qualitative research descriptive analysis

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Characteristics of Qualitative Descriptive Studies: A Systematic Review

MSN, CRNP, Doctoral Candidate, University of Pennsylvania School of Nursing

Justine S. Sefcik

MS, RN, Doctoral Candidate, University of Pennsylvania School of Nursing

Christine Bradway

PhD, CRNP, FAAN, Associate Professor of Gerontological Nursing, University of Pennsylvania School of Nursing

Qualitative description (QD) is a term that is widely used to describe qualitative studies of health care and nursing-related phenomena. However, limited discussions regarding QD are found in the existing literature. In this systematic review, we identified characteristics of methods and findings reported in research articles published in 2014 whose authors identified the work as QD. After searching and screening, data were extracted from the sample of 55 QD articles and examined to characterize research objectives, design justification, theoretical/philosophical frameworks, sampling and sample size, data collection and sources, data analysis, and presentation of findings. In this review, three primary findings were identified. First, despite inconsistencies, most articles included characteristics consistent with limited, available QD definitions and descriptions. Next, flexibility or variability of methods was common and desirable for obtaining rich data and achieving understanding of a phenomenon. Finally, justification for how a QD approach was chosen and why it would be an appropriate fit for a particular study was limited in the sample and, therefore, in need of increased attention. Based on these findings, recommendations include encouragement to researchers to provide as many details as possible regarding the methods of their QD study so that readers can determine whether the methods used were reasonable and effective in producing useful findings.

Qualitative description (QD) is a label used in qualitative research for studies which are descriptive in nature, particularly for examining health care and nursing-related phenomena ( Polit & Beck, 2009 , 2014 ). QD is a widely cited research tradition and has been identified as important and appropriate for research questions focused on discovering the who, what, and where of events or experiences and gaining insights from informants regarding a poorly understood phenomenon. It is also the label of choice when a straight description of a phenomenon is desired or information is sought to develop and refine questionnaires or interventions ( Neergaard et al., 2009 ; Sullivan-Bolyai et al., 2005 ).

Despite many strengths and frequent citations of its use, limited discussions regarding QD are found in qualitative research textbooks and publications. To the best of our knowledge, only seven articles include specific guidance on how to design, implement, analyze, or report the results of a QD study ( Milne & Oberle, 2005 ; Neergaard, Olesen, Andersen, & Sondergaard, 2009 ; Sandelowski, 2000 , 2010 ; Sullivan-Bolyai, Bova, & Harper, 2005 ; Vaismoradi, Turunen, & Bondas, 2013 ; Willis, Sullivan-Bolyai, Knafl, & Zichi-Cohen, 2016 ). Furthermore, little is known about characteristics of QD as reported in journal-published, nursing-related, qualitative studies. Therefore, the purpose of this systematic review was to describe specific characteristics of methods and findings of studies reported in journal articles (published in 2014) self-labeled as QD. In this review, we did not have a goal to judge whether QD was done correctly but rather to report on the features of the methods and findings.

Features of QD

Several QD design features and techniques have been described in the literature. First, researchers generally draw from a naturalistic perspective and examine a phenomenon in its natural state ( Sandelowski, 2000 ). Second, QD has been described as less theoretical compared to other qualitative approaches ( Neergaard et al., 2009 ), facilitating flexibility in commitment to a theory or framework when designing and conducting a study ( Sandelowski, 2000 , 2010 ). For example, researchers may or may not decide to begin with a theory of the targeted phenomenon and do not need to stay committed to a theory or framework if their investigations take them down another path ( Sandelowski, 2010 ). Third, data collection strategies typically involve individual and/or focus group interviews with minimal to semi-structured interview guides ( Neergaard et al., 2009 ; Sandelowski, 2000 ). Fourth, researchers commonly employ purposeful sampling techniques such as maximum variation sampling which has been described as being useful for obtaining broad insights and rich information ( Neergaard et al., 2009 ; Sandelowski, 2000 ). Fifth, content analysis (and in many cases, supplemented by descriptive quantitative data to describe the study sample) is considered a primary strategy for data analysis ( Neergaard et al., 2009 ; Sandelowski, 2000 ). In some instances thematic analysis may also be used to analyze data; however, experts suggest care should be taken that this type of analysis is not confused with content analysis ( Vaismoradi et al., 2013 ). These data analysis approaches allow researchers to stay close to the data and as such, interpretation is of low-inference ( Neergaard et al., 2009 ), meaning that different researchers will agree more readily on the same findings even if they do not choose to present the findings in the same way ( Sandelowski, 2000 ). Finally, representation of study findings in published reports is expected to be straightforward, including comprehensive descriptive summaries and accurate details of the data collected, and presented in a way that makes sense to the reader ( Neergaard et al., 2009 ; Sandelowski, 2000 ).

It is also important to acknowledge that variations in methods or techniques may be appropriate across QD studies ( Sandelowski, 2010 ). For example, when consistent with the study goals, decisions may be made to use techniques from other qualitative traditions, such as employing a constant comparative analytic approach typically associated with grounded theory ( Sandelowski, 2000 ).

Search Strategy and Study Screening

The PubMed electronic database was searched for articles written in English and published from January 1, 2014 to December 31, 2014, using the terms, “qualitative descriptive study,” “qualitative descriptive design,” and “qualitative description,” combined with “nursing.” This specific publication year, “2014,” was chosen because it was the most recent full year at the time of beginning this systematic review. As we did not intend to identify trends in QD approaches over time, it seemed reasonable to focus on the nursing QD studies published in a certain year. The inclusion criterion for this review was data-based, nursing-related, research articles in which authors used the terms QD, qualitative descriptive study, or qualitative descriptive design in their titles or abstracts as well as in the main texts of the publication.

All articles yielded through an initial search in PubMed were exported into EndNote X7 ( Thomson Reuters, 2014 ), a reference management software, and duplicates were removed. Next, titles and abstracts were reviewed to determine if the publication met inclusion criteria; all articles meeting inclusion criteria were then read independently in full by two authors (HK and JS) to determine if the terms – QD or qualitative descriptive study/design – were clearly stated in the main texts. Any articles in which researchers did not specifically state these key terms in the main text were then excluded, even if the terms had been used in the study title or abstract. In one article, for example, although “qualitative descriptive study” was reported in the published abstract, the researchers reported a “qualitative exploratory design” in the main text of the article ( Sundqvist & Carlsson, 2014 ); therefore, this article was excluded from our review. Despite the possibility that there may be other QD studies published in 2014 that were not labeled as such, to facilitate our screening process we only included articles where the researchers clearly used our search terms for their approach. Finally, the two authors compared, discussed, and reconciled their lists of articles with a third author (CB).

Study Selection

Initially, although the year 2014 was specifically requested, 95 articles were identified (due to ahead of print/Epub) and exported into the EndNote program. Three duplicate publications were removed and the 20 articles with final publication dates of 2015 were also excluded. The remaining 72 articles were then screened by examining titles, abstracts, and full-texts. Based on our inclusion criteria, 15 (of 72) were then excluded because QD or QD design/study was not identified in the main text. We then re-examined the remaining 57 articles and excluded two additional articles that did not meet inclusion criteria (e.g., QD was only reported as an analytic approach in the data analysis section). The remaining 55 publications met inclusion criteria and comprised the sample for our systematic review (see Figure 1 ).

Flow Diagram of Study Selection

Of the 55 publications, 23 originated from North America (17 in the United States; 6 in Canada), 12 from Asia, 11 from Europe, 7 from Australia and New Zealand, and 2 from South America. Eleven studies were part of larger research projects and two of them were reported as part of larger mixed-methods studies. Four were described as a secondary analysis.

Quality Appraisal Process

Following the identification of the 55 publications, two authors (HK and JS) independently examined each article using the Critical Appraisal Skills Programme (CASP) qualitative checklist ( CASP, 2013 ). The CASP was chosen to determine the general adequacy (or rigor) of the qualitative studies included in this review as the CASP criteria are generic and intend to be applied to qualitative studies in general. In addition, the CASP was useful because we were able to examine the internal consistency between study aims and methods and between study aims and findings as well as the usefulness of findings ( CASP, 2013 ). The CASP consists of 10 main questions with several sub-questions to consider when making a decision about the main question ( CASP, 2013 ). The first two questions have reviewers examine the clarity of study aims and appropriateness of using qualitative research to achieve the aims. With the next eight questions, reviewers assess study design, sampling, data collection, and analysis as well as the clarity of the study’s results statement and the value of the research. We used the seven questions and 17 sub-questions related to methods and statement of findings to evaluate the articles. The results of this process are presented in Table 1 .

CASP Questions and Quality Appraisal Results (N = 55)

Note . The CASP questions are adapted from “10 questions to help you make sense of qualitative research,” by Critical Appraisal Skills Programme, 2013, retrieved from http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf . Its license can be found at http://creativecommons.org/licenses/by-nc-sa/3.0/

Once articles were assessed by the two authors independently, all three authors discussed and reconciled our assessment. No articles were excluded based on CASP results; rather, results were used to depict the general adequacy (or rigor) of all 55 articles meeting inclusion criteria for our systematic review. In addition, the CASP was included to enhance our examination of the relationship between the methods and the usefulness of the findings documented in each of the QD articles included in this review.

Process for Data Extraction and Analysis

To further assess each of the 55 articles, data were extracted on: (a) research objectives, (b) design justification, (c) theoretical or philosophical framework, (d) sampling and sample size, (e) data collection and data sources, (f) data analysis, and (g) presentation of findings (see Table 2 ). We discussed extracted data and identified common and unique features in the articles included in our systematic review. Findings are described in detail below and in Table 3 .

Elements for Data Extraction

Data Extraction and Analysis Results

Note . NR = not reported

Quality Appraisal Results

Justification for use of a QD design was evident in close to half (47.3%) of the 55 publications. While most researchers clearly described recruitment strategies (80%) and data collection methods (100%), justification for how the study setting was selected was only identified in 38.2% of the articles and almost 75% of the articles did not include any reason for the choice of data collection methods (e.g., focus-group interviews). In the vast majority (90.9%) of the articles, researchers did not explain their involvement and positionality during the process of recruitment and data collection or during data analysis (63.6%). Ethical standards were reported in greater than 89% of all articles and most articles included an in-depth description of data analysis (83.6%) and development of categories or themes (92.7%). Finally, all researchers clearly stated their findings in relation to research questions/objectives. Researchers of 83.3% of the articles discussed the credibility of their findings (see Table 1 ).

Research Objectives

In statements of study objectives and/or questions, the most frequently used verbs were “explore” ( n = 22) and “describe” ( n = 17). Researchers also used “identify” ( n = 3), “understand” ( n = 4), or “investigate” ( n = 2). Most articles focused on participants’ experiences related to certain phenomena ( n = 18), facilitators/challenges/factors/reasons ( n = 14), perceptions about specific care/nursing practice/interventions ( n = 11), and knowledge/attitudes/beliefs ( n = 3).

Design Justification

A total of 30 articles included references for QD. The most frequently cited references ( n = 23) were “Whatever happened to qualitative description?” ( Sandelowski, 2000 ) and “What’s in a name? Qualitative description revisited” ( Sandelowski, 2010 ). Other references cited included “Qualitative description – the poor cousin of health research?” ( Neergaard et al., 2009 ), “Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research” ( Pope & Mays, 1995 ), and general research textbooks ( Polit & Beck, 2004 , 2012 ).

In 26 articles (and not necessarily the same as those citing specific references to QD), researchers provided a rationale for selecting QD. Most researchers chose QD because this approach aims to produce a straight description and comprehensive summary of the phenomenon of interest using participants’ language and staying close to the data (or using low inference).

Authors of two articles distinctly stated a QD design, yet also acknowledged grounded-theory or phenomenological overtones by adopting some techniques from these qualitative traditions ( Michael, O'Callaghan, Baird, Hiscock, & Clayton, 2014 ; Peacock, Hammond-Collins, & Forbes, 2014 ). For example, Michael et al. (2014 , p. 1066) reported:

The research used a qualitative descriptive design with grounded theory overtones ( Sandelowski, 2000 ). We sought to provide a comprehensive summary of participants’ views through theoretical sampling; multiple data sources (focus groups [FGs] and interviews); inductive, cyclic, and constant comparative analysis; and condensation of data into thematic representations ( Corbin & Strauss, 1990 , 2008 ).

Authors of four additional articles included language suggestive of a grounded-theory or phenomenological tradition, e.g., by employing a constant comparison technique or translating themes stated in participants’ language into the primary language of the researchers during data analysis ( Asemani et al., 2014 ; Li, Lee, Chen, Jeng, & Chen, 2014 ; Ma, 2014 ; Soule, 2014 ). Additionally, Li et al. (2014) specifically reported use of a grounded-theory approach.

Theoretical or Philosophical Framework

In most (n = 48) articles, researchers did not specify any theoretical or philosophical framework. Of those articles in which a framework or philosophical stance was included, the authors of five articles described the framework as guiding the development of an interview guide ( Al-Zadjali, Keller, Larkey, & Evans, 2014 ; DeBruyn, Ochoa-Marin, & Semenic, 2014 ; Fantasia, Sutherland, Fontenot, & Ierardi, 2014 ; Ma, 2014 ; Wiens, Babenko-Mould, & Iwasiw, 2014 ). In two articles, data analysis was described as including key concepts of a framework being used as pre-determined codes or categories ( Al-Zadjali et al., 2014 ; Wiens et al., 2014 ). Oosterveld-Vlug et al. (2014) and Zhang, Shan, and Jiang (2014) discussed a conceptual model and underlying philosophy in detail in the background or discussion section, although the model and philosophy were not described as being used in developing interview questions or analyzing data.

Sampling and Sample Size

In 38 of the 55 articles, researchers reported ‘purposeful sampling’ or some derivation of purposeful sampling such as convenience ( n = 10), maximum variation ( n = 8), snowball ( n = 3), and theoretical sampling ( n = 1). In three instances ( Asemani et al., 2014 ; Chan & Lopez, 2014 ; Soule, 2014 ), multiple sampling strategies were described, for example, a combination of snowball, convenience, and maximum variation sampling. In articles where maximum variation sampling was employed, “variation” referred to seeking diversity in participants’ demographics ( n = 7; e.g., age, gender, and education level), while one article did not include details regarding how their maximum variation sampling strategy was operationalized ( Marcinowicz, Abramowicz, Zarzycka, Abramowicz, & Konstantynowicz, 2014 ). Authors of 17 articles did not specify their sampling techniques.

Sample sizes ranged from 8 to 1,932 with nine studies in the 8–10 participant range and 24 studies in the 11–20 participant range. The participant range of 21–30 and 31–50 was reported in eight articles each. Six studies included more than 50 participants. Two of these articles depicted quite large sample sizes (N=253, Hart & Mareno, 2014 ; N=1,932, Lyndon et al., 2014 ) and the authors of these articles described the use of survey instruments and analysis of responses to open-ended questions. This was in contrast to studies with smaller sample sizes where individual interviews and focus groups were more commonly employed.

Data Collection and Data Sources

In a majority of studies, researchers collected data through individual ( n = 39) and/or focus-group ( n = 14) interviews that were semistructured. Most researchers reported that interviews were audiotaped ( n = 51) and interview guides were described as the primary data collection tool in 29 of the 51 studies. In some cases, researchers also described additional data sources, for example, taking memos or field notes during participant observation sessions or as a way to reflect their thoughts about interviews ( n = 10). Written responses to open-ended questions in survey questionnaires were another type of data source in a small number of studies ( n = 4).

Data Analysis

The analysis strategy most commonly used in the QD studies included in this review was qualitative content analysis ( n = 30). Among the studies where this technique was used, most researchers described an inductive approach; researchers of two studies analyzed data both inductively and deductively. Thematic analysis was adopted in 14 studies and the constant comparison technique in 10 studies. In nine studies, researchers employed multiple techniques to analyze data including qualitative content analysis with constant comparison ( Asemani et al., 2014 ; DeBruyn et al., 2014 ; Holland, Christensen, Shone, Kearney, & Kitzman, 2014 ; Li et al., 2014 ) and thematic analysis with constant comparison ( Johansson, Hildingsson, & Fenwick, 2014 ; Oosterveld-Vlug et al., 2014 ). In addition, five teams conducted descriptive statistical analysis using both quantitative and qualitative data and counting the frequencies of codes/themes ( Ewens, Chapman, Tulloch, & Hendricks, 2014 ; Miller, 2014 ; Santos, Sandelowski, & Gualda, 2014 ; Villar, Celdran, Faba, & Serrat, 2014 ) or targeted events through video monitoring ( Martorella, Boitor, Michaud, & Gelinas, 2014 ). Tseng, Chen, and Wang (2014) cited Thorne, Reimer Kirkham, and O’Flynn-Magee (2004)’s interpretive description as the inductive analytic approach. In five out of 55 articles, researchers did not specifically name their analysis strategies, despite including descriptions about procedural aspects of data analysis. Researchers of 20 studies reported that data saturation for their themes was achieved.

Presentation of Findings

Researchers described participants’ experiences of health care, interventions, or illnesses in 18 articles and presented straightforward, focused, detailed descriptions of facilitators, challenges, factors, reasons, and causes in 15 articles. Participants’ perceptions of specific care, interventions, or programs were described in detail in 11 articles. All researchers presented their findings with extensive descriptions including themes or categories. In 25 of 55 articles, figures or tables were also presented to illustrate or summarize the findings. In addition, the authors of three articles summarized, organized, and described their data using key concepts of conceptual models ( Al-Zadjali et al., 2014 ; Oosterveld-Vlug et al., 2014 ; Wiens et al., 2014 ). Martorella et al. (2014) assessed acceptability and feasibility of hand massage therapy and arranged their findings in relation to pre-determined indicators of acceptability and feasibility. In one longitudinal QD study ( Kneck, Fagerberg, Eriksson, & Lundman, 2014 ), the researchers presented the findings as several key patterns of learning for persons living with diabetes; in another longitudinal QD study ( Stegenga & Macpherson, 2014 ), findings were presented as processes and themes regarding patients’ identity work across the cancer trajectory. In another two studies, the researchers described and compared themes or categories from two different perspectives, such as patients and nurses ( Canzan, Heilemann, Saiani, Mortari, & Ambrosi, 2014 ) or parents and children ( Marcinowicz et al., 2014 ). Additionally, Ma (2014) reported themes using both participants’ language and the researcher’s language.

In this systematic review, we examined and reported specific characteristics of methods and findings reported in journal articles self-identified as QD and published during one calendar year. To accomplish this we identified 55 articles that met inclusion criteria, performed a quality appraisal following CASP guidelines, and extracted and analyzed data focusing on QD features. In general, three primary findings emerged. First, despite inconsistencies, most QD publications had the characteristics that were originally observed by Sandelowski (2000) and summarized by other limited available QD literature. Next, there are no clear boundaries in methods used in the QD studies included in this review; in a number of studies, researchers adopted and combined techniques originating from other qualitative traditions to obtain rich data and increase their understanding of the phenomenon under investigation. Finally, justification for how QD was chosen and why it would be an appropriate fit for a particular study is an area in need of increased attention.

In general, the overall characteristics were consistent with design features of QD studies described in the literature ( Neergaard et al., 2009 ; Sandelowski, 2000 , 2010 ; Vaismoradi et al., 2013 ). For example, many authors reported that study objectives were to describe or explore participants’ experiences and factors related to certain phenomena, events, or interventions. In most cases, these authors cited Sandelowski (2000) as a reference for this particular characteristic. It was rare that theoretical or philosophical frameworks were identified, which also is consistent with descriptions of QD. In most studies, researchers used purposeful sampling and its derivative sampling techniques, collected data through interviews, and analyzed data using qualitative content analysis or thematic analysis. Moreover, all researchers presented focused or comprehensive, descriptive summaries of data including themes or categories answering their research questions. These characteristics do not indicate that there are correct ways to do QD studies; rather, they demonstrate how others designed and produced QD studies.

In several studies, researchers combined techniques that originated from other qualitative traditions for sampling, data collection, and analysis. This flexibility or variability, a key feature of recently published QD studies, may indicate that there are no clear boundaries in designing QD studies. Sandelowski (2010) articulated: “in the actual world of research practice, methods bleed into each other; they are so much messier than textbook depictions” (p. 81). Hammersley (2007) also observed:

“We are not so much faced with a set of clearly differentiated qualitative approaches as with a complex landscape of variable practice in which the inhabitants use a range of labels (‘ethnography’, ‘discourse analysis’, ‘life history work’, narrative study’, ……, and so on) in diverse and open-ended ways in order to characterize their orientation, and probably do this somewhat differently across audiences and occasions” (p. 293).

This concept of having no clear boundaries in methods when designing a QD study should enable researchers to obtain rich data and produce a comprehensive summary of data through various data collection and analysis approaches to answer their research questions. For example, using an ethnographical approach (e.g., participant observation) in data collection for a QD study may facilitate an in-depth description of participants’ nonverbal expressions and interactions with others and their environment as well as situations or events in which researchers are interested ( Kawulich, 2005 ). One example found in our review is that Adams et al. (2014) explored family members’ responses to nursing communication strategies for patients in intensive care units (ICUs). In this study, researchers conducted interviews with family members, observed interactions between healthcare providers, patients, and family members in ICUs, attended ICU rounds and family meetings, and took field notes about their observations and reflections. Accordingly, the variability in methods provided Adams and colleagues (2014) with many different aspects of data that were then used to complement participants’ interviews (i.e., data triangulation). Moreover, by using a constant comparison technique in addition to qualitative content analysis or thematic analysis in QD studies, researchers compare each case with others looking for similarities and differences as well as reasoning why differences exist, to generate more general understanding of phenomena of interest ( Thorne, 2000 ). In fact, this constant comparison analysis is compatible with qualitative content analysis and thematic analysis and we found several examples of using this approach in studies we reviewed ( Asemani et al., 2014 ; DeBruyn et al., 2014 ; Holland et al., 2014 ; Johansson et al., 2014 ; Li et al., 2014 ; Oosterveld-Vlug et al., 2014 ).

However, this flexibility or variability in methods of QD studies may cause readers’ as well as researchers’ confusion in designing and often labeling qualitative studies ( Neergaard et al., 2009 ). Especially, it could be difficult for scholars unfamiliar with qualitative studies to differentiate QD studies with “hues, tones, and textures” of qualitative traditions ( Sandelowski, 2000 , p. 337) from grounded theory, phenomenological, and ethnographical research. In fact, the major difference is in the presentation of the findings (or outcomes of qualitative research) ( Neergaard et al., 2009 ; Sandelowski, 2000 ). The final products of grounded theory, phenomenological, and ethnographical research are a generation of a theory, a description of the meaning or essence of people’s lived experience, and an in-depth, narrative description about certain culture, respectively, through researchers’ intensive/deep interpretations, reflections, and/or transformation of data ( Streubert & Carpenter, 2011 ). In contrast, QD studies result in “a rich, straight description” of experiences, perceptions, or events using language from the collected data ( Neergaard et al., 2009 ) through low-inference (or data-near) interpretations during data analysis ( Sandelowski, 2000 , 2010 ). This feature is consistent with our finding regarding presentation of findings: in all QD articles included in this systematic review, the researchers presented focused or comprehensive, descriptive summaries to their research questions.

Finally, an explanation or justification of why a QD approach was chosen or appropriate for the study aims was not found in more than half of studies in the sample. While other qualitative approaches, including grounded theory, phenomenology, ethnography, and narrative analysis, are used to better understand people’s thoughts, behaviors, and situations regarding certain phenomena ( Sullivan-Bolyai et al., 2005 ), as noted above, the results will likely read differently than those for a QD study ( Carter & Little, 2007 ). Therefore, it is important that researchers accurately label and justify their choices of approach, particularly for studies focused on participants’ experiences, which could be addressed with other qualitative traditions. Justifying one’s research epistemology, methodology, and methods allows readers to evaluate these choices for internal consistency, provides context to assist in understanding the findings, and contributes to the transparency of choices, all of which enhance the rigor of the study ( Carter & Little, 2007 ; Wu, Thompson, Aroian, McQuaid, & Deatrick, 2016 ).

Use of the CASP tool drew our attention to the credibility and usefulness of the findings of the QD studies included in this review. Although justification for study design and methods was lacking in many articles, most authors reported techniques of recruitment, data collection, and analysis that appeared. Internal consistencies among study objectives, methods, and findings were achieved in most studies, increasing readers’ confidence that the findings of these studies are credible and useful in understanding under-explored phenomenon of interest.

In summary, our findings support the notion that many scholars employ QD and include a variety of commonly observed characteristics in their study design and subsequent publications. Based on our review, we found that QD as a scholarly approach allows flexibility as research questions and study findings emerge. We encourage authors to provide as many details as possible regarding how QD was chosen for a particular study as well as details regarding methods to facilitate readers’ understanding and evaluation of the study design and rigor. We acknowledge the challenge of strict word limitation with submissions to print journals; potential solutions include collaboration with journal editors and staff to consider creative use of charts or tables, or using more citations and less text in background sections so that methods sections are robust.

Limitations

Several limitations of this review deserve mention. First, only articles where researchers explicitly stated in the main body of the article that a QD design was employed were included. In contrast, articles labeled as QD in only the title or abstract, or without their research design named were not examined due to the lack of certainty that the researchers actually carried out a QD study. As a result, we may have excluded some studies where a QD design was followed. Second, only one database was searched and therefore we did not identify or describe potential studies following a QD approach that were published in non-PubMed databases. Third, our review is limited by reliance on what was included in the published version of a study. In some cases, this may have been a result of word limits or specific styles imposed by journals, or inconsistent reporting preferences of authors and may have limited our ability to appraise the general adequacy with the CASP tool and examine specific characteristics of these studies.

Conclusions

A systematic review was conducted by examining QD research articles focused on nursing-related phenomena and published in one calendar year. Current patterns include some characteristics of QD studies consistent with the previous observations described in the literature, a focus on the flexibility or variability of methods in QD studies, and a need for increased explanations of why QD was an appropriate label for a particular study. Based on these findings, recommendations include encouragement to authors to provide as many details as possible regarding the methods of their QD study. In this way, readers can thoroughly consider and examine if the methods used were effective and reasonable in producing credible and useful findings.

Acknowledgments

This work was supported in part by the John A. Hartford Foundation’s National Hartford Centers of Gerontological Nursing Excellence Award Program.

Hyejin Kim is a Ruth L. Kirschstein NRSA Predoctoral Fellow (F31NR015702) and 2013–2015 National Hartford Centers of Gerontological Nursing Excellence Patricia G. Archbold Scholar. Justine Sefcik is a Ruth L. Kirschstein Predoctoral Fellow (F31NR015693) through the National Institutes of Health, National Institute of Nursing Research.

Conflict of Interest Statement

The Authors declare that there is no conflict of interest.

Contributor Information

Hyejin Kim, MSN, CRNP, Doctoral Candidate, University of Pennsylvania School of Nursing.

Justine S. Sefcik, MS, RN, Doctoral Candidate, University of Pennsylvania School of Nursing.

Christine Bradway, PhD, CRNP, FAAN, Associate Professor of Gerontological Nursing, University of Pennsylvania School of Nursing.

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Chapter 5: Qualitative descriptive research

Darshini Ayton

Learning outcomes

Upon completion of this chapter, you should be able to:

• Identify the key terms and concepts used in qualitative descriptive research.
• Discuss the advantages and disadvantages of qualitative descriptive research.

What is a qualitative descriptive study?

The key concept of the qualitative descriptive study is description.

Qualitative descriptive studies (also known as ‘exploratory studies’ and ‘qualitative description approaches’) are relatively new in the qualitative research landscape. They emerged predominantly in the field of nursing and midwifery over the past two decades. 1 The design of qualitative descriptive studies evolved as a means to define aspects of qualitative research that did not resemble qualitative research designs to date, despite including elements of those other study designs. 2

Qualitative descriptive studies  describe  phenomena rather than explain them. Phenomenological studies, ethnographic studies and those using grounded theory seek to explain a phenomenon. Qualitative descriptive studies aim to provide a comprehensive summary of events. The approach to this study design is journalistic, with the aim being to answer the questions who, what, where and how. 3

A qualitative descriptive study is an important and appropriate design for research questions that are focused on gaining insights about a poorly understood research area, rather than on a specific phenomenon. Since qualitative descriptive study design seeks to describe rather than explain, explanatory frameworks and theories are not required to explain or ‘ground’ a study and its results. 4 The researcher may decide that a framework or theory adds value to their interpretations, and in that case, it is perfectly acceptable to use them. However, the hallmark of genuine curiosity (naturalistic enquiry) is that the researcher does not know in advance what they will be observing or describing. 4 Because a phenomenon is being described, the qualitative descriptive analysis is more categorical and less conceptual than other methods. Qualitative content analysis is usually the main approach to data analysis in qualitative descriptive studies. 4 This has led to criticism of descriptive research being less sophisticated because less interpretation is required than with other qualitative study designs in which interpretation and explanation are key characteristics (e.g. phenomenology, grounded theory, case studies).

Diverse approaches to data collection can be utilised in qualitative description studies. However, most qualitative descriptive studies use semi-structured interviews (see Chapter 13) because they provide a reliable way to collect data. 3 The technique applied to data analysis is generally categorical and less conceptual when compared to other qualitative research designs (see Section 4). 2,3 Hence, this study design is well suited to research by practitioners, student researchers and policymakers. Its straightforward approach enables these studies to be conducted in shorter timeframes than other study designs. 3 Descriptive studies are common as the qualitative component in mixed-methods research ( see Chapter 11 ) and evaluations ( see Chapter 12 ), 1 because qualitative descriptive studies can provide information to help develop and refine questionnaires or interventions.

For example, in our research to develop a patient-reported outcome measure for people who had undergone a percutaneous coronary intervention (PCI), which is a common cardiac procedure to treat heart disease, we started by conducting a qualitative descriptive study. 5 This project was a large, mixed-methods study funded by a private health insurer. The entire research process needed to be straightforward and achievable within a year, as we had engaged an undergraduate student to undertake the research tasks. The aim of the qualitative component of the mixed-methods study was to identify and explore patients’ perceptions following PCI. We used inductive approaches to collect and analyse the data. The study was guided by the following domains for the development of patient-reported outcomes, according to US Food and Drug Administration (FDA) guidelines, which included:

• Feeling: How the patient feels physically and psychologically after medical intervention
• Function: The patient’s mobility and ability to maintain their regular routine
• Evaluation: The patient’s overall perception of the success or failure of their procedure and their perception of what contributed to it. 5(p458)

We conducted focus groups and interviews, and asked participants three questions related to the FDA outcome domains:

• From your perspective, what would be considered a successful outcome of the procedure?

Probing questions: Did the procedure meet your expectations? How do you define whether the procedure was successful?

• How did you feel after the procedure?

Probing question: How did you feel one week after and how does that compare with how you feel now?

• After your procedure, tell me about your ability to do your daily activities?

Prompt for activities including gardening, housework, personal care, work-related and family-related tasks.

Probing questions: Did you attend cardiac rehabilitation? Can you tell us about your experience of cardiac rehabilitation? What impact has medication had on your recovery?

• What, if any, lifestyle changes have you made since your procedure? 5(p459)

Data collection was conducted with 32 participants. The themes were mapped to the FDA patient-reported outcome domains, with the results confirming previous research and also highlighting new areas for exploration in the development of a new patient-reported outcome measure. For example, participants reported a lack of confidence following PCI and the importance of patient and doctor communication. Women, in particular, reported that they wanted doctors to recognise how their experiences of cardiac symptoms were different to those of men.

The study described phenomena and resulted in the development of a patient-reported outcome measure that was tested and refined using a discrete-choice experiment survey, 6 a pilot of the measure in the Victorian Cardiac Outcomes Registry and a Rasch analysis to validate the measurement’s properties. 7

Advantages and disadvantages of qualitative descriptive studies

A qualitative descriptive study is an effective design for research by practitioners, policymakers and students, due to their relatively short timeframes and low costs. The researchers can remain close to the data and the events described, and this can enable the process of analysis to be relatively simple. Qualitative descriptive studies are also useful in mixed-methods research studies. Some of the advantages of qualitative descriptive studies have led to criticism of the design approach, due to a lack of engagement with theory and the lack of interpretation and explanation of the data. 2

Table 5.1. Examples of qualitative descriptive studies

Qualitative descriptive studies are gaining popularity in health and social care due to their utility, from a resource and time perspective, for research by practitioners, policymakers and researchers. Descriptive studies can be conducted as stand-alone studies or as part of larger, mixed-methods studies.

• Bradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care research. Glob Qual Nurs Res. 2017;4. doi:10.1177/2333393617742282
• Lambert VA, Lambert CE. Qualitative descriptive research: an acceptable design. Pac Rim Int J Nurs Res Thail. 2012;16(4):255-256. Accessed June 6, 2023. https://he02.tci-thaijo.org/index.php/PRIJNR/article/download/5805/5064
• Doyle L et al. An overview of the qualitative descriptive design within nursing research. J Res Nurs. 2020;25(5):443-455. doi:10.1177/174498711988023
• Kim H, Sefcik JS, Bradway C. Characteristics of qualitative descriptive studies: a systematic review. Res Nurs Health. 2017;40(1):23-42. doi:10.1002/nur.21768
• Ayton DR et al. Exploring patient-reported outcomes following percutaneous coronary intervention: a qualitative study. Health Expect. 2018;21(2):457-465. doi:10.1111/hex.1263
• Barker AL et al. Symptoms and feelings valued by patients after a percutaneous coronary intervention: a discrete-choice experiment to inform development of a new patient-reported outcome. BMJ Open. 2018;8:e023141. doi:10.1136/bmjopen-2018-023141
• Soh SE et al. What matters most to patients following percutaneous coronary interventions? a new patient-reported outcome measure developed using Rasch analysis. PLoS One. 2019;14(9):e0222185. doi:10.1371/journal.pone.0222185
• Hiller RM et al. Coping and support-seeking in out-of-home care: a qualitative study of the views of young people in care in England. BMJ Open. 2021;11:e038461. doi:10.1136/bmjopen-2020-038461
• Backman C, Cho-Young D. Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home – a qualitative descriptive study. Patient Prefer Adherence. 2019;13:617-626. doi:10.2147/PPA.S201054

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• Section 2: Home
• Developing the Quantitative Research Design
• Qualitative Descriptive Design

Overview of Descriptive Design

Sources of data.

• Design and Development Research (DDR) For Instructional Design
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• Action Research Resource
• Case Study Design in an Applied Doctorate
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A descriptive design is a flexible, exploratory approach to qualitative research. Descriptive design is referred to in the literature by other labels including generic, general, basic, traditional, interpretive, and pragmatic. Descriptive design as an acceptable research design for dissertation and other robust scholarly research has received varying degrees of acceptance within the academic community. However, descriptive design has been gaining momentum since the early 2000’s as a suitable design for studies that do not fall into the more mainstream genres of qualitative research (ie. Case study, phenomenology, ethnography, narrative inquiry and grounded theory). In contrast to other qualitative designs, descriptive design is not aligned to specific methods (for example, bracketing in phenomenology, bounded systems in case study, or constant comparative analysis in grounded theory). Rather, descriptive design “borrows” methods appropriate to the proposed study from other designs. 

Arguments supporting the flexible nature of descriptive designs describe it as being preferable to forcing a research approach into a design that is not quite appropriate for the nature of the intended study. However, descriptive design has also been criticized for this mixing of methods as well as for the limited literature describing it. The descriptive design can be the foundation for a rigorous study within the ADE program. Because of the flexibility of the methods used, a descriptive design provides the researcher with the opportunity to choose methods best suited to a practice-based research purpose.   

• Example Descriptive Design in an Applied Doctorate

Sources of Data in Descriptive Design

Because of the exploratory nature of descriptive design, the triangulation of multiple sources of data are often used for additional insight into the phenomenon. Sources of data that can be used in descriptive studies are similar to those that may be used in other qualitative designs and include interviews, focus groups, documents, artifacts, and observations.

The following video provides additional considerations for triangulation in qualitative designs including descriptive design: Triangulation: Pairing Thematic and Content Analysis

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The Art of Descriptive Analysis in Qualitative Research

Table of Contents

Have you ever wondered how researchers interpret the rich tapestry of human experiences within social sciences? The key lies in the nuanced art of descriptive analysis in qualitative research . This in-depth approach, far from being just a collection of quotes or anecdotes, is a meticulous process that captures the essence of a phenomenon and lays a foundation for profound understanding.

Understanding “Thick Description”

At the heart of qualitative analysis is the concept of “ thick description ,” a term popularized by anthropologist Clifford Geertz . But what exactly does it entail? Let’s peel back the layers:

• Contextualizing the Narrative: “Thick description” goes beyond mere observation, embedding the subject within its socio\-cultural milieu , providing a detailed canvas for the reader.
• Intentions and Meanings: It’s not just about the “what” but also the “why.” Researchers strive to interpret the intentions behind actions and the meanings they hold for individuals involved.
• Process over Product: The focus is on understanding the process through which events unfold and actions are taken, highlighting the dynamic nature of social interactions.

Embarking on the Descriptive Journey

Engaging in descriptive analysis is akin to embarking on a journey through the complexities of human behavior . Here’s how researchers navigate this path:

• Immersive Engagement : Researchers often immerse themselves in the settings they study, becoming, to some extent, participants to gain an insider’s view.
• Meticulous Documentation : Every observation is carefully documented, capturing not just the action but the setting, the actors, and the atmosphere.
• Reflective Interpretation : The analysis is reflective, meaning that researchers continually interpret and re-interpret data, often finding new insights with each review.

The Power of Narrative in Descriptive Analysis

One of the most effective tools in the arsenal of qualitative researchers is the power of narrative . Stories are not just modes of entertainment but are fundamental to how we understand and interpret the world around us. Through narrative, researchers can convey the complexities and subtleties of human experiences, making their findings relatable and profound.

Challenges and Considerations in Descriptive Analysis

While the descriptive approach is powerful, it’s not without its challenges. Researchers must navigate a landscape filled with potential pitfalls:

• Subjectivity and Bias : Researchers’ own backgrounds and perspectives can color their interpretations. Acknowledging and mitigating biases is crucial for the integrity of the analysis.
• Balancing Detail and Relevance: How much detail is too much? Researchers must strike a balance between richness of description and the relevance to the research question.
• Ethical Responsibilities: With in-depth descriptions come ethical considerations. Protecting the identities and respecting the privacy of participants is paramount.

Techniques to Enhance Descriptive Analysis

To enhance the quality and credibility of their descriptive analysis, researchers employ several techniques:

• Triangulation : Using multiple sources or methods to cross-check information ensures a more reliable interpretation.
• Member Checking : Researchers may return to participants with their findings to verify the accuracy and resonance of their interpretations.
• Peer Debriefing : Seeking input from colleagues can provide fresh perspectives and help challenge preconceptions.

Applications of Descriptive Analysis

Descriptive analysis is not just an academic exercise; it has real-world applications that can shape policies, inform practices, and enrich our understanding of societal issues:

• Policy Development : Rich descriptions can inform policymakers about the lived experiences of individuals affected by their decisions.
• Educational Practices : In education, understanding the complexities of classroom dynamics can lead to more effective teaching strategies.
• Social Change : Descriptive analysis can highlight areas of social injustice or inequality, serving as a catalyst for change.

Descriptive analysis in qualitative research is more than just a methodological choice; it’s a commitment to understanding the layered and multifaceted nature of human experiences. By embracing the richness of “thick description,” researchers can provide insights that resonate on a deeply human level, influencing thought and action.

What do you think? How can the practice of descriptive analysis be improved in qualitative research? Can you think of a situation where “thick description” might be particularly beneficial or challenging?

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Research Methodologies & Methods

1 Logic of Inquiry in Social Research

• A Science of Society
• Comte’s Ideas on the Nature of Sociology
• Observation in Social Sciences
• Logical Understanding of Social Reality

2 Empirical Approach

• Empirical Approach
• Rules of Data Collection
• Cultural Relativism
• Problems Encountered in Data Collection
• Difference between Common Sense and Science
• What is Ethical?
• What is Normal?
• Understanding the Data Collected
• Managing Diversities in Social Research
• Problematising the Object of Study
• Conclusion: Return to Good Old Empirical Approach

3 Diverse Logic of Theory Building

• Concern with Theory in Sociology
• Concepts: Basic Elements of Theories
• Why Do We Need Theory?
• Hypothesis Description and Experimentation
• Controlled Experiment
• Designing an Experiment
• How to Test a Hypothesis
• Sensitivity to Alternative Explanations
• Rival Hypothesis Construction
• The Use and Scope of Social Science Theory
• Theory Building and Researcher’s Values

4 Theoretical Analysis

• Premises of Evolutionary and Functional Theories
• Critique of Evolutionary and Functional Theories
• Turning away from Functionalism
• What after Functionalism
• Post-modernism
• Trends other than Post-modernism

5 Issues of Epistemology

• Some Major Concerns of Epistemology
• Rationalism
• Phenomenology: Bracketing Experience

6 Philosophy of Social Science

• Foundations of Science
• Science, Modernity, and Sociology
• Rethinking Science
• Crisis in Foundation

7 Positivism and its Critique

• Heroic Science and Origin of Positivism
• Early Positivism
• Consolidation of Positivism
• Critiques of Positivism

8 Hermeneutics

• Methodological Disputes in the Social Sciences
• Tracing the History of Hermeneutics
• Hermeneutics and Sociology
• Philosophical Hermeneutics
• The Hermeneutics of Suspicion
• Phenomenology and Hermeneutics

9 Comparative Method

• Relationship with Common Sense; Interrogating Ideological Location
• The Historical Context
• Elements of the Comparative Approach

10 Feminist Approach

• Features of the Feminist Method
• Feminist Methods adopt the Reflexive Stance
• Feminist Discourse in India

11 Participatory Method

• Delineation of Key Features

12 Types of Research

• Basic and Applied Research
• Descriptive and Analytical Research
• Empirical and Exploratory Research
• Quantitative and Qualitative Research
• Explanatory (Causal) and Longitudinal Research
• Experimental and Evaluative Research
• Participatory Action Research

13 Methods of Research

• Evolutionary Method
• Comparative Method
• Historical Method
• Personal Documents

14 Elements of Research Design

• Structuring the Research Process

15 Sampling Methods and Estimation of Sample Size

• Classification of Sampling Methods
• Sample Size

16 Measures of Central Tendency

• Relationship between Mean, Mode, and Median
• Choosing a Measure of Central Tendency

17 Measures of Dispersion and Variability

• The Variance
• The Standard Deviation
• Coefficient of Variation

18 Statistical Inference- Tests of Hypothesis

• Statistical Inference
• Tests of Significance

19 Correlation and Regression

• Correlation
• Method of Calculating Correlation of Ungrouped Data
• Method Of Calculating Correlation Of Grouped Data

20 Survey Method

• Rationale of Survey Research Method
• History of Survey Research
• Defining Survey Research
• Sampling and Survey Techniques
• Operationalising Survey Research Tools
• Advantages and Weaknesses of Survey Research

21 Survey Design

• Preliminary Considerations
• Stages / Phases in Survey Research
• Formulation of Research Question
• Survey Research Designs
• Sampling Design

22 Survey Instrumentation

• Techniques/Instruments for Data Collection
• Questionnaire Construction
• Issues in Designing a Survey Instrument

23 Survey Execution and Data Analysis

• Problems and Issues in Executing Survey Research
• Data Analysis
• Ethical Issues in Survey Research

24 Field Research – I

• History of Field Research
• Ethnography
• Theme Selection
• Gaining Entry in the Field
• Key Informants
• Participant Observation

25 Field Research – II

• Interview its Types and Process
• Feminist and Postmodernist Perspectives on Interviewing
• Narrative Analysis
• Interpretation
• Case Study and its Types
• Life Histories
• Oral History
• PRA and RRA Techniques

26 Reliability, Validity and Triangulation

• Concepts of Reliability and Validity
• Three Types of “Reliability”
• Working Towards Reliability
• Procedural Validity
• Field Research as a Validity Check
• Method Appropriate Criteria
• Triangulation
• Ethical Considerations in Qualitative Research

27 Qualitative Data Formatting and Processing

• Qualitative Data Processing and Analysis
• Description
• Classification
• Making Connections
• Theoretical Coding
• Qualitative Content Analysis

28 Writing up Qualitative Data

• Problems of Writing Up
• Grasp and Then Render
• “Writing Down” and “Writing Up”
• Write Early
• Writing Styles
• First Draft

29 Using Internet and Word Processor

• What is Internet and How Does it Work?
• Internet Services
• Searching on the Web: Search Engines
• Accessing and Using Online Information
• Online Journals and Texts
• Statistical Reference Sites
• Data Sources
• Uses of E-mail Services in Research

30 Using SPSS for Data Analysis Contents

• Introduction
• Starting and Exiting SPSS
• Creating a Data File
• Univariate Analysis
• Bivariate Analysis

31 Using SPSS in Report Writing

• Why to Use SPSS
• Working with SPSS Output
• Copying SPSS Output to MS Word Document

32 Tabulation and Graphic Presentation- Case Studies

• Structure for Presentation of Research Findings
• Data Presentation: Editing, Coding, and Transcribing
• Case Studies
• Qualitative Data Analysis and Presentation through Software
• Types of ICT used for Research

33 Guidelines to Research Project Assignment

• Overview of Research Methodologies and Methods (MSO 002)
• Research Project Objectives
• Preparation for Research Project
• Stages of the Research Project
• Supervision During the Research Project
• Submission of Research Project
• Methodology for Evaluating Research Project

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Home » Qualitative Research – Methods, Analysis Types and Guide

Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

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

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

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

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

Focus Groups

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

Ethnographic Studies

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

Text Analysis

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

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

Process of Observation

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

Record Keeping

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

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

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

Qualitative Research Analysis Methods

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

Thematic Analysis

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

Content Analysis

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

Discourse Analysis

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

Grounded Theory Analysis

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

Narrative Analysis

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

Phenomenological Analysis

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

Comparative Analysis

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

Applications of Qualitative Research

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

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

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

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

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

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

Purpose of Qualitative Research

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

Qualitative research can serve multiple purposes, including:

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

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

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

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

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

Advantages of Qualitative Research

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

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

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

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

Also see Research Methods

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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11 Descriptive and interpretive approaches to qualitative research

• Published: June 2005
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This chapter explores descriptive and interpretive approaches to qualitative research. This includes the formulation of the problem, data collection, the specifics of sampling, data analysis in descriptive/interpretive qualitative research, generation of categories, and extracting and interpreting the main findings.

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Qualitative Data Coding

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Coding is the process of analyzing qualitative data (usually text) by assigning labels (codes) to chunks of data that capture their essence or meaning. It allows you to condense, organize and interpret your data.

A code is a word or brief phrase that captures the essence of why you think a particular bit of data may be useful. A good analogy is that a code describes data like a hashtag describes a tweet.

Coding is an iterative process, with researchers refining and revising their codes as their understanding of the data evolves.

The ultimate goal is to develop a coherent and meaningful coding scheme that captures the richness and complexity of the participants’ experiences and helps answer the research questions.

Step 1: Familiarize yourself with the data

• Read through your data (interview transcripts, field notes, documents, etc.) several times. This process is called immersion.
• Think and reflect on what may be important in the data before making any firm decisions about ideas, or potential patterns.

Step 2: Decide on your coding approach

• Will you use predefined deductive codes (based on theory or prior research), or let codes emerge from the data (inductive coding)?
• Will a piece of data have one code or multiple?
• Will you code everything or selectively? Broader research questions may warrant coding more comprehensively.

If you decide not to code everything, it’s crucial to:

• Have clear criteria for what you will and won’t code
• Be transparent about your selection process in research reports
• Remain open to revisiting uncoded data later in analysis

Step 3: Do a first round of coding

• Go through the data and assign initial codes to chunks that stand out
• Create a code name (a word or short phrase) that captures the essence of each chunk
• Keep a codebook – a list of your codes with descriptions or definitions
• Be open to adding, revising or combining codes as you go

Descriptive codes

• In vivo coding / Semantic coding : This method uses words or short phrases directly from the participant’s own language as codes. It deals with the surface-level content, labeling what participants directly say or describe. It identifies keywords, phrases, or sentences that capture the literal content. Participant : “I was just so overwhelmed with everything.” Code : “overwhelmed”
• Process coding : Uses gerunds (“-ing” words) to connote observable or conceptual action in the data. Participant : “I started by brainstorming ideas, then I narrowed them down.” Codes : “brainstorming ideas,” “narrowing down”
• Open coding : A form of initial coding where the researcher remains open to any possible theoretical directions indicated by the data. Participant : “I found the class really challenging, but I learned a lot.” Codes : “challenging class,” “learning experience”
• Descriptive coding : Summarizes the primary topic of a passage in a word or short phrase. Participant : “I usually study in the library because it’s quiet.” Code : “study environment”

Step 4: Review and refine codes

• Look over your initial codes and see if any can be combined, split up, or revised
• Ensure your code names clearly convey the meaning of the data
• Check if your codes are applied consistently across the dataset
• Get a second opinion from a peer or advisor if possible

Interpretive codes

Interpretive codes go beyond simple description and reflect the researcher’s understanding of the underlying meanings, experiences, or processes captured in the data.

These codes require the researcher to interpret the participants’ words and actions in light of the research questions and theoretical framework.

For example, latent coding is a type of interpretive coding which goes beyond surface meaning in data. It digs for underlying emotions, motivations, or unspoken ideas the participant might not explicitly state

Latent coding looks for subtext, interprets the “why” behind what’s said, and considers the context (e.g. cultural influences, or unconscious biases).

• Example: A participant might say, “Whenever I see a spider, I feel like I’m going to pass out. It takes me back to a bad experience as a kid.” A latent code here could be “Feelings of Panic Triggered by Spiders” because it goes beyond the surface fear and explores the emotional response and potential cause.

It’s useful to ask yourself the following questions:

• What are the assumptions made by the participants? 
• What emotions or feelings are expressed or implied in the data?
• How do participants relate to or interact with others in the data?
• How do the participants’ experiences or perspectives change over time?
• What is surprising, unexpected, or contradictory in the data?
• What is not being said or shown in the data? What are the silences or absences?

Theoretical codes

Theoretical codes are the most abstract and conceptual type of codes. They are used to link the data to existing theories or to develop new theoretical insights.

Theoretical codes often emerge later in the analysis process, as researchers begin to identify patterns and connections across the descriptive and interpretive codes.

• Structural coding : Applies a content-based phrase to a segment of data that relates to a specific research question. Research question : What motivates students to succeed? Participant : “I want to make my parents proud and be the first in my family to graduate college.” Interpretive Code : “family motivation” Theoretical code : “Social identity theory”
• Value coding : This method codes data according to the participants’ values, attitudes, and beliefs, representing their perspectives or worldviews. Participant : “I believe everyone deserves access to quality healthcare.” Interpretive Code : “healthcare access” (value) Theoretical code : “Distributive justice”

Pattern codes

Pattern coding is often used in the later stages of data analysis, after the researcher has thoroughly familiarized themselves with the data and identified initial descriptive and interpretive codes.

By identifying patterns and relationships across the data, pattern codes help to develop a more coherent and meaningful understanding of the phenomenon and can contribute to theory development or refinement.

For Example

Let’s say a researcher is studying the experiences of new mothers returning to work after maternity leave. They conduct interviews with several participants and initially use descriptive and interpretive codes to analyze the data. Some of these codes might include:

• “Guilt about leaving baby”
• “Struggle to balance work and family”
• “Support from colleagues”
• “Flexible work arrangements”
• “Breastfeeding challenges”

As the researcher reviews the coded data, they may notice that several of these codes relate to the broader theme of “work-family conflict.”

They might create a pattern code called “Navigating work-family conflict” that pulls together the various experiences and challenges described by the participants.

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• Open access
• Published: 13 May 2024

Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

• Léa Solh Dost   ORCID: orcid.org/0000-0001-5767-1305 1 , 2 ,
• Giacomo Gastaldi   ORCID: orcid.org/0000-0001-6327-7451 3 &
• Marie P. Schneider   ORCID: orcid.org/0000-0002-7557-9278 1 , 2  

BMC Health Services Research volume  24 , Article number:  620 ( 2024 ) Cite this article

274 Accesses

Metrics details

Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients’ perspectives of their medications from hospital to two months after discharge.

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

Conclusions

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients’ difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients’ needs, increase their safety, and standardize physicians’, pharmacists’, and nurses’ roles and responsibilities.

Peer Review reports

Introduction

Continuity of patient care is characterized as the collaborative engagement between the patient and their physician-led care team in the ongoing management of healthcare, with the mutual objective of delivering high-quality and cost-effective medical care [ 1 ]. Continuity of care is under great pressure during the transition of care from hospital to outpatient care, with a risk of compromising patients’ safety [ 2 , 3 ]. The early post-discharge period is a high-risk and fragile transition: once discharged, one in five patients experience at least one adverse event during the first three weeks following discharge, and more than half of these adverse events are drug-related [ 4 , 5 ]. A retrospective study examining all discharged patients showed that adverse drug events (ADEs) account for up to 20% of 30-day hospital emergency readmissions [ 6 ]. During hospitalization, patients’ medications are generally modified, with an average of nearly four medication changes per patient [ 7 ]. Information regarding medications such as medication changes, the expected effect, side effects, and instructions for use are frequently poorly communicated to patients during hospitalization and at discharge [ 8 , 9 , 10 , 11 ]. Between 20 and 60% of discharged patients lack knowledge of their medications [ 12 , 13 ]. Consideration of patients’ needs and their active engagement in decision-making during hospitalization regarding their medications are often lacking [ 11 , 14 , 15 ]. This can lead to unsafe discharge and contribute to medication adherence difficulties, such as non-implementation of newly prescribed medications [ 16 , 17 ].

Patients with multiple comorbidities and polypharmacy are at higher risk of ADE [ 18 ]. Type 2 diabetes is one of the chronic health conditions most frequently associated with comorbidities and patients with type 2 diabetes often lack care continuum [ 19 , 20 , 21 ]. The prevalence of patients hospitalized with type 2 diabetes can exceed 40% [ 22 ] and these patients are at higher risk for readmission due to their comorbidities and their medications, such as insulin and oral hypoglycemic agents [ 23 , 24 , 25 ].

Interventions and strategies to improve patient care and safety at transition have shown mixed results worldwide in reducing cost, rehospitalization, ADE, and non-adherence [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. However, interventions that are patient-centered, with a patient follow-up and led by interprofessional healthcare teams showed promising results [ 34 , 35 , 36 ]. Most of these interventions have not been implemented routinely due to the extensive time to translate research into practice and the lack of hybrid implementation studies [ 37 , 38 , 39 , 40 , 41 ]. In addition, patient-reported outcomes and perspectives have rarely been considered, yet patients’ involvement is essential for seamless and integrated care [ 42 , 43 ]. Interprofessional collaboration in which patients are full members of the interprofessional team, is still in its infancy in outpatient care [ 44 ]. Barriers and facilitators regarding medications at the transition of care have been explored in multiple qualitative studies at one given time in a given setting (e.g., at discharge, one-month post-discharge) [ 8 , 45 , 46 , 47 , 48 ]. However, few studies have adopted a holistic methodology from the hospital to the outpatient setting to explore changes in patients’ perspectives over time [ 49 , 50 , 51 ]. Finally, little is known about whether, how, and when patients return to their daily routine following hospitalization and the impact of hospitalization weeks after discharge.

In Switzerland, continuity of care after hospital discharge is still poorly documented, both in terms of contextual analysis and interventional studies, and is mainly conducted in the hospital setting [ 31 , 35 , 52 , 53 , 54 , 55 , 56 ]. The first step of an implementation science approach is to perform a contextual analysis to set up effective interventions adapted to patients’ needs and aligned to healthcare professionals’ activities in a specific context [ 41 , 57 ]. Therefore, the main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and on their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients’ perspectives of their medications from hospital to two months after discharge.

Study design

This qualitative longitudinal study, conducted from October 2020 to July 2021, used a qualitative descriptive methodology through four consecutive in-depth semi-structured interviews per participant at three, 10-, 30- and 60-days post-discharge, as illustrated in Fig.  1 . Longitudinal qualitative research is characterized by qualitative data collection at different points in time and focuses on temporality, such as time and change [ 58 , 59 ]. Qualitative descriptive studies aim to explore and describe the depth and complexity of human experiences or phenomena [ 60 , 61 , 62 ]. We focused our qualitative study on the 60 first days after discharge as this period is considered highly vulnerable and because studies often use 30- or 60-days readmission as an outcome measure [ 5 , 63 ].

This qualitative study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ). Ethics committee approval was sought and granted by the Cantonal Research Ethics Commission, Geneva (CCER) (2020 − 01779).

Recruitment took place during participants’ hospitalization in the general internal medicine divisions at the Geneva University Hospitals in the canton of Geneva (500 000 inhabitants), Switzerland. Interviews took place at participants’ homes, in a private office at the University of Geneva, by telephone or by secure video call, according to participants’ preference. Informal caregivers could also participate alongside the participants.

Study flowchart

Researcher characteristics

All the researchers were trained in qualitative studies. The diabetologist and researcher (GG) who enrolled the patients in the study was involved directly or indirectly (advice asked to the Geneva University Hospital diabetes team of which he was a part) for most participants’ care during hospitalization. LS (Ph.D. student and community pharmacist) was unknown to participants and presented herself during hospitalization as a “researcher” and not as a healthcare professional to avoid any risk of influencing participants’ answers. This study was not interventional, and the interviewer (LS) invited participants to contact a healthcare professional for any questions related to their medication or medical issues.

Population and sampling strategy

Patients with type 2 diabetes were chosen as an example population to describe polypharmacy patients as these patients usually have several health issues and polypharmacy [ 20 , 22 , 25 ]. Inclusions criteria for the study were: adult patients with type 2 diabetes, with at least two other comorbidities, hospitalized for at least three days in a general internal medicine ward, with a minimum of one medication change during hospital stay, and who self-managed their medications once discharged home. Exclusion criteria were patients not reachable by telephone following discharge, unable to give consent (patients with schizophrenia, dementia, brain damage, or drug/alcohol misuse), and who could not communicate in French. A purposive sampling methodology was applied aiming to include participants with different ages, genders, types, and numbers of health conditions by listing participants’ characteristics in a double-entry table, available in Supplementary Material 1 , until thematic saturation was reached. Thematic saturation was considered achieved when no new code or theme emerged and new data repeated previously coded information [ 64 ]. The participants were identified if they were hospitalized in the ward dedicated to diabetes care or when the diabetes team was contacted for advice. The senior ward physician (GG) screened eligible patients and the interviewer (LS) obtained written consent before hospital discharge.

Data collection and instruments

Sociodemographic (age, gender, educational level, living arrangement) and clinical characteristics (reason for hospitalization, date of admission, health conditions, diabetes diagnosis, medications before and during hospitalization) were collected by interviewing participants before their discharge and by extracting participants’ data from electronic hospital files by GG and LS. Participants’ pharmacies were contacted with the participant’s consent to obtain medication records from the last three months if information regarding medications before hospitalization was missing in the hospital files.

Semi-structured interview guides for each interview (at three, 10-, 30- and 60-days post-discharge) were developed based on different theories and components of health behavior and medication adherence: the World Health Organization’s (WHO) five dimensions for adherence, the Information-Motivation-Behavioral skills model and the Social Cognitive Theory [ 65 , 66 , 67 ]. Each interview explored participants’ itinerary in the healthcare system and their perspectives on their medications. Regarding medications, the following themes were mentioned at each interview: changes in medications, patients’ understanding and implication; information on their medications, self-management of their medications, and patients’ medication adherence. Other aspects were mentioned in specific interviews: patients’ hospitalization and experience on their return home (interview 1), motivation (interviews 2 and 4), and patient’s feedback on the past two months (interview 4). Interview guides translated from French are available in Supplementary Material 2 . The participants completed self-reported and self-administrated questionnaires at different interviews to obtain descriptive information on different factors that may affect medication management and adherence: self-report questionnaires on quality of life (EQ-5D-5 L) [ 68 ], literacy (Schooling-Opinion-Support questionnaire) [ 69 ], medication adherence (Adherence Visual Analogue Scale, A-VAS) [ 70 ] and Belief in Medication Questionnaire (BMQ) [ 71 ] were administered to each participant at the end of selected interviews to address the different factors that may affect medication management and adherence as well as to determine a trend of determinants over time. The BMQ contains two subscores: Specific-Necessity and Specific-Concerns, addressing respectively their perceived needs for their medications, and their concerns about adverse consequences associated with taking their medication [ 72 ].

Data management

Informed consent forms, including consent to obtain health data, were securely stored in a private office at the University of Geneva. The participants’ identification key was protected by a password known only by MS and LS. Confidentiality was guaranteed by pseudonymization of participants’ information and audio-recordings were destroyed once analyzed. Sociodemographic and clinical characteristics, medication changes, and answers to questionnaires were securely collected by electronic case report forms (eCRFs) on RedCap®. Interviews were double audio-recorded and field notes were taken during interviews. Recorded interviews were manually transcribed verbatim in MAXQDA® (2018.2) by research assistants and LS and transcripts were validated for accuracy by LS. A random sample of 20% of questionnaires was checked for accuracy for the transcription from the paper questionnaires to the eCRFs. Recorded sequences with no link to the discussed topics were not transcribed and this was noted in the transcripts.

Data analysis

A descriptive statistical analysis of sociodemographic, clinical characteristics and self-reported questionnaire data was carried out. A thematic analysis of transcripts was performed, as described by Braun and Clarke [ 73 ], by following six steps: raw data was read, text segments related to the study objectives were identified, text segments to create new categories were identified, similar or redundant categories were reduced and a model that integrated all significant categories was created. The analysis was conducted in parallel with patient enrolment to ensure data saturation. To ensure the validity of the coding method, transcripts were double coded independently and discussed by the research team until similar themes were obtained. The research group developed and validated an analysis grid, with which LS coded systematically the transcriptions and met regularly with the research team to discuss questions on data analysis and to ensure the quality of coding. The analysis was carried out in French, and the verbatims of interest cited in the manuscript were translated and validated by a native English-speaking researcher to preserve the meaning.

In this analysis, we used the term “healthcare professionals” when more than one profession could be involved in participants’ medication management. Otherwise, when a specific healthcare professional was involved, we used the designated profession (e.g. physicians, pharmacists).

Patient and public involvement

During the development phase of the study, interview guides and questionnaires were reviewed for clarity and validity and adapted by two patient partners, with multiple health conditions and who experienced previously a hospital discharge. They are part of the HUG Patients Partners + 3P platform for research and patient and public involvement.

Interviews and participants’ descriptions

A total of 75 interviews were conducted with 21 participants. In total, 31 patients were contacted, seven refused to participate (four at the project presentation and three at consent), two did not enter the selection criteria at discharge and one was unreachable after discharge. Among the 21 participants, 15 participated in all interviews, four in three interviews, one in two interviews, and one in one interview, due to scheduling constraints. Details regarding interviews and participants characteristics are presented in Tables  1 and 2 .

The median length of time between hospital discharge and interviews 1,2,3 and 4 was 5 (IQR: 4–7), 14 (13-20), 35 (22-38), and 63 days (61-68), respectively. On average, by comparing medications at hospital admission and discharge, a median of 7 medication changes (IQR: 6–9, range:2;17) occurred per participant during hospitalization and a median of 7 changes (5–12) during the two months following discharge. Details regarding participants’ medications are described in Table  3 .

Patient self-reported adherence over the past week for their three most challenging medications are available in Supplementary Material 3 .

Qualitative analysis

We defined care transition as the period from discharge until the first medical appointment post-discharge, and outpatient care as the period starting after the first medical appointment. Data was organized into three key themes (A. Medication management, B. Medication understanding, and C. Medication adherence) divided into subthemes at three time points (1. Hospitalization, 2. Care transition and 3. Outpatient care). Figure  2 summarizes and illustrates the themes and subthemes with their influencing factors as bullet points.

Participants’ medication management, understanding and adherence during hospitalization, care transition and outpatient care

A. Medication management

A.1 medication management during hospitalization: medication management by hospital staff.

Medications during hospitalization were mainly managed by hospital healthcare professionals (i.e. nurses and physicians) with varying degrees of patient involvement: “At the hospital, they prepared the medications for me. […] I didn’t even know what the packages looked like.” Participant 22; interview 1 (P22.1) Some participants reported having therapeutic education sessions with specialized nurses and physicians, such as the explanation and demonstration of insulin injection and glucose monitoring. A patient reported that he was given the choice of several treatments and was involved in shared decision-making. Other participants had an active role in managing and optimizing dosages, such as rapid insulin, due to prior knowledge and use of medications before hospitalization.

A.2 Medication management at transition: obtaining the medication and initiating self-management

Once discharged, some participants had difficulties obtaining their medications at the pharmacy because some medications were not stored and had to be ordered, delaying medication initiation. To counter this problem upstream, a few participants were provided a 24-to-48-hour supply of medications at discharge. It was sometimes requested by the patient or suggested by the healthcare professionals but was not systematic. The transition from medication management by hospital staff to self-management was exhausting for most participants who were faced with a large amount of new information and changes in their medications: “ When I was in the hospital, I didn’t even realize all the changes. When I came back home, I took away the old medication packages and got out the new ones. And then I thought : « my God, all this…I didn’t know I had all these changes » ” P2.1 Written documentation, such as the discharge prescription or dosage labels on medication packages, was helpful in managing their medication at home. Most participants used weekly pill organizers to manage their medications, which were either already used before hospitalization or were introduced post-discharge. The help of a family caregiver in managing and obtaining medications was reported as a facilitator.

A.3 Medication management in outpatient care: daily self-management and medication burden

A couple of days or weeks after discharge, most participants had acquired a routine so that medication management was less demanding, but the medication burden varied depending on the participants. For some, medication management became a simple action well implemented in their routine (“It has become automatic” , P23.4), while for others, the number of medications and the fact that the medications reminded them of the disease was a heavy burden to bear on a daily basis (“ During the first few days after getting out of the hospital, I thought I was going to do everything right. In the end, well [laughs] it’s complicated. I ended up not always taking the medication, not monitoring the blood sugar” P12.2) To support medication self-management, some participants had written documentation such as treatment plans, medication lists, and pictures of their medication packages on their phones. Some participants had difficulties obtaining medications weeks after discharge as discharge prescriptions were not renewable and participants did not see their physician in time. Others had to visit multiple physicians to have their prescriptions updated. A few participants were faced with prescription or dispensing errors, such as prescribing or dispensing the wrong dosage, which affected medication management and decreased trust in healthcare professionals. In most cases, according to participants, the pharmacy staff worked in an interprofessional collaboration with physicians to provide new and updated prescriptions.

B. Medication understanding

B.1 medication understanding during hospitalization: new information and instructions.

The amount of information received during hospitalization varied considerably among participants with some reporting having received too much, while others saying they received too little information regarding medication changes, the reason for changes, or for introducing new medications: “They told me I had to take this medication all my life, but they didn’t tell me what the effects were or why I was taking it.” P5.3

Hospitalization was seen by some participants as a vulnerable and tiring period during which they were less receptive to information. Information and explanations were generally given verbally, making it complicated for most participants to recall it. Some participants reported that hospital staff was attentive to their needs for information and used communication techniques such as teach-back (a way of checking understanding by asking participants to say in their own words what they need to know or do about their health or medications). Some participants were willing to be proactive in the understanding of their medications while others were more passive, had no specific needs for information, and did not see how they could be engaged more.

B.2 Medication understanding at transition: facing medication changes

At hospital discharge, the most challenging difficulty for participants was to understand the changes made regarding their medications. For newly diagnosed participants, the addition of new medications was more difficult to understand, whereas, for experienced participants, changes in known medications such as dosage modification, changes within a therapeutic class, and generic substitutions were the most difficult to understand. Not having been informed about changes caused confusion and misunderstanding. Therefore, medication reconciliation done by the patient was time-consuming, especially for participants with multiple medications: “ They didn’t tell me at all that they had changed my treatment completely. They just told me : « We’ve changed a few things. But it was the whole treatment ». ” P2.3 Written information, such as the discharge prescription, the discharge report (brief letter summarizing information about the hospitalization, given to the patient at discharge), or the label on the medication box (written by the pharmacist with instructions on dosage) helped them find or recall information about their medications and diagnoses. However, technical terms were used in hospital documentations and were not always understandable. For example, this participant said: “ On the prescription of valsartan, they wrote: ‘resume in the morning once profile…’[once hypertension profile allows]… I don’t know what that means.” P8.1 In addition, some documents were incomplete, as mentioned by a patient who did not have the insulin dosage mentioned on the hospital prescription. Some participants sought help from healthcare professionals, such as pharmacists, hospital physicians, or general practitioners a few days after discharge to review medications, answer questions, or obtain additional information.

B.3 Medication understanding in the outpatient care: concerns and knowledge

Weeks after discharge, most participants had concerns about the long-term use of their medications, their usefulness, and the possible risk of interactions or side effects. Some participants also reported having some lack of knowledge regarding indications, names, or how the medication worked: “I don’t even know what Brilique® [ticagrelor, antiplatelet agent] is for. It’s for blood pressure, isn’t it?. I don’t know.” P11.4 According to participants, the main reasons for the lack of understanding were the lack of information at the time of prescribing and the large number of medications, making it difficult to search for information and remember it. Participants sought information from different healthcare professionals or by themselves, on package inserts, through the internet, or from family and friends. Others reported having had all the information needed or were not interested in having more information. In addition, participants with low medication literacy, such as non-native speakers or elderly people, struggled more with medication understanding and sought help from family caregivers or healthcare professionals, even weeks after discharge: “ I don’t understand French very well […] [The doctor] explained it very quickly…[…] I didn’t understand everything he was saying” P16.2

C. Medication adherence

C.2 medication adherence at transition: adopting new behaviors.

Medication adherence was not mentioned as a concern during hospitalization and a few participants reported difficulties in medication initiation once back home: “I have an injection of Lantus® [insulin] in the morning, but obviously, the first day [after discharge], I forgot to do it because I was not used to it.” P23.1 Participants had to quickly adopt new behaviors in the first few days after discharge, especially for participants with few medications pre-hospitalization. The use of weekly pill organizers, alarms and specific storage space were reported as facilitators to support adherence. One patient did not initiate one of his medications because he did not understand the medication indication, and another patient took her old medications because she was used to them. Moreover, most participants experienced their hospitalization as a turning point, a time when they focused on their health, thought about the importance of their medications, and discussed any new lifestyle or dietary measures that might be implemented.

C.3 Medication adherence in outpatient care: ongoing medication adherence

More medication adherence difficulties appeared a few weeks after hospital discharge when most participants reported nonadherence behaviors, such as difficulties implementing the dosage regimen, or intentionally discontinuing the medication and modifying the medication regimen on their initiative. Determinants positively influencing medication adherence were the establishment of a routine; organizing medications in weekly pill-organizers; organizing pocket doses (medications for a short period that participants take with them when away from home); seeking support from family caregivers; using alarm clocks; and using specific storage places. Reasons for nonadherence were changes in daily routine; intake times that were not convenient for the patient; the large number of medications; and poor knowledge of the medication or side effects. Healthcare professionals’ assistance for medication management, such as the help of home nurses or pharmacists for the preparation of weekly pill-organizers, was requested by participants or offered by healthcare professionals to support medication adherence: “ I needed [a home nurse] to put my pills in the pillbox. […] I felt really weak […] and I was making mistakes. So, I’m very happy [the doctor] offered me [home care]. […] I have so many medications.” P22.3 Some participants who experienced prehospitalization non-adherence were more aware of their non-adherence and implemented strategies, such as modifying the timing of intake: “I said to my doctor : « I forget one time out of two […], can I take them in the morning? » We looked it up and yes, I can take it in the morning.” P11.2 In contrast, some participants were still struggling with adherence difficulties that they had before hospitalization. Motivations for taking medications two months after discharge were to improve health, avoid complications, reduce symptoms, reduce the number of medications in the future or out of obligation: “ I force myself to take them because I want to get to the end of my diabetes, I want to reduce the number of pills as much as possible.” P14.2 After a few weeks post-hospitalization, for some participants, health and illness were no longer the priority because of other life imperatives (e.g., family or financial situation).

This longitudinal study provided a multi-faceted representation of how patients manage, understand, and adhere to their medications from hospital discharge to two months after discharge. Our findings highlighted the varying degree of participants’ involvement in managing their medications during their hospitalization, the individualized needs for information during and after hospitalization, the complicated transition from hospital to autonomous medication management, the adaptation of daily routines around medication once back home, and the adherence difficulties that surfaced in the outpatient care, with nonadherence prior to hospitalization being an indicator of the behavior after discharge. Finally, our results confirmed the lack of continuity in care and showed the lack of patient care standardization experienced by the participants during the transition from hospital to outpatient care.

This in-depth analysis of patients’ experiences reinforces common challenges identified in the existing literature such as the lack of personalized information [ 9 , 10 , 11 ], loss of autonomy during hospitalization [ 14 , 74 , 75 ], difficulties in obtaining medication at discharge [ 11 , 45 , 76 ] and challenges in understanding treatment modifications and generics substitution [ 11 , 32 , 77 , 78 ]. Some of these studies were conducted during patients’ hospitalization [ 10 , 75 , 79 ] or up to 12 months after discharge [ 80 , 81 ], but most studies focused on the few days following hospital discharge [ 9 , 11 , 14 , 82 ]. Qualitative studies on medications at transition often focused on a specific topic, such as medication information, or a specific moment in time, and often included healthcare professionals, which muted patients’ voices [ 9 , 10 , 11 , 47 , 49 ]. Our qualitative longitudinal methodology was interested in capturing the temporal dynamics, in-depth narratives, and contextual nuances of patients’ medication experiences during transitions of care [ 59 , 83 ]. This approach provided a comprehensive understanding of how patients’ perspectives and behaviors evolved over time, offering insights into the complex interactions of medication management, understanding and adherence, and turning points within their medication journeys. A qualitative longitudinal design was used by Fylan et al. to underline patients’ resilience in medication management during and after discharge, by Brandberg et al. to show the dynamic process of self-management during the 4 weeks post-discharge and by Lawton et al. to examine how patients with type 2 diabetes perceived their care after discharge over a period of four years [ 49 , 50 , 51 ]. Our study focused on the first two months following hospitalization and future studies should focus on following discharged and at-risk patients over a longer period, as “transitions of care do not comprise linear trajectories of patients’ movements, with a starting and finishing point. Instead, they are endless loops of movements” [ 47 ].

Our results provide a particularly thorough description of how participants move from a state of total dependency during hospitalization regarding their medication management to a sudden and complete autonomy after hospital discharge impacting medication management, understanding, and adherence in the first days after discharge for some participants. Several qualitative studies have described the lack of shared decision-making and the loss of patient autonomy during hospitalization, which had an impact on self-management and created conflicts with healthcare professionals [ 75 , 81 , 84 ]. Our study also highlights nuanced patient experiences, including varying levels of patient needs, involvement, and proactivity during hospitalization and outpatient care, and our results contribute to capturing different perspectives that contrast with some literature that often portrays patients as more passive recipients of care [ 14 , 15 , 74 , 75 ]. Shared decision-making and proactive medication are key elements as they contribute to a smoother transition and better outcomes for patients post-discharge [ 85 , 86 , 87 ].

Consistent with the literature, the study identifies some challenges in medication initiation post-discharge [ 16 , 17 , 88 ] but our results also describe how daily routine rapidly takes over, either solidifying adherence behavior or generating barriers to medication adherence. Participants’ nonadherence prior to hospitalization was a factor influencing participants’ adherence post-hospitalization and this association should be further investigated, as literature showed that hospitalized patients have high scores of non-adherence [ 89 ]. Mortel et al. showed that more than 20% of discharged patients stopped their medications earlier than agreed with the physician and 25% adapted their medication intake [ 90 ]. Furthermore, patients who self-managed their medications had a lower perception of the necessity of their medication than patients who received help, which could negatively impact medication adherence [ 91 ]. Although participants in our study had high BMQ scores for necessity and lower scores for concerns, some participants expressed doubts about the need for their medications and a lack of motivation a few weeks after discharge. Targeted pharmacy interventions for newly prescribed medications have been shown to improve medication adherence, and hospital discharge is an opportune moment to implement this service [ 92 , 93 ].

Many medication changes were made during the transition of care (a median number of 7 changes during hospitalization and 7 changes during the two months after discharge), especially medication additions during hospitalization and interruptions after hospitalization. While medication changes during hospitalization are well described, the many changes following discharge are less discussed [ 7 , 94 ]. A Danish study showed that approximately 65% of changes made during hospitalization were accepted by primary healthcare professionals but only 43% of new medications initiated during hospitalization were continued after discharge [ 95 ]. The numerous changes after discharge may be caused by unnecessary intensification of medications during hospitalization, delayed discharge letters, lack of standardized procedures, miscommunication, patient self-management difficulties, or in response to an acute situation [ 96 , 97 , 98 ]. During the transition of care, in our study, both new and experienced participants were faced with difficulties in managing and understanding medication changes, either for newly prescribed medication or changes in previous medications. Such difficulties corroborate the findings of the literature [ 9 , 10 , 47 ] and our results showed that the lack of understanding during hospitalization led to participants having questions about their medications, even weeks after discharge. Particular attention should be given to patients’ understanding of medication changes jointly by physicians, nurses and pharmacists during the transition of care and in the months that follow as medications are likely to undergo as many changes as during hospitalization.

Implication for practice and future research

The patients’ perspectives in this study showed, at a system level, that there was a lack of standardization in healthcare professional practices regarding medication dispensing and follow-up. For now, in Switzerland, there are no official guidelines on medication prescription and dispensation during the transition of care although some international guidelines have been developed for outpatient healthcare professionals [ 3 , 99 , 100 , 101 , 102 ]. Here are some suggestions for improvement arising from our results. Patients should be included as partners and healthcare professionals should systematically assess (i) previous medication adherence, (ii) patients’ desired level of involvement and (iii) their needs for information during hospitalization. Hospital discharge processes should be routinely implemented to standardize hospital discharge preparation, medication prescribing, and dispensing. Discharge from the hospital should be planned with community pharmacies to ensure that all medications are available and, if necessary, doses of medications should be supplied by the hospital to bridge the gap. A partnership with outpatient healthcare professionals, such as general practitioners, community pharmacists, and homecare nurses, should be set up for effective asynchronous interprofessional collaboration to consolidate patients’ medication management, knowledge, and adherence, as well as to monitor signs of deterioration or adverse drug events.

Future research should consolidate our first attempt to develop a framework to better characterize medication at the transition of care, using Fig. 2   as a starting point. Contextualized interventions, co-designed by health professionals, patients and stakeholders, should be tested in a hybrid implementation study to test the implementation and effectiveness of the intervention for the health system [ 103 ].

Limitations

This study has some limitations. First, the transcripts were validated for accuracy by the interviewer but not by a third party, which could have increased the robustness of the transcription. Nevertheless, the interviewer followed all methodological recommendations for transcription. Second, patient inclusion took place during the COVID-19 pandemic, which may have had an impact on patient care and the availability of healthcare professionals. Third, we cannot guarantee the accuracy of some participants’ medication history before hospitalization, even though we contacted the participants’ main pharmacy, as participants could have gone to different pharmacies to obtain their medications. Fourth, our findings may not be generalizable to other populations and other healthcare systems because some issues may be specific to multimorbid patients with type 2 diabetes or to the Swiss healthcare setting. Nevertheless, issues encountered by our participants regarding their medications correlate with findings in the literature. Fifth, only 15 out of 21 participants took part in all the interviews, but most participants took part in at least three interviews and data saturation was reached. Lastly, by its qualitative and longitudinal design, it is possible that the discussion during interviews and participants’ reflections between interviews influenced participants’ management, knowledge, and adherence, even though this study was observational, and no advice or recommendations were given by the interviewer during interviews.

Discharged patients are willing to take steps to better manage, understand, and adhere to their medications, yet they are also faced with difficulties in the hospital and outpatient care. Furthermore, extensive changes in medications not only occur during hospitalization but also during the two months following hospital discharge, for which healthcare professionals should give particular attention. The different degrees of patients’ involvement, needs and resources should be carefully considered to enable them to better manage, understand and adhere to their medications. At a system level, patients’ experiences revealed a lack of standardization of medication practices during the transition of care. The healthcare system should provide the ecosystem needed for healthcare professionals responsible for or involved in the management of patients’ medications during the hospital stay, discharge, and outpatient care to standardize their practices while considering the patient as an active partner.

Data availability

The anonymized quantitative survey datasets and the qualitative codes are available in French from the corresponding author on reasonable request.

Abbreviations

adverse drug events

Adherence Visual Analogue Scale

Belief in Medication Questionnaire

Consolidated Criteria for Reporting Qualitative Research

case report form

standard deviation

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Acknowledgements

The authors would like to thank all the patients who took part in this study. We would also like to thank the Geneva University Hospitals Patients Partners + 3P platform as well as Mrs. Tourane Corbière and Mr. Joël Mermoud, patient partners, who reviewed interview guides for clarity and significance. We would like to thank Samuel Fabbi, Vitcoryavarman Koh, and Pierre Repiton for the transcriptions of the audio recordings.

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

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LS, GG, and MS conceptualized and designed the study. LS and GG screened and recruited participants. LS conducted the interviews. LS, GG, and MS performed data analysis and interpretation. LS drafted the manuscript and LS and MS worked on the different versions. MS and GG approved the final manuscript.

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Solh Dost, L., Gastaldi, G. & Schneider, M. Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes. BMC Health Serv Res 24 , 620 (2024). https://doi.org/10.1186/s12913-024-10784-9

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Moving between positions: a qualitative study of mentoring relationships in chronic eating disorders

• Roni Elran-Barak 1 &
• Shiran Elmalah-Alon 1  

Journal of Eating Disorders volume  12 , Article number:  59 ( 2024 ) Cite this article

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Metrics details

Eating disorders (ED) are chronic and challenging-to-treat conditions, often persisting over extended periods. Some patients with EDs require prolonged intensive rehabilitation services, which may include weekly home visits by paraprofessional mentors serving as support persons, providing guidelines, emotional care, and assistance. This study aims to enhance our understanding of the nature of the relationship formed between mentors and patients with EDs.

Design & Methods

Fifteen in-depth qualitative interviews were conducted with patients and paraprofessional mentors. Interviews were analyzed using a descriptive phenomenological approach by two researchers to enhance reliability.

Qualitative analysis highlighted that mentors play a crucial role in patients’ rehabilitation. Mentors adapt two positions (investigative and embracing) to address the encountered difficulties, including conflicts, tension, and confusion associated with (in)equality and reciprocity in the mentoring relationship.

Practice Implications

Paraprofessional mentors can assist people with ED in their rehabilitation process. To support patients with EDs effectively, it is crucial to train and supervise the mentors in navigating between roles and dealing with boundaries, secrets, lies, and exposure to various aspects of the rehabilitation process. Additionally, we recommend further research using quantitative and empirical tools to complement the qualitative findings presented.

Impact and implications

Paraprofessional mentors can make a crucial contribution to the rehabilitation of patients with eating disorders.

Eating disorder mentors have a complex task in learning how to move between the embracing and the investigative position.

The mentor’s physical entry into the patient’s home is critically significant, as it enables an encounter typified by less concealment.

It is important to make such mentoring services available to more patients with eating disorders.

It is advised to develop a special training program for mentors, so that they can acquire knowledge and learn about the specific dynamics that are common among patients with eating disorders.

Plain English summary

Eating disorders (ED) can be challenging to treat, often requiring long-term intensive support. Paraprofessional mentors are support persons who make weekly home visits to help patients in the rehabilitation process.

The study aims to understand the relationship between mentors and patients with ED. Researchers interviewed 15 patients and mentors. They discovered that mentors play a key role in helping patients get better by taking on two important roles. First, mentors act like investigators, trying to understand the challenges and problems that patients face. Second, mentors act as supporters, offering comfort and assistance during difficult times.

The study emphasizes the importance of including mentorship in ED treatment and rehabilitation. It also suggests that training and supervision for paraprofessional mentors are crucial to help them handle their roles effectively, especially when dealing with boundaries and complex situations.

Introduction

Eating disorders (ED) are a group of complex and life-threatening psychiatric disorders manifested in disturbed body image and maladaptive eating patterns. They include, among other things, extreme diets, fasting, binge eating, the use of laxatives, and induced vomiting [ 10 , 25 ]. The most common EDs are anorexia nervosa, bulimia nervosa, and binge EDs, all of which can have a lengthy and chronic course that has a profound influence on patients’ health and well-being [ 15 , 21 ]. In the most severe EDs there is – in addition to pathological eating patterns and disturbed body image – reduced psychosocial functioning, which may include difficulties in obtaining an education, preserving employment, and maintaining a social life [ 28 ]. Multidisciplinary rehabilitation that includes medical, nutritional, emotional, and familial care is essential in order to address the various aspects of the EDs [ 4 , 19 ]. In-home paraprofessional mentoring care is provided to some patients with severe EDs, but studies focusing on this type of care are scarce.

In-home mentoring takes place in the natural environment of the patient and, as such, is characterized by direct non-hierarchal personal contact and collaborative work [ 3 , 8 , 13 , 22 , 23 , 24 ]. Originally designed for individuals with severe mental illness who struggle to navigate life independently within the community [ 9 ], home-based mentoring offers personal support and guidance across various aspects of life, such as employment, education and social interactions. In the context of EDs, mentors hold multifaceted responsibilities. Not only do they address and support patients in establishing healthy and regular eating habits, but they also extend their focus to other essential life domains. Many patients with EDs who participate in a mentoring program also participate in regular psychotherapy sessions, and some additionally consult with a dietician. The mentoring serves as an additional treatment modality, aiding patients in managing their day-to-day tasks, thereby enhancing the overall recovery and rehabilitation process.

There are very few studies whose focus is on mentoring in EDs [ 3 , 8 , 13 , 22 , 23 , 24 ]. In some, the focus has been on peer mentoring (i.e., by a peer with an ED), and in some, including the current study, the focus has been on mentoring by a non-professional (e.g., psychology students who are still not licensed to work as mental health providers). A systematic review [ 8 ] exploring the benefits, effects, and experiences of mentoring on those with EDs suggests that mentoring has great value for both mentors and mentees. The results of a qualitative study [ 13 ] focusing on mentoring among mentees undergoing intensive ED medical treatment, followed by participation in a mentoring program, revealed several benefits for mentees. These advantages included feelings of hope, reconnection with others, and increased engagement with the world. The majority of mentees emphasized the exceptional and irreplaceable support provided by their mentors. Ending the mentoring relationship at the conclusion of the program emerged as a significant challenge, with mentors citing boundary management as a primary obstacle.

Research on mentoring indicates that many fundamental challenges present in therapeutic relationships, such as building trust, fostering a sense of security, demonstrating non-judgmental attitudes, empathy, and understanding, are also relevant within mentoring relationships [ 3 , 13 ]. In the context of EDs, distinctive challenges emerge, notably when attempting to address ED behaviors such as increasing caloric intake, which patients often perceive as disrupting their perceived “perfect solution” [ 30 ]. In fact, any intervention challenging the patient’s eating habits can trigger opposition, refusal to cooperate, and even false reports of eating behaviors [ 31 ]. The aim of this study was therefore to expand the body of literature addressing the unique bond formed between mentors and patients with EDs by investigating both mentors’ and patients’ personal subjective experience within this mentoring relationship.

Sample and procedure

The sample included 15 Israeli women, comprising ten patients and five paraprofessional mentors (as described in Tables  1 and 2 ). Sampling was stopped when data reached saturation [ 14 ], that is when no new information or insights are obtained from the data collected. This occurs when the researcher repeatedly encounters the same themes, concepts, or patterns in the data, and further data collection is unlikely to provide additional understanding or perspectives. The mentoring program was structured as the second phase of a rehabilitation program tailored for individuals with EDs who have finished an intensive rehabilitation program [ 16 ] and transitioned to independent living. The mentees had weekly sessions with a psychotherapist and a dietician in addition to the mentoring sessions. The mentors were supervised by the psychotherapist and/or the dietician. The aims of the mentoring program were negotiated and agreed upon between the patient, the mentor, the psychotherapist, and the dietician. The paraprofessional mentors were mostly students (Table  2 ). They were recruited for the mentoring position through a job positing published by the rehabilitation organization. This organization was also responsible for mentor supervision. Mentors mostly viewed this position as a part-time job allowing them to gain therapeutic skills while completing their formal mental-health education.

The research was approved by the authors’ university ethics committee (#2066). Participants were recruited to the study through an organization that provides rehabilitation services. The second author reached out to the organization’s director to request the names of potential mentors and mentees. Subsequently, the author contacted these individuals to explain the study procedure. To ensure free and independent participation, the program director was not informed about the participants’ decisions to participate or decline involvement in the study. Participants were not compensated by the research team for the interview time. All participants signed an informed consent prior to the interviews.

The qualitative interview

The qualitative interviews were conducted in Hebrew, face-to-face (at patients’ homes or a coffee shop), in 2019 by the second author, and each lasted about 90 min. In accordance with the phenomenological method, a semi-structured interview was conducted, which focuses on questions that describe participants’ experience and their cognitive perceptions regarding the subject of the study [ 5 ]. The interview began with the following statement: “Please describe your experience in the mentoring relationship.” Next, participants were asked specific questions regarding different aspects, including the nature of the mentoring relationship and the role of the mentor in the rehabilitation process. The complete interview guidelines have been attached as a supplement, but the interviewer (second author) had the flexibility to navigate between questions to facilitate a natural flow in the conversation.

The qualitative analysis

We analyzed the interviews using a descriptive phenomenological approach [ 7 , 18 ]. Todres’ [ 26 ] concept of phenomenological qualitative analysis was used to reveal the essential general structure or structures of meaning within the shared experiences of the research participants. This process is conducted via bracketing: attempting to reduce the influence of researchers’ prior knowledge on the analysis [ 27 ]. To address biases, and to enhance reliability, the transcripts of the interviews were analyzed independently by the two coauthors [ 1 ]. Throughout the analysis, we systematically set aside our preconceived notions, beliefs, and presumptions regarding the subject matter. This process allowed us to engage with the data openly without imposing our prior knowledge. Following individual analyses, a collaborative discussion was conducted. We aimed to ensure that the outcomes truly reflected the shared experiences of all participants, thus enhancing the credibility and trustworthiness of our study. This joint discussion was held to integrate the results and to choose the quotations that best represented the shared experience of all participants. Another independent reader also read our analyses and approved them.

The four themes presented below describe how the mentor’s physical entry into the patient’s home is perceived as having critical significance in the rehabilitation and recovery process. We describe the mentoring relationship as a unique opportunity for advancing the rehabilitative process (first and second themes), while highlighting the challenges associated with the mentor’s presence in the patient’s home (third and fourth themes). All four themes demonstrate the two positions that the mentors adopt: The investigative and the embracing positions. These positions emerged as key findings, identified through our analysis of the interviews, and were labeled as a result of our thorough examination of the data.

1. First theme: home-based care as an opportunity for a dialogue about “what’s on the table”

Interviewees emphasized that the mentor’s presence in the patient’s home allowed the exposure of eating habits and symptoms they had been hiding for a long time (“what’s on the table”). Sometimes, the straightforward act in which the mentor opens the patient’s refrigerator can be perceived as a moment of intimacy and a breakthrough during which the mentor can gain information about the patient’s eating regimen.

Naomi (mentor)

We enter their home, in the full sense of the word, their life, their home. Unlike for example the dietitians, where it’s the patients who come to the dietitians and tell them at the clinic how it went this week […], you [the mentor] can open her [the patient’s] fridge to see if there are diet products inside.

In the following citation, the mentee and mentor cook together. The quate demonstrates how the mentor moves between the investigative and the embracing positions and suggests that this transition can be quick. The patient, in this case, devotes herself to the act of learning and she is willing to give up previous habits, even if doing so is difficult and threatening.

Shahar (patient)

I took the egg out of the fridge and when I had to put it in the mixing bowl, a little spilled out. She [the mentor] asked me if [spilling] was intentional or unintentional and to be honest I didn’t know the answer … So she told me to “pay attention” […] and then I came to get the oil and she told me I needed a tablespoon of it. For an omelet! That’s crazy… and I wouldn’t agree to it […] She really kind of taught me that the oil should cover the whole bottom of the pan … after that I wanted to pat the omelet with absorbent paper … because it was really shiny and greasy-looking. I asked her if I could, even though I knew she wouldn’t let me, but I tried my luck.

In the following description Maayan describes a joint cooking experience with her mentor. There is a feeling, in the quote, of a mother and daughter cooking together. Maayan appreciates the mentor’s knowledge but even more than that, she appreciates the specialness and uniqueness of this joint cooking experience.

Maayan (patient)

Practically, I actually also learned to cook with the help of the mentor. I still keep a recipe book I made with one of the mentors …. and it was really like the two of us were thinking together about what I felt like eating, finding a recipe and experimenting with it, so it was, like, a very meaningful experience for me.

The following quote demonstrates how the mentor’s containing and caring presence (embracing position) allows Liat to confront her “pasta issue.” With the mentor’s help, Liat can allow herself to experience the difficulty and loss of control, but can also collect herself and confront the anxiety that arises in her when she eats pasta.

Liat (patient)

I had anxiety about pasta for years. It’s something I would never eat… and every time we [the mentor and I] wanted to make pasta, it ended up being put off […] So we went out one evening to eat pasta … we planned it. And it was insanely hard, I had a panic attack. I said to her, “I’m getting on a bus, I’m going home…, this is all too much for me,” and she really managed to get my panic attack under control, but I couldn’t eat the pasta. Then, we realized we might have jumped the gun: going out to eat pasta in a restaurant. When we made the pasta at home, […] and I knew what was in it, and I made it, it was a little bit easier. A month later we finally did go out to eat, in a restaurant, and I was more able to deal with it ….

The following quote demonstrates how the investigative position can help identify problematic areas that need to be addressed.

Romi (mentor)

The mentor comes inside the girl’s house, assesses the situation, notices the little details. For example, I suddenly noticed with one of my patients that she had a beer mug on the counter. I asked her about it and she gave me some vague answer. After a while she told me about some beer she drank […] Because I went in, and because I know what’s going on with her, I was actually able to see and stop the drinking routine before it evolved into something bigger.

Maya, for her part, uses the term “spotlight” to describe the role of the mentor. That is, the mentor’s intervention is experienced as a kind of strong beam of light that shines in a certain direction: the direction of recovery. The mentor illuminates the path of recovery, mentions the challenges Maya needs to overcome, and presents matters in a healthy language, a language of recovery.

Maya (patient)

She [the mentor]is in my life to put a spotlight specifically on my ED. It’s very easy to forget this spotlight sometimes […] she [the mentor] is there to remind me that the thoughts that drive people [with an ED] are not the same thoughts that drive people without an ED.

In conclusion, this theme demonstrates how the mentor’s presence in the patient’s home enables the breaking of concealment habits and promotes rehabilitative work aimed to extinguish behaviors resulting directly from the ED. Rehabilitation is made possible through the mentor’s moving back and forth between an embracing position and an “investigative” position that heeds details, casts doubt, and asks difficult questions.

2. Second theme: home-based care as an opportunity to work on “beside the table” issues

In contrast to the first theme, which revolved around aspects related directly to eating (“on the table”), in the second theme we see how the mentor’s presence in the house allows the mentor to witness the ED’s effect on areas of life that are not directly related to food (“beside the table”). For instance, in the next quotation, the experience of shopping with the mentor is described as an example of intimacy.

Inbal (patient)

The mentor is in my life at the most personal level. She comes inside the house, she sees how I really live. Ummm, I know . I think she knows my life best. And she sees me in a variety of situations… situations in which others don’t see me. I can tell the dietitian certain things about myself, but she doesn’t experience what it’s like to actually go buy bras with me or go shopping with me and see what I have trouble with.

In addition to shopping, another “beside the table issue” is basic hygiene. In the next quote, the mentor’s flexibility, and the transition she makes between being an authority figure and being a partner, seem to create an opening for the formation of an intimate bond.

Agam (mentor)

Some houses were tough to enter, like one in which there were severe hygiene issues. It was challenging; I’d feel the need to clean up after our sessions, take a shower, and launder my clothes. There was garbage strewn around, which puzzled me. Our mentoring goals included establishing a hygiene routine; she struggled to shower regularly. We set rules, like ensuring that she showered before our meetings. We had intimate conversations; hygiene touches personal spaces deeply. We discussed menstruation and hygiene neglect. I guided her, even showing her how to wash her legs thoroughly. These were unique situations I’d never experienced.

In the following quote we can see the mentor’s position as an investigator who reveals hidden information that no one had previously been aware of: The mentor identifies suicidal actions that would not have been identified in any other therapeutic situation. The role of the patient is to plant clues, and the role of the mentor is to reveal that which is hidden by paying attention to details.

I once found a rope on her desk, and it turned out that she slept with it tied around her neck at night. This is something that would be missed in conversation with the dietitian if she [the patient] chose not to share it. And it’s not that she shared it with me. I just saw it because I was there.

Liat’s next quote expands on the mentor’s role as an investigator. The patient won’t reveal her secrets if no one asks questions; however, when the mentor asks the right questions, the patient will stop hiding. She’ll answer the mentor’s questions, even if they are difficult.

One time when she [the mentor] came to my house, she saw that I was taking a shower in the dark. […] she just happened to notice. No one else noticed. My roommate didn’t notice; in the rehabilitation house they didn’t notice. I had always showered in the dark; this was not something new… she [the mentor] had a conversation with me about it, [I was surprised that] it didn’t seem to be something strange or unheard of to her. And we started working on it […] I had to start showering with the light on, and she [the mentor] would sit outside […] I think that when she gave me [permission to be myself]… without judgment and without criticism, I allowed myself to reveal the darkest, strangest, most illogical things associated with my ED.

In the following two quotes, both the mentor and the patient agree that very little escapes the mentor’s eyes; she notices all sorts of behaviors. Liat uses the term “eyes in the back” to describe the situation in which the mentor is vigilant and observing all patients’ behaviors. Naomi provides a specific example - excessive shopping that the patient conceals from her psychotherapist but not from her mentor, as the mentor can see the new items when she visits the mentee.

You feel that you are seen; you feel that no matter what you do, the mentor will take notice […] There should be someone there who has eyes in the back of her head. Someone who knows how to read situations, who is very alert, who knows by the tone of your voice on the phone what is happening.

The mentor can show her [the patient] things she does not see herself […] For example, let’s say someone had a bad day and [to make herself feel better] she went shopping and spent a thousand shekels […] Now, the patient won’t bring this subject up in any conversation because it’s not related to food; it’s not something she’s going to report. And there’s no social worker looking at her expenses. So it’s the mentor who has to put it together and talk about it with the patient.

Nofar summarizes the mentoring experience and claims that without the mentor’s support, she could not have had a successful rehabilitation.

Nofar (patient)

There’s no chance I could have succeeded in the outside world without someone watching out for me, guarding me, setting boundaries for me. I really needed them to do these things for me […] There’s no chance I would have been able to do all these things alone. No chance.

In conclusion, the quotes illustrate the theme of “seeing,” according to which the mentor observes the patient closely, and the patient perceives the gaze as benevolent, one that helps promote recovery. In this sense it can be said that the mentor-patient relationship is a kind of dance between the two: the mentor can be both an investigator and a benevolent mother, and the patient allows the mentor to understand “what is happening.” Together they work toward rehabilitation in all life areas.

3. Third theme: confrontations, secrets, and lies

In the third theme, cases are depicted in which the patient feels anger toward the mentor. The mentor requires the patient to undergo a rehabilitative process and give up her ED behaviors, but the patient, in some cases, feels that she is not yet able to make these changes. In the following quote, the difficulty of bringing a mentor into the home, opening up, and devoting oneself to the rehabilitative process is described. This difficulty can later cause the patient to engage in secrets and lies.

Adi (patient)

At first, I thought I might not want the experience of having a mentor, and maybe I wouldn’t need one. Like, it’s a little hard to accept the idea that you’re going to have a mentor twice a week, and I thought that maybe I could manage on my own.

Unsurprisingly, patients often have ambivalent feelings toward the in-home mentor. Alongside moments when they want the mentor’s assistance, there are moments when they would prefer to be left alone. The mentor’s examining gaze can be perceived as threatening, and at times patients find it difficult to go along with the expectation of change and rehabilitation.

There are times when it’s difficult for them [the patients] – particularly at times when they don’t want me to see their symptoms, they don’t want my help, they prefer to be “inside” their ED, alone. There are times when they come to me and say, “I don’t have an ED, so why are you watching me?” On the other hand, there are the times they say, “Wait a minute, you’re here to help me and I need this help and I do want you to watch and eat with me and tell me if I’m eating poorly.”

The ED can be so ingrained, and so strong, that patients will try to preserve certain behaviors, even if doing so means lying, keeping secrets, and concealing things from the mentor.

A patient will end up lying about the amount she’s really supposed to eat. Or let’s say she’s supposed to have a chocolate drink or a cup of coffee in addition to a snack, and she’ll say, “No, it’s only in the morning” or “It’s only at ten” or “I’ve already drunk or already eaten,” and all sorts of such things. Or there are girls who will say, “I’ll do it later” or “I’ll do it tomorrow,” and you just know they won’t […] You’ll either close your eyes to it and [ignore it] and say, “Okay, I believe she’ll do it tomorrow” or you’ll [confront her] but say it in a tone of: “I want to help you, to be with you, let’s do it together, let’s make it easy on you.”

When the mentor enters the patient’s home, the patient’s ability to hide is at least partially taken away from her, making her feel she has no choice but to find other ways to hide the things she is afraid to reveal. The following quote shows the patient’s insight into her behaviors:

There are many things that are hidden from sight, that are very difficult to see if you do not bring them up … Let’s put it this way: I wouldn’t want to be a mentor to someone with an ED … it’s … it’s hard, it’s hard. You have to be very sharp to see that … not everything is fine […] I think you have to keep your eyes wide open because we are manipulative and liars… […] We know how to make people believe every word that comes out of our mouths and turn everything around in a way [.] that’s safe for us. But this is not necessarily good for us. I think you [the mentor] must absolutely be skeptical of everything we tell you.

The next quote describes how despite the confrontations, anger, and lies, the mentoring relationship can eventually be used to promote rehabilitation.

There’s no way even to cheat a little bit, or to fool the mentor. Yesterday at dinner I made myself a toasted cheese sandwich and she [the mentor] said, before I had even put the sandwich in the sandwich maker, “Remember, do not squash it down too much. Just put the top down and close it; so the cheese doesn’t come out of the toast” [.] So when she said to me, “Remember not to do it,” I immediately said, “I didn’t even want to do that! Why are you putting ideas in my head??” Like I got mad at her… but that wasn’t right of me to get mad at her, because actually I probably did plan to do what she said, and that’s why I got annoyed that she said it […] mentoring is intense, and it’s just the two of you and the mentor gets to know your “tricks” very quickly.

In conclusion, the above quotes highlight the inevitable conflicts that arise in the mentoring relationship. It seems clear that this relationship has to withstand complex challenges of lies and concealment, and that the ability of the mentor and mentee to overcome these challenges is critical in the recovery process.

4. Fourth theme: home-based care as an acknowledgment of inequality - similar but different

Sometimes patients try to see the mentor as a friend or older sister, thus blurring the hierarchy that exists between them. In the following quote we can see Jasmine’s difficulty in accepting the built-in inequality of the mentor-patient relationship.

Jasmine (patient)

A lot of my difficulties with Shirley [the mentor] stemmed from the fact that it was an unequal relationship. I wanted to know more about her ]…[ It was hard for me because I felt like, because of the situation we were in, she couldn’t see that I too had abilities. And also there were moments when I didn’t want to express any particular weaknesses because I wanted to be with her in some equal place. Because there’s something really weird about it. It’s true that she’s not my age, she’s older than me by a few years, but it doesn’t matter, I have girlfriends who are her age, I have older girlfriends. We often had a lot of laughs, and it was funny and fun for us, like on a human level, we already knew each other so well that it was like … She knew about my difficulties, she knew about my weaknesses, about my strengths. I kept telling her about me, but I seemed to know nothing about her… .

In contrast to Jasmine who experienced difficulties with the inequality, Reut described the advantage of the mentor’s “in-between” position.

Reut (patient)

I think it’s good to have someone who’s somewhere between being a professional and being a …. I don’t know how to define it… a more mature person who can accompany you during the process […] a friend who was older than me and in a different place in life. Um … there is something about this in-between situation […] the lack of formal professional training allows for something a little more fluid and natural. It feels like the help [from the mentor] is also more at the everyday level […] things are more practical .

The tension around the unequal mentor-patient status can also put the mentor in uncomfortable and challenging situations. Linoy ranged from wanting to set a personal example for the patients to wanting to be authentic (e.g., eating the amount of food that actually suited her). Linoy made sacrifices in order to create in the patient a feeling (even a deceptive one) of equality in the relationship.

Linoy (mentor)

I don’t really have the option of coming and telling the patients I’m not hungry. [When we sit down for meals] I should be able to eat the same amounts they’re supposed to eat; I can’t eat less than what they’re supposed to eat. There is some minimum I need to eat, so I eat it, there’s nothing to be done about it. I try to plan my day accordingly and not show any difficulty [when I’m with them]. If I have a hard time eating, they’ll definitely notice; girls with EDs are very sensitive to these little nuances. So, of course, they watch me too. It bothers me. First of all it bothers me because I’m eating alongside them and it feels a bit intrusive sometimes: They look at what I eat, and whether I eat properly, and whether I’m different [from the patient]; it is a bit intrusive. On the other hand, it’s also my job. I’m supposed to come and set an example for them and if I don’t set an example for them, it’s a bit problematic in my opinion.

In many cases, patients try to overstep boundaries and invade the mentor’s privacy; they also test the relationship in ways that could threaten it. As can be seen below, this issue intensifies when Agam wonders whether, in different circumstances, she and the patient could have been friends.

The girls I worked with were around my age, studying social work or education. We frequented similar places, had mutual acquaintances, and even worked in similar settings. One of the girls started asking me personal questions from the very first session—not extremely personal, but enough for me to set clear boundaries. She’d comment on my Facebook photos, discussing whether they were flattering or not, asking about my weight, my past, and my diet. It wasn’t easy. I had to firmly tell her not to ask such questions, to clarify that we weren’t going to discuss my weight, that I wasn’t her girlfriend. It took time for us to adjust to each other. Eventually, with most of the girls, I felt it was successful. However, some of them felt like they could have been my little sister in another universe. There were moments when I could have had fun with them, but it was challenging initially. I had to understand what triggered me in their presence and quickly discern what was my own and what was theirs.

Along these same lines, sometimes there was tension between mentor and patient regarding perceptions of the relationship’s boundaries. Merav’s below quote highlights the confusion that was created when the mentor angrily dismissed Merav’s interest in her personal life.

Merav (patient)

My mentor had moved apartments and she talked about her move. [After a few days] I asked her how the move went because I care about her and I was interested, because I really love her. […] But she was very angry with me. She said she didn’t want to talk about it, and that she was the one who would decide whether to talk about it […]and it wasn’t pleasant for her … and I told her that it felt like she had something against me, that she had a hard time with me. So if she was having a hard time with me, then let’s talk about it.

Iris, a mentor, talked about how carefully the boundaries between mentor and patient must be negotiated.

Iris (mentor)

But I realized over the years that in order to make contact, in order to get them to trust me, I would need to bend the boundaries a bit at first. Like, I would need to be a bit warm with them or speak to them from a place of equal standing, so that later they would listen to me and give me respect.

In conclusion, this theme demonstrates how the closeness between mentor and patient can create tension and sometimes even role confusion: There must be an acknowledgement of the similarities between them but also of the essential difference. Many mentors aim to meet this challenge by setting clear boundaries while also allowing, at times, moments of flexibility and boundary crossing (e.g., when the mentor shares something personal about her life with the mentee) in order to maintain a sense of partnership and intimacy.

This qualitative study was designed to examine the unique experience of in-home mentoring relationships in the context of EDs, as perceived by both mentors and patients. Four themes emerged, all of which describe the unique bonding experience between the two, and its contribution to the rehabilitation process. Mentors and patients alike emphasized that the mentor’s physical entry into the patient’s home is critically significant, as it enables an encounter typified by less concealment, during which the mentor can gain access to the patient’s hidden and intimate world. Figure  1 demonstrates the complex task of the ED mentor who enters the patient’s home and must learn to move between the embracing and investigative position while dealing with boundaries, secrets and lies, and exposure to what’s both “on” and “beside” the table.

Home-based care for eating disorders - When the mentor enters the patient’s home

Patients with EDs tend to be secretive about their symptoms [ 2 , 12 ]. They tend to avoid sharing the difficulties they face while at the same time feeling they are “alone in the world” and cannot trust other people, including therapists, especially due to the fear and shame of being exposed to judgment. In addition, as some of the ED symptoms (e.g., fasting, vomiting, over-exercising) serve the patients’ goal (i.e., losing weight), they would rather conceal these symptoms than have the therapist try to eradicate them [ 2 , 20 ]. Therefore, secrecy and lack of self-disclosure are perceived in the literature as one of the major challenges faced by ED therapists [ 2 , 12 ]. In this context, the mentoring relationship, which allows the mentor to come inside the house and see what’s “on the table” can be helpful in overcoming concealment issues that oftentimes prevent ED treatments from succeeding.

Prior findings from qualitative interviews about mentoring relationships in the context of EDs have highlighted the concealment barrier [ 17 ] – that is, when patients avoid revealing information about themselves to their mentors. It is possible that patients fear that mentors will criticize and even reject them [ 20 ] and may worry that once mentors know what is really happening, they will put pressure on patients to change their eating habits (e.g., add more food to their meals) [ 11 ]. In a retrospective study [ 29 ], it was suggested that secretive behaviors were planned and conscious strategies among most (57-73%) patients with EDs. These secretive behaviors include attempts to conceal the truth, such as providing incorrect information about what has been consumed, or refusing to get on the scale during therapeutic sessions. It has also been suggested that therapists’ attempts to discover these secretive behaviors are followed by patients’ negative reactions [ 29 ]. Our findings suggest that the mentor’s entrance into the patient’s home can on the one hand be experienced as intrusive and threatening (as explained in the third theme), but at the same time can break the vicious cycle of secrecy (as explained in the first and second themes) and promote recovery. The mentoring relationship takes place in the midst of a conflict in which patients both wish to receive help but also fear the consequences of their exposure. If mentors are able to behave in a consistent and empathic way, while being sensitive to patients’ internal conflict (i.e., moving between the embracing and the investigative position, according to the patient’s needs) both parties will presumably be able to overcome this barrier and help patients reveal what they are going through.

Another major challenge in the mentoring relationship is the issue of boundaries. Clear boundaries, for instance regarding the role of each member, are crucial in helping mental health professionals define, determine, and maintain the therapeutic relationship [ 6 ]. The mentor-patient relationship in this context suffers from an inherent lack of clarity about the nature of the distance between the parties – for example, when patients invade mentors’ privacy by looking at the mentors as friends and expecting them to reveal details about their personal lives (as explained in the fourth theme). Our findings suggest that each mentor must find her own individual way of defining boundaries in this context, and therefore mentors would benefit from close supervision to help them tailor and establish boundaries for the benefit of their patients.

Overall, the study findings highlight important aspects of mentors´ tasks and roles in the context of severe and enduring EDs. Some of these tasks and roles overlap with those of other mental health providers (e.g., dieticians, psychotherapists), while others are specific to the mentors. Both mentors and other ED professionals must learn how to move between the “embracing” position, in which they hold a containing and caring presence, and the “investigative” position, in which they identify problematic areas that need to be addressed. However, the mentoring relationship is unique because certain boundaries may easily dissolve, requiring mentors to put extra effort into their establishment. The mentoring relationship takes place in the mentee’s home, and the mentor can therefore be perceived as a visiting friend, in contrast to the experience that takes place in a formal therapeutic setting typically found in a clinic. This “informal” setting demands that mentors navigate the delicate balance between intimacy and professionalism and work diligently to establish clear boundaries that might otherwise easily dissolve. It is also possible that the mentor and mentee will be of similar ages or backgrounds, adding depth to the mentoring bond but also creating a challenge to the professional relationship. Given that mentors work in a team, and often receive supervision from the psychotherapist or the dietician who regularly sees the patient, it is vital for all team members to align on treatment goals and collaborate effectively toward achieving them.

Despite the contribution of this qualitative study to the field, several limitations should be noted. Although saturation was achieved, it is possible that participants who were not included in this study (e.g., patients who refuse receiving assistance from mentors) would have shed light on factors other than the ones presented. We would recommend that researchers, in further studies, examine the mentoring relationship via the use of quantitative and empirical tools to supplement the findings presented. Such studies could include standardized surveys assessing mentor-mentee dynamics, structured observation protocols during mentoring sessions, and outcome measures quantifying specific aspects of recovery or progress.

The findings of this study have important implications for practice. First, it is critical to draw attention to the significant contribution that mentoring relationships can make to patients with EDs, and it is important to make this service available to more patients. That said, mentors are not licensed mental health professionals; they therefore need to have a great deal of knowledge about mental health rehabilitation in general and EDs in particular. They must also have several personal strengths including sensitivity, empathy, persistence, and assertiveness. These personal strengths will help them overcome the main challenges that are experienced, according to our findings (Fig.  1 ), in home-based mentoring relationships. It is important to develop a special training program for mentors, so that they can acquire knowledge and learn about the specific dynamics that are common among patients with EDs. In addition, clinical supervision is required so that mentors can bring up their mentor-patient dilemmas with mental health professionals (e.g., clinical social workers) along the way. Due to the nature of EDs, mentors’ dilemmas (e.g., boundaries, secrecy) can be complex, and mentoring work in this context can put a great deal of pressure on mentors that can be both stressful and cumulative. Mentors need to be able to reflect on their dilemmas in the presence of a clinical supervisor, as it may be almost impossible for mentors to find solutions on their own, and without continuous clinical supervision.

Data availability

Data and study materials are available upon request from the corresponding author.

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SEA initiated the study, conducted the data collection and wrote her thesis dissertation under the supervision of REB. REB wrote the manuscript text based on the dissertation and prepared the tables and the figures. All authors reviewed the manuscript.

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Elran-Barak, R., Elmalah-Alon, S. Moving between positions: a qualitative study of mentoring relationships in chronic eating disorders. J Eat Disord 12 , 59 (2024). https://doi.org/10.1186/s40337-024-01007-x

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• Original research
• Open access
• Published: 16 May 2024

Envisaging challenges for the emerging medicinal Cannabis sector in Lesotho

• Regina M. Thetsane   ORCID: orcid.org/0000-0003-3666-0142 1  

Journal of Cannabis Research volume  6 , Article number:  23 ( 2024 ) Cite this article

91 Accesses

Metrics details

Cultivation of Cannabis and its use for medical purposes has existed for millennia on the African continent. The plant has also been widely consumed in the African continent since time immemorial. In particular, Lesotho has been largely growing Cannabis since approximately the 1550s and was illegally grown and unlawfully used for both medicinal and recreational purposes. It was only in 2017 when Lesotho started licensing Cannabis companies and regulating cultivation of Cannabis for medicinal purposes. However, the Lesotho Cannabis industry seems to have excluded the Small, Medium and Micro Enterprises (SMMEs) in the legalisation of Cannabis, the sector has the potential for small Cannabis enterprises in Lesotho.

This study attempts to examine challenges facing the evolving Cannabis sector in Lesotho as envisaged by Cannabis company managers with the aim of being proactive while addressing such challenges.

The qualitative descriptive method was employed using both primary and secondary data. For the selection of the three Cannabis managers exponential non-discriminative snowball sampling was adopted and interviews with the managers were recorded and transcribed verbatim. Thematic analysis was used to analyse the descriptive explanations of the Cannabis managers to determine the themes that were further consolidated into categories.

The implementation and compliance with the laws in the Lesotho medicinal Cannabis sector has proved very challenging, with long timeframes for finalising regulatory frameworks and not being applied objectively. The industry does not provide opportunities for Small, Medium and Micro Enterprises (SMMEs) to venture into the Cannabis business.

In Lesotho, the Cannabis sector appears to be faced with many challenges emanating from the implementation and enforcement of Cannabis laws. The Lesotho Government should review its Cannabis laws and regulations with a view to benefiting SMMEs and legalising Cannabis production so as to serve both the domestic and international markets.

Introduction

The production of medical Cannabis in Lesotho was previously regulated under the Dangerous Medicines Act of 1973 (Government of Lesotho, 1978 ), which was superseded in 2008 by the Drugs of Abuse Act (Government of Lesotho 2008 ). This initiative allowed the Government to provide access to specific drugs for medical and scientific purposes (Chatwin 2017 ). Lesotho became the first in African country to change an existing legislation and decriminalise the cultivation of Cannabis for medical use (Prohibition Partners, 2019 ). The new law came into effect through the Drug of Abuse (Cannabis) Regulations Act of 2018 (Phakela 2018 ). Following the Kingdom of Lesotho, some African countries which legalised cannabis include, Uganda, Malawi, Swaziland, Zimbabwe and Morocco (Mkhize 2018 ). Cannabis production, with the highest levels of production globally taking place in Africa, has existed for millennia (Duvall 2019 ). For instance, ten thousand five hundred metric tons or approximately 25% of the global production of Cannabis herb reportedly took place in Africa in 2005 (United Nation’s Office on Drugs and Crime’s (UNODC, 2022 )). While the highest rates have originated in West and Central Africa (13%) and in Southern Africa (8.5% (UNODC, 2022 )), such, countries as, Ghana, Lesotho, South Africa and eSwatini have largely been growing Cannabis for ages (Prohibition Partners, 2019 ). Further, despite its use for recreational and medicinal purposes, the greater percentage of the Lesotho Cannabis has been illegal, the 70% of which has also been smuggled into the neighbouring South Africa (Deon 2021 ). Generally, Cannabis, which came to be known esoterically by local various constructs, be they, matekoane, khomo ea fatše , likata and kakana ; elsewhere labelled marijuana, was found to be a more profitable crop that would enable Basotho to earn a better living than any other cash crops, such as, maize, sorghum and wheat. To date, many Basotho families have long been subsisting and collecting the extra income from selling Cannabis to both recreational and medicinal drug users to cover such additional costs as school fees for their children at different levels of schooling in Lesotho (Deon 2021 ).

Only in 2017 did Lesotho start licensing Cannabis companies and regulating the cultivation of Cannabis for medicinal purposes (Duvall 2019 ). Since then, the number of medicinal Cannabis businesses operating in Lesotho has grown rapidly following such a legislative change. In the same year, 2017, the first Lesotho company to be granted licences to produce Cannabis for medical and scientific purposes was the MG Health Limited Company. In the ensuing, the country has been experiencing an influx of foreign investment Cannabis companies. As Kabi ( 2018 ) stated that the Lesotho Ministry of Health (MoH) had granted thirty-three Cannabis licences across five licence categories: cultivation, processing, transport, retail and distribution in the same year.

Because of the influx of Cannabis companies, Lesotho has been projected to become a major source for medicinal Cannabis export into the markets of both Canada and the United Kingdom (UK), resulting in reducing poverty and unemployment in the country. This view is supported by Uwakonye ( 2020 ), who argues that in a resource-deficient country, for instance, Lesotho, the Cannabis industry may also upsurge the economy and become a solution to the high rate of youth unemployment (26.91%) (Aaron 2023 ). Considering the influx of medicinal Cannabis companies in Lesotho, the country’s economy, mainly driven by the construction industry, was projected to grow by 1.8 per cent in 2023, while the Cannabis industry was projected to contract (Central Bank of Lesotho, 2022 ), thereby rendering the future of this critically emerging sector rather oblique. Therefore, against this backdrop, this study set out to examine challenges facing the Cannabis sector in Lesotho.

Literature review

The most common Cannabis species grown around the world, including in Africa, and of course in Lesotho is Cannabis sativa , which can be traced to Asia (Government of Canada 2023 ). Cannabis sativa contains a complex mix of approximately 60 unique cannabinoids along with various chemical compounds (Western Cape Tourism, Trade and Investment Promotion Agency (Wessgro), ( 2021 ). The main active ingredient responsible for the production of Cannabis is delta-9-tetrahydrocannabinol (THC) (Wessgro), ( 2021 ). The National Institute on Drug Abuse (NIDA) ( 2019 ) also reported that the most commonly used parts of Cannabis sativa are dried leaves, flowers, stems and seeds and contain the mind-altering chemical THC and other similar compounds.

Medical Cannabis product

The name Medical Cannabis relates to the therapeutic activity of herbal Cannabis and its constituents (Whiting et al. 2015 ). For Wessgro ( 2021 ), medicinal Cannabis is a legal, high-quality and standardised product made from crude Cannabis. Having started in China, Asia, then the Middle East, and Africa, the use of Cannabis for medicinal purposes spread to the rest of the world (Lafaye et al. 2017 ). As Bridgeman and Abazia ( 2017 ) pointed out, the Cannabis plant contains more than 100 different chemicals, known as cannabinoids, while Delta-9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD) are the main relevant chemicals used in medicine. The authors further argued that THC makes an individual euphoric when smoking Cannabis or eating foodstuffs with cannabis contents. For the purpose of this research, medicinal Cannabis refers to plant-derived Cannabis products prescribed by medical practitioners for treating specific conditions as in epilepsy and pain (Bridgeman & Abazia 2017 ).

Cannabis can include high CBD and low THC products, although CBD products also appear as consumer goods. Medical Cannabis products are currently prepared as plant materials, oils, tinctures, edibles or capsules (Prohibition Partners, 2019 ). Medicinal Cannabis is administered with the intention of alleviating pains caused by diseases and illnesses, such as, Multiple Sclerosis (MS), depression, anxiety, Human Immunodeficiency Virus ( HIV), nausea and vomiting, associated with chemotherapy, Posttraumatic Stress Disorder (PTSD), epilepsy or opioid addiction (National Academies of Sciences, Engineering, and Medicine (NASEM), 2017 ). However, medicinal Cannabis-related matters could be complicated in that, Cannabis is still an illegal drug and is legally constrained at the national and international levels in many countries (Mpela 2021 ). With some significant improvements in terms of legal imperatives by the industry, many challenges seem to lie ahead. Also noticeable worldwide is the increasing number of the Cannabis companies, making the industry highly competitive, something which has posed challenges for this particular industry. Doing business, coupled with observing the pertinent legal frameworks, using, distributing and growing Cannabis in such a legally multifaceted landscape, the Cannabis companies have encountered some difficulties (Matthew 2023 ).

The challenges facing the Cannabis sector

The complex legal landscape.

The medicinal Cannabis industry has been inhibited by regulatory restrictions for a long time. However, the legal market has emerged rapidly as many governments have started to legalise the production and use of medical Cannabis. For instance, many jurisdictions, especially in Europe, North America and South America, have liberalised control measures on Cannabis by decriminalising some instances of production, sales, possession and use. Some African countries, including Lesotho, have not been any exception to such a worldwide surge. Included in this industry are various activities, involving different professionals with direct, ancillary or tangential roles in the legal production, extraction, transport, sale and consumption or use of medical Cannabis, recreational Cannabis and any other related by-products (Duvall 2019 ). Further involve in cannabis industry are medical personnel, legal professionals, policy makers, dispensary owners and employees, cultivators and farmers, transport and handling personnel, and individuals as well as company manufacturing products as in oils and seeds for health and beauty products (Pacula and Smart 2017 ). However, with the industry being widely known for enforcing laws, some of which being clouded by ambiguous and contradictory regulations, Cannabis companies would end up operating with limited success (Bodwitch et al., 2019 ; Gianotti et al., 2017 ).

Cannabis cultivation methods

Medicinal Cannabis may grow either outdoors or indoors, thus differing from species to species as well as distinctive forms of produce, depending on different geographical situations. Outdoor cultivation is the traditional and original method of Cannabis cultivation that has been used for so long, mainly in African countries. Growing Cannabis outdoors exposes a crop to the elements, offering natural light and significantly reducing costs for growers. Nonetheless, the challenge is that Cannabis is exposed to harsh environmental conditions that may hinder an outdoor crop. For instance, prolonged heavy rains, insects and aggressive plants, such as, thistles, animals and extreme weather conditions are all potential crop killers. Improper soil and water resource management and pest control may also induce critical environmental hazards (Zheng et al. 2021 ). As a result, outdoor Cannabis growing could limit the growers’ control over environmental crossover from neighbouring fields.

In addition, medicinal Cannabis is mostly grown in green houses, mostly in developed countries. Joost ( 2019 ) reported that the intention is to mimic the elements of the outdoors that facilitate plant growth while maintaining full control over environmental parameters. The positive side of growing Cannabis in greenhouses is that the grower can detect how much carbon dioxide is in the air; how much moisture the plant needs; and even how well the soil conducts electricity (Bahji and Stephenson 2019 ). However, high upfront costs, including the building structures, equipment, water, electricity and other utilities, are the major downside of growing Cannabis indoors. Vaughan et al. ( 2021 ) argue that the light used indoors often reaches beyond greenhouses, causing some dissatisfaction on the part of the local communities and potentially disturbing ecosystem processes (Rich et al., 2020 ). Nonetheless, in 2019 and 2020, it was reported that growth in indoor Cannabis cultivation appeared to have overtaken growth in outdoor cultivation at the global level, with the overall net number of countries recording improved indoor cultivation being three times the net number of countries reporting a moribund outdoor cultivation (UNODC, 2022 ).

Competition

The common place increasing competition from Cannabis companies entering into the space is justifiably a major concern. The more countries legalise the medicinal Cannabis, the more companies enter into the Cannabis industry. For instance, on the African continent, Lesotho, Uganda, Malawi, Rwanda, Eswatini, Zimbabwe, Morocco and South Africa have already legalised the medicinal Cannabis. Such a series of legal frameworks in the Cannabis industry by the African countries may lead to a stiff competition among the Cannabis companies and across the African countries. A high competition may also threaten and push SMMEs Cannabis out of the emerging legal Cannabis industry (David et al. 2020 ).

Start-up costs

The Cannabis industry start-ups differ from traditional businesses with regard to the initial upfront costs. These are the expenses that Cannabis companies incur in the process of starting a new business venture. In many African countries, the expenses incurred include acquiring a licence fee for Cannabis production. The case in point is Lesotho where a licence fee for Cannabis production is approximately $350 000. In South Africa and Malawi, the production licence fee is approximately $1,465 and $10,000 respectively. In addition to the licence fee, setting up a medicinal Cannabis facility in South Africa, which cannot be afforded by many SMME Cannabis growers is estimated at $182,000 to $304 000. Adinoff and Reiman ( 2019 ) also argue that in the United States, economically disadvantaged individuals cannot participate in the legalised Cannabis market due to its high costs. In this view of this state of affairs, some researchers observe the participation of SMMEs Cannabis in the industry as crucial with potentially positive impact on the economy and citizens’ livelihoods in any given countries. This view is supported by Rusenga et al. ( 2022 ), who argue that legalising Cannabis production for medical purposes is extremely good. However, guaranteeing the involvement of ordinary citizens, SMMEs and local producers in the industry has to date proved challenging for many African countries.

The research capacity

In order to successfully inform health care decisions for a public policy, the research capacity of the Cannabis industry should be strengthened. Such policy-making decisions would require input from many stakeholders. These include clinical and public health Cannabis researchers; research methodologists; representatives from working groups who have developed research reporting guidelines; organisations engaged in standard development; representatives from scientific publications; and government agencies, with direct or indirect involvement in the research process (NASEM, 2017 ). In particular, institutions of higher learning should also come on board in advancing Cannabis research and offering courses geared towards the Cannabis industry.

Igiri et al. ( 2021 ) indicated that institutions of higher learning should offer courses, whose foci range from the business side of operations to growing and cultivating plants. Such courses could equip students with Cannabis consultancy, growing, technical extraction and dispensary operator skills. Establishing industry-focused universities for Cannabis research should be prioritised for the benefit of the country concerned. Besides, higher-learning institutions, particularly in Southern Africa, should be given funding for research, something has to date been a major barrier. Therefore, without adequate financial support, Cannabis research would hardly inform the health care and public health practice; nor would any initiatives for keeping pace with changes in Cannabis policy and patterns of Cannabis use make any headway. Supporting this view, Egbetokun et al. ( 2022 ) attribute low research output to poor funding and non-conducive and weak organisational climate in Africa. Some universities on the continent have few postgraduate programmes that further adversely affect their research output. Apart from lack of financial support for research and appropriate infrastructure, including laboratory facilities and equipment, the internet bandwidth required for collaboration with the global scholarly community, hence accessing more knowledge resources has been wanting (Igiri et al. 2021 ).

Research methodology

Based on the qualitative design, the methodology used aimed to explore Cannabis managers’ experiences with the challenges in the emerging Cannabis industry in Lesotho. For secondary data collection, the study thus critically reviewed relevant documentary sources, while for primary data collection, semi-structured interviews each of which lasted from 10 to 15 min were conducted on a one-on-one basis in the Board room of each individual organisation. With the participants’ consent, the interviews were audio-recorded and transcribed verbatim for analysis. Ethical Approval was granted on the 28th August, 2020 by the Ministry of Health and Ethics Committee and the National University of Lesotho Institutional Review Board (IRB) REF: ID 94-2020.

Respondents

The respondents for the study were the Cannabis companies’ managers, whose companies were registered, licenced and actively operated in Lesotho. There were eight registered and licenced Cannabis companies (Kabi 2018 ) which were all contacted for the interview. This information cannot be confirmed as the Chairperson of “Phekoane” (The Cannabis Association of Lesotho) could not provide the exact number of the registered Cannabis companies in Lesotho until the completion of the current study. The selection of the Cannabis managers adopted non-probability exponential non-discriminative snowball sampling, where the first manager, recruited to the sample group, provided multiple referrals, each of which was explored until the primary data from the adequate samples were collected (Mahin et al. 2017 ). This resulted in three Cannabis companies’ managers interviewed while five declined.

While it would be ideal to contact the entire target population for data collection, constrained resources, including time and access to certain participants became a factor. As such, sampling, particularly snowball sampling, was selected for this study. Snowball sampling is a purposeful method of data collection applied when samples with the target characteristics are not easily accessible (Vaughan et al. 2017 ). This technique was thus adopted for selecting the participant Cannabis managers from whom potentially rich data could be gathered for the study. The first Cannabis company manager contacted, provided multiple Cannabis managers who were followed up. Also, new referrals who accepted to participate pointed to more Cannabis managers, some of whose contact details were unavailable though. In the ensuing, the researcher arranged for the interview meetings with the readily available participants.

Data processing and analysis

Premised on the qualitative approach, the interviews were transcribed verbatim and analysed. In the process, a thematic analysis was chosen as the analytical instrument for preserving the descriptions and explanations of the Cannabis managers rather than analysing the actual content or raw data for in-depth meanings (Vaismoradi et al. 2013 ). The first step was to review transcripts comprehensively and ascribe them into themes. This was followed by the process of abstraction and coding to label meaningful units, with the codes being arranged according to categories throughout the analysis. The analysed report was discussed with the managers for confirmation and providing feedback.

The results

Company managers’ demographic profiles.

The data collection for this study drew on the participant managers, with the following demographic profiles: the managers’ gender, ages, current management positions, the highest qualifications and work experience in the management position. The summarised demographic profiles of each interviewed manager are presented in Table  1.1 .

As shown in Table  1.1 , the age of the three managers interviewed ranged from 25 to 64. All the participants were managers in the Cultivation Department. This might be because the three companies in which the managers agreed to be interviewed were at their initial stage of Cannabis production (cultivation). Regarding the level of education, the two managers each had a master’s degree, while one had a first degree. Further noted is that the closest master’s degree to Cannabis cultivation held by one of the respondents is Master’s in Agriculture. All the target managers had three years of experience in cultivation management.

Challenges for the emerging medicinal Cannabis sector

Challenges for the emerging medicinal Cannabis sector were reported as having varied categories. These include the ‘Legislation framework, interpretation and implementation’, ‘non-conformity to medical Cannabis regulations’, ‘Lack of accredited laboratories’ ‘Irrelevant skills’, ‘Accessibility of the Cannabis international markets’ and ‘Cannabis licence fees’. The responses, composed of verbatim statements made by the focal Cannabis cultivation managers are discussed below:

The legislation framework, interpretation and implementation

The respondents point to an array of limitations on the Lesotho Cannabis industry legislation, including its enforcement and implementation.

For example, as noted by Respondent 1 :

The legislation governing the Cannabis industry in Lesotho is unclear, difficult to comprehend, and it is not applied fairly.

Respondent 3 also commented :

I am wondering if these people who are in charge of the legal aspect of the Cannabis were ever exposed to some training on Cannabis laws and regulations under the auspices of the Ministry of Health. These people know nothing about Cannabis laws in the country.

This theme highlights the importance of careful interpretation and implementation of Cannabis laws and regulations in Lesotho.

Non-conformances to medical Cannabis regulations

The theme basically relates to non-conformity to medical rules and regulations. Crucial here is the first theme, legislation interpretation and implementation. The respondents observed the staff in the Ministry of Health as not complying with the rules and regulations of the industry. Such non-compliance may negatively impact on the industry, thus rendering the country at risk of being blacklisted by the International Narcotics Control Board (INCB).

In amplification of the above , Respondent 2 had this to say :

The staff in the Ministry do not have any interest in the industry. This is demonstrated by a lack of conformity to the industry regulations. As it stands, Lesotho is at risk of being blacklisted in the International Narcotics Control Board (INCB) because the Ministry have to date not being able to provide required annual reports.

Responded 3 remarked thus :

Those people in the Ministry are always sitting in offices; they do not go out to inspect and collect figures of the companies harvest. Nor do they know how much Cannabis Lesotho is producing. I won’t be surprised if people are still smuggling our Cannabis.

This theme suggests that the industry should adapt to a fast-changing, complex Cannabis legal landscape. Strict regulatory measures are required to protect both the domestic and international Cannabis markets and support the transition of small-scale illegal cultivators to the legal regime.

Lack of accredited laboratories

With the Cannabis industry finally in the legal realm in Lesotho, Cannabis testing has emerged as key to the emerging Cannabis sector. Cannabis testing enables growers, distributors and sellers to observe the Lesotho Cannabis regulations, while offering the highest quality, consistent and easy-to-dose products that are safely consumable to the customers. To this end, since Lesotho does not currently have its own testing laboratories, having all the companies take the samples to South Africa for Cannabis testing has been considered very expensive by the respondents.

Respondent 1 commented thus :

There are no accredited laboratories for testing the levels of Tetrahydrocannabinol (THC) and Cannabidiol (CBD) in our Cannabis products. Thus, the samples are taken to foreign countries for tests, something which turns out to be expensive for our companies.

Respondent 3 had this to say :

Some small Cannabis companies do not test their products at all because they cannot afford to take their Cannabis to South Africa. The laboratory that was located in the Letšeng Diamond Mining Company is not working. How could we have good cannabis produce while we do not have any testing laboratories?

Lack of relevant skills

The Cannabis industry in Lesotho is under the auspices of the Ministry of Health. The respondents observed that the employees attached to the Department of Cannabis in the Ministry do not have requisite skills and competencies.

In support of their views respondent 1 had this to say :

The Lesotho Health Ministry staff are very incompetent and do not have any interest and skills to run the sector. Neither are they willing to learn about the Cannabis industry, yet they are required to assist us with regulations related to licences, production, manufacturing, distribution and retailing of Cannabis. There is also a limited number of manufacturing pharmacists with comprehensive skills in the Cannabis industry, coupled with lack of compliance with Good Manufacturing Practices (GMP) and (GACP) Good Agricultural and Collection Practices and Good Manufacturing.

The other two respondents commented on the importance of training employees on Cannabis-related courses.

Respondent 1 stated as follows :

Our higher-learning institutions should introduce courses on Cannabis plants, including Cannabis short courses, targeting Cannabis employees who lack cannabis knowledge. Programme review should be done so that the country can provide Cannabis programmes needed by the country.

Respondent 2 remarked :

Cannabis companies should also offer their employees scholarships to further their studies, particularly in areas related to Cannabis production, Cannabis products and cultivation security. It could even be mandatory for all the Cannabis companies to provide hands-on experience for their employees in documenting the whole process, including growing the plant.

This theme suggests the importance of training employees to acquire requisite and relevant skills and competencies for the newly emerging Cannabis industry.

The international Cannabis markets

Currently, Lesotho has only one company producing and manufacturing Cannabis. It is the only one company which export the medicinal Cannabis flower as an active pharmaceutical ingredient (API) to the EU market. This means that the majority of the Lesotho Cannabis companies have, to date, not complied with the GMP requirements. As such, they cannot export the Lesotho Cannabis products to the international market.

Respondent 1 had this to say :

Without being granted the GMP (Good manufacturing practices and GACP (Good Agricultural and Collection Practices), Lesotho cannot sell anywhere in the world, nor can the country export to and access the international Cannabis markets.

This theme advocates for the improvement of the production of Cannabis in Lesotho in order to meet international standards for being granted the GMP and GACP. This theme relates to adhering and conforming to the rules and regulations governing the Cannabis industry.

Cannabis licence fees

The theme relating to the Cannabis licence fee is very important, as it affects the establishment of Cannabis companies in Lesotho. The Basotho people cannot venture into not afford operating in the Cannabis industry mainly because of the initial costly licencing. This indicates that although the 2008 legislation made it possible to grow Cannabis for medicinal purposes in Lesotho, growing it even for recreational purposes, without the licence from the Lesotho Ministry of Health still remains illegal in the country.

As Respondent 3 indicated :

It is not easy for the Basotho to establish their own Cannabis companies because the Cannabis licence fee is very expensive in Lesotho. Only the elite and multinationals have benefited from the Cannabis legislation that was heralded as something that would spread the economic gains amongst the Basotho.

This theme could be seen as the industry denying the local Basotho an opportunity to venture into the Cannabis business. Rather, the industry could be considered to be reserved for only few individuals with the potential or capacity to raise the required capital. The majority of the Basotho who have been cultivating Cannabis since time immemorial have apparently been excluded if not constrained by such Cannabis regulatory frameworks in Lesotho. Of the most favoured by the current or emerging Cannabis regulatory frameworks seem to be the large businesses over the smallholder farmers in the country.

Despite mixed experiences and limitations the Cannabis managers shared several challenges faced by the emerging Cannabis industry in Lesotho.

Industry legislation and compliance

The Cannabis industry in Lesotho is still at the rudimentary stage. Therefore, it is instructive to highlight, as reported by the respondents, that the legislation governing the industry is not yet refined nor fairly implemented. As observed globally, the scenario of Lesotho regarding the implementation of and compliance with the laws in the medicinal Cannabis sector has posed some challenges. Long timeframes for finalising regulatory frameworks have also met with problems of objective application (Rychert et al. 2021 ). However, due to the nature of this Cannabis products, the legality and regulation of the Cannabis industry is crucial. Regulatory bodies around the world have been instituting policies and guidelines to help to ensure safe and effective Cannabis production. Therefore, Lesotho is no exception as a member of the International Narcotics Control Board (INCB). The INCB responsibility is to administer a system of estimates for narcotic drugs and a voluntary assessment system for psychotropic substances, and to monitor licit activities involving drugs through a statistical returns system, with a view to assisting governments towards achieving, inter alia, a balance between supply and demand (INCB, 2011 ). Consequently, Lesotho is expected to enforce and adhere to the Cannabis laws, rules and regulations and duly submit regular reports regarding the Cannabis status for the INCB’s consideration.

The growing demand for medicinal Cannabis in Lesotho has created a booming industry that requires relevant and requisite skills. Taking the point further De Gobbi et al. ( 2022 ), highlights the Lesotho’s opportunity for the booming Cannabis sector for which requisite skills and knowledge could be inculcated among the Basotho for their vigorous involvement in the industry. Such skills could benefit the Basotho, including Cannabis cultivators and the Lesotho legal framework personnel. However, Letete ( 2023 ) reported that the Lesotho Cannabis industry has not lived up to the Basotho expectations. Small-scale growers are excluded from the emerging Cannabis industry, expatiating their illegal subsistence farming activities even more risky. As noted earlier, participation in the Cannabis sector, especially its licence fees, has become unaffordable for many Basotho interested in dealing in the Cannabis industry. Kabi ( 2018 ) attested that of the 33 people who had acquired licences to grow medical marijuana, only 13 had then paid M540, 000 ($28.18) for their operators’ licences. Concurring, Bloomer ( 2019 ) saw the current start-up costs for Cannabis production as being extremely high, thus excluding SMME participation in the industry in some African countries, including Lesotho and Malawi. This might be because, in particular, the Lesotho government has not done much to improve the possibilities of those who are already farming Cannabis inside the Lesotho legal framework.

Accredited testing laboratories

The Cannabis industry is a fast-paced industry, with the constantly changing job market, which requires different infrastructure and skill demands. One of the main requirements for effective Cannabis production are readily available and accredited test laboratories. With such test laboratories, determining potency of Cannabis products could be easily confirmed to avoid any harmful contaminants and ensure regulatory limits. Josh ( 2021 ) confirmed that Cannabis is predominantly tested for accurate labels and safety before consumption. On the other hand, Cannabis operators use testing results to improve their processes and to monitor the product quality versus state-specific regulatory requirements that could cause their products to pass or fail. It is, therefore, mandatory for countries, including Lesotho to provide Cannabis-testing infrastructure and ensure consumption of accurately labelled and uncontaminated products.

The industry-oriented skills

The Cannabis industry emanates from science-based to business-based careers, and the skills needed for each Cannabis job vary greatly (Fong, 2020 ). However, this fast-paced industry, with its constantly changing job market and varied skill demands, needs some of the most in-demand Cannabis skills as in basic Cannabis knowledge, reading and writing, basic computer and general skills. Jobs beyond an extractor require a bachelor’s degree in such areas as business, engineering, biology, chemistry, agriculture and horticulture, while scientific careers will require a master’s and doctorates. Careers related to law and policy, criminal justice and pharmacy are interconnected with Cannabis. Health professionals would especially need more education to ensure that they understand the medical benefits (Dattani 2018 ). On this basis, local institutions should introduce programmes that are geared towards the Cannabis industry skills. Cannabis SMMEs who may want to enter the Cannabis industry should also be provided with relevant training for participating in the industry.

Limitations of the study

As in any other study, some limitations have been noted in this particular study. This was all the more so, considering that the Cannabis industry was primarily in its infancy stage during the fieldwork for this study in the country. While the coming into being of the industry somewhat spurred this research study, at the time, some of the potentially relevant and information-rich participants could not come forward for providing data as expected. Neither could the precise number of the registered Cannabis companies be determined in the Kingdom of Lesotho at the time. Only a few companies appeared to have registered albeit not being fully operational. On the face of it, and of course, without necessarily undervaluing the phenomenon reported in this study, the snowball sampling technique, coupled with purposive sampling, were judiciously adopted for data collection. As such, from the purposively sampled target Cannabis managers, the study has been able to present, analyse and interpret the data which, as revealed, could shed light on the phenomena under study. Of course, with such a small sample, largely typical of the qualitative research adopted here, the findings may not be generalised to other contexts. Nevertheless, it is hoped that from the findings, conclusive remarks on the phenomenon of Cannabis production and its related legislative imperatives in the Kingdom of Lesotho could be made. From such conclusions, as noted below, future studies could carry over for further interrogating the Cannabis industry in Lesotho and possibly elsewhere.

Conclusions and recommendations

Considering the above findings, conclusions can be drawn based on the aim of the study. Conducting interviews with the Cannabis company managers, the study set out to identify challenges facing the Cannabis sector in Lesotho. The paper has found majority of the Lesotho Cannabis challenges as emanating from the legal framework governing the Cannabis sector in Lesotho. Inconsistencies in implementing and complying with the Cannabis laws and regulations by the Government Ministry of Health employees have also been noted. Issuing people with medicinal Cannabis licences has been done without any follow up on their use on the ground. At the time of study, Lesotho had thirty-three Cannabis companies, eight (8) of which were legally registered, and only one (1) had been granted Good Manufacturing Practices (GMP) certification. The GMP is a certification granted to producers who have stuck to the guidelines and regulations for dealing in Cannabis products according to GMP (Novak and Iguera 2019 ). This could indicate that Cannabis companies in Lesotho do not fully comply with the laws and regulations of the sector, resulting in only one Cannabis company being able to export Cannabis to EU markets. However, the export of medicinal Cannabis is necessary because not all countries have legalised medicinal Cannabis. However, the countries with legalised medicinal Cannabis apparently have limited domestic production capacity. For Lesotho to benefit from the Cannabis industry, strict compliance with the Cannabis laws is crucial.

The higher-learning institutions in Lesotho have the potential to support Cannabis career pathways by introducing and providing Cannabis-related programmes, thus assisting in producing a skilled and knowledgeable Cannabis workforce. However, also critical for the ultimate transfer of medicinal Cannabis skills and standards to the locals is the commercial knowledge of the international investors in the country. As such, the government should take measures to strengthen linkages with the medical Cannabis industry and promote economic activities so as to create low-skill jobs for small-scale farmers. With such newly created low-skill jobs, the locals should be retrained to work in the medical Cannabis industry, with the foreign workers being recruited largely or only for rare and/or special skills.

Cannabis production is increasingly becoming critical to Lesotho and to the international community. Therefore, the legalisation of the medicinal Cannabis sector should be reviewed so as to involve relevant stakeholders in Lesotho. In particular, the Lesotho Government should urgently spearhead such a review of the Cannabis laws and regulations for benefit of the entire Basotho nation, including the SMMEs, thus turning the extant illegal growers into legal growers who could also respond to the domestic marketing demands. As noted earlier, the Lesotho Government could thus formulate clear regulatory infrastructure to ensure responsive and sustainable Cannabis industry. Finally, liaising with higher-learning institutions, particularly in the country, the Government could develop requisite talents among the interested citizens, who would, in turn, be vigorously involved in the industry in Lesotho. Such strides could consolidate the Lesotho’s position as the leading trendsetter against which other African countries may benchmark.

Abbreviations

An Active Pharmaceutical Ingredient

Cannabidiol

Good Manufacturing Practices

High Pressure Sodium Light

International Narcotics Control Board

Light-emitting Diode

Ministry of Health

National Academies of Sciences, Engineering, and Medicine

National Institute on Drug Abuse

Doctor of Philosophy

Good Agricultural and Collection Practice

Small, Medium and Microenterprises

Tetrahydrocannabinol

United Nations Office on Drugs and Crime

United States of America

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The author would like to thank the three Cannabis companies that allowed their managers to participate in the interviews scheduled for this study.

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The Ethical Approval was granted on 28th August 2020 by the Ministry of Health, the Ethics Committee and the National University of Lesotho Institutional Review Board (IRB) REF: ID 94-2020. Before the interview process, I asked the respondents to ask to read a participant information statement and to tick a check box giving consent for participating in the study. They were also assured of their completely voluntary participation. Should anyone decide to or not participate, there would be no undesirable consequences, whatsoever. Because of the sensitive nature of the information about the Cannabis industry in Lesotho, the respondents were further assured that their responses (raw data) would remain confidential and anonymous, and that they would have a right to view if necessary.

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Thetsane, R.M. Envisaging challenges for the emerging medicinal Cannabis sector in Lesotho. J Cannabis Res 6 , 23 (2024). https://doi.org/10.1186/s42238-024-00229-9

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The global community is actively pursuing alternative energy sources to mitigate environmental concerns and decrease dependence on fossil fuels. Biodiesel, recognized as a clean and eco-friendly fuel with advantages over petroleum-based alternatives, has been identified as a viable substitute. However, its commercialization encounters challenges due to costly production processes. Establishing a more efficient supply chain for mass production and distribution could surmount these obstacles, rendering biodiesel a cost-effective solution. Despite numerous review articles across various renewable energy supply chain domains, there remains a gap in the literature specifically addressing the biodiesel supply chain network design. This research entails a comprehensive systematic literature review (SLR) focusing on the design of biodiesel supply chain networks. The primary objective is to formulate an economically, environmentally, and socially optimized supply chain framework. The review also seeks to offer a holistic overview of pertinent technical terms and key activities involved in these supply chains. Through this SLR, a thorough examination and synthesis of existing literature will yield valuable insights into the design and optimization of biodiesel supply chains. Additionally, it will identify critical research gaps in the field, proposing the exploration of fourth-generation feedstocks, integration of multi-channel chains, and the incorporation of sustainability and resilience aspects into the supply chain network design. These proposed areas aim to address existing knowledge gaps and enhance the overall effectiveness of biodiesel supply chain networks.

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Rahmani, S., Goli, A. & Zackery, A. Biodiesel supply chain network design: a comprehensive review with qualitative and quantitative insights. Environ Sci Pollut Res (2024). https://doi.org/10.1007/s11356-024-33392-w

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