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Qualitative Health Research

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Qualitative Health Research provides an international, interdisciplinary forum to enhance health and health care and further the development and understanding of qualitative health research. The journal is an invaluable resource for researchers and academics, administrators and others in the health and social service professions, and graduates, who seek examples of studies in which the authors used qualitative methodologies. Each issue of Qualitative Health Research provides readers with a wealth of information on conceptual, theoretical, methodological, and ethical issues pertaining to qualitative inquiry. A Variety of Perspectives We encourage submissions across all health-related areas and disciplines. Qualitative Health Research understands health in its broadest sense and values contributions from various traditions of qualitative inquiry. As a journal of SAGE Publishing, Qualitative Health Research aspires to disseminate high-quality research and engaged scholarship globally, and we are committed to diversity and inclusion in publishing. We encourage submissions from a diverse range of authors from across all countries and backgrounds. There are no fees payable to submit or publish in Qualitative Health Research .

Original, Timely, and Insightful Scholarship Qualitative Health Research aspires to publish articles addressing significant and contemporary health-related issues. Only manuscripts of sufficient originality and quality that align with the aims and scope of Qualitative Health Research will be reviewed. As part of the submission process authors are required to warrant that they are submitting original work, that they have the rights in the work, that they have obtained, and that can supply all necessary permissions for the reproduction of any copyright works not owned by them, and that they are submitting the work for first publication in the Journal and that it is not being considered for publication elsewhere and has not already been published elsewhere. Please note that Qualitative Health Research does not accept submissions of papers that have been published elsewhere. Sage requires authors to identify preprints upon submission (see https://us.sagepub.com/en-us/nam/preprintsfaq ). This Journal is a member of the Committee on Publication Ethics (COPE) .

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Qualitative Health Research is an international, interdisciplinary, refereed journal for the enhancement of health care and to further the development and understanding of qualitative research methods in health care settings. We welcome manuscripts in the following areas: the description and analysis of the illness experience, health and health-seeking behaviors, the experiences of caregivers, the sociocultural organization of health care, health care policy, and related topics. We also seek critical reviews and commentaries addressing conceptual, theoretical, methodological, and ethical issues pertaining to qualitative enquiry.

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Qualitative research in healthcare: an introduction to grounded theory using thematic analysis

Affiliation.

1 AL Chapman, Department of Infectious Diseases, Monklands Hospital, Airdrie ML6 0JS, UK. Email [email protected].
PMID: 26517098
DOI: 10.4997/JRCPE.2015.305

In today's NHS, qualitative research is increasingly important as a method of assessing and improving quality of care. Grounded theory has developed as an analytical approach to qualitative data over the last 40 years. It is primarily an inductive process whereby theoretical insights are generated from data, in contrast to deductive research where theoretical hypotheses are tested via data collection. Grounded theory has been one of the main contributors to the acceptance of qualitative methods in a wide range of applied social sciences. The influence of grounded theory as an approach is, in part, based on its provision of an explicit framework for analysis and theory generation. Furthermore the stress upon grounding research in the reality of participants has also given it credence in healthcare research. As with all analytical approaches, grounded theory has drawbacks and limitations. It is important to have an understanding of these in order to assess the applicability of this approach to healthcare research. In this review we outline the principles of grounded theory, and focus on thematic analysis as the analytical approach used most frequently in grounded theory studies, with the aim of providing clinicians with the skills to critically review studies using this methodology.

Keywords: grounded theory; healthcare; inductive analysis; qualitative research; quality improvement; thematic analysis.

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http://orcid.org/0000-0001-5660-8224 Veronika Williams ,
Anne-Marie Boylan ,
http://orcid.org/0000-0003-4597-1276 David Nunan
Nuffield Department of Primary Care Health Sciences , University of Oxford, Radcliffe Observatory Quarter , Oxford , UK
Correspondence to Dr Veronika Williams, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; veronika.williams{at}phc.ox.ac.uk

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

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qualitative research

Introduction

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

Critical appraisal of qualitative research

Is it necessary.

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

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

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

How is appraisal currently performed?

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

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

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

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

On the need for specific appraisal tools

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

Concepts of rigour or trustworthiness within qualitative research 31

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

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

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

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

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

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

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

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

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

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

Williams V ,
Boylan AM ,
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↵ CASP (Critical Appraisal Skills Programme). date unknown . http://www.phru.nhs.uk/Pages/PHD/CASP.htm .
↵ The Joanna Briggs Institute . JBI QARI Critical appraisal checklist for interpretive & critical research . Adelaide : The Joanna Briggs Institute , 2014 .
Stephens J ,

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

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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

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Qualitative studies are often used to research phenomena that are difficult to quantify numerically. 1,2 These may include concepts, feelings, opinions, interpretations and meanings, or why people behave in a certain way. Although qualitative research is often described in opposition to quantitative research, the approaches are complementary, and many researchers use mixed methods in their projects, combining the strengths of both approaches. 2 Many comprehensive texts exist on qualitative research methodology including those with a focus on healthcare related research. 2-4 Here we give a brief introduction to the rationale, methods and quality assessment of qualitative research.

https://doi.org/10.1136/dtb.2017.2.0457

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Introduction
Conclusions
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BP indicates blood pressure; PCP, primary care physician.

eFigure. Flow Diagram for Study Population Selection

eTable. Plausible Influencing Factors for Scenarios of Suboptimal Clinician Guideline Medication Adherence, Based on Analysis of Metareview Findings

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Poor Physician Adherence to Clinical Guidelines in Hypertension JAMA Network Open Invited Commentary August 6, 2024 Michel Burnier, MD

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Lu Y , Arowojolu O , Qiu X , Liu Y , Curry LA , Krumholz HM. Barriers to Optimal Clinician Guideline Adherence in Management of Markedly Elevated Blood Pressure : A Qualitative Study . JAMA Netw Open. 2024;7(8):e2426135. doi:10.1001/jamanetworkopen.2024.26135

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Barriers to Optimal Clinician Guideline Adherence in Management of Markedly Elevated Blood Pressure : A Qualitative Study

1 Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
2 Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
3 Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
4 Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
Invited Commentary Poor Physician Adherence to Clinical Guidelines in Hypertension Michel Burnier, MD JAMA Network Open

Question What are the plausible scenarios and factors contributing to clinician nonadherence to the guidelines for hypertension management?

Findings In this qualitative study of 100 patients with markedly elevated blood pressure, 3 domains of suboptimal adherence were developed (clinician-related scenarios, patient-related scenarios, and clinical complexity–related scenarios) and several plausible contributing factors were identified, including a lack of clear protocols and processes to implement guidelines, infrastructure limitations, clinicians’ lack of autonomy and authority, excessive workload, time constraints, and clinician belief or perception.

Meaning This study introduced a taxonomy poised to inform targeted interventions, thereby enhancing guideline adherence and elevating care quality for severe hypertension.

IMPORTANCE Hypertension poses a substantial public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal.

OBJECTIVE To develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence.

DESIGN, SETTING, and PARTICIPANTS This qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System included participants who had at least 2 consecutive visits with markedly elevated blood pressure (BP; defined as at least 2 consecutive readings of systolic BP ≥160 mm Hg and diastolic BP ≥100 mm Hg) between January 1, 2013, and December 31, 2021, and no prescription for antihypertensive medication within a 90 days of the second BP measurement. Data analysis was conducted from January to December 2023.

MAIN OUTCOMES AND MEASURES The primary outcome was scenarios and influencing factors contributing to clinician nonadherence to the guidelines for hypertension management. A thematic analysis of EHR data was conducted to generate a pragmatic taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension.

RESULTS Of the 20 654 patients who met criteria, 200 were randomly selected and thematic saturation was reached after analyzing 100 patients (mean [SD] age at index visit, 66.5 [12.8] years; 50 female [50%]; 8 Black [8%]; 5 Hispanic or Latino [5%]; 85 White [85%]). Three content domains emerged: (1) clinician-related scenarios (defined as noninitiation or nonintensification of treatment due to issues relating to clinician intention, capability, or scope), which included 2 subcategories (did not address and diffusion of responsibility); (2) patient-related scenarios (defined as noninitiation or nonintensification of treatment due to patient behavioral considerations), which included 2 subcategories (patient nonadherence and patient preference); and (3) clinical complexity–related scenarios (defined as noninitiation or nonintensification of treatment due to clinical situational complexities), which included 3 subcategories (diagnostic uncertainty, maintenance of current intervention, and competing medical priorities).

CONCLUSIONS AND RELEVANCE In this qualitative study of EHR data, a taxonomy of suboptimal adherence scenarios for severe hypertension was developed and barriers to guideline adherence were identified. This pragmatic taxonomy lays the foundation for developing targeted interventions to improve clinician adherence to guidelines and patient outcomes.

Hypertension is a major public health issue, affecting almost one-half of the US adult population. Among patients with hypertension, those with severely elevated blood pressure (BP; defined as at least 2 consecutive readings of systolic BP ≥160 mm Hg or diastolic BP ≥100 mm Hg) comprise about 12% 1 , 2 and face a higher risk of complications, including severe and rapid systemic end-organ damage, compared with those with modestly elevated BP. 3 This condition requires prompt and appropriate pharmacological treatment. The 2017 American College of Cardiology and American Heart Association guidelines 3 recommend immediate evaluation and drug treatment followed by careful monitoring and dose adjustments for patients with severe hypertension. Despite these well-established clinical practice guidelines, clinician adherence remains suboptimal. A recent study 4 based on electronic health record (EHR) data in the ambulatory setting found that almost 30% of patients with severely elevated BP had no active antihypertensive drug prescription before their second visit, and only 54% of those who were prescribed at least 1 antihypertensive drug class were prescribed the guideline-recommended 2-drug class combination therapy. This finding highlights a missed opportunity to improve guideline adherence in this population.

Clinicians’ adherence to medication guidelines is a complex and multifaceted process that substantially impacts the implementation of evidence-based practice. 5 The literature highlights various scenarios resulting in nonadherence to medication guidelines. These scenarios include situations where the recorded BP does not accurately reflect the patient’s typical BP, such as when home BPs are below the target range or when the patient is experiencing pain. 6 In addition, scenarios such as the prioritization of other clinical concerns over hypertension, the need for ongoing monitoring and lifestyle counseling, and disagreements with specific recommendations, also result in nonadherence. 6 Moreover, how clinicians address patient-level factors, such as medication nonadherence and individual patient preferences, substantially influences guideline adherence. Clinician-level factors, including the belief that hypertension management is another clinician’s responsibility, further impact guideline adherence. Medication-related issues, such as adverse drug events and use of medications from external sources, present additional adherence challenges. 6 By recognizing and addressing these multifaceted factors, health care systems can implement strategies to improve clinician adherence to medication guidelines and enhance patient outcomes.

However, the current body of research on clinician guideline adherence in managing markedly elevated BP lacks a comprehensive identification of the reasons behind the inadequate treatment, particularly those based on routinely collected information during clinical practice, such as data from medical records. This information is particularly crucial as pharmacological interventions are vital in reducing BP and associated complications for this patient population. Furthermore, previous studies may have inadequately reported or underrepresented barriers to clinician guideline adherence, potentially due to methodological limitations. 5 Consequently, we aimed to address these gaps by conducting a content analysis of EHRs to develop a comprehensive taxonomy of scenarios representing suboptimal guideline adherence in the ambulatory management of severe hypertension. This information can potentially guide the creation and implementation of focused interventions, enhancing adherence to guidelines and quality of care for severe hypertension. Moreover, because the information is derived from EHR data, it is pragmatic and enables the development of practical, automated EHR-based clinical decision support tools. 7

This qualitative study was approved by the institutional review board at Yale University and the need for informed consent was waived. This study was reported according to the Standards for Reporting Qualitative Research ( SRQR ) reporting guideline. 8 The dataset included data from adult patients at Yale New Haven Health System (YNHHS) who had at least 2 consecutive outpatient visits between January 1, 2013, and December 31, 2021. YNHHS is a large academic health system comprising 5 distinct hospitals and their associated ambulatory clinics in Connecticut and Rhode Island. All YNHHS hospitals used a secure, centralized EHR system designed by Epic Corporation to collect and store clinical and administrative data. The EHR data are maintained in a data repository at the YNHHS server.

Eligible patients were aged 18 to 85 years and had markedly elevated BP, defined as having measurements of systolic BP of 160 mm Hg or greater or diastolic BP of 100 mm Hg or greater in at least 2 consecutive outpatient visits between January 1, 2013, and December 31, 2021, with no new antihypertensive medication prescription within 90 days of the index date. The index date was defined as the date of the second severely elevated BP reading. Patients with markedly elevated BP were selected as a focus given that the need to urgently achieve BP control in this population is unequivocal. Any 2 consecutive visits were required to be at least 1 day apart. We had access to all available data in the medical records, including patient demographics, past medical histories, vital signs, outpatient medications, laboratory results, encounter notes and scanned documents. Of note, identification of patient race and ethnicity was conducted using data extracted from the EHR. This data was classified based on information provided directly by the patients themselves, either through self-report at the time of registration or during patient intake processes. The specific categories for race included in our study were Black, White, and other (defined as any race not otherwise specified), while ethnicity is categorized as Hispanic or Latino, non-Hispanic, and other (defined as any ethnicity not otherwise specified). A total of 20 654 patients met the eligibility criteria (eFigure in Supplement 1 ). We randomly selected 200 records from the group of all eligible patients for qualitative analysis, intending to select more if we did not achieve saturation (where no new concepts emerged from analyses of subsequent data 9 ).

Using a previously published inductive, systematic approach, 10 - 14 we conducted a thematic analysis of EHR data to generate a pragmatic taxonomy of suboptimal clinician guideline adherence scenarios in managing severe hypertension.

Through an iterative process, a team of 3 clinicians and/or experienced cardiovascular researchers (O.A., Y.L., and H.M.K.) developed a rubric to systematically abstract data from the EHR. We obtained demographic data (including age, sex, race, and ethnicity) and clinical data relevant to the diagnosis and treatment of hypertension (including BP measurements, medical history, medication prescriptions, and medical context of the encounter) and established criteria for consistency (to support explicit review). Additionally, the data extraction rubric was designed to offer flexibility, allowing reviewers to go beyond strict numerical or binary criteria and make subjective assessments. This approach included evaluating the rationale behind a clinician’s decisions, considering the medical context of each encounter, and interpreting data points with a nuanced understanding of patient history, comorbidities, or unique clinical scenarios. Furthermore, while the rubric establishes consistency criteria, it also provides guidance for implicit review, enabling reviewers to use their clinical judgment to uncover underlying reasons for suboptimal adherence to guidelines not explicitly stated in the EHR (implicit review). 14 - 17

Two abstractors (O.A. and X.Q.) participated in a training session, during which they collectively abstracted 15 medical records using the rubric and generated a narrative summary for each case. Decision rules and operational definitions were refined to reduce ambiguity and to facilitate standardized data abstraction. Discrepancies were resolved during face-to-face meetings with discussion among all reviewers until consensus was reached. Once the rubric was finalized, each abstractor reviewed a random sample of 50 medical records. Cases were reviewed until reviewers determined they reached saturation; that is, no new constructs emerged from reviewing subsequent cases. 9 Specifically, when reviewers felt they reached saturation, they reviewed another 10 charts to confirm no further constructs were identified.

The cases abstracted using the rubric were analyzed using conventional content analysis. Content analysis is a systematic, replicable technique for compressing many words of text into fewer content categories based on explicit coding rules. 18 , 19 Content analysis enables researchers to sift through large volumes of data with relative ease in a systematic fashion, and it is useful in examining the patterns in documentation. 20

We used emergent coding and established categories following a preliminary examination of the abstracted data obtained in step 2. First, 1 author (O.A.) independently reviewed the abstracted data and identified a set of suboptimal clinician guideline adherence scenarios to form the initial code list, which was then developed into a consolidated code book. Second, 2 authors (O.A. and Y.L.) reviewed this code book for face validity and revised it based on group discussion. Third, the consolidated code book was trialed on 10 cases by the coding group (O.A. and Y.L.) to ensure consistent coding application. The coding group checked that the reliability of the coding was established (agreement >95%). Then all cases were coded by the coding group. Finally, a larger author group (O.A., Y.L., L.C., and H.M.K.) used an iterative, consensus-based discussion process to group the coding into major content themes with subthemes, maintaining a consensus and primary data referencing approach. 21

The thematic analysis and qualitative data were analyzed using NVIVO software version 12.0 (QSR International). The analysis was conducted from January to December 2023.

Thematic saturation was reached after analyzing 100 patients. These 100 patients (mean [SD] age at index visit, 66.5 [12.8] years; 50 female [50%]; 8 Black [8%]; 5 Hispanic or Latino [5%]; 85 White [85%]) were included in the final content analysis ( Table 1 ). A total of 31 patients (31.0%) had private insurance, 58 (58%) had Medicare, and 11 (11%) had Medicaid; there were no participants without health insurance. The mean (SD) systolic BP and diastolic BP of the sample at the index date was 166.2 (11.5) mmHg and 87.7 (12.7) mmHg, respectively. The median (IQR) time between visits was 42 (18-85) days. A large proportion of patients had comorbidities at the index date, including 23 patients (23%) with obesity (body mass index ≥30 [calculated as weight in kilograms divided by height in meters squared]), 16 (16%) with diabetes, 31 (31%) with dyslipidemia, and 36 (36%) with cancer.

Based on a thematic analysis of data available in the EHR for patients meeting our criteria, we identified a variety of scenarios of suboptimal clinician guideline adherence in managing severe hypertension pertaining to either noninitiation or nonintensification of pharmacological therapy ( Table 2 ). Noninitiation of pharmacological treatment was defined as an absence of the initiation of antihypertensive therapy in response to severely elevated BP in a patient with at least 2 consecutive readings of severely elevated BP. Nonintensification of pharmacological treatment was defined as failure to intensify or modify treatment or initiate an urgent referral on the index visit for a patient with severely elevated BP who was previously taking antihypertensive medication.

These identified scenarios (subcategories) of suboptimal clinician guideline adherence were taxonomized and grouped into 3 main content domains: clinician-related scenarios, patient-related scenarios, and clinical complexity–related scenarios ( Figure ). Table 3 includes example quotations or clinical situations pertaining to each scenario.

Clinician-related scenarios were defined as instances where clinicians did not initiate or intensify antihypertensive treatment due to factors related to their intentions, capabilities, or scope. Under this main content domain, we identified 2 subcategories: did not address and diffusion of responsibility ( Figure ). Did not address included instances in which the clinician encountered on the index date neither acknowledged nor prioritized the BP at the visit. For example, Table 3 highlights a clinical scenario in which a patient who presented to a clinician for wound care had a second consecutive markedly elevated BP reading at presentation, but this was not addressed in the encounter note, nor was any action or intervention relating to the BP carried out. Diffusion of responsibility included instances in which the specialist visited did not initiate or intensify treatment, explicitly displacing responsibility to a hypertension-managing clinician (ie, primary care physician or cardiology), excluding cases where an urgent referral to the clinician was made. For example, our analysis identified a case where a patient had a visit with a podiatrist and exhibited markedly elevated blood pressure. The podiatrist noted that the patient needed to see their primary care physician, but no follow-up occurred.

Patient-related scenarios were defined as instances where clinicians did not initiate or intensify antihypertensive treatment due to considerations related to patient behavior. Under this main content domain, we identified 2 subcategories: patient nonadherence and preference ( Figure ). Patient nonadherence included instances where the clinician did not intensify intervention due to the patient’s nonadherence to current therapy. For example, our analysis identified a case in which a patient who had previously had adequate BP control while taking metoprolol had not taken his medication in 2 days when he presented with markedly elevated BP and the clinician decided to counsel the patient on adherence rather than modify or intensify treatment at the visit ( Table 3 ). Patient preference included instances where the clinician did not initiate nor intensify intervention due to patient preference.

These scenarios involve instances where clinicians did not initiate or intensify antihypertensive treatment due to the complexities of the clinical situation. Under this main content domain, we identified 3 subcategories: diagnostic uncertainty with BP measurement, maintenance of current BP intervention, and competing medical priorities ( Figure ). Diagnostic uncertainty with BP measurement included cases where the clinician did not initiate or intensify treatment due to variation in BP measurements, either at home or in the office. It also reflected situations where clinic BP measurements contradicted home measurements, thus creating uncertainty in determining the true hypertensive status of the patient. Maintenance of current BP intervention included cases where the clinician chose to delay intensifying treatment to observe if current antihypertensives and/or lifestyle modifications would result in BP control. Competing medical priorities included cases in which the clinician chose to delay intensifying treatment due to several competing medical conditions ( Table 3 ). For example, our analysis identified a case where a patient had substantial kidney injury, and the physician decided not to treat the patient’s hypertension due to the kidney condition

This qualitative study provides novel insights into the factors contributing to suboptimal adherence to guidelines among clinicians treating patients with markedly elevated BP in ambulatory settings. Our taxonomy, derived from EHR data, not only categorizes these instances but also describes the factors influencing each scenario of suboptimal adherence. Such a pragmatic framework is poised to inform targeted interventions, thus enhancing adherence and patient outcomes.

Our study advances the existing body of literature in several ways. We have previously detailed various mechanisms through which patients experience persistent hypertension, such as the lack of intensification in pharmacological treatment, failure to implement prescribed therapies, and nonresponse to treatment. 11 Building on this, the current study specifically illuminates the mechanisms behind clinicians’ failure to treat ambulatory patients with severely elevated BP effectively and explores the reasons for these shortcomings. To our knowledge, this is the first study to develop a taxonomy for categorizing instances of suboptimal clinician adherence to guidelines in managing patients with markedly elevated BP using clinical data. Compared with prior work on clinical inertia, 22 , 23 a key strength of this study is its foundation in EHR data. EHRs capture a broad spectrum of clinical interactions across diverse patient demographics, enhancing our findings’ practicality and external validity. 7 Research based on EHR data can inform more effective clinical decisions by evaluating the quality and cost implications of guideline-conformant care for chronic conditions such as hypertension. Furthermore, EHRs assist in pinpointing the issue of suboptimal clinician guideline adherence in the management of substantially elevated BP and serve as a robust framework for integrating potential EHR-based solutions such as decision support tools.

Various influencing factors were hypothesized for each taxonomized scenario of suboptimal clinician adherence to guidelines in managing severe hypertension. These factors, frequently reported in the literature, 5 , 24 , 25 span health organization, health professional, patient, and guideline contexts. In clinician-related scenarios (eg, did not address and diffusion of responsibility) barriers may include unclear institutional roles, insufficient consultation time, excessive workload, and infrastructure limitations (eTable in Supplement 1 ). Factors such as clinician autonomy, authority, or role misperceptions can also play a part, alongside unclear guidelines. Patient-related barriers, like nonadherence or preference, might arise from clinician reluctance influenced by patient characteristics, clinician beliefs, fear of complications, and patient unawareness or demotivation. Perceptions of guideline inflexibility also contribute to these barriers. Clinical complexity scenarios, including diagnostic uncertainty, maintenance of interventions, and competing priorities, are affected by organizational issues, reliance on clinical experience over guidelines, patient comorbidities, and guideline perceptions restricting clinical judgment and autonomy.

Our findings underscore the necessity of addressing the multidimensional nature of guideline nonadherence. Under the proposed taxonomy, each category and subcategory of nonadherence scenarios is linked to specific factors and targeted interventions. For example, scenarios affected by organizational factors may improve with robust leadership, clear priorities, sufficient staffing, knowledge-sharing forums, streamlined processes, and regular communicative audits with constructive feedback. 5 , 26 - 28 Health organizations can further support clinician adherence by integrating evidence-based decision support tools within EHR systems, such as automated alerts, reminders, and advanced patient portals, along with improved collaborative tools for care teams. 29 Addressing health professional–level factors involves fostering a willingness to embrace new practices, educating about guidelines, and reinforcing personal accountability. 7 , 30 For patient-level factors, strategies include raising health awareness, early education, clear communication about the impact of nonadherence, and peer support. Concerning the guidelines themselves, simplifying their presentation, tailoring them to the local context, and involving end-users in their development can enhance their usability and adherence. 7 , 31

Reflecting on the broader implications, this study’s findings can stimulate health care policies aimed at systematizing adherence to guidelines and, thus, improve the quality of care delivered. This is particularly pertinent in light of our identification of implicit bias and structural racism as underlying factors contributing to nonadherence, which are critical to address in the pursuit of equitable health care. 32 , 33

While our study’s EHR-based nature substantially enhances its applicability, there are several limitations. First, encounter notes within the EHR may not always provide sufficient detail to conclusively ascertain the intentions or rationale underpinning specific clinical decisions. We did not have information on the characteristics of the physicians, which may play an important role in physician behavior. Additionally, the study’s reliance on the reviewers’ judgment, coupled with the breadth and quality of the referenced meta-review, 6 could potentially influence the determination of factors contributing to the identified scenarios of nonadherence. The study was conducted at a single academic site, which may limit the applicability of the findings across different types of health care settings. Additionally, our sample predominantly consisted of White patients who were mostly insured. This demographic limitation restricts the generalizability of our findings to more diverse populations.

In conclusion, by highlighting the multifaceted reasons for suboptimal guideline adherence, our qualitative study provides a foundation for developing nuanced interventions. As we look toward a future of health care that is both evidence-based and patient-centered, it is imperative that we consider the complex interplay of factors at the organizational, professional, patient, and guideline levels that influence clinician behaviors.

Accepted for Publication: June 9, 2024.

Published: August 6, 2024. doi:10.1001/jamanetworkopen.2024.26135

Corresponding Author: Harlan M. Krumholz, MD, SM, Center for Outcomes Research and Evaluation, Yale New Haven Hospital, 195 Church St, 5th Floor, New Haven, CT 06510 ( [email protected] ).

Author Contributions: Drs Lu and Krumholz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Lu and Arowojolu are co–first authors.

Concept and design: Lu, Arowojolu, Qiu, Krumholz.

Acquisition, analysis, or interpretation of data: Lu, Arowojolu, Qiu, Liu, Curry.

Drafting of the manuscript: Lu, Arowojolu.

Critical review of the manuscript for important intellectual content: Arowojolu, Qiu, Liu, Curry, Krumholz.

Statistical analysis: Lu, Arowojolu, Liu.

Administrative, technical, or material support: Arowojolu.

Supervision: Lu, Arowojolu.

Conflict of Interest Disclosures: Dr. Lu reported receiving grants from the National Heart, Lung, and Blood Institute of the National Institutes of Health (award Nos and R01HL169171) and the Patient-Centered Outcomes Research Institute (award No. HM-2022C2-28354) outside the submitted work. Dr Krumholz reported receiving options for Element Science and Identifeye and payments from F-Prime for advisory roles; being a cofounder and holding equity in Hugo Health, Refactor Health, and ENSIGHT-AI; and having research contracts through Yale University from Janssen, Kenvue, Novartis, and Pfizer outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (award No R01HL69954 to Dr Lu).

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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Looking to “Level the Field”: A Qualitative Study of How Clinicians Operationalize Social Determinants in Critical Care

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Understanding digital sweatshops: A qualitative investigation of workers’ perspectives

Published: 26 August 2024

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Manoj Kumar Kamila ORCID: orcid.org/0000-0001-8456-5778 1 ,
Sahil Singh Jasrotia 2 &
Pooja Singh Kushwaha 1

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Digital sweatshops represent exploitative digital workplaces where individuals are compelled to work long hours under high demands for minimal compensation. This study employs in-depth, semi-structured interviews with digital workers to explore digital sweatshop operations’ challenges and adverse aspects, mainly focusing on ethical considerations. The collected data were transcribed and analyzed using grounded theory methodology. The findings highlight three key themes: conditions mitigating factors, organisational factors, and work environment factors, all of which contribute to the persistence of digital sweatshops. The study advocates for comprehensive labour laws, education and advocacy for digital employees, mental health support, transparency and accountability, skill development, career advancement, and ethical business practices. These recommendations are intended to help governments and organizations create a fair and ethical digital workplace, prioritizing workers’ rights and well-being.

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Digital Work Environment Rounds – Systematic Inspections of Usability Supported by the Legislation

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Navigating sexual minority identity in sport: a qualitative exploration of sexual minority student-athletes in China

Meng Xiang 1 , 2 ,
Kim Geok Soh 2 ,
Yingying Xu 3 ,
Seyedali Ahrari 4 &
Noor Syamilah Zakaria 5

BMC Public Health volume 24 , Article number: 2304 ( 2024 ) Cite this article

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Sexual minority student-athletes (SMSAs) face discrimination and identity conflicts in intercollegiate sport, impacting their participation and mental health. This study explores the perceptions of Chinese SMSAs regarding their sexual minority identities, aiming to fill the current gap in research related to non-Western countries.

A qualitative methodology was adopted, utilising the Interpretive Phenomenological Analysis (IPA) approach with self-categorization theory as the theoretical framework. Participants were recruited through purposive and snowball sampling, and data were collected via semi-structured interviews, documents, and field notes. Sixteen former and current Chinese SMSAs participated in this study.

The study reveals four themes: hidden truths, prioritisation of athlete identity, self-stereotyping, and attempt. The results revealed that while SMSAs were common in intercollegiate sport, their identities were often concealed and not openly discussed. The predominant focus on athlete identity in sport overshadowed their sexual minority identities. Additionally, SMSAs developed self-stereotypes that influenced their thoughts and behaviours. The non-heterosexual team atmosphere in women’s teams led to the development of intimate relationships among teammates.

Conclusions

The findings from this study could be incorporated into existing sport policies to ensure the safe participation of SMSAs in Chinese intercollegiate sports. This research offers valuable insights for the development and implementation of inclusive policies. Future research in China could investigate the attitudes of coaches and heterosexual student-athletes toward sexual minority identities to inform targeted interventions.

Peer Review reports

Collegiate sport serves as a conduit for hope, competition, learning, success, and enhanced well-being for students [ 1 , 2 ]. Within this context, situated at the intersection of student-athlete and sexual minority identities [ 3 ], sexual minority student-athletes (SMSAs) experience more challenges than their heterosexual counterparts. Sexual minority constitutes a group of individuals whose sexual and affectual orientation, romantic attraction, or sexual characteristics differ from that of heterosexuals. Sexual minority persons are inclusive of lesbian, gay, bi+, and asexual-identified individuals [ 4 ].

In an effort to enhance the support of SMSAs in sport, Team DC, the association of sexual minorities sport club, awarded seven SMSAs the 2023 Team DC College Scholarship [ 5 ]. Besides the Team DC scholarship, there are the Rambler Scholarship, US Lacrosse SMSAs Inclusion Scholarship, NCAA Women’s Athletics Scholarship and Ryan O’Callaghan Foundation [ 6 , 7 , 8 ]. These scholarships were set up to make sport a more welcoming and safer environment for SMSAs. In particular, the Sexual Minority Scholarship echoes the International Olympic Committee’s framework of equity, inclusion, and non-discrimination, which states that everyone has the right to participate in sport without discrimination and in a manner that respects their health, safety and dignity [ 9 , 10 ].

Despite efforts by educational and sport organisations to foster inclusivity, research shows that the sport environment remains hostile to sexual minority individuals [ 11 , 12 ]. In intercollegiate sport, empirical evidence points to persistent negative attitudes [ 13 , 14 , 15 , 16 , 17 ], which are expressed through marginalisation, exclusion, use of homophobic language, discrimination, and harassment [ 17 , 18 , 19 , 20 ]. SMSAs frequently confront the difficult choice of disclosing their identity, often opting for concealment. Denison et al. found that SMSAs who disclose their identity to their teams may face increased discrimination [ 21 ]. Pariera et al. also observed deep-rooted fears among SMSAs of being marginalised by their teams upon revealing their sexual orientation [ 22 ]. Consequently, the hostile environment led to lower participation rates among sexual minority youth compared to their heterosexual counterparts [ 23 ].

In China, there is a lack of clear public policies related to the sexual minority population [ 24 ]. Despite homosexuality being removed from the Chinese Classification of Mental Disorders-3 in 2001 [ 25 ]. China’s stance towards sexual minority issues remains ambiguous. Many scholars describe this attitude as “no approval, no disapproval, and no promotion” [ 26 , 27 , 28 , 29 ]. Due to the lack of legal protection, sexual minorities frequently encounter discrimination. A Chinese national survey revealed that only 5.1% of sexual minority individuals felt comfortable being open about their gender and sexual identity in China [ 30 ]. This discrimination is particularly severe among Chinese sexual minority youth, who are at higher risk of bullying in school and college [ 31 , 32 ]. These youths face childhood victimisation [ 33 , 34 , 35 ], which heightens their risk of mental and behavioural health issues [ 36 , 37 , 38 ], including non-medical use of prescription drugs [ 39 ], depression [ 40 , 41 ], and suicide [ 42 ].

While sports participation is crucial for the well-being of sexual minority individuals, research on the sports participation of sexual minority youth in China is limited. The literature highlights a significant gap in understanding the status and circumstances of SMSAs in China. Most existing studies focus on Western populations [ 43 , 44 , 45 ], overlooking the unique sociocultural interactions affecting SMSAs in non-Western contexts, making it challenging for China to apply these findings. Furthermore, the lack of reliable research on the interactions between sexual minorities and institutions in Chinese higher education hampers a comprehensive understanding of SMSAs’ situations. This research gap impedes the development of effective interventions to foster inclusivity. Persistent discrimination and inadequate protective policies underscore the urgent need for academic, policy, and practical advancements to support sexual minorities in China [ 46 ]. Therefore, the aim of this study was to explore SMSAs’ perceptions of their sexual minority identity in Chinese sports, providing insights to guide the creation of supportive educational and organisational strategies.

Homonegativity and discrimination in sport

Homonegativity refers to any prejudicial attitude or discriminatory behaviour directed towards an individual because of their homosexual orientation [ 47 ]. Compared to the more common term “homophobia,” [ 48 ] “homonegativity” more accurately describes negative attitudes towards homosexuality [ 49 ] because the fear is not irrational but is learned from parents, peers, teachers, coaches, and the daily interaction environment [ 50 ]. Sport context is an integral part of society, and an extensive body of research has consistently demonstrated the presence of homonegativity in sport [ 12 , 21 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ].

Homonegativity can manifest in forms such as verbal harassment, physical violence, or discriminatory behaviours. The “Out on the Fields” survey, conducted in 2015, represents the first large-scale international study focusing on homophobia in sports [ 60 ]. Participants were from six countries: Canada, Australia, Ireland, the United States, New Zealand, and the United Kingdom. It revealed extensive discrimination in sport, with a high percentage of gay men and lesbians experiencing verbal slander, bullying, threats, and physical assault. The OUTSPORT project, completed in 2019 and funded by the European Union, is the first comprehensive EU-wide study on homophobia and transphobia in sport. The project collected data from over 5500 sexual minority individuals across all 28 EU member countries [ 61 ]. The results revealed that a significant portion of participants faced adverse experiences in sport contexts related to their sexual orientation and gender identity, including verbal abuse, structural discrimination, physical boundary crossing, and violence. An overwhelming majority of respondents (92.9%) view homophobia and transphobia in sport as current issues. Additionally, 20% of respondents reported avoiding participation in sport due to concerns about their sexual orientation or gender identity, while 16% of active participants experienced at least one related negative incident in the past year. Notably, male student-athletes exhibited higher levels of homophobic attitudes compared to their female counterparts and non-physical education students [ 15 , 16 , 62 ]. Conversely, female athletes reported experiencing less fear of exclusion and a more inclusive team environment [ 22 , 63 , 64 ], highlighting significant gender disparities in homonegativity in sport.

Group and individual identity

The distinct team interaction inherent in sport may enhance or support expressions of homonegativity and discrimination, as Social Identity Theory posits that negative beliefs about certain groups may develop group identity [ 65 , 66 , 67 ]. This phenomenon is particularly noticeable in intercollegiate sport, where a strong emphasis on physical attributes and abilities often results in prejudices against those who deviate from established norms [ 16 ]. Such discrimination and mistreatment of SMSAs frequently stem from their teammates and coaches. Many SMSAs choose to conceal their sexual orientation due to fear of ostracism [ 60 ], with team members often identified as the primary perpetrators of discrimination [ 61 ].

Therefore, navigating sexual identity within intercollegiate sport is challenging for SMSAs, as their minority status becomes a focal point, impacting their overall experience [ 68 , 69 ]. They encounter a unique psychological and emotional burden, striving to reconcile societal norms and expectations with their true selves. This constant negotiation and management of their identity across different contexts further complicates their experiences, frequently leading to difficulties in maintaining authenticity [ 19 ]. Therefore, SMSAs in intercollegiate sport face intricate challenges in balancing their authentic identity with societal norms, significantly impacting their experience and sense of self.

Theoretical framework

Self-categorisation theory (SCT), an extension of Social Identity Theory, provides a valuable perspective for examining the perceptions of SMSAs in China, focusing on intragroup processes and individual navigation of personal and social identities [ 70 , 71 ]. Key principles of SCT, including self-categorisation, salience, depersonalisation, and individuality [ 67 ], are instrumental in understanding how SMSAs navigate their sexual identities within the confines of sport norms. Applying SCT, this study could explore the complex interplay of intragroup relations and identity processes among SMSAs in the Chinese sport context, underscoring how contextual factors distinctly shape their identity.

Purpose of the study

The purpose of this study is to explore SMSAs’ perceptions of their sexual minority identity within the Chinese sports context and understand how this identity influences their participation in sports. By illuminating the specific challenges and issues related to sexual minority identity in Chinese intercollegiate sports, this study provides a deeper understanding of the experiences of sexual minorities in this field.

Research design

This study was conducted with the interpretivist paradigm, which emphasises understanding the subjective experiences and meanings that individuals assign to their world. It posits that reality is not objective but is constructed through individual perceptions and social interactions [ 72 ]. Given the aim of exploring the perceptions of sexual minority identity in sport from SMSAs’ perspectives, a qualitative research approach is appropriate. In line with the purpose of the study, the Interpretative Phenomenological Analysis (IPA) was adopted in this study, an approach aimed at understanding people’s lived experiences and how they make sense of these experiences in the context of their personal and social worlds [ 73 ]. IPA research encompasses phenomenology, hermeneutics, and idiography and emphasises the personal significance of self-reflection among individuals with a shared experience in a specific context [ 74 ]. Additionally, IPA is particularly suitable for research focusing on identity and self-awareness [ 75 ]. The features and focus of IPA are consistent with the purpose of this study. Therefore, IPA was considered a suitable approach to explore the SMSAs’ perceptions of their sexual minority identity within the sport context in China.

Researcher characteristics and reflexivity

During the data collection phase of this study, the first researcher was a Ph.D. candidate and had obtained her Ph.D. by the time of this manuscript’s submission. Her doctoral committee continuously supervised the research. The first researcher’s doctoral committee members are proficient in qualitative research. The first researcher and the second coder have received systematic qualitative training, are skilled in qualitative analysis software (NVivo), and have published empirical studies using the IPA approach. Although none of the research team members were SMSAs, the first researcher and the second coder maintained long-term contact with SMSAs through their involvement in sport teams. The first researcher was a former student-athlete and is currently working as a coach. Given her background, she has had extensive time to interact with and understand SMSAs within student teams.

Participants and procedures

Purposive and snowball sampling methods were employed to recruit a homogeneous sample for this study, as recommended by Smith and Nizza [ 73 ]. Following approval from Universiti Putra Malaysia’s Human Research Review Committee, the researcher initially reached out to SMSAs within her network, subsequently expanding outreach through social media to reach a broader pool of potential participants. The participants were selected based on specific inclusion criteria (Table 1 ), ensuring relevance to the study’s focus. Of the 22 individuals contacted, 16 agreed to participate, while six individuals declined participation due to concerns regarding potential exposure. The sample included a diverse representation of sexual minority subgroups: one asexual man, four bisexual women, three gay men, and eight lesbians. Given the relatively low prevalence of asexual individuals [ 76 , 77 ], we only had one participant from this subgroup. Strict confidentiality measures were enforced, with participants assigned pseudonyms and their college affiliations omitted for anonymity. The demographic details of the participants are outlined in Table 2 .

In phenomenological research, the focus is on rich individual experiences rather than data saturation [ 78 ]. Similarly, IPA research aims to explore participants’ personal and social worlds through detailed, in-depth analysis [ 79 ]. Smith and Nizza [ 73 ] also highlighted that in IPA research, sample size is less crucial because of the emphasis on detailed analysis in small, homogeneous samples. Therefore, the richness of data and the depth of insight into each participant’s experience are more important than the number of participants or reaching data saturation. This study utilised IPA’s in-depth analytical approach with sixteen participants to provide detailed data. This methodological approach allows for a comprehensive exploration of individual experiences, aligning with the study’s objectives.

Data collection

Data for this study were collected through semi-structured interviews (Appendix A), allowing participants to choose the mode, time, and location, including face-to-face or online sessions on Chinese social networks. Each interview’s length is detailed in Table 2 , with an average duration of 63 min. Before each interview, participants signed informed consent forms following a detailed briefing on the study’s purpose and procedures. Given the sensitive nature of the research, the interviews were conducted solely between the researcher and the participant to ensure a safe and comfortable environment, fostering open and honest communication.

The methods of data collection exhibited some qualitative differences. In face-to-face interviews, participants were often cautious and hesitant to share personal experiences. Conversely, online interviews proved more effective, as participants felt more relaxed, leading to quicker rapport and greater openness. This difference likely stems from the reduced perceived risk of exposure in an online setting. Due to the clear objectives of the study and the structured interview guide, there were no differences between the data from current SMSAs and former SMSAs.

Notably, one participant provided data through written essays instead of a semi-structured interview due to concerns about exposure and discomfort. After discussing the matter, the participant agreed to respond to interview questions in written form. The first researcher sent the interview questions to the participant, who then provided written responses. Follow-up questions were asked based on these initial responses, resulting in four sets of essay responses. This approach, which aligns with the conventions of phenomenological research [ 80 ], allowed the participant to express their experiences comfortably. The essay data were analysed alongside the semi-structured interview data, with common themes identified across all responses.

Documents and field notes supplemented the data collection. Documents included photographs, videos, and diaries. With participant consent, these documents were analysed for relevance to the research purpose. Field notes captured contextual information during both face-to-face and online interviews, including keywords and participants’ pauses and intonations, with immediate elaboration post-interview to avoid biases [ 81 , 82 ]. These detailed notes contextualised data analysis [ 74 ] and contributed to the research’s credibility.

Data analysis

The data analysis in this study followed a seven-step process aligned with IPA research guidelines and contemporary IPA terminology. The data analysis procedure is depicted in Fig. 1 . The IPA analysis is iterative and inductive [ 83 ], involving the organisation of data into a structured format for easy tracking through various stages – from initial exploratory notes on transcripts to the development of empirical statements, theme clustering, and final group theme structure. The theoretical framework was incorporated at the final stage of empirical theme development.

To enhance the study’s validity, the first author invited another Ph.D. candidate to participate in the data analysis process. After the interview recordings were translated into transcripts using audio software, the first researcher listened to the recordings repeatedly to correct the transcripts. The second coder reviewed the recordings to ensure the transcriptions were accurate and verbatim. The first author employed NVivo software (released in March 2020) for coding, and the second coder utilised manual coding. All data were analysed in Chinese to maintain linguistic integrity and then translated into English for theme presentation.

Data Analysis Procedure. Adapted from Smith et al. ( 74 )

The procedures of this study adhered to the COREQ Checklist [ 84 ] (Appendix B) and the IPA Quality Evaluation Guide [ 85 ] to ensure rigour. The research met the good quality requirements for IPA studies as outlined by Smith [ 85 ] (Table 3 ). Throughout the research, emphasis was placed on internal validity, external validity, and reliability to maintain the study’s rigour and quality. The methods employed to address these aspects are summarised in Table 4 .

This study explored SMSAs’ perceptions of sexual minority identity within intercollegiate sport in China. From the perspective of SCT, the results uncovered four key themes from SMSA’s team-based interactive experiences. The research themes, along with their corresponding sub-themes and occurrences, are presented in Table 5 .

Hidden truths

The hidden truths refer to facts, scenarios, or knowledge that are not commonly known or readily available. In this study, the existence of SMSAs in intercollegiate sport was undeniable, yet it remained concealed due to the prevailing lack of transparency.

SMSAs are common in sport

This research uncovered the extensive existence of SMSAs in Chinese sport. Almost all participants acknowledged the ubiquity of sexual minorities in sport, with 12 out of the 16 participants specifically highlighting the presence of SMSAs in collegiate sport:

I think everyone is generally aware of sexual minorities; all people are aware of them to a greater or lesser extent. It is generally agreed that the existence of sexual minorities is a common phenomenon in modern society, and even more so in Sport, as anyone involved in sport knows that (Adam).

Participants frequently described the presence of SMSAs in intercollegiate sport, using terms like “widespread”, “common”, “normal”, and “quite many”. Several participants also provided specific details about the number of SMSAs in their respective teams. Jackie remarked, “At that time, half of my teammates were lesbians” (Jackie). Similarly, Zoe noted the significant presence of SMSAs in her team, “I think it (the number of SMSAs) was almost half of the team at that time. But I don’t know about the senior players; almost half of our junior players were SMSAs” (Zoe).

Silent identity

Participants noted the prevalence of SMSAs in sport but also emphasised the difficulty of openly discussing sexual minority identity in this context. They described the sport environment as reserved and lacking open conversations about SMSAs and their experiences.

The reticent nature of sport teams regarding sexual minority identity was evident in their attitudes. William observed, “I feel like most of my teammates just don’t take a stand. They don’t want to make a statement about SMSAs. Nor did they say they supported it or didn’t support it” (William). Similarly, Mia considered sexual minority identity as a personal issue, inappropriate for open discussion.

No one wants to ask or discuss this openly…we live in a very conservative environment all the time, and none of this content is something that teammates should be concerned about, and people would feel offended if you don’t handle it well (Mia).

Some SMSAs viewed avoiding discussions on sexual minorities in sport as respectful to teammates, aiming for a comfortable, stress-free environment. Joy said, “We came here to play, right? I don’t think any of the other players want to feel phased by who you are” (Joy). Mia echoed this sentiment:

…in team training, the game is the game, and I rarely bring other emotions into it…. In the company of most of our teammates, we don’t interact with each other in that way. It’s probably a default rule that respect is distance, I guess (Mia).

Charlotte, involved in volleyball and basketball, recounted a teammate’s public derogation due to her sexual minority identity, an incident not openly addressed by the team. She perceived sexual identity as a “taboo” topic. The narratives revealed a cautious approach among SMSAs towards expressing their sexual minority identity in sport. They felt compelled to carefully manage their sexual orientation, minimising its disclosure. This hesitancy likely stemmed from the existing reticence and limited acceptance of SMSAs in sport, fostering a sense of invisibility and concern over potential negative consequences.

Prioritisation of athlete identity

The theme of prioritisation of athlete identity suggests that for SMSAs, their identity as an athlete may play a more prominent or influential role in shaping their self-conception compared to their sexual minority identity.

Be an athlete

Several participants believed their primary role as student-athletes was to engage in sport, and they valued this aspect of their identity significantly. Joy expressed this sentiment, “I love volleyball very much … I don’t care much about relationships; I just love volleyball, and I think we are all here to do this, and nothing else matters. You don’t need to stress about it (sexual minority identity)” (Joy).

Emma echoed a similar perspective, noting, “I think my teammates are very professional; our program requires a high technical standard, and we spend most of our time training; other than that, things don’t seem that important” (Emma). When queried about the importance of sexual minority identity, she responded, “Yes, at least not concerning sport performance, or maybe it will have a bad effect” (Emma). Additionally, some participants felt that in the context of sport, sexual minority identity might be sidelined. Adam commented:

“We don’t share it (sexual minority identity) unless someone asks. We’re a team first, and then we’re individuals, and for me, I’m important personally, but in the team, we all probably need to sacrifice some of ourselves to make the team more united and stronger” (Adam).

Participants’ views as both student-athletes and sexual minorities highlighted contrasts in the intercollegiate sport environment. Their student-athlete identity was key in shaping self-perception and fostering a sense of community, while their sexual minority identity was often marginalised in aspects of interpersonal relations, team support, and self-identity development.

Sport performance first norms

In team sport, leaders are crucial in creating inclusive spaces for SMSAs and setting behavioural and attitudinal standards, including those towards SMSAs. In this study, some participants believed that coaches’ criteria for acceptance of sexual minority individuals or intra-team romantic relationships were based on athletic performance.

Some coaches firmly believe that team relationships negatively impact team performance and, therefore, strictly prohibit romantic relationships between teammates. Joy recalled,

She couldn’t accept that… she thinks being an athlete like that is ridiculous. It would make a mess; her team would be in a mess. She said you two are dating and that playing will affect your emotions, which means she meant to say there is no way I can treat another girl as a normal teammate… (Joy).

In contrast, some coaches adopt a more tolerant attitude. Jackie’s coach believes that if the team’s overall performance is not affected, issues such as sexual orientation or team relationships can be ignored. Jackie stated, “My coach is male and old, but he should know what’s going on, especially since our captain has dated several teammates and the coach pretends not to know. He would only care if we were winning games” (Jackie).

Whether it instructs prohibition or an indifferent attitude, both narratives reflect that the team’s norms for inclusivity are based on sport performance. These norms also influence how SMSAs assess their own sexual minority identity within the team, as Adam said:

As of now, I have someone in the team that I have a crush on and haven’t dated. Maybe if he and I argued over training or a game, it would affect the performance of the team and the relationship between teammates…. I don’t think I could let that happen (Adam).

The participants’ narratives emphasise how the “Sports Performance First” norms influence the attitudes and behaviours of coaches and SMSAs within the team. These norms not only shape the team culture but also profoundly affect how SMSAs navigate their identities and relationships in the team environment.

However, the excessive focus on sport performance highlights the athletic identity of student-athletes while neglecting their other identities, especially those of sexual minorities. This singular focus leads to the neglect of the personal needs and diverse identities of athletes. Although these measures may seem to ensure the overall performance of the team, they overlook the psychological health and holistic development needs of the individuals.

Self-stereotyping

Self-stereotyping denotes the tendency of SMSAs to describe themselves using stereotypical attributes in the sport context. These descriptions frequently align with stereotypical perceptions prevalent in the external environment. SMSAs tend to be perceived as having specific physical traits or behavioural tendencies.

Specific physical traits

Sophia provided an illustrative example of self-stereotyping through her personal experience. She commented:

In the beginning, I would think that if you are an SMSA, you must fit some characteristics. For example, at that time, I saw some lesbians in my team who had short hair or wore baggy t-shirts; I was a bit frustrated by my long hair and feminine appearance…and I felt that I might not quite fit those criteria. So, then I cut my hair and even wore a wrapping bra to the training ground (Sophia). Sophia’s narrative underscores how the pressure to conform to certain physical traits led her to change her appearance to fit the stereotypical image of an SMSA within the sport context.

Behavioural tendencies

In addition to physical traits, SMSAs also feel compelled to conform to certain behavioural tendencies that are stereotypically associated with SMSAs. Zoe explained, “Because of who I am (T), I felt I should have to perform stronger, so I put up with much training…. I felt I should be there to protect the other players; if I were vulnerable, I would look down on myself” (Zoe). This indicates a sense of obligation among some female SMSAs to embody strength, aligning with the stereotypical image of female SMSAs in sport. Conversely, male SMSAs in men’s teams often faced stereotypes of being fragile, weak, or exhibiting feminine traits. Royal noted that behaviours of some male SMSAs, like engaging in non-sport-related banter, led to gossip and negative perceptions within men’s sport. To avoid these stereotypes, Royal aimed to mimic the mannerisms of heterosexual athletes, as he explained:

I try to avoid being close to the team’s prominent male SMSAs and try to stay out of related conversations; I don’t want to be a standard gay; I want to have the same college life as the rest of the team (heterosexuality) (Royal).

Stereotypes in sport often forced SMSAs into roles incongruent with their authentic identities, significantly impacting their self-expression and identity. The pressure to conform to societal norms in sport settings created internal conflicts for SMSAs, challenging their ability to maintain their true sense of self.

This theme addresses situations where student-athletes engage in intra-team intimacy or mimic being SMSAs in sport. This attempt has two key elements: prolonged contact leading to intimacy and influence from sexual minority teammates.

Prolonged contact leading to intimacy

Participants noted that extensive training and competition schedules in sport fostered close bonds among team members. Lucas shared, “When we were preparing for the tournament, we trained together every morning and evening…the game spanned for almost a month, and after that, we felt as close as family to our teammates” (Lucas). Similarly, Ruby pointed out, “Back then, we were training every afternoon until late at night; it was quite hard (the training was very strenuous) … it lasted for six months” (Ruby). These prolonged interactions sometimes led to the development of more profound attractions among student-athletes.

“I think we had many moments of trust and intimacy together on the field that built up some heartfelt feelings. These feelings made me feel emotions beyond that of a teammate…. Then I realised that gender might not be so important because it’s hard to build that kind of relationship in a typical romance” (Savannah).

Influence from sexual minority teammates

Participants also described how interactions with sexual minority teammates led them to explore their own sexual identities, as illustrated by Ava’s recounting of her initial same-gender relationship experience:

That time we went out to a tournament, and I found that four of my teammates, three of them were lesbians…we didn’t have games at night, so they had been talking to their girlfriends every night on the phone, and I just felt as if that was not too bad. Probably influenced by them, I got a girlfriend at that tournament as well…. Even though we broke up when we returned, I could accept girls (Ava).

Mia described a similar experience:

There were some lesbians in my team, and then it just seemed natural that I got close to one of them…. Well, I was thinking about whether that relationship would affect the team. But then I found out that there were other couples on the team. So, I feel like I wasn’t doing anything wrong (Mia).

The phenomenon highlights the significant role of peer influence in team settings. When individuals are around many teammates in same-gender relationships, it fosters an environment that normalises such relationships. Notably, this influence is not coercive but stems from observing and interacting with teammates who are comfortable with their sexual orientations. This environment helps individuals feel accepted and more confident in exploring their identities and relationships.

This study explored the perceptions of SMSAs regarding their sexual identity within intercollegiate sport in China. Its importance lies in its contribution to understanding the complex realities of SMSAs in China, an area that has lacked depth in the literature. By reaffirming the necessity of examining these athletes’ experiences, this study reveals the intricate conflict between adhering to team norms and expressing personal characteristics within the context of the Chinese social and cultural background.

The results show that SMSAs are a recognised reality in Chinese intercollegiate sport, consistent with findings from Western countries. While precise figures of sexual minorities in sport may vary across countries, it is acknowledged that they are present at all competitive levels, from school and college sport to the professional sphere [ 22 , 86 , 87 , 88 , 89 , 90 , 91 ]. Although no national census on sexual minorities in China or in sports environments exists, related research indicates that many college and university students self-identify as sexual minorities. For instance, an online survey conducted across 26 colleges and universities in 10 Chinese provinces found that over 8% of students identify as sexual minorities [ 36 ]. Additionally, another national survey revealed that nearly a quarter of college students identify as non-heterosexual [ 92 ]. Recognising and addressing the unique challenges faced by sexual minority youth, who make up a notable percentage of the student population, is essential for sport and educational institutions.

Despite the apparent prevalence of SMSAs, the study confirms that their identities often remain hidden in the context of Chinese intercollegiate sport. This can be attributed to two main reasons: First is the concern about discrimination if exposed. Chinese sexual minorities frequently report experiencing abuse or discrimination in families, schools, and workplaces [ 93 ]. Additionally, conversion therapies and discriminatory counselling practices persist in mental health services [ 94 ], creating an environment where discrimination is a significant concern, thereby reducing the likelihood of SMSAs coming out in the sports environment. The second reason is the constraint of traditional Chinese culture. The dominant Confucian culture in China emphasises harmony, internalised homonegativity, and conformity [ 95 , 96 ], often at the expense of individual expression and identity development. This cultural backdrop influences how sexual minorities perceive their own identities [ 97 ] and creates an ideological constraint that leads to social rejection and resistance towards sexual minorities [ 98 ], thereby reducing the visibility of sexual orientation-related topics in the Chinese sport context.

Moreover, SMSAs in China often prioritise their athlete identity over their sexual minority identity, influenced by the attitudes of team leaders. This tendency is reinforced by coaches who primarily focus on the biological sex of athletes and lack training or understanding related to sexual minority issues [ 99 ]. Consequently, the Chinese coaches’ lack of knowledge about sex and sexual orientation exacerbates the silence surrounding sexual minority identities in the Chinese collegiate sport environment and intensifies the identity conflict for SMSAs. Emphasising athletic performance is central in sport but should not overshadow the holistic development of student-athletes. McCavanagh and Cadaret [ 100 ] noted that student-athletes might face challenges in reconciling various aspects of their identity in a heteronormative sport context. The suppression of sexual minority identity can lead to isolation from potential support systems that nurture positive sexual and gender identities. Prioritising athletic success over broader student development in sport departments limits growth opportunities for all students, including SMSAs. Chavez et al. [ 101 ] emphasised that student development requires recognising and valuing diversity, suggesting that a singular focus on athletic prowess can diminish the benefits of diversity among student-athletes. Embracing diversity is not only a personal journey but also one that can enhance the collective experience within sport settings.

In addition, self-stereotyping within SCT involves aligning one’s self-concept with the characteristics of valued social categories [ 102 ]. Latrofa [ 103 ] suggests that members of low-status groups, like SMSAs in sport, may self-stereotype to align more closely with their group, reflecting recognition of lower status and self-perception through peers. This study revealed SMSAs shape their self-identity based on the attitudes prevalent in their sport environment, with influences from peers and coaches being internalised as personal attitudes [ 104 ]. Such self-stereotyping supports maintaining a favourable social identity and adhering to group norms but can reinforce negative stereotypes and prejudices within sport.

Internalising stereotypes may lead SMSAs to develop prejudices against themselves and others, perpetuating discrimination. It can also hinder individual development, impacting self-esteem and confidence. For example, aligning with negative stereotypes could cause SMSAs to doubt their worth and capabilities, affecting emotional well-being and satisfaction. Liu and Song’s [ 105 ] survey of Chinese college students illustrated the direct impact of gender self-stereotypes on life satisfaction, highlighting the significant effects of self-stereotyping on individual well-being.

Furthermore, in the context of traditional and reserved Chinese culture, intercollegiate sport offers a relatively free and open space for sexual minority women. The results of this study suggest that the visibility of sexual minority women in teams and the long time spent together allow these athletes to explore and establish intimate relationships. These results are similar to findings in Spanish studies [ 103 ], which highlighted the protective and liberating role of sports teams in the sexual exploration of female sexual minority athletes. Research by Organista and Kossakowski on Polish female footballers [ 106 ] and Xiong and Guo [ 96 ] on Chinese women’s basketball teams also revealed a climate of non-heteronormativity in women’s sport. These climates provide a sanctuary from heterosexual pressures, allowing sexual minority athletes to engage in sport free from traditional constraints. Such environments help female sexual minority athletes navigate and subvert heteronormative norms by cultivating supportive subcultural networks within their teams.

This study addresses the lack of in-depth research on the experiences of SMSAs in Chinese intercollegiate sport. It fills the gap by exploring the complex realities of SMSAs, focusing on their identity conflicts and the influence of the Chinese social and cultural background. Specifically, this study provides valuable insights that align with SCT [ 71 ]. This study addresses a notable gap in the existing literature regarding sexual minority sport participation, as rarely have these perceptions been explored. Drawing from the lens of SCT, the results of this study revealed several valuable insights into how their sexual minority identity impacts their participation in sport. These findings not only enhance our understanding of how SCT applies to the sport experiences of sexual minority individuals but also contribute to the advancement of SCT in research on sexual minority sport participation. The themes uncovered in this study closely align with central SCT concepts such as identity salience, self-stereotyping, and depersonalisation, illuminating the ways SMSAs comprehend and express their sexual minority identity within the intercollegiate sport context. SCT, with its focus on both intragroup and intergroup relations within the multifaceted construct of the self, offers valuable insights into the complexities of SMSAs’ self-perceptions and the intricacies involved in developing and manifesting their identities in the realm of sport.

Based on the results, more effort needs to be put into understanding sexual minority identities in intercollegiate sport. By examining the perspectives and experiences of SMSAs, we can gain insights into the interactions and influences of sexual minority individuals in the sport context. The interplay between an individual’s self-perception and situational dynamics results in a self-identity that mirrors the collective. In addition, the prevalent pressures and normative prejudices inherent in the sport system significantly influence their self-identity. Therefore, valuing SMSAs’ understanding of their self-identity shows respect for each person’s differences and rights. We hope the findings will be incorporated into existing sport policies to promote inclusivity and ensure safe participation for sexual minority students. To encourage and support the full development of SMSAs, college athletics and related institutions should prioritise understanding and respecting their perceptions of their sexual minority identity. By doing so, institutions can create a more inclusive and supportive environment that acknowledges and addresses the unique challenges faced by SMSAs.

Nevertheless, caution should be exercised when generalizing the findings, especially for subgroups with low representation, such as asexual individuals. While the study provides valuable insights into SMSAs’ perceptions of their sexual minority identity within the Chinese sport context, the limited number of asexual participants means their unique perspectives may not be fully captured. Therefore, these findings may not fully represent all sexual minority subgroups.

Future research could focus on exploring the perceptions and experiences among various sexual minority subgroups within sport participation in China. Additionally, considering the cultural diversity across China’s vast geographic regions, it would be valuable to examine how SMSAs perceive their minority identity in different cultural contexts. Given the scarcity of related studies in China, it is also important to survey other stakeholders in the sport environment, such as coaches and heterosexual student-athletes, to gain a broader understanding of perceptions of sexual minority identities. These insights can inform the development of targeted interventions aimed at ensuring the safe and inclusive participation of SMSAs in intercollegiate sport.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to ethical considerations but are available from the corresponding author on reasonable request.

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Iran J Nurs Midwifery Res
v.20(6); Nov-Dec 2015

Challenges in conducting qualitative research in health: A conceptual paper

Hamidreza khankeh.

1 Department of Health in Disaster and Emergencies and Nursing, University of Social Welfare and Rehabilitation, Tehran, Iran and Department of Clinical Sciences and Education, Karolinska Institute, Stockholm, Sweden

Maryam Ranjbar

2 Department of Psychology in Institute of Humanities and Social Studies, and Social Determinants of Health Research Center in University of Social Welfare and Rehabilitation, Tehran, Iran

Davoud Khorasani-Zavareh

3 Social Determinants of Health Research Center, Uremia University of Medical Sciences, Uremia, Iran and Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

Ali Zargham-Boroujeni

4 Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Eva Johansson

5 Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

Background:

Qualitative research focuses on social world and provides the tools to study health phenomena from the perspective of those experiencing them. Identifying the problem, forming the question, and selecting an appropriate methodology and design are some of the initial challenges that researchers encounter in the early stages of any research project. These problems are particularly common for novices.

Materials and Methods:

This article describes the practical challenges of using qualitative inquiry in the field of health and the challenges of performing an interpretive research based on professional experience as a qualitative researcher and on available literature.

One of the main topics discussed is the nature of qualitative research, its inherent challenges, and how to overcome them. Some of those highlighted here include: identification of the research problem, formation of the research question/aim, and selecting an appropriate methodology and research design, which are the main concerns of qualitative researchers and need to be handled properly. Insights from real-life experiences in conducting qualitative research in health reveal these issues.

Conclusions:

The paper provides personal comments on the experiences of a researcher in conducting pure qualitative research in the field of health. It offers insights into the practical difficulties encountered when performing qualitative studies and offers solutions and alternatives applied by these authors, which may be of use to others.

I NTRODUCTION

Health services and health policy research can be based on qualitative research methods, especially when they deal with a rapid change and develop a more fully integrated theory base and research agenda. However, the field must be with the best traditions and techniques of qualitative methods and should distinguish the essentiality of special training and experience in applying these methods.[ 1 ]

Qualitative research methodologies could help improve our understanding of health-related phenomena. Health knowledge must also include interpretive action to maintain scientific quality when research methods are applied. Qualitative and quantitative strategies should be seen as complementary rather than being thought of as incompatible. Although the procedures of interpreting texts are different from those of statistical analysis, due to their different type of data and questions to be answered, the underlying scientific principles are very much the same.[ 2 ]

While working for more than a decade as qualitative designer, Khankeh faced a lot of challenges in conducting qualitative research in the field of health which occupied the mind of other health researchers. Therefore, this article contributes to the discussion of challenges related to qualitative research in healthcare in the light of personal experiences of a researcher conducting purely qualitative health research.

A M AIN I SSUE FOR THE Q UALITATIVE R ESEARCHER

Qualitative research methods involve systematic collection, organizing, and interpretation of material in textual form derived from talk or observations. They are useful to explore the meanings of social phenomena as experienced by individuals in their natural context. The health community still looks at qualitative research with skepticism and accuses it for the subjective nature and absence of facts. Scientific standards, criteria and checklists do exist and the adequacy of guidelines has been vigorously debated within this cross-disciplinary field.[ 2 ]

Clinical knowledge consists of interpretive action and interaction – factors that involve communication, shared opinions, and experiences. The current quantitative research methods indicate a confined access to clinical knowledge, since they insert only the questions and phenomena that can be controlled, measured, and are countable where it is necessary to investigate, share and contest the tacit knowledge of an experienced practitioner. Qualitative research focuses on the people's social world, and not their disease. It is concerned with increased understanding of the meaning of certain conditions for health professionals and patients, and how their relationships are built in a particular social context.[ 3 ] These kinds of research allow exploration of the social events as experienced by individuals in their natural context. Qualitative inquiry could contribute to a broader understanding of health science [ 4 ] considering the substantial congruence between the core elements of health practice and the principles underpinning qualitative research. The globalization progress augments the necessity of qualitative research.[ 5 ]

Corbin (2008) reported that in the past 10 years, the interest in qualitative methods in general and grounded theory in particular has burgeoned according to a review of the literature and dissertation abstracts.[ 6 ]

A researcher engaged in qualitative research will be confronted with a number of challenges. Identifying the research problem and forming the research question are some of the initial challenges that researchers encounter in the early stages of a qualitative research project. Researchers and students sometimes fail to understand that adopting a qualitative approach is only the first stage in the process of selecting an appropriate research methodology.[ 7 ]

Once the initial research question has been identified, the crucial decision to be made is on the selection of an appropriate method, such as content analysis, ethnography, or grounded theory, and selecting the research design as well. Subsequent arrangements would be on the proper methods of data collection, participants, and the research setting, according to the methodology and the research question.[ 8 ] Qualitative researchers should also handle other important concerns such as data analysis, ethical issues, and rigor methods of results.

In this paper, we are going to discuss important practical challenges of qualitative inquiry in health and the challenges faced by researchers using interpretive research methodologies.

U NDERSTANDING THE R EAL N ATURE OF Q UALITATIVE R ESEARCH AND ITS C HALLENGES

It is important to provide an honest and concise appreciation of the essential characteristics of the qualitative research before discussing the challenges of the interpretive research approach to studies in health.

Virtues of qualitative research

Qualitative research does not promise a clear or direct and orderly method of tackling research problems in health studies. It does not provide researchers with a set of rules to be followed or give them a comforting sense of security and safety backup against possible mistakes on the road to knowledge. This research method depends on the “power of words and images,” but does not offer the assimilated meanings such as numbers and equations; it is rather “an attentive search of meaning and understanding” and an attempt for profound comprehension and awareness of the problems and phenomena. The essentially “diagnostic and exploratory nature” of qualitative research is invaluable in developing conceptualizations in health as an evolving discipline. It tenders the possible tap into the sea of complex interactions in health that can be as follows.

Researchers launch the quest for new theories in health which should acknowledge that “qualitative research is an approach rather than a particular set of techniques, and its appropriateness derives from the nature of the social phenomena to be explored.”[ 9 ] In qualitative research, knowledge derives from the context-specific perspective on the experienced phenomena, interpretations, and explanation of social experiences.

Why qualitative research in the health professions?

Researcher should justify the reason for which he or she selected qualitative research. Qualitative researchers pursue a holistic and exclusive perspective. The approach is helpful in understanding human experiences, which is important for health professionals who focus on caring, communication, and interaction.[ 10 ] Many potential researchers intend to find the answer to the questions about a problem or a major issue in clinical practice or quantitative research can not verify them.

In fact, they choose qualitative research for some significant reasons:

The emotions, perceptions, and actions of people who suffer from a medical condition can be understood by qualitative research
The meanings of health professions will only be uncovered through observing the interactions of professionals with clients and interviewing about their experience. This is also applicable to the students destined for the healthcare field
Qualitative research is individualized; hence, researchers consider the participants as whole human beings, not as a bunch of physical compartments
Observation and asking people are the only ways to understand the causes of particular behaviors. Therefore, this type of research can develop health or education policies; policies for altering health behavior can only be effective if the behavior's basis is clearly understood.[ 10 , 11 ]

Before adhering to a distinct research methodology, researchers have to exactly understand the nature and character of their inquiries and the knowledge they choose to create. The majority of health researchers face many loopholes in justification. However, all defects and challenges of qualitative research should be realized rather than discarded as a compelling way to knowledge structure. New endeavors in excellent academic achievement and building new tradition of qualitative research in health can be facilitated through acknowledging traps and clarifying the real practical challenges.[ 9 ]

Finally, qualitative research provides investigators with the tools to study the health phenomena from the perspective of those experiencing them. This approach is especially applied in situ ations that have not been previously studied, where major gaps exists in research field, and when there is a need for a new perspective to be identified for the arena of health care intervention.[ 6 ]

Based on corbin and strauss (2008), “ Committed qualitative researchers lean toward qualitative work because they are drawn to the fluid, evolving, and dynamic nature of this approach in contrast to the more rigid and structured format of quantitative methods. Qualitative researchers enjoy serendipity and discovery. It is the endless possibilities to learn more about people that qualitative researchers resonate to. It is not distance that qualitative researchers want between themselves and their participants, but the opportunity to connect with them at a human level (Epistemology). Qualitative researchers have a natural curiosity that leads them to study worlds that interest them and that they otherwise might not have access to. Furthermore, qualitative researchers enjoy playing with words, making order out of seeming disorder, and thinking in terms of complex relationships. For them, doing qualitative research is a challenge that brings the whole self into the process .”

Choosing an approach for health research

Researchers select approaches and methodology based on some scientific logics, not on being easy or interesting. The nature and type of the research question or problem; the researcher's epistemological stance, capabilities, knowledge, skills, and training; and the resources available for the research project are the criteria upon which adopting methodology and procedures depend.[ 6 , 10 ]

Inconsistency between research question and methodology, insufficient methodological knowledge, and lack of attention on philosophical underpinning of qualitative methodology can be mentioned as some important challenges here.

There are several different ways of qualitative research and researchers will have to select between various approaches. The qualitative research is based on the theoretical and philosophical assumptions that researchers try to understand. Then, the research methodology and process should be chosen to be consistent with these basic assumptions and the research question as well.[ 10 ]

Some researchers believe that there is no need to study the methodology and methods before beginning the research. Many researchers neglect to gain this knowledge because they are not aware of the qualitative inquiry complexities which make them go wrong. For instance, lack of information about interview, qualitative data analysis, or sampling is very common.[ 10 ]

My experience shows that lack of knowledge, experience, and skills in a research team to do qualitative research can hinder the formation of original knowledge and improvement in understanding the phenomenon under study. The result of such a study will not be new and interesting, and even the study process will be very mechanical without good interpretation or enough exploration. Sometimes there is an inconsistency between research question, research methodology, and basic philosophical assumptions, and the researchers fail to justify their methods of choice in line with the research question and the ontological and epidemiological assumptions.

Finally, the researcher's intentions, the aims of the research question/inquiry, and the chosen approach are regarded as the most important reasons to select a qualitative research method consistent with them and their underpinning philosophical assumptions as well.[ 6 , 10 ]

Research question and aim

Qualitative research is exciting because it asks questions about people's everyday lives and experiences. A qualitative researcher will have the chance of discovering the “significant truths” in the lives of people. That is a wonderful privilege, but you need to get those questions right if you dig into people's lives and ask about their real experiences. An adequate and explicit research question, or a set of interrelated questions, builds the basis for a good research. But excellent research questions are not easy to write at all. A good research requires a good research question as well because it allows us to identify what we really want to know. However, at the beginning of a project, researchers may be uncertain about what exactly they intend to know, so vague questions can lead to an unfocused project.

Common problems coming up with a research question include:

Deciding about the research area among a range of issues that are heeded in your field of interest
Not capable of pointing toward any interesting area or topic sufficient to focus a major piece of work on
Knowing about the area you want to concentrate on (e.g. emergency), but not a certain topic
Knowing what area and topic is specifically difficult to articulate a clear question.

Just make sure that you give serious consideration to the chosen area as the basis of your research and that a qualitative project is relevant and possible

Having identified a research area, your next step will be to identify a topic within that interesting area. Research questions should be derived from the literature. The research question can come from the list of “suggestions for future work” at the end of a paper you have found interesting. Moreover, you can search for some verifiable gaps through literature review, or based on your personal or professional experience and expert opinion , which should be studied. Therefore, all the previous studies that have already been conducted in the area are considered as important. In this way, you do not run the risk of asking a research question that has already been addressed and/or answered. Based on my experience, novice researchers have some problems finding the right topics in their field of interest because they do not perform a broad literature review to find the gaps and problems suitable to be investigated. Sometimes their field of interest is different from that of their supervisors or there are no experts to help them in this regard.

Although the topic may retain your interest and you may be committed to undertake such a study, it is important to recognize that some topics of personal relevance may also be deeply significant and difficult to research. Finally you need to make sure that your topic of interest is the one that you can actually study within the project constraints such as time and fund.[ 12 ]

Once you have identified your interesting topic for research (according to a broad literature review, personal and professional experience, and/or expert opinion), you can begin to create a research question.

Forming the research question is one of the initial challenges that researchers encounter in the early stages of a research project. Therefore, it acquires significance by the very fact that it provides brief, but nevertheless, important information on the research topic that allows the reader to decide if the topic is relevant, researchable, and a remarkable issue. Furthermore, the research question in qualitative studies has an additional significance as it determines the manner of conducting the study.

The qualitative research question delineates the procedures that are executed in the study and provides a map to the readers by which they can trail the researcher's intentions and actions in the study. Therefore, special attention is needed on how a qualitative research question will specifically be structured, organized, and formed in the way to quote the necessary information and elements that allow the readers to assess and evaluate the study.

The formation of a qualitative research question acquires a basic conducting role for the study and a fundamental function to develop an audit trail that can empower the readers to judge the value, rigor, and validity of the whole research project. Hence, researchers should not only pay special attention toward developing a significant and relevant question, but also formulate it properly. The qualitative research question must be provided in such a way as to impart, reflect, and conjoin the theoretical and abstract assumptions with the practical and pragmatic means of attaining them.

In plain words, a good qualitative research question implicates particular phrasing, whereas the order of words should make the topic of interest amenable to the qualitative quest.

The researcher has to concentrate on how the content of the research topic is understood when phrasing the qualitative research questions, adhering to the topic with the philosophical/theoretical suggestions and to the structure of the study which requires compounding specific principal elements.

The content of a good qualitative research question takes the form of a declarative rather than an interrogative statement

Also, the content provides a brief focus on the issue to be investigated, but does not define the exact relationship of the variables to make these relationships flexible in emanating from the study according to the qualitative research theory. The qualitative research question incepts necessarily with an active verb like understanding, exploring, interpreting, constructing, explaining, describing, etc., to reflect the paradigm/philosophy underpinning the qualitative study. Consequently, specific nouns that represent the aims of qualitative studies, such as experiences, feelings, views, perspectives, knowledge, etc., should be applied. Finally, the methodology or method should appear in the qualitative research question coherent with them. Meanwhile, the structure of a good qualitative research question will address five of the following six: who, when, where, what, how, and why, and the entire research question should devise the sixth element.[ 13 ]

For instance, “Exploring the experiences of self-immolated women regarding their motives for attempting suicide: A qualitative content analysis study in Kermanshah Iran”

Make sure that your research question is consistent with the approach you are adopting. It is like an easy trap if you decide about the research question before considering the proper way by which you are intending to make assumptions and analyze your data.

My experiences show that novice researchers formulate their research question without considering the approach of their study in a proper way and usually their research questions are very broad, unclear, and vague. Since the intention of their studies is not completely clear at the beginning, they cannot decide about the research approach; also, they have to change their research question and take different directions in the course of study or they will end up without adequate results that can help readers or consumers improve their understanding or solve the problem.

Although a researcher initiates a study with a general question and topic, the interesting aspect of qualitative research is that the questions, which are more specific and can help in further data collection and analysis, arise during the course of the study. Thus, a qualitative research question can be broadly, rather than narrowly, focused in the beginning. Researcher can try to refine and make it more focused later. This is why qualitative research is usually cyclic rather than linear. Qualitative research is cyclic, which means that the research question in this approach immerses gradually into the topic. It means that when you come to know more and more about your topic, your ideas develop about what to focus, either through reading, thinking about what you have read, or in early stages of data analysis. Finally, it is literature review, general reading, and discussion with an expert supervisor that can help you find the right topic. If the background knowledge is poor at the beginning of the study, broad but clear research question can be reasonable. Research question may become more focused or develop in a different direction according to more reading and/or preliminary data analysis. A clear and focused research question is articulated and used to conduct further analysis and any future literature reviews necessary for the final write-up.

However, it is very important to take time to choose a research question, because it can be a very challenging exercise. Actually, the ultimate success of the project depends on selecting a clear and convenient question. The question should be appropriate for the qualitative research and for the specific approach you choose which must be grounded in research. It must ask precisely what you want to find out and be articulated and clear. Knowing this will help you plan your project.[ 12 ]

Choosing the right methodology and research design

Crucial decisions need to be made about an appropriate methodology, such as ethnography or grounded theory, after identifying the initial research question. The main concern of novice researchers is to find the reason and appropriate design to do the research, and proper methodology to answer the question. Researchers ought to figure out about the planning of qualitative research and how to choose the methodology.

Researchers sometimes fail to understand that in the process of selecting an adequate research methodology, adopting a qualitative approach is only the first stage. Students, and sometimes researchers, choose qualitative research because they think it is easier to use than the other methodologies. But this reasoning is fumble since qualitative research is a complex methodology where data collection and analysis can be mostly challenging. Sometimes lack of planning and inadequate attention paid to the properness of the selected approach considering the purpose of research will be problematic.

For new qualitative researchers, it often seems that the researcher should totally concentrate on the dual process of data collection and data analysis. It is very important to consider thorough planning in all stages of the research process, from developing the question to the final write-up of the findings for publication.[ 6 ]

The research design and methodology must be adequate to address the selected topics and the research question. Researchers have to identify, describe, and justify the methodology they chose, besides the strategies and procedures involved. So, it is pivotal to find the proper method for the research question. It should be noticed that some of the details of a qualitative research project cannot be ascertained in advance and may be specified as they arise during the research process.[ 10 ] An important problem for novice researchers is the little acknowledgement of different approaches that address different kinds and levels of questions and take a different stance on the kind of phenomena which is focused upon. More discussion and debates are necessary before selecting and justifying an approach.

The need for consistency and coherence becomes more obvious when we consider the risk of something called “method-slurring.” This is the problem of blurring distinctions between qualitative approaches. Each approach has to demonstrate its consistency to its foundations and will reflect them in data collection, analysis, and knowledge claim.

It may be important to acknowledge the distinctive features by specific approaches such as phenomenology or grounded theory at some levels such as the type of question they are suited to answer, data collection methods they are consistent with, and also the kinds of analysis and presentation of the results that fit within the approach – such as “goodness of fit” or logical staged linking – and can be referred to as “consistency.”

If such consistency occurs, then the whole thing “hangs together” as coherent; that is, the kind of knowledge generated in the results or presentation section doing what is said it would do following the aims of the project. In order to consider these criteria of consistency and coherence in greater detail, we need to look at the distinctive differences between qualitative approaches in the following: the aims of the research approach, its roots in different disciplines and ideologies, the knowledge claims linked to it, and to a lesser extent, the data collection and analysis specific to each approach.[ 11 ]

My experience shows that novice researchers have some problems to justify their methodology of choice and sometimes they experience some degree of methodological slurring. They do not have any clear understanding of the research process in terms of data gathering strategies, data analysis method, and even appropriate sampling plan, which should be indentified based on philosophical and methodological principles.

Finally, besides the above-mentioned problems, regarding research design, there are two common problems encountered especially by students who want to do qualitative study; sometimes researchers and research team try to identify everything, even the sample size, in advance when they design their study because they have a strong background of quantitative research, and this is completely in contrast with the flexible nature and explorative approach of qualitative research. The other problem is the examination committee and the format of proposal of grant sites and funding agencies, which are based on the principles of quantitative study. This rigid format pushes the researchers to try to clarify everything in advance. So, flexibility is regarded as the most important credibility criterion in all kinds of qualitative research and it should be considered when designing the study and following its process.[ 1 ]

C ONCLUSIONS

Qualitative research focuses on social world and provides investigators with the tools to study health phenomena from the perspective of those experiencing them.

Identifying the research problem, forming the research question, and selecting an appropriate methodology and research design are some of the initial challenges that researchers encounter in the early stages of a qualitative research project.

Once the research problem and the initial research question are identified, the crucial decision has to be made in selecting the appropriate methodology. Subsequent arrangements would be on the proper methods of data collection, and choosing the participants and the research setting according to the methodology and the research question. It is highly recommended that the researchers exactly understand the nature and character of their inquiries and the knowledge they choose to create before adhering to a distinct research methodology based on scientific knowledge.

The essence and type of the research question or problem, the researcher's epistemological stance, capabilities, knowledge, skills and training, and the resources available for the research project are the criteria upon which the adopting methodology and procedures depend.

Inconsistency between research question and methodology, insufficient methodological knowledge, and lack of attention to the philosophical underpinning of qualitative methodology are some important challenges.

Lack of knowledge, experience, and skills to do qualitative research can hinder the formation of original knowledge and improvement in understanding the phenomenon under study. The result of such a study will not be new and interesting, and even the study process will be very mechanical without good interpretation or enough exploration. A good research requires a good research question as well because it allows us to identify what we really want to know. However, at the beginning of a project, researchers may be wavering about what they exactly intend to know; so, vague questions can lead to an unfocused project.

Broad literature review, personal and professional experience, and/or expert opinion can be regarded as the main sources to identify interesting research topics and research questions as well. Forming the research question is one of the initial challenges that researchers encounter in the early stages of a research project. Therefore, it acquires significance by the very fact that it provides brief, but nevertheless, important information on the research topic that allows the reader to decide if the topic is relevant, researchable, and a remarkable issue that can help the researcher to determine the manner of conducting the study.

Then crucial decisions need to be made about an appropriate methodology. The main concern of novice researchers is to find the reason and appropriate design to do the research and the proper methodology to answer the question. Researchers first ought to figure out the planning of qualitative research and how to choose the methodology.

It is very important to consider thorough planning in all stages of the research process, from developing the question to final write-up of the findings for publication. It is worth knowing that some of the details of a qualitative research project cannot be ascertained in advance and may be specified as they arise during the research process. For a novice researcher, more discussions and debates are necessary before selecting and justifying an approach.

Method-slurring is another common problem, which means the act of blurring distinctions between qualitative approaches. Each approach has to demonstrate its consistency to its foundations and will reflect them in data collection, analysis, and knowledge claim.

It is not rare to find that researchers and research team try to identify everything, even sample size, in advance when they design their qualitative study because of the strong background they have about the quantitative research. This is completely in contrast with the flexible nature and explorative approach of qualitative research; as these kinds of researches are completely explorative, the mentioned issues – such as sample size – should be clarified in the course of the study.

The other problem is the examination committee and the format of proposal in the grant sites and funding agencies, which is based on the principles of quantitative study. Therefore, flexibility is actually the most important credibility criterion in all qualitative researches that should be considered when a study is designed and the study process is followed.

As the final word, the researcher should make sure that he/she gives serious consideration to the chosen area as the basis of research and that a qualitative project is relevant and possible. Thus, forming the research question in a proper way and selecting appropriate methodology can guarantee original, interesting, and applied knowledge, which at least can increase our understanding about the meaning of certain conditions for professionals and patients and how their relationships are built in a particular social context.

Source of Support: Nil

Conflict of Interest: None declared.

R EFERENCES

IMAGES

(PDF) Qualitative research in health care: Assessing quality in
Qualitative Methods for Health Research
(PDF) Qualitative methods in research on healthcare quality
Qualitative Research in Nursing and Healthcare; 1 Edition; ISBN
Qualitative Research in the Health Sciences: Methodologies, Methods and
(PDF) Qualitative Research for Improved Health Programs: A Guide to

COMMENTS

Qualitative Health Research: Sage Journals
Qualitative Health Research (QHR) is a peer-reviewed monthly journal that provides an international, interdisciplinary forum to enhance health care and further the development and understanding of qualitative research in health-care settings.QHR is an invaluable resource for researchers and academics, administrators and others in the health and social service professions, and graduates who ...
SSM
SSM - Qualitative Research in Health is a peer-reviewed, open access journal that publishes international and interdisciplinary qualitative research, methodological, and theoretical contributions related to medical care, illness, disease, health, and wellbeing from across the globe.. SSM - Qualitative Research in Health is edited by Stefan Timmermans, a Senior Editor at Social Science & Medicine.
Qualitative Methods in Health Care Research
The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings. Table 1.
Qualitative Research in Healthcare: Necessity and Characteristics
Qualitative research is conducted in the following order: (1) selection of a research topic and question, (2) selection of a theoretical framework and methods, (3) literature analysis, (4) selection of the research participants and data collection methods, (5) data analysis and description of findings, and (6) research validation.
Qualitative research in health: value and visibility
The values of qualitative research in health policy planning and development, health services organisation and delivery, and enhancing the understanding of comprehensive health interventions have been increasingly recognised over the past two decades.1-3 Qualitative research seeks to, in its nature, explore and/or explain the phenomena in the real world, which shape or are shaped by human ...
The value of qualitative methods to public health research, policy and
The Value of Qualitative Health Research. The following quotation succinctly argues the need for qualitative research methods in public health: Public health, we believe, needs both epidemiology and qualitative research. Without epidemiology we cannot answer questions about the prevalence of and association between health determinants and outcomes.
Qualitative Research in Health Care
Provides the essential information that health care researchers and health professionals need to understand the basics of qualitative research. Now in its fourth edition, this concise, accessible, and authoritative introduction to conducting and interpreting qualitative research in the health care field has been fully revised and updated.
Qualitative Health Research
Qualitative Health Research provides an international, interdisciplinary forum to enhance health and health care and further the development and understanding of qualitative health research.The journal is an invaluable resource for researchers and academics, administrators and others in the health and social service professions, and graduates, who seek examples of studies in which the authors ...
The SAGE Handbook of Qualitative Methods in Health Research
The Sage Handbook of Qualitative Methods in Health Research is a comprehensive and authoritative source on qualitative research methods.. The Handbook compiles accessible yet vigorous academic contributions by respected academics from the fast-growing field of qualitative methods in health research and consists of:. A series of case studies in the ways in which qualitative methods have ...
The value of qualitative methods to public health research, policy and
Fortunately, published accounts of qualitative research in various other health disciplines flourishes, for example, there are now at least two health journals that are exclusively designed for this purpose (Qualitative Health Research and International Journal of Qualitative Studies on Health and Well-being).
An Introduction to Qualitative Health Research
Qualitative health research has been defined as a discipline, which has its roots in qualitative research and yet is unique in its focus, methods, and rules. The focus of qualitative health research is to describe, explore, and explain the health-illness continuum and issues specific to health services or policy contexts. Research designs ...
Qualitative Methods in Health Care Research
The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes.
Qualitative Health Research
Qualitative Health Research: Create email alert. Also from Sage. CQ Library Elevating debate opens in new tab; Sage Data Uncovering insight opens in new tab; Sage Business Cases Shaping futures opens in new tab; Sage Campus Unleashing potential opens in new tab; Sage Knowledge Multimedia learning resources opens in new tab;
How to use qualitative methods for health and health services research
In qualitative research, ... It is especially useful in health services research, where it may be necessary to understand more about the patient, the family and factors influencing decision-making. Establishing an answerable research question is a critical first step in qualitative research. Consider your target population and your available ...
Qualitative Research in Health Care
Index (Pages: 153-156) First Page. PDF. This fully revised and updated edition of Qualitative Research in Health Care offers a clear and accessible introduction to conducting and interpreting qualitative research, incorporating new examples, references and chapters relevant for a comprehensive introduction to the subject.
Qualitative research in healthcare: an introduction to ...
Abstract. In today's NHS, qualitative research is increasingly important as a method of assessing and improving quality of care. Grounded theory has developed as an analytical approach to qualitative data over the last 40 years. It is primarily an inductive process whereby theoretical insights are generated from data, in contrast to deductive ...
Critical appraisal of qualitative research: necessity, partialities and
Although the importance of qualitative research to improve health services and care is now increasingly widely supported (discussed in paper 1), the role of appraising the quality of qualitative health research is still debated.8 10 Despite a large body of literature focusing on appraisal and rigour,9 11-15 often referred to as ...
Qualitative Descriptive Methods in Health Science Research
The purpose of this methodology paper is to describe an approach to qualitative design known as qualitative descriptive that is well suited to junior health sciences researchers because it can be used with a variety of theoretical approaches, sampling techniques, and data collection strategies.
Understanding qualitative research in health care
Qualitative research allows deeper understanding of the richness and complexity of social phenomena. Qualitative methods can provide evidence on health and illness and can be used in various ways: 3. To complement quantitative methods, or when quantitative methods are impractical (e.g. when the topic is sensitive, poses measurement problems or ...
Journal Description: Qualitative Health Research: Sage Journals
Qualitative Health Research provides an international, interdisciplinary forum to enhance health and health care and further the development and understanding of qualitative health research.The journal is an invaluable resource for researchers and academics, administrators and others in the health and social service professions, and graduates, who seek examples of studies in which the authors ...
Full article: In search of the pleasure of moving through bodily re
Qualitative Research in Sport, Exercise & Health 10: 457-475. Web of Science ® Google Scholar Anens E, Zetterberg L, Urell C, Emtner M, Hellström K 2017 Self-reported physical activity correlates in Swedish adults with multiple sclerosis: A cross-sectional study.
Barriers to Optimal Clinician Guideline Adherence in Management of
IMPORTANCE Hypertension poses a substantial public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal. OBJECTIVE To develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence.. DESIGN, SETTING, and PARTICIPANTS This qualitative content ...
20 Years of Impactful Telehealthcare Research from AHRQ's Digital
Mr. Chaney is senior advisor for dissemination and innovation in AHRQ's Digital Healthcare Research Division. Dr. Arora, a former AHRQ grantee, is a distinguished and regents professor of medicine and founder and director of Project ECHO, based at the University of New Mexico Health Sciences Center.
Looking to "Level the Field": A Qualitative Study of How Clinicians
Looking to "Level the Field": A Qualitative Study of How Clinicians Operationalize Social Determinants in Critical Care August 6, 2024 Annals of the American Thoracic Society Read the full article. Authors. Deepa Ramadurai, Heta Patel, Jacqueline Chan, Juliet Young, Justin T. Clapp, Joanna L. Hart ... Health Services Research August 11 ...
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Through qualitative research, the current study seeks to promote global employee ethics and ultimately help to eliminate sweatshop labour practices. ... Translating the theory of intersectionality into quantitative and mixed methods for empirical gender transformative research on health. Culture, Health & Sexuality, 22(sup1), 145-160. https ...
Qualitative Research and its Uses in Health Care
Grounded theory, phenomenology and ethnography are three approaches used in qualitative research. Grounded theory approach is a commonly used qualitative method in the social sciences to inductively generate or discover a theory out of the data. 9 Phenomenology and ethnography are more commonly used qualitative approaches in health care and ...
Research Ethics in Qualitative Health Research
Qualitative health research consists of the systematic investigation of personal health, health services, and public health by means of qualitative methods (Green & Thorogood, 2018). The aim of the spring school was to foster an exchange of best practice examples in addressing challenges in the ethics review and practice of qualitative health ...
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Background Sexual minority student-athletes (SMSAs) face discrimination and identity conflicts in intercollegiate sport, impacting their participation and mental health. This study explores the perceptions of Chinese SMSAs regarding their sexual minority identities, aiming to fill the current gap in research related to non-Western countries. Methods A qualitative methodology was adopted ...
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Qualitative research focuses on social world and provides the tools to study health phenomena from the perspective of those experiencing them. Identifying the problem, forming the question, and selecting an appropriate methodology and design are some of the initial challenges that researchers encounter in the early stages of any research project.
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A qualitative research method with a phenomenological approach was employed to capture the nuanced experiences of nurses and midwives regarding the hospital duty roster. A semistructured interview guide facilitated data collection, ensuring a comprehensive exploration of participants' experiences. ... BMC Health Services Research, 18(1 ...

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Introduction

Critical appraisal of qualitative research

How is appraisal currently performed?

On the need for specific appraisal tools

Concepts of rigour or trustworthiness within qualitative research 31

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Navigating sexual minority identity in sport: a qualitative exploration of sexual minority student-athletes in China

Conclusions

Homonegativity and discrimination in sport

Group and individual identity

Theoretical framework

Purpose of the study

Research design

Researcher characteristics and reflexivity

Participants and procedures

Data collection

Data analysis

Hidden truths

SMSAs are common in sport

Silent identity

Prioritisation of athlete identity

Be an athlete

Sport performance first norms

Self-stereotyping

Specific physical traits

Behavioural tendencies

Prolonged contact leading to intimacy

Influence from sexual minority teammates

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