qualitative research data lacks validity

Qualitative Research: An Overview

• First Online: 24 April 2019

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• Yanto Chandra 3 &
• Liang Shang 4  

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Qualitative research is one of the most commonly used types of research and methodology in the social sciences. Unfortunately, qualitative research is commonly misunderstood. In this chapter, we describe and explain the misconceptions surrounding qualitative research enterprise, why researchers need to care about when using qualitative research, the characteristics of qualitative research, and review the paradigms in qualitative research.

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Qualitative research is defined as the practice used to study things –– individuals and organizations and their reasons, opinions, and motivations, beliefs in their natural settings. It involves an observer (a researcher) who is located in the field , who transforms the world into a series of representations such as fieldnotes, interviews, conversations, photographs, recordings and memos (Denzin and Lincoln 2011 ). Many researchers employ qualitative research for exploratory purpose while others use it for ‘quasi’ theory testing approach. Qualitative research is a broad umbrella of research methodologies that encompasses grounded theory (Glaser and Strauss 2017 ; Strauss and Corbin 1990 ), case study (Flyvbjerg 2006 ; Yin 2003 ), phenomenology (Sanders 1982 ), discourse analysis (Fairclough 2003 ; Wodak and Meyer 2009 ), ethnography (Geertz 1973 ; Garfinkel 1967 ), and netnography (Kozinets 2002 ), among others. Qualitative research is often synonymous with ‘case study research’ because ‘case study’ primarily uses (but not always) qualitative data.

The quality standards or evaluation criteria of qualitative research comprises: (1) credibility (that a researcher can provide confidence in his/her findings), (2) transferability (that results are more plausible when transported to a highly similar contexts), (3) dependability (that errors have been minimized, proper documentation is provided), and (4) confirmability (that conclusions are internally consistent and supported by data) (see Lincoln and Guba 1985 ).

We classify research into a continuum of theory building — >   theory elaboration — >   theory testing . Theory building is also known as theory exploration. Theory elaboration refers to the use of qualitative data and a method to seek “confirmation” of the relationships among variables or processes or mechanisms of a social reality (Bartunek and Rynes 2015 ).

In the context of qualitative research, theory/ies usually refer(s) to conceptual model(s) or framework(s) that explain the relationships among a set of variables or processes that explain a social phenomenon. Theory or theories could also refer to general ideas or frameworks (e.g., institutional theory, emancipation theory, or identity theory) that are reviewed as background knowledge prior to the commencement of a qualitative research project.

For example, a qualitative research can ask the following question: “How can institutional change succeed in social contexts that are dominated by organized crime?” (Vaccaro and Palazzo 2015 ).

We have witnessed numerous cases in which committed positivist methodologists were asked to review qualitative papers, and they used a survey approach to assess the quality of an interpretivist work. This reviewers’ fallacy is dangerous and hampers the progress of a field of research. Editors must be cognizant of such fallacy and avoid it.

A social enterprises (SE) is an organization that combines social welfare and commercial logics (Doherty et al. 2014 ), or that uses business principles to address social problems (Mair and Marti 2006 ); thus, qualitative research that reports that ‘social impact’ is important for SEs is too descriptive and, arguably, tautological. It is not uncommon to see authors submitting purely descriptive papers to scholarly journals.

Some qualitative researchers have conducted qualitative work using primarily a checklist (ticking the boxes) to show the presence or absence of variables, as if it were a survey-based study. This is utterly inappropriate for a qualitative work. A qualitative work needs to show the richness and depth of qualitative findings. Nevertheless, it is acceptable to use such checklists as supplementary data if a study involves too many informants or variables of interest, or the data is too complex due to its longitudinal nature (e.g., a study that involves 15 cases observed and involving 59 interviews with 33 informants within a 7-year fieldwork used an excel sheet to tabulate the number of events that occurred as supplementary data to the main analysis; see Chandra 2017a , b ).

As mentioned earlier, there are different types of qualitative research. Thus, a qualitative researcher will customize the data collection process to fit the type of research being conducted. For example, for researchers using ethnography, the primary data will be in the form of photos and/or videos and interviews; for those using netnography, the primary data will be internet-based textual data. Interview data is perhaps the most common type of data used across all types of qualitative research designs and is often synonymous with qualitative research.

The purpose of qualitative research is to provide an explanation , not merely a description and certainly not a prediction (which is the realm of quantitative research). However, description is needed to illustrate qualitative data collected, and usually researchers describe their qualitative data by inserting a number of important “informant quotes” in the body of a qualitative research report.

We advise qualitative researchers to adhere to one approach to avoid any epistemological and ontological mismatch that may arise among different camps in qualitative research. For instance, mixing a positivist with a constructivist approach in qualitative research frequently leads to unnecessary criticism and even rejection from journal editors and reviewers; it shows a lack of methodological competence or awareness of one’s epistemological position.

Analytical generalization is not generalization to some defined population that has been sampled, but to a “theory” of the phenomenon being studied, a theory that may have much wider applicability than the particular case studied (Yin 2003 ).

There are different types of contributions. Typically, a researcher is expected to clearly articulate the theoretical contributions for a qualitative work submitted to a scholarly journal. Other types of contributions are practical (or managerial ), common for business/management journals, and policy , common for policy related journals.

There is ongoing debate on whether a template for qualitative research is desirable or necessary, with one camp of scholars (the pluralistic critical realists) that advocates a pluralistic approaches to qualitative research (“qualitative research should not follow a particular template or be prescriptive in its process”) and the other camps are advocating for some form of consensus via the use of particular approaches (e.g., the Eisenhardt or Gioia Approach, etc.). However, as shown in Table 1.1 , even the pluralistic critical realism in itself is a template and advocates an alternative form of consensus through the use of diverse and pluralistic approaches in doing qualitative research.

Alvesson, M., & Kärreman, D. (2007). Constructing mystery: Empirical matters in theory development. Academy of Management Review, 32 (4), 1265–1281.

Article   Google Scholar  

Bartunek, J. M., & Rynes, S. L. (2015). Qualitative research: It just keeps getting more interesting! In Handbook of qualitative organizational research (pp. 41–55). New York: Routledge.

Google Scholar  

Brinkmann, S. (2018). Philosophies of qualitative research . New York: Oxford University Press.

Bucher, S., & Langley, A. (2016). The interplay of reflective and experimental spaces in interrupting and reorienting routine dynamics. Organization Science, 27 (3), 594–613.

Chandra, Y. (2017a). A time-based process model of international entrepreneurial opportunity evaluation. Journal of International Business Studies, 48 (4), 423–451.

Chandra, Y. (2017b). Social entrepreneurship as emancipatory work. Journal of Business Venturing, 32 (6), 657–673.

Corley, K. G., & Gioia, D. A. (2004). Identity ambiguity and change in the wake of a corporate spin-off. Administrative Science Quarterly, 49 (2), 173–208.

Cornelissen, J. P. (2017). Preserving theoretical divergence in management research: Why the explanatory potential of qualitative research should be harnessed rather than suppressed. Journal of Management Studies, 54 (3), 368–383.

Denis, J. L., Lamothe, L., & Langley, A. (2001). The dynamics of collective leadership and strategic change in pluralistic organizations. Academy of Management Journal, 44 (4), 809–837.

Denzin, N. K., & Lincoln, Y. S. (2011). Introduction. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (4th ed.). Thousand Oaks: Sage.

Doherty, B., Haugh, H., & Lyon, F. (2014). Social enterprises as hybrid organizations: A review and research agenda. International Journal of Management Reviews, 16 (4), 417–436.

Dubé, L., & Paré, G. (2003). Rigor in information systems positivist case research: Current practices, trends, and recommendations. MIS Quarterly, 27 (4), 597–636.

Easton, G. (2010). Critical realism in case study research. Industrial Marketing Management, 39 (1), 118–128.

Eisenhardt, K. M. (1989a). Building theories from case study research. Academy of Management Review, 14 (4), 532–550.

Eisenhardt, K. M. (1989b). Making fast strategic decisions in high-velocity environments. Academy of Management Journal, 32 (3), 543–576.

Fairclough, N. (2003). Analysing discourse: Textual analysis for social research . Abingdon: Routledge.

Book   Google Scholar  

Flyvbjerg, B. (2006). Five misunderstandings about case-study research. Qualitative Inquiry, 12 (2), 219–245.

Friese, S. (2011). Using ATLAS.ti for analyzing the financial crisis data [67 paragraphs]. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 12 (1), Art. 39. http://nbn-resolving.de/urn:nbn:de:0114-fqs1101397

Garfinkel, H. (1967). Studies in ethnomethodology . Malden: Blackwell Publishers.

Geertz, C. (1973). Interpretation of cultures . New York: Basic Books.

Gehman, J., Glaser, V. L., Eisenhardt, K. M., Gioia, D., Langley, A., & Corley, K. G. (2017). Finding theory–method fit: A comparison of three qualitative approaches to theory building. Journal of Management Inquiry, 27 , 284–300. in press.

Gioia, D. A. (1992). Pinto fires and personal ethics: A script analysis of missed opportunities. Journal of Business Ethics, 11 (5–6), 379–389.

Gioia, D. A. (2007). Individual epistemology – Interpretive wisdom. In E. H. Kessler & J. R. Bailey (Eds.), The handbook of organizational and managerial wisdom (pp. 277–294). Thousand Oaks: Sage.

Chapter   Google Scholar  

Gioia, D. (2019). If I had a magic wand: Reflections on developing a systematic approach to qualitative research. In B. Boyd, R. Crook, J. Le, & A. Smith (Eds.), Research methodology in strategy and management . https://books.emeraldinsight.com/page/detail/Standing-on-the-Shoulders-of-Giants/?k=9781787563360

Gioia, D. A., & Chittipeddi, K. (1991). Sensemaking and sensegiving in strategic change initiation. Strategic Management Journal, 12 (6), 433–448.

Gioia, D. A., Price, K. N., Hamilton, A. L., & Thomas, J. B. (2010). Forging an identity: An insider-outsider study of processes involved in the formation of organizational identity. Administrative Science Quarterly, 55 (1), 1–46.

Gioia, D. A., Corley, K. G., & Hamilton, A. L. (2013). Seeking qualitative rigor in inductive research: Notes on the Gioia methodology. Organizational Research Methods, 16 (1), 15–31.

Glaser, B. G., & Strauss, A. L. (2017). Discovery of grounded theory: Strategies for qualitative research . New York: Routledge.

Graebner, M. E., & Eisenhardt, K. M. (2004). The seller’s side of the story: Acquisition as courtship and governance as syndicate in entrepreneurial firms. Administrative Science Quarterly, 49 (3), 366–403.

Grayson, K., & Shulman, D. (2000). Indexicality and the verification function of irreplaceable possessions: A semiotic analysis. Journal of Consumer Research, 27 (1), 17–30.

Hunt, S. D. (1991). Positivism and paradigm dominance in consumer research: Toward critical pluralism and rapprochement. Journal of Consumer Research, 18 (1), 32–44.

King, G., Keohane, R. O., & Verba, S. (1994). Designing social inquiry: Scientific inference in qualitative research . Princeton: Princeton University Press.

Kozinets, R. V. (2002). The field behind the screen: Using netnography for marketing research in online communities. Journal of Marketing Research, 39 (1), 61–72.

Langley, A. (1988). The roles of formal strategic planning. Long Range Planning, 21 (3), 40–50.

Langley, A., & Abdallah, C. (2011). Templates and turns in qualitative studies of strategy and management. In Building methodological bridges (pp. 201–235). Bingley: Emerald Group Publishing Limited.

Langley, A., Golden-Biddle, K., Reay, T., Denis, J. L., Hébert, Y., Lamothe, L., & Gervais, J. (2012). Identity struggles in merging organizations: Renegotiating the sameness–difference dialectic. The Journal of Applied Behavioral Science, 48 (2), 135–167.

Langley, A. N. N., Smallman, C., Tsoukas, H., & Van de Ven, A. H. (2013). Process studies of change in organization and management: Unveiling temporality, activity, and flow. Academy of Management Journal, 56 (1), 1–13.

Lin, A. C. (1998). Bridging positivist and interpretivist approaches to qualitative methods. Policy Studies Journal, 26 (1), 162–180.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry . Beverly Hills: Sage.

Mair, J., & Marti, I. (2006). Social entrepreneurship research: A source of explanation, prediction, and delight. Journal of World Business, 41 (1), 36–44.

Nag, R., Corley, K. G., & Gioia, D. A. (2007). The intersection of organizational identity, knowledge, and practice: Attempting strategic change via knowledge grafting. Academy of Management Journal, 50 (4), 821–847.

Ozcan, P., & Eisenhardt, K. M. (2009). Origin of alliance portfolios: Entrepreneurs, network strategies, and firm performance. Academy of Management Journal, 52 (2), 246–279.

Prasad, P. (2018). Crafting qualitative research: Beyond positivist traditions . New York: Taylor & Francis.

Pratt, M. G. (2009). From the editors: For the lack of a boilerplate: Tips on writing up (and reviewing) qualitative research. Academy of Management Journal, 52 (5), 856–862.

Ramoglou, S., & Tsang, E. W. (2016). A realist perspective of entrepreneurship: Opportunities as propensities. Academy of Management Review, 41 (3), 410–434.

Sanders, P. (1982). Phenomenology: A new way of viewing organizational research. Academy of Management Review, 7 (3), 353–360.

Sobh, R., & Perry, C. (2006). Research design and data analysis in realism research. European Journal of Marketing, 40 (11/12), 1194–1209.

Stake, R. E. (2010). Qualitative research: Studying how things work . New York: Guilford Press.

Strauss, A., & Corbin, J. M. (1990). Basics of qualitative research: Grounded theory procedures and techniques . Thousand Oaks: Sage.

Vaccaro, A., & Palazzo, G. (2015). Values against violence: Institutional change in societies dominated by organized crime. Academy of Management Journal, 58 (4), 1075–1101.

Weick, K. E. (1989). Theory construction as disciplined imagination. Academy of Management Review, 14 (4), 516–531.

Welch, C. L., Welch, D. E., & Hewerdine, L. (2008). Gender and export behaviour: Evidence from women-owned enterprises. Journal of Business Ethics, 83 (1), 113–126.

Welch, C., Piekkari, R., Plakoyiannaki, E., & Paavilainen-Mäntymäki, E. (2011). Theorising from case studies: Towards a pluralist future for international business research. Journal of International Business Studies, 42 (5), 740–762.

Wodak, R., & Meyer, M. (Eds.). (2009). Methods for critical discourse analysis . London: Sage.

Yin, R. K. (1981). Life histories of innovations: How new practices become routinized. Public Administration Review, 41 , 21–28.

Yin, R. (2003). Case study research: Design and methods . Thousand Oaks: Sage.

Young, R. A., & Collin, A. (2004). Introduction: Constructivism and social constructionism in the career field. Journal of Vocational Behavior, 64 (3), 373–388.

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Chandra, Y., Shang, L. (2019). Qualitative Research: An Overview. In: Qualitative Research Using R: A Systematic Approach. Springer, Singapore. https://doi.org/10.1007/978-981-13-3170-1_1

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Qualitative Data – Strengths and Limitations

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Last Updated on September 1, 2021 by Karl Thompson

A summary of the theoretical, practical and ethical strengths and weaknesses of qualitative data sources such as unstructured interviews, participant observation and documents.

Examples of Qualitative Data

Theoretical strengths, practical strengths, ethical strengths, theoretical limitations, practical limitations, ethical limitations, nature of topic – when would you use it, when would you avoid using it, signposting.

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• Published: 13 September 2024

A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia

• Wolde Facha   ORCID: orcid.org/0000-0002-7463-524X 1 ,
• Takele Tadesse 1 ,
• Eskinder Wolka 1 &
• Ayalew Astatkie 2  

Scientific Reports volume  14 , Article number:  21440 ( 2024 ) Cite this article

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• Health care
• Medical research

Loss to follow-up (LTFU) from Option B plus, a lifelong antiretroviral therapy (ART) for pregnant women living with human immunodeficiency virus (HIV), irrespective of their clinical stage and CD4 count, threatens the elimination of vertical transmission of the virus from mothers to their infants. However, evidence on reasons for LTFU and resumption after LTFU to Option B plus care among women has been limited in Ethiopia. Therefore, this study explored why women were LTFU from the service and what made them resume or refuse resumption after LTFU in Ethiopia. An exploratory, descriptive qualitative study using 46 in-depth interviews was employed among purposely selected women who were lost from Option B plus care or resumed care after LTFU, health care providers, and mother support group (MSG) members working in the prevention of mother-to-child transmission unit. A thematic analysis using an inductive approach was used to analyze the data and build subthemes and themes. Open Code Version 4.03 software assists in data management, from open coding to developing themes and sub-themes. We found that low socioeconomic status, poor relationship with husband and/or family, lack of support from partners, family members, or government, HIV-related stigma, and discrimination, lack of awareness on HIV treatment and perceived drug side effects, religious belief, shortage of drug supply, inadequate service access, and fear of confidentiality breach by healthcare workers were major reasons for LTFU. Healthcare workers' dedication to tracing lost women, partner encouragement, and feeling sick prompted women to resume care after LTFU. This study highlighted financial burdens, partner violence, and societal and health service-related factors discouraged compliance to retention among women in Option B plus care in Ethiopia. Women's empowerment and partner engagement were of vital importance to retain them in care and eliminate vertical transmission of the virus among infants born to HIV-positive women.

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Introduction.

Lost to follow-up is a major challenge in the prevention of mother-to-child transmission (PMTCT) of HIV among HIV-exposed infants (HEI). Globally, about 1.5 million children under 15 years old were living with HIV, and 130,000 acquired the virus in 2022 1 . In the African region, an estimated 1.3 million children aged 0–14 were living with HIV at the end of 2022, and 109,000 children were newly infected 2 . Five out of six paediatric HIV infections occurred in sub-Saharan Africa in 2022 3 . Most of these infections are due to mother-to-child transmission (MTCT), accounting for around 90% of all new infections 4 , 5 . Without any intervention, between 15 and 45 percent of infants born to HIV-positive mothers are likely to acquire the virus from their mothers, with half dying before their second birthday without treatment 3 . Almost 70% of new HIV infections were due to mothers not receiving ART or dropping off during pregnancy or breastfeeding 3 .

In Ethiopia, the burden of MTCT of HIV is high, with a pooled prevalence ranging from 5.6% to 11.4% 6 , 7 , 8 , 9 , 10 . Ethiopia adopted the 2013 World Health Organization’s Option B plus recommendations as the preferred strategy for the PMTCT of HIV in 2013 11 , 12 , 13 , 14 . Accordingly, a combination of triple antiretroviral (ARV) drugs was provided for all HIV-infected pregnant and/or breastfeeding women, irrespective of their CD4 count and World Health Organization (WHO) clinical staging 11 , 13 . Besides, the drug type was switched from an EFV-based to a DTG-based regimen to enhance maternal life quality and decrease LTFU from Option B plus care 11 , 15 . The Efavirenz-based regimen consists of Tenofovir (TDF), Lamivudine (3TC), and Efavirenz (EFV), while the DTG-based regimen consists of TDF, 3TC, and DTG 13 , 15 , 16 . The change in regimen was due to better tolerability and rapid viral suppression, thereby retaining women in care and achieving MTCT of HIV targets 17 , 18 .

The trend of women accessing ART for PMTCT services increases, and new HIV infections decrease over time 3 , 19 , 20 . However, the effectiveness of Option B plus depends not only on service coverage but also on drug adherence and retention in care 4 , 15 , 21 . In this regard, quantitative studies conducted in Ethiopia showed that the prevalence of LTFU from Option B plus ranged from 4.2% to 18.2% 22 , 23 , 24 . Besides, the overall incidence of LTFU ranged from 9 to 9.4 per 1000 person-months of observation 25 , 26 , which is a challenge for the success of the program.

Qualitative studies also revealed that the main reasons for LTFU among women were maternal educational status, drug side effects, lack of partner and family support, lack of HIV status disclosure, poverty, discordant HIV test results, religious belief, stigma, and discrimination, long distance to the health facility, and history of poor adherence to ART 27 , 28 , 29 , 30 , 31 , 32 . Reasons for resumption to care were a decline in health status, a desire to have an uninfected child, and support from others 30 , 33 . Unless the above risk factors for LTFU are managed, the national plan to eliminate the MTCT of HIV by 2025 will not be achieved 34 .

Currently, because of its fewer side effects and better tolerability, a Dolutegravir (DTG)-based regimen is given as a preferred first-line regimen to pregnant and/or breastfeeding women to reduce the risk of LTFU 13 , 16 . The goal is to reduce new HIV transmissions and achieve Sustainable Development Goal (SDG) 3.3 of ending Acquired Immunodeficiency Syndrome (AIDS) as a public health threat by 2030 35 , 36 , 37 . As mentioned above, there is rich information on the prevalence and risk factors of LTFU among women on Option B plus care before the DTG-based regimen was implemented. Besides, the previous qualitative studies addressed the reasons for LTFU from providers’ and/or women’s perspectives rather than including mother support group (MSG) members. However, there was a lack of evidence that explored the reasons for LTFU and resumption of care after LTFU from the perspectives of MSG members, lost women, and healthcare workers (HCWs) providing care to women. Therefore, this study aimed to explore the reasons why women LTFU and resumed Option B plus care after the implementation of a DTG-based regimen in Ethiopia.

Materials and methods

Study design and setting.

An exploratory, descriptive qualitative study 38 was conducted between June and October 2023. This study was conducted in two regions of Ethiopia: Central Ethiopia and South Ethiopia. These neighbouring regions were formed on August 19, 2023, after the disintegration of the Southern Nations, Nationalities, and Peoples' Region after a successful referendum 39 . The authors included these nearby regions to get an adequate sample size and cover a wider geographic area. In these regions, 140 health facilities (49 hospitals and 91 health centers) provided PMTCT and ART services to 28,885 patients at the time of the study, of whom 1,236 were pregnant or breastfeeding women (675 in South Ethiopia and 561 in Central Ethiopia).

Participants and data collection

Study participants were women who were lost from PMTCT care or resumed PMTCT care after LTFU, MSG members, and HCWs provided PMTCT care. Mother support group members were HIV-positive women working in the PMTCT unit to share experiences and provide counselling services on breastfeeding, retention, and adherence, and to trace women when they lost Option B plus care 11 , 40 . Healthcare workers were nurses or midwives working in the PMTCT unit to deliver services to women enrolled in Option B plus care.

Purposive criterion sampling was employed to select study participants from twenty-one facilities (nine health centers and twelve hospitals) providing PMTCT service. A total of 46 participants were included in the study. The interview included 15 women (eleven lost and four resumed care after LTFU), 14 providers, and 17 MSG members. Healthcare workers and MSG members were chosen based on the length of time they spent engaging with women on Option B plus care; the higher the work experience, the more they were selected to get adequate information about the study participants. Including the study participants in each group continued until data saturation.

The principal investigator, with the help of HCWs and MSG members, identified lost women from the PMTCT registration books and appointment cards. A woman's status was recorded as LTFU if she missed the last clinic appointment for at least 28 days without documented death or transfer out to another facility 15 . Providers contacted women based on their addresses recorded during enrolment in Option B plus care, either via phone (if functional) or by conducting home visits for those unable to be reached. Informed written consent was obtained, and the research assistants conducted in-depth interviews at women’s homes or health facilities based on their preferences. After an interview, eleven women who lost care were counselled to resume PMTCT care, but nine returned to care and two refused to resume care. Besides, the principal investigator, HCWs, and MSG members identified women who resumed care after LTFU, called them via phone to visit the health facility at their convenience, and conducted the interview after obtaining consent. The research team covered transportation costs and provided adherence counselling to women post-interview. A woman resumed care if she came back to PMTCT care on her own or healthcare workers’ efforts after LTFU.

One-on-one, in-depth interviews were conducted with eligible MSG members and HCWs at respective health facilities. A semi-structured interview guide translated into the local language (Amharic) was used to collect data. The guide comprises the following constructs: why women are lost to follow-up from PMTCT care, what made them resume caring after LTFU, and why they did not resume Option B plus care after LTFU with probing questions (Supplementary File 1 ). The interview was conducted for 18 to 37 min with each participant, and the duration was communicated to study participants before the interview. The interview was audio-taped, and field notes were taken during the interviews.

Data management and analysis

Thematic analysis was used to analyze the data. The research assistants transcribed the interviews verbatim within 48 h of data collection and translated them from the local language (Amharic) to English for analysis. The principal investigator read the translated document several times to get a general sense of the content. An inductive approach was applied to allow the conceptual clustering of ideas and patterns to emerge. The authors preferred an inductive approach to analyze data since there were no pre-determined categories. The core meaning of the phrases and sentences relevant to the research aim was searched. Codes were assigned to the phrases and sentences in the transcript, which were later used to develop themes and subthemes. The subthemes were substantiated by quotes from the interviews. The interviews developed two themes: reasons for LTFU and the reasons for resumption after LTFU. The findings were triangulated from healthcare workers, MSG members, and client responses. Open code software version 4.03 was used to assist in data management, from open coding to the development themes and sub-themes.

Background characteristics of the study participants

We successfully interviewed 46 participants (14 providers, 15 women, and 17 MSG members) until data saturation. The mean (± standard deviation [SD]) of age was 25.53 (± 0.99) years for women, 32.5 (± 1.05) years for MSG members, and 32.2 (± 1.05) years for care providers. Three out of fifteen women did not disclose their HIV status to their partner, and 5/15 women’s partners were discordant. The mean (± SD) service years in the PMTCT unit were 10.3 (± 1.3) for MSG members and 3.29 (± 0.42) for care providers (Supplementary File 2 ).

Reasons for LTFU

Women who started ART to prevent MTCT of HIV were lost from care due to different reasons. Societal and individual-related factors and health facility-related factors were the two main dimensions that made women LTFU. The societal and individual-related factors were socioeconomic status, relations with husbands or families, lack of support, HIV-related stigma and discrimination, lack of awareness and perceived antiretroviral (ARV) side effects, and religious belief. Health facility-related factors such as lack of confidentiality, drug supply shortages, and inadequate service access led to women's loss from Option B plus care (Supplementary File 3 ).

Societal and individual-related factors

Socioeconomic status.

Lack of money to buy food was a major identified problem for women’s LTFU. Women who did not have adequate food to eat became undernourished, which significantly increased the risk of LTFU. Besides, they did not want to swallow ARV drugs with an empty stomach and thus did not visit health facilities to collect their drugs.

“My life is miserable. I have nothing to eat at my home. How would I take the drug on an empty stomach? Let the disease kill me rather than die due to hunger. This is why I stopped to take the medicine and LTFU.” (W-02, 30-year-old woman, divorced, daily labourer)

Women also disappeared from PMTCT care due to a lack of money to cover transportation costs to reach health facilities.

I need a lot of money to pay for transportation that I can’t afford. Sometimes I came to the hospital borrowing money for transportation. It is challenging to attend a follow-up schedule regularly to collect ART medications.” (W-11, 26-year-old woman, married, housewife)

Relationships with husbands and/or families

Fear of violence and divorce by sexual partners were identified as major reasons for the LTFU of women from PMTCT care. Due to fear of partner violence and divorce, women did not want to be seen by their partners while visiting health facilities for Option B plus care and swallowing ARV drugs. As a result, they missed clinic appointments, did not swallow the drugs, and consequently lost care.

“Due to discordant test results, my husband divorced me. Then I went to my mother's home with my child. I haven’t returned to take the drug since then and have lost PMTCT care.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Women did not disclose their HIV status to their discordant sexual partners and family members due to fear of stigma and discrimination. As a result, they did not swallow drugs in front of others and were unable to collect the drugs from health facilities.

“I know a mother who picked up her drugs on market day as if she came to the market to buy goods. No one knows her status. She hides the drug and swallows it when her husband sleeps.” (P-05, 29-year-old provider, female, 3 years of experience in the PMTCT unit) “I don't want to be seen at the ART unit. I have no reason to convince the discordant husband to visit a health facility after delivery. My husband kills me if he knows that I am living with HIV. This is why I discontinued the care.” (W-12, 18-year-old woman, married, housewife)

Women who lack partner support in caring for children at home during visits to health facilities find it difficult to adhere to clinic visits. Besides, women who did not get financial and psychological support from their partners faced difficulties in retaining care.

“Taking care of children is not business for my husband. How could I leave my two children alone at home? Or can I bring them biting with my teeth?” (W-05, 24-year-old woman, divorced, daily labourer) “ I didn't get any financial or psychological support from my husband. This made me drop PMTCT care.” (W-15, 34-year-old woman, married, daily labourer) Lack of support

Women living with HIV also had complaints of lack of support from the government, non-governmental organizations (NGOs), and HIV-related associations in cash and in kind. As a result, they were disappointed to remain in care.

"Previously, we got financial and material support from NGOs. Besides, the government arranged places for material production and goods sale to improve our economic status. However, now we didn't get any support from anywhere. This made our lives hectic to retain PMTCT care.” (W-06, 29-year-old woman, married, daily labourer)

HIV-related stigma and discrimination

Fear of stigma and discrimination by sexual partners, family members, and the community were mentioned as reasons for LTFU. Gossip, isolation, and rejection from societal activities were the dominant stigma experiences the women encountered. As a result, they did not want to be seen by others who knew them while collecting ARV drugs from health facilities, and consequently, they were lost from care and treatment.

“Despite getting PMTCT service at the nearby facility, some women come to our hospital traveling long distances. They don't want to be seen by others while taking ARV drugs there due to fear of stigma and discrimination by the community.” (P-10, 34-year-old provider, female, 2 years of experience in the PMTCT unit) “I am a daily labourer and bake ‘injera’ (a favourite food in Ethiopia) at someone's house to run my life. If the owner knew my status, I am sure she would not allow me to continue the job. In that case, what would I give my child to eat?” (W-12, 18-year-old woman, married, housewife) “My family did not know that I was living with the virus. If they knew it, I am sure they would not allow me to contact them during any events. Thus, I am afraid of telling them that I had the virus in my blood.” (W-05, 24-year-old woman, divorced, daily labourer)

Lack of awareness and perceived ARV side effects

Sometimes women went to another area for different reasons without taking ARV drugs with them. As per the Ethiopian national treatment guidelines 13 , they could get the drugs temporarily from any nearby facility that delivers PMTCT service. However, those who did not know that they could get the drugs from other nearby PMTCT facilities lost their care until their return. Others were lost, considering that ARV drugs harm the health status of their babies.

“One mother refused to retain in care after the delivery of a congenitally malformed baby (no hands at birth). She said, 'This abnormal child was born due to the drug I was taking for HIV. I delivered two healthy children before taking this medication. I don't want to re-use the drug that made me give birth to a malformed baby." (P-14, 32-year-old provider, female, 4 years of experience in the PMTCT unit)

When they did not encounter any health problems, women were lost from care, considering that they had become healthy and not in need of ART. Some of them also believe that having HIV is a result of sin, not a disease. Besides, some women believed that it was not possible to have a discordant test result with their partner.

“I didn't commit any sexual practice other than with my husband. His test result is negative. So, from where did I get the virus? I don't want to take the drug again.” (W-02, 30-year-old woman, divorced, daily labourer)

Religious belief

Some study participants mentioned religious belief as a reason for LTFU and a barrier to resumption after LTFU. Women discontinued Option B plus care due to their religious faith and refused to resume care as they were cured by the Holy Water and prayer by religious leaders.

“I went to Holy Water and was there for two months. My health status resumed due to prayer by monks and priests there. Despite not taking the drugs during my stay, God cured me of this evil disease with Holy Water. Now I am healthy, and there is no need to take the medicine again.” (W-09, 25-year-old woman, married, daily labourer)

Some women believed that God cured them and made their children free of the virus despite not taking ART for themselves and not giving ARV prophylaxis for their infants.

“Don't raise this issue again (when MSG asked to resume PMTCT care). I don't want to use the medicine. I am cured of the disease by the word of God, and my child is too. My God did not lie in His word.” (MSG-16, 32-year-old MSG, married, 16 years of service experience “Don't come to my home again. I don't have the virus now. I have been praying for it, and God cured me.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Health facility-related factors

Shortage of drug supply.

Women were not provided with all HIV-related services free of charge and were required to pay for therapeutic and prophylactic drugs for themselves and their infants. Most facilities face a shortage of prophylactic drugs, primarily cotrimoxazole and nevirapine syrups, for infants and women, and other drugs used to treat opportunistic infections. As a result, women lost their PMTCT care when told to buy prophylactic syrups for infants and therapeutic drugs to treat opportunistic infections for themselves.

“Lack of cotrimoxazole syrup is one of the major reasons for women to miss PMTCT clinic visits. In our facility, it was out of stock for the last three months. Women can't afford its cost due to their economic problems.” (MSG-03, 34-year-old provider, married, 12 years of service experience)

Inadequate service access

Most women travelled long distances to reach health facilities to get PMTCT service due to the absence of a PMTCT site in their area. Due to a lack of transportation access and/or cost, they were forced to miss clinic visits for PMTCT care.

“In this district, there were only two PMTCT sites. Women travelled long distances to get the service. To reach our facility, they must travel half a day or pay more than three hundred Ethiopian birr for a motorbike that some cannot afford. Thus, women lost the service due to inadequate service access.” (P-06, 30-year-old provider, male, 2 years of experience in the PMTCT unit)

In almost all facilities, PMTCT service was not given on weekends and holidays, despite women's interest in being served at these times. When ARV drugs were stocked out at their homes, they did not get the drugs if facilities were not providing services on weekends and holidays. When appointment date was passed, they lost care due to fear of health workers’ reactions.

Lack of confidentiality

Despite maintaining ethical principles to retain women in care, breaches of confidentiality by HCWs were one of the reasons for LTFU by women. Women were afraid of meeting someone they knew or that their privacy would not be respected. As a result, they lost from PMTCT care.

“I don’t want to visit the facility. All my information was distributed to the community by a HCW who counselled me at the antenatal clinic.” (W-09, 25-year-old woman, married, daily labourer)

Reasons for resumption after LTFU

Healthcare workers' commitment to searching for lost women, partners’ encouragement, and women’s health status were key reasons for resuming women's Option B plus services after LTFU.

Healthcare workers’ commitment

The majority of lost women resumed Option B plus care after LTFU when healthcare workers called them via phone or conducted home visits for those who could not be reached by phone call.

“We went to a woman’s home, who started ART during delivery and lost for four months, travelling about 90 kilometers. She just cried when she saw us. She said, 'As long as you sacrificed your time traveling such a long distance to return me and save my life, I will never disappear from care today onward.' Then, she returned immediately and was linked to the ART unit after completing her PMTCT program.” (P-13, 32-year-old provider, male, 5 years of experience in the PMTCT unit) “We have an appointment date registry for every woman. We waited for them for seven days after they failed to arrive on the scheduled appointment date. From the 8th day onward, we called them via phone if it was available and functional. If we didn't find them via phone, we conducted home visits and returned them to care.” (P-02, 24-year-old provider, female, 3 years of experience in the PMTCT unit)

Partner encouragement

Women who got their partners' encouragement did not drop out of PMTCT care. Besides, most women returned to care and restarted their ARV drugs due to partner encouragement.

“I did not disclose my HIV status to my husband, which was diagnosed during the antenatal period. I lost my care after the delivery of a male baby. When my husband knew my status, rather than disagreeing, he encouraged me to resume the care to live healthily and to prevent the transmission of HIV to our baby. This was why I resumed care after LTFU.” (W-14, 28-year-old woman, divorced, daily labourer)

Women’s health status

Some women returned to Option B plus care on their own when they felt sick and wanted to stay healthy.

“When I felt healthy, I was away from care for about eight months. Later on, when I sought medical care for the illness, doctors gave me medicine and linked me to this unit (the PMTCT unit). I returned because of sickness.” (W-06, 29-year-old woman, married, daily labourer)

This qualitative study assessed the reasons why women left the service and why they resumed care after LTFU. The study aimed to enhance program implementation by providing insights into reasons for LTFU and facilitators for resumption from women's, health professionals', and MSG members' perspectives. We found that financial problems, partner violence, lack of support, HIV-related stigma and discrimination, lack of awareness, religious belief, shortage of drug supply, poor access to health services, and fear of confidentiality breaches by healthcare providers were major reasons for LTFU from PMTCT care. Healthcare workers’ commitment, partner encouragement, and feeling sick made women resume PMTCT care after LTFU.

In this study, fear of partner violence and divorce were identified as major reasons that made women discontinue the PMTCT service. Men are the primary decision-makers regarding healthcare service utilization, and the lack of male involvement in the continuity of PMTCT care decreases maternal health service utilization, including PMTCT services 41 , 42 . In addition, economic dependence on men threatened women not to adhere to clinic appointments without their partner’s willingness due to fear of violence and divorce 28 . Thus, strengthening couple counselling and testing 13 , male involvement in maternal health services, and women empowerment strategies like promoting education, property ownership, and authority sharing to reach decisions on health service utilization were crucial to retaining women in PMTCT care. Besides, legal authorities and community and religious leaders should be involved in preventing domestic violence and raising awareness about the negative effects of divorce on child health.

Financial constraints to cover daily expenses were major reasons expressed by women for LTFU from PMTCT care. Consistent with other studies, this study revealed that a lack of money to cover transportation costs resulted in poor adherence to ART and subsequent loss of PMTCT care 27 , 29 , 43 . As evidenced by other studies, lack of food resulting from financial problems was a major reason for LTFU in the study area 30 . As a result, women prefer death to living with hunger due to food scarcity, which led them to LTFU. Besides, women of poor economic status spent more time on jobs to get money to cover day-to-day expenses than thinking of appointment dates. Thus, governments and organizations working on HIV prevention programs should strengthen economic empowerment programs like arranging loans to start businesses and creating job opportunities for women living with HIV.

Despite continuous information dissemination via different media, fear of stigma and discrimination was a frequently reported reason for LTFU among women in PMTCT care. Consistent with other studies conducted in Ethiopia and other African countries, our study identified that fear of stigma and discrimination by partners, family, and community members are significant risk factors for LTFU 27 , 28 , 29 , 31 . As a result, women did not usually disclose their HIV status to their partners 28 , 32 so that they could not get financial and psychological support. This highlights the need to intensify interventions by different stakeholders to reduce HIV-related stigma and discrimination in the study area. Women's associations, community-based organizations, and religious, community, and political leaders should continuously work on advocacy and awareness creation to combat HIV-related stigma and discrimination.

Our study revealed that a lack of support for women made them discontinue life-saving ARV drugs. In developing countries like Ethiopia, most women living with HIV have low socio-economic status to run their lives, and thus they need support. However, as claimed by the majority of study participants, the government and organizations working on HIV programs were decreasing support from time to time. This was in line with qualitative studies such that lack of support by family members or partners 27 was identified as a barrier to adherence to and retention in PMTCT care 27 , 28 , 29 , 30 , 32 . Organizations working on HIV programs need to design strategies so that poor women get support from partners, family members, the community, religious leaders, and the government to stay in PMTCT care. Moreover, some women thought incentives and support must be given to retain them in Option B plus care. Thus, HCWs should inform women during counselling sessions that they should not link getting PMTCT care to incentives or support.

Women infected with HIV want to be healthy and have HIV-free infants, which could be achieved by proper utilization of recommended therapy as per the protocol 27 , 43 . However, women’s religious beliefs were found to interfere with adherence to the recommended treatment protocol, made them LTFU, and refused resumption after LTFU. Although religious belief did not oppose the use of ARV drugs at any time, women did not take the medicine when they went to Holy Water and prayer. As evidenced by previous studies, lost women perceived that they were cured of the disease with the help of God and refused to resume PMTCT care 27 , 30 . This finding suggests the need for sustained community sensitization about HIV and its treatment, engaging religious leaders. They need to inform women on ART that taking ARV drugs does not contradict religious preaching, and they should not discontinue the drug at any religious engagement.

Once on ART, women should not regress from care and treatment due to problems related to the facility. Unlike the study conducted in Malawi, which reported a shortage of drugs as not a cause of LTFU 29 , in the study area there was a shortage of drugs and supplies to give appropriate care to women and their infants and to retain them in care. They did not get all services related to HIV free of charge and were requested to pay for them, including the cotrimoxazole syrup given to their infants. The finding was consistent with the study conducted in Malawi, where the irregular availability of cotrimoxazole syrup was mentioned as a risk factor for LTFU 32 .

On some occasions, there may also be a shortage of ARV prophylaxis (Nevirapine and Zidovudine syrups) at some facilities for their infants that they couldn’t get from private pharmacies. Services related to PMTCT care were expected to be free of charge for mothers and their infants throughout the care. Ensuring an adequate supply of prophylactic and therapeutic drugs should be considered to prevent the MTCT of HIV and control the spread of the disease among communities via appropriate resource allocation. Facilities should have an adequate supply of ARV prophylaxis and should not request that women pay for diagnostic services. Besides, they always need to provide cotrimoxazole syrup free of charge for HIV-exposed infants.

Lack of awareness of a continuum of PMTCT care among women is a major challenge to retaining them in care. Women who experienced malpractice against standard care practice and had misconceptions about the disease were at higher risk for LTFU. Those women who forgot to take ARV drugs due to different reasons (maybe due to poor counselling) did not get the benefits of ART. Improved counselling and appropriate patient-provider interaction increase women’s engagement in care and reduce the risk of LTFU 28 , 44 . Thus, proper counselling on adherence, malpractice, and misconceptions should be strengthened by healthcare providers in PMTCT units to create optimal awareness for retention.

Maintaining clients’ confidentiality is the backbone of achieving HIV-related treatment goals. However, some women disappear from PMTCT care due to a lack of confidentiality by HCWs delivering the service. Although not large, women claimed a lack of privacy during counselling, and disclosing their HIV status in the community was practiced by some healthcare professionals. The finding was consistent with the study conducted in developing countries, including Ethiopia, where lack of privacy and fear regarding breaches of confidentiality by healthcare workers were identified as risk factors for LTFU 31 , 32 , 44 . Thus, HCWs should deliver appropriate counselling services and maintain clients’ confidentiality to develop trust among women.

The validity of the findings of this study was strengthened by the triangulating data collected from women, MSG members, and HCWs delivering PMTCT service. Besides, the study included women from the community who had already been lost from care during the study, which minimized the risk of recall bias. However, we recognized the following limitations. First, the study did not explore the husband’s perspective to validate the findings from women and HCWs. Second, the study may have different reasons for LTFU for women who were unreached or unwilling to participate compared to those who agreed to be interviewed. Thus, further studies are advised to include the husband’s perception to validate their concern and to address all women who have lost care.

Conclusions

Financial constraints to cover transportation costs, fear of partner divorce and violence, HIV-related stigma and discrimination, lack of psychological support, religious belief, shortage of drug supply, inadequate service access, and breach of confidentiality by HCWs were major reasons for women’s lost. Healthcare workers’ commitment to searching for lost women, partners’ encouragement to resume care, and women’s desire to live healthily were explored as reasons for resumption after LTFU. Women empowerment, partner engagement, involving community and religious leaders, awareness creation on the effect of HIV-related stigma and discrimination for the community, and service delivery as per the protocol were of vital importance to retain women on care and resume care after LTFU. Besides, HCWs should address false beliefs related to the disease during counseling sessions to retain women in care.

Data availability

All data generated or analysed during this study are included in this article and its Supplementary Information files.

WHO. HIV statistics, globally and by WHO region, 2023. WHO, Epidemiological [Internet]. 2023;1–8. Available from: https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/overview

WHO. HIV/AIDS WHO Regional Office for Africa [Internet]. 2023. Available from: https://www.afro.who.int/health-topics/hivaids%0A

UNICEF. Elimination of mother-to-child transmission [Internet]. UNICEF Data: Monitoring the situation of children and women. 2023. Available from: https://data.unicef.org/topic/5 in 6 paediatric HIV infections occurred in sub-Saharan Africa in 2022emtct/

Frontières, M. S. Prevention of mother-to-child transmission of HIV. Medecins Sans Frontieres; 2020. p. 45.

FMoH. Health Sector Transformation Plan HSTP II(2020/21–2024/25). Vol. 25. Addis Ababa; 2021.

Facha, W., Tadesse, T., Wolka, E. & Astatkie, A. Magnitude and risk factors of mother-to-child transmission of HIV among HIV-exposed infants after Option B+ implementation in Ethiopia: A systematic review and meta-analysis. AIDS Res. Ther. 21 (1), 1–12 (2024).

Article   Google Scholar  

Endalamaw, A., Demsie, A., Eshetie, S. & Habtewold, T. D. A systematic review and meta-analysis of vertical transmission route of HIV in Ethiopia. BMC Infect. Dis. 18 (1), 1–11 (2018).

Kassa, G. M. Mother-to-child transmission of HIV infection and its associated factors in Ethiopia: A systematic review and meta-analysis. BMC Infect. Dis. 18 (1), 1–9 (2018).

Geremew, D., Tebeje, F. & Ambachew, S. Seroprevalence of HIV among pregnant women in Ethiopia: A systematic review and meta-analysis. BMC Res. Notes https://doi.org/10.1186/s13104-018-4022-1 (2018).

Article   PubMed   PubMed Central   Google Scholar  

Getaneh, T. et al. Early diagnosis, vertical transmission of HIV and its associated factors among exposed infants after implementation of the Option B + regime in Ethiopia : A systematic review and meta-analysis. IJID Regions 4 (September 2021), 66–74. https://doi.org/10.1016/j.ijregi.2022.05.011 (2022).

FMoH. National comprehensive and integrated prevention of mother-to-child transmission of HIV guideline. Addis Ababa; 2017. p. 97.

WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection:Recommendations for a public health approach. WHO Press. 2013. p. 251.

FMoH. National comprehensive PMTCT/MNCH integrated training manual. Addis Ababa: FMoH; 2021. p. 368–70.

FMoH. Competency-based national comprehensive PMTCT/MNCH training participant ’s manual. Addis Ababa; 2017. p. 357.

FMoH. National comprehensive HIV prevention, care, and treatment training participant manual. FMoH. 2021. p. 158.

USAID. Tenofovir, Lamivudine and Dolutegravir (TLD) Transition [Internet]. 2019. p. 2. Available from: https://www.fhi360.org/sites/default/files/media/documents/linkages-tld-transition-information.pdf

WHO. Updated recommendations on first-line and second-line antiretroviral regimens and post-exposure prophylaxis and recommendations on early infant diagnosis of HIV: interim guidelines. Geneva (2018).

Walmsley, S. L. et al. Dolutegravir plus Abacavir-Lamivudine for the treatment of HIV-1 Infection. N. Engl. J. Med. 369 (19), 1807–1818 (2013).

Article   CAS   PubMed   Google Scholar  

Astawesegn, F. H., Stulz, V., Conroy, E. & Mannan, H. Trends and effects of antiretroviral therapy coverage during pregnancy on mother-to-child transmission of HIV in Sub-Saharan Africa. Evidence from panel data analysis. BMC Infect. Dis. 22 (1), 1–13. https://doi.org/10.1186/s12879-022-07119-6 (2022).

Article   CAS   Google Scholar  

UNAIDS. Global HIV statistics [Internet]. 2023. Available from: https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf

FMoH. Implementation manual for DTG rollout and ART optimization in Ethiopia. Addis Ababa; 2019. p. 56.

Chaka, T. E. & Abebe, T. W. K. R. Option B+ prevention of mother-to-child transmission of HIV/AIDS service intervention outcomes in selected health facilities, Adama town, Ethiopia. HIV/AIDS Res. Palliat. Care 11 , 77–82 (2019).

Demissie, D., Bayissa, M., Maru, H. & Michael, T. Assessment of loss to follow-up (LTFU) and associated factors among pregnant women initiated antiretroviral under Option B+ in selected health facilities of West Zone Oromia, Ethiopia. EC Gynaecol. 8 (5), 314–321 (2019).

Google Scholar  

Almado, G. A. & King, J. E. Retention in care and health outcomes of HIV-exposed infants in a prevention of mother-to-child transmission of HIV (PMTCT) cohort in Addis Ababa, Ethiopia. HIV/AIDS Res. Palliat. Care 13 , 171–179 (2021).

Azanaw, M. M., Baraki, A. G. & Yenit, M. K. Incidence and predictors of loss to follow-up among pregnant and lactating women in the Option B+ PMTCT program in Northwestern Ethiopia: A seven-year retrospective cohort study. Front. Glob. Women’s Health. 4 (July), 1–12 (2023).

Tolossa, T., Kassa, G. M., Chanie, H., Abajobir, A. & Mulisa, D. Incidence and predictors of lost to follow-up among women under Option B+ PMTCT program in western Ethiopia: A retrospective follow-up study. BMC Res. Notes 13 (1), 1–7. https://doi.org/10.1186/s13104-019-4882-z (2020).

Kim, M. H. et al. Why did I stop? Barriers and facilitators to uptake and adherence to ART in option B+ HIV care in Lilongwe, Malawi. PLoS ONE 11 (2), 1–16 (2016).

Getaneh, T., Negesse, A. & Dessie, G. Experiences and reasons of attrition from option B+ among mothers under prevention of mother to child transmission program in northwest Ethiopia: Qualitative study. HIV/AIDS Res. Palliat. Care 13 (8), 851–859 (2021).

Mpinganjira, S., Tchereni, T., Gunda, A. & Mwapasa, V. Factors associated with loss-to-follow-up of HIV-positive mothers and their infants enrolled in HIV care clinic: A qualitative study. BMC Public Health 20 (1), 1–10 (2020).

Sariah, A. et al. Why did I stop? and why did I restart? Perspectives of women lost to follow-up in option B+ HIV care in Dar es Salaam, Tanzania. BMC Public Health 19 (1), 1–11 (2019).

Kassaw, M. W., Matula, S. T., Abebe, A. M., Kassie, A. M. & Abate, B. B. The perceived determinants and recommendations by mothers and healthcare professionals on the loss-to-follow-up in Option B+ program and child mortality in the Amhara region, Ethiopia. BMC Infect. Dis. 20 (1), 1–13 (2020).

Cataldo, F. et al. Exploring the experiences of women and health care workers in the context of PMTCT Option B plus in Malawi. J. Acquir. Immune Defic. Syndr. 74 (5), 517–522 (2017).

Masereka, E. M. et al. Increasing retention of HIV positive pregnant and breastfeeding mothers on Option B+ by upgrading and providing full time HIV services at a lower health facility in rural Uganda. BMC Public Health 19 (1), 1–6 (2019).

FMoH. National strategic plan for triple elimination of transmission of HIV , Syphilis , and Hepatitis B virus 2021–2025. Addis Ababa; 2021.

UNAIDS. The Path That Ends AIDS. The 2023 UNAIDs Global AIDS Update. 2023.

United Nations. Sustainable Development Goals (SDGs). SDG Resource Document [Internet]. 2015;1–19. Available from: https://sustainabledevelopment.un.org/content/documents/21252030 Agenda for Sustainable Development web.pdf

UNAIDS. The Global HIV/AIDS Epidemic [Internet]. 2023 [cited 2024 Feb 6]. Available from: https://www.kff.org/global-health-policy/fact-sheet/the-global-hiv-aids-epidemic/

Gray, J. R., Grove, S. K. & Sutherland, S. Burns and Grove’s Practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence [Internet]. 8th ed. Elsevier Inc; 2017. 70–72 p. Available from: https://lccn.loc.gov/2016030245

Wikepedia. South Ethiopia Regional State [Internet]. 2023. Available from: https://en.wikipedia.org/wiki/South_Ethiopia_Regional_State#cite_note-3

Sadeeh, R. The Role of Mother Support Groups. In: WHO [Internet]. 1993. p. 62–119. Available from: https://apps.who.int/iris/bitstream/handle/10665/58728/WHO_NUT_MCH_93.1_(part2).pdf

Farré, L. The Role of Men in the Economic and Social Development of Women [Internet]. World Bank Blogs. 2013. Available from: https://blogs.worldbank.org/developmenttalk/the-role-of-men-in-the-economic-and-social-development-of-women

Mondal, D., Karmakar, S. & Banerjee, A. Women’s autonomy and utilization of maternal healthcare in India: Evidence from a recent national survey. PLoS ONE 15 (12), 1-12 December. https://doi.org/10.1371/journal.pone.0243553 (2020).

Gugsa, S. et al. Exploring factors associated with ART adherence and retention in care under Option B+ strategy in Malawi: A qualitative study. PLoS ONE 12 (6), 1–18 (2017).

Kisigo, G. A. et al. “At home, no one knows”: A qualitative study of retention challenges among women living with HIV in Tanzania. PLoS ONE 15 , 1–15. https://doi.org/10.1371/journal.pone.0238232 (2020).

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Acknowledgements

The authors acknowledge the staff of the South Ethiopia and Central Ethiopia Regional Health Bureaus for their technical and logistic support. Moreover, the authors sincerely thank the research assistants who translated and transcribed the interview. The authors would also like to thank the study participants who were involved in the study.

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W.F. was involved in the study's conception, design, execution, data acquisition, analysis, interpretation, and manuscript drafting. T.T., E.W., and A.A. were involved in the project concept, guidance, and critical review of the article. All the authors have reviewed and approved the final manuscript and agreed to publish it in scientific reports.

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Facha, W., Tadesse, T., Wolka, E. et al. A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia. Sci Rep 14 , 21440 (2024). https://doi.org/10.1038/s41598-024-71252-2

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Strengths and Limitations of Qualitative and Quantitative Research Methods

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Saturation in qualitative research: exploring its conceptualization and operationalization

Benjamin saunders.

1 Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK

Tom Kingstone

Shula baker, jackie waterfield.

2 School of Health Sciences, Queen Margaret University, Edinburgh, EH21 6UU UK

Bernadette Bartlam

Heather burroughs, clare jinks.

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Introduction

In broad terms, saturation is used in qualitative research as a criterion for discontinuing data collection and/or analysis. 1 Its origins lie in grounded theory (Glaser and Strauss 1967 ), but in one form or another it now commands acceptance across a range of approaches to qualitative research. Indeed, saturation is often proposed as an essential methodological element within such work. Fusch and Ness ( 2015 : p. 1408) claim categorically that ‘failure to reach saturation has an impact on the quality of the research conducted’; 2 Morse ( 2015 : p. 587) notes that saturation is ‘the most frequently touted guarantee of qualitative rigor offered by authors’; and Guest et al. ( 2006 : p. 60) refer to it as having become ‘the gold standard by which purposive sample sizes are determined in health science research.’ A number of authors refer to saturation as a ‘rule’ (Denny 2009 ; Sparkes et al. 2011 ), or an ‘edict’ (Morse 1995 ), of qualitative research, and it features in a number of generic quality criteria for qualitative methods (Leininger 1994 ; Morse et al. 2002 ).

However, despite having apparently attained something of the status of orthodoxy, saturation is defined within the literature in varying ways—or is sometimes undefined—and raises a number of problematic conceptual and methodological issues (Dey 1999 ; Bowen 2008 ; O’Reilly and Parker 2013 ). Drawing on a number of examples in the literature, this paper seeks to explore some of these issues in relation to three core questions:

‘What?’—in what way(s) is saturation defined?

‘where and why’—in what types of qualitative research, and for what purpose, should saturation be sought, ‘when and how’—at what stage in the research is saturation sought, and how can we assess if it has been achieved.

In addressing these questions, we will explore the implications of different models of saturation—and the theoretical and methodological assumptions that underpin them—for the varying purposes saturation may serve across different qualitative approaches. In doing so, the paper will contribute to the small but growing literature that has critically examined the concept of saturation (e.g. Bowen 2008 ; O’Reilly and Parker 2013 ; Walker 2012 ; Morse 2015 ; Nelson 2016 ), aiming to extend the discussion around its conceptualization and use. We will argue not only for greater transparency in the reporting of saturation, as others have done (Bowen 2008 ; Francis et al. 2010 ), but also for a more thorough consideration on the part of qualitative researchers regarding how saturation relates to the research question(s) they are addressing, in addition to the theoretical and analytical approach they have adopted, with due recognition of potential inconsistencies and contradictions in its use.

In their original treatise on grounded theory, Glaser and Strauss ( 1967 : p. 61) defined saturation in these terms:

The criterion for judging when to stop sampling the different groups pertinent to a category is the category’s theoretical saturation . Saturation means that no additional data are being found whereby the sociologist can develop properties of the category. As he sees similar instances over and over again, the researcher becomes empirically confident that a category is saturated. He goes out of his way to look for groups that stretch diversity of data as far as possible, just to make certain that saturation is based on the widest possible range of data on the category.

Here, the decision to be made relates to further sampling, and the determinant of adequate sampling has to do with the degree of development of a theoretical category in the process of analysis. Saturation is therefore closely related to the notion of theoretical sampling—the idea that sampling is guided by ‘the necessary similarities and contrasts required by the emerging theory’ (Dey 1999 : p. 30)—and causes the researcher to ‘combine sampling, data collection and data analysis, rather than treating them as separate stages in a linear process’ (Bryman 2012 : p. 18).

Also writing from a grounded theory standpoint, Urquhart ( 2013 : p. 194) defines saturation as: ‘the point in coding when you find that no new codes occur in the data. There are mounting instances of the same codes, but no new ones’, whilst Given ( 2016 : p. 135) considers saturation as the point at which ‘additional data do not lead to any new emergent themes’. A similar position regarding the (non)emergence of new codes or themes has been taken by others (e.g. Birks and Mills 2015 ; Olshansky 2015 ). 3 These definitions show a change of emphasis, and suggest a second model of saturation. Whilst the focus remains at the level of analysis, the decision to be made appears to relate to the emergence of new codes or themes, rather than the degree of development of those already identified. Moreover, Urqhart ( 2013 ) and Birks and Mills ( 2015 ) relate saturation primarily to the termination of analysis, rather than to the collection of new data.

According to Starks and Trinidad ( 2007 : p. 1375), however, theoretical saturation occurs ‘when the complete range of constructs that make up the theory is fully represented by the data’. Whilst not wholly explicit, this definition suggests a third model of saturation with a different directional logic: not ‘given the data, do we have analytical or theoretical adequacy?’, but ‘given the theory, do we have sufficient data to illustrate it?’ 4

If we move outside the grounded theory literature, 5 a fourth perspective becomes apparent in which there are references to data saturation, rather than theoretical saturation (e.g. Fusch and Ness 2015 ). 6 This view of saturation seems to centre on the question of how much data (usually number of interviews) is needed until nothing new is apparent, or what Sandelowski ( 2008 : p. 875) calls ‘informational redundancy’ (e.g. Francis et al. 2010 ; Guest et al. 2006 ). Grady ( 1998 : p. 26) provides a similar description of data saturation as the point at which:

New data tend to be redundant of data already collected. In interviews, when the researcher begins to hear the same comments again and again, data saturation is being reached… It is then time to stop collecting information and to start analysing what has been collected.

Whilst several others have defined data saturation in a similar way (e.g. Hill et al. 2014 : p. 2; Middlemiss et al. 2015 ; Jackson et al. 2015 ), Legard et al. ( 2003 ) seem to adopt a narrower, more individual-oriented perspective on data saturation, whereby saturation operates not at the level of the dataset as a whole, but in relation to the data provided by an individual participant; i.e. it is achieved at a particular point within a specific interview:

Probing needs to continue until the researcher feels they have reached saturation, a full understanding of the participant’s perspective (Legard et al. 2003 : p. 152).

From this perspective, the researcher’s response to the data—through which decisions are made about whether or not any new ‘information’ is being generated—is not necessarily perceived as forming part of the analysis itself. Thus, in this model, the process of saturation is located principally at the level of data collection and is thereby separated from a fuller process of data analysis, and hence from theory.

Four different models of saturation seem therefore to exist (Table  1 ). The first of these, rooted in traditional grounded theory, uses the development of categories and the emerging theory in the analysis process as the criterion for additional data collection, driven by the notion of theoretical sampling; using a term in common use, but with a more specific definitional focus, this model could thus be labelled as theoretical saturation . The second model takes a similar approach, but saturation focuses on the identification of new codes or themes, and is based on the number of such codes or themes rather than the completeness of existing theoretical categories. This can be termed inductive thematic saturation . In this model, saturation appears confined to the level of analysis; its implication for data collection is at best implicit. In the third model, a reversal of the preceding logic is suggested, whereby data is collected so as to exemplify theory, at the level of lower-order codes or themes, rather than to develop or refine theory. This model can be termed a priori thematic saturation , as it points to the idea of pre-determined theoretical categories and leads us away from the inductive logic characteristic of grounded theory. Finally, the fourth model—which, again aligning with the term already in common use, we will refer to as data saturation —sees saturation as a matter of identifying redundancy in the data, with no necessary reference to the theory linked to these data; saturation appears to be distinct from formal data analysis.

Table 1

Models of saturation and their principal foci in the research process

‘Hybrid’ forms of saturation

Some authors appear to espouse interpretations of saturation that combine two or more of the models defined above, making its conceptualization less distinct. For example, Goulding ( 2005 ) suggests that both data and theory should be saturated within grounded theory, and Drisko ( 1997 : p. 192) defines saturation in terms of ‘the comprehensiveness of both the data collection and analysis’. Similarly, Morse’s view of saturation seems to embody elements of both theoretical and data saturation. She links saturation with the idea of replication, in a way that suggests a process of data saturation:

However, when the domain has been fully sampled – when all data have been collected – then replication of data occurs and, with this replication… the signal of saturation (Morse 1995 : p. 148).

Morse notes elsewhere that she is able to tell when her students have achieved saturation, as they begin to talk about the data in more generalized terms and ‘can readily supply examples when asked. These students know their data’ (Morse 2015 : p. 588). This too suggests a form of data saturation. However, Morse also proposes that saturation is lacking when ‘there are too few examples in each category to identify the characteristics of concepts, and to develop theory’ (Morse 2015 : p. 588). This perspective seems to be located firmly in the idea of theory development (as other parts of the quoted papers by Morse make clear), though a heavy emphasis is placed at the level of the data and the way in which the data exemplify theory, thereby seeming to evoke both data and theoretical saturation.

Hennink et al. ( 2017 ) go further, appearing to combine elements of all four models of saturation. They firstly identify ‘code saturation’, the point at which ‘no additional issues are identified and the codebook begins to stabilize’ ( 2017 : p. 4), which seems to combine elements of both inductive thematic saturation and data saturation. However, within this approach saturation is discussed as relating not only to codes developed inductively, but also to a priori codes, which echoes the third model: a priori thematic saturation. They go on to distinguish ‘code saturation’ from ‘meaning saturation’; in the latter, the analyst attempts to ‘fully understand conceptual codes or the conceptual dimensions of… concrete codes’ ( 2017 : p. 14). This focus on saturating the dimensions of codes seems more akin to theoretical saturation; however, their analysis remains at the level of codes, rather than theoretical categories developed from these codes, and Hennink et al. explicitly position their approach outside grounded theory methods.

Morse ( 2015 : p. 587) takes the view that saturation is ‘present in all qualitative research’ and as previously noted, it is commonly considered as the ‘gold standard’ for determining sample size in qualitative research, with little distinction between different types of qualitative research. We question this perspective, and would instead argue—as is suggested by the different models of saturation considered in the previous section—that saturation has differing relevance, and a different meaning, depending on the role of theory, a viewpoint somewhat supported by other commentators who have questioned its application across the spectrum of qualitative methods (Walker 2012 ; O’Reilly and Parker 2013 ; van Manen et al. 2016 ).

In a largely deductive approach (i.e. one that relies wholly or predominantly on applying pre-identified codes, themes or other analytical categories to the data, rather than allowing these to emerge inductively) saturation may refer to the extent to which pre-determined codes or themes are adequately represented in the data—rather like the idea of the categories being sufficiently replete with instances, or ‘examples’, of data, as suggested in the a priori thematic saturation model outlined above. Thus, in their attempt to establish an adequate sample size for saturation, Francis et al. ( 2010 ) refer explicitly to research in which conceptual categories have been pre-established through existing theory, and it is significant in this respect that they link saturation with the notion of content validity. In contrast, within a more inductive approach (e.g. the inductive thematic saturation and theoretical saturation models outlined above), saturation suggests the extent to which ‘new’ codes or themes are identified within the data, and/or the extent to which new theoretical insights are gained from the data via this process.

In both the deductive and the inductive approach, we can make sense of the role of saturation, however much it differs in each case, because the underlying approach to analysis is essentially thematic, and usually occurs in the context of interview or focus group studies involving a number of informants. It is less straightforward to identify a role for saturation in qualitative approaches that are based on a biographical or narrative approach to analysis, or that, more generally, include a specific focus on accounts of individual informants (e.g. interpretative phenomenological analysis). In such studies, analysis tends to focus more on strands within individual accounts rather than on analytical themes ; these strands are essentially continuous, whereas themes are essentially recurrent. Accordingly, Marshall and Long ( 2010 ) suggest that saturation was not appropriate in their study of maternal coping processes, based on narrative methods. Elsewhere, however, a less straightforward picture emerges. Hawkins and Abrams ( 2007 ) utilized saturation in the context of a study based on life-history interviews with 39 formerly homeless mentally ill men and women. The authors state: ‘Of the 39 participants, six did not complete a second interview because they were unavailable, impaired, or the research team felt the first interview had achieved saturation’ (p. 2035), suggesting that judgments of saturation were made within each participant’s account. Power et al. ( 2015 ) adopted a story-telling approach to women’s experience of post-partum hospitalization, and recruitment continued until data saturation, which was established through ‘the repetition of responses’ (p. 372). Analysis was thematic, and it is not clear whether saturation was determined in relation to themes across participants’ stories, or within individual stories. Similarly, in a study of osteoarthritis in footballers, based on interpretative phenomenological analysis, Turner et al. ( 2002 ) employed saturation, which was defined both in terms of the emergence of themes from the analysis and a ‘consensus across views expressed’ (p. 298), which suggests that, notwithstanding the interpretive phenomenological analysis perspective adopted, saturation was sought more across than within cases. Hale et al. ( 2007 : p. 91) argue, however, that saturation is not normally an aim in interpretative phenomenological analysis, owing to the concern to obtain ‘full and rich personal accounts’, which highlights the particular analytical focus within individual accounts in this approach, and van Manen dissociates saturation from phenomenological research more generally (van Manen et al. 2016 ).

Considering the various types of research in which saturation might feature helps to clarify the purposes it is intended to fulfil. When used in a deductive approach to analysis, saturation serves to demonstrate the extent to which the data instantiate previously determined conceptual categories, whereas in more inductive approaches, and grounded theory in particular, it says something about the adequacy of sampling in relation to theory development (although we have seen that there are differing accounts of how specifically this should be achieved). In narrative research, a role for saturation is harder to discern. Rather than the sufficient development of theory, it might be seen to indicate the ‘completeness’ of a biographical account. However, one could question whether the point at which a participant’s story is interpreted as being ‘complete’—having presumably conveyed everything seen to be relevant to the focus of the study—is, in fact, usefully described by the concept of saturation, given the distance that this moves us away from the operationalization of saturation in broadly thematic approaches. This might, furthermore, lead us to ask whether there is the risk of saturation losing its coherence and utility if its potential conceptualization and uses are stretched too widely.

The same issue is relevant with regard to a number of other, less obvious, purposes that have been proposed for saturation. For example, it has been claimed to demonstrate the trustworthiness of coding (Damschroder et al. 2007 )—but as saturation will be a direct and automatic consequence of one’s coding decisions, it is not clear how it can be an independent measure of their quality. Dubé et al. ( 2016 ) suggest that saturation says something about (though not conclusively) the ability to extrapolate findings, and Boddy ( 2016 : p. 428) claims that ‘once saturation is reached, the results must be capable of some degree of generalisation’; this seems to move us away from the notion of the theoretical adequacy of an analysis, and the explanatory scope of a theory, toward a much more empirical sense of generalizability. The use of saturation in these two cases could perhaps indicate a degree of confusion in some studies about the meaning of saturation and its purpose, even when taking into account the differing models of saturation outlined earlier. Therefore, we would suggest that for saturation to be conceptually meaningful and practically useful there should be some limit to the purposes to which it can be applied.

Perspectives taken on saturation

The perspective taken on what is meant by saturation within a given study will have implications for when it will be sought. Taking the fourth model of saturation identified earlier—the data saturation approach, as based on the notion of informational redundancy—it is clear that saturation can be identified at an early stage in the process, as from this perspective saturation is often seen as separate from, and preceding, formal analysis. Decisions about when further data collection is unnecessary are commonly based on the researcher’s sense of what they are hearing within interviews, and this decision can therefore be made prior to coding and category development. In a focus group study of HIV perceptions in Ghana, Ganle ( 2016 ) used the notion of saturation to determine when each focus group discussion should terminate. Such a decision would seem, however, to relate to only a very preliminary stage of analysis and is likely to be driven by only a rudimentary sense of any emergent theory. A similar point can be made in relation to Hancock el al.’s ( 2016 ) study of male nurses’ views on selecting a nursing speciality. They talk of logging each instance in which their focus group participants ‘discussed a theme’, with saturation then judged in relation to the number of times themes were discussed. Though not elaborated upon, this appears to imply a very narrow definition of a theme as something that can be somehow ‘observed’ during the course of a focus group. However, interpretations at this stage regarding what might constitute a theme, before even beginning to consider whether identified themes are saturated, will be superficial at best. Moreover, conclusions reached at this stage may not be particularly informative as regards subsequent theory development—pieces of data that appear to be very similar when first considered may be found to exemplify different theoretical constructs on detailed analysis, and correspondingly, data that are empirically dissimilar may turn out to have much in common theoretically. Judgments at this stage will also relate to a framework of themes and categories that is theoretically immature, and that may be subject to considerable modification; for example, the changes that may occur during the successive stages of open, selective and theoretical coding in grounded theory (Glaser 1978 ).

With regard to the second model identified, inductive thematic saturation, the fact that the focus is more explicitly on reaching saturation at the level of analysis—i.e. in relation to the (non-)emergence of new codes or themes—might suggest it will be achieved at a later stage than in data saturation approaches (notwithstanding the concurrent nature of data-collection and analysis in many qualitative approaches). However, focusing on the emergence or otherwise of codes rather than on their theoretical development still points us towards saturation being achieved at a relatively early stage. Hennink et al. ( 2017 ) highlight this in a study on patient retention in HIV care, in which they found that saturation of codes was achieved at an earlier point than saturation of the ‘dimensions, nuances, or insights’ related to codes. Hennink et al. argue that an approach to saturation relying only on the number of codes ‘misses the point of saturation’ ( 2017 : p. 15) owing to a lack of understanding of the ‘meaning’ of these codes.

In contrast to data saturation and inductive thematic saturation, the first model of saturation considered, theoretical saturation—as based on the grounded theory notion of determining when the properties of theoretical categories are adequately developed—indicates that the process of analysis is at a more advanced stage and at a higher level of theoretical generality. Accordingly, Zhao and Davey ( 2015 : p. 1178) refer to a form of saturation determined by ‘theoretical completeness’ and ceased sampling ‘when dimensions and gaps of each category of the grounded theory had been explicated,’ and Bowen ( 2008 ) gives a detailed account of how evidence of saturation emerged at the level of thematic categories and the broader process of theory construction.

Saturation as event or process

A key issue underlying the identification of saturation is the extent to which it is viewed as an event or a process. Commonly, saturation is referred to as a ‘point’ (e.g. Otmar et al. 2011 ; Jassim and Whitford 2014 ; Kazley et al. 2015 ), suggesting that it should be thought of as a discrete event that can be recognized as such by the analyst. Strauss and Corbin ( 1998 : p. 136), however, talk about saturation as a ‘matter of degree’, arguing that there will always be the potential for ‘the “new” to emerge’. They suggest that saturation should be more concerned with reaching the point where further data collection becomes ‘counter-productive’, and where the ‘new’ does not necessarily add anything to the overall story or theory. Mason ( 2010 ) makes a similar argument, talking of the point at which there are ‘diminishing returns’ from further data-collection, and a number of researchers seem to take this more incremental approach to saturation. Aiken et al. ( 2015 : p. 154), for example, refer in their interview study of unintended pregnancy to being ‘confident of having achieved or at least closely approached thematic saturation.’ Nelson ( 2016 ), echoing Dey’s ( 1999 ) earlier view, argues that the term ‘saturation’ is itself problematic, as it intuitively lends itself to thinking in terms of a fixed point and a sense of ‘completeness’. He thus argues that ‘conceptual depth’ may be a more appropriate term—at least from a grounded theory perspective—whereby the researcher considers whether sufficient depth of understanding has been achieved in relation to emergent theoretical categories.

On this incremental reading of saturation, the analysis does not suddenly become ‘rich’ or ‘insightful’ after that one additional interview, but presumably becomes rich er or more insightful. The question will then be ‘how much saturation is enough?’, rather than ‘has saturation occurred?’ 7 This is a less straightforward question, but one that much better highlights the fact that this can only be a matter of the analyst’s decision—saturation is an ongoing, cumulative judgment that one makes, and perhaps never completes, 8 rather than something that can be pinpointed at a specific juncture.

Uncertainty and equivocation

A desire to identify a specific point in time at which saturation is achieved seems often to give rise to a degree of uncertainty or equivocation. In a number of studies, saturation is claimed, but further data collection takes place in an apparent attempt to ‘confirm’ (Jassim and Whitford 2014 : p. 191; Forsberg et al. 2000 : p. 328) or ‘validate’ (Vandecasteele et al. 2015 : p. 2789) this claim; for example:

After the 10th interview, there were no new themes generated from the interviews. Therefore, it was deemed that the data collection had reached a saturation point. We continued data collection for two more interviews to ensure and confirm that there are no new themes emerging (Jassim and Whitford ( 2014 : pp. 190–191).

Furthermore, a reluctance to rely on evidence of saturation sometimes indicates that saturation is being used in at best an unclear, or at worst an inconsistent or incoherent, fashion. For example, Hill et al. ( 2014 : p. 2), whilst espousing the principle of saturation, seem not fully to trust it:

Saturation was monitored continuously throughout recruitment. For completeness we chose to fully recruit to all participant groups to reduce the chance of missed themes.

Similarly, Jackson et al. ( 2000 : p. 1406) claim that saturation had been established, but then appear to retreat somewhat from this conclusion:

Following analysis of eight sets of data, data saturation was established… however, two additional participants were recruited to ensure data saturation was achieved.

Constantinou et al. ( 2017 ) propose that, given the potential for uncertainty about the point at which saturation is reached, attention should focus more on providing evidence that saturation has been reached, than on concerns about the point at which this occurred. Thus, rather curiously, they propose that it ‘does not hurt to include all interviews from the initial sampling’ ( 2017 : p. 13). This view is inherently problematic, however, as not only does it imply that saturation is a retrospective consideration following the completion of data collection, rather than as guiding ongoing sampling decisions, but one could also argue that saturation loses its relevance if all data are included regardless of whether or not they contribute further insights or add to conceptual understanding. This approach appears to indicate a preoccupation with having enough data to show evidence of saturation, i.e. not too few interviews, rather than saturation aiding decisions about the adequacy of the sample.

Whilst the above suggests ambivalence towards assessing the point at which saturation is achieved, others report having made the conscious decision to continue sampling beyond saturation, appearing to seek additional objective evidence to bolster their sampling decisions. For instance, in investigating staff and patient views on a stroke unit, Tutton et al. ( 2012 : p. 2063) talk of how, despite having achieved saturation, ‘increased observation may have increased the degree of immersion in the lives of those on the unit’, whilst Naegeli et al. ( 2013 : p. 3) look to gain ‘more in-depth understanding… beyond the saturation point’. Similar points are made by Kennedy et al. ( 2012 : p. 859), who talk of looking for ‘novel aspects’ after the achievement of saturation, and Poletti et al. ( 2007 : p. 511), who propose the need to ‘fill gaps in the data’ following saturation. These examples suggest a view that there is something of theoretical importance that is not captured by saturation, though it is unclear from the explanations given as to exactly what this is. 9

Another indication of an ambivalent view taken on saturation is suggested by Mason’s ( 2010 ) observation that sample sizes in studies based on interviews are commonly multiples of ten. This suggests that, in practice, rules of thumb or other a priori guidelines are commonly used in preference to an adaptive approach such as saturation. Quite frequently, studies that adopt the criterion of saturation propose at the same time a prior sample size (e.g. McNulty et al. 2015 ; Long-Sutehall et al. 2011 ). In a similar way, Niccolai et al. ( 2016 ) sought saturation during their analysis, but also state (p. 843) that:

An a priori sample size of 30 to 40 was selected based on recommendations for qualitative studies of this nature… and the anticipated complexity and desired level of depth for our research questions.

Fusch and Ness ( 2015 : p. 1409) appear to endorse this somewhat inconsistent approach when advocating that the researcher should choose a sample size that has ‘the best opportunity for the researcher to reach data saturation’. 10

This tentative and equivocal commitment to saturation may reflect a practical response to the demands of funding bodies and ethics committees for a clear statement of sample size prior to starting a study (O’Reilly and Parker 2013 )—perceived obligations that, in practice, may be given priority over methodological considerations. However, it may also arise from the specific but somewhat uncertain logic that underlies saturation. Determining that further data collection or analysis is unnecessary on the basis of what has been concluded from data gathered hitherto is essentially a statement about the unobserved (what would have happened if the process of data collection and/or analysis had proceeded) based on the observed (the data collection and/or analysis that has taken place hitherto). Furthermore, if saturation is used in relation to negative case analysis in grounded theory (i.e. sources of data that may question or disconfirm aspects of the emergent theory) the logic becomes more tenuous—a statement about the unobserved based on the unobserved. 11 In either case, an uncertain predictive claim is made about the nature of data yet to be collected, and furthermore a claim that could only be tested if the decision to halt data collection were to be overturned. Additionally, the underlying reasoning makes specific assumptions about the way in which the analysis will generate theory, and the earlier in the process of theory development that this occurs the less warranted such assumptions may be. Accordingly, researchers who confidently propose saturation as a criterion for sampling at the outset of a study may become less certain as to how it should be operationalized once the study is in progress, and may therefore be reluctant to abide by it.

This paper has offered a critical reflection on the concept of saturation and its use in qualitative research, contributing to the small body of literature that has examined the complexities of the concept and its underlying assumptions. Drawing on recent examples of its use, saturation has been discussed in relation to three key sets of questions: What? Where and why? When and how?

Extending previous literature that has highlighted the variability in the use of saturation (O’Reilly and Parker 2013 ; Walker 2012 ), we have scrutinized the different ways in which it has been operationalized in the research literature, identifying four models of saturation, each of which appears to make different core assumptions about what saturation is, and about what exactly is being saturated. These have been labelled as: theoretical saturation, inductive thematic saturation, a priori thematic saturation, and data saturation. Moving forward, the identification and recognition of these different models of saturation may aid qualitative researchers in untangling some of the inconsistencies and contradictions that characterize its use.

Saturation’s apparent position as a ‘gold standard’ in assessing quality and its near universal application in qualitative research have been previously questioned (Guest et al. 2006 ; O’Reilly and Parker 2013 ; Malterud et al. 2016 ). Similarly, doubts have been raised regarding its common adoption as a sole criterion of the adequacy of data collection and analysis (Charmaz 2005 ), or of the adequacy of theory development: ‘Elegance, precision, coherence, and clarity are traditional criteria for evaluating theory, somewhat swamped by the metaphorical emphasis on saturation’ (Dey 2007 : p. 186). On the basis of such critiques, we have examined how saturation might be considered in relation to different theoretical and analytical approaches. Whilst we concur with the argument that saturation should not be afforded unquestioned status, polarization of saturation as either applicable or non-applicable to different approaches, as has been suggested (Walker 2012 ), may be too simplistic. Instead we propose that saturation has differing relevance, and a different meaning, depending on the role of theory, the analytic approach adopted, and so forth, and thus may usefully serve different purposes for different types of research—purposes that need to be clearly articulated by the researcher.

Whilst arguing for flexibility in terms of the purpose and use of saturation, we also suggest that there must be some limit to this range of purposes. Some of the ways in which saturation has been operationalized, we would suggest, risk stretching or diluting its meaning to the point where it becomes too widely encompassing, thereby undermining its coherence and utility.

When and how saturation may be judged to have been reached will differ depending on the type of study, as well as assumptions about whether it represents a distinct event or an ongoing process. The view of saturation as an event has been problematized by others (Strauss and Corbin 1998 ; Dey 1999 ; Nelson 2016 ), and we have explored the implications of conceptualizing saturation in this way, arguing that it appears to give rise to a degree of uncertainty and equivocation, in part driven by the uncertain logic of the concept itself—as a statement about the unobserved based on the observed. This uncertainty appears to give rise to inconsistencies and contradictions in its use, which we would argue could be resolved, at least in part, if saturation were to be considered as a matter of degree, rather than simply as something either attained or unattained. However, whilst considering saturation in incremental terms may increase researchers’ confidence in making claims to it, we suggest it is only through due consideration of the specific purpose for which saturation is being used, and what one is hoping to saturate, that the uncertainty around the concept can be resolved.

In highlighting and examining these areas of complexity, this paper has extended previous discussions of saturation in the literature. Whilst consideration of the concept has led some commentators to argue for the need for qualitative researchers to provide a more thorough and transparent reporting of how they achieved saturation in their research, thus allowing readers to assess the validity of this claim (Bowen 2008 ; Francis et al. 2010 ), our arguments go beyond this. We contend that there is a need not only for more transparent reporting, but also for a more thorough re-evaluation of how saturation is conceptualized and operationalized, including recognition of potential inconsistencies and contradictions in the use of the concept—this re-evaluation can be guided through attending to the four approaches we have identified and their implications for the purposes and uses of saturation. This may lead to a more consistent use of saturation, not in terms of its always being used in the same way, but in relation to consistency between the theoretical position and analytic framework adopted, allowing saturation to be used in such a way as to best meet the aims and objectives of the research. It is through consideration of such complexities in the context of specific approaches that saturation can have most value, enabling it to move away from its increasingly elevated yet uneasy position as a taken-for-granted convention of qualitative research.

Acknowledgements

This paper has been informed by discussions with members of the social sciences group of the Institute for Primary Care and Health Sciences at Keele University. TK is funded by South Staffordshire and Shropshire NHS Foundation Trust. CJ is partly funded by NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands (CLAHRC, West Midlands); the views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Compliance with ethical standards

Conflicts of interest.

All authors declare to have no conflicts of interest.

1 Although primarily employed in primary research, principles of saturation have also been applied to qualitative synthesis (Garrett et al. 2012 ; Lipworth et al. 2013 ). However, our focus here is on its use in primary studies.

2 These authors proceed to make the more extreme claim that saturation ‘is important in any study, whether quantitative, qualitative, or mixed methods’ (Fusch and Ness 2015 : p. 1411).

3 It should be noted that Birks and Mills ( 2015 ) also state that, as part of theoretical saturation, ‘Categories are clearly articulated with sharply defined and dimensionalized properties’, suggesting a somewhat broader view of saturation, in which the nature of emerging themes is important, rather than just the fact of their (non)emergence.

4 This evokes Glaser’s criticism of Strauss’s approach to sampling, which he regards as conventional, rather than theoretical, sampling: ‘In conventional sampling the analyst questions, guesses and uses experience to go where he thinks he will have the data to test his hypotheses and find the theory that he has preconceived. Discovery to Strauss does not mean induction and emergence, it means finding his theory in data so that it can be tested’ (Glaser 1992 : p. 103).

5 Charmaz ( 2008 , 2014 ) is critical of the extension of the notion of saturation beyond the context of grounded theory, and in particular of its extension into what we here refer to as data saturation.

6 Few authors draw an explicit distinction between data and theoretical saturation—among the exceptions are Bowen ( 2008 ), Sandelowski ( 2008 ), O’Reilly and Parker ( 2013 ), and Hennink et al. ( 2017 ).

7 Hence, Dey ( 1999 : p. 117) suggests the term ‘sufficiency’ in preference to ‘saturation’.

8 This reflects Glaser and Strauss’s ( 1967 : p. 40) view of theory generation: ‘one is constantly alert to emergent perspectives that will change and help develop his theory. These perspectives can easily occur even on the final day of study or even when the manuscript is reviewed in page proof; so the published word is not the final one, but only a pause in the never-ending process of generating theory’.

9 On occasions, a reason for going beyond saturation appears to be ethical rather than methodological. Despite reaching saturation, France et al. ( 2008 : p. 22) note that owing to their ‘commitment to and respect for all the women who wanted to participate in the study, data collection did not end until all had been interviewed.’ Similarly, Kennedy et al. ( 2012 : p. 858) report that they exceeded saturation as this appeared to be ‘more ethical than purposefully choosing individuals to re-interview, or only interviewing until saturation’.

10 Bloor and Wood ( 2006 : p. 165) suggest that this tendency may stem from researchers feeling obliged to abide by sample sizes previously declared to funding bodies or ethics committees, whilst making claims to saturation in order to retain a sense of methodological credibility. Some authors—e.g. Guest et al. ( 2006 ), Francis et al. ( 2010 ), Hennink et al. ( 2017 )—have attempted for formulate procedures whereby the specific number of participants required to achieve saturation is calculated in advance.

11 The first logic is counter-inductive—future non-occurrences of data, codes or theoretical insights are posited on the basis of prior occurrences. In relation to negative case analysis, however, the logic becomes inductive—future non-occurrences are posited on the basis of prior non-occurrences.

Contributor Information

Julius Sim, Phone: +44 (0)1782 734253, Email: [email protected] .

Jackie Waterfield, Email: ku.ca.umq@dleifretawj .

• Aiken ARA, Dillaway C, Mevs-Korff N. A blessing I can’t afford: factors underlying the paradox of happiness about unintended pregnancy. Soc. Sci. Med. 2015; 132 :149–155. doi: 10.1016/j.socscimed.2015.03.038. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Birks M, Mills J. Grounded Theory: A Practical Guide. 2. London: Sage; 2015. [ Google Scholar ]
• Bloor M, Wood F. Keywords in Qualitative Methods: A Vocabulary of Research Concepts. London: Sage; 2006. [ Google Scholar ]
• Boddy CR. Sample size for qualitative research. Qual. Mark. J. 2016; 19 (4):426–432. doi: 10.1108/QMR-06-2016-0053. [ CrossRef ] [ Google Scholar ]
• Bowen GA. Naturalistic inquiry and the saturation concept: a research note. Qual. Res. 2008; 8 (1):137–152. doi: 10.1177/1468794107085301. [ CrossRef ] [ Google Scholar ]
• Bryman A. How many qualitative interviews is enough? In: Baker SE, Edwards R, editors. How Many Qualitative Interviews is Enough? Expert Voices and Early Career Reflections on Sampling and Cases in Qualitative Research. Southampton: ESRC National Centre for Research Methods, University of Southampton; 2012. pp. 18–20. [ Google Scholar ]
• Charmaz K. Grounded theory in the 21st century: applications for advancing social justice studies. In: Denzin NK, Lincoln YS, editors. The Sage Handbook of Qualitative Research. 3. Thousand Oaks: Sage; 2005. pp. 507–535. [ Google Scholar ]
• Charmaz K. Grounded theory as an emergent method. In: Hesse-Biber S, Leavy P, editors. Handbook of Emergent Methods. New York: Guilford Press; 2008. pp. 155–170. [ Google Scholar ]
• Charmaz K. Constructing Grounded Theory. 2. Thousand Oaks: Sage; 2014. [ Google Scholar ]
• Constantinou C, Georgiou M, Perdikogianni M. A comparative method for themes saturation (CoMeTS) in qualitative interviews. Qual. Res. 2017 [ Google Scholar ]
• Damschroder LJ, Pritts JL, Neblo MA, Kalarickal RJ, Creswell JW, Hayward RA. Patients, privacy and trust: patients’ willingness to allow researchers to access their medical records. Soc. Sci. Med. 2007; 64 (1):223–235. doi: 10.1016/j.socscimed.2006.08.045. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Denny E. “I never know from one day to another how I will feel”: pain and uncertainty in women with endometriosis. Qual. Health Res. 2009; 19 (7):985–995. doi: 10.1177/1049732309338725. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dey I. Grounding Grounded Theory: Guidelines for Qualitative Inquiry. San Diego: Academic Press; 1999. [ Google Scholar ]
• Dey I. Grounding categories. In: Bryant A, Charmaz K, editors. The SAGE Handbook of Grounded Theory. Thousand Oaks: Sage; 2007. pp. 167–190. [ Google Scholar ]
• Drisko JW. Strengthening qualitative studies and reports. J. Soc. Work Educ. 1997; 33 (1):185–187. doi: 10.1080/10437797.1997.10778862. [ CrossRef ] [ Google Scholar ]
• Dubé E, Vivion M, Sauvageau C, Gagneur A, Gagnos R, Guay M. “Nature does things well, why should we interfere?”: vaccine hesitancy among mothers. Qual. Health Res. 2016; 26 (3):411–425. doi: 10.1177/1049732315573207. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Forsberg A, Bäckman L, Möller A. Experiencing liver transplantation: a phenomenological approach. J. Adv. Nurs. 2000; 32 (2):327–334. doi: 10.1046/j.1365-2648.2000.01480.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• France NEM, Farrell K, Kearney B, Myatt S. Women living with fibromyalgia: “do no harm” Int. J. Hum. Caring. 2008; 12 (4):21–25. [ Google Scholar ]
• Francis JJ, Johnston M, Robertson C, Glidewell L, Entwhistle V, Eccles MP, Grimshaw JM. What is an adequate sample size? Operationalising data saturation for theory-driven interview studies. Psychol. Health. 2010; 25 (10):1229–1245. doi: 10.1080/08870440903194015. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fusch PI, Ness LR. Are we there yet? Data saturation in qualitative research. Qual. Rep. 2015; 20 (9):1408–1416. [ Google Scholar ]
• Ganle JK. Hegemonic masculinity, HIV/AIDS risk perception and sexual behavior change among young people in Ghana. Qual. Health Res. 2016; 26 (6):763–781. doi: 10.1177/1049732315573204. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Garrett CR, Gask LL, Hays R, Cherrington A, Bundy C, Dickens C, Waheed W, Coventry PA. Accessing primary health care: a meta-ethnography of the experiences of British South Asian patients with diabetes, coronary heart disease or a mental health problem. Chronic Illn. 2012; 8 (2):135–155. doi: 10.1177/1742395312441631. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Given LM. 100 Questions (and Answers) About Qualitative Research. Thousand Oaks: Sage; 2016. [ Google Scholar ]
• Glaser BG. Theoretical Sensitivity. Mill Valley: Sociology Press; 1978. [ Google Scholar ]
• Glaser BG. Emergence vs Forcing: Basics of Grounded Theory Analysis. Mill Valley: Sociology Press; 1992. [ Google Scholar ]
• Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine; 1967. [ Google Scholar ]
• Grady MP. Qualitative and Action Research: A Practitioner Handbook. Bloomington: Phi Delta Kappa Educational Foundation; 1998. [ Google Scholar ]
• Goulding C. Grounded theory, ethnography and phenomenology: a comparative analysis of three qualitative strategies for marketing research. Eur. J. Mark. 2005; 39 (3/4):294–308. doi: 10.1108/03090560510581782. [ CrossRef ] [ Google Scholar ]
• Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006; 18 (1):59–82. doi: 10.1177/1525822X05279903. [ CrossRef ] [ Google Scholar ]
• Hale ED, Treharne GJ, Kitas GD. Qualitative methodologies II: a brief guide to applying interpretative phenomenological analysis in musculoskeletal care. Musculoskelet. Care. 2007; 6 (2):86–96. doi: 10.1002/msc.113. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hancock ME, Amankwaa L, Revell MA, Mueller D. Focus group data saturation: a new approach to data analysis. Qual. Rep. 2016; 21 (11):2124–2130. [ Google Scholar ]
• Hawkins RL, Abrams C. Disappearing acts: the social networks of formerly homeless individuals with co-occurring disorders. Soc. Sci. Med. 2007; 65 (10):2031–2042. doi: 10.1016/j.socscimed.2007.06.019. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hennink MM, Kaiser BN, Marconi VC. Code saturation versus meaning saturation: how many interviews are enough? Qual. Health Res. 2017; 27 (4):591–608. doi: 10.1177/1049732316665344. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hill CL, Baird WO, Walters SJ. Quality of life in children and adolescents with osteogenesis imperfecta: a qualitative interview based study. Health Qual. Life Outcomes. 2014; 12 :54. doi: 10.1186/1477-7525-12-54. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jackson D, Daly J, Davidson P, Elliott D. Women recovering from first-time myocardial infarction (MI): a feminist qualitative study. J. Adv. Nurs. 2000; 32 (6):1403–1411. doi: 10.1046/j.1365-2648.2000.01622.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jackson M, Harrison P, Swinburn B, Lawrence M. Using a qualitative vignette to explore a complex public health issue. Qual. Health Res. 2015; 25 (10):1395–1409. doi: 10.1177/1049732315570119. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jassim GA, Whitford DL. Understanding the experiences and quality of life issues of Bahraini women with breast cancer. Soc. Sci. Med. 2014; 107 :189–195. doi: 10.1016/j.socscimed.2014.01.031. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kazley AS, Johnson E, Simpson K, Chavin K, Baliga P. African American patient knowledge of kidney disease: a qualitative study of those with advanced chronic kidney disease. Chronic Illn. 2015; 11 (4):245–255. doi: 10.1177/1742395314556658. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kennedy F, Harcourt D, Rumsey N. The shifting nature of women’s experiences and perceptions of ductal carcinoma in situ. J. Adv. Nurs. 2012; 68 (4):856–867. doi: 10.1111/j.1365-2648.2011.05788.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Legard R, Keegan J, Ward K. In-depth interviews. In: Ritchie J, Lewis J, editors. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: Sage; 2003. pp. 139–169. [ Google Scholar ]
• Leininger M. Evaluation criteria and critique of qualitative research studies. In: Morse JM, editor. Critical Issues in Qualitative Research Methods. Thousand Oaks: Sage; 1994. pp. 95–115. [ Google Scholar ]
• Lipworth W, Taylor N, Braithwaite J. Can the theoretical domains framework account for the implementation of clinical quality interventions? BMC Health Serv. Res. 2013; 13 :530. doi: 10.1186/1472-6963-13-530. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Long-Sutehall T, Willis H, Palmer R, Ugboma D, Addington-Hall J, Coombs M. Negotiated dying: a grounded theory of how nurses shape withdrawal of treatment in hospital critical care units. Int. J. Nurs. Stud. 2011; 48 (12):1466–1474. doi: 10.1016/j.ijnurstu.2011.06.003. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual. Health Res. 2016; 26 (13):1753–1760. doi: 10.1177/1049732315617444. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Marshall V, Long BC. Coping processes as revealed in the stories of mother of children with autism. Qual. Health Res. 2010; 20 (1):105–116. doi: 10.1177/1049732309348367. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mason, M.: Sample size and saturation in PhD studies using qualitative interviews. Forum Qual. Health Res. 11 (3), art 8 (2010)
• McNulty C, Ricketts EJ, Rugman C, Hogan A, Charlett A, Campbell R. On behalf of the CIRT study group: a qualitative study exploring the acceptability of the McNulty–Zelen design for randomised controlled trials evaluating educational interventions. BMC Family Pract. 2015; 16 :169. doi: 10.1186/s12875-015-0356-0. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Middlemiss T, Lloyd-Williams M, Laird BJ, Fallon MT. Symptom control trials in patients with advanced cancer: a qualitative study. J. Pain Symptom Manag. 2015; 50 (5):642–649. doi: 10.1016/j.jpainsymman.2015.05.009. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morse JM. The significance of saturation. Qual. Health Res. 1995; 5 (2):147–149. doi: 10.1177/104973239500500201. [ CrossRef ] [ Google Scholar ]
• Morse JM. Data were saturated… Qual. Health Res. 2015; 25 (5):587–588. doi: 10.1177/1049732315576699. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morse JM, Barrett M, Mayan M, Olson K, Spiers J. Verification strategies for establishing reliability and validity in qualitative research. Int. J. Qual. Methods. 2002; 1 (2):1–19. doi: 10.1177/160940690200100202. [ CrossRef ] [ Google Scholar ]
• Naegeli AN, Flood E, Tucker J, Devlen J, Edson-Heredia E. The patient experience with fatigue and content validity of a measure to assess fatigue severity: qualitative research in patients with ankylosing spondylitis (AS) Health Qual. Life Outcomes. 2013; 11 :192. doi: 10.1186/1477-7525-11-192. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nelson J. Using conceptual depth criteria: addressing the challenge of reaching saturation in qualitative research. Qual. Res. 2016 [ Google Scholar ]
• Niccolai LM, Hansen CE, Credle M, Shapiro ED. Parents’ recall and reflections on experiences related to HPV vaccination for their children. Qual. Health Res. 2016; 26 (6):842–850. doi: 10.1177/1049732315575712. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Olshansky EF. Generating theory using grounded theory methodology. In: de Chesnay M, editor. Nursing Research Using Grounded Theory: Qualitative Designs and Methods in Nursing. New York: Springer; 2015. pp. 19–28. [ Google Scholar ]
• O’Reilly M, Parker N. ‘Unsatisfactory saturation’: a critical exploration of the notion of saturated sample sizes in qualitative research. Qual. Res. 2013; 13 (2):190–197. doi: 10.1177/1468794112446106. [ CrossRef ] [ Google Scholar ]
• Otmar R, Kotowicz MA, Nicholson GC, Pasco JA. Methodological reflections on using pilot data from fracture patients to develop a qualitative study. BMC Res. Notes. 2011; 4 :508. doi: 10.1186/1756-0500-4-508. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Poletti T, Balabanova D, Ghazaryan O, Kocharyan H, Hakobyan M, Arakelyan K, Normand C. The desirability and feasibility of scaling up community health insurance in low-income settings—lessons from Armenia. Soc. Sci. Med. 2007; 64 (3):509–520. doi: 10.1016/j.socscimed.2006.09.005. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Power T, Jackson D, Carter B, Weaver R. Misunderstood as mothers: women’s stories of being hospitalized for illness in the postpartum period. J. Adv. Nurs. 2015; 71 (2):370–380. doi: 10.1111/jan.12515. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sandelowski M. Theoretical saturation. In: Given LM, editor. The SAGE Encyclopedia of Qualitative Research Methods. Thousand Oaks: Sage; 2008. pp. 875–876. [ Google Scholar ]
• Sparkes E, Duarte RV, Raphael JH, Denny E, Ashford RL. Qualitative exploration of psychological factors associated with spinal cord stimulation outcome. Chronic Illn. 2011; 8 (4):239–251. doi: 10.1177/1742395311433132. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Starks H, Trinidad SB. Choose your method: a comparison of phenomenology, discourse analysis, and grounded theory. Qual. Health Res. 2007; 17 (10):1372–1380. doi: 10.1177/1049732307307031. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2. Thousand Oaks: Sage; 1998. [ Google Scholar ]
• Turner A, Barlow J, Ilbery B. Play hurt, live hurt: living with and managing osteoarthritis from the perspective of ex-professional footballers. J. Health Psychol. 2002; 7 (3):285–301. doi: 10.1177/1359105302007003222. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tutton E, Seers K, Langstaff D, Westwood M. Staff and patient views of the concept of hope on a stroke unit: a qualitative study. J. Adv. Nurs. 2012; 68 (9):2061–2069. doi: 10.1111/j.1365-2648.2011.05899.x. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Urquhart C. Grounded Theory for Qualitative Research: A Practical Guide. Thousand Oaks: Sage; 2013. [ Google Scholar ]
• Vandecasteele T, Debyser B, Van Hecke A, De Backer T, Beeckman D, Verhaeghe S. Nurses’ perceptions of transgressive behaviour in care relationships: a qualitative study. J. Adv. Nurs. 2015; 71 (12):2786–2798. doi: 10.1111/jan.12749. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Manen M, Higgins I, van der Reit P. A conversation with Max van Manen on phenomenology in its original sense. Nurs. Health Sci. 2016; 18 (1):4–7. doi: 10.1111/nhs.12274. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Walker JL. The use of saturation in qualitative research. Can. J. Cardiovasc. Nurs. 2012; 22 (12):37–41. [ PubMed ] [ Google Scholar ]
• Zhao X, Davey G. Contesting modernity: tobacco use and romanticism among older Dai farmers in Xishuangbanna, China. Soc. Health Illn. 2015; 37 (8):1173–1190. doi: 10.1111/1467-9566.12305. [ PubMed ] [ CrossRef ] [ Google Scholar ]