 characteristics and five themes. We thank our research team and participants who shared their experiences and made this study possible. We thank Dr. Xiaofang Yao at Federation University Australia and Dr. Lixian Tu at Shanghai University of Political Science and Law for their support throughout the English translation.

This study is support by the BIT Research and Innovation Promoting Project (Grant No. 2022YCXY053).

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MG conducted the interviews, analyzed the data and wrote the manuscript under the guidance of XJ. XJ formulated this study and contributed to editing of the manuscript and critical revisions. WW assisted with the writing and editing of the final manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

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Guo, M., Jia, X. & Wang, W. How would you describe a mentally healthy college student based on Chinese culture? A qualitative research from the perspective of college students. BMC Psychol 12 , 207 (2024). https://doi.org/10.1186/s40359-024-01689-7

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