structured interviews qualitative research

Structured vs. unstructured interviews: A complete guide

Last updated

7 March 2023

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Miroslav Damyanov

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Interviews can help you understand the context of a subject, eyewitness accounts of an event, people's perceptions of a product, and more.

In some instances, semi-structured or unstructured interviews can be more helpful; in others, structured interviews are the right choice to obtain the information you seek.

In some cases, structured interviews can save time, making your research more efficient. Let’s dive into everything you need to know about structured interviews.

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• What are structured interviews?

Structured interviews are also known as standardized interviews, patterned interviews, or planned interviews. They’re a research instrument that uses a standard sequence of questions to collect information about the research subject. 

Often, you’ll use structured interviews when you need data that’s easy to categorize and quantify for a statistical analysis of responses.

Structured interviews are incredibly effective at helping researchers identify patterns and trends in response data. They’re great at minimizing the time and resources necessary for data collection and analysis.

What types of questions suit structured interviews?

Often, researchers use structured interviews for quantitative research . In these cases, they usually employ close-ended questions. 

Close-ended questions have a fixed set of responses from which the interviewer can choose. Because of the limited response selection set, response data from close-ended questions is easy to aggregate and analyze.

Researchers often employ multiple-choice or dichotomous close-ended questions in interviews. 

For multiple-choice questions, interviewees may choose between three or more possible answers. The interviewer will often restrict the response to four or five possible options. An interviewee will likely need help recalling more, which can slow down and complicate the interview process. 

For dichotomous questions, the interviewee may choose between two possible options. Yes or no and true or false questions are examples of dichotomous questions.

Open-ended questions are common in structured interviews. However, researchers use them when conducting qualitative research and looking for in-depth information about the interviewee's perceptions or experiences. 

These questions take longer for the interviewee to answer, and the answers take longer for the researcher to analyze. There's also a higher possibility of the researcher collecting irrelevant data. However, open-ended questions are more effective than close-ended questions in gathering in-depth information.

Sometimes, researchers use structured interviews in qualitative research. In this case, the research instrument contains open-ended questions in the same sequence. This usage is less common because it can be hard to compare feedback, especially with large sample sizes.

• What types of structured interviews are there?

Researchers conduct structured interviews face-to-face, via telephone or videoconference, or through a survey instrument. 

Face-to-face interviews help researchers collect data and gather more detailed information. They can collect and analyze facial expressions, body language, tone, and inflection easier than they might through other interview methods . 

However, face-to-face interviews are the most resource-intensive to arrange. You'll likely need to assume travel and other related logistical costs for a face-to-face interview. 

These interviews also take more time and are more vulnerable to bias than some other formats. For these reasons, face-to-face interviews are best with a small sample size.

You can conduct interviews via an audio or video call. They are less resource-intensive than face-to-face interviews and can use a larger sample size. 

However, it can be difficult for the interviewer to engage effectively with the interviewee within this format, which can inject bias or ambiguity into the responses. This is particularly true for audio calls, especially if the interviewer and interviewee have not met before the interview. 

A video call can help the interviewer capture some data from body language and facial expressions, but less so than in a face-to-face interview. Technical issues are another thing to consider. If you’re studying a group of people that live in an area with limited Internet connectivity, this can make a video call challenging.

Survey questionnaires mirror the essential elements of structured interviews by containing a consistent sequence of standard questions. Surveys in quantitative research usually include close-ended questions. This data collection method can be beneficial if you need feedback from a large sample size.

Surveys are resource-efficient from a data administration standpoint but are more limited in the data they can gather. Further, if a survey question is ambiguous, you can’t clear up the ambiguity before someone responds. 

By contrast, in a face-to-face or tele-interview, an interviewee may ask clarifying questions or exhibit confusion when asked an unclear question, allowing the interviewer to clarify.

• What are some common examples of structured interviews?

Structured interviews are relevant in many fields. You can find structured interviews in human resources, marketing, political science, psychology, and more. 

Academic and applied researchers commonly use them to verify insights from analyzing academic literature or responses from other interview types.

However, one of the most common structured interview applications lies outside the research realm: Human resource professionals and hiring managers commonly use these interviews to hire employees.

A hiring manager can easily compare responses and whittle down the applicant pool by posing a standard set of closed-ended interview questions to multiple applicants. 

Further, standard close-ended or open-ended questions can reduce bias and add objectivity and credibility to the hiring process.

Structured interviews are common in political polling. Candidates and political parties may conduct structured interviews with relatively small voter groups to obtain feedback. They ask questions about issues, messaging, and voting intentions to craft policies and campaigns.

• What do you need to conduct a structured interview?

The tools you need to conduct a structured interview vary by format. But fundamentally, you will need: 

A participant

An interviewer

A pen and pad (or other note-taking tools)

A recording device

A consent form

A list of interview questions

While some interviewees may express qualms about you recording the interview, it’s challenging to conduct quality interviews while taking detailed notes. Even if you have a note-taker in the room, note-taking may introduce bias and can’t capture body language or facial expressions. 

Depending on the nature of your study, others may wish to review your sources. If they call your conclusions into question, audio recordings are additional evidence in your favor.

To record, you should ask the interviewee to sign a consent form. Check with your employer's legal counsel or institutional review board at your academic institution for guidance about obtaining consent legally in your state. 

If you're conducting a face-to-face interview, a camcorder, digital camera, or even some smartphones are sufficient for recording.

For a tele-interview, you'll find that today's leading video conferencing software applications feature a convenient recording function for data collection.

If a survey is your method of choice, you'll need the survey and a distribution and collection method. Online survey software applications allow you to create surveys by inputting the questions and distributing your survey via text or email. 

In some cases, survey companies even offer packages in which they will call those who do not respond via email or text and conduct the survey over the phone.

• How to conduct a structured interview

If you're planning a face-to-face interview, you'll need to take a few steps to do it efficiently. 

First, prepare your questions and double-check that the structured interview format is best for your study. Make sure that they are neutral, unbiased, and close-ended. Ask a friend or colleague to test your questions pre-interview to ensure they are clear and straightforward.

Choose the setting for your interviews. Ideally, you'll select a location that is easy to get to. If you live in a city, consider addresses accessible via public transportation. 

The room where your interview takes place should be comfortable, without distraction, and quiet, so your recording device clearly captures your interviewee's audio.

If you're looking to interview people with specific characteristics, you'll need to recruit them. Some companies specialize in interview recruitment. You provide the attributes you need, and they identify a pool of candidates for a fee. Alternatively, you can advertise to participants on social media and other relevant avenues. 

If you're looking for college students in a specific region, look at student newspaper ads or affiliated social media pages. 

You'll also want to incentivize participation, as recruiting interview respondents without compensation is exceedingly difficult. It’s best to include a line or two about requiring written consent for participation and how you’ll use the interview audio.

When you have an interview participant, discuss the intent of your research and acquire their consent. Ensure your recording tools are working well, and begin your interview. 

Don't rely on the recordings alone: Note the most significant insights from your participant, as you could easily forget them when it's time to analyze your data.

You'll want to transcribe your audio at the data analysis stage. Some recording applications use AI to generate transcripts. Remove filler words and other sounds to generate a clear transcript for the best results. 

A written transcript will help you analyze data and pull quotes from your audio to include in your final research paper.

• What are other common types of interviews?

Typically, you'll find researchers using at least one of these other common interview types:

Semi-structured interviews

As the name suggests, semi-structured interviews include some elements of a structured interview. You’ll include preplanned questions, but you can deviate from those questions to explore the interviewee's answers in greater depth.

Typically, a researcher will conduct a semi-structured interview with preplanned questions and an interview guide. The guide will include topics and potential questions to ask. Sometimes, the guide may also include areas or questions to avoid asking.

Unstructured interviews

In an unstructured interview , the researchers approach the interview subjects without predetermined questions. Researchers often use this qualitative instrument to probe into personal experiences and testimony, typically toward the beginning of a research study. 

Often, you’ll validate the insights you gather during unstructured and semi-structured interviews with structured interviews, surveys, and similar quantitative research tools.

Focus group interviews

Focus group interviews differ from the other three types of interviews as you pose the questions to a small group. Focus groups are typically either structured or semi-structured. When researchers employ structured interview questions, they are typically confident in the areas they wish to explore. 

Semi-structured interviews are perfect for a researcher seeking to explore broad issues. However, you must be careful that unplanned questions are unambiguous and neutral. Otherwise, you could wind up with biased results.

What is a structured vs. an unstructured interview?

A structured interview consists of standard preplanned questions for data collection. These questions may be close-ended, open-ended, or a combination. 

By contrast, an unstructured interview includes unplanned questions. In these interviews, you’ll usually equip facilitators with an interview guide. This includes guidelines for asking questions and samples that can help them ask relevant questions.

What are the advantages of a structured interview?

Relative to other interview formats, a structured interview is usually more time-efficient. With a preplanned set of questions, your interview is less likely to go into tangents, especially if you use close-ended questions. 

The more structure you provide to the interview, the more likely you are to generate responses that are easy to analyze. By contrast, an unstructured interview may involve a freewheeling conversation with off-topic and irrelevant feedback that lasts a long time.

What is an example of a structured question?

A structured question is any question you ask in an interview that you’ve preplanned and standardized.

For example, if you conduct five interviews and the first question you ask each one is, "Do you believe the world is round, yes or no?" you have asked them a structured question. This is also a close-ended dichotomous question.

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• Types of Interviews in Research | Guide & Examples

Types of Interviews in Research | Guide & Examples

Published on March 10, 2022 by Tegan George . Revised on June 22, 2023.

An interview is a qualitative research method that relies on asking questions in order to collect data . Interviews involve two or more people, one of whom is the interviewer asking the questions.

There are several types of interviews, often differentiated by their level of structure.

• Structured interviews have predetermined questions asked in a predetermined order.
• Unstructured interviews are more free-flowing.
• Semi-structured interviews fall in between.

Interviews are commonly used in market research, social science, and ethnographic research .

Table of contents

What is a structured interview, what is a semi-structured interview, what is an unstructured interview, what is a focus group, examples of interview questions, advantages and disadvantages of interviews, other interesting articles, frequently asked questions about types of interviews.

Structured interviews have predetermined questions in a set order. They are often closed-ended, featuring dichotomous (yes/no) or multiple-choice questions. While open-ended structured interviews exist, they are much less common. The types of questions asked make structured interviews a predominantly quantitative tool.

Asking set questions in a set order can help you see patterns among responses, and it allows you to easily compare responses between participants while keeping other factors constant. This can mitigate   research biases and lead to higher reliability and validity. However, structured interviews can be overly formal, as well as limited in scope and flexibility.

• You feel very comfortable with your topic. This will help you formulate your questions most effectively.
• You have limited time or resources. Structured interviews are a bit more straightforward to analyze because of their closed-ended nature, and can be a doable undertaking for an individual.
• Your research question depends on holding environmental conditions between participants constant.

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Semi-structured interviews are a blend of structured and unstructured interviews. While the interviewer has a general plan for what they want to ask, the questions do not have to follow a particular phrasing or order.

Semi-structured interviews are often open-ended, allowing for flexibility, but follow a predetermined thematic framework, giving a sense of order. For this reason, they are often considered “the best of both worlds.”

However, if the questions differ substantially between participants, it can be challenging to look for patterns, lessening the generalizability and validity of your results.

• You have prior interview experience. It’s easier than you think to accidentally ask a leading question when coming up with questions on the fly. Overall, spontaneous questions are much more difficult than they may seem.
• Your research question is exploratory in nature. The answers you receive can help guide your future research.

An unstructured interview is the most flexible type of interview. The questions and the order in which they are asked are not set. Instead, the interview can proceed more spontaneously, based on the participant’s previous answers.

Unstructured interviews are by definition open-ended. This flexibility can help you gather detailed information on your topic, while still allowing you to observe patterns between participants.

However, so much flexibility means that they can be very challenging to conduct properly. You must be very careful not to ask leading questions, as biased responses can lead to lower reliability or even invalidate your research.

• You have a solid background in your research topic and have conducted interviews before.
• Your research question is exploratory in nature, and you are seeking descriptive data that will deepen and contextualize your initial hypotheses.
• Your research necessitates forming a deeper connection with your participants, encouraging them to feel comfortable revealing their true opinions and emotions.

A focus group brings together a group of participants to answer questions on a topic of interest in a moderated setting. Focus groups are qualitative in nature and often study the group’s dynamic and body language in addition to their answers. Responses can guide future research on consumer products and services, human behavior, or controversial topics.

Focus groups can provide more nuanced and unfiltered feedback than individual interviews and are easier to organize than experiments or large surveys . However, their small size leads to low external validity and the temptation as a researcher to “cherry-pick” responses that fit your hypotheses.

• Your research focuses on the dynamics of group discussion or real-time responses to your topic.
• Your questions are complex and rooted in feelings, opinions, and perceptions that cannot be answered with a “yes” or “no.”
• Your topic is exploratory in nature, and you are seeking information that will help you uncover new questions or future research ideas.

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Depending on the type of interview you are conducting, your questions will differ in style, phrasing, and intention. Structured interview questions are set and precise, while the other types of interviews allow for more open-endedness and flexibility.

Here are some examples.

• Semi-structured
• Unstructured
• Focus group
• Do you like dogs? Yes/No
• Do you associate dogs with feeling: happy; somewhat happy; neutral; somewhat unhappy; unhappy
• If yes, name one attribute of dogs that you like.
• If no, name one attribute of dogs that you don’t like.
• What feelings do dogs bring out in you?
• When you think more deeply about this, what experiences would you say your feelings are rooted in?

Interviews are a great research tool. They allow you to gather rich information and draw more detailed conclusions than other research methods, taking into consideration nonverbal cues, off-the-cuff reactions, and emotional responses.

However, they can also be time-consuming and deceptively challenging to conduct properly. Smaller sample sizes can cause their validity and reliability to suffer, and there is an inherent risk of interviewer effect arising from accidentally leading questions.

Here are some advantages and disadvantages of each type of interview that can help you decide if you’d like to utilize this research method.

Advantages and disadvantages of interviews

Type of interview	Advantages	Disadvantages
Structured interview
Semi-structured interview		, , , and
Unstructured interview		, , , and
Focus group		, , and , since there are multiple people present

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

• Student’s  t -distribution
• Normal distribution
• Null and Alternative Hypotheses
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Data cleansing
• Reproducibility vs Replicability
• Peer review
• Prospective cohort study

Research bias

• Implicit bias
• Cognitive bias
• Placebo effect
• Hawthorne effect
• Hindsight bias
• Affect heuristic
• Social desirability bias

The four most common types of interviews are:

• Structured interviews : The questions are predetermined in both topic and order. 
• Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.
• Unstructured interviews : None of the questions are predetermined.
• Focus group interviews : The questions are presented to a group instead of one individual.

The interviewer effect is a type of bias that emerges when a characteristic of an interviewer (race, age, gender identity, etc.) influences the responses given by the interviewee.

There is a risk of an interviewer effect in all types of interviews , but it can be mitigated by writing really high-quality interview questions.

Social desirability bias is the tendency for interview participants to give responses that will be viewed favorably by the interviewer or other participants. It occurs in all types of interviews and surveys , but is most common in semi-structured interviews , unstructured interviews , and focus groups .

Social desirability bias can be mitigated by ensuring participants feel at ease and comfortable sharing their views. Make sure to pay attention to your own body language and any physical or verbal cues, such as nodding or widening your eyes.

This type of bias can also occur in observations if the participants know they’re being observed. They might alter their behavior accordingly.

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest. It is one of 4 types of interviews .

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

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

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The Interview Method In Psychology

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.

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Interviews involve a conversation with a purpose, but have some distinct features compared to ordinary conversation, such as being scheduled in advance, having an asymmetry in outcome goals between interviewer and interviewee, and often following a question-answer format.

Interviews are different from questionnaires as they involve social interaction. Unlike questionnaire methods, researchers need training in interviewing (which costs money).

How Do Interviews Work?

Researchers can ask different types of questions, generating different types of data . For example, closed questions provide people with a fixed set of responses, whereas open questions allow people to express what they think in their own words.

The researcher will often record interviews, and the data will be written up as a transcript (a written account of interview questions and answers) which can be analyzed later.

It should be noted that interviews may not be the best method for researching sensitive topics (e.g., truancy in schools, discrimination, etc.) as people may feel more comfortable completing a questionnaire in private.

There are different types of interviews, with a key distinction being the extent of structure. Semi-structured is most common in psychology research. Unstructured interviews have a free-flowing style, while structured interviews involve preset questions asked in a particular order.

Structured Interview

A structured interview is a quantitative research method where the interviewer a set of prepared closed-ended questions in the form of an interview schedule, which he/she reads out exactly as worded.

Interviews schedules have a standardized format, meaning the same questions are asked to each interviewee in the same order (see Fig. 1).

   Figure 1. An example of an interview schedule

The interviewer will not deviate from the interview schedule (except to clarify the meaning of the question) or probe beyond the answers received.  Replies are recorded on a questionnaire, and the order and wording of questions, and sometimes the range of alternative answers, is preset by the researcher.

A structured interview is also known as a formal interview (like a job interview).

• Structured interviews are easy to replicate as a fixed set of closed questions are used, which are easy to quantify – this means it is easy to test for reliability .
• Structured interviews are fairly quick to conduct which means that many interviews can take place within a short amount of time. This means a large sample can be obtained, resulting in the findings being representative and having the ability to be generalized to a large population.

Limitations

• Structured interviews are not flexible. This means new questions cannot be asked impromptu (i.e., during the interview), as an interview schedule must be followed.
• The answers from structured interviews lack detail as only closed questions are asked, which generates quantitative data . This means a researcher won’t know why a person behaves a certain way.

Unstructured Interview

Unstructured interviews do not use any set questions, instead, the interviewer asks open-ended questions based on a specific research topic, and will try to let the interview flow like a natural conversation. The interviewer modifies his or her questions to suit the candidate’s specific experiences.

Unstructured interviews are sometimes referred to as ‘discovery interviews’ and are more like a ‘guided conservation’ than a strictly structured interview. They are sometimes called informal interviews.

Unstructured interviews are most useful in qualitative research to analyze attitudes and values. Though they rarely provide a valid basis for generalization, their main advantage is that they enable the researcher to probe social actors’ subjective points of view.

Interviewer Self-Disclosure

Interviewer self-disclosure involves the interviewer revealing personal information or opinions during the research interview. This may increase rapport but risks changing dynamics away from a focus on facilitating the interviewee’s account.

In unstructured interviews, the informal conversational style may deliberately include elements of interviewer self-disclosure, mirroring ordinary conversation dynamics.

Interviewer self-disclosure risks changing the dynamics away from facilitation of interviewee accounts. It should not be ruled out entirely but requires skillful handling informed by reflection.

• An informal interviewing style with some interviewer self-disclosure may increase rapport and participant openness. However, it also increases the chance of the participant converging opinions with the interviewer.
• Complete interviewer neutrality is unlikely. However, excessive informality and self-disclosure risk the interview becoming more of an ordinary conversation and producing consensus accounts.
• Overly personal disclosures could also be seen as irrelevant and intrusive by participants. They may invite increased intimacy on uncomfortable topics.
• The safest approach seems to be to avoid interviewer self-disclosures in most cases. Where an informal style is used, disclosures require careful judgment and substantial interviewing experience.
• If asked for personal opinions during an interview, the interviewer could highlight the defined roles and defer that discussion until after the interview.
• Unstructured interviews are more flexible as questions can be adapted and changed depending on the respondents’ answers. The interview can deviate from the interview schedule.
• Unstructured interviews generate qualitative data through the use of open questions. This allows the respondent to talk in some depth, choosing their own words. This helps the researcher develop a real sense of a person’s understanding of a situation.
• They also have increased validity because it gives the interviewer the opportunity to probe for a deeper understanding, ask for clarification & allow the interviewee to steer the direction of the interview, etc. Interviewers have the chance to clarify any questions of participants during the interview.
• It can be time-consuming to conduct an unstructured interview and analyze the qualitative data (using methods such as thematic analysis).
• Employing and training interviewers is expensive and not as cheap as collecting data via questionnaires . For example, certain skills may be needed by the interviewer. These include the ability to establish rapport and knowing when to probe.
• Interviews inevitably co-construct data through researchers’ agenda-setting and question-framing. Techniques like open questions provide only limited remedies.

Focus Group Interview

Focus group interview is a qualitative approach where a group of respondents are interviewed together, used to gain an in‐depth understanding of social issues.

This type of interview is often referred to as a focus group because the job of the interviewer ( or moderator ) is to bring the group to focus on the issue at hand. Initially, the goal was to reach a consensus among the group, but with the development of techniques for analyzing group qualitative data, there is less emphasis on consensus building.

The method aims to obtain data from a purposely selected group of individuals rather than from a statistically representative sample of a broader population.

The role of the interview moderator is to make sure the group interacts with each other and do not drift off-topic. Ideally, the moderator will be similar to the participants in terms of appearance, have adequate knowledge of the topic being discussed, and exercise mild unobtrusive control over dominant talkers and shy participants.

A researcher must be highly skilled to conduct a focus group interview. For example, the moderator may need certain skills, including the ability to establish rapport and know when to probe.

• Group interviews generate qualitative narrative data through the use of open questions. This allows the respondents to talk in some depth, choosing their own words. This helps the researcher develop a real sense of a person’s understanding of a situation. Qualitative data also includes observational data, such as body language and facial expressions.
• Group responses are helpful when you want to elicit perspectives on a collective experience, encourage diversity of thought, reduce researcher bias, and gather a wider range of contextualized views.
• They also have increased validity because some participants may feel more comfortable being with others as they are used to talking in groups in real life (i.e., it’s more natural).
• When participants have common experiences, focus groups allow them to build on each other’s comments to provide richer contextual data representing a wider range of views than individual interviews.
• Focus groups are a type of group interview method used in market research and consumer psychology that are cost – effective for gathering the views of consumers .
• The researcher must ensure that they keep all the interviewees” details confidential and respect their privacy. This is difficult when using a group interview. For example, the researcher cannot guarantee that the other people in the group will keep information private.
• Group interviews are less reliable as they use open questions and may deviate from the interview schedule, making them difficult to repeat.
• It is important to note that there are some potential pitfalls of focus groups, such as conformity, social desirability, and oppositional behavior, that can reduce the usefulness of the data collected.

For example, group interviews may sometimes lack validity as participants may lie to impress the other group members. They may conform to peer pressure and give false answers.

To avoid these pitfalls, the interviewer needs to have a good understanding of how people function in groups as well as how to lead the group in a productive discussion.

Semi-Structured Interview

Semi-structured interviews lie between structured and unstructured interviews. The interviewer prepares a set of same questions to be answered by all interviewees. Additional questions might be asked during the interview to clarify or expand certain issues.

In semi-structured interviews, the interviewer has more freedom to digress and probe beyond the answers. The interview guide contains a list of questions and topics that need to be covered during the conversation, usually in a particular order.

Semi-structured interviews are most useful to address the ‘what’, ‘how’, and ‘why’ research questions. Both qualitative and quantitative analyses can be performed on data collected during semi-structured interviews.

• Semi-structured interviews allow respondents to answer more on their terms in an informal setting yet provide uniform information making them ideal for qualitative analysis.
• The flexible nature of semi-structured interviews allows ideas to be introduced and explored during the interview based on the respondents’ answers.
• Semi-structured interviews can provide reliable and comparable qualitative data. Allows the interviewer to probe answers, where the interviewee is asked to clarify or expand on the answers provided.
• The data generated remain fundamentally shaped by the interview context itself. Analysis rarely acknowledges this endemic co-construction.
• They are more time-consuming (to conduct, transcribe, and analyze) than structured interviews.
• The quality of findings is more dependent on the individual skills of the interviewer than in structured interviews. Skill is required to probe effectively while avoiding biasing responses.

The Interviewer Effect

Face-to-face interviews raise methodological problems. These stem from the fact that interviewers are themselves role players, and their perceived status may influence the replies of the respondents.

Because an interview is a social interaction, the interviewer’s appearance or behavior may influence the respondent’s answers. This is a problem as it can bias the results of the study and make them invalid.

For example, the gender, ethnicity, body language, age, and social status of the interview can all create an interviewer effect. If there is a perceived status disparity between the interviewer and the interviewee, the results of interviews have to be interpreted with care. This is pertinent for sensitive topics such as health.

For example, if a researcher was investigating sexism amongst males, would a female interview be preferable to a male? It is possible that if a female interviewer was used, male participants might lie (i.e., pretend they are not sexist) to impress the interviewer, thus creating an interviewer effect.

Flooding interviews with researcher’s agenda

The interactional nature of interviews means the researcher fundamentally shapes the discourse, rather than just neutrally collecting it. This shapes what is talked about and how participants can respond.

• The interviewer’s assumptions, interests, and categories don’t just shape the specific interview questions asked. They also shape the framing, task instructions, recruitment, and ongoing responses/prompts.
• This flooding of the interview interaction with the researcher’s agenda makes it very difficult to separate out what comes from the participant vs. what is aligned with the interviewer’s concerns.
• So the participant’s talk ends up being fundamentally shaped by the interviewer rather than being a more natural reflection of the participant’s own orientations or practices.
• This effect is hard to avoid because interviews inherently involve the researcher setting an agenda. But it does mean the talk extracted may say more about the interview process than the reality it is supposed to reflect.

Interview Design

First, you must choose whether to use a structured or non-structured interview.

Characteristics of Interviewers

Next, you must consider who will be the interviewer, and this will depend on what type of person is being interviewed. There are several variables to consider:

• Gender and age : This can greatly affect respondents’ answers, particularly on personal issues.
• Personal characteristics : Some people are easier to get on with than others. Also, the interviewer’s accent and appearance (e.g., clothing) can affect the rapport between the interviewer and interviewee.
• Language : The interviewer’s language should be appropriate to the vocabulary of the group of people being studied. For example, the researcher must change the questions’ language to match the respondents’ social background” age / educational level / social class/ethnicity, etc.
• Ethnicity : People may have difficulty interviewing people from different ethnic groups.
• Interviewer expertise should match research sensitivity – inexperienced students should avoid interviewing highly vulnerable groups.

Interview Location

The location of a research interview can influence the way in which the interviewer and interviewee relate and may exaggerate a power dynamic in one direction or another. It is usual to offer interviewees a choice of location as part of facilitating their comfort and encouraging participation.

However, the safety of the interviewer is an overriding consideration and, as mentioned, a minimal requirement should be that a responsible person knows where the interviewer has gone and when they are due back.

Remote Interviews

The COVID-19 pandemic necessitated remote interviewing for research continuity. However online interview platforms provide increased flexibility even under normal conditions.

They enable access to participant groups across geographical distances without travel costs or arrangements. Online interviews can be efficiently scheduled to align with researcher and interviewee availability.

There are practical considerations in setting up remote interviews. Interviewees require access to internet and an online platform such as Zoom, Microsoft Teams or Skype through which to connect.

Certain modifications help build initial rapport in the remote format. Allowing time at the start of the interview for casual conversation while testing audio/video quality helps participants settle in. Minor delays can disrupt turn-taking flow, so alerting participants to speak slightly slower than usual minimizes accidental interruptions.

Keeping remote interviews under an hour avoids fatigue for stare at a screen. Seeking advanced ethical clearance for verbal consent at the interview start saves participant time. Adapting to the remote context shows care for interviewees and aids rich discussion.

However, it remains important to critically reflect on how removing in-person dynamics may shape the co-created data. Perhaps some nuances of trust and disclosure differ over video.

Vulnerable Groups

The interviewer must ensure that they take special care when interviewing vulnerable groups, such as children. For example, children have a limited attention span, so lengthy interviews should be avoided.

Developing an Interview Schedule

An interview schedule is a list of pre-planned, structured questions that have been prepared, to serve as a guide for interviewers, researchers and investigators in collecting information or data about a specific topic or issue.

• List the key themes or topics that must be covered to address your research questions. This will form the basic content.
• Organize the content logically, such as chronologically following the interviewee’s experiences. Place more sensitive topics later in the interview.
• Develop the list of content into actual questions and prompts. Carefully word each question – keep them open-ended, non-leading, and focused on examples.
• Add prompts to remind you to cover areas of interest.
• Pilot test the interview schedule to check it generates useful data and revise as needed.
• Be prepared to refine the schedule throughout data collection as you learn which questions work better.
• Practice skills like asking follow-up questions to get depth and detail. Stay flexible to depart from the schedule when needed.
• Keep questions brief and clear. Avoid multi-part questions that risk confusing interviewees.
• Listen actively during interviews to determine which pre-planned questions can be skipped based on information the participant has already provided.

The key is balancing preparation with the flexibility to adapt questions based on each interview interaction. With practice, you’ll gain skills to conduct productive interviews that obtain rich qualitative data.

The Power of Silence

Strategic use of silence is a key technique to generate interviewee-led data, but it requires judgment about appropriate timing and duration to maintain mutual understanding.

• Unlike ordinary conversation, the interviewer aims to facilitate the interviewee’s contribution without interrupting. This often means resisting the urge to speak at the end of the interviewee’s turn construction units (TCUs).
• Leaving a silence after a TCU encourages the interviewee to provide more material without being led by the interviewer. However, this simple technique requires confidence, as silence can feel socially awkward.
• Allowing longer silences (e.g. 24 seconds) later in interviews can work well, but early on even short silences may disrupt rapport if they cause misalignment between speakers.
• Silence also allows interviewees time to think before answering. Rushing to re-ask or amend questions can limit responses.
• Blunt backchannels like “mm hm” also avoid interrupting flow. Interruptions, especially to finish an interviewee’s turn, are problematic as they make the ownership of perspectives unclear.
• If interviewers incorrectly complete turns, an upside is it can produce extended interviewee narratives correcting the record. However, silence would have been better to let interviewees shape their own accounts.

Recording & Transcription

Design choices.

Design choices around recording and engaging closely with transcripts influence analytic insights, as well as practical feasibility. Weighing up relevant tradeoffs is key.

• Audio recording is standard, but video better captures contextual details, which is useful for some topics/analysis approaches. Participants may find video invasive for sensitive research.
• Digital formats enable the sharing of anonymized clips. Additional microphones reduce audio issues.
• Doing all transcription is time-consuming. Outsourcing can save researcher effort but needs confidentiality assurances. Always carefully check outsourced transcripts.
• Online platform auto-captioning can facilitate rapid analysis, but accuracy limitations mean full transcripts remain ideal. Software cleans up caption file formatting.
• Verbatim transcripts best capture nuanced meaning, but the level of detail needed depends on the analysis approach. Referring back to recordings is still advisable during analysis.
• Transcripts versus recordings highlight different interaction elements. Transcripts make overt disagreements clearer through the wording itself. Recordings better convey tone affiliativeness.

Transcribing Interviews & Focus Groups

Here are the steps for transcribing interviews:

• Play back audio/video files to develop an overall understanding of the interview
• Format the transcription document:
• Add line numbers
• Separate interviewer questions and interviewee responses
• Use formatting like bold, italics, etc. to highlight key passages
• Provide sentence-level clarity in the interviewee’s responses while preserving their authentic voice and word choices
• Break longer passages into smaller paragraphs to help with coding
• If translating the interview to another language, use qualified translators and back-translate where possible
• Select a notation system to indicate pauses, emphasis, laughter, interruptions, etc., and adapt it as needed for your data
• Insert screenshots, photos, or documents discussed in the interview at the relevant point in the transcript
• Read through multiple times, revising formatting and notations
• Double-check the accuracy of transcription against audio/videos
• De-identify transcript by removing identifying participant details

The goal is to produce a formatted written record of the verbal interview exchange that captures the meaning and highlights important passages ready for the coding process. Careful transcription is the vital first step in analysis.

Coding Transcripts

The goal of transcription and coding is to systematically transform interview responses into a set of codes and themes that capture key concepts, experiences and beliefs expressed by participants. Taking care with transcription and coding procedures enhances the validity of qualitative analysis .

• Read through the transcript multiple times to become immersed in the details
• Identify manifest/obvious codes and latent/underlying meaning codes
• Highlight insightful participant quotes that capture key concepts (in vivo codes)
• Create a codebook to organize and define codes with examples
• Use an iterative cycle of inductive (data-driven) coding and deductive (theory-driven) coding
• Refine codebook with clear definitions and examples as you code more transcripts
• Collaborate with other coders to establish the reliability of codes

Ethical Issues

Informed consent.

The participant information sheet must give potential interviewees a good idea of what is involved if taking part in the research.

This will include the general topics covered in the interview, where the interview might take place, how long it is expected to last, how it will be recorded, the ways in which participants’ anonymity will be managed, and incentives offered.

It might be considered good practice to consider true informed consent in interview research to require two distinguishable stages:

• Consent to undertake and record the interview and
• Consent to use the material in research after the interview has been conducted and the content known, or even after the interviewee has seen a copy of the transcript and has had a chance to remove sections, if desired.

Power and Vulnerability

• Early feminist views that sensitivity could equalize power differences are likely naive. The interviewer and interviewee inhabit different knowledge spheres and social categories, indicating structural disparities.
• Power fluctuates within interviews. Researchers rely on participation, yet interviewees control openness and can undermine data collection. Assumptions should be avoided.
• Interviews on sensitive topics may feel like quasi-counseling. Interviewers must refrain from dual roles, instead supplying support service details to all participants.
• Interviewees recruited for trauma experiences may reveal more than anticipated. While generating analytic insights, this risks leaving them feeling exposed.
• Ultimately, power balances resist reconciliation. But reflexively analyzing operations of power serves to qualify rather than nullify situtated qualitative accounts.

Some groups, like those with mental health issues, extreme views, or criminal backgrounds, risk being discredited – treated skeptically by researchers.

This creates tensions with qualitative approaches, often having an empathetic ethos seeking to center subjective perspectives. Analysis should balance openness to offered accounts with critically examining stakes and motivations behind them.

Potter, J., & Hepburn, A. (2005). Qualitative interviews in psychology: Problems and possibilities.  Qualitative research in Psychology ,  2 (4), 281-307.

Houtkoop-Steenstra, H. (2000). Interaction and the standardized survey interview: The living questionnaire . Cambridge University Press

Madill, A. (2011). Interaction in the semi-structured interview: A comparative analysis of the use of and response to indirect complaints. Qualitative Research in Psychology, 8 (4), 333–353.

Maryudi, A., & Fisher, M. (2020). The power in the interview: A practical guide for identifying the critical role of actor interests in environment research. Forest and Society, 4 (1), 142–150

O’Key, V., Hugh-Jones, S., & Madill, A. (2009). Recruiting and engaging with people in deprived locales: Interviewing families about their eating patterns. Social Psychological Review, 11 (20), 30–35.

Puchta, C., & Potter, J. (2004). Focus group practice . Sage.

Schaeffer, N. C. (1991). Conversation with a purpose— Or conversation? Interaction in the standardized interview. In P. P. Biemer, R. M. Groves, L. E. Lyberg, & N. A. Mathiowetz (Eds.), Measurement errors in surveys (pp. 367–391). Wiley.

Silverman, D. (1973). Interview talk: Bringing off a research instrument. Sociology, 7 (1), 31–48.

Structured Interviews: Guide to Standardized Questions

Introduction

Types of interviews in qualitative research, what are structured interviews good for, structured interview process.

Qualitative researchers are used to dealing with unstructured data in social settings that are often dynamic and unpredictable. That said, there are research methods that can provide some more control over this unpredictable data while collecting insightful data .

The structured interview is one such method. Researchers can conduct a structured interview when they want to standardize the research process to give all respondents the same questions and analyze differences between answers.

In this article, we'll look at structured interviews, when they are ideal for your research, and how to conduct them.

Interviews are intentionally crafted sources of data in social science research. There are three types of interviews in research that balance research rigor and rich data collection .

To better understand structured interviews, it's important to contrast them with the other types of interviews that also serve useful purposes in research. As always, the best tool for data collection depends on your research inquiry.

Structured interviews

The structured interview format is the most rigid of the three types of interviews conceptualized in qualitative research. Imagine policy makers want to understand the perceptions of dozens or even hundreds of individuals. In this case, it may make it easier to streamline the interview process by simply asking the same questions of all respondents.

The same structured interview questions are posed to each and every respondent, akin to how hiring managers ask the same questions to all applicants during the hiring process. The intention behind this approach is to ensure that the interview is the same no matter who the respondent is, leaving only the differences in responses to be analyzed .

Moreover, the standardized interview format typically involves respondents being asked the same set of questions in the same order. A uniform sequence of questions ensures for an easy analysis when you can line up answers across respondents.

Unstructured interviews

An unstructured interview is the exact opposite of a structured interview, as unstructured interviews have no predetermined set of questions. Instead of a standardized interview, a researcher may opt for a study that remains open to exploring any issues or topics that a participant brings up in their interview. While this can generate unexpected insights, it can also be time-consuming and may not always yield answers that are directly related to the original research question guiding the study.

However, this doesn't make a study that employs unstructured interviews less rigorous . In fact, unstructured interviews are a great tool for inductive inquiry . One typical use for unstructured interviews is to probe not only for answers but for the salient points of a topic to begin with.

When a researcher uses an unstructured interview, they usually have a topic in mind but not a predetermined set of data points to analyze at the outset. This format allows respondents to speak at length on their perspectives and offer the researcher insights that can later form a theoretical framework for future research that could benefit from a structured interview format.

Moreover, this format provides the researcher with the greatest degree of freedom in determining questions depending on how they interact with their respondents. A respondent's body language, for example, may signal discomfort with a particularly controversial question. The interviewer can thus decide to adjust or reword their questions to create a more comfortable environment for the respondent.

Semi-structured interviews

A semi-structured interview lies in the middle ground between the structured and unstructured interview. This type of interview still relies on predetermined questions as a structured interview does. However, unlike structured interviews, a semi-structured interview also allows for follow-up questions to respondents when their answers warrant further probing. The predetermined questions thus serve as a guide for the interviewer, but the wording and ordering of questions can be adjusted, and additional questions can be asked during the course of the interview.

A researcher may conduct semi-structured interviews when they need flexibility in asking questions but can still benefit from advance preparation of key questions. In this case, much of the advice in this article about structured interviews still applies in terms of ensuring some degree of standardization when conducting research.

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Consider that more free-flowing interview formats in qualitative research allow for the interviewer to more freely probe a respondent for deeper, more insightful answers on the topic of inquiry. This approach to research is useful when the researcher needs to develop theoretical coherence surrounding a new topic or research context in which it would be difficult to predict beforehand which questions are worth asking.

In this sense, structured interviews make more sense for research inquiries with a well-defined theoretical framework that guides the data collection and data analysis process . With such a framework in mind, researchers can devise questions that are grounded in existing research so that new insights further develop that scholarship.

Advantages of structured interviews

Formal, structured interviews are ideal for keeping interviewers and interview respondents focused on the topic at hand. A conversation might take unanticipated turns without a set goal or predetermined objective in mind; a structured interview helps keep the dialogue from going down any irrelevant tangents and minimize potentially unnecessary, extended monologues.

Another key advantage of structured interviews is that it makes comparisons across participants easier. Since each person was asked the same questions, the data is produced in a consistent format. Researchers can then focus on analyzing answers to a particular question, and there is minimal data organization work that needs to be done to facilitate the analysis.

There are also benefits in terms of the logistics of conducting structured interviews. Interviewers concerned with time constraints will find this format beneficial to their data collection .

Moreover, ensuring that respondents are asked the same questions in the same order limits the need for training interviewers to conduct interviews in a consistent manner. Unstructured and semi-structured interviews rely on the ability to ask follow-up questions in moments when the responses provide opportunities for deeper elaboration.

Those who conduct a structured interview, on the other hand, need only read from an interview guide with a list of questions to pose to respondents. This allows the researcher more freedom to rely on assistants to conduct interviews with minimal training and resources.

Disadvantages of structured interviews

In structured interviews, there is little room for asking probing questions of respondents, particularly if the researcher believes that follow-up questions might adversely influence how the respondent answers subsequent core questions. Restricting the interview to a predetermined set of questions may mitigate this effect, but it may also prevent a sufficiently clear understanding of respondents' perspectives established from the use of follow-up questions.

Forcing the interviewer to ask the same order of questions in an interview can also have a consequential effect on the data collection . Because every respondent is different, the interview questions may resonate with each person in different ways. A skillful interviewer conducting unstructured or semi-structured interviews has the freedom to make choices about what questions to ask in order to gather the most insightful data.

Ultimately, the biggest disadvantage of structured interviews comes from their biggest advantage: using predetermined questions can be a double-edged sword, providing consistency and systematic organization but also limiting the research to the questions that were decided before conducting the interviews. This makes it crucial that researchers have a clear understanding of which questions they want to ask and why. It can also be helpful to conduct pilot tests of the interview, to test out the structured questions with a handful of people and assess if any changes to the questions need to be made.

Why not just do surveys?

You might think that a structured interview is no different from a survey with open-ended questions. After all, the questions are determined ahead of time and won't change over the course of data collection . In many ways, there are many similarities in both methods.

There are, of course, benefits to either approach. Surveys permit data collection from much larger numbers of respondents than may be feasible for an interview study. Structured interviews, however, allow the interviewer some degree of flexibility, particularly when the respondent has trouble understanding the question or needs further prompting to provide a sufficient response.

Moreover, the interpersonal interaction between the interviewer and respondent offers potential for richer data collection because of the degree of rapport established through face-to-face communication. Where written questions may seem static and impersonal, an in-person interview (or at least one conducted in real time) might make the respondent more comfortable in answering questions.

Individual interviews are also more likely to generate detailed responses to questions in comparison to surveys. Interviews are also well suited for research topics that bear some personal significance for participants, providing ample space for them to express themselves.

When you conduct a structured interview, you are designing a study that is as standardized as possible to mitigate context effects and ensure the ease of data collection and analysis . As with all interviews conducted in qualitative research , there is an intentional process to planning for structured interviews with considerations that researchers should keep in mind.

Research design

As mentioned above, research inquiries with clearly defined theoretical frameworks tend to benefit from structured interviews. Researchers can create a list of questions from such frameworks so that answers speak directly to, affirm, or challenge the existing scholarship surrounding the topic of interest.

A researcher should conduct a literature review to determine the extent of theoretical coherence in the topic they are researching. Are there aspects of a topic or phenomenon that scholars have identified that can serve as key data points around which questions can be crafted? Conversely, is it a topic or phenomenon that lacks sufficient conceptualization?

If your literature review does not allow you to create or use a robust theoretical framework for data collection, consider other types of interviews that allow you to inductively generate that framework in data analysis .

You should also make decisions about the conditions under which you conduct interviews. Some studies go as far as making sure that the interview environment is a uniform context across respondents. Are interviews in a quiet, comfortable environment? What time of day are interviews conducted?

The degree to which you ensure uniform conditions across interviews is up to you. Whatever you decide, however, creating an environment where respondents feel free to volunteer answers will facilitate rich data collection that will make data analysis more meaningful.

Structured interview questions

An interview guide is an essential tool for structured interviews. This guide is little more than a list of required questions to ask, but this list ensures consistency across the interviews in your study.

When you write questions for a structured interview, rely on your literature review to identify salient points around which you can design questions. This approach ensures that you are grounding your data collection in the established research.

When crafting your guide, think about the time constraints and the likely length of answers that your respondents may give. Structured interviews can involve five or 25 questions, but if you are limited to 30-45 minutes per respondent, you will need to consider whether you can ask the required questions and collect sufficient responses within your timeframe.

As a result, it's important to pilot your questions with preliminary respondents or other researchers. A pilot interview allows you to test your interview protocol and make tweaks to your question guide before conducting your study in earnest.

Collecting data from structured interviews

Data collection refers to conducting the interviews , recording what you and your respondents say, and transcribing those recordings for data analysis . While this is a simple enough task, it is important to consider the equipment you use to collect data.

If the verbal utterances of your respondents are your sole concern, then an audio recorder should be sufficient for capturing your respondents' answers. Your choice of equipment can be as simple as a smartphone audio recorder application. Alternatively, you can consider professional equipment to make sure you collect as much audio detail as possible from your interviews.

Communication studies, for example, may be more concerned about the interviewer effect (e.g., studies that ask controversial questions to evoke particular responses) or the context effects (i.e., the effect of the surrounding environment on respondents) in interviews . In such cases, interviewers may capture data with video recordings to analyze body language or facial expressions to certain interview questions. Responses caught on video can be analyzed for any patterns across respondents.

Analyzing structured interviews

Once you have transcribed your interviews, you can analyze your data. One of the more common means for analyzing qualitative data is thematic analysis , which relies on the identification of commonly recurring themes throughout your research. What codes occur the most often? Are there commonalities across responses that are worth pointing out to your research audience?

It's a good idea to code each response by the question they address. The set order of questions in a structured interview study makes it easy to identify the answers given by each respondent. By coding each answer by the question they respond to and the themes apparent in the response, you will be able to analyze what themes and patterns occur in each set of answers.

You can also analyze differences between respondents. In ATLAS.ti, you can place interview transcripts into document groups to organize and divide your data along salient categories such as gender, age group, socioeconomic status, and other identifiers you may find useful. In doing so, you will be able to restrict your data analysis to a specific group of interview respondents to see how their answers differ from other groups.

Presenting interview findings

Disseminating qualitative research is often a matter of summarizing the salient points of your data analysis so that it is easy to understand, insightful, and useful to your research audience. For research collecting data from interviews , two of the more common approaches to presenting findings include visualizations and excerpts.

Visualizations are ideal for representing the salient ideas arising from large sets of otherwise unstructured data . Meaningful illustrations such as frequency charts, word clouds, and Sankey diagrams can prove more persuasive than an extended narrative in a research paper or presentation.

Consider the word cloud in the screenshot of ATLAS.ti below. This word cloud was generated from the transcripts of a set of interviews to illustrate what concepts appear the most often in the selected data. Concepts mentioned more often appear closer to the center of the cloud, showing which keywords appear most frequently in the data. Such a visualization can provide a quick illustration to show to your research audience what topics emerged in the data analysis.

You can also effectively represent each of your themes with an example or two from the responses in your data . Data exemplars are representations that the researcher deems are typical of or significant about the portion of the data under discussion. Often in research that employs interviews or observations , an author will present an exemplar to explain a theme that is significant to theory development or challenges an existing theory.

ATLAS.ti provides tools to restrict your view of the data to codes you find significant to your findings. The Code Manager view makes it easy to look not at the entire data set but the specific segments of text that have been coded with a particular code. In similar fashion, ATLAS.ti's Query Tool is ideal for defining a set of criteria based on the codes in the data to see which data segments are most relevant to your research inquiry.

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How to carry out great interviews in qualitative research.

11 min read An interview is one of the most versatile methods used in qualitative research. Here’s what you need to know about conducting great qualitative interviews.

What is a qualitative research interview?

Qualitative research interviews are a mainstay among q ualitative research techniques, and have been in use for decades either as a primary data collection method or as an adjunct to a wider research process. A qualitative research interview is a one-to-one data collection session between a researcher and a participant. Interviews may be carried out face-to-face, over the phone or via video call using a service like Skype or Zoom.

There are three main types of qualitative research interview – structured, unstructured or semi-structured.

• Structured interviews Structured interviews are based around a schedule of predetermined questions and talking points that the researcher has developed. At their most rigid, structured interviews may have a precise wording and question order, meaning that they can be replicated across many different interviewers and participants with relatively consistent results.
• Unstructured interviews Unstructured interviews have no predetermined format, although that doesn’t mean they’re ad hoc or unplanned. An unstructured interview may outwardly resemble a normal conversation, but the interviewer will in fact be working carefully to make sure the right topics are addressed during the interaction while putting the participant at ease with a natural manner.
• Semi-structured interviews Semi-structured interviews are the most common type of qualitative research interview, combining the informality and rapport of an unstructured interview with the consistency and replicability of a structured interview. The researcher will come prepared with questions and topics, but will not need to stick to precise wording. This blended approach can work well for in-depth interviews.

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What are the pros and cons of interviews in qualitative research?

As a qualitative research method interviewing is hard to beat, with applications in social research, market research, and even basic and clinical pharmacy. But like any aspect of the research process, it’s not without its limitations. Before choosing qualitative interviewing as your research method, it’s worth weighing up the pros and cons.

Pros of qualitative interviews:

• provide in-depth information and context
• can be used effectively when their are low numbers of participants
• provide an opportunity to discuss and explain questions
• useful for complex topics
• rich in data – in the case of in-person or video interviews , the researcher can observe body language and facial expression as well as the answers to questions

Cons of qualitative interviews:

• can be time-consuming to carry out
• costly when compared to some other research methods
• because of time and cost constraints, they often limit you to a small number of participants
• difficult to standardize your data across different researchers and participants unless the interviews are very tightly structured
• As the Open University of Hong Kong notes, qualitative interviews may take an emotional toll on interviewers

Qualitative interview guides

Semi-structured interviews are based on a qualitative interview guide, which acts as a road map for the researcher. While conducting interviews, the researcher can use the interview guide to help them stay focused on their research questions and make sure they cover all the topics they intend to.

An interview guide may include a list of questions written out in full, or it may be a set of bullet points grouped around particular topics. It can prompt the interviewer to dig deeper and ask probing questions during the interview if appropriate.

Consider writing out the project’s research question at the top of your interview guide, ahead of the interview questions. This may help you steer the interview in the right direction if it threatens to head off on a tangent.

Avoid bias in qualitative research interviews

According to Duke University , bias can create significant problems in your qualitative interview.

• Acquiescence bias is common to many qualitative methods, including focus groups. It occurs when the participant feels obliged to say what they think the researcher wants to hear. This can be especially problematic when there is a perceived power imbalance between participant and interviewer. To counteract this, Duke University’s experts recommend emphasizing the participant’s expertise in the subject being discussed, and the value of their contributions.
• Interviewer bias is when the interviewer’s own feelings about the topic come to light through hand gestures, facial expressions or turns of phrase. Duke’s recommendation is to stick to scripted phrases where this is an issue, and to make sure researchers become very familiar with the interview guide or script before conducting interviews, so that they can hone their delivery.

What kinds of questions should you ask in a qualitative interview?

The interview questions you ask need to be carefully considered both before and during the data collection process. As well as considering the topics you’ll cover, you will need to think carefully about the way you ask questions.

Open-ended interview questions – which cannot be answered with a ‘yes’ ‘no’ or ‘maybe’ – are recommended by many researchers as a way to pursue in depth information.

An example of an open-ended question is “What made you want to move to the East Coast?” This will prompt the participant to consider different factors and select at least one. Having thought about it carefully, they may give you more detailed information about their reasoning.

A closed-ended question , such as “Would you recommend your neighborhood to a friend?” can be answered without too much deliberation, and without giving much information about personal thoughts, opinions and feelings.

Follow-up questions can be used to delve deeper into the research topic and to get more detail from open-ended questions. Examples of follow-up questions include:

• What makes you say that?
• What do you mean by that?
• Can you tell me more about X?
• What did/does that mean to you?

As well as avoiding closed-ended questions, be wary of leading questions. As with other qualitative research techniques such as surveys or focus groups, these can introduce bias in your data. Leading questions presume a certain point of view shared by the interviewer and participant, and may even suggest a foregone conclusion.

An example of a leading question might be: “You moved to New York in 1990, didn’t you?” In answering the question, the participant is much more likely to agree than disagree. This may be down to acquiescence bias or a belief that the interviewer has checked the information and already knows the correct answer.

Other leading questions involve adjectival phrases or other wording that introduces negative or positive connotations about a particular topic. An example of this kind of leading question is: “Many employees dislike wearing masks to work. How do you feel about this?” It presumes a positive opinion and the participant may be swayed by it, or not want to contradict the interviewer.

Harvard University’s guidelines for qualitative interview research add that you shouldn’t be afraid to ask embarrassing questions – “if you don’t ask, they won’t tell.” Bear in mind though that too much probing around sensitive topics may cause the interview participant to withdraw. The Harvard guidelines recommend leaving sensitive questions til the later stages of the interview when a rapport has been established.

More tips for conducting qualitative interviews

Observing a participant’s body language can give you important data about their thoughts and feelings. It can also help you decide when to broach a topic, and whether to use a follow-up question or return to the subject later in the interview.

Be conscious that the participant may regard you as the expert, not themselves. In order to make sure they express their opinions openly, use active listening skills like verbal encouragement and paraphrasing and clarifying their meaning to show how much you value what they are saying.

Remember that part of the goal is to leave the interview participant feeling good about volunteering their time and their thought process to your research. Aim to make them feel empowered , respected and heard.

Unstructured interviews can demand a lot of a researcher, both cognitively and emotionally. Be sure to leave time in between in-depth interviews when scheduling your data collection to make sure you maintain the quality of your data, as well as your own well-being .

Recording and transcribing interviews

Historically, recording qualitative research interviews and then transcribing the conversation manually would have represented a significant part of the cost and time involved in research projects that collect qualitative data.

Fortunately, researchers now have access to digital recording tools, and even speech-to-text technology that can automatically transcribe interview data using AI and machine learning. This type of tool can also be used to capture qualitative data from qualitative research (focus groups,ect.) making this kind of social research or market research much less time consuming.

Data analysis

Qualitative interview data is unstructured, rich in content and difficult to analyze without the appropriate tools. Fortunately, machine learning and AI can once again make things faster and easier when you use qualitative methods like the research interview.

Text analysis tools and natural language processing software can ‘read’ your transcripts and voice data and identify patterns and trends across large volumes of text or speech. They can also perform khttps://www.qualtrics.com/experience-management/research/sentiment-analysis/

which assesses overall trends in opinion and provides an unbiased overall summary of how participants are feeling.

Another feature of text analysis tools is their ability to categorize information by topic, sorting it into groupings that help you organize your data according to the topic discussed.

All in all, interviews are a valuable technique for qualitative research in business, yielding rich and detailed unstructured data. Historically, they have only been limited by the human capacity to interpret and communicate results and conclusions, which demands considerable time and skill.

When you combine this data with AI tools that can interpret it quickly and automatically, it becomes easy to analyze and structure, dovetailing perfectly with your other business data. An additional benefit of natural language analysis tools is that they are free of subjective biases, and can replicate the same approach across as much data as you choose. By combining human research skills with machine analysis, qualitative research methods such as interviews are more valuable than ever to your business.

Related resources

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

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Qualitative study design: Interviews

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research
• Case Studies
• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

Interviews are intended to find out the experiences, understandings, opinions, or motivations of participants. The relationship between the interviewer and interviewee is crucial to the success of the research interview; the interviewer builds an environment of trust with the interviewee/s, guiding the interviewee/s through a set of topics or questions to be discussed in depth.

Interviews are the most commonly used qualitative data gathering technique and are used with grounded theory, focus groups, and case studies.

• Interviews are purposive conversations between the researcher and the interviewee, either alone or as part of a group
• Interviews can be face to face, via telecommunications (Skype, Facetime, or phone), or via email (internet or email interview)
• The length of an interview varies. They may be anywhere from thirty minutes to several hours in length, depending on your research approach
• Structured interviews use a set list of questions which need to be asked in order, increasing the reliability and credibility of the data but decreasing responsiveness to interviewee/s. Structured interviews are like a verbal survey
• Unstructured interviews are where the interviewer has a set list of topics to address but no predetermined questions. This increases the flexibility of the interview but decreases the reliability of the data. Unstructured interviews may be used in long-term field observation research
• Semi-structured interviews are the middle ground. Semi-structured interviews require the interviewer to have a list of questions and topics pre-prepared, which can be asked in different ways with different interviewee/s. Semi-structured interviews increase the flexibility and the responsiveness of the interview while keeping the interview on track, increasing the reliability and credibility of the data. Semi-structured interviews are one of the most common interview techniques.
• Flexible – probing questions can be asked, and the order of questions changed, depending on the participant and how structured or unstructured the interview is
• Quick way to collect data
• Familiarity – most interviewees are familiar with the concept of an interview and are comfortable with this research approach

Limitations

• Not all participants are equally articulate or perceptive
• Questions must be worded carefully to reduce response bias
• Transcription of interviews can be time and labour intensive

Example questions

• What are the experiences of midwives in providing care to high-risk mothers, where there is a history of drug or alcohol use?

Example studies

Sandelin, A., Kalman, S., Gustafsson, B. (2019). Prerequisites for safe intraoperative nursing care and teamwork – operating theatre nurses’ perspectives: a qualitative interview study, Journal of Clinical Nursing, 28, 2635-2643. Doi: 10.1111/jocn.14850  

Babbie, E. (2008). The basics of social research (4th ed). Belmont: Thomson Wadsworth

Creswell, J.W. & Creswell, J.D. (2018). Research design: Qualitative, quantitative and mixed methods approaches (5th ed). Thousand Oaks: SAGE

Jamshed, S. (2014). Qualitative research method-interviewing and observation. Journal of basic and clinical pharmacy, 5(4), 87-88. doi:10.4103/0976-0105.141942

Lindlof, T. & Taylor, B. (2002). Qualitative communication research methods (2nd ed). Thousand Oaks: SAGE .  

• << Previous: Surveys & questionnaires
• Next: Sampling >>
• Last Updated: Jul 3, 2024 11:46 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

Qualitative Interviewing

• Reference work entry
• First Online: 13 January 2019
• Cite this reference work entry

• Sally Nathan 2 ,
• Christy Newman 3 &
• Kari Lancaster 3  

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Qualitative interviewing is a foundational method in qualitative research and is widely used in health research and the social sciences. Both qualitative semi-structured and in-depth unstructured interviews use verbal communication, mostly in face-to-face interactions, to collect data about the attitudes, beliefs, and experiences of participants. Interviews are an accessible, often affordable, and effective method to understand the socially situated world of research participants. The approach is typically informed by an interpretive framework where the data collected is not viewed as evidence of the truth or reality of a situation or experience but rather a context-bound subjective insight from the participants. The researcher needs to be open to new insights and to privilege the participant’s experience in data collection. The data from qualitative interviews is not generalizable, but its exploratory nature permits the collection of rich data which can answer questions about which little is already known. This chapter introduces the reader to qualitative interviewing, the range of traditions within which interviewing is utilized as a method, and highlights the advantages and some of the challenges and misconceptions in its application. The chapter also provides practical guidance on planning and conducting interview studies. Three case examples are presented to highlight the benefits and risks in the use of interviewing with different participants, providing situated insights as well as advice about how to go about learning to interview if you are a novice.

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Interviews in the social sciences

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• Structured Interviews: Definition, Types + [Question Examples]

In carrying out a systematic investigation into specific subjects and contexts, researchers often make use of structured and semi-structured interviews. These are methods of data gathering that help you to collect first-hand information with regards to the research subject, using different methods and tools. 

Structured and semi-structured interviews are appropriate for different contexts and observations. As a researcher, it is important for you to understand the right contexts for these types of interviews and how to go about collecting information using structured or semi-structured interviewing methods. 

What is a Structured Interview?

A structured interview is a type of quantitative interview that makes use of a standardized sequence of questioning in order to gather relevant information about a research subject. This type of research is mostly used in statistical investigations and follows a premeditated sequence. 

In a structured interview, the researcher creates a set of interview questions in advance and these questions are asked in the same order so that responses can easily be placed in similar categories. A structured interview is also known as a patterned interview, planned interview or a standardized interview. 

What is a Semi-Structured Interview?

A semi-structured interview is a type of qualitative interview that has a set of premeditated questions yet, allows the interviewer to explore new developments in the cause of the interview. In some way, it represents the midpoint between structured and unstructured interviews. 

In a semi-structured interview, the interviewer is at liberty to deviate from the set interview questions and sequence as long as he or she remains with the overall scope of the interview. In addition, a semi-structured interview makes use of an interview guide which is an informal grouping of topics and questions that the interviewer can ask in different ways. 

Examples & Advantages of Semi-structured Interviews

An example of a semi-structured interview could go like this;

• Did you visit the doctor yesterday?
• Why did you have the visit?
• What was the outcome of the visit?

Each question is a prompt aimed at getting the respondent to give away more information

Advantages of a Semi-structured Interview

• They offer a more personalized approach that allows respondents to be a lot more open during the interview
• This interview-style combines both unstructured and structured interview styles so it merges the advantages of both.
• Allows two-way communication between candidates and interviewers

Types of Structured Interview

Structured interview examples can be classified into three, namely; the face-to-face interview, telephone interviews, and survey/questionnaires interviews

Face-to-Face Structured Interview

A face-to-face structured interview is a type of interview where the researcher and the interviewee exchange information physically. It is a method of data collection that requires the interviewer to collect information through direct communication with the respondent in line with the research context and already prepared questions. 

Face-to-face structured interviews allow the interviewer to collect factual information regarding the experiences and preferences of the research respondent. It helps the researcher minimize survey dropout rates and improve the quality of data collected, which results in more objective research outcomes. 

Learn: How to Conduct an Exit Survey

Advantages of Face-to-face Structured Interview

• It allows for more in-depth and detailed data collection.
• Body language and facial expressions observed during a face-to-face structured interview can inform data analysis.
• Visual materials can be used to support face-to-face structured interviews.
• A face-to-face structured interview allows you to gather more accurate information from the research subjects. 

Disadvantages of Face-to-face Structured Interview

• A face-to-face structured interview is expensive to conduct because it requires a lot of staff and personnel. Different costs are incurred during a face-to-face structured interview including logistics and remuneration. 
• This type of interview is limited to a small data sample size.
• A face-to-face structured interview is also time-consuming.
• It can be affected by bias and subjectivity . 

Tele-Interviews

A tele-interview is a type of structured interview that is conducted through a video or audio call. In this type of interview, the researcher gathers relevant information by communicating with the respondent via a video call or telephone conversation. 

Tele-interviews are usually conducted in accordance with the standardized interview sequence as is the norm with structured interviews. It makes use of close-ended questions in order to gather the most relevant information from the interviewee, and it is a method of quantitative observation. 

Advantages of Tele-interviews

• Tele-interviews are more convenient and result in higher survey response rates.
• It is not time-consuming as interviews can be completed relatively fast.
• It has a large data sample size as it can be used to gather information over a large geographical area.
• It is cost-effective.
• It helps the interviewee to target specific data samples.

Disadvantages of a Tele-interview

• It does not allow for qualitative observation of the research sample.
• It can lead to survey response bias.
• It is subject to network availability and other technical parameters.
• It is difficult for the interviewer to build rapport with an interviewee via this means; especially if they are meeting for the first time. 
• It may be difficult to read the interviewee’s body language, even with a video call. Body language usually serves as a means of gathering additional information about the research subjects. 

Use this: Interview Schedule Form

Surveys/Questionnaires  

A structured questionnaire is a common tool used in quantitative observation. It is made up of a set of standardized questions, usually close-ended arranged in a standardized interview sequence, and administered to a fixed data sample, in order to collect relevant information. 

In other words, a questionnaire is a method of data gathering that involves gathering information from target groups via a set of premeditated questions. You can administer a questionnaire physically or you can create and administer it online using data-gathering platforms like Formplus. 

Advantages of Survey/Questionnaire

• It is time-efficient and allows you to gather information from large data samples.
• Information collected via a questionnaire can easily be processed and placed in data categories.
• A questionnaire is a flexible and convenient method of data collection.
• It is also cost-efficient; especially when administered online.
• Surveys and questionnaires are useful in describing the numerical characteristics of large sets of data. 

Disadvantages of Surveys/Questionnaires  

• A high rate of survey response bias due to survey fatigue.
• High survey drop-out rate. 
• Surveys and questionnaires are susceptible to researcher error; especially when the researcher makes wrong assumptions about the data sample.
• Surveys and questionnaires are rigid in nature.
• In some cases, survey respondents are not entirely honest with their responses and this affects the accuracy of research outcomes. 

Tools used in Structured Interview 

• Audio Recorders

An audio recorder is a data-gathering tool that is used to collect information during an interview by recording the conversation between the interviewer and the interviewee. This data collection tool is typically used during face-to-face interviews in order to accurately capture questions and responses. 

The recorded information is then extracted and transcribed for data categorization and data analysis. There are different types of audio recording equipment including analog and digital audio recorders, however, digital audio recorders are the best tools for capturing interactions in structured interviews. 

• Digital Camera

A digital camera is another common tool used for structured tele-interviews. It is a type of camera that captures interactions in digital memory, which are pictures. 

In many cases, digital cameras are combined with other tools in a structured interview in order to accurately gather information about the research sample. It is an effective method of gathering visual information. 

Just as its name implies, a camcorder is the hybridization of a camera and a recorder. It is a portable dual-purpose tool used in structured interviews to collect static and live-motion visual data for later playback and analysis. 

A telephone is a communication device that is used to facilitate interaction between the researcher and interviewee; especially when both parties in different geographical spaces.

• Formplus Survey/Questionnaire

Formplus is a data-gathering platform that you can use to create and administer questionnaires for online survey s. In the form builder, you can add different fields to your form in order to collect a variety of information from respondents. 

Apart from allowing you to add different form fields to your questionnaires and surveys, Formplus also enables you to create smart forms with conditional logic and form lookup features. It also allows you to personalize your survey using different customization options in the form builder. 

Best Types of Questions For Structured Interview

Open-ended questions.

An open-ended question is a type of question that does not limit the respondent to a set of answers. In other words, open-ended questions are free-form questions that give the interviewee the freedom to express his or her knowledge, experiences and thoughts. 

Open-ended questions are typically used for qualitative observation where attention is paid to an in-depth description of the research subjects. These types of questions are designed to elicit full and detailed responses from the research subjects, unlike close-ended questions that require brief responses. 

Examples of Open-Ended Questions

• What do you think about the new packaging?
• How can we improve our services?
• Why did you choose this outfit?
• How can we serve you better? 

Advantages of Open-Ended Questions

• Open-ended questions are useful for qualitative observation.
• Open-ended questions help you gain unexpected insights and in-depth information. 
• It exposes the researcher to an infinite range of responses.
• It helps the researcher arrive at more objective research outcomes. 

Disadvantages of Open-ended Questions 

• Data collection using open-ended questions is time-consuming.
• It cannot be used for quantitative research.
• There is a great possibility of capturing large volumes of irrelevant data. 

Using Open-ended Questions for Interviews 

In interviews, open-ended questions are used to gain insight into the thoughts and experiences of the respondents. To do this, the interviewer generates a set of open-ended questions that can be asked in any sequence, and other open-ended questions may arise in follow-up inquiries.

Use this: Interview Feedback Form 

Close-Ended Questions

A close-ended question is a type of question that restricts the respondent to a range of probable responses as options. It is often used in quantitative research to gather statistical data from interviewees, and there are different types of close-ended questions including multiple choice and Likert scale questions . 

A close-ended question is primarily defined by the need to have a set of predefined responses which the interviewee chooses from. These types of questions help the researcher to categorize data in terms of numerical value and to restrict interview responses to the most valid data. 

Examples of Close-ended Questions

1. Do you enjoy using our product?

• I don’t Know

2. Have you ever visited London?

3. Did you enjoy the relationship seminar?

• No, I did not
• I can’t say

4. On a scale of 1-5, rate our service delivery. (1-Poor; 5-Excellent). 

5. How often do you visit home? 

• Somewhat often
• I don’t visit home. 

Advantages of Close-ended Questions 

• It is useful for statistical inquiries.
• Close-ended questions are straight-forward and easy to respond to.
• Data gathered through close-ended questions are easy to analyze.
• It reduces the chances of gathering irrelevant responses.

Disadvantages of Close-Ended Questions 

• Close-ended questions are highly subjective in nature and have a high probability of survey response bias .
• Close-ended questions do not allow you to collect in-depth information about the experiences of the research subjects.
• Close-ended questions cannot be used for qualitative observation. 

Using Close-ended Questions for Unstructured Interviews

Close-ended questions are used in interviews for statistical inquiries. In many cases, interviews begin with a set of close-ended questions which lead to further inquiries depending on the type, that is, structured, unstructured, or semi-structured interviews. 

Also Read: Structured vs Unstructured Interviews

Multiple Choice Question

A multiple-choice question is a type of close-ended question that provides respondents with a list of possible answers. The interviewee is required to choose one or more options in response to the question; depending on the question type and stipulated instructions. 

Typically, a multiple-choice question is one of the most common types of questions used in a survey or questionnaire. It is also a valid means of quantitative inquiry because it pays attention to the numerical value of data categories. A multiple-choice question is made up of 3 parts which are the stem, the correct answer(s) and the distractors.  

Examples of Multiple Choice Questions

• How many times do you visit home?

2. What types of shirts do you wear? (Choose as many that apply)

• Long-sleeved Shirt
• Short-sleeved Shirt 

3. Which of the following gadgets do you use?

4. What is your highest level of education?

Advantages of Multiple Choice Question

• A multiple-choice question is an effective method of assessment; especially n qualitative research. 
• It is time-efficient. 
• It reduces the chances of interviewer bias because of its objective approach. 

Disadvantages of Multiple Choice Questions

• Multiple Choice questions are limited to certain types of knowledge. 
• It cannot be used for problem-solving and high-order reasoning assessments. 
• It can lead to ambiguity and misinterpretation which causes survey response bias. 
• Survey fatigue leads to high survey drop-out rates. 

Dichotomous Questions

A dichotomous question is a type of close-ended question that can only have two possible answers. It is a method of quantitative observation and it is typically used for educational research and assessments, and other research processes that involve statistical evaluation. 

It is important for researchers to limit the use of dichotomous questions to situations where there are only 2 possible answers. These types of questions are restricted to yes/no, true/false or agree/disagree options and they are used to gather information related to the experiences of the research subjects. 

Examples of Dichotomous Questions

1. Do you enjoy using this product?

2. I have always used this product for my hair.

3. Are you lactose-intolerant?

4. Have you ever witnessed an explosion?

5. Have you ever visited our farm?

Advantages of Dichotomous Questions

• It is an effective method of quantitative research. 
• Surveys containing dichotomous questions are easy to administer.
• It is non-ambivalent in nature.
• It allows for ease of data-gathering and analysis.
• Dichotomous questions are brief, easy and simplified in nature. 

Disadvantages of Dichotomous Questions

• A dichotomous question is limited in nature.
• It cannot be used to gather qualitative information in research. 
• It is not suitable for in-depth data gathering. 

Learn: Types of Screening Interview 

How to Prepare a Structured Interview

• Choose the right setting

It’s important to provide a comfortable setting for your respondent. If you don’t, they’ll be subject to participant bias which can then skew the results of your interview.

• Tell them the purpose of your interview

You need to give your participants a heads up on why you’re conducting this. This is also the stage where you talk about any confidentiality clauses and get informed consent from your researchers. Explain how these answers will be used and who will have access to it. 

• Prepare your questions

Start by asking the basics to warm up your respondents. Then depending on your structured interview style, you can then choose tailored questions. E.g multiple-choice, dichotomous, open-ended, or close-ended questions. Ensure your questions are as neutral as possible and give room for your respondents to add any extra impressions or comments.

• Verify that your tools are working

Check that your audio recorder is working fine and that your camera is properly placed before you kick off the interview. For phone interviews, confirm that you have enough call credits or that your internet connection is stable. If you’re using Formplus, you don’t have to bother about getting cut off thanks to the offline form feature. This means you can still record responses even when your respondents have poor or zero internet connection

• Make notes and record observations

Ensure that your notes are legible and clear enough for you to revert. Write down your observations. Were your respondents nervous or surprised at any particular question?

Also Read: Unstructured Interviews

How to Use Formplus For Structured Interview

Sign into formplus.

In the Formplus builder, you can easily create a questionnaire for your structured interview by dragging and dropping preferred fields into your form. To access the Formplus builder, you will need to create an account on Formplus. 

Once you do this, sign in to your account and click on “Create Form ” to begin. 

Edit Form Title

Click on the field provided to input your form title, for example, “Structured Interview Questionnaire”.

• Click on the edit button to edit the form.
• Add Fields: Drag and drop preferred form fields into your form in the Formplus builder inputs column. There are several field input options for survey forms in the Formplus builder including table fields and you can create a smarter questionnaire by using the conditional logic feature. 
• Edit fields: You can modify your form fields to be hidden, required or read-only depending on your data sample and the purpose of the interview. 
• Click on “Save”
• Preview form. 

Customise Form

Formplus allows you to add unique features to your structured questionnaire. You can personalize your questionnaire using various customization options in the builder. Here, you can add background images, your organization’s logo, and other features. You can also change the display theme of your form. 

Share your Form Link with Respondents

Formplus allows you to share your questionnaire with interviewees using multiple form-sharing options. You can use the direct social media sharing buttons to share your form link to your organization’s social media pages. 

You can also embed your questionnaire into your website so that form respondents can easily fill it out when they visit your webpage. Formplus enables you to send out email invitations to interviewees and to also share your questionnaire as a QR code.

Conclusion  

It is important for every researcher to understand how to conduct structured and unstructured interviews. While a structured interview strictly follows an interview sequence comprising standardized questions, a semi-structured interview allows the researcher to digress from the sequence of inquiry, based on the information provided by the respondent. 

You can conduct a structured interview using an audio recorder, telephone or surveys. Formplus allows you to create and administer online surveys easily, and you can add different form fields to allow you to collect a variety of information using the form builder. 

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Qualitative Research 101: Interviewing

5 Common Mistakes To Avoid When Undertaking Interviews

By: David Phair (PhD) and Kerryn Warren (PhD) | March 2022

Undertaking interviews is potentially the most important step in the qualitative research process. If you don’t collect useful, useable data in your interviews, you’ll struggle through the rest of your dissertation or thesis.  Having helped numerous students with their research over the years, we’ve noticed some common interviewing mistakes that first-time researchers make. In this post, we’ll discuss five costly interview-related mistakes and outline useful strategies to avoid making these.

Overview: 5 Interviewing Mistakes

• Not having a clear interview strategy /plan
• Not having good interview techniques /skills
• Not securing a suitable location and equipment
• Not having a basic risk management plan
• Not keeping your “ golden thread ” front of mind

1. Not having a clear interview strategy

The first common mistake that we’ll look at is that of starting the interviewing process without having first come up with a clear interview strategy or plan of action. While it’s natural to be keen to get started engaging with your interviewees, a lack of planning can result in a mess of data and inconsistency between interviews.

There are several design choices to decide on and plan for before you start interviewing anyone. Some of the most important questions you need to ask yourself before conducting interviews include:

• What are the guiding research aims and research questions of my study?
• Will I use a structured, semi-structured or unstructured interview approach?
• How will I record the interviews (audio or video)?
• Who will be interviewed and by whom ?
• What ethics and data law considerations do I need to adhere to?
• How will I analyze my data? 

Let’s take a quick look at some of these.

The core objective of the interviewing process is to generate useful data that will help you address your overall research aims. Therefore, your interviews need to be conducted in a way that directly links to your research aims, objectives and research questions (i.e. your “golden thread”). This means that you need to carefully consider the questions you’ll ask to ensure that they align with and feed into your golden thread. If any question doesn’t align with this, you may want to consider scrapping it.

Another important design choice is whether you’ll use an unstructured, semi-structured or structured interview approach . For semi-structured interviews, you will have a list of questions that you plan to ask and these questions will be open-ended in nature. You’ll also allow the discussion to digress from the core question set if something interesting comes up. This means that the type of information generated might differ a fair amount between interviews.

Contrasted to this, a structured approach to interviews is more rigid, where a specific set of closed questions is developed and asked for each interviewee in exactly the same order. Closed questions have a limited set of answers, that are often single-word answers. Therefore, you need to think about what you’re trying to achieve with your research project (i.e. your research aims) and decided on which approach would be best suited in your case.

It is also important to plan ahead with regards to who will be interviewed and how. You need to think about how you will approach the possible interviewees to get their cooperation, who will conduct the interviews, when to conduct the interviews and how to record the interviews. For each of these decisions, it’s also essential to make sure that all ethical considerations and data protection laws are taken into account.

Finally, you should think through how you plan to analyze the data (i.e., your qualitative analysis method) generated by the interviews. Different types of analysis rely on different types of data, so you need to ensure you’re asking the right types of questions and correctly guiding your respondents.

Simply put, you need to have a plan of action regarding the specifics of your interview approach before you start collecting data. If not, you’ll end up drifting in your approach from interview to interview, which will result in inconsistent, unusable data.

2. Not having good interview technique

While you’re generally not expected to become you to be an expert interviewer for a dissertation or thesis, it is important to practice good interview technique and develop basic interviewing skills .

Let’s go through some basics that will help the process along.

Firstly, before the interview , make sure you know your interview questions well and have a clear idea of what you want from the interview. Naturally, the specificity of your questions will depend on whether you’re taking a structured, semi-structured or unstructured approach, but you still need a consistent starting point . Ideally, you should develop an interview guide beforehand (more on this later) that details your core question and links these to the research aims, objectives and research questions.

Before you undertake any interviews, it’s a good idea to do a few mock interviews with friends or family members. This will help you get comfortable with the interviewer role, prepare for potentially unexpected answers and give you a good idea of how long the interview will take to conduct. In the interviewing process, you’re likely to encounter two kinds of challenging interviewees ; the two-word respondent and the respondent who meanders and babbles. Therefore, you should prepare yourself for both and come up with a plan to respond to each in a way that will allow the interview to continue productively.

To begin the formal interview , provide the person you are interviewing with an overview of your research. This will help to calm their nerves (and yours) and contextualize the interaction. Ultimately, you want the interviewee to feel comfortable and be willing to be open and honest with you, so it’s useful to start in a more casual, relaxed fashion and allow them to ask any questions they may have. From there, you can ease them into the rest of the questions.

As the interview progresses , avoid asking leading questions (i.e., questions that assume something about the interviewee or their response). Make sure that you speak clearly and slowly , using plain language and being ready to paraphrase questions if the person you are interviewing misunderstands. Be particularly careful with interviewing English second language speakers to ensure that you’re both on the same page.

Engage with the interviewee by listening to them carefully and acknowledging that you are listening to them by smiling or nodding. Show them that you’re interested in what they’re saying and thank them for their openness as appropriate. This will also encourage your interviewee to respond openly.

Need a helping hand?

3. Not securing a suitable location and quality equipment

Where you conduct your interviews and the equipment you use to record them both play an important role in how the process unfolds. Therefore, you need to think carefully about each of these variables before you start interviewing.

Poor location: A bad location can result in the quality of your interviews being compromised, interrupted, or cancelled. If you are conducting physical interviews, you’ll need a location that is quiet, safe, and welcoming . It’s very important that your location of choice is not prone to interruptions (the workplace office is generally problematic, for example) and has suitable facilities (such as water, a bathroom, and snacks).

If you are conducting online interviews , you need to consider a few other factors. Importantly, you need to make sure that both you and your respondent have access to a good, stable internet connection and electricity. Always check before the time that both of you know how to use the relevant software and it’s accessible (sometimes meeting platforms are blocked by workplace policies or firewalls). It’s also good to have alternatives in place (such as WhatsApp, Zoom, or Teams) to cater for these types of issues.

Poor equipment: Using poor-quality recording equipment or using equipment incorrectly means that you will have trouble transcribing, coding, and analyzing your interviews. This can be a major issue , as some of your interview data may go completely to waste if not recorded well. So, make sure that you use good-quality recording equipment and that you know how to use it correctly.

To avoid issues, you should always conduct test recordings before every interview to ensure that you can use the relevant equipment properly. It’s also a good idea to spot check each recording afterwards, just to make sure it was recorded as planned. If your equipment uses batteries, be sure to always carry a spare set.

4. Not having a basic risk management plan

Many possible issues can arise during the interview process. Not planning for these issues can mean that you are left with compromised data that might not be useful to you. Therefore, it’s important to map out some sort of risk management plan ahead of time, considering the potential risks, how you’ll minimize their probability and how you’ll manage them if they materialize.

Common potential issues related to the actual interview include cancellations (people pulling out), delays (such as getting stuck in traffic), language and accent differences (especially in the case of poor internet connections), issues with internet connections and power supply. Other issues can also occur in the interview itself. For example, the interviewee could drift off-topic, or you might encounter an interviewee who does not say much at all.

You can prepare for these potential issues by considering possible worst-case scenarios and preparing a response for each scenario. For instance, it is important to plan a backup date just in case your interviewee cannot make it to the first meeting you scheduled with them. It’s also a good idea to factor in a 30-minute gap between your interviews for the instances where someone might be late, or an interview runs overtime for other reasons. Make sure that you also plan backup questions that could be used to bring a respondent back on topic if they start rambling, or questions to encourage those who are saying too little.

In general, it’s best practice to plan to conduct more interviews than you think you need (this is called oversampling ). Doing so will allow you some room for error if there are interviews that don’t go as planned, or if some interviewees withdraw. If you need 10 interviews, it is a good idea to plan for 15. Likely, a few will cancel , delay, or not produce useful data.

5. Not keeping your golden thread front of mind

We touched on this a little earlier, but it is a key point that should be central to your entire research process. You don’t want to end up with pages and pages of data after conducting your interviews and realize that it is not useful to your research aims . Your research aims, objectives and research questions – i.e., your golden thread – should influence every design decision and should guide the interview process at all times. 

A useful way to avoid this mistake is by developing an interview guide before you begin interviewing your respondents. An interview guide is a document that contains all of your questions with notes on how each of the interview questions is linked to the research question(s) of your study. You can also include your research aims and objectives here for a more comprehensive linkage. 

You can easily create an interview guide by drawing up a table with one column containing your core interview questions . Then add another column with your research questions , another with expectations that you may have in light of the relevant literature and another with backup or follow-up questions . As mentioned, you can also bring in your research aims and objectives to help you connect them all together. If you’d like, you can download a copy of our free interview guide here .

Recap: Qualitative Interview Mistakes

In this post, we’ve discussed 5 common costly mistakes that are easy to make in the process of planning and conducting qualitative interviews.

To recap, these include:

If you have any questions about these interviewing mistakes, drop a comment below. Alternatively, if you’re interested in getting 1-on-1 help with your thesis or dissertation , check out our dissertation coaching service or book a free initial consultation with one of our friendly Grad Coaches.

Psst... there’s more!

This post was based on one of our popular Research Bootcamps . If you're working on a research project, you'll definitely want to check this out ...

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• Harvard Library
• Research Guides
• Faculty of Arts & Sciences Libraries

Library Support for Qualitative Research

• Interview Research
• Resources for Methodology
• Remote Research & Virtual Fieldwork

Resources for Research Interviewing

Nih-funded qualitative research.

• Oral History
• Data Management & Repositories
• Campus Access

Types of Interviews

• Engaging Participants

Interview Questions

• Conducting Interviews
• Transcription
• Coding and Analysis
• Managing & Finding Interview Data
• UX & Market Research Interviews

Textbooks, Guidebooks, and Handbooks  

• The Ethnographic Interview by James P. Spradley  “Spradley wrote this book for the professional and student who have never done ethnographic fieldwork (p. 231) and for the professional ethnographer who is interested in adapting the author’s procedures (p. iv). Part 1 outlines in 3 chapters Spradley’s version of ethnographic research, and it provides the background for Part 2 which consists of 12 guided steps (chapters) ranging from locating and interviewing an informant to writing an ethnography. Most of the examples come from the author’s own fieldwork among U.S. subcultures . . . Steps 6 and 8 explain lucidly how to construct a domain and a taxonomic analysis” (excerpted from book review by James D. Sexton, 1980).  
• Fundamentals of Qualitative Research by Johnny Saldana (Series edited by Patricia Leavy)  Provides a soup-to-nuts overview of the qualitative data collection process, including interviewing, participant observation, and other methods.  
• InterViews by Steinar Kvale  Interviewing is an essential tool in qualitative research and this introduction to interviewing outlines both the theoretical underpinnings and the practical aspects of the process. After examining the role of the interview in the research process, Steinar Kvale considers some of the key philosophical issues relating to interviewing: the interview as conversation, hermeneutics, phenomenology, concerns about ethics as well as validity, and postmodernism. Having established this framework, the author then analyzes the seven stages of the interview process - from designing a study to writing it up.  
• Practical Evaluation by Michael Quinn Patton  Surveys different interviewing strategies, from, a) informal/conversational, to b) interview guide approach, to c) standardized and open-ended, to d) closed/quantitative. Also discusses strategies for wording questions that are open-ended, clear, sensitive, and neutral, while supporting the speaker. Provides suggestions for probing and maintaining control of the interview process, as well as suggestions for recording and transcription.  
• The SAGE Handbook of Interview Research by Amir B. Marvasti (Editor); James A. Holstein (Editor); Jaber F. Gubrium (Editor); Karyn D. McKinney (Editor)  The new edition of this landmark volume emphasizes the dynamic, interactional, and reflexive dimensions of the research interview. Contributors highlight the myriad dimensions of complexity that are emerging as researchers increasingly frame the interview as a communicative opportunity as much as a data-gathering format. The book begins with the history and conceptual transformations of the interview, which is followed by chapters that discuss the main components of interview practice. Taken together, the contributions to The SAGE Handbook of Interview Research: The Complexity of the Craft encourage readers simultaneously to learn the frameworks and technologies of interviewing and to reflect on the epistemological foundations of the interview craft.  
• The SAGE Handbook of Online Research Methods by Nigel G. Fielding, Raymond M. Lee and Grant Blank (Editors) Bringing together the leading names in both qualitative and quantitative online research, this new edition is organised into nine sections: 1. Online Research Methods 2. Designing Online Research 3. Online Data Capture and Data Collection 4. The Online Survey 5. Digital Quantitative Analysis 6. Digital Text Analysis 7. Virtual Ethnography 8. Online Secondary Analysis: Resources and Methods 9. The Future of Online Social Research

ONLINE RESOURCES, COMMUNITIES, AND DATABASES  

• Interviews as a Method for Qualitative Research (video) This short video summarizes why interviews can serve as useful data in qualitative research.  
• Companion website to Bloomberg and Volpe's  Completing Your Qualitative Dissertation: A Road Map from Beginning to End,  4th ed Provides helpful templates and appendices featured in the book, as well as links to other useful dissertation resources.
• International Congress of Qualitative Inquiry Annual conference hosted by the International Center for Qualitative Inquiry at the University of Illinois at Urbana-Champaign, which aims to facilitate the development of qualitative research methods across a wide variety of academic disciplines, among other initiatives.  
• METHODSPACE ​​​​​​​​An online home of the research methods community, where practicing researchers share how to make research easier.  
• SAGE researchmethods ​​​​​​​Researchers can explore methods concepts to help them design research projects, understand particular methods or identify a new method, conduct their research, and write up their findings. A "methods map" facilitates finding content on methods.

The decision to conduct interviews, and the type of interviewing to use, should flow from, or align with, the methodological paradigm chosen for your study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

Structured:

• Structured Interview. Entry in The SAGE Encyclopedia of Social Science Research Methodsby Floyd J. Fowler Jr., Editors: Michael S. Lewis-Beck; Alan E. Bryman; Tim Futing Liao (Editor)  A concise article noting standards, procedures, and recommendations for developing and testing structured interviews. For an example of structured interview questions, you may view the Current Population Survey, May 2008: Public Participation in the Arts Supplement (ICPSR 29641), Apr 15, 2011 at https://doi.org/10.3886/ICPSR29641.v1 (To see the survey questions, preview the user guide, which can be found under the "Data and Documentation" tab. Then, look for page 177 (attachment 8).

Semi-Structured:

• Semi-Structured Interview. Entry in The SAGE Encyclopedia of Qualitative Research Methodsby Lioness Ayres; Editor: Lisa M. Given  The semi-structured interview is a qualitative data collection strategy in which the researcher asks informants a series of predetermined but open-ended questions. The researcher has more control over the topics of the interview than in unstructured interviews, but in contrast to structured interviews or questionnaires that use closed questions, there is no fixed range of responses to each question.

Unstructured:

• Unstructured Interview. Entry in The SAGE Encyclopedia of Qualitative Research Methodsby Michael W. Firmin; Editor: Lisa M. Given  Unstructured interviews in qualitative research involve asking relatively open-ended questions of research participants in order to discover their percepts on the topic of interest. Interviews, in general, are a foundational means of collecting data when using qualitative research methods. They are designed to draw from the interviewee constructs embedded in his or her thinking and rationale for decision making. The researcher uses an inductive method in data gathering, regardless of whether the interview method is open, structured, or semi-structured. That is, the researcher does not wish to superimpose his or her own viewpoints onto the person being interviewed. Rather, inductively, the researcher wishes to understand the participant's perceptions, helping him or her to articulate percepts such that they will be understood clearly by the journal reader.

Genres and Uses

Focus groups:.

• "Focus Groups." Annual Review of Sociology 22 (1996): 129-1524.by David L. Morgan  Discusses the use of focus groups and group interviews as methods for gathering qualitative data used by sociologists and other academic and applied researchers. Focus groups are recommended for giving voice to marginalized groups and revealing the group effect on opinion formation.  
• Qualitative Research Methods: A Data Collector's Field Guide (See Module 4: "Focus Groups")by Mack, N., et al.  This field guide is based on an approach to doing team-based, collaborative qualitative research that has repeatedly proven successful in research projects sponsored by Family Health International (FHI) throughout the developing world. With its straightforward delivery of information on the main qualitative methods being used in public health research today, the guide speaks to the need for simple yet effective instruction on how to do systematic and ethically sound qualitative research. The aim of the guide is thus practical. In bypassing extensive discussion on the theoretical underpinnings of qualitative research, it distinguishes itself as a how-to guide to be used in the field.

In-Depth (typically One-on-One):

• A Practical Introduction to in-Depth Interviewingby Alan Morris  Are you new to qualitative research or a bit rusty and in need of some inspiration? Are you doing a research project involving in-depth interviews? Are you nervous about carrying out your interviews? This book will help you complete your qualitative research project by providing a nuts and bolts introduction to interviewing. With coverage of ethics, preparation strategies and advice for handling the unexpected in the field, this handy guide will help you get to grips with the basics of interviewing before embarking on your research. While recognising that your research question and the context of your research will drive your approach to interviewing, this book provides practical advice often skipped in traditional methods textbooks.  
• Qualitative Research Methods: A Data Collector's Field Guide (See Module 3: "In-Depth Interviews")by Mack, N., et al.  This field guide is based on an approach to doing team-based, collaborative qualitative research that has repeatedly proven successful in research projects sponsored by Family Health International (FHI) throughout the developing world. With its straightforward delivery of information on the main qualitative methods being used in public health research today, the guide speaks to the need for simple yet effective instruction on how to do systematic and ethically sound qualitative research. The aim of the guide is thus practical. In bypassing extensive discussion on the theoretical underpinnings of qualitative research, it distinguishes itself as a how-to guide to be used in the field.

Folklore Research and Oral Histories:

In addition to the following resource, see the  Oral History   page of this guide for helpful resources on Oral History interviewing.

American Folklife Center at the Library of Congress. Folklife and Fieldwork: A Layman’s Introduction to Field Techniques Interviews gathered for purposes of folklore research are similar to standard social science interviews in some ways, but also have a good deal in common with oral history approaches to interviewing. The focus in a folklore research interview is on documenting and trying to understand the interviewee's way of life relative to a culture or subculture you are studying. This guide includes helpful advice and tips for conducting fieldwork in folklore, such as tips for planning, conducting, recording, and archiving interviews.

An interdisciplinary scientific program within the Institute for Quantitative Social Science which encourages and facilitates research and instruction in the theory and practice of survey research. The primary mission of PSR is to provide survey research resources to enhance the quality of teaching and research at Harvard.

• Internet, Phone, Mail, and Mixed-Mode Surveysby Don A. Dillman; Jolene D. Smyth; Leah Melani Christian  The classic survey design reference, updated for the digital age. The new edition is thoroughly updated and revised, and covers all aspects of survey research. It features expanded coverage of mobile phones, tablets, and the use of do-it-yourself surveys, and Dillman's unique Tailored Design Method is also thoroughly explained. This new edition is complemented by copious examples within the text and accompanying website. It includes: Strategies and tactics for determining the needs of a given survey, how to design it, and how to effectively administer it. How and when to use mail, telephone, and Internet surveys to maximum advantage. Proven techniques to increase response rates. Guidance on how to obtain high-quality feedback from mail, electronic, and other self-administered surveys. Direction on how to construct effective questionnaires, including considerations of layout. The effects of sponsorship on the response rates of surveys. Use of capabilities provided by newly mass-used media: interactivity, presentation of aural and visual stimuli. The Fourth Edition reintroduces the telephone--including coordinating land and mobile.

User Experience (UX) and Marketing:

• See the  "UX & Market Research Interviews"  tab on this guide, above. May include  Focus Groups,  above.

Screening for Research Site Selection:

• Research interviews are used not only to furnish research data for theoretical analysis in the social sciences, but also to plan other kinds of studies. For example, interviews may allow researchers to screen appropriate research sites to conduct empirical studies (such as randomized controlled trials) in a variety of fields, from medicine to law. In contrast to interviews conducted in the course of social research, such interviews do not typically serve as the data for final analysis and publication.

ENGAGING PARTICIPANTS

Research ethics  .

• Human Subjects (IRB) The Committee on the Use of Human Subjects (CUHS) serves as the Institutional Review Board for the University area which includes the Cambridge and Allston campuses at Harvard. Find your IRB  contact person , or learn about  required ethics training.  You may also find the  IRB Lifecycle Guide  helpful. This is the preferred IRB portal for Harvard graduate students and other researchers. IRB forms can be downloaded via the  ESTR Library  (click on the "Templates and Forms" tab, then navigate to pages 2 and 3 to find the documents labelled with “HUA” for the Harvard University Area IRB. Nota bene: You may use these forms only if you submit your study to the Harvard University IRB). The IRB office can be reached through email at [email protected] or by telephone at (617) 496-2847.  
• Undergraduate Research Training Program (URTP) Portal The URTP at Harvard University is a comprehensive platform to create better prepared undergraduate researchers. The URTP is comprised of research ethics training sessions, a student-focused curriculum, and an online decision form that will assist students in determining whether their project requires IRB review. Students should examine the  URTP's guide for student researchers: Introduction to Human Subjects Research Protection.  
• Ethics reports From the Association of Internet Researchers (AoIR)  
• Respect, Beneficence, and Justice: QDR General Guidance for Human Participants If you are hoping to share your qualitative interview data in a repository after it has been collected, you will need to plan accordingly via informed consent, careful de-identification procedures, and data access controls. Consider  consulting with the Qualitative Research Support Group at Harvard Library  and consulting with  Harvard's Dataverse contacts  to help you think through all of the contingencies and processes.  
• "Conducting a Qualitative Child Interview: Methodological Considerations." Journal of Advanced Nursing 42/5 (2003): 434-441 by Kortesluoma, R., et al.  The purpose of this article is to illustrate the theoretical premises of child interviewing, as well as to describe some practical methodological solutions used during interviews. Factors that influence data gathered from children and strategies for taking these factors into consideration during the interview are also described.  
• "Crossing Cultural Barriers in Research Interviewing." Qualitative Social Work 63/3 (2007): 353-372 by Sands, R., et al.  This article critically examines a qualitative research interview in which cultural barriers between a white non-Muslim female interviewer and an African American Muslim interviewee, both from the USA, became evident and were overcome within the same interview.  
• Decolonizing Methodologies: Research and Indigenous Peoples by Linda Tuhiwai Smith  This essential volume explores intersections of imperialism and research - specifically, the ways in which imperialism is embedded in disciplines of knowledge and tradition as 'regimes of truth.' Concepts such as 'discovery' and 'claiming' are discussed and an argument presented that the decolonization of research methods will help to reclaim control over indigenous ways of knowing and being. The text includes case-studies and examples, and sections on new indigenous literature and the role of research in indigenous struggles for social justice.  

This resource, sponsored by University of Oregon Libraries, exemplifies the use of interviewing methodologies in research that foregrounds traditional knowledge. The methodology page summarizes the approach.

• Ethics: The Need to Tread Carefully. Chapter in A Practical Introduction to in-Depth Interviewing by Alan Morris  Pay special attention to the sections in chapter 2 on "How to prevent and respond to ethical issues arising in the course of the interview," "Ethics in the writing up of your interviews," and "The Ethics of Care."  
• Handbook on Ethical Issues in Anthropology by Joan Cassell (Editor); Sue-Ellen Jacobs (Editor)  This publication of the American Anthropological Association presents and discusses issues and sources on ethics in anthropology, as well as realistic case studies of ethical dilemmas. It is meant to help social science faculty introduce discussions of ethics in their courses. Some of the topics are relevant to interviews, or at least to studies of which interviews are a part. See chapters 3 and 4 for cases, with solutions and commentary, respectively.  
• Research Ethics from the Chanie Wenjack School for Indigenous Studies, Trent University  (Open Access) An overview of Indigenous research ethics and protocols from the across the globe.  
• Resources for Equity in Research Consult these resources for guidance on creating and incorporating equitable materials into public health research studies that entail community engagement.

The SAGE Handbook of Qualitative Research Ethics by Ron Iphofen (Editor); Martin Tolich (Editor)  This handbook is a much-needed and in-depth review of the distinctive set of ethical considerations which accompanies qualitative research. This is particularly crucial given the emergent, dynamic and interactional nature of most qualitative research, which too often allows little time for reflection on the important ethical responsibilities and obligations. Contributions from leading international researchers have been carefully organized into six key thematic sections: Part One: Thick Descriptions Of Qualitative Research Ethics; Part Two: Qualitative Research Ethics By Technique; Part Three: Ethics As Politics; Part Four: Qualitative Research Ethics With Vulnerable Groups; Part Five: Relational Research Ethics; Part Six: Researching Digitally. This Handbook is a one-stop resource on qualitative research ethics across the social sciences that draws on the lessons learned and the successful methods for surmounting problems - the tried and true, and the new.

RESEARCH COMPLIANCE AND PRIVACY LAWS

Research Compliance Program for FAS/SEAS at Harvard : The Faculty of Arts and Sciences (FAS), including the School of Engineering and Applied Sciences (SEAS), and the Office of the Vice Provost for Research (OVPR) have established a shared Research Compliance Program (RCP). An area of common concern for interview studies is international projects and collaboration . RCP is a resource to provide guidance on which international activities may be impacted by US sanctions on countries, individuals, or entities and whether licenses or other disclosure are required to ship or otherwise share items, technology, or data with foreign collaborators.

• Harvard Global Support Services (GSS) is for students, faculty, staff, and researchers who are studying, researching, or working abroad. Their services span safety and security, health, culture, outbound immigration, employment, financial and legal matters, and research center operations. These include travel briefings and registration, emergency response, guidance on international projects, and managing in-country operations.

Generative AI: Harvard-affiliated researchers should not enter data classified as confidential ( Level 2 and above ), including non-public research data, into publicly-available generative AI tools, in accordance with the University’s Information Security Policy. Information shared with generative AI tools using default settings is not private and could expose proprietary or sensitive information to unauthorized parties.

Privacy Laws: Be mindful of any potential privacy laws that may apply wherever you conduct your interviews. The General Data Protection Regulation is a high-profile example (see below):

• General Data Protection Regulation (GDPR) This Regulation lays down rules relating to the protection of natural persons with regard to the processing of personal data and rules relating to the free movement of personal data. It protects fundamental rights and freedoms of natural persons and in particular their right to the protection of personal data. The free movement of personal data within the Union shall be neither restricted nor prohibited for reasons connected with the protection of natural persons with regard to the processing of personal data. For a nice summary of what the GDPR requires, check out the GDPR "crash course" here .

SEEKING CONSENT  

If you would like to see examples of consent forms, ask your local IRB, or take a look at these resources:

• Model consent forms for oral history, suggested by the Centre for Oral History and Digital Storytelling at Concordia University  
• For NIH-funded research, see this  resource for developing informed consent language in research studies where data and/or biospecimens will be stored and shared for future use.

POPULATION SAMPLING

If you wish to assemble resources to aid in sampling, such as the USPS Delivery Sequence File, telephone books, or directories of organizations and listservs, please contact our  data librarian  or write to  [email protected] .

• Research Randomizer   A free web-based service that permits instant random sampling and random assignment. It also contains an interactive tutorial perfect for students taking courses in research methods.  
• Practical Tools for Designing and Weighting Survey Samples by Richard Valliant; Jill A. Dever; Frauke Kreuter  Survey sampling is fundamentally an applied field. The goal in this book is to put an array of tools at the fingertips of practitioners by explaining approaches long used by survey statisticians, illustrating how existing software can be used to solve survey problems, and developing some specialized software where needed. This book serves at least three audiences: (1) Students seeking a more in-depth understanding of applied sampling either through a second semester-long course or by way of a supplementary reference; (2) Survey statisticians searching for practical guidance on how to apply concepts learned in theoretical or applied sampling courses; and (3) Social scientists and other survey practitioners who desire insight into the statistical thinking and steps taken to design, select, and weight random survey samples. Several survey data sets are used to illustrate how to design samples, to make estimates from complex surveys for use in optimizing the sample allocation, and to calculate weights. Realistic survey projects are used to demonstrate the challenges and provide a context for the solutions. The book covers several topics that either are not included or are dealt with in a limited way in other texts. These areas include: sample size computations for multistage designs; power calculations related to surveys; mathematical programming for sample allocation in a multi-criteria optimization setting; nuts and bolts of area probability sampling; multiphase designs; quality control of survey operations; and statistical software for survey sampling and estimation. An associated R package, PracTools, contains a number of specialized functions for sample size and other calculations. The data sets used in the book are also available in PracTools, so that the reader may replicate the examples or perform further analyses.  
• Sampling: Design and Analysis by Sharon L. Lohr  Provides a modern introduction to the field of sampling. With a multitude of applications from a variety of disciplines, the book concentrates on the statistical aspects of taking and analyzing a sample. Overall, the book gives guidance on how to tell when a sample is valid or not, and how to design and analyze many different forms of sample surveys.  
• Sampling Techniques by William G. Cochran  Clearly demonstrates a wide range of sampling methods now in use by governments, in business, market and operations research, social science, medicine, public health, agriculture, and accounting. Gives proofs of all the theoretical results used in modern sampling practice. New topics in this edition include the approximate methods developed for the problem of attaching standard errors or confidence limits to nonlinear estimates made from the results of surveys with complex plans.  
• "Understanding the Process of Qualitative Data Collection" in Chapter 13 (pp. 103–1162) of 30 Essential Skills for the Qualitative Researcher by John W. Creswell  Provides practical "how-to" information for beginning researchers in the social, behavioral, and health sciences with many applied examples from research design, qualitative inquiry, and mixed methods.The skills presented in this book are crucial for a new qualitative researcher starting a qualitative project.  
• Survey Methodology by Robert M. Groves; Floyd J. Fowler; Mick P. Couper; James M. Lepkowski; Eleanor Singer; Roger Tourangeau; Floyd J. Fowler  coverage includes sampling frame evaluation, sample design, development of questionnaires, evaluation of questions, alternative modes of data collection, interviewing, nonresponse, post-collection processing of survey data, and practices for maintaining scientific integrity.

The way a qualitative researcher constructs and approaches interview questions should flow from, or align with, the methodological paradigm chosen for the study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

Constructing Your Questions

Helpful texts:.

• "Developing Questions" in Chapter 4 (pp. 98–108) of Becoming Qualitative Researchers by Corrine Glesne  Ideal for introducing the novice researcher to the theory and practice of qualitative research, this text opens students to the diverse possibilities within this inquiry approach, while helping them understand how to design and implement specific research methods.  
• "Learning to Interview in the Social Sciences" Qualitative Inquiry, 9(4) 2003, 643–668 by Roulston, K., deMarrais, K., & Lewis, J. B. See especially the section on "Phrasing and Negotiating Questions" on pages 653-655 and common problems with framing questions noted on pages 659 - 660.  
• Qualitative Research Interviewing: Biographic Narrative and Semi-Structured Methods (See sections on “Lightly and Heavily Structured Depth Interviewing: Theory-Questions and Interviewer-Questions” and “Preparing for any Interviewing Sequence") by Tom Wengraf  Unique in its conceptual coherence and the level of practical detail, this book provides a comprehensive resource for those concerned with the practice of semi-structured interviewing, the most commonly used interview approach in social research, and in particular for in-depth, biographic narrative interviewing. It covers the full range of practices from the identification of topics through to strategies for writing up research findings in diverse ways.  
• "Scripting a Qualitative Purpose Statement and Research Questions" in Chapter 12 (pp. 93–102) of 30 Essential Skills for the Qualitative Researcher by John W. Creswell  Provides practical "how-to" information for beginning researchers in the social, behavioral, and health sciences with many applied examples from research design, qualitative inquiry, and mixed methods.The skills presented in this book are crucial for a new qualitative researcher starting a qualitative project.  
• Some Strategies for Developing Interview Guides for Qualitative Interviews by Sociology Department, Harvard University Includes general advice for conducting qualitative interviews, pros and cons of recording and transcription, guidelines for success, and tips for developing and phrasing effective interview questions.  
• Tip Sheet on Question Wording by Harvard University Program on Survey Research

Let Theory Guide You:

The quality of your questions depends on how you situate them within a wider body of knowledge. Consider the following advice:

A good literature review has many obvious virtues. It enables the investigator to define problems and assess data. It provides the concepts on which percepts depend. But the literature review has a special importance for the qualitative researcher. This consists of its ability to sharpen his or her capacity for surprise (Lazarsfeld, 1972b). The investigator who is well versed in the literature now has a set of expectations the data can defy. Counterexpectational data are conspicuous, readable, and highly provocative data. They signal the existence of unfulfilled theoretical assumptions, and these are, as Kuhn (1962) has noted, the very origins of intellectual innovation. A thorough review of the literature is, to this extent, a way to manufacture distance. It is a way to let the data of one's research project take issue with the theory of one's field.

McCracken, G. (1988), The Long Interview, Sage: Newbury Park, CA, p. 31

When drafting your interview questions, remember that everything follows from your central research question. Also, on the way to writing your "operationalized" interview questions, it's  helpful to draft broader, intermediate questions, couched in theory. Nota bene:  While it is important to know the literature well before conducting your interview(s), be careful not to present yourself to your research participant(s) as "the expert," which would be presumptuous and could be intimidating. Rather, the purpose of your knowledge is to make you a better, keener listener.

If you'd like to supplement what you learned about relevant theories through your coursework and literature review, try these sources:

• Annual Reviews   Review articles sum up the latest research in many fields, including social sciences, biomedicine, life sciences, and physical sciences. These are timely collections of critical reviews written by leading scientists.  
• HOLLIS - search for resources on theories in your field   Modify this example search by entering the name of your field in place of "your discipline," then hit search.  
• Oxford Bibliographies   Written and reviewed by academic experts, every article in this database is an authoritative guide to the current scholarship in a variety of fields, containing original commentary and annotations.  
• ProQuest Dissertations & Theses (PQDT)   Indexes dissertations and masters' theses from most North American graduate schools as well as some European universities. Provides full text for most indexed dissertations from 1990-present.  
• Very Short Introductions   Launched by Oxford University Press in 1995, Very Short Introductions offer concise introductions to a diverse range of subjects from Climate to Consciousness, Game Theory to Ancient Warfare, Privacy to Islamic History, Economics to Literary Theory.

CONDUCTING INTERVIEWS

Equipment and software:  .

• Lamont Library  loans microphones and podcast starter kits, which will allow you to capture audio (and you may record with software, such as Garage Band). 
• Cabot Library  loans digital recording devices, as well as USB microphones.

If you prefer to use your own device, you may purchase a small handheld audio recorder, or use your cell phone.

• Audio Capture Basics (PDF)  - Helpful instructions, courtesy of the Lamont Library Multimedia Lab.
• Getting Started with Podcasting/Audio:  Guidelines from Harvard Library's Virtual Media Lab for preparing your interviewee for a web-based recording (e.g., podcast, interview)
• ​ Camtasia Screen Recorder and Video Editor
• Zoom: Video Conferencing, Web Conferencing
• Visit the Multimedia Production Resources guide! Consult it to find and learn how to use audiovisual production tools, including: cameras, microphones, studio spaces, and other equipment at Cabot Science Library and Lamont Library.
• Try the virtual office hours offered by the Lamont Multimedia Lab!

TIPS FOR CONDUCTING INTERVIEWS

Quick handout:  .

• Research Interviewing Tips (Courtesy of Dr. Suzanne Spreadbury)

Remote Interviews:  

• For Online or Distant Interviews, See "Remote Research & Virtual Fieldwork" on this guide .  
• Deborah Lupton's Bibliography: Doing Fieldwork in a Pandemic

Seeking Consent:

Books and articles:  .

• "App-Based Textual Interviews: Interacting With Younger Generations in a Digitalized Social Reallity."International Journal of Social Research Methodology (12 June 2022). Discusses the use of texting platforms as a means to reach young people. Recommends useful question formulations for this medium.  
• "Learning to Interview in the Social Sciences." Qualitative Inquiry, 9(4) 2003, 643–668 by Roulston, K., deMarrais, K., & Lewis, J. B. See especially the section on "Phrasing and Negotiating Questions" on pages 653-655 and common problems with framing questions noted on pages 659-660.  
• "Slowing Down and Digging Deep: Teaching Students to Examine Interview Interaction in Depth." LEARNing Landscapes, Spring 2021 14(1) 153-169 by Herron, Brigette A. and Kathryn Roulston. Suggests analysis of videorecorded interviews as a precursor to formulating one's own questions. Includes helpful types of probes.  
• Using Interviews in a Research Project by Nigel Joseph Mathers; Nicholas J Fox; Amanda Hunn; Trent Focus Group.  A work pack to guide researchers in developing interviews in the healthcare field. Describes interview structures, compares face-to-face and telephone interviews. Outlines the ways in which different types of interview data can be analysed.  
• “Working through Challenges in Doing Interview Research.” International Journal of Qualitative Methods, (December 2011), 348–66 by Roulston, Kathryn.  The article explores (1) how problematic interactions identified in the analysis of focus group data can lead to modifications in research design, (2) an approach to dealing with reported data in representations of findings, and (3) how data analysis can inform question formulation in successive rounds of data generation. Findings from these types of examinations of interview data generation and analysis are valuable for informing both interview practice as well as research design.

Videos:  

The way a qualitative researcher transcribes interviews should flow from, or align with, the methodological paradigm chosen for the study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these).

TRANSCRIPTION

Before embarking on a transcription project, it's worthwhile to invest in the time and effort necessary to capture good audio, which will make the transcription process much easier. If you haven't already done so, check out the  audio capture guidelines from Harvard Library's Virtual Media Lab , or  contact a media staff member  for customized recommendations. First and foremost, be mindful of common pitfalls by watching this short video that identifies  the most common errors to avoid!

SOFTWARE:  

• Adobe Premiere Pro Speech-To-Text  automatically generates transcripts and adds captions to your videos. Harvard affiliates can download Adobe Premiere in the Creative Cloud Suite.  
• GoTranscript  provides cost-effective human-generated transcriptions.  
• pyTranscriber  is an app for generating automatic transcription and/or subtitles for audio and video files. It uses the Google Cloud Speech-to-Text service, has a friendly graphical user interface, and is purported to work nicely with Chinese.   
• Otter  provides a new way to capture, store, search and share voice conversations, lectures, presentations, meetings, and interviews. The startup is based in Silicon Valley with a team of experienced Ph.Ds and engineers from Google, Facebook, Yahoo and Nuance (à la Dragon). Free accounts available. This is the software that  Zoom  uses to generate automated transcripts, so if you have access to a Zoom subscription, you have access to Otter transcriptions with it (applicable in several  languages ). As with any automated approach, be prepared to correct any errors after the fact, by hand.  
• Panopto  is available to Harvard affiliates and generates  ASR (automated speech recognition) captions . You may upload compatible audio files into it. As with any automatically generated transcription, you will need to make manual revisions. ASR captioning is available in several  languages . Panopto maintains robust security practices, including strong authentication measures and end-to-end encryption, ensuring your content remains private and protected.  
• REV.Com  allows you to record and transcribe any calls on the iPhone, both outgoing and incoming. It may be useful for recording phone interviews. Rev lets you choose whether you want an AI- or human-generated transcription, with a fast turnaround. Rev has Service Organization Controls Type II (SOC2) certification (a SOC2 cert looks at and verifies an organization’s processing integrity, privacy practices, and security safeguards).   
• Scribie Audio/Video Transcription  provides automated or manual transcriptions for a small fee. As with any transcription service, some revisions will be necessary after the fact, particularly for its automated transcripts.  
• Sonix  automatically transcribes, translates, and helps to organize audio and video files in over 40 languages. It's fast and affordable, with good accuracy. The free trial includes 30 minutes of free transcription.  
• TranscriptionWing  uses a human touch process to clean up machine-generated transcripts so that the content will far more accurately reflect your audio recording.   
• Whisper is a tool from OpenAI that facilitates transcription of sensitive audiovisual recordings (e.g., of research interviews) on your own device. Installation and use depends on your operating system and which version you install. Important Note: The Whisper API, where audio is sent to OpenAI to be processed by them and then sent back (usually through a programming language like Python) is NOT appropriate for sensitive data. The model should be downloaded with tools such as those described in this FAQ , so that audio is kept to your local machine. For assistance, contact James Capobianco .

EQUIPMENT:  

• Transcription pedals  are in circulation and available to borrow from the Circulation desk at Lamont, or use at Lamont Library's Media Lab on level B. For hand-transcribing your interviews, they work in conjunction with software such as  Express Scribe , which is loaded on Media Lab computers, or you may download for free on your own machine (Mac or PC versions; scroll down the downloads page for the latter). The pedals are plug-and-play USB, allow a wide range of playback speeds, and have 3 programmable buttons, which are typically set to rewind/play/fast-forward. Instructions are included in the bag that covers installation and set-up of the software, and basic use of the pedals.

NEED HELP?  

• Try the virtual office hours offered by the Lamont Multimedia Lab!    
• If you're creating podcasts, login to  Canvas  and check out the  Podcasting/Audio guide . 

Helpful Texts:  

• "Transcription as a Crucial Step of Data Analysis" in Chapter 5 of The SAGE Handbook of Qualitative Data Analysisby Uwe Flick (Editor)  Covers basic terminology for transcription, shares caveats for transcribers, and identifies components of vocal behavior. Provides notation systems for transcription, suggestions for transcribing turn-taking, and discusses new technologies and perspectives. Includes a bibliography for further reading.  
• "Transcribing the Oral Interview: Part Art, Part Science " on p. 10 of the Centre for Community Knowledge (CCK) newsletter: TIMESTAMPby Mishika Chauhan and Saransh Srivastav

QUALITATIVE DATA ANALYSIS

Software  .

• Free download available for Harvard Faculty of Arts and Sciences (FAS) affiliates
• Desktop access at Lamont Library Media Lab, 3rd floor
• Desktop access at Harvard Kennedy School Library (with HKS ID)
• Remote desktop access for Harvard affiliates from  IQSS Computer Labs . Email them at  [email protected] and ask for a new lab account and remote desktop access to NVivo.
• Virtual Desktop Infrastructure (VDI) access available to Harvard T.H. Chan School of Public Health affiliates

CODING AND THEMEING YOUR DATA

Data analysis methods should flow from, or align with, the methodological paradigm chosen for your study, whether that paradigm is interpretivist, critical, positivist, or participative in nature (or a combination of these). Some established methods include Content Analysis, Critical Analysis, Discourse Analysis, Gestalt Analysis, Grounded Theory Analysis, Interpretive Analysis, Narrative Analysis, Normative Analysis, Phenomenological Analysis, Rhetorical Analysis, and Semiotic Analysis, among others. The following resources should help you navigate your methodological options and put into practice methods for coding, themeing, interpreting, and presenting your data.

• Users can browse content by topic, discipline, or format type (reference works, book chapters, definitions, etc.). SRM offers several research tools as well: a methods map, user-created reading lists, a project planner, and advice on choosing statistical tests.  
• Abductive Coding: Theory Building and Qualitative (Re)Analysis by Vila-Henninger, et al.  The authors recommend an abductive approach to guide qualitative researchers who are oriented towards theory-building. They outline a set of tactics for abductive analysis, including the generation of an abductive codebook, abductive data reduction through code equations, and in-depth abductive qualitative analysis.  
• Analyzing and Interpreting Qualitative Research: After the Interview by Charles F. Vanover, Paul A. Mihas, and Johnny Saldana (Editors)   Providing insight into the wide range of approaches available to the qualitative researcher and covering all steps in the research process, the authors utilize a consistent chapter structure that provides novice and seasoned researchers with pragmatic, "how-to" strategies. Each chapter author introduces the method, uses one of their own research projects as a case study of the method described, shows how the specific analytic method can be used in other types of studies, and concludes with three questions/activities to prompt class discussion or personal study.   
• "Analyzing Qualitative Data." Theory Into Practice 39, no. 3 (2000): 146-54 by Margaret D. LeCompte   This article walks readers though rules for unbiased data analysis and provides guidance for getting organized, finding items, creating stable sets of items, creating patterns, assembling structures, and conducting data validity checks.  
• "Coding is Not a Dirty Word" in Chapter 1 (pp. 1–30) of Enhancing Qualitative and Mixed Methods Research with Technology by Shalin Hai-Jew (Editor)   Current discourses in qualitative research, especially those situated in postmodernism, represent coding and the technology that assists with coding as reductive, lacking complexity, and detached from theory. In this chapter, the author presents a counter-narrative to this dominant discourse in qualitative research. The author argues that coding is not necessarily devoid of theory, nor does the use of software for data management and analysis automatically render scholarship theoretically lightweight or barren. A lack of deep analytical insight is a consequence not of software but of epistemology. Using examples informed by interpretive and critical approaches, the author demonstrates how NVivo can provide an effective tool for data management and analysis. The author also highlights ideas for critical and deconstructive approaches in qualitative inquiry while using NVivo. By troubling the positivist discourse of coding, the author seeks to create dialogic spaces that integrate theory with technology-driven data management and analysis, while maintaining the depth and rigor of qualitative research.   
• The Coding Manual for Qualitative Researchers by Johnny Saldana   An in-depth guide to the multiple approaches available for coding qualitative data. Clear, practical and authoritative, the book profiles 32 coding methods that can be applied to a range of research genres from grounded theory to phenomenology to narrative inquiry. For each approach, Saldaña discusses the methods, origins, a description of the method, practical applications, and a clearly illustrated example with analytic follow-up. Essential reading across the social sciences.  
• Flexible Coding of In-depth Interviews: A Twenty-first-century Approach by Nicole M. Deterding and Mary C. Waters The authors suggest steps in data organization and analysis to better utilize qualitative data analysis technologies and support rigorous, transparent, and flexible analysis of in-depth interview data.  
• From the Editors: What Grounded Theory is Not by Roy Suddaby Walks readers through common misconceptions that hinder grounded theory studies, reinforcing the two key concepts of the grounded theory approach: (1) constant comparison of data gathered throughout the data collection process and (2) the determination of which kinds of data to sample in succession based on emergent themes (i.e., "theoretical sampling").  
• “Good enough” methods for life-story analysis, by Wendy Luttrell. In Quinn N. (Ed.), Finding culture in talk (pp. 243–268). Demonstrates for researchers of culture and consciousness who use narrative how to concretely document reflexive processes in terms of where, how and why particular decisions are made at particular stages of the research process.   
• The Ethnographic Interview by James P. Spradley  “Spradley wrote this book for the professional and student who have never done ethnographic fieldwork (p. 231) and for the professional ethnographer who is interested in adapting the author’s procedures (p. iv) ... Steps 6 and 8 explain lucidly how to construct a domain and a taxonomic analysis” (excerpted from book review by James D. Sexton, 1980). See also:  Presentation slides on coding and themeing your data, derived from Saldana, Spradley, and LeCompte Click to request access.  
• Qualitative Data Analysis by Matthew B. Miles; A. Michael Huberman   A practical sourcebook for researchers who make use of qualitative data, presenting the current state of the craft in the design, testing, and use of qualitative analysis methods. Strong emphasis is placed on data displays matrices and networks that go beyond ordinary narrative text. Each method of data display and analysis is described and illustrated.  
• "A Survey of Qualitative Data Analytic Methods" in Chapter 4 (pp. 89–138) of Fundamentals of Qualitative Research by Johnny Saldana   Provides an in-depth introduction to coding as a heuristic, particularly focusing on process coding, in vivo coding, descriptive coding, values coding, dramaturgical coding, and versus coding. Includes advice on writing analytic memos, developing categories, and themeing data.   
• "Thematic Networks: An Analytic Tool for Qualitative Research." Qualitative Research : QR, 1(3), 385–405 by Jennifer Attride-Stirling Details a technique for conducting thematic analysis of qualitative material, presenting a step-by-step guide of the analytic process, with the aid of an empirical example. The analytic method presented employs established, well-known techniques; the article proposes that thematic analyses can be usefully aided by and presented as thematic networks.  
• Using Thematic Analysis in Psychology by Virginia Braun and Victoria Clark Walks readers through the process of reflexive thematic analysis, step by step. The method may be adapted in fields outside of psychology as relevant. Pair this with One Size Fits All? What Counts as Quality Practice in Reflexive Thematic Analysis? by Virginia Braun and Victoria Clark

TESTING OR GENERATING THEORIES

The quality of your data analysis depends on how you situate what you learn within a wider body of knowledge. Consider the following advice:

Once you have coalesced around a theory, realize that a theory should  reveal  rather than  color  your discoveries. Allow your data to guide you to what's most suitable. Grounded theory  researchers may develop their own theory where current theories fail to provide insight.  This guide on Theoretical Models  from Alfaisal University Library provides a helpful overview on using theory.

MANAGING & FINDING INTERVIEW DATA

Managing your elicited interview data, general guidance:  .

• Research Data Management @ Harvard A reference guide with information and resources to help you manage your research data. See also: Harvard Research Data Security Policy , on the Harvard University Research Data Management website.  
• Data Management For Researchers: Organize, Maintain and Share Your Data for Research Success by Kristin Briney. A comprehensive guide for scientific researchers providing everything they need to know about data management and how to organize, document, use and reuse their data.  
• Open Science Framework (OSF) An open-source project management tool that makes it easy to collaborate within and beyond Harvard throughout a project's lifecycle. With OSF you can manage, store, and share documents, datasets, and other information with your research team. You can also publish your work to share it with a wider audience. Although data can be stored privately, because this platform is hosted on the Internet and designed with open access in mind, it is not a good choice for highly sensitive data.  
• Free cloud storage solutions for Harvard affiliates to consider include:  Google Drive ,  DropBox , or  OneDrive ( up to DSL3 )  

Data Confidentiality and Secure Handling:  

• Data Security Levels at Harvard - Research Data Examples This resource provided by Harvard Data Security helps you determine what level of access is appropriate for your data. Determine whether it should be made available for public use, limited to the Harvard community, or be protected as either "confidential and sensitive," "high risk," or "extremely sensitive." See also:  Harvard Data Classification Table  
• Harvard's Best Practices for Protecting Privacy and  Harvard Information Security Collaboration Tools Matrix Follow the nuts-and-bolts advice for privacy best practices at Harvard. The latter resource reveals the level of security that can be relied upon for a large number of technological tools and platforms used at Harvard to conduct business, such as email, Slack, Accellion Kiteworks, OneDrive/SharePoint, etc.  
• “Protecting Participant Privacy While Maintaining Content and Context: Challenges in Qualitative Data De‐identification and Sharing.” Proceedings of the ASIST Annual Meeting 57 (1) (2020): e415-420 by Myers, Long, and Polasek Presents an informed and tested protocol, based on the De-Identification guidelines published by the Qualitative Data Repository (QDR) at Syracuse University. Qualitative researchers may consult it to guide their data de-identification efforts.  
• QDS Qualitative Data Sharing Toolkit The Qualitative Data Sharing (QDS) project and its toolkit was funded by the NIH National Human Genome Research Institute (R01HG009351). It provides tools and resources to help researchers, especially those in the health sciences, share qualitative research data while protecting privacy and confidentiality. It offers guidance on preparing data for sharing through de-identification and access control. These health sciences research datasets in ICPSR's Qualitative Data Sharing (QDS) Project Series were de-identified using the QuaDS Software and the project’s QDS guidelines.  
• Table of De-Identification Techniques  
• Generative AI Harvard-affiliated researchers should not enter data classified as confidential ( Level 2 and above ), including non-public research data, into publicly-available generative AI tools, in accordance with the University’s Information Security Policy. Information shared with generative AI tools using default settings is not private and could expose proprietary or sensitive information to unauthorized parties.  
• Harvard Information Security Quick Reference Guide Storage guidelines, based on the data's security classification level (according to its IRB classification) is displayed on page 2, under "handling."  
• Email Encryption Harvard Microsoft 365 users can now send encrypted messages and files directly from the Outlook web or desktop apps. Encrypting an email adds an extra layer of security to the message and its attachments (up to 150MB), and means only the intended recipient (and their inbox delegates with full access) can view it. Message encryption in Outlook is approved for sending high risk ( level 4 ) data and below.  

Sharing Qualitative Data:  

• Repositories for Qualitative Data If you have cleared this intention with your IRB, secured consent from participants, and properly de-identified your data, consider sharing your interviews in one of the data repositories included in the link above. Depending on the nature of your research and the level of risk it may present to participants, sharing your interview data may not be appropriate. If there is any chance that sharing such data will be desirable, you will be much better off if you build this expectation into your plans from the beginning.  
• Guide for Sharing Qualitative Data at ICPSR The Inter-university Consortium for Political and Social Research (ICPSR) has created this resource for investigators planning to share qualitative data at ICPSR. This guide provides an overview of elements and considerations for archiving qualitative data, identifies steps for investigators to follow during the research life cycle to ensure that others can share and reuse qualitative data, and provides information about exemplars of qualitative data  

International Projects:

• Research Compliance Program for FAS/SEAS at Harvard The Faculty of Arts and Sciences (FAS), including the School of Engineering and Applied Sciences (SEAS), and the Office of the Vice Provost for Research (OVPR) have established a shared Research Compliance Program (RCP). An area of common concern for interview studies is international projects and collaboration . RCP is a resource to provide guidance on which international activities may be impacted by US sanctions on countries, individuals, or entities and whether licenses or other disclosure are required to ship or otherwise share items, technology, or data with foreign collaborators.

Finding Extant Interview Data

Finding journalistic interviews:  .

• Academic Search Premier This all-purpose database is great for finding articles from magazines and newspapers. In the Advanced Search, it allows you to specify "Document Type":  Interview.  
• Guide to Newspapers and Newspaper Indexes Use this guide created to Harvard Librarians to identify newspapers collections you'd like to search. To locate interviews, try adding the term  "interview"  to your search, or explore a database's search interface for options to  limit your search to interviews.  Nexis Uni  and  Factiva  are the two main databases for current news.   
• Listen Notes Search for podcast episodes at this podcast aggregator, and look for podcasts that include interviews. Make sure to vet the podcaster for accuracy and quality! (Listen Notes does not do much vetting.)  
• NPR  and  ProPublica  are two sites that offer high-quality long-form reporting, including journalistic interviews, for free.

Finding Oral History and Social Research Interviews:  

• To find oral histories, see the Oral History   page of this guide for helpful resources on Oral History interviewing.  
• Repositories for Qualitative Data It has not been a customary practice among qualitative researchers in the social sciences to share raw interview data, but some have made this data available in repositories, such as the ones listed on the page linked above. You may find published data from structured interview surveys (e.g., questionnaire-based computer-assisted telephone interview data), as well as some semi-structured and unstructured interviews.  
• If you are merely interested in studies interpreting data collected using interviews, rather than finding raw interview data, try databases like  PsycInfo ,  Sociological Abstracts , or  Anthropology Plus , among others. 

Finding Interviews in Archival Collections at Harvard Library:

In addition to the databases and search strategies mentioned under the  "Finding Oral History and Social Research Interviews" category above,  you may search for interviews and oral histories (whether in textual or audiovisual formats) held in archival collections at Harvard Library.

• HOLLIS searches all documented collections at Harvard, whereas HOLLIS for Archival Discovery searches only those with finding aids. Although HOLLIS for Archival Discovery covers less material, you may find it easier to parse your search results, especially when you wish to view results at the item level (within collections). Try these approaches:

Search in  HOLLIS :  

• To retrieve items available online, do an Advanced Search for  interview* OR "oral histor*" (in Subject), with Resource Type "Archives/Manuscripts," then refine your search by selecting "Online" under "Show Only" on the right of your initial result list.  Revise the search above by adding your topic in the Keywords or Subject field (for example:  African Americans ) and resubmitting the search.  
•  To enlarge your results set, you may also leave out the "Online" refinement; if you'd like to limit your search to a specific repository, try the technique of searching for  Code: Library + Collection on the "Advanced Search" page .   

Search in  HOLLIS for Archival Discovery :  

• To retrieve items available online, search for   interview* OR "oral histor*" limited to digital materials . Revise the search above by adding your topic (for example:  artist* ) in the second search box (if you don't see the box, click +).  
• To preview results by collection, search for  interview* OR "oral histor*" limited to collections . Revise the search above by adding your topic (for example:  artist* ) in the second search box (if you don't see the box, click +). Although this method does not allow you to isolate digitized content, you may find the refinement options on the right side of the screen (refine by repository, subject or names) helpful.  Once your select a given collection, you may search within it  (e.g., for your topic or the term interview).

UX & MARKET RESEARCH INTERVIEWS

Ux at harvard library  .

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• Published: 22 March 2008

Methods of data collection in qualitative research: interviews and focus groups

• P. Gill 1 ,
• K. Stewart 2 ,
• E. Treasure 3 &
• B. Chadwick 4  

British Dental Journal volume  204 ,  pages 291–295 ( 2008 ) Cite this article

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Interviews and focus groups are the most common methods of data collection used in qualitative healthcare research

Interviews can be used to explore the views, experiences, beliefs and motivations of individual participants

Focus group use group dynamics to generate qualitative data

Qualitative research in dentistry

Conducting qualitative interviews with school children in dental research

Analysing and presenting qualitative data

This paper explores the most common methods of data collection used in qualitative research: interviews and focus groups. The paper examines each method in detail, focusing on how they work in practice, when their use is appropriate and what they can offer dentistry. Examples of empirical studies that have used interviews or focus groups are also provided.

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Interviews in the social sciences

A review of technical and quality assessment considerations of audio-visual and web-conferencing focus groups in qualitative health research

Professionalism in dentistry: deconstructing common terminology, introduction.

Having explored the nature and purpose of qualitative research in the previous paper, this paper explores methods of data collection used in qualitative research. There are a variety of methods of data collection in qualitative research, including observations, textual or visual analysis (eg from books or videos) and interviews (individual or group). 1 However, the most common methods used, particularly in healthcare research, are interviews and focus groups. 2 , 3

The purpose of this paper is to explore these two methods in more detail, in particular how they work in practice, the purpose of each, when their use is appropriate and what they can offer dental research.

Qualitative research interviews

There are three fundamental types of research interviews: structured, semi-structured and unstructured. Structured interviews are, essentially, verbally administered questionnaires, in which a list of predetermined questions are asked, with little or no variation and with no scope for follow-up questions to responses that warrant further elaboration. Consequently, they are relatively quick and easy to administer and may be of particular use if clarification of certain questions are required or if there are likely to be literacy or numeracy problems with the respondents. However, by their very nature, they only allow for limited participant responses and are, therefore, of little use if 'depth' is required.

Conversely, unstructured interviews do not reflect any preconceived theories or ideas and are performed with little or no organisation. 4 Such an interview may simply start with an opening question such as 'Can you tell me about your experience of visiting the dentist?' and will then progress based, primarily, upon the initial response. Unstructured interviews are usually very time-consuming (often lasting several hours) and can be difficult to manage, and to participate in, as the lack of predetermined interview questions provides little guidance on what to talk about (which many participants find confusing and unhelpful). Their use is, therefore, generally only considered where significant 'depth' is required, or where virtually nothing is known about the subject area (or a different perspective of a known subject area is required).

Semi-structured interviews consist of several key questions that help to define the areas to be explored, but also allows the interviewer or interviewee to diverge in order to pursue an idea or response in more detail. 2 This interview format is used most frequently in healthcare, as it provides participants with some guidance on what to talk about, which many find helpful. The flexibility of this approach, particularly compared to structured interviews, also allows for the discovery or elaboration of information that is important to participants but may not have previously been thought of as pertinent by the research team.

For example, in a recent dental public heath study, 5 school children in Cardiff, UK were interviewed about their food choices and preferences. A key finding that emerged from semi-structured interviews, which was not previously thought to be as highly influential as the data subsequently confirmed, was the significance of peer-pressure in influencing children's food choices and preferences. This finding was also established primarily through follow-up questioning (eg probing interesting responses with follow-up questions, such as 'Can you tell me a bit more about that?') and, therefore, may not have emerged in the same way, if at all, if asked as a predetermined question.

The purpose of research interviews

The purpose of the research interview is to explore the views, experiences, beliefs and/or motivations of individuals on specific matters (eg factors that influence their attendance at the dentist). Qualitative methods, such as interviews, are believed to provide a 'deeper' understanding of social phenomena than would be obtained from purely quantitative methods, such as questionnaires. 1 Interviews are, therefore, most appropriate where little is already known about the study phenomenon or where detailed insights are required from individual participants. They are also particularly appropriate for exploring sensitive topics, where participants may not want to talk about such issues in a group environment.

Examples of dental studies that have collected data using interviews are 'Examining the psychosocial process involved in regular dental attendance' 6 and 'Exploring factors governing dentists' treatment philosophies'. 7 Gibson et al . 6 provided an improved understanding of factors that influenced people's regular attendance with their dentist. The study by Kay and Blinkhorn 7 provided a detailed insight into factors that influenced GDPs' decision making in relation to treatment choices. The study found that dentists' clinical decisions about treatments were not necessarily related to pathology or treatment options, as was perhaps initially thought, but also involved discussions with patients, patients' values and dentists' feelings of self esteem and conscience.

There are many similarities between clinical encounters and research interviews, in that both employ similar interpersonal skills, such as questioning, conversing and listening. However, there are also some fundamental differences between the two, such as the purpose of the encounter, reasons for participating, roles of the people involved and how the interview is conducted and recorded. 8

The primary purpose of clinical encounters is for the dentist to ask the patient questions in order to acquire sufficient information to inform decision making and treatment options. However, the constraints of most consultations are such that any open-ended questioning needs to be brought to a conclusion within a fairly short time. 2 In contrast, the fundamental purpose of the research interview is to listen attentively to what respondents have to say, in order to acquire more knowledge about the study topic. 9 Unlike the clinical encounter, it is not to intentionally offer any form of help or advice, which many researchers have neither the training nor the time for. Research interviewing therefore requires a different approach and a different range of skills.

The interview

When designing an interview schedule it is imperative to ask questions that are likely to yield as much information about the study phenomenon as possible and also be able to address the aims and objectives of the research. In a qualitative interview, good questions should be open-ended (ie, require more than a yes/no answer), neutral, sensitive and understandable. 2 It is usually best to start with questions that participants can answer easily and then proceed to more difficult or sensitive topics. 2 This can help put respondents at ease, build up confidence and rapport and often generates rich data that subsequently develops the interview further.

As in any research, it is often wise to first pilot the interview schedule on several respondents prior to data collection proper. 8 This allows the research team to establish if the schedule is clear, understandable and capable of answering the research questions, and if, therefore, any changes to the interview schedule are required.

The length of interviews varies depending on the topic, researcher and participant. However, on average, healthcare interviews last 20-60 minutes. Interviews can be performed on a one-off or, if change over time is of interest, repeated basis, 4 for example exploring the psychosocial impact of oral trauma on participants and their subsequent experiences of cosmetic dental surgery.

Developing the interview

Before an interview takes place, respondents should be informed about the study details and given assurance about ethical principles, such as anonymity and confidentiality. 2 This gives respondents some idea of what to expect from the interview, increases the likelihood of honesty and is also a fundamental aspect of the informed consent process.

Wherever possible, interviews should be conducted in areas free from distractions and at times and locations that are most suitable for participants. For many this may be at their own home in the evenings. Whilst researchers may have less control over the home environment, familiarity may help the respondent to relax and result in a more productive interview. 9 Establishing rapport with participants prior to the interview is also important as this can also have a positive effect on the subsequent development of the interview.

When conducting the actual interview it is prudent for the interviewer to familiarise themselves with the interview schedule, so that the process appears more natural and less rehearsed. However, to ensure that the interview is as productive as possible, researchers must possess a repertoire of skills and techniques to ensure that comprehensive and representative data are collected during the interview. 10 One of the most important skills is the ability to listen attentively to what is being said, so that participants are able to recount their experiences as fully as possible, without unnecessary interruptions.

Other important skills include adopting open and emotionally neutral body language, nodding, smiling, looking interested and making encouraging noises (eg, 'Mmmm') during the interview. 2 The strategic use of silence, if used appropriately, can also be highly effective at getting respondents to contemplate their responses, talk more, elaborate or clarify particular issues. Other techniques that can be used to develop the interview further include reflecting on remarks made by participants (eg, 'Pain?') and probing remarks ('When you said you were afraid of going to the dentist what did you mean?'). 9 Where appropriate, it is also wise to seek clarification from respondents if it is unclear what they mean. The use of 'leading' or 'loaded' questions that may unduly influence responses should always be avoided (eg, 'So you think dental surgery waiting rooms are frightening?' rather than 'How do you find the waiting room at the dentists?').

At the end of the interview it is important to thank participants for their time and ask them if there is anything they would like to add. This gives respondents an opportunity to deal with issues that they have thought about, or think are important but have not been dealt with by the interviewer. 9 This can often lead to the discovery of new, unanticipated information. Respondents should also be debriefed about the study after the interview has finished.

All interviews should be tape recorded and transcribed verbatim afterwards, as this protects against bias and provides a permanent record of what was and was not said. 8 It is often also helpful to make 'field notes' during and immediately after each interview about observations, thoughts and ideas about the interview, as this can help in data analysis process. 4 , 8

Focus groups

Focus groups share many common features with less structured interviews, but there is more to them than merely collecting similar data from many participants at once. A focus group is a group discussion on a particular topic organised for research purposes. This discussion is guided, monitored and recorded by a researcher (sometimes called a moderator or facilitator). 11 , 12

Focus groups were first used as a research method in market research, originating in the 1940s in the work of the Bureau of Applied Social Research at Columbia University. Eventually the success of focus groups as a marketing tool in the private sector resulted in its use in public sector marketing, such as the assessment of the impact of health education campaigns. 13 However, focus group techniques, as used in public and private sectors, have diverged over time. Therefore, in this paper, we seek to describe focus groups as they are used in academic research.

When focus groups are used

Focus groups are used for generating information on collective views, and the meanings that lie behind those views. They are also useful in generating a rich understanding of participants' experiences and beliefs. 12 Suggested criteria for using focus groups include: 13

As a standalone method, for research relating to group norms, meanings and processes

In a multi-method design, to explore a topic or collect group language or narratives to be used in later stages

To clarify, extend, qualify or challenge data collected through other methods

To feedback results to research participants.

Morgan 12 suggests that focus groups should be avoided according to the following criteria:

If listening to participants' views generates expectations for the outcome of the research that can not be fulfilled

If participants are uneasy with each other, and will therefore not discuss their feelings and opinions openly

If the topic of interest to the researcher is not a topic the participants can or wish to discuss

If statistical data is required. Focus groups give depth and insight, but cannot produce useful numerical results.

Conducting focus groups: group composition and size

The composition of a focus group needs great care to get the best quality of discussion. There is no 'best' solution to group composition, and group mix will always impact on the data, according to things such as the mix of ages, sexes and social professional statuses of the participants. What is important is that the researcher gives due consideration to the impact of group mix (eg, how the group may interact with each other) before the focus group proceeds. 14

Interaction is key to a successful focus group. Sometimes this means a pre-existing group interacts best for research purposes, and sometimes stranger groups. Pre-existing groups may be easier to recruit, have shared experiences and enjoy a comfort and familiarity which facilitates discussion or the ability to challenge each other comfortably. In health settings, pre-existing groups can overcome issues relating to disclosure of potentially stigmatising status which people may find uncomfortable in stranger groups (conversely there may be situations where disclosure is more comfortable in stranger groups). In other research projects it may be decided that stranger groups will be able to speak more freely without fear of repercussion, and challenges to other participants may be more challenging and probing, leading to richer data. 13

Group size is an important consideration in focus group research. Stewart and Shamdasani 14 suggest that it is better to slightly over-recruit for a focus group and potentially manage a slightly larger group, than under-recruit and risk having to cancel the session or having an unsatisfactory discussion. They advise that each group will probably have two non-attenders. The optimum size for a focus group is six to eight participants (excluding researchers), but focus groups can work successfully with as few as three and as many as 14 participants. Small groups risk limited discussion occurring, while large groups can be chaotic, hard to manage for the moderator and frustrating for participants who feel they get insufficient opportunities to speak. 13

Preparing an interview schedule

Like research interviews, the interview schedule for focus groups is often no more structured than a loose schedule of topics to be discussed. However, in preparing an interview schedule for focus groups, Stewart and Shamdasani 14 suggest two general principles:

Questions should move from general to more specific questions

Question order should be relative to importance of issues in the research agenda.

There can, however, be some conflict between these two principles, and trade offs are often needed, although often discussions will take on a life of their own, which will influence or determine the order in which issues are covered. Usually, less than a dozen predetermined questions are needed and, as with research interviews, the researcher will also probe and expand on issues according to the discussion.

Moderating a focus group looks easy when done well, but requires a complex set of skills, which are related to the following principles: 15

Participants have valuable views and the ability to respond actively, positively and respectfully. Such an approach is not simply a courtesy, but will encourage fruitful discussions

Moderating without participating: a moderator must guide a discussion rather than join in with it. Expressing one's own views tends to give participants cues as to what to say (introducing bias), rather than the confidence to be open and honest about their own views

Be prepared for views that may be unpalatably critical of a topic which may be important to you

It is important to recognise that researchers' individual characteristics mean that no one person will always be suitable to moderate any kind of group. Sometimes the characteristics that suit a moderator for one group will inhibit discussion in another

Be yourself. If the moderator is comfortable and natural, participants will feel relaxed.

The moderator should facilitate group discussion, keeping it focussed without leading it. They should also be able to prevent the discussion being dominated by one member (for example, by emphasising at the outset the importance of hearing a range of views), ensure that all participants have ample opportunity to contribute, allow differences of opinions to be discussed fairly and, if required, encourage reticent participants. 13

Other relevant factors

The venue for a focus group is important and should, ideally, be accessible, comfortable, private, quiet and free from distractions. 13 However, while a central location, such as the participants' workplace or school, may encourage attendance, the venue may affect participants' behaviour. For example, in a school setting, pupils may behave like pupils, and in clinical settings, participants may be affected by any anxieties that affect them when they attend in a patient role.

Focus groups are usually recorded, often observed (by a researcher other than the moderator, whose role is to observe the interaction of the group to enhance analysis) and sometimes videotaped. At the start of a focus group, a moderator should acknowledge the presence of the audio recording equipment, assure participants of confidentiality and give people the opportunity to withdraw if they are uncomfortable with being taped. 14

A good quality multi-directional external microphone is recommended for the recording of focus groups, as internal microphones are rarely good enough to cope with the variation in volume of different speakers. 13 If observers are present, they should be introduced to participants as someone who is just there to observe, and sit away from the discussion. 14 Videotaping will require more than one camera to capture the whole group, as well as additional operational personnel in the room. This is, therefore, very obtrusive, which can affect the spontaneity of the group and in a focus group does not usually yield enough additional information that could not be captured by an observer to make videotaping worthwhile. 15

The systematic analysis of focus group transcripts is crucial. However, the transcription of focus groups is more complex and time consuming than in one-to-one interviews, and each hour of audio can take up to eight hours to transcribe and generate approximately 100 pages of text. Recordings should be transcribed verbatim and also speakers should be identified in a way that makes it possible to follow the contributions of each individual. Sometimes observational notes also need to be described in the transcripts in order for them to make sense.

The analysis of qualitative data is explored in the final paper of this series. However, it is important to note that the analysis of focus group data is different from other qualitative data because of their interactive nature, and this needs to be taken into consideration during analysis. The importance of the context of other speakers is essential to the understanding of individual contributions. 13 For example, in a group situation, participants will often challenge each other and justify their remarks because of the group setting, in a way that perhaps they would not in a one-to-one interview. The analysis of focus group data must therefore take account of the group dynamics that have generated remarks.

Focus groups in dental research

Focus groups are used increasingly in dental research, on a diverse range of topics, 16 illuminating a number of areas relating to patients, dental services and the dental profession. Addressing a special needs population difficult to access and sample through quantitative measures, Robinson et al . 17 used focus groups to investigate the oral health-related attitudes of drug users, exploring the priorities, understandings and barriers to care they encounter. Newton et al . 18 used focus groups to explore barriers to services among minority ethnic groups, highlighting for the first time differences between minority ethnic groups. Demonstrating the use of the method with professional groups as subjects in dental research, Gussy et al . 19 explored the barriers to and possible strategies for developing a shared approach in prevention of caries among pre-schoolers. This mixed method study was very important as the qualitative element was able to explain why the clinical trial failed, and this understanding may help researchers improve on the quantitative aspect of future studies, as well as making a valuable academic contribution in its own right.

Interviews and focus groups remain the most common methods of data collection in qualitative research, and are now being used with increasing frequency in dental research, particularly to access areas not amendable to quantitative methods and/or where depth, insight and understanding of particular phenomena are required. The examples of dental studies that have employed these methods also help to demonstrate the range of research contexts to which interview and focus group research can make a useful contribution. The continued employment of these methods can further strengthen many areas of dentally related work.

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Gill, P., Stewart, K., Treasure, E. et al. Methods of data collection in qualitative research: interviews and focus groups. Br Dent J 204 , 291–295 (2008). https://doi.org/10.1038/bdj.2008.192

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Best Practices for Reducing Bias in the Interview Process

Ilana bergelson.

Department of Urology, University of Iowa, Iowa City, USA

Elizabeth Takacs

Purpose of review.

Objective measures of residency applicants do not correlate to success within residency. While industry and business utilize standardized interviews with blinding and structured questions, residency programs have yet to uniformly incorporate these techniques. This review focuses on an in-depth evaluation of these practices and how they impact interview formatting and resident selection.

Recent Findings

Structured interviews use standardized questions that are behaviorally or situationally anchored. This requires careful creation of a scoring rubric and interviewer training, ultimately leading to improved interrater agreements and biases as compared to traditional interviews. Blinded interviews eliminate even further biases, such as halo, horn, and affinity bias. This has also been seen in using multiple interviewers, such as in the multiple mini-interview format, which also contributes to increased diversity in programs. These structured formats can be adopted to the virtual interviews as well.

There is growing literature that using structured interviews reduces bias, increases diversity, and recruits successful residents. Further research to measure the extent of incorporating this method into residency interviews will be needed in the future.

Introduction

Optimizing the criteria to rank residency applicants is a difficult task. The National Residency Matching Program (NRMP) is designed to be applicant-centric, with the overarching goal to provide favorable outcomes to the applicant while providing opportunity for programs to match high-quality candidates. From a program’s perspective, the NRMP is composed of three phases: the screening of applicants, the interview, and the creation of the rank list. While it is easy to compare candidates based on objective measures, these do not always reflect qualities required to be a successful resident or physician. Prior studies have demonstrated that objective measures such as Alpha Omega Alpha status, United States Medical Licensing Exams (USMLE), and class rank do not correlate with residency performance measures [ 1 ]. Due to the variability of these factors to predict success and recognition of the importance of the non-cognitive traits, most programs place increased emphasis on candidate interviews to assess fit [ 2 ].

Unfortunately, the interview process lacks standardization across residency programs. Industry and business have more standardized interviews and utilize best practices that include blinded interviewers, use of structured questions (situational and/or behavioral anchored questions), and skills testing. Due to residency interview heterogeneity, studies evaluating the interview as a predictor of success have failed to reliably predict who will perform well during residency. Additionally, resident success has many components, such that isolating any one factor, such as the interview, may be problematic and argues for a more holistic approach to resident selection [ 3 ]. Nevertheless, there are multiple ways the application review and interview can be standardized to promote transparency and improve resident selection.

Residency programs have begun adopting best practices from business models for interviewing, which include standardized questions, situational and/or behavioral anchored questions, blinded interviewers, and use of the multiple mini-interview (MMI) model. The focus of this review is to take a more in-depth look at practices that have become standard in business and to review the available data on the impact of these practices in resident selection.

Unstructured Versus Structured Interviews

Unstructured interviews are those in which questions are not set in advance and represent a free-flowing discussion that is conversational in nature. The course of an unstructured interview often depends on the candidate’s replies and may offer opportunities to divert away from topics that are important to applicant selection. While unstructured interviews may involve specific questions such as “tell me about a recent book you read” or “tell me about your research,” the questions do not seek to determine specific applicant attributes and may vary significantly between applicants. Due to their free-form nature, unstructured interviews may be prone to biased or illegal questions. Additionally, due to a lack of a specific scoring rubric, unstructured interviews are open to multiple biases in answer interpretation and as such generally show limited validity [ 4 ]. For the applicant, unstructured interviews allow more freedom to choose a response, with some studies reporting higher interviewee satisfaction with these questions [ 5 ].

In contrast to the unstructured interview, structured interviews use standardized questions that are written prior to an interview, are asked of every candidate, and are scored using an established rubric. Standardized questions may be behaviorally or situationally anchored [ 5 ]. Due to their uniformity, standardized interviews have higher interrater reliability and are less prone to biased or illegal questions.

Behavioral questions ask the candidate to discuss a specific response to a prior experience, which can provide insight into how an applicant may behave in the future [ 5 ]. Not only does the candidate’s response reflect a possible prediction of future behavior, it can also demonstrate the knowledge, priorities, and values of the candidate [ 5 ]. Questions are specifically targeted to reflect qualities the program is searching for (Table ​ (Table1) 1 ) [ 5 – 7 ].

Behavioral questions and character traits [ 5 – 7 ]

Behavioral question example	Trait evaluated
Tell me about a time in which you had to use your spoken communication skills to get a point across that was important to you.	Communication, patience
Can you tell me a time during one of your rotations where you needed to take a leadership role in the case workup or care of the patient? How did this occur and what was the outcome?	Drive, determination
Tell us about a time when you made a major mistake. How did you handle it?	Integrity
What is the most difficult experience you have had in medical school?	Recognition of own limitations

Situational questions require an applicant to predict how they would act in a hypothetical situation and are intended to reflect a realistic scenario the applicant may encounter during residency; this can provide insight into priorities and values [ 5 ]. For example, asking what an applicant would do when receiving sole credit for something they worked on with a colleague can provide insight into the integrity of a candidate [ 4 ]. These types of questions can be especially helpful for fellowships, as applicants would already have the clinical experience of residency to draw from [ 5 ].

Using standardized questions provides a method to recruit candidates with characteristics that ultimately correlate to resident success and good performance. Indeed, structured interview scores have demonstrated an ability to predict which students perform better with regard to communication skills, patient care, and professionalism in surgical and non-surgical specialties [ 8 •]. In fields such as radiology, non-cognitive abilities that can be evaluated in behavioral questions, such as conscientiousness or confidence, are thought to critically influence success in residency and even influence cognitive performance [ 1 ]. This has also been demonstrated in obstetrics and gynecology, where studies have shown that resident clinical performance after 1 year had a positive correlation with the rank list percentile that was generated using a structured interview process [ 9 ].

Creating Effective Structured Interviews

To be effective, standardized interview questions should be designed in a methodical manner. The first step in standardizing the interview process is determining which core values predict resident success in a particular program. To that end, educational leaders and faculty within the department should come to a consensus on the main qualities they seek in a resident. From there, questions can be formatted to elicit those traits during the interview process. Some programs have used personality assessment inventories to establish these qualities. Examples include openness to experience, humility, conscientiousness, and honesty. Further program-specific additions can be included, such as potential for success in an urban versus rural environment [ 10 ].

Once key attributes have been chosen and questions have been selected, a scoring rubric can be created. The scoring of each question is important as it helps define what makes a high-performing versus low-performing answer. Once a scoring system is determined, interviewers can be trained to review the questions, score applicant responses, and ensure they do not revise the questions during the interview [ 11 ]. Questions and the grading rubric should be further scrutinized through mock interviews with current residents, including discussing responses of the mock interviewee and modifying the questions and rubric prior to formal implementation [ 12 ]. Interviewer training itself is critical, as adequate training leads to improved interrater agreements [ 13 ]. Figure  1 demonstrates the steps to develop a behavioral interview question.

Example of standardized question to evaluate communication with scoring criteria

Rating the responses of the applicants can come with errors that ultimately reduce validity. For example, central tendency error involves interviewers not rating students at the extremes of a scale but rather placing all applicants in the middle; leniency versus severity refers to interviewers who either give all applicants high marks or give everyone low marks; contrast effects involve comparing one applicant to another rather than solely focusing on the rubric for each interviewee. These rating errors reflect the importance of training and providing feedback to interviewers [ 4 ].

Blinded Interviewers

Blinding the interviewers to the application prior to meeting with a candidate is intended to eliminate various biases within the interview process (Table ​ (Table2) 2 ) [ 14 , 15 ]. In addition to grades and test scores, aspects of the application that can either introduce or exacerbate bias include photographs, demographics, letters of recommendation, selection to medical honor societies, and even hobbies. Impressions of candidates can be formed prematurely, with the interview then serving to simply confirm (or contradict) those impressions [ 16 •]. Importantly, application blinding may also decrease implicit bias against applicants who identify as underrepresented in medicine [ 17 ].

Examples of bias [ 14 , 15 ]

Type of bias	Definition
Halo	Taking someone’s positive characteristic and ignoring any other information that may contradict this positive perception
Horn	Taking someone’s negative characteristic and ignoring any other information that may contradict this negative perception
Affinity	Increased affinity with those who have shared experiences, such as hometown or education
Conformity	When the view of the majority can push one individual to also feel similarly about a candidate, regardless of whether this reflects their true feelings; can occur when there are multiple interviewers on one panel
Confirmation	Making an initial opinion and then looking for specific information to support that opinion

Despite the proven success of these various interview tactics, their use in resident selection remains limited, with only 5% of general surgery programs using standardized interview questions and less than 20% using even a limited amount of blinding (e.g., blinding of photograph) [ 2 ]. Some programs have continued to rely on unblinded interviews and prioritize USMLE scores and course grades in ranking [ 18 ]. Due to their potential benefits and ability to standardize the interview process, it is critical that programs become familiar with the various interview practices so that they can select the best applicants while minimizing the significant bias in traditional interview formats.

Multiple Mini-interview (MMI)

The use of multiple interviews by multiple interviewers provides an opportunity to ask the applicant more varied questions and also allows for the averaging out of potential interviewer bias leading to more consistent applicant scoring and ability to predict applicant success [ 7 ]. Training of the interviewers in interviewing techniques, scoring, and avoiding bias is also likely to decrease scoring variability. Similarly, the use of the same group of interviewers for all candidates should be encouraged in order to limit variance in scoring amongst certain faculty [ 19 ].

One interview method that incorporates multiple interviewers and has had growing frequency in medical school interviews as well as residency interviews is the MMI model. This system provides multiple interviews in the form of 6–12 stations, each of which evaluates a non-medical question designed to assess specific non-academic applicant qualities [ 20 ]. While the MMI format can intimidate some candidates, others find that it provides an opportunity to demonstrate traits that would not be observed in an unstructured interview, such as multitasking, efficiency, flexibility, interpersonal skills, and ethical decision-making [ 21 ]. Furthermore, MMI has been shown to have increased reliability as shown in a study of five California medical schools that showed inter-interviewer consistency was higher for MMIs than traditional interviews which were unstructured and had a 1:1 ratio of interviewer to applicant [ 22 ].

The MMI format is also versatile enough to incorporate technical competencies even through a virtual platform. In general surgery interviews, MMI platforms have been designed to test traits such as communication and empathy but also clinical knowledge and surgical aptitude through anatomy questions and surgical skills (knot tying and suturing). Thus, MMIs are not only versatile, but also have an ability to evaluate cognitive traits and practical skills [ 23 ].

MMI also has the potential to reduce resident attrition. For example, in evaluating students applying to midwifery programs in Australia, attrition rates and grades were compared for admitted students using academic rank and MMI scores obtained before and after the incorporation of MMIs into their selection program. The authors found that when using MMIs, enrolled students had not only higher grades but significantly lower attrition rates. MMI was better suited to show applicants’ passion and commitment, which then led to similar mindsets of accepted applicants as well as a support network [ 24 ]. Furthermore, attrition rates have been found to be higher in female residents in general surgery programs [ 25 ]. Perhaps with greater diversity, which is associated with use of standardized interviews, the number of women can increase in surgical specialties and thus reduce attrition rate in this setting as well.

Impact of Interview Best Practices on Bias and Diversity

An imperative of all training programs is to produce a cohort of physicians with broad and diverse experiences representative of the patient populations they treat. To better address diversity within surgical residencies, particularly regarding women and those who are underrepresented in medicine, it is important that interviews be designed to minimize bias against any one portion of the applicant pool. Diverse backgrounds and cultures within a program enhance research, innovation, and collaboration as well as benefit patients [ 26 ]. Patients have shown greater satisfaction and reception when they share ethnicity or background with their provider, and underrepresented minorities in medicine often go on to work in underserved communities [ 27 ].

All interviewers undoubtedly have elements of implicit bias; Table ​ Table2 2 describes the common subtypes of implicit bias [ 14 ]. While it is difficult to eliminate bias in the interview process, unstructured or “traditional” interviews are more likely to risk bias toward candidates than structured interviews. Studies have demonstrated that Hispanic and Black applicants receive scores one quarter of a standard deviation lower than Caucasian applicants [ 28 ]. “Like me” bias is just one example of increased subjectivity with unstructured interviews, where interviewers prefer candidates who may look like, speak like, or share personal experiences with the interviewer [ 29 ].

Furthermore, unstructured interviews provide opportunities to ask inappropriate or illegal questions, including those that center on religion, child planning, and sexual orientation [ 30 ]. Inappropriate questions tend to be disproportionately directed toward certain groups, with women more likely to get questions regarding marital status and to be questioned and interrupted than male counterparts [ 28 , 31 ].

Structured interviews, conversely, have been shown to decrease bias in the application process. Faculty trained in behavior-based interviews for fellowship applications demonstrated that there were reduced racial biases in candidate evaluations due to scoring rubrics [ 12 ]. Furthermore, as structured questions are determined prior to the interview and involve training of interviewers, structured interviews are less prone to illegal and inappropriate questions [ 32 ]. Interviewers can ask additional questions such as “could you be more specific?” with the caveat that probing should be minimized and kept consistent between applications. This way the risk of prompting the applicant toward a response is reduced [ 4 ].

Implementing Interview Types During the Virtual Interview Process

An added complexity to creating standardized interviews is incorporating a virtual platform. Even prior to the move toward virtual interviews instituted during the COVID-19 pandemic, studies on virtual interviews showed that they provided several advantages over in-person interviews, including decreased cost, reduction in time away from commitments for applicants and staff, and ability to interview at more programs. A significant limitation, for applicants and for programs, is the inability to interact informally, which allows applicants to evaluate the environment of the hospital and the surrounding community [ 33 •]. Following their abrupt implementation in 2020 during the COVID-19 pandemic, virtual interviews have remained in place and likely will remain in place in some form into the future due to their significant benefits in reducing applicant cost and improving interview efficiency. Although these types of interviews are in their relative infancy in the resident selection process, studies have found that standardized questions and scoring rubrics that have been used in person can still be applied to a virtual interview setting without degrading interview quality [ 34 ].

The virtual format may also allow for further interview innovation in the form of standardized video interviews. For medical student applicants, the Association of American Medical Colleges (AAMC) has trialed a standardized video interview (SVI) that includes recording of applicant responses, scoring, and subsequent release to the Electronic Residency Application Service (ERAS) application. Though early data in the pilot was promising, the program was not continued after the 2020 cycle due to lack of interest [ 35 ]. There is limited evidence supporting the utility of this type of interview in residency training, and one study found that these interviews did not add significant benefit as the scores did not associate with other candidate attributes such as professionalism [ 32 ]. Similarly, a separate study found no correlation between standardized video interviews and faculty scores on traits such as communication and professionalism. Granted, there was no standardization in what the faculty asked, and they were not blinded to academic performance of the applicants [ 36 ]. While there was an evaluation of six emergency medicine programs that demonstrated a positive linear correlation between the SVI score and the traditional interview score, it was a very low r coefficient; thus the authors concluded that the SVI was not adequate to replace the interview itself [ 37 ].

Conclusions: Future Steps in Urology and Beyond

The shift to structured interviews in urology has been slow. Within the last decade, studies consistent with other specialties demonstrated that urology program directors prioritized USMLE scores, reference letters, and away rotations at the program director’s institution as the key factors in choosing applicants [ 38 ]. More recently, a survey of urology programs found < 10% blinded the recruitment team at the screening step, with < 20% blinding the recruitment team during the interview itself [ 39 ]. In 2020 our program began using structured interview questions and blinded interviewers to all but the personal statement and letters of recommendation. After querying faculty and interviewees, we have found that most interviewers do not miss the additional information, and applicants feel that they are able to have more eye contact with faculty who are not looking down at the application during the interview. Structured behavioral interview questions have allowed us to focus on the key attributes important to our program. With time we hope to see that inclusion of these metrics helps diversify our resident cohort, improve resident satisfaction with the training program, and produce successful future urologists.

Despite the slow transition in urology and other fields, there is a growing body of literature in support of standardized interviews for evaluating key candidate traits that ultimately lead to resident success and reducing bias while increasing diversity. With time, the hope is that programs will continue incorporating these types of interviews in the resident selection process.

Compliance with Ethical Standards

The authors have no financial or non-financial interests to disclose.

This article does not contain any studies with human or animal subjects performed by any of the authors.

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• Published: 01 July 2024

Understanding the challenges of identifying, supporting, and signposting patients with alcohol use disorder in secondary care hospitals, post COVID-19: a qualitative analysis from the North East and North Cumbria, England

• Katherine Jackson 1 ,
• Rosie Baker 2 ,
• Amy O’Donnell 1 ,
• Iain Loughran 3 ,
• William Hartrey 4 &
• Sarah Hulse 5  

BMC Health Services Research volume  24 , Article number:  772 ( 2024 ) Cite this article

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Alcohol-related mortality and morbidity increased during the COVID-19 pandemic in England, with people from lower-socioeconomic groups disproportionately affected. The North East and North Cumbria (NENC) region has high levels of deprivation and the highest rates of alcohol-related harm in England. Consequently, there is an urgent need for the implementation of evidence-based preventative approaches such as identifying people at risk of alcohol harm and providing them with appropriate support. Non-alcohol specialist secondary care clinicians could play a key role in delivering these interventions, but current implementation remains limited. In this study we aimed to explore current practices and challenges around identifying, supporting, and signposting patients with Alcohol Use Disorder (AUD) in secondary care hospitals in the NENC through the accounts of staff in the post COVID-19 context.

Semi-structured qualitative interviews were conducted with 30 non-alcohol specialist staff (10 doctors, 20 nurses) in eight secondary care hospitals across the NENC between June and October 2021. Data were analysed inductively and deductively to identify key codes and themes, with Normalisation Process Theory (NPT) then used to structure the findings.

Findings were grouped using the NPT domains ‘implementation contexts’ and ‘implementation mechanisms’. The following implementation contexts were identified as key factors limiting the implementation of alcohol prevention work: poverty which has been exacerbated by COVID-19 and the prioritisation of acute presentations (negotiating capacity); structural stigma (strategic intentions); and relational stigma (reframing organisational logics). Implementation mechanisms identified as barriers were: workforce knowledge and skills (cognitive participation); the perception that other departments and roles were better placed to deliver this preventative work than their own (collective action); and the perceived futility and negative feedback cycle (reflexive monitoring).

Conclusions

COVID-19, has generated additional challenges to identifying, supporting, and signposting patients with AUD in secondary care hospitals in the NENC. Our interpretation suggests that implementation contexts, in particular structural stigma and growing economic disparity, are the greatest barriers to implementation of evidence-based care in this area. Thus, while some implementation mechanisms can be addressed at a local policy and practice level via improved training and support, system-wide action is needed to enable sustained delivery of preventative alcohol work in these settings.

Peer Review reports

Alcohol is now the leading risk factor for ill-health, early mortality, and disability amongst working age adults (aged 15 to 49) in England, and the fifth leading risk factor for ill-health across all age groups [ 1 ]. Evidence also shows significant socioeconomic inequalities in alcohol-related harm [ 2 ]. Over half of the one million hospital admissions relating to alcohol in England each year occur in the lowest three socioeconomic deciles [ 3 ] and rates of alcohol-related deaths increase with decreasing socioeconomic status [ 4 ]. In 2020 people under 75 years living in the most deprived areas in England had a 4.8 times greater likelihood of premature mortality from alcohol-related liver disease than those living in the most affluent areas [ 5 ].

Although globally, there is mixed evidence about the impact of the COVID-19 pandemic and associated social and economic restrictions on alcohol consumption [ 6 ], some studies suggest that people who were already drinking alcohol heavily increased their intake during this period [ 7 , 8 ]. Latest data for England show that the total number of deaths from conditions that were wholly attributed to alcohol rose by 20% in a single year in 2020, the largest increase on record [ 9 ]. In England, and elsewhere, it has been argued that COVID-19 should be regarded as a syndemic rather than a pandemic, as it has interacted with, and most adversely affected those in the most deprived social groups who were already experiencing the greatest inequalities [ 10 ]. In the case of alcohol use, COVID-19 may have interacted with and exacerbated the social conditions associated with alcohol use such as poverty, and loneliness and isolation [ 11 , 12 ]. Moreover, with evidence that alcohol-related harms will continue to increase, there is concern this will further widen health inequalities for those communities and regions who are likely to be most affected [ 8 , 13 ]. Thus, there is an urgent need for the implementation of evidence-based preventative strategies to reduce alcohol harm and associated inequalities, as part of a wider system level approach that includes primary, secondary and specialist care settings [ 8 ]. From here we use the term Alcohol Use Disorder (AUD), to refer to a spectrum of alcohol use from harmful to dependent alcohol use [ 14 ].

In secondary care hospitals, the UK government prioritised the implementation of Alcohol Care Teams (ACTs) in England in the National Health Service (NHS) Long Term Plan with the aim of improving care and reducing alcohol-related harms [ 15 ]. ACTs are clinician-led, multidisciplinary teams designed to support provision of integrated alcohol treatment pathways across primary, secondary and community care, and have been shown to reduce alcohol harms through reductions in avoidable bed days; readmissions; Accident and Emergency Department (AED) attendances; and ambulance call outs [ 16 ]. However, the non-specialist secondary care workforce also has an essential role in identifying and managing people at risk, using evidence-based approaches such as screening patients for excessive alcohol use and the provision brief advice [ 17 ]. Given that people may not always present primarily with alcohol-related concerns, routine screening provides an important opportunity to identify people at an earlier stage in their drinking and thereby prevent escalation of alcohol-related problems. Current NHS clinical guidance [ 18 ] requires that non-specialist healthcare staff ‘should be competent to identify harmful drinking (high-risk drinking) and alcohol dependence’ (p46). This includes having the skills to assess the need for an intervention or to provide an appropriate referral.

Despite this guidance however, evidence from prior to the pandemic suggests a range of barriers exist in the delivery and widespread implementation of alcohol prevention work by non-specialist secondary care staff. These include time pressures, limited knowledge and awareness of AUD, and a lack of training, skills, and financial support [ 19 , 20 , 21 , 22 ]. Many studies also highlight that the delivery of preventative support for AUD in secondary care is hampered by wider social cultural challenges such as the stigma of heavy alcohol use and widespread belief that problematic alcohol use is a personal responsibility and represents moral failing, leading to an emphasis on individuals to manage their own care [ 22 ]. Additionally, as AUD frequently co-occurs with other physical and mental health conditions [ 23 ], non-specialist healthcare staff can find themselves ill-equipped to provide the best standard of care for these patients who have multiple and complex needs [ 24 ]. Moreover, in England, as in other health systems, the impact of COVID-19 has created additional pressures and challenges for the whole NHS, including secondary hospitals. There are more people visiting AED than before the pandemic, with longer waiting lists for treatment and fewer hospital beds [ 25 ]. There is also record dissatisfaction amongst the workforce, with more doctors now stating they want to leave the NHS than before the pandemic [ 26 ].

Given the clear need for preventive work to reduce inequalities in alcohol-related harm and the current challenges within secondary care in a post-COVID-19 context, there is value in exploring the views of secondary care staff about supporting patients with AUD since the pandemic. Moreover, the low levels of delivery of preventative support for AUD across different sites suggest there is merit in using implementation science theory [ 27 ] to support improved explanation and understanding of this situation [ 27 , 28 ]. Normalisation Process Theory [ 29 ] has been used extensively in studies conducted in other health settings to understand and evaluate past and future implementation efforts e.g. [ 28 , 30 , 31 , 48 , 33 ], including in relation to alcohol screening and brief intervention in England and Australia [ 30 , 31 ]. NPT is a sociological implementation theory that identifies three domains as shaping the implementation of a new intervention or practice: contexts; mechanisms; and outcomes. Contexts refer to the ‘events in systems unfolding over time within and between settings in which implementation work is done.’ [ 34 ]; mechanisms are factors that ‘motivate and shape the work that people do when they participate in implementation processes’ [ 34 ]; outcomes refer to what changes occur when interventions are implemented. NPT is a conceptual tool and can be used at different stages of the research process [ 29 ]. In this study NPT has been used retrospectively during the analysis stage.

The aim of the present study is to use NPT to elucidate possible explanations for why the preventative practice of identifying, supporting, and referring patients with AUD to appropriate support is not consistently taking place in secondary care in the NENC in the post COVID-19 context. We also aim to make recommendations for areas that should be targeted by policy and practice initiatives.

Study setting

We conducted a qualitative study with health care professionals working in eight secondary care hospitals in the eight NHS Trusts in the North East and North Cumbria (NENC) region of England. The NENC experiences significant health inequalities [ 35 ], including health inequalities in alcohol-related harm. In 2021, the region had the highest reported alcohol specific and alcohol related mortality and the most alcohol related and alcohol specific admissions in England [ 36 ].

The data collection was carried out between June and October 2021. At this time, most COVID-19 restrictions had just been lifted in the NENC [ 37 ] but the impacts of COVID-19 on patients, staff and health care delivery were still ongoing.

As such, the study was planned to contribute to a baseline understanding of support for AUD in secondary care in the NENC conducted as part of a wider regional alcohol health needs assessment (2022) which would inform and direct strategic action and resource allocation in secondary care to improve alcohol-related outcomes post-COVID-19. The Principal Investigator (PI) for the study was the alcohol lead for the NENC Integrated Care System (SH), and the wider study team included representation from Primary Care, Secondary Care, Public Health, and Academia.

We used the method of qualitative semi-structured interviews to enable us to focus on issues that we wanted to explore, as well as allowing the participants flexibility to discuss the issues that were important to them [ 38 ]. We adopted a critical realist approach to the interpretation of data which purports that data can be taken as evidence for ‘real phenomena and processes’, but also recognises that the knowledge generated through qualitative research is situated and partial [ 39 ].

As part of a wider ambition to build research capacity in the study region, a novel aspect of the study design is that six junior doctors from the Gastroenterology Research and Audit through North Trainees, were trained in qualitative interview skills by a qualitative methodologist from the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC) and supported by members of the study team to recruit staff and carry out the interviews with secondary care clinicians.

Participants

We used a form of stratified purposive sampling [ 40 ] as the recruitment of healthcare professionals was structured to provide insights across all the NHS Trusts in the study region, a range of clinical specialities, and a range of points across the clinical pathway, with both medical and nursing staff. As such, professionals working in AED, Medical specialties, Psychiatric Liaison (PL), Gastroenterology or Surgical specialties were eligible to participate. Junior doctor interviewers or the PI contacted potential participants either by email or face-to-face and explained the purpose of the study. People who expressed an interest were then provided with the study participant information sheet and consent form. The sampling was deemed complete when the quota of participants was met for each trust.

Data collection involved semi-structured interviews based on a topic guide. The topic guide was developed by the study team and was informed by the National Institute for Clinical Excellence – Quality Standard 11 [ 41 ], which contains guidance about identifying and supporting adults and young people who may have an AUD and caring for people with alcohol-related health problems (see Additional file 1 ).

All interviews were conducted via Microsoft Teams, lasted an average of 33 min, were audio recorded and transcribed by professional transcriptionists before being fully anonymised by KJ and IL.

Data analysis involved three stages:

Stage 1: Generating descriptive codes from each area of the data set

In the first stage of analysis, once all transcripts were available, in order to generate insights that could contribute to the baseline understanding of the current situation with regards to support for AUD in secondary care, one researcher (IL) used a method of thematic analysis [ 42 ] and drew on deductive and inductive reasoning to identify descriptive codes against each focus question area of the interview topic guide. This researcher read and re-read the full data set, allowing them to identify descriptive codes across staff accounts.

Stage 2: Generating descriptive and interpretive codes and themes from across the full data set

Following this, to generate insights which went beyond the question areas of the topic guide a second researcher (KJ) familiarised themselves with the data. In contrast to Stage 1, they were less restricted by the original topic guide and through a process of constant comparison began to identify both descriptive and interpretive broad thematic topic areas and codes, across the different areas of the interviews. After the first half of the interview transcripts were coded by the researcher in this way, the broad thematic topic areas were discussed with the wider study team in two meetings. In these meetings the broad topic areas and associated coding framework were refined. This refined framework was applied to future transcripts, with flexibility to add further codes as the analysis progressed. At the end of this process, a decision was made by the team to focus the interpretation for this paper on current practices around identifying, supporting, and signposting patients with AUD in secondary care hospitals because it was felt that this focus could make a meaningful contribution to the existing literature in a post-pandemic context.

Stage 3: Applying Normalisation Process Theory retrospectively to data to generate the final interpretation

To ensure the usefulness of the findings of the current analysis to support the design and delivery of future policy and practice to reduce inequalities in alcohol related harm, academic members of the team suggested using an appropriate implementation theory, namely NPT, to guide our interpretation and understanding of data from this point in the analysis [ 34 ]. NPT had not been used in the study to this point and has been used retrospectively as a sensitising, and partial structuring, device, as seen in previous comparable research e.g. [ 28 , 43 ].

[ 29 , 34 ]. First, when applying NPT, we returned to the codes identified at Stage 2 to identify those that related to the practice of identifying, supporting, and signposting patients with AUD to explore how they may fit alongside the domains of NPT. At this point it was evident that most of the codes related to how implementation contexts and mechanisms were felt to adversely affect provision of support for patients with AUD. In contrast, we found negligible data related to the third NPT domain of outcomes (i.e. what changes occur when interventions are implemented). It was therefore agreed that applying the context and mechanisms domains could be valuable to show how contexts and mechanisms limit the implementation of the phenomena of interest. For transparency however, data not included at this stage is indicated in Additional file 2 .

Next, we separated the codes generated in Stage 2 into overarching thematic areas, these were then labelled as either contexts or mechanisms. For example, poverty and austerity were labelled as contexts, and workforce skills and knowledge were labelled as mechanisms. Details of each stage of the analysis and where the codes generated at Stage 2 of the analysis were mapped, against the NPT context and mechanism domains are shown in Additional file 2 .

Following this we endeavoured to align the thematic topic areas in each NPT domain into its associated constructs. It should be noted that our initial researcher-generated thematic areas aligned easily with three of the four NPT mechanism constructs. Conversely, as the NPT context constructs are a new addition to NPT theory, there were few practical examples of how these should be operationalised meaning it took more interpretive work to understand how our data mapped to these constructs. Through reflective discussions as a team, however, we identified that the researcher-generated themes aligned with three of the four context constructs. Table  1 below summarises the implementation context and mechanism constructs and identifies where our data do and do not map to these constructs. COVID-19 provides an overarching context to the study however as the timing of the interviews meant it penetrated almost all the data.

In keeping with the critical realist approach which recognises the situatedness of knowledge, we see researcher positionality as important to consider in the interpretation of qualitative data. Research can never be value free but, it is necessary to be explicit about where positionality might have affected the interactions [ 45 ]. The junior doctor interviewers and the PI who collected the data had experience of clinical work on the topic of the research. Indeed, the transcripts indicated that there were times when the interviewers aligned themselves or discussed their own experiences in the interviews. Some of the junior doctor interviewers recorded reflexive notes about the interviews, these were used during Stages 1 and 2 of the analysis to support interpretation, but have not been used as data. The researcher who conducted Stage 1 of the analysis has a professional background in healthcare but no direct experience of the topic area. The researcher who led the rest of the analysis has experience of carrying out research about AUD, but no clinical experience of working with people experiencing AUD. Other members of the project team have direct experience of working in hospital settings with patients experiencing AUD. Agreement amongst this heterogeneous research team about the final interpretation gives us confidence that it is grounded in the data. Moreover, this agreement amongst the research team about the final interpretation, and the congruence of findings with the existing literature on the topic of the research prior to COVID-19, gives us confidence that the insider researchers did not compromise the quality of the original empirical data.

In total, 30 staff in the study region were interviewed across the eight NHS Trusts, including 20 nurses and 10 doctors (see Table  2 ) based in five departments: AED; PL; Medical; Surgical; and Gastroenterology ( n  = 6 each). Information related to participant gender and ethnicity are not available and we have not analysed the data with these as a focus. The absence of this data also helps to preserve the anonymity of participants because the geographical region of the study is named.

Overall, participants’ accounts suggested that they were not consistently trying to identify AUD or assessing the need for intervention in the patients they worked with. Where any identification of AUD did take place, this appeared to often be through informal questioning rather than utilising formal, validated screening questionnaires. The following response was typical:

We’ll just ask about units a week. I know that there is a screening tool, there is a chart of some sort and it’s a physical thing that I think the alcohol and drugs nurses use on medications. So we don’t use that on a regular basis. As of now, there’s still a paper–based documenting system, but we don’t use that necessarily. (Participant 14 – Doctor, Trust 4, AED)

Conversely, some staff working in PL teams suggested they more commonly tried to identify AUD. Although again, validated screening questionnaires appeared to be used inconsistently:

Substance misuse is always an integral part of the assessment that we do. . We do have specific packs that we are trained to carry out our assessments to. I think in practice, we often don’t follow those verbatim and we will just do a free form assessment and substances are always part of that… .: “Do you consider that’s an issue for you, is it something that you want help with?” We’re always having those conversations. (Participant 8 – Nurse, Trust 2, PL)

Many staff’s accounts suggested they did not consistently signpost patients with identified AUD to a service that could provide an assessment of need or provide further care. Using NPT to frame our interpretation, in the next section we aim to highlight current practice around these phenomena and identify areas that appeared to be key barriers to implementation.

Implementation contexts

The successful implementation of interventions requires supportive implementation environments both within and outside the settings in which they are delivered. Our data highlighted several key aspects of the implementation context/s that are barriers to the widespread implementation of asking about, supporting, and signposting patients with AUD in secondary care in the study region. As the data collection was conducted very soon after COVID-19 restrictions ended, COVID-19 was an overarching context of the staffs’ accounts.

Widespread poverty, austerity, and the prioritisation of acute conditions – negotiating capacity

Negotiating capacity refers to how contexts shape the extent to which interventions can fit into existing ways of working [ 34 ]. Through the participants’ accounts we identified two aspects of context which appear to limit negotiating capacity: widespread poverty and austerity within the study region; and the focus of secondary care hospitals on the acute and presenting health needs of patients.

Most staff accounts suggested they perceived AUD to be common in the communities their hospitals covered and the patients they saw. Many staff linked the prevalence of AUD in the region to the high rates of poverty. To illustrate, Participant 23 commented that the basic provision for patients with AUD in the hospital, was in stark contrast to the apparent need in the community:

The demographic for around here, people are poor, they do drink, people do smoke,. . people take drugs a lot around here and the help, there isn’t [anything for them] it’s absolutely crazy. (Participant 23 - Nurse, Trust 6, Surgical)

While the need to support patients with AUD was perceived to have been high prior to the COVID-19 pandemic, many staff noted that they had seen a rise in patients presenting with or showing signs of AUD following the pandemic, with some suggesting that they felt that the presentations of alcohol-related morbidity and mortality were likely to increase in the future:

Our numbers [of patients with AUD] have gone up by 100% in five years. . So it’s not going anywhere, and I predict that at the beginning of next year we’re going to see huge influence on alcoholic dependence. Because we’ve already seen people who are having fits, first fits, people who were drinking prior to COVID or probably drinking too much, at high risk, not necessarily dependent and then, furloughed, have begun to drink every day and developed alcohol dependence. (Participant 25 - Nurse, Trust 7, Gastroenterology)

A small number of participants mentioned that because of the observed high levels of AUD in the study region it was harder to decide how to prioritise who to ask about alcohol. They indicated that they were unlikely to ask patients about alcohol if they were drinking at what they saw as lower levels, as they perceived most people were drinking a lot. For example, Participant 7 said:

If they were a binge drinker or they drank more than was recommended, it’s kind of like, where do you take that? How do I talk to my patients about that? Thinking about where we live, our demographic of the type of patients that we see, it’s very common that patients would drink more alcohol than the recommended. So, I guess that is the challenge of how you would approach that to the patient, without coming across like you were being judgmental or self-righteous when you’re trying to give them this advice. And actually asking them; ‘do you even see it as a problem?’ A lot of patients that you would speak to you wouldn’t even say that that is a problem. (Participant 7 - Nurse, Trust 2, Surgical)

Thus, these accounts indicated that the normalisation and prevalence of heavy drinking in some communities actively constrained the extent to which staff could integrate asking about and supporting patients with alcohol use into their day to day work .

Conversely, and illustrating how contexts can be barriers to implementation in one setting but facilitate it in others [ 44 ], some staff working in PL described how they had recently begun doing more systematic screening for AUD because it was recognised as being so prevalent in the patients they saw.

[Previously] unless alcohol was kind of front and centre and was an issue that was discussed from the get-go, it wasn’t always something that was really looked into in great detail as part of our assessments. Whereas now that we do the AUDIT, there’s an AUDIT-C tool with all patients. (Participant 4 – Nurse, Trust 1, PL)

Nonetheless, staff accounts more commonly focused on the need to tackle severe alcohol harm rather than preventative work. In-keeping with other research studies and clinical knowledge, the participants’ suggested that a key reason that patients aren’t routinely being asked about AUD in secondary care is because staff need to prioritise the presenting acute condition/s. Something which is colloquially termed ‘the rule of rescue’. Thus, any identification of AUD, where it did happen, was primarily focused on managing patients whose alcohol use was already affecting, or had the potential to affect, the treatment of their acute physical or mental illness. Participants almost always linked this to the pressurised setting and the restricted time they had to work with patients, as further limiting their capacity to address a patient’s drinking. This context is illustrated in the following quotes:

‘I’m asking [about alcohol] because it effects how I care for that patient and not necessarily about educating them’ (Participant 15 – Doctor, Trust 4, Medical). . .I think asking about the preventative problems, and screening for problems, is something that we just don’t do. If someone comes in and they’re alcohol dependent, realistically the thing you think about most is, right well we need to make sure that we’ve got the right things for if they withdraw, you don’t think, oh well shall we see if there’s anything we can do and to be fair, you don’t really have the time, I don’t think. (Participant 6 - Doctor, Trust 2, AED)

Overall, time and the focus on acute conditions, were commonly cited by staff as key contextual factors, that limited their negotiating capacity to ask patients about alcohol and to provide follow-up support.

Stigma at a structural level – strategic intentions

Strategic intentions refers to how contexts shape the formulation and planning of interventions. Many staff accounts suggested that they perceived there was little visible commitment to the prevention of AUD within their NHS trust or at a national NHS level. Many staff suggested they had seen no communications about providing preventative support to patients with AUD from their trust:

There’s nothing to my knowledge, Trust–wide, of how we help this cohort of patients. There doesn’t seem to be anything written in stone, on the help that we provide. (Participant 21 – Nurse, Trust 6, AED)

Others emphasised that although they had seen some communications about alcohol from their trust, these were limited. Some participants’ accounts indicated a sense of frustration that alcohol was not being prioritised by the NHS and moreover that any care offered to patients with AUD was voluntary rather than a designated part of their core work. For example, in one trust it was noted that the role of the Alcohol Lead was not formalised:

At the moment it’s almost voluntary and there’s always something else that comes along that’s more immediate, more important or seems that way. People aren’t taking the longer view that if we don’t address this problem now then the tsunami of liver disease will just continue. (Participant 10 - Doctor, Trust 3, Gastroenterology)

Relational stigma – reframing organisational logic

Reframing organisational logic refers to the extent to which social structural and social cognitive resources shape the implementation environment [ 34 ]. The stigma which was evident at a structural level was also directly perceived to impact the care of patients with AUD at a relational level. Many staff mentioned that the identification of AUD and subsequent signposting for patients who drink heavily are obstructed because some staff perceive that heavy alcohol use is a personal failing and individual problem. Indeed, judgement or stigma was explicitly proposed by participants as one of the key reasons that AUD prevention and treatment interventions were not implemented, or attempts weren’t made to help people with AUD:

People find them incredibly frustrating and [like] they’re not real patients or people who need [help]. (Participant 4 - Nurse, Trust 4, PL)

This judgement was also seen to be compounded by austerity and the increased demands on health and social care post COVID-19, meaning those who were more challenging or difficult to help were often the easiest group to not manage.

Relational stigma appeared evident in the reluctance of some staff to speak to patients about alcohol. For example, a few participants expressed concern about how patients would respond if they were to ask them about their alcohol use because heavy alcohol consumption can sometimes be perceived by patients and wider society as a personal failing or as evidence of a lack of control:

It’s quite a personal conversation to have with somebody and you’ve got a small thin curtain between every single patient and having those conversations when everybody hears the conversation that you have in the bay, so I think that sometimes contributes to it. (Participant 24 – Nurse, Trust 7, Medicine)

Moreover, the effects of stigma seemed evident in the extent to which staff perceived people would be honest about or disclose their heavy drinking and the extent to which would subsequently make adaptions to investigate further. Some staff said that they did not have the time to build rapport with patients to generate a context where they perceived patients might be more likely to be truthful about their drinking:

It comes down to them being honest. If they say that they don’t drink a lot then we wouldn’t give any advice. (Participant 26 – Nurse, Trust 7, Surgical)

The data also suggests that the extent to which staff appeared willing to identify or support patients with AUD is related to them not seeing it as relevant to the presenting problem which relates to the prioritisation of acute conditions and the negotiating capacity.

Implementation mechanisms

Alongside contexts, we identified a number of mechanisms that appeared to be barriers to implementation across our participants’ accounts.

Workforce knowledge and skills – cognitive participation

All participants’ accounts suggested that there was no mandatory training within trusts to support staff to deliver alcohol prevention work. While participants acknowledged there was indeed very little mandatory training about most conditions, many staff suggested they had not been trained post-University in how to have conversations with patients about alcohol, to assess need, or how to refer and signpost on:

. . we’ve got team days where we go through mandatory training and do little courses and do all our training, but there’s nothing about alcohol on there whereas it might be quite useful because we do get a lot of patients with alcohol issues so that would be beneficial. . we’ve had no training or updates on what’s out there in the community. (Participant 9 – Nurse, Trust 2, Medical)

In a small number of trusts, some staff with a specific remit around alcohol stated they were in the process of developing training about identification within their teams and appeared optimistic about the spread and impact of this.

Where staff did ask about alcohol, a barrier to referring people with AUD to appropriate services was their limited awareness of relevant services within the community. Indeed, a few participants conveyed the sentiment of Participant 11 who described their perception of asking about alcohol in their hospital as a ‘ tick box exercise rather than purposeful tool .’ (Nurse, Trust 3, Medical). Only a small number of participants seemed very knowledgeable about local community services; like Participant 9 above, most staff accounts suggested a lack of awareness of relevant organisations they could refer patients to. Some staff indicated that knowledge of appropriate services was made more challenging because of the frequent change in service provision and cuts and short-term commissioning of relevant voluntary and community sector services:

It is a bit vague at the moment as to exactly what they are going to do with the provider changing over. . when the Covid stuff started, they stopped coming in and just did electronic stuff. But I think they’ve started coming in again. But I don’t quite know what hours they are planning to come in, with the new changeover of people. (Participant 1 – Doctor, Trust 1, Gastroenterology)

In a context of frequent service changeovers and decommissioning, widespread poverty and austerity, and limited awareness of appropriate local services, there appeared to be a heavy reliance on referrals to primary care by staff, even when they didn’t know what primary care would offer patients. This is illustrated by this quote from Participant 15:

Sometimes if people ask me, or if I’ve found that they’ve got like deranged liver functions, I’ll often just sort of say to them, if it fits with an alcohol picture, I would say: “It does look like your alcohol use is affecting your liver, it might be something you think about cutting down,” but at that point I’m not always sure where to refer them to, so I usually end up saying you can get support from your GP. Yes. (Participant 15 – Doctor, Trust 4, Medical)

Role legitimacy – collective action

When asked directly in the interviews about whether they felt that managing AUD was their responsibility most participants stated that it was. However, their wider accounts indicated that many participants and their colleagues relied heavily on calling on staff in other departments to manage patients with AUD who they saw as better placed to address these patients’ needs. In particular, the participants commonly suggested that alcohol nurses or other staff in gastroenterology were most able to help:

In our trust, I’m not sure if it’s the same as any others, when we do the nurse’s admission, we ask how many units they’ve had and if they score over ten then they automatically get pinged to the alcohol nurses who will come and see them. Or we refer them and call the alcohol nurses here. . (Participant 28 – Nurse, Trust 8, AED)

Staff in the site where an ACT had recently been set-up suggested that the introduction of this service had significantly improved the care that they could offer people with visible presentations of AUD and provided a clearer route for signposting. However, the reliance on this service also served to illustrate the limited support prior to this in these sites and the significant care gap at other sites who did not have this provision. Moreover, the accounts of a few participants suggested that due to the high level of need for alcohol dependent support, the ACTs appeared to have little capacity to do preventative work:

The alcohol care team nurses are building up good relationships with some of our more frequent members that are coming on ward. And then they’re able to get permission off them to do more like referrals to [community alcohol service], discussions about tapering down or alcohol reduction therapy, discussions about cognitive behavioural therapies, discussions with housing officers and things, discussions with safeguarding. . having said that, like I say they are getting an abundance of referrals daily now and I think unfortunately it’s ended up a lot bigger than they were expecting, a bit of a mammoth task. (Participant 2 – Nurse, Trust 1, Medical)

In contrast to staff in other departments, as mentioned above, staff from PL teams suggested that identifying patients’ patterns of alcohol use, usually through formalised screening, had relatively recently become part of their core work. Nonetheless, the focus was still on management of AUD rather than prevention, as most indicated that the implementation of this was in response to the prevalence of heavy drinking in the patients they saw. Here the mechanism of collective action appears to be shaped by the context of poverty and austerity.

Perceived futility and negative feedback cycle – reflexive monitoring

Participants’ accounts indicated that they had little information about the outcomes of the people that they saw with AUD. Some staff mentioned that the only time they saw patients again, whether or not they delivered an intervention, was when they re-attended. The following response was typical:

We put them on file with the GP letter, and we don’t know what happens after that. (Participant 26 – Nurse, Trust 7, Surgical)

In the context of this perceived futility, staff appeared to find it difficult to have hope for patients when they experienced only negative reinforcement. Compounding this it was also evident that the recording of information about alcohol use and any advice or signposting were limited in most departments. Although some PL services and some trusts seemed to be trying to record screening more systematically at the time of the research, it was still not mandatory and was not always prioritised as the following quote illustrates:

[We] have the AUDIT -C put on e-records, and that provided some challenges as well. . there’s a lot of things that are recorded, you get a lot of alerts, we know that. . staff just tap off them, if they’re not mandatory, So, it was about trying to sell it is an important message. (Participant 25 - Nurse, Trust 7, Gastroenterology)

Here again we see the link between contexts and mechanisms whereby the lack of systematic recording of patients’ alcohol use is likely to be influenced by the context of structural stigma and its impact on strategic intentions.

This paper reports the findings of a collaborative study between practitioners, policy makers, and academics which aimed to explore the challenges to the delivery of identification, support, and subsequent signposting for AUD in the secondary care settings in the NENC region post- COVID-19. Our findings broadly concur with what was already known about the challenges of implementing identification and support for AUD in secondary care hospitals prior to the COVID-19 pandemic. For example, the persistent contextual challenge of time pressures, and the lack of key enabling mechanisms, such as having a workforce with the skills and knowledge to confidently ask about alcohol and signpost patients appropriately [ 22 ]. However, our findings extend existing evidence by highlighting some additional barriers to alcohol prevention work in secondary care in the post-COVID-19 context. Moreover, the use of theory, specifically NPT domains, enables us to illuminate the interplay of context and mechanisms which make implementation of AUD care especially difficult in this setting.

A key contribution of this study to the extant literature is that it provides empirical evidence of how COVID-19 has served to amplify the challenges already experienced by secondary care staff trying to delivery preventative alcohol work in hospital settings. Many staff indicated that the sheer scale of people presenting with possible AUD since COVID-19, meant they did not have the time to ask people or to prioritise asking people about alcohol. Where people were identified as experiencing AUD, provision of effective signposting and support for patients was adversely affected by lack of staff awareness about relevant care providers and lack of capacity in local services due to the impact of austerity and cuts to public services. Two trusts in the study region had ACTs in place at the time of the interviews, as part of the wider NHS commitment to reduction alcohol harm in England [ 16 ]. This appeared to have increased the capacity of the non-specialist workforce at these two sites to refer patients identified as experiencing AUD onto appropriate specialist support. However, a tentative, but notable, finding of this study was that while ACTs were making a difference in these trusts for those with existing alcohol dependence, they were limited in their capacity to deliver more preventative work around AUD (initially part of their remit) due to the high level of need amongst the dependent patient population. This warrants further exploration, with further insights potentially to come via the wider programme of work around ACTs that is currently ongoing in England [ 46 ]. Overall, the study provides empirical evidence that the implementation of the preventative practices to support a reduction in AUD may be particularly difficult in areas of deprivation such as the NENC meaning that inequalities are likely to be widening with other more affluent regions.

Stigma, the process of marking certain groups as being somehow contagious or of less value than others [ 47 ], is internationally recognised as a significant constraining factor to the delivery of compassionate and appropriate healthcare for patients with AUD and other substance use in secondary care and other health and social care settings [ 47 , 48 ]. In this study we chose to approach stigma as a structural and relational concept, seeing relational stigma as developing from structural stigma [ 49 ]. The role of structural stigma for limiting the implementation of identifying, supporting, and signposting patients with AUD was striking, as our data highlighted that the prevention of heavy alcohol use does not appear to be a visible priority within individual trusts, and arguably the wider NHS. Limited resources were perceived available for this area of care, and little visible commitment to support patients with AUD despite the scale of the problem. Stigma was also evident at a relational level in our participants accounts of the interactions between staff and patients, notably staff’s reluctance to ask about alcohol use and their perception that patients did not want to disclose their AUD. However, it should be noted that many of the staff who took part in the study suggested that they did not perceive patients in this way yet continued to struggle to provide alcohol prevention care. Thus, this relational stigma is likely an important, but only partial explanation for limited care provision. Nonetheless, our findings suggest that structural stigma is one of the main barriers to the identification of alcohol use and care in secondary care settings in the NENC. This echoes the damning findings of the ‘Remeasuring the Units’ report, also published since the pandemic, that argued that stigma contributes to the missed opportunities in secondary care for patients who ultimately die from alcohol-related liver disease [ 5 ].

This study was conducted primarily as a vehicle to understand and bring about change in workforce practice around the prevention of alcohol harm in NENC secondary care services. It was an integral component of a broader Health Care Needs Assessment (2022) on alcohol undertaken in response to increasing levels of alcohol harm in this region of the UK, which led to recommendations over four overarching themes: service delivery; workforce; data; and leadership from the healthcare system. The results of the study have directly shaped the regional strategy for the reduction of alcohol harm, a key element of which is the integrated alcohol workforce strategy for the NENC which aims to better support the NHS workforce to prevent alcohol harm through: increased awareness of the Chief Medical Officer alcohol guidance; improved pathways to community-based alcohol treatment and recovery support; workforce training and development; and support for staff to address their own drinking. The evidence highlighting the importance of stigma have additionally led to a strategic drive for senior leaders to acknowledge the impact alcohol has on their organisation and the communities they serve, and to take action to work in partnership to reduce this. There is also cross-system support to tackle relational stigma, initially though a co-ordinated multi-agency media campaign.

Overall, our interpretation has signalled areas of policy and practice which can be targeted to try to increase the uptake of these preventive strategies in the secondary care settings. However, ultimately the findings illustrate that the challenge for implementation of these evidence based preventative measures is not just upskilling the workforce or increasing resources. It also indicates that we need to address the complex interplay of contextual factors and implementation mechanisms which have been compounded by the pandemic and contribute to reinforcing and increasing existing inequalities. The works contributes to calls for a multi-layered response to reducing alcohol harm and wider cultural change for how alcohol use and substance use is perceived.

Study strengths and limitations

A strength of the study is that it was undertaken in an area experiencing some of the greatest inequalities from the COVID-19 pandemic. This allowed us to see the challenges to delivering preventative work in these contexts, which might be similar in other regions. A further strength is that mapping the empirical data onto an evidence-based implementation theory, which has been widely use in different settings, enabled us to focus on the aspects of the implementation, that are likely to be important across other settings too. Framing the interpretation using the NPT domains has helped us to emphasise how contexts and mechanisms interact to make the implementation at this particular time and place difficult. A key limitation of the study is that as it was based in one region of England, we cannot know for sure if these insights are transferrable beyond this context.

Secondary care hospitals are an important setting for the delivery of preventative care for AUD, due to the frequency with which AUD co-occurs with other physical and mental health conditions. Prior to the pandemic there was evidence that non-specialist healthcare staff can find caring for patients with alcohol-related presentations difficult, meaning that identifying, supporting, and that signposting patients was happening inconsistently. In this study, we highlight the additional challenges facing secondary care staff due to post-pandemic pressures and the significant rise in alcohol-related harm in some regions such as the NENC. Thus, whilst the mechanisms for implementing alcohol prevention work in secondary care need attention, our findings suggest that the greatest barrier is contextual, including widespread structural stigma.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Normalisation Process Theory

Alcohol Care Teams

North East and North Cumbria

Alcohol Use Disorder

Accident and Emergency Department

Psychiatric Liaison Teams

Alcohol Use Disorders Identification Test

Alcohol Use Disorders Identification Test Consumption

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Acknowledgements

In addition to co-authors WH and RB we are grateful to the four junior doctors Jamie Catlow, Rebecca Dunn, Sarah Manning and Satyasheel Ramful from the Gastroenterology Research and Audit through North Trainees who collected data for the study. We are grateful to Dr Matthew Breckons the qualitative methodologist who co-trained (with AOD and KJ) the junior doctors in qualitative interview skills. We are especially grateful to the thirty staff who gave up their time to participate in the research.

The project was funded by the North East and North Cumbria Integrated Care System Prevention Programme.

AO is Deputy Theme Lead – Prevention, Early Intervention and Behaviour Change within the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC) (NIHR200173). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. AO and KJ are also part-funded by a NIHR Advanced Fellowship (ADEPT: Alcohol use disorder and DEpression Prevention and Treatment, Grant: NIHR300616). The NIHR have not had any role in the design, implementation, analysis, write-up and/or dissemination of this research.

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SH and RB designed the study; SH, RB and WH were involved in the data collection; IL and KJ analysed and interpreted the data with support from AOD, SH, RB and WH; KJ drafted the manuscript with support from SH, AOD, RB, IL and WH. All authors approved the submitted version.

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Jackson, K., Baker, R., O’Donnell, A. et al. Understanding the challenges of identifying, supporting, and signposting patients with alcohol use disorder in secondary care hospitals, post COVID-19: a qualitative analysis from the North East and North Cumbria, England. BMC Health Serv Res 24 , 772 (2024). https://doi.org/10.1186/s12913-024-11232-4

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• HHK Wilson 1 , 2 , 5 ,
• B. Harris Roxas 2 ,
• N. Lintzeris 1 , 3 , 4 , 5 &
• MF Harris 5  

BMC Primary Care volume  25 , Article number:  236 ( 2024 ) Cite this article

Metrics details

Chronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs’ experiences diagnosing and managing pOUD in their chronic pain patients.

This qualitative research used semi-structured interviews and a case study to investigate GPs’ experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual’s perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed.

Twenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions.

Conclusions

Negative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.

Peer Review reports

‘Fear is the cheapest room in the house. I’d like to see you in better living conditions’ Hafiz, Persian mystic and poet.

A leading cause of disability worldwide [ 1 ], chronic pain is defined as persistent pain continuing for longer than 3–6 months and occurring on most days [ 2 ]. It is a complex condition, ‘an individual, multifactorial experience influenced by culture, previous pain events, beliefs, expectations, mood and resilience’ [ 3 ]. It has been estimated that 20% of Australians over age 45 experience chronic pain [ 2 ]. Nearly one fifth of patients seen by their general practitioner (GP) are suffering chronic pain [ 4 ]. Rates of opioid prescribing by Australian GPs for chronic pain are high [ 2 ]. One or more opioid prescriptions, mostly oxycodone, were provided to 3.1 million (13%) of the Australian population in 2016-17 with 1.5% (46,500 people) taking them on a daily basis [ 5 ].

Long term opioid use, that is, daily use on most days for more than 3 months [ 6 , 7 ], is associated with increasing evidence of significant harms and limited effectiveness for chronic pain [ 8 , 9 , 10 , 11 ]. Risky opioid use or non-medical use of opioids in people prescribed opioids is common [ 12 ]. Opioid risk increases with dose and length of use [ 13 , 14 ]. Each day, in Australia, three people die and 150 are hospitalised due to pharmaceutical opioid overdose [ 5 ]. Other significant health risks include hyperalgesia (increased pain sensitivity), endocrine abnormalities, falls, fractures, motor vehicle accidents, aberrant medication behaviours and medication on-selling or sharing [ 8 , 15 , 16 , 17 ]. Nearly one in 10 people prescribed opioids for chronic pain in Australia meet criteria for Opioid Use Disorder (OUD) [ 14 ]. OUD is categorised by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM-5-TR) as a pattern of opioid use with clinically significant impacts [ 18 ]. Opioid Agonist Treatment (OAT), is an evidence-based treatment for OUD and prescription OUD (pOUD) and includes two opioid medications, methadone and buprenorphine [ 19 , 20 ]. In Australia, state based OAT programs allow GPs to diagnose and prescribe methadone and buprenorphine for OUD [ 21 ]. This treatment, like many other chronic conditions, can be appropriately managed for many patients in general practice [ 22 ].

In the UK, 50% of GPs prescribed OAT in 2005 [ 23 ]. While in Ireland, 54% of GPs trained in the management of OUD in 2018 [ 24 , 25 ]. In 2022, in contrast, 2,352 private prescribers (mostly GPs) provided OAT Australia wide [ 26 ]. With 31,926 GPs working in Australia in 2022 [ 27 ], this suggests low engagement, with only 7% of Australian GPs providing OAT. This is supported by research that suggests Australian GP assessment of pOUD, management with OAT and referrals for OUD to specialist Alcohol and Other Drugs services are low [ 28 , 29 , 30 ]. Australian and international literature suggests that issues of stigma, poor remuneration, low knowledge, confidence, and lack of specialist support adversely affect GP involvement in OAT [ 31 , 32 , 33 , 34 ]. Our recent scoping review found that current published literature described GPs’ concern regarding risk of prescription opioid overdose, addiction and diversion, but screening for pOUD was haphazard [ 35 ]. We could find no literature that explored Australian GPs’ experience of diagnosing and managing pOUD in their chronic pain patients for whom they prescribed opioids [ 35 ].

Research aim

This research aims to gain an in-depth understanding of GPs’ attitudes and experience diagnosing and managing pOUD in their patients’ prescribed opioids for chronic pain in the community general practice setting in the state of New South Wales, Australia.

Study design and setting

This qualitative study used semi-structured interviews to explore GPs’ experience of diagnosing and managing pOUD in patients prescribed opioids for chronic pain. The semi-structured interview method was chosen as it is useful to investigate individuals’ subjective experience [ 36 ]. We used the Theory of Planned Behaviour (TPB) to frame, code and investigate the issues [ 37 ].

TPB assesses an individual’s perception of the issues that surround a decision to undertake a behaviour and elucidates the factors that increase or decrease intention to undertake this behaviour. It describes three subjective factors perceived by individuals: subjective behavioural, normative and control beliefs. Behavioural beliefs are guided by emotions (affect) and thoughts (cognition) and inform positive and negative attitudes. Normative beliefs are guided by perceived social norms; what a person thinks others do themselves and whether others support or oppose the individual undertaking the behaviour. Control beliefs describe barriers or facilitators, both internal, e.g., knowledge, and external e.g., time. The negative or positive strengths of these three factors affect intention to undertake a behaviour, which influences whether the actual behaviour is performed [ 37 , 38 ]. The theory also suggests that subjective control beliefs can directly influence behaviour [ 39 ]. See Fig.  1 .

It is important to note that TPB only addresses individuals’ perceptions. It is not a model for behaviour change nor does it systematically address how systems affect behaviour.

The interview guide asked about participant’s experience with chronic pain and pOUD through the lens of TPB and their awareness of any policies or strategies to support GP opioid prescribing. (See supplemental File 1 – interview guide).

TPB factors and how they affect behaviour

A two-part case study supported the interview guide. Part one, depicted a 42-year-old woman prescribed opioids in hospital after acute pelvic and spinal injury some years previously, who attends her GP practice regularly for opioid prescriptions. Part two describes signs and symptoms that suggest pOUD. (See Table  1 ).

Participant recruitment

GPs in New South Wales (NSW), Australia, were recruited via Primary Healthcare Networks, an Australian GP Facebook page called ‘GPs Down Under’ and via snowballing by email. All interviews were undertaken via a video conferencing platform (Zoom) from May to September 2021 by the lead author (HW). To be eligible, participants needed to be federally registered as medical practitioners, and working in the community primary care setting in NSW. The study was limited to NSW due to variations in opioid and OAT prescribing legislation and accreditation in each state/territory in Australia.

Data collection

The interviews were audio recorded, transcribed verbatim and de-identified. Data were stored on a secure server. A reflective journal helped support the audit trail.

Data analysis

The data were analysed deductively using the mid-level theoretical framework of TPB [ 37 ] and inductively with open coding, including thematic analysis [ 40 ]. Top-level codes were grouped under the ‘a priori’ conceptual categories of subjective behavioural beliefs, subjective normative beliefs and subjective control beliefs while open coding allowed the analysis of other aspects that were seen to be important [ 41 ]. Higher-order concepts were interpreted through testing of codes, reiterative reflection, and extensive rereading of transcripts. The data was managed via QSR N-Vivo software. Authors HW and BHR reviewed the transcripts to support data accuracy and integrity.

COREQ checklist for qualitative reporting [ 42 ] are included in supplemental file 2 .

Researcher positionality

We used an interpretive description approach. This emphasised analysis of in-depth contextual description, drawing on interpretation, clinical and research experience in order to understand practice-based issues [ 43 , 44 ]. The lead researcher (HW) is a GP, addiction specialist and PhD student with extensive clinical experience managing chronic pain, prescribing opioids and OAT. The senior researchers include a GP (MH), a primary care researcher (BHR) and an addiction specialist (NL).

Ethics approval

Ethics approval was obtained from the Human Research Ethics Committee of the South Eastern Sydney Local Health District (HREC 18/018 (LNR/18/POWH/156) and University of NSW HREC18/018. All methods were carried out in accordance with relevant guidelines and regulations and informed consent was obtained from all participants involved in this study.

Twenty-four GPs took part in the study. They all saw patients with chronic pain and 23 reported currently prescribing opioids for this indication. Fifteen were female. There was a wide range of ages and practice experience. Participants worked across metropolitan, regional and rural NSW [ 45 ]. Five prescribed OAT currently (one was a GP and a Fellow of the Chapter of Addiction Medicine) and 2 GPs reported prescribing OAT in the past but not currently. (See Table  2 ).

This study used the three factors in TPB (see Fig.  1 ) to analyse the interviews, however there was an overarching universal theme of holistic and complex care.

Holistic complex care in the general practice setting

Participants gave extensive responses to the case study patient’s presentation and her social, vocational, family, mental and physical co-morbidities. This universal approach may be linked to each participant’s identity as a GP and appeared integral to their professional approach to patients.

 ‘….how does the pain limit what she can do? how’s it affecting her relationships? What else is going on for her husband and her teenage kids?   Endometriosis (a disorder of abnormal spread of the womb lining) … the psoriasis (a chronic skin condition) … mental health issues… she’s probably perimenopausal (the period of time around menopause) … she hasn’t even managed to get back to work…’ (GP18, female, metro, established GP).

Participants were aware of the complexities of managing chronic pain and suggested that chronic pain rarely presented alone, and this was difficult to adequately address.

‘No one ever comes in just for their chronic pain. And it’s a 15 minute consultation, usually that they’ve booked. And there’s a lot of other things going on….a lot of them are either too disorganized, too much going on with their life socially or within other medical conditions…’ (GP4, female, regional, new fellow).

Sitting underneath the theme of ‘holistic complex care in the general practice setting’ were the three factors of TPB.

Subjective behavioural beliefs diagnosing and managing pOUD

Many participants sighed or paused for long periods when answering questions related to diagnosis and management of pOUD in chronic pain patients prescribed opioids.

Positive salient affective/cognitive (thoughts/feelings) beliefs

Some participants described positive thoughts and feelings about diagnosing and managing pOUD. This included being a good doctor, doing the right thing, achieving something difficult and appropriate treatment leading to better patient outcomes.

‘because when you have the right diagnosis…. you have the right treatment…’ (GP1, male, rural, new fellow). ‘…it would benefit several of my patients in real life, and it would certainly benefit Judy’ (case study patient). (GP3, female, rural, registrar)

Negative salient affective/cognitive (thoughts/feelings) beliefs

Drawing on past experience, most participants expressed high levels of negative thoughts and feelings when considering pOUD in chronic pain patients. They described the case study as ‘really difficult’ and a ‘heart sink patient’ , like patients they had seen in the past. Patients, whom, they had found to be time-consuming and someone they didn’t want to see or knew they would continue to think and worry about after the consultation.

‘a demanding patient… one of those patients, … oh, I have to see her today or you’d go home, and think, oh, why did I say that, or do that. So it’s one of those patients, that you kind of dwell on before and after the consult…’ (GP10, male, rural, established GP).

Most participants described the difficulty and futility of trying to talk to chronic pain patients about changing their opioid treatment.

‘You raised it a hundred times previously and like a broken record, you raise it again and at some point, you think, what’s the point? Like, I raised it a hundred times and it gets nowhere so why should I bother?’ (GP9, male, regional, established GP).

Many expressed a sense of nihilism, that there was not much they could do beyond prescribing opioids.

‘…you feel like there’s nothing I can do, apart from giving them this medication…’ (GP9, male, regional, established GP).

Participants were worried that diagnosing and managing pOUD would fracture the GP-patient therapeutic alliance.

‘… feeling like the rapport is broken, that they won’t come back and see you and you have no idea what happens to them …’ (GP16, female, metro, new fellow).

Some participants expressed regret prescribing opioids and described feeling guilty and complicit. They felt a personal responsibility for opioid harms experienced by patients.

‘…you have to come to terms with the fact that you have done something, which actually is not good health care. You know that’s a pretty sobering thing to realize that you’ve actually been complicit…’ (GP14, female, regional, established GP). ‘I feel quite guilty when people come in and they’re like this, because we’ve started (opioids)…. and now this person is in a whole heap of trouble, and mess. ’ (GP9, female, metro, established GP).

The risks of prescription opioid overdose and withdrawal were recognised by all participants. This led to feeling overwhelmed by the situation for some participants.

‘…if you do give them the medication you’re worried about them overdosing, if you don’t give them the medication you worry about them getting withdrawal symptoms…’ (GP17, male, metro, established GP).

Many participants described the onerous responsibility of managing pOUD long term if they diagnosed it, as they believed management was going to be difficult.

‘I don’t want to be the one to do it, because I don’t want to be the one that’s taking responsibility, I know this sounds horrible, but I really don’t want to be the one that’s taking responsibility for the ongoing care with this because I know that it’s gonna be really difficult…’ (GP20, female, new fellow, metro).

Some suggested that with all the competing demands placed on GPs, addressing pOUD was low on their priorities. They suggested that this was a group of people who appeared stable and didn’t complain about their medication. As a result, some participants suggested they found it easier to continue prescribing opioids for the management of chronic pain. The participants found considering the issue of pOUD immediately made the happy patient unhappy and took time, was complex and impossible to manage.

‘…these people generally are stable, they’re often not complaining too much, they just pitch up every four weeks, and we, we forget actually, it becomes very low on that list of priorities, if I’m honest, I think it just sort of gets sucked up in doing everything every day, and you have to actually make that conscious decision, are you going to address this problem?’ (GP4, female, metro, established GP).

Many participants expressed a guilty relief when patients with complex chronic pain presentations stopped seeing them. They expressed concern about the risk of burnout.

‘….you never want to be sacked by a patient, but I wasn’t disappointed….she was quite a demanding patient saturating my energy and my time…’ (GP11, male, rural, established GP). ‘…they’re long hard consults… you risk burning out really…I don’t want to burn out by loading up my days with dealing with this…’ (GP10, male, rural, established GP).

Most participants described feeling uncomfortable and avoiding difficult conversations about pOUD with chronic pain patients. As health professionals they wanted to help and found it difficult to frame the conversation in a way that would assist the patient to reconsider their treatment.

‘…how do I really explain that well to the patient, because a lot of them will just think, you’re not helping me, or you’re taking away something that I need. And I think that’s the hardest thing as a GP….is that you want to help. And so, if you’ve got someone saying well this is helping me and you’re taking it away, how you explain, frame that for them, I still find really difficult…’ (GP4, female, regional, established GP).

The difficulty of the conversation seemed to lead to therapeutic inertia for the participants.

‘…and especially if I’m running late, or busy or if I’m tired, there’s a temptation to just, you know, tie them over. Yeah, not have that difficult conversation.’ (GP9, male, outer metro, established GP).

The participants with training in the management of OUD expressed similar negative experiences and attitudes.

‘I find these patients really, really difficult. With what I feel is a reasonable amount of experience and knowledge about how to treat…I still feel uncomfortable…’ (GP3, male, metro, established GP).

Most participants noted that while the patient in the case study seemed to have some insight into their situation, this was uncommon. In their experience, patients had little insight or desire to change their medication and could not perceive doing anything differently. The discussion felt like a battle where the GP tries to discuss changing treatment and the patient defends their position.

‘…it’s ‘why are you even asking me this question, it’s not a problem, …it’s never been a problem before?’ … they know that they have to put up a fight to get the script, because there’s a general sort of culture of ‘no I don’t want to give this medication to you’ every time. You know, every time I ask, I have to fight for it.’ (GP2, female, rural, established GP).

Prescribing opioids for chronic pain was seen as part of a GP’s role but many did not consider managing pOUD as ‘usual business’.

‘…prescribing opiates, even large doses of opiates…the vibe is it’s a normal part of general practice, while the vibe is, I think, perhaps treating substance use disorders, and maybe particularly with opiate use disorders is not….’ (GP15, male, metro, established GP).

Some participants described the need to actively work to change their mindset, to stop and consider that the treatment they were providing could be causing harm.

‘I remember having to stop and just go, hang on, I am giving this medication that is causing her more harm, and it was such a different mindset for me to have to just go, this is not working and it was a medication I was prescribing for her.’ (GP13, female, metro, established GP).

Subjective normative beliefs diagnosing and managing pOUD

Diagnosing/managing poud supported by others.

Many participants perceived that specialist pain and addiction services were happy for them to diagnose and manage pOUD as this would relieve pressure on their services. One participant suggested that some of their GP colleagues were supportive, but only because this meant they would not have to do this themselves. This was seen as a perverse disincentive to diagnose and manage pOUD.

‘…it would be; ‘I’m (The GP colleague) really glad that you’re (the participant) doing this so I don’t have to do it, and then everyone would refer…rather than taking it on themselves…’ (GP2, female, rural, established GP).

Diagnosing/managing pOUD NOT supported by others

Some participants suggested that while they might be happy to undertake diagnosing and managing pOUD, they had to consider their colleagues who may be concerned about risks and how this would affect practice amenity and other patients’ safety. Some participants suggested that staff would not approve of people with pOUD and did not want ‘these patients’ in the practice.

‘Changing the stigma of my (senior) colleague…it’s not going to be easy to change his mind about things, change his views, his perception, and he would feel like, ‘what are you turning this clinic into?’’ (GP6, male, metro, new fellow).

Most participants perceived that patients themselves did not want a pOUD diagnosis, they did not want their management to change or become part of a stigmatised patient group, they did not want referral to drug and alcohol services and did not see themselves as possibly needing a change in treatment plan, such as deprescribing or OAT.

‘…this poor girl literally sat in my room crying, being like, “I don’t want to be labelled a druggie”….’ (GP19, female, metro, new fellow). ‘…they don’t see themselves as someone who should be on methadone or suboxone. And there’s a lot of shame and stigma around that …’ (GP2, female, rural, established GP).

Some participants recognised the complexity of dual diagnosis of chronic pain and pOUD and described a regulatory system that had a dichotomous view of the patients, they were either pain patients or had pOUD who had to be treated with OAT. For the participants, this meant that pOUD diagnosis inexorably led to OAT, something that no patient wanted. To avoid this, they avoided the diagnosis of pOUD.

Administrative staff responding to demanding patients at reception added to a sense for some participants that they were powerless and this increased the chance that an opioid prescription would be written and decreased their ability to drive change.

‘…they’re (patients) putting pressure on reception staff to make sure they’ve got the script. And so, I guess there’s that pressure to do what they wanted…and in the time they wanted it to be done. And I can feel that kind of balance of power on the doctor patient relationship. Switching more to them being in control, being more and more demanding and telling me what I was going to do, rather than me guiding them on optimal treatment and actually being able to help them make a change’ (GP18, female, metro, established GP).

Participants who currently prescribed OAT were less affected by the social norms of colleagues but were equally concerned about the patient’s desire not to be diagnosed.

Diagnosing/managing pOUD undertaken by others

GP colleagues who undertook OAT prescribing were seen as addiction colleagues not as mainstream GPs by non-OAT prescribing GPs.

‘….she (GP Colleague) is the addiction specialist…’ (GP24, male, rural, established GP).

This suggests that treating pOUD was not normative for GPs. Participants had little experience of other GPs prescribing OAT. Those who did prescribe saw this as a professional responsibility rather than something they wanted to do.

‘I’m not really interested in taking (more of) these (OAT) patients on …that’s just being honest.’ (GP10, male, rural, established GP). ‘It’s not my forte in general practice and I must admit, this isn’t something I seek out.’ (GP22, female, metro, new fellow).

Subjective behavioural controls diagnosing and managing pOUD

Internal behavioural controls.

Many participants described lack of knowledge, skills and low confidence with diagnosis and management of pOUD in chronic pain patients. Many participants without addiction training did not know the criteria for the diagnosis of OUD.

‘…it is something that I don’t know a lot about, I don’t see a lot of, I’m not doing it all day long…’ (GP 11, female, metro, established GP).

Younger participants suggested they would be happy to prescribe but did not have the knowledge and skills needed to do this.

‘.it’s a knowledge and management thing rather than an I don’t want to do it. I just feel like I’m not sure how.’ (GP7, female, rural, registrar).

Many participants indicated that they felt unprepared to be involved in the management of pOUD. They suggested that patients with aberrant behaviours such as injecting and diverting medication needed addiction services and that they would not be able to manage these issues. For this group of GPs, patients exhibiting aberrant behaviour were negatively compared to chronic pain patients with dependence on pain medications.

‘…if I’m suspecting substance abuse behaviours rather than dependence on the medication someone with chronic pain can have, then it changes things, I need to involve more of an addiction specialist, or addiction services rather than to continue prescribing myself…’ (GP 12, female, rural, established GP).

Referral to specialist services was considered by most participants. They suggested that they would tend to refer patients like the case study to pain specialists and would be reluctant to refer to drug and alcohol services.

‘I haven’t done it (referred to drug and alcohol) for a long, long while, though…I probably haven’t had a lot of experience with it…’ (GP18, female, metro, established GP).

Concern and fear of perceived risks associated with prescribing OAT for pOUD in their chronic pain patients was a feature of many participants’ responses. They were concerned that prescribing OAT would lead to an influx of patients requesting this treatment and worried about being overwhelmed by this demand.

‘I don’t necessarily want to open the floodgates to all of the people who might be interested or need my help in that zone because there’s so much of it around here, and I don’t think that I can treat or see them all and I’m scared that if I open up that door that it will be never ending.’ (GP2, female, regional, established GP).

External behavioural controls

Lack of time, money and support, were universal to the participants’ experience. They described how limited consultation time and poor remuneration stopped them from engaging in what they saw as difficult, time-consuming conversations. The lack of adequate remuneration suggested for them that GPs’ time and effort was not valued.

‘…they’re long hard consults…not paid, as well as what you deserve to be remunerated for, you know how much effort you’re putting in and how much reward you’re getting financially is not great…at the end of the day …you want to feel valued…’ (GP10, male, rural, established GP).

Conversations with patients about their pain and opioid use were made easier with more consultation time for many participants.

‘I think, framing things correctly, is more difficult when you don’t have time. Just having plenty of time available and having just that sense of calm. It just makes your difficult conversation much easier.’ (GP 9, male, outer metro, established GP).

Treatment affordability was described by many participants as an important barrier preventing many patients from accessing alternatives to opioids.

‘…a lot of the alternative things that I can use though, are very restricted financially depending on your patient…’ (GP8, female, metro, established GP).

Participants working in private billing practices (government funded with additional patient co-payment) suggested a different experience compared to working in bulkbilling (wholly government funded) practices. These participants suggested their patients, who had higher levels of education, health literacy and better financial status, showed higher engagement with advised treatment options and greater ability to pay for more costly alternative treatments.

‘a lot of our patients are very much about prevention and trying to get off medication…because we’re private clinic,…that changes the dynamic and… I would say probably (the) overwhelming majority of my patients have…. university degrees and they’re pretty well educated and…have high health literacy.’ (GP16, female, metro new fellow).

Low levels of specialist support were seen as a barrier to assisting patients with chronic pain and pOUD by most participants.

‘I just don’t have necessarily have access to a chronic pain team or that kind of help…’ (GP7, female, rural registrar). ‘…the couple of times I’ve tried to work with drug and alcohol. The doctor I’ve spoken to hasn’t been that helpful and so that’s made me more reluctant to talk with them, because it’s kind of feels like well wherever I turn my patients are getting knocked back. And so, it’s hard to access this specialist support for my patients.’ (GP18, female, metro, established GP).

One GP who expressed interest in providing OAT described how he was inundated by patients from the public addiction service and had to stop accepting referrals. This was compounded by the lack of promised support from the specialist service.

‘I just got pummelled and eventually ended up saying, no. Sorry, I just don’t have the capacity to take on large numbers of patients, but also because the promise the system, the reality was always substantially less than the expectation, in terms of that support availability.’ (GP24, male, rural, established GP).

The role of specialist patient centred shared care and support was seen as a great advantage by many participants and one that could lead to better outcomes.

‘I think it can be fantastic, obviously, to have a shared care arrangement where, especially with complex comorbidity, then the more people on the team and the more eyes on the situation, the better the outcome is for the patients, 100% having expert advice that’s accessible and patient centred is terrific.’ (GP11, female, metro, established GP).

Some suggested that they had good understanding of their patient within their context and knew what local services were available. They suggested the value of good professional relationships with their local pharmacists.

‘I can ring my community pharmacist and go, Hey, what do you think about this person and their dosing? Do you think that there’s any issues or like, how do you think that they should go? …and I feel like I can trust them, I know them because they’re around the corner.’ (GP2, female, rural, established GP).

Many participants were worried that patients might experience stigma with other health professionals. This led to avoidance of using the term pOUD, with patients, in the medical record or letters to other services. They suggested that this may lead to inferior treatment by other health professionals.

‘I don’t love labels…if I’m referring a patient to hospital,…I don’t want them to be discriminated against any way…’ (GP12, female, rural, established GP).

The three TPB factors investigated in this study are summarised in Fig.  2 below.

Theory of Planned Behaviour factors

This study, based on GP self-report, explored the subjective behavioural, normative and control beliefs that impact pOUD diagnosis and management in patients prescribed opioids for chronic pain. Overall, the beliefs expressed by the participants suggest there will be low intention and therefore low levels of actual diagnosis or management of pOUD if this develops in their chronic pain patients on opioids.

All participants responded to the scenario in the case study with a holistic generalist approach considering the impact of multiple biopsychosocial issues. They gave considered, thoughtful responses regarding their difficulties and their failings in their approach to working with patients prescribed opioids for chronic pain.

Participants expressed feelings of conflict and futility in the face of diagnosing and managing pOUD in their chronic pain patients. They described negative emotional experiences, discomfort and fear, and feelings of being complicit in causing harms to their patients. They suggested that diagnosing and managing pOUD was important, but this was outweighed by their past experiences of difficult conversations, difficult patients, fragile therapeutic alliances, a lack of sense of control and a sense of futility and powerlessness that they could positively influence their patients’ use of opioids. This led to avoidance of these conversations. Difficult conversations with patients experiencing chronic pain have been previously described in the literature [ 46 ], but to our knowledge, the difficulty of conversations around diagnosing and managing pOUD in patients prescribed opioids for chronic pain has not been studied.

Diagnosing and managing pOUD was not the norm for participants and impacted by lack of support from colleagues, practice staff and specialist services [ 32 , 47 ]. The idea that staff did not want “these patients” in the practice belies the fact that patients with pOUD were already in the practice, just not yet diagnosed. Participants described positive support from some of their medical colleagues, but only because this enabled those colleagues to avoid diagnosing and managing pOUD themselves. Paramount was the lack of positive patient social norms. Participants believed that patients didn’t want to have these conversations, they didn’t want the diagnosis, or change in management. Participants believed that their patients saw themselves as pain sufferers, that they needed their opioids and did not want to consider management that would make them part of a stigmatised group of people with OUD.

Participants had few role models to provide them with a basis to undertake this behaviour. They expected to be left unsupported and unable to provide the level of care required for this chronic condition. Prescribing for pOUD was not seen as ‘normal’ work for many participants, but rather as specialist work, outside the responsibility of general practice. No one wanted this diagnosis, not the patient, not the participant and not the participant’s GP practice. The risk of ‘inundation’ that participants felt is compounded by a long standing lack of ODT prescribers [ 28 ] and the resulting unmet treatment need in Australia [ 48 , 49 ].

Participants described low levels of knowledge, skill, and confidence as well as barriers including limited time, remuneration, little specialist support and difficult regulatory requirements. Internal and external behavioural controls to prescribing OAT; lack of skill, knowledge, confidence, time, remuneration and specialist support have been described in previous studies [ 31 , 32 , 33 , 34 ]. External controls also speak to systemic and structural issues, particularly time constraints that are integral to the ‘fee for service’ structure in Australian general practice [ 50 ].

Participants were highly aware of the risks associated with long term prescribed opioids [ 51 , 52 ]. However, their knowledge of pOUD, the variety of treatments available and regulatory requirements was often incomplete. The task of re-considering treatment options required participants to re-orient their approach deliberately and consciously. This did not come easily. Putting limits and boundaries on patient opioid requests was conflictual. Negotiating a person-centred approach that did not give in to patient demand was perceived to be difficult. Participants considered the role of reducing opioid dose, changing treatment plan but avoided the diagnosis of pOUD as they felt they had to choose between continuing the status quo, or diagnosing pOUD, a diagnosis that they felt must inexorably lead to a difficult change in management and force them to move the patient to treatment with methadone or buprenorphine under the NSW OAT program [ 53 ], despite the fact that this is not mandatory. This decreased participants’ intent to diagnose and manage pOUD and dovetailed into the participants’ fear that they would be overwhelmed by demand.

Stigma is often cited as a reason GPs avoid treating addiction [ 54 ]. Experience of stigma and discrimination prevents people seeking or staying in care, leading to poorer treatment effectiveness and adverse patient outcomes [ 55 ]. Stigma and bias were important factors driving participant beliefs and intentions in this study. This was not simple and had two important aspects; participants’ lived experience of difficult conversations with patients at risk of pOUD and their concern about the risk of patient stigma and discrimination by colleagues and other health services. Past experience led to a tendency to believe that all future conversations would be conflictual, that all patients would be complex [ 56 ], when in fact there are a wide range of patient presentations and levels of stability [ 57 ]. Both past experience and concern about stigma from other services led to inertia and avoidance of the conversation and the diagnosis. Medicolegal concerns about the implications of diagnosis were important, however participants were also aware of the risk of not diagnosing pOUD, including medicolegal risk [ 58 , 59 ]. On balance, the difficult emotional work, lack of social norms and adverse internal and external behavioural controls pushed them towards inaction, despite the risks.

Strengths and limitations

This study examined the lived experience of GPs working in rural, regional and metro NSW. The participants spoke frankly about their difficulties. A qualitative method with a mid-range theory supported the study’s ability to do this as did the insider status of the GP interviewer.

Our participants included female GPs who tend to see more patients with complex and psychological issues [ 60 ] and younger GPs who may be more open to addressing addiction [ 61 ]. As a result, this group may be more open to the issue of pOUD in chronic pain and reluctance to diagnose and manage pOUD may be even stronger among other Australian GPs.

The study relied on participant’s self-report. Memory may have been selective, misattributed or exaggerated. Participants may have wished to appear more confident and comfortable than they really were. Social desirability bias may have led them to report what they felt they should do rather than what they actually do in practice. This may have been mitigated by the use of an experienced ‘insider’ interviewer; a GP who has experienced the issues and as a result was able to put participants at ease using a curious questioning style that encouraged frank discussion.

Australian State and Territory regulatory requirements limit access to OAT. In NSW, GPs can prescribe for up to 30 people without training and for 200 after training [ 62 ]. This is more liberal than other Australian jurisdictions, which have a varied range of prescriber restrictions. Given the complex barriers experienced by GPs in NSW, it is likely that less liberal rules in other jurisdictions will further negatively impact GPs’ willingness to prescribe OAT.TPB describes a framework for individual intention, and it is important to address systems issues that impact on behaviour, including societal stigma, fear and loathing of people with substance use disorders and lack of legitimacy for these as a chronic medical condition. Constraints including time, remuneration and regulatory requirements are both perceived and actual, they are structural and systemic. TPB cannot address this and is limited to individual intentions.

This research is limited to the experience of GPs and does not investigate the perspectives from other stakeholders such as patients, carers and policy makers.

Our analysis suggests that there were major perceived barriers to diagnosing and managing pOUD in patients prescribed opioids for chronic pain by GPs in general practice in NSW, Australia. Negative attitudes, negative social norms and negative perceived behavioural controls lead to low intention to diagnose and manage pOUD, and therefore low chance that this will occur, a decision which is associated with potential significant harms. Without adequately addressing these barriers, we cannot hope to change this.

Implications

Understanding GPs’ past negative experience and the influence of this on current behaviours is core to improving the diagnosis and management of pOUD in chronic pain patients prescribed opioids. It is essential to address not only the perceived behavioural controls such as time, remuneration and skills, but also to reduce the negative beliefs and strengthen appropriate social norms for GPs. These may be addressed by giving GPs opportunities to reflect on their patients with chronic pain through audit and education that includes building skills to manage difficult clinical interactions [ 63 ]. Repeated and early exposure to these complexities for doctors in training may assist. Ensuring people with lived experience of pOUD are involved in leading this training would be helpful as may building role models and champions [ 64 ] in primary health networks and GP colleges.

Additional support from specialist services to GPs (both in managing chronic pain and pOUD), training other team members in the practice on pOUD, including reception staff/practice managers, nurses, and allied health staff will ensure they have better understanding of the complexities of patients’ issues and skills to manage these. Providing a signal that this care is supported and valued through changes to funding mechanisms, i.e., creating specific Medicare item numbers for this treatment may also positively impact social norms.

Better understanding of the treatment options for people who develop pOUD for GPs with comorbidity (chronic pain and pOUD) treatment guidelines could improve knowledge and better nuanced regulatory approaches may support this.

There have been several policy changes in Australia including OUD prescribing guidelines, regulatory changes, and the introduction of real time prescription monitoring. It is unclear if these changes will be sufficient to change the frequency that pOUD is diagnosed and managed in general practice. Further investigation through the lens of TPB will help government, policy makers and service managers to assess the positive impact of these changes on this complex clinical presentation and GPs intention to diagnose and manage pOUD.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the sensitive, confidential, and potentially re-identifiable nature of the semi structured interviews undertaken. Additionally, our ethics approvals does not allow disclosure of these data. More details are available from the corresponding author on reasonable request.

Abbreviations

General Practitioner

Prescription Opioid Use Disorder

Opioid Agonist Treatment

Alcohol and Other Drugs

Theory of Planned Behaviour

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The authors acknowledge the general practitioners who generously gave their time to participate in this research.

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HW undertook the research, interviewed participants, interpreted the data, wrote, and revised the manuscript. BHR, NL and MH supported and reviewed the analysis, reviewed, and approved the final version of the manuscript. and take responsibility for the integrity of the data and the accuracy of the data analysis and take responsibility for the integrity of the work as a whole, from inception to published article. All authors read and approved the final manuscript. This research forms part of HW’s PhD through the University of NSW, Sydney, Australia. 

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Wilson, H., Roxas, B.H., Lintzeris, N. et al. Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour. BMC Prim. Care 25 , 236 (2024). https://doi.org/10.1186/s12875-024-02474-6

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Cognitive influencing factors of ICU nurses on enteral nutrition interruption: a mixed methods study

• Huiling Pan 1 , 2 ,
• Chuanlai Zhang 1 , 2 ,
• Ruiqi Yang 1 , 2 ,
• Peng Tian 1 , 2 ,
• Jie Song 1 , 2 &
• Zonghong Zhang 1 , 2  

BMC Nursing volume  23 , Article number:  433 ( 2024 ) Cite this article

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The incidence of clinically avoidable enteral nutrition interruptions is high. ICU nurses, as the implementers and monitors of enteral nutrition, have a close relationship between their cognitive level of enteral nutrition interruption and the incidence of enteral nutrition interruption. The level of ICU nurses’ cognition of enteral nutrition interruption and the key factors influencing the level of ICU nurses’ cognition of enteral nutrition interruption are not known.

This study aims to explore the cognitive level of ICU nurses on enteral nutrition interruption and delve into the key factors that affect their cognitive level from the perspective of management.

A sequential explanatory mixed methods research design was used.

With the convenience sampling method, an online survey questionnaire was distributed to ICU nurses in Chongqing, and 336 valid questionnaires were collected. After the survey, ICU managers were invited to participate in qualitative interviews, in which 10 participants from five hospitals completed face-to-face individual semi-structured interviews and were analyzed with thematic analysis.

The survey found that ICU nurses had a good level of cognition towards enteral nutrition interruption but poor knowledge about the definition, causes, and consequences of enteral nutrition interruption, as well as negative attitudes toward active learning, assessment, and communication. And the longer work time in the ICU, joining the nutrition team, receiving systematic training, and acquiring relevant knowledge from academic journals more frequently were favorable to improving ICU nurses’ knowledge level of enteral nutrition interruption. Personal interviews further identified the key factors affecting their cognitive level, including (1) lack of knowledge, (2) lack of proactive thinking, (3) lack of enteral nutrition management programs, and (4) lack of quality management tools for enteral nutrition interruption.

Although ICU nurses demonstrate a relatively high level of cognition, there is still room for improvement. ICU administrators must take specific measures to improve the knowledge of ICU nurses, especially in non-tertiary hospitals, in order to prevent nurse-induced enteral nutrition interruption in all ICUs and improve medical quality.

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Peer Review reports

Introduction

Critically ill patients often experience physiological, pathological, and metabolic disorders that limit nutritional intake, and the prevalence of malnutrition is as high as 38–78% [ 1 ]. Malnutrition refers to a state of energy or nutrient deficiency caused by inadequate intake or utilization barriers [ 2 ], and it is a major factor contributing to adverse clinical outcomes for patients. Studies have found [ 3 , 4 , 5 ] that malnutrition in ICU patients increases the incidence of complications such as ICU length of stay, days of mechanical ventilation, infections and organ failure, and mortality. Therefore, nutritional therapy is particularly important in the management of critically ill patients.

Enteral nutrition (EN) has become the preferred nutritional support treatment for ICU patients due to its alignment with normal physiological metabolic processes [ 6 ]. Guidelines recommend [ 6 , 7 ] that ICU patients should receive 80–100% of their target feeding volume within 3–7 days of initiating EN. 60–75% of patients in the ICU, however, as shown in several studies [ 8 , 9 , 10 ], do not reach the target feeding volume. Research [ 10 ] has found that the feeding deficiency rates were 54% and 15% ( p  < 0.001) on trial days with and without enteral nutrition interruption (ENI), respectively, indicating a positive correlation between ENI and insufficient feeding.

Enteral nutrition interruption (ENI) [ 11 ] is defined as an interruption of EN lasting 1 h or more with continuous enteral feeding or if the patient does not receive the expected amount of nutrients within 30 min with intermittent enteral feeding. Studies have found [ 10 ] that the average ENI time for ICU patients is up to 12 (6–24) hours per day. The causes of ENI are underestimated target feeding volumes, feeding intolerance, medical procedures, etc., which can be divided into patient factors and subjective factors [ 12 , 13 ]. Among these, avoidable subjective factors related to medical operations account for approximately 72% of the total time of ENI [ 14 , 15 ]. This is related to multiple factors such as physicians, nurses, frontline administrators, and healthcare institution management. ICU nurses, as the primary role in EN screening, assessment, implementation, monitoring, and complication intervention, are closely related to the occurrence of ENI in patients [ 16 ]. Studies have shown [ 17 ] that nurses not starting EN in a timely manner after medical procedures or outpatient examinations are the primary cause of ENI.

The Theory of Reasoned Action [ 18 ] proposes that individuals make behavioral decisions through rational thinking, and this decision-making process is influenced by various factors such as knowledge, attitude, and social environment. Thus, nurse-induced enteral nutrition interruption may be related to their level of knowledge, beliefs, and consequent practice behaviors related to ENI. To explore the current situation of ENI caused by ICU medical staff, previous studies [ 19 ] have examined the cognition of ENI among ICU medical staff in Wuhan. Little study, however, has been found to explore the key factors that affect their cognitive status. Currently, ICU managers lack a unified and standardized EN management plan. Furthermore, ICU nurses and doctors have different levels of knowledge, and nurses interact with patients more frequently, so a questionnaire is needed to evaluate ICU nurses’ cognition of ENI.

ICU manager [ 20 ] refers to the doctor or nurse who is responsible for the daily operation, management, supervision, and improvement of the ICU. ICU managers, as one of the key personnel in the whole link management and quality control of enteral nutrition, usually view problems from an overall perspective, and their perspectives and observations are more objective, in-depth, and comprehensive, which helps us understand the difficulties and challenges of ICU nurses in practice. We, therefore, use a sequential explanatory mixed methods research design [ 21 ] to investigate the cognitive level and influencing factors of ENI among ICU nurses through a cross-sectional survey. Based on the results, we will develop an interview outline to delve into the key factors influencing ICU nurses’ cognition of ENI from the perspective of ICU managers. This will lay the foundation for developing targeted interventions aimed at improving ICU nurses’ cognition of ENI, and provide the basis for improving the EN management program, so as to avoid nurse-induced ENI and improve medical quality.

Methodology

Research design.

A sequential explanatory mixed methods research design [ 21 ] was used that included both quantitative and qualitative research. The interview guide for the qualitative research was developed based on the findings of the quantitative research and served to complement and explain the quantitative results.

Quantitative research

Participants.

Convenience sampling was used to conduct a cognitive survey on ENI among ICU nurses in Chongqing. The recruited object of this study was ICU registered nurses who had worked in general ICUs for at least one year. The first page of the questionnaire describes the purpose of this study and informed consent. Respondents can only access the survey questions after giving informed consent. After completing and submitting the survey, participants were considered to have given informed consent. In addition, researchers can judge according to the basic information filled in by participants to exclude those who do not meet the inclusion criteria. The sample size of this study was at least 193 according to previous similar studies [ 22 ].

Data collection

The scale used in this study is the “ICU Healthcare Providers’ ENI Knowledge, Attitude, and Practice Scale,” developed by the Yuanyuan Mi team in 2022 [ 22 ], which is used to understand the current level of knowledge, attitude, and practice of ENI among ICU medical staff. This scale comprised three dimensions: knowledge, belief, and practice, with 14, 10, and 17 items, respectively, and total score ranges of 14–70, 10–50, and 17–85. Items were rated using a Likert 5-point scale, with 1 indicating “not at all,” 2 “uncertain,” 3 “slightly,” 4 “fairly,” and 5 “completely.” Scores below 4 indicated poor cognitive levels of ENI among ICU nurses; scores equal to or greater than 4 indicated that ICU nurses have a good level of ENI awareness. Reportedly, the Cronbach’s alpha for the original scale was 0.953, the test-retest reliability was 0.795, and the total content validity coefficient was 0.975, indicating that the scale had good reliability and validity. In addition, the Cronbach’s alpha was 0.965 when the scale was retested using data from this study.

In this study, 10 demographic variables and the “ICU Healthcare Providers’ ENI Knowledge, Attitude, and Practice Scale” developed by the Yuanyuan Mi team [ 22 ] were converted into an online questionnaire. A cross-sectional survey was conducted among ICU nurses in Chongqing in October 2023. 366 questionnaires were distributed through the questionnaire star platform, and 366 were recovered, with a recovery rate of 100%. Two researchers checked the content of the questionnaire and the duration of the questionnaire, deleted 30 invalid questionnaires, and finally found 336 valid questionnaires, for an effective rate of 91.8%.

Data analysis

Data were downloaded from the Questionnaire Star platform and analyzed in SPSS 27.0. Statistical significance was set at p  < 0.05. Means (standard deviations) and frequencies (percentages) were used for descriptive statistics. Differences and associations between ICU nurses’ EN cognition scores and demographic variables were analyzed using t-tests, chi-square tests, and binary logistic regression. Pearson’s correlation was used to assess the relationship between the total cognition score and the scores of each dimension.

Qualitative research

Purposeful sampling was used to select ICU EN managers willing to participate in qualitative interviews from hospitals where the questionnaire was administered. Eligible participants included healthcare providers from general ICUs involved in EN management for at least three years and willing to participate in this semi-structured interview. A total of 10 ICU managers were included in this study for personal interviews. Information saturation [ 23 ] was reached at interview 8, meaning that no new themes emerged at the end of the interview process. Two further interviews were conducted to confirm the results.

Data were collected through semi-structured interviews conducted by the first and second authors with participants in December 2023. The interview guide (see to S1 ) was developed by the lead author, guided by the Theory of Reasoned Action [ 18 ], and based on questionnaire results, a review of domestic and international literature, and expert consultation. Participants were contacted by phone before the interview to explain the purpose and significance of the study, obtain informed consent regarding confidentiality principles, recording, and other issues. Interviews were conducted at mutually agreed-upon times, ensuring privacy and a quiet environment. The interview time should be controlled at about 30 min. During the interviews, non-verbal cues such as body language, facial expressions, and tone of voice were observed and recorded along with audio recordings. A pilot interview was conducted with two ICU managers meeting the inclusion criteria before the qualitative study’s implementation, but their data were not included in the final analysis.

Audio recordings and written notes were transcribed verbatim within 24 h of the interview’s conclusion and stored on a computer for backup. Data analysis was based on the Theory of Reasoned Action [ 18 ] and aimed to identify key factors influencing the improvement of ICU nurses’ cognitive levels regarding ENI. A deductive thematic analysis approach [ 24 ] was employed, involving the following steps: (a) familiarization with the data; (b) initial code generation; (c) theme search based on initial codes; (d) theme review; (e) theme definition and labeling; and (f) report writing.

Quality control

To ensure reliability, the research team met regularly, and team members reviewed the study data and analysis results. For the quantitative study, the online survey was anonymous. To ensure the authenticity and validity of the questionnaire results, each respondent was given only one chance to answer the questionnaire and was required to answer all the questions before submitting the questionnaire. To prevent the inclusion of low-quality questionnaires, it was assumed that each question would take no less than 2 s to answer, and in combination with the number of demographic characteristics entries (10) and scale entries (41), questionnaires with an answer time of less than 2 min were excluded from this study. The researcher observed and collected the filled-in data through the background of the questionnaire and double-checked the extracted information to ensure the completeness of the information. In the qualitative study, interview transcripts were collected by two research members trained in qualitative research, and one researcher organized the audio-recorded interviews into text within 24 h of the end of the interviews, which was then returned to the interviewees for confirmation by two researchers who repeatedly read and proofread the information. Participant recruitment, interviews, and data analysis were conducted simultaneously to help researchers determine information saturation. No repeat interviews were conducted.

Ethical considerations

Ethical approval was obtained from the ethics committee of the Second Affiliated Hospital of Chongqing Medical University (Ke Lunshen No. (139) in 2023). The front page of the questionnaire sent to potential participants during the quantitative phase had an “informed consent” option, which was clicked on to allow participants to access the electronic questionnaire. Participants who submitted the questionnaire were considered to have obtained their informed consent. Participants in the quantitative phase volunteered their participation, and the questionnaire’s demographic data did not include names. Each participant was assigned a numerical code to ensure the confidentiality of survey responses. In the qualitative phase, participants provided written informed consent, and their interview recordings were analyzed anonymously and reported solely for research purposes by the study team.

Quantitative phase

Demographic characteristics of icu nurses.

Among the 366 participants who completed the questionnaire, 336 (91.8%) were considered to have provided valid questionnaires. The mean age of the 336 study subjects was 31.24 ± 5.68 years, ranging from 22 to 59 years old. Among them, 192 (57.1%) nurse had junior professional title, a total of 285 (84.8%) held a bachelor’s degree or higher, and the average ICU working time was 6.88 ± 5.05 years. Most of the nurses worked in tertiary care hospitals [ N  = 212 (63.1%)], but a few were members of the nutrition team [ N  = 83 (24.7%)]. This survey showed that only 54 (16.1%) nurses had received systematic training on knowledge related to enteral nutrition, and only 25 (7.4%) nurses reported that they regularly obtained knowledge related to enteral nutrition from academic journals. (See Table  1 )

Cognitive level of ICU nurses regarding enteral nutrition interruption

As shown in Table  2 , the mean score of ICU nurses’ knowledge of enteral nutrition interruption was 165.04 (22.86), which was higher than 164 (41 × 4), i.e., the cognitive level of ICU nurses regarding ENI was better. On the knowledge dimension, the mean score of ICU nurses’ knowledge of the definition, causes, and consequences of ENI was lower than 4, which was poor in this area; while " Unless contraindicated, the head of the bed should be elevated by 30–45° during EN administration to critically ill patients " and “When the medical and nursing-related examination, diagnosis, and treatment procedures are completed, enteral nutrition feeding should be resumed in a timely manner” had the highest scores, which were both higher than 4, indicating better knowledge in this area. The mean scores of ICU nurses in the belief dimension of ENI were all higher than 4, indicating better beliefs. On the behavioral dimension, ICU nurses scored higher than 4 on all behaviors except for lower scores on active learning about ENI, active patient assessment, and communication with physicians.

Pearson’s correlation analysis among knowledge, belief, and behavior dimensions

As shown in Table  3 , there was a strong positive correlation between the total cognitive score and the scores for the knowledge, belief, and behavior dimensions ( r  = 0.830, 0.766, and 0.850, respectively, P  < 0.01). There was also a positive correlation between the knowledge dimension score and the scores for the belief and behavior dimensions ( r  = 0.487 and 0.549, respectively, P  < 0.01). Furthermore, there was a positive correlation between the belief dimension score and the behavior dimension score ( r  = 0.535, P  < 0.01).

Univariate analysis of knowledge, belief and behavior against demographic characteristics

ICU nurses were deemed to have a low cognitive capacity about ENI if they received a single-item score of less than 4. Therefore, a cutoff value of ≥ 4 was used to categorize the participants’ total cognitive scores, knowledge dimension scores, belief dimension scores, and behavior dimension scores into two categories: low (= 0) and high (= 1). These were used as dependent variables. Univariate analysis of ICU nurses’ demographics and cognitive scores showed that age, nutrition team membership, and frequency of acquiring relevant knowledge from academic journals were associated with ICU nurses’ level of cognition about ENI; professional title, nutrition team membership, systematic training, and frequency of acquiring relevant knowledge from academic journals were associated with ICU nurses’ knowledge scores about ENI; and frequency of acquiring relevant knowledge was associated with ICU nurses’ ENI belief dimension and behavioral dimension scores. A P-value of < 0.05 was considered statistically significant. (See Table  4 )

Factors associated with improving ICU nurses’ cognitive level

Variables with a P-value of < 0.10 from the univariate analysis were included as independent variables in a logistic regression model. The results showed that a high frequency of reading academic journals was a facilitating factor for improving ICU nurses’ cognitive level regarding ENI. Additionally, longer work time in the ICU, participation in nutritional groups, receipt of systematic training, and a high frequency of acquiring related knowledge about EN from academic journals were promoting factors for enhancing ICU nurses’ knowledge dimension scores regarding ENI (see Table  5 ).

Qualitative phase

Ten ICU managers with bachelor’s degrees or above, ages ranging from 40 to 53, took part in individual semi-structured interviews from five hospitals. The duration of the interviews was roughly 12–36 min (see to S2 ). Four key factors were identified from qualitative data analysis that influence ICU nurses’ cognitive level regarding ENI: (1) Lack of knowledge; (2) Lack of active thinking; (3) Lack of EN management plans; and (4) Lack of quality management tools for ENI.

Lack of knowledge

According to participants, ENI is common in the ICU and is related to ICU nurses’ lack of knowledge about it. Many nurses are unclear about the definition, causes, and consequences of ENI. As Participant 5 described, ‘Many nurses are not yet aware of the concept of ENI and do not know how long a sustained pumping pause is an interruption of enteral nutrition, so much so that they are not particularly concerned about the time of restarting EN after a pause in EN, which leads to an increase in the duration and frequency of ENI in patients’. Furthermore, many participants stated that many nurses believe that pausing EN for a few hours during continuous enteral feeding does not constitute an interruption because the gastrointestinal tract remains active, which can damage a patient’s gastrointestinal function. Therefore, pausing for a few hours is similar to intermittent enteral feeding, allowing the patient’s intestine to rest. ICU nurses have a vague understanding of the definition and causes of ENI. What’s more, Participant 9 added, ‘Many nurses directly suspend EN when the gastric residual volume (GRV) exceeds 200 mL! Sometimes, when the GRV is assessed to be below 200 mL, the returned nutrient solution is discarded without realizing the relationship between ENI and adverse outcomes related to inadequate feeding’.

Lack of active thinking

Participants believed that the limitations in ICU nurses’ cognitive level regarding ENI were related to their mechanical work and lack of active thinking. Various reasons for ICU nurses’ lack of active thinking were described. Notably, due to limited human resources, ICU nurses, apart from handling doctor’s orders and basic care, also need to deal with emergencies and adverse reactions among critically ill patients, such as resuscitation, vomiting, and diarrhea. At the same time, they need to dynamically assess patients and fill out numerous assessment forms, making their workload heavy. As Participant 5 explained, ‘For example, when ICU nurses administer a doctor’s order of 1000 mL of nutrient solution to a patient, they routinely adjust the feeding speed, mechanically fill out various forms, and habitually assess the patient’s enteral feeding intolerance. If the patient tolerates it, they simply finish the feeding and move on, rarely thinking about whether the patient’s EN feeding has reached their nutritional goals……If the patient is intolerant, they habitually discard the syringe return fluid when the GRV is greater than 200 mL or even 50 mL and directly suspend the patient’s EN!’ Participants felt that ICU nurses, as implementers and monitors of EN, had a diminished sense of active learning as their sense of active thinking weakened. Participant 6 stated, ‘ICU nurses lack knowledge of biochemical indicators related to EN (such as phosphorus), hemodynamics, patients’ total enteral nutrition target, calories, and protein, and believe that nurses do not need to master these, lacking active learning consciousness’. Although many hospitals have EN management teams, most participants stated that team members are not very motivated, often forced to accept tasks, and lack active learning consciousness, which may be related to their lack of demand, competition, and conflict of interest.

Lack of EN management plans

It was evident from the interviews that the management level varies among different medical units, and there is inconsistency in the quality of care provided by doctors and nurses. The absence of standardized EN management plans that can be referred to has limited the improvement of ICU nurses’ cognitive level regarding ENI. For example, there is a lack of solutions to address inconsistencies between theory and practice. Participant 4 described, ‘Nurses are confused about the different gastric residual volume thresholds recommended by multiple guidelines, resulting in behaviors such as suspending EN when the volume exceeds 200mL. There is a lack of regulations regarding GRV thresholds and guidance on how to adjust or reduce the feeding rate in our department’. Participant 1 stated, ‘Nurses are unclear about whether it is necessary to routinely aspirate gastric residuals every 4–6 hours’. Participant 6 added, ‘The department lacks an active feeding strategy for restarting enteral nutrition to promote early active venting of patients’. Furthermore, participants felt that the management of EN in ICU patients requires multidisciplinary collaborative management, but the triad of physicians, nurses, and nutritionists each had their own role and lacked a closely linked management process. Participant 7 described, ‘ICU doctors have better knowledge of nutrition, less consultation with the Nutrition Department is requested, and nutritionists are unable to dynamically assess the EN status of patients in a timely manner, to the extent that it is mostly left to the ICU doctors themselves to determine the problem of patients’ EN compliance’. And participant 3 said, ‘Currently, ICU nurses put a lot of effort into screening, assessment, implementation, monitoring, and complication intervention of EN, and their awareness is gradually increasing (smiled), while physicians are less involved in the management of the EN process!’ What’s more, participants described that the initial nutritional screening assessor varies from ICU to ICU, that some are nurses whereas others are physicians, that it is not yet known who leads the management of EN in ICU patients, and that there is a lack of a collaborative management process between the medical and nursing professions.

Lack of quality management tools for enteral nutrition interruptions

Participants noted that current clinical EN management primarily consists of EN guidelines, implementation procedures, nutritional screening tools, enteral nutrition tolerance assessment forms, and aspiration risk assessment forms. However, there is still a lack of quality management tools specifically designed for ENI. This makes it difficult for ICU nurses to identify avoidable causes of ENIs, which in turn hinders their ability to reduce the occurrence of such interruptions. Participants described some avoidable issues related to ENIs. Participant 6 described, ‘ICU nurses often pause EN when the amount of GRV exceeds 200 mL, lacking a standardized deceleration or reduction in volume’. Participant 2 described, ‘Clinical situations often arise where infusions are not completed within 24 hours……This is attributed to unreasonable infusion speed settings, excessive preoperative fasting durations, forgetting to report to doctors after suspensions, forgetting to restart infusions, and equipment malfunctions.” Although the EN management team has identified issues related to ENIs during the management process, they lack plans for implementation and problem-solving. They expressed a desire to use quality management tools to manage ENIs and reduce those caused by human factors.

Understanding the cognitive level and influencing factors of ICU nurses regarding ENIs is crucial, as their cognition has a direct relationship with achieving the nutritional targets for ICU patients’ EN [ 16 ]. This study helps ICU managers understand the key factors affecting the cognitive level of ICU nurses’ ENI in order to lay the foundation for ICU managers to develop targeted interventions aimed at improving the cognitive level of ICU nurses’ ENI. Analysis of the questionnaire revealed that ICU nurses generally have a good level of cognition regarding ENIs, with a poorer understanding of their definitions, causes, and consequences. Additionally, they exhibited a negative attitude towards actively seeking knowledge, assessing, and communicating. However, there is still room for improvement, such as by joining nutrition groups, receiving systematic training on EN, participating in related academic conferences, and regularly acquiring EN knowledge from academic journals. Based on this, ICU managers further explained the key factors influencing nurses’ cognitive levels: a lack of knowledge regarding ENIs, inactive thinking about achieving EN feeding targets, a lack of management processes for addressing inconsistencies between theory and practice, and a lack of quality management tools for ENIs. These findings provide a basis for ICU managers to improve EN management plans. Therefore, it is recommended that ICU managers accordingly develop targeted interventions aimed at improving ICU nurses’ cognition of enteral nutrition interruptions in order to avoid nurse-induced ENI and improve medical quality.

This study is consistent with the findings of Mi Yuanyuan [ 19 ] et al. that ICU nurses have a better level of ENI cognition. However, this study also found that the number of years working in the ICU and nutrition team members were the influencing factors for the ICU nurses’ ENI knowledge dimension scores. This may be related to the fact that only ICU healthcare workers in tertiary hospitals were included in the study by Mi Yuanyuan [ 19 ] et al. or to the fact that nutrition team members accounted for as much as one-third of the ICU nurses in the study by Mi Yuanyuan [19] et al. This is also a side effect of the unequal levels of ENI awareness among ICU nurses in different levels of hospitals. In the future, more ICU nurses in secondary hospitals can be included to explore the current status of ENI cognitive level of ICU nurses in different grades of hospitals. Furthermore, unlike previous studies [19] , this study conducted qualitative interviews with ICU managers on the basis of a questionnaire survey of ICU nurses, which explored the key factors affecting the cognitive level of ICU nurses’ ENI in more depth and laid the foundation for ICU managers to formulate targeted interventions aiming to enhance the cognitive level of ICU nurses’ enteral nutrition interruption.

In this study, we found that high years of working experience in ICU, joining the nutrition team, receiving systematic training, and a high frequency of acquiring knowledge related to enteral nutrition from academic journals were the contributing factors to increasing the level of ICU nurses’ knowledge of enteral nutrition interruption. The longer the working years, the richer the clinical experience and related knowledge of ICU nurses. However, as shown in this study, nearly half [ N  = 154 (45.8%)] of the ICU nurses had less than 5 years of working experience; therefore, there is an urgent need to improve the level of ICU nurses’ cognition of ENI in other ways in order to balance the level of cognition of ICU nurses with different years of working experience. For example, by joining a nutrition team and receiving relevant systematic training, ICU nurses can be helped to gain a systematic, comprehensive, and in-depth understanding of knowledge related to enteral nutrition and to increase nurses’ awareness of and interest in the interruption of enteral nutrition [ 25 ]. This is to promote proactive thinking by ICU nurses and to improve their scores in proactive learning about interruption of enteral nutrition, proactive assessment of patients, and communication with physicians [ 26 ]. Further, ICU nurses can also compensate for knowledge blindness by frequently acquiring knowledge related to enteral nutrition from academic journals. Academic journals, as authoritative repositories of academic knowledge, have the most cutting-edge knowledge in the field, such as clinical guidelines and original research with practical guidance, and ICU nurses’ frequent acquisition of enteral nutrition-related knowledge from academic journals is conducive to a systematic and in-depth understanding of the guidelines, consensus, original research, and the frontiers of enteral nutrition in order to enhance nurses’ knowledge of enteral nutrition interruption. Therefore, ICU administrators can encourage nurses to join nutrition teams and conduct multi-pathway training to promote nurses’ acquisition of knowledge from academic journals in order to improve ICU nurses’ level of knowledge about enteral nutrition interruptions, as well as to promote nurses’ proactive thinking in order to avoid unnecessary enteral nutrition interruptions.

Nurses are susceptible to the influence of external factors, and procedures and systems are fundamental to regulating nurses’ behavior. The development of enteral nutrition management protocols is beneficial to standardizing ICU nurses’ management of patients with enteral nutritional feedings in order to improve the level of ICU nurses’ perception of enteral nutritional interruption. A national survey [ 27 ] found that enteral nutrition is usually prioritized lower than other urgent care needs for ICU patients. Furthermore, there is a lack of uniform and standardized clinical protocols for enteral nutrition management in critically ill patients [ 28 , 29 ]. This has hindered the improvement of the level of ENI awareness among ICU nurses in different levels of hospitals to a certain extent and is not conducive to the homogenization of ICU healthcare personnel in various healthcare institutions. Enteral nutrition is critical to the recovery of ICU patients [ 4 ]. It is necessary to enhance ICU nurses’ knowledge of enteral nutrition management to facilitate the development of standardized enteral nutrition protocols [ 30 , 31 ]. Currently, the threshold for GRV is not uniform in clinical settings, with 200–500 mL being the most common [ 32 , 33 ]. This is not conducive to ICU nurses’ judgment of GRV thresholds, which may lead to some degree to nurse-induced ENI. Furthermore, guidelines have recommended that routine monitoring of GRV [ 7 ] during the EN may not be necessary, but most clinical nurses still habitually aspirate gastric residual to monitor patients’ gastrointestinal intolerance, which may be related to the ICU nurses’ fear of the risk of patients’ vomiting or aspiration [ 34 ] or to their insufficiently in-depth view of the problem. At the same time, there is currently a clinical controversy over whether the gastric residual aspirates should be returned or discarded [ 35 ]. This may explain, in part, why some ICU nurses currently choose to discard the gastric residual aspirates directly to avoid contamination, and some ICU nurses choose to tie back the gastric residual aspirates to minimize the risk of fluid and electrolyte imbalance in the patient. Therefore, there is an urgent need for the development of standard enteral nutrition management protocols to address the currently controversial issues and to standardize ICU nurses’ behavior regarding enteral nutrition management.

The formulation of the scheme is conducive to standardizing the behavior of nurses, but the optimization of the implementation effect of the scheme requires the application of quality management tools. Currently, there is a lack of quality management tools in clinical practice to monitor the rate of implementation of EN measures [ 5 , 6 ]. Previous studies have shown [ 12 , 13 ] that the reasons for ENI in ICU patients include hemodynamic instability, high GRV, and medical procedures. It is difficult to avoid ENI, but as shown by Kagan et al. [ 36 ], the use of nutritional management feeding platforms (such as the smART + platform) can monitor ICU patients’ ENI in real-time, calculate the amount of compensation needed when restarting, and ultimately help patients reach their EN goal. In other words, most ENIs caused by ICU nurses can be avoided through the use of management tools28. As a fine and process management method, the Plan-Do-Check-Act (PDCA) cycle method is a continuous quality management tool that targets clinical weaknesses, proposes countermeasures, and improves the implementation rate of measures. It has been widely used in ICU quality management [ 37 ]. Therefore, in the future, ICU managers can use quality management tools to dig deeper into the reasons for enteral nutrition interruption, promote the development and implementation of related plans, and solve the problem at the source in order to reduce avoidable enteral nutrition interruption, standardize nurses’ behaviors, and maximize the application of enteral nutrition management programs.

Strengths and limitations

This study boasts both strengths and limitations. Leveraging the advantages of mixed methods research, we delved into the key factors influencing ICU nurses’ cognition of ENI from both the nurses’ and management’s perspectives. This lays the foundation for targeted interventions aimed at enhancing ICU nurses’ understanding of ENI, ultimately aiming to prevent such interruptions caused by the nurses themselves. Rather, we must acknowledge its limitations. Our use of sequential explanatory mixed methods means our ability to explore the critical factors influencing ICU nurses’ cognition of ENI is somewhat limited, but this could be addressed through alternative mixed methods designs. Furthermore, our study sample was limited to a geographical region, potentially limiting the generalizability of our findings. Future research could expand the scope of the investigation. Nevertheless, this study provides novel insights and valuable perspectives for ICU managers to improve their department’s EN management strategies.

Overall, the level of ICU nurses’ cognition of enteral nutrition interruption is good, but there is still room for improvement. ICU nurses can improve the level of knowledge related to ENI and increase their proactive thinking about the management of enteral nutrition target feeding compliance by joining the nutrition team, participating in the systematic training of knowledge related to enteral nutrition, and frequently acquiring knowledge from academic journals. Furthermore, ICU managers should apply a quality management tool for enteral nutrition interruptions and develop targeted interventions aimed at improving ICU nurses’ cognition of enteral nutrition interruptions in order to provide a basis for improving the department’s enteral nutrition management program, so as to avoid nurse-induced ENI and improve medical quality.

Data availability

All data generated or analyzed during the study are available from the corresponding author [Chuanlai Zhang] on request.

Abbreviations

• Intensive care units
• Enteral nutrition
• Enteral nutrition interruption

Gastric residual volume

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Acknowledgements

We would like to thank the nurses who participated in this study.

This work was supported by the Medical Quality (Evidence-Based) Management Research Program (Award No.: YLZLXZ23G107) in 2023 of National Institute of Hospital Administration, National Health and Health Commission of the People’s Republic of China, Kuanren Talents Program of The Second Affiliated Hospital of Chongqing Medical University and Chongqing Municipal Education Commission’s 14th Five-Year Key Discipline Support Project.

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Huiling Pan, Chuanlai Zhang, Ruiqi Yang, Peng Tian, Jie Song & Zonghong Zhang

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Conceptualization, ZCL; Methodology, PHL, ZCL, YRQ, TP, SJ and ZZH; Data curation, PHL, YRQ, TP, SJ and ZZH; Investigation, PHL, ZCL, YRQ, TP, SJ and ZZH; Formal analysis, PHL and YRQ; Writing- Original draft preparation, PHL; Funding acquisition, ZCL; Supervision, ZCL; Resources, TP, SJ and ZZH; Validation, TP, SJ and ZZH; Writing –review & editing, ZCL and YRQ.

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Pan, H., Zhang, C., Yang, R. et al. Cognitive influencing factors of ICU nurses on enteral nutrition interruption: a mixed methods study. BMC Nurs 23 , 433 (2024). https://doi.org/10.1186/s12912-024-02098-2

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Learning sustainability: post-graduate students’ perceptions on the use of social media platforms to enhance academic writing.

1. Introduction

2. literature review, 2.1. online communication through social media for educational purposes, 2.2. academic writing, 2.3. social media, academic writing, and the fourth goal of sustainable development, 3. research questions.

• How do post-graduate students perceive the role of social media platforms in enhancing their academic writing?
• What are the obstacles to the use of social media platforms that hinder enhancing academic writing?

4. Methodology

4.1. participants, 4.2. research approach, 4.3. research procedure, 4.4. data collection and analysis.

• What social media tools were used by you in writing the research plan?
• Which of these tools do you prefer to use? Why?
• Describe your experience using your favorite tool in some detail.
• What do you think of the use of these tools in terms of their usefulness in improving the quality of your writing of the research plan? Why?
• From your point of view, what are the disadvantages of using these tools that may negatively affect the quality of your writing of the research plan? Why?
• From your point of view, what are the obstacles to using these tools that may reduce their usefulness in improving the quality of your writing of the research plan? Why?
• Do you prefer using social media tools or traditional methods of communicating with the supervisor regarding the development of the research plan? Why?
• Familiarizing yourself with your data: The authors of the study were the interviewers. Therefore, they were very familiar with the data.
• Generating initial codes: The initial interesting codes from the data were identified. The codes were then assessed in a meaningful way regarding the research questions.
• Searching for themes: Here the analysis re-focused on the codes on a broader level, which is generating themes. In this phase, different codes are sorted into potential themes.
• Reviewing themes: The initial list of themes was refined, and some candidate themes that did not have enough data to support them were ignored.
• Defining and naming themes: In this phase, the data were defined by identifying the essence of what each theme was about and were refined by determining what aspect of the data each theme captured. Table 2 illustrates the themes and frequencies of the interview data revealed from the thematic analysis.
• Producing the report: This phase involved the final analysis under the themes and write-up of the final report. The final report of the data analysis and the concluded findings will be reviewed in the following section.

5. Findings and Discussion

6. limitation, 7. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Click here to enlarge figure

Demographic Data		n	Percentages
Gender	Males	4	40%
	Females	6	60%
Age range	22–27 years old	8	80%
	28–31 years old	2	20%
Specialization in Masters	Educational Technology	10	100%
Specialization in Bachelor’s degree	Science	1	10%
	Math	2	20%
	Computer Sciences	4	40%
	Arabic	1	10%
	Early Childhood	1	10%
	Social Studies	1	10%

Main Themes	Sub Themes	Frequency	Percentages
Social media tools	WhatsApp	7	70%
	Microsoft Teams	4	40%
	Zoom	3	30%
	Twitter	2	20%
	Telegram	1	10%
	Blackboard	1	10%
Benefits	Easy communication	7	70%
	Transcending the limits of space	6	60%
	Instant feedback	5	50%
	Repeat review files	5	50%
	Interactive guidance	5	50%
	Save time and effort	5	50%
	File and resource sharing	5	50%
	Transcending the limits of time	4	40%
	Diverse file format	3	30%
	Communicate experienced researchers	3	30%
Favorite method of holding meetings	Distance	6	60%
	Blended	4	40%
Obstacles	Technical problems	5	50%
	Poor face-to-face communication skills	3	30%
	Distracting	3	30%
	Lack of technical skills	1	10%
	Burden	1	10%

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Al Mulhim, E.N.; Ismaeel, D.A. Learning Sustainability: Post-Graduate Students’ Perceptions on the Use of Social Media Platforms to Enhance Academic Writing. Sustainability 2024 , 16 , 5587. https://doi.org/10.3390/su16135587

Al Mulhim EN, Ismaeel DA. Learning Sustainability: Post-Graduate Students’ Perceptions on the Use of Social Media Platforms to Enhance Academic Writing. Sustainability . 2024; 16(13):5587. https://doi.org/10.3390/su16135587

Al Mulhim, Ensaf Nasser, and Dina Ahmed Ismaeel. 2024. "Learning Sustainability: Post-Graduate Students’ Perceptions on the Use of Social Media Platforms to Enhance Academic Writing" Sustainability 16, no. 13: 5587. https://doi.org/10.3390/su16135587

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• Published: 29 May 2023

Facilitators and barriers to collaboration between pre-hospital emergency and emergency department in traffic accidents: a qualitative study

• Hasan Jamshidi 1 ,
• Reza Khani Jazani 2 ,
• Ali Khani Jeihooni 3 ,
• Ahmad Alibabaei 4 ,
• Shahram Alamdari 5 &
• Majid Najafi Kalyani 6  

BMC Emergency Medicine volume  23 , Article number:  58 ( 2023 ) Cite this article

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Death caused by traffic accidents is one of the major problems of health systems in low- and middle-income countries. Rapid handover of the traffic accident victims and proper collaboration between the pre-hospital and emergency departments (EDs) play a critical role in improving the treatment process and decreasing the number of accidental deaths. Considering the importance of the collaboration between pre-hospital and emergency departments, this study was designed to investigate the facilitators and barriers of collaboration between pre-hospital and emergency departments in traffic accidents.

This research is a qualitative study using content analysis. In order to collect data, semi-structured interviews were used. Seventeen subjects (including pre-hospital and emergency department personnel, emergency medicine specialists, and hospital managers) were selected through purposive sampling and were interviewed. After transcribing and reviewing interviews, data analysis was performed with the qualitative content analysis approach.

The participants consisted of 17 individuals (15 persons in pre-hospital and emergency departments with at least three years of work experience, one emergency medicine specialist and one hospital manager) who were selected by purposive sampling. The interviews were analyzed and three main categories and seven sub-categories were extracted. The main categories included “individual capabilities”, “development of mutual understanding”, and “infrastructures and processes”.

Proper and practical planning and policymaking to strengthen facilitators and eliminate barriers to collaborate between pre-hospital and emergency departments are key points in promoting collaboration between these two important sectors of health system and reducing the traffic accident casualties in Iran.

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Traffic accidents kill about 1.2 million people and injure or disable 20 to 50 million individuals annually, accounting for 25% of the world’s deaths and 22% of the world’s disabilities. They are also the major challenge facing the global health system [ 1 ], as well as the health systems in low and middle income countries. Iran with 28,000 deaths per year has the first rank in the world in terms of the frequency of fatalities related to driving [ 2 , 3 , 4 ]. Road accidents in Iran are 20 times the world average and the second leading cause of death [ 3 ]. In Iran, the pre-hospital emergency department is responsible for providing primary health care and delivering the injured from traffic accidents to the emergency department, where usually one-third of its beds are occupied by road accident victims [ 5 , 6 ]. The process of traffic victims’ handover is illustrated in Fig.  1 .

The process of traffic victims’ handover in Iran

Initially, emergency medical technicians (EMTs) would be present at the accident scene and perform basic resuscitation measures on the victims of traffic accidents.

Then, the injured are handed over to the nurse in charge of triage in the hospital’s emergency department.

After being admitted to the hospital, the injured are visited by an emergency medicine specialist and the necessary measures are taken.

In the event of an accident, intra-departmental and inter-departmental collaboration is of great importance, and the providing effective services requires the collaboration of all health system staff [ 7 , 8 ]. According to a number of studies, one of the factors causing high mortalities in traffic accidents is the lack of proper collaboration between pre-hospital departments and emergency departments in many developing countries [ 9 ]. Accelerating patient handover, facilitating the continuation of treatment process, reducing mortality, and increasing satisfaction are the results of effective collaboration between pre-hospital departments and emergency departments [ 9 , 10 , 11 , 12 , 13 ].

Despite the great importance of collaboration and its significant impacts on reducing mortalities of road accidents [ 14 ], few quantitative studies have been conducted in this field [ 15 , 16 ]. A majority of studies conducted in Iran have also focused on the quantity and causes of delay in starting pre-hospital care or management factors [ 17 ]. Erie et al. reported the lack of proper collaboration between emergency department staff and other organizations as one of the challenges experienced by pre-hospital emergency staff and believed that they need to collaborate with physicians, nurses, midwives, and psychotherapists to promote care in patient handover [ 18 ]. The promotion of pre-hospital and emergency department collaboration requires identifying their challenges and problems. In this regard, identifying the experiences of the personnel involved in this process seems to be a great contribution. A comprehensive understanding of all aspects of this phenomenon is needed to identify facilitators or barriers affecting the collaboration between pre-hospital and emergency departments. Since neither quantitative studies nor one or more questionnaires are sufficient to approach such an in-depth understanding, the present qualitative study was conducted to identify facilitators and barriers of collaboration between the pre-hospital and emergency departments.

Materials and methods

Methodology and population of the study.

The present study is a qualitative research based on the content analysis approach. This study was conducted on 17 healthcare professionals affiliated with Fasa University of Medical Sciences including seven emergency medical technicians (EMTs), six nurses (triage and emergency department nurses), two general physicians, one emergency medicine specialist, and one hospital manager. The data were collected from two pre-hospital emergency centers in Fasa City, and Valiasr hospital emergency department in Fasa, Fars, Iran. This major hospital is a trauma center receiving more than 2000 traffic accident victims annually.

The criteria for entering the study were having at least 3 years of work experience, having rich experience, and willingness to participate in the study. Purposive sampling initiated in 2015 and continued with theoretical sampling and individual in-depth individual interviews until data saturation was reached.

Data collection and analysis

Semi-structured face-to-face interviews were used to collect the data. All interviews began with an open question, such as “Talk about a day at work and your collaboration with the emergency department staff.“ and some guiding questions like “Please give me an example.“ were also used to further clarify the topic. During the interviews, follow-up questions were asked to clarify the concepts. On average, the interviews lasted for 50 min. After explaining the purpose and the method of the interview and obtaining the participants’ informed consent regarding the recording of their speeches, the interviews were recorded and then transcribed verbatim by the researchers. The interviews were conducted by three qualitative research experts. The data were then reviewed several times to reach an overall understanding.

Two of the three researchers reviewed the data independently using standard content analysis methods, extracting semantic units from the interview statements (including words, sentences, and paragraphs), and coded them based on their similarities and differences. According to continuous thinking, interpretation, and comparison of data, key categories and themes were extracted and primary categories were identified. The final categories were extracted by summarizing the concepts and codes and according to the differences or similarities of the initial categories [ 19 ].

The interview was developed for this study has previously been published [ 20 ].

The validity of this study was obtained by using continuous comparison methods and observation by the research team and external observers. Credibility was obtained through researcher’s long-term engagement, the combination of data collection, repeated reviews, supervisor’s reviews, and continuous comparison of data. External member checks were used to achieve dependencies. Manuscripts and notes were handed to two associated professors, who approved the confirmability of the findings. Finally, the transferability of the present study was approved due to the description of the rich data [ 19 , 21 ]. Some ethical considerations included confidentiality of information, written informed consent form for interviews and interview records, and the right to withdraw from the study whenever the participants wanted, were considered. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences.

The participants in this study were 17 individuals (13 people in pre-hospital and emergency departments with at least three years of work experience, two general physicians, one emergency medicine specialist, and one hospital manager) who were selected through purposive sampling. The average age of the participants was 35 years and their average work experience was eight years. According to the data analysis, three main categories (individual capabilities, development of mutual understanding, and infrastructures and processes) were extracted. Table  1 summarizes the three main categories and seven sub-categories we derived, along with a representative quotation for each of them (Table  1 ).

1. Individual capabilities

“Individual capabilities” was the first extracted category and consisted of two subcategories: “individual knowledge” and “individual experience.” The individual capabilities provide opportunities for staff to be more scientifically and empirically efficient and to demonstrate better interactive responsiveness in inter-sectorial collaboration and patient delivery to facilitate the collaboration process.

Individual knowledge.

The results indicated that the more successful the individuals were in acquiring knowledge individually, the more effectively they played their role in inter-sectorial collaboration. Higher levels of knowledge and being scientifically updated provide the basis for more effective and facilitated collaboration. Having undergraduate or higher educational records had provided the knowledge for these staff. In this regard, one of the physicians from emergency department stated, “When trained emergency staff handover a patient, they well-express the patient’s history and problems so that the recipient feels comfortable. In fact, personnel’s high levels of education make the patient handover less difficult.“

Another emergency medical technician from the pre-hospital emergency department said, “The trained personnel in the triage department ask many questions regarding the condition of the injured, the mechanism of the injury, and the patient’s affected organs. They also check symptoms. In this way, I feel comfortable when delivering the injured to them.“

Individual experience.

The results indicate that the more experienced the staff are, the more effective the inter-sectorial collaboration is, and that the higher level of experience as a facilitator provides the basis for more effective collaboration.

For instance, one emergency department nurse, with eight years of work experience mentioned, “I am more comfortable with someone with better and longer work experience because he or she knows better what is important when handing over a traffic accident injured.“

The most important foundations for the emergence of inter-sectorial collaboration were studying scientific books related to the field, having theoretical knowledge, and practical and field experiences.

2. Development of mutual understanding

The development of the mutual understanding was the second category containing three subcategories: “common educational program”, “sharing experiences”, and “empathic behaviors”. Developing mutual understanding provides opportunities for scientific, skillful, attitudinal and behavioral closeness of personnel and facilitates the collaboration process and vice versa.

Common educational programs.

The participants considered their joint programs important and emphasized on its effective role in facilitating collaboration. One emergency medical technician quoted, “The emergency department holds a monthly educational class on topics like trauma or transportation. We have more understanding and collaboration with the hospital staff who participate in these classes”. Another participant also noted, “The personnel who participate in joint workshops have a better collaboration because of a greater understanding of each other’s problems.”

From the participants’ point of view, strengthening the areas of developing joint educational programs, including joint classes and workshops, plays a key role in facilitating collaboration between the pre-hospital and emergency departments.

Sharing experiences.

Sharing experiences also facilitates collaboration. One of the emergency department staff said, “Staff who only have a working experience in a hospital triage cannot understand the current state of a person who has just been injured in an accident and is to be handed over; however, those who have experience in both pre-hospital and emergency departments better understand this condition.“

From the participants’ perspective, sharing experiences through having joint operational maneuvers and familiarizing personnel with the difficulties and complexities of work in both departments are crucial in facilitating collaboration between the pre-hospital and emergency departments.

Empathic behaviors.

Empathic behaviors, mutual understanding, and creating a friendly atmosphere in the work environment were other facilitators of collaboration, which were emphasized by the participants. The results indicated that respectful, professional, and friendly behaviors make inter-sectorial collaboration more effective. In these places, which are filled with engagement and friendship, solving possible shortcomings and problems are done with collective effort, and individual challenges are less likely to happen.

Regarding the positive role of mutual respect among staff, as an effective factor in reducing job stress and facilitating collaboration, one of the emergency department participants stated, “There is more collaboration between those who respect each other.“

Concerning the familiarity and the professional and friendly behaviors of the staff in these two departments, as another important factor facilitating collaboration, one nurse from the emergency department claimed, “When the staff are friendly and sympathetic, there is no conflict. This is not a problem for the patient. Our friendship allows us to deliver and admit patients in a shorter time since we do not pay attention to trivial matters. If there are some unaccomplished tasks, the emergency department staff will take care of them so that everything works better.” Another participant said, “There is much more collaboration between friends than between those who do not know each other.“

In the busy and stressful conditions of the emergency room and hospital, professional, respectful, and friendly behaviors along with reduced tension and conflict increase collaboration and mutual understanding.

3. Infrastructures and processes

Infrastructures and processes were the third category and the most important factor influencing collaboration between pre-hospital and emergency departments. The availability or unavailability of specific infrastructures and work processes was one of the facilitators or barriers to inter-sectorial collaboration. This category was sub-classified as “adequate and similar equipment” “and “deficiencies in work processes.“

Adequate and similar equipment.

The availability of appropriate communication facilities was important since entering accidents scenes to the end of the patient transportation process. The lack of equipment and communication standards between the pre-hospital departments and emergency departments was a noticeable barrier to collaboration. The lack of wireless communication between the ambulance and the hospital as well as the lack of a direct telephone line from the pre-hospital emergency headquarters to the hospital was another example of such inadequacies.

One EMT from the pre-hospital emergency department said, “I do not have the opportunity to directly connect to the hospital from the accident scene. I cannot report the number of injured and the type of injuries to the hospital from the accident scene for them to be prepared. Thus, the onset of their treatment is delayed”. According to the participants, the lack of communication equipment for coordination between the pre-hospital departments and emergency department was a problem that seriously disrupted the patient’s rapid transport to the hospital and preparedness for collaboration.

Regarding the importance of the equipment, since pre-hospital and hospital emergency departments are managed separately in Iran, and given that pre-hospital emergency staff sometimes have to supply and replace the equipment consumed for the injured in the hospital emergency room, the existence of sufficient facilities and equipment needed by the injured and the availability of similar equipment in both sectors are important factors facilitating collaboration among staff. In this regard, one emergency medical technician asserted, “Having enough equipment in the emergency room of the hospital removes the collaboration problems; whenever I take a patient, there are enough empty beds and backboards, so I hand over the injured easily and the emergency room staff prepare a backboard for me. In this way, there is no conflict”.

The adequacy and uniformity of equipment and consumables, sufficient number of emergency experts, and recovery beds in the emergency room were important factors facilitating the handover of road accident victims.

Defects and disorganizations.

Patient handover and evolution are among the most important pillars of interpersonal collaboration. However, the inadequacy of processes such as documentation, development of clinical guidelines, handover of the injured from traffic incidents, delivery of consumables as well as time constraints played the role of a barrier for optimal collaboration.

One of the participants from the pre-hospital emergency department stated, “The form containing the written emergency report and patient’s history does not contain a number of important issues. For example, no blood sugar level is included for a patient with a low level of consciousness. Besides, all patients’ information is not recorded”.

The defects in the current pre-hospital emergency forms were due to the absence of some important records and patient information, and inconsistent reporting during patient handovers caused disruptions in collaboration.

Another case was the lack of coding regarding work processes and clinical guidelines. One of the nurses working in the emergency department noted, “In general, the hospital does not have a specific protocol for the delivery of emergency patients taken by ambulance, even the beds are not classified according to the triage level to locate, for example, red and green patients for further diagnoses”.

The absence of a defined protocol or a specific person in charge of admitting injuries imposes extra waiting on technicians, prolongs the delivery time, interferes with personnel duties in these two sectors, and negatively affects collaboration. Another problem in the rapid handover of injured patients was replacing pre-hospital emergency equipment consumed for the patient at the accident scene and during the delivery by emergency department equipment.

One of the emergency medical technicians from the pre-hospital emergency sector mentioned, “There is no one in charge of receiving the supplies and delivering the consumed equipment to us. I have to wait for a letter to the pharmacy. At the pharmacy, I can receive the commodity after hearing complaints and questions like: Who wrote the letter? Why do you want it? For whom was it used? It is a waste of time; I cannot answer the questions posed by the pharmacy staff since my focus was on saving the patient!“ Another participant asserted, “Another barrier to collaboration is the delivery of equipment. I myself have to go to the pharmacy and waste a lot of time to receive them, since no one is in charge of doing the same task or the equipment could be available in the triage ward so that we do not waste our time.“

Incomplete delivery of consumables, as well as wasting technician’s time in the hospital, and the creation of an environment full of tension is another barrier to collaboration between the pre-hospital department and emergency department.

A time limit is set for patient delivery by the pre-hospital emergency staff. This means that the personnel have to deliver injured patients from the pre-hospital emergency department to the emergency department staff within 10 min. The requirement to comply with this time limit has posed a lot of stress on the pre-hospital emergency staff and interrupted their collaboration with the hospital staff. An emergency medical technician states, “They have set a maximum of 10 minutes for me to stay at the hospital. When it takes longer, I will receive an alert. If the patient is in critical condition with multiple traumas, I need double-checking because I have to explain many points to the doctor and nurses. Sometimes, I have a heart attack patient, so I have to stay longer and help him to be relocated and handed over; however, I cannot collaborate appropriately with the triage department since my 10 minutes is over and I am stressed out to get back to the station early.“

Data analysis revealed the facilitators and barriers to the collaboration between pre-hospital and emergency departments in the case of traffic incidents in Iran. They were classified into three categories: individual capabilities, development of mutual understanding, and infrastructures and processes. These categories represent the significant role of individual and organizational factors in creating the facilitators and barriers to collaboration.

The participants believed that the staff who were more successful in acquiring knowledge and experience, had better collaboration. Higher education and more hands-on experience created more effective collaboration between pre-hospital and emergency departments. These findings were consistent with Bost’s et al.’s findings indicating that the knowledge, experience, and capability of personnel are important factors affecting collaboration [ 22 ]. Oen et al. also pointed out the personnel’s lack of knowledge as the cause of patient handover problems and as one of the challenges facing collaboration [ 14 ]. One of the challenges to collaboration was the lack of experience, as Ace and Apkar noted [ 23 , 24 ].

The findings indicated that the development of mutual understanding along with a joint educational program, sharing experiences, and the occurrence of empathic behaviors were among the facilitators of collaboration as emphasized by the participants. In line with these findings, Jensen et al. also reported that the development of mutual understanding improves the quality of collaboration in patient delivery [ 25 ]. The results of the study conducted by Bruce et al. also highlighted the positive role of joint educational programs in reducing the risks of patient handover [ 26 ]. The participants stated that the existence of shared knowledge and experiences helps to better understand shared experiences with patients, the workplace, and medical interventions at the accident scene and hospital, leading to improved collaboration.

One example of mutual understanding is empathic behaviors. This factor contributed significantly to increase collaboration. Professional, friendly, supportive behaviors and previous knowledge about each other would increase encouragement, trust and mutual relationship among colleagues. In this case, the collaboration is facilitated and problems are solved with a better and faster collective effort. The findings of this study are confirmed by those obtained by Beh Nia et al., who believed that poor intragroup communication and mistrust are challenges to collaboration [ 27 ]. Dawson et al. also described staff encouragement as a positive factor in improving patient handover between pre-hospital emergency and emergency department medical staff [ 9 ]. Other researchers have also emphasized on the critical role of trust in facilitating and enhancing collaboration and reducing mistakes [ 28 , 29 ].

The results indicated that if infrastructures were provided and the processes were defined and formulated, they will facilitate collaboration; otherwise, they prevent collaboration. Establishing a timely, accurate, and professional communication is the basis of establishing a mutual collaboration. The results of this study showed that pre-hospital emergency personnel suffered from lack of communication facilities and believe that this deficiency affects patient care, reporting, and coordination. In a qualitative study, Khademian et al. investigated the effective factors in improving teamwork in a trauma center. They also announced the inefficiency of the information sharing system as a barrier to optimal teamwork [ 30 ]. Studies by Miyers et al. highlighted the relationship and coordination between pre-hospital emergency information systems and other relevant information systems to provide appropriate pre-hospital emergency services [ 31 ]. The role of communication equipment as one of the most influential components in the performance of Iran’s pre-hospital emergency department is similar to the results found by Adent. In his study, the preferred key feature of the French pre-hospital emergency department was introduced to be the well-suited communication equipment system [ 32 ]. On the other hand, technology has been served the health systems in different countries. A review of pre-hospital emergency systems in developed countries shows that online medical communication is currently one of the popular features used and plays a fundamental role in providing services to far-reaching areas, that is, the principle of equality in access to services and communication acceleration. In Iran, however, the technological progress in the pre-hospital emergency departments is not similar to that observed in the developed countries and does not have such features [ 32 , 33 , 34 , 35 , 36 ].

In the case of other infrastructures, the availability of equipment and the similarity of equipment and supplies in the pre-hospital and emergency departments was one of the most influential factors for inter-sectorial collaboration. Mock et al. found the significant effect of physical resources on the care provided for traffic accidents [ 12 ]. In Vitkaitis’ study, the most important problems were emergency services in Lithuania, old ambulances, and the lack of integrated standards for medical education, which was emphasized as one of the factors affecting the poor performance of emergency medical services in this country [ 37 ]. These results are in line with the findings of the current study, indicating that pre-hospital and emergency department personnel are considered as specialists and capital in each country and their time is valueless. If they have access to sufficient infrastructure and facilities, they will have better collaboration, services, and will be more successful in satisfying patients.

According to the findings, the infrastructures and processes play an important role in effective collaboration; plus, their inadequacy causes problems in proper collaboration. Deficiencies such as lack of programming, specific processes for patient handover, equipment, reporting, and documentation are considered to be important barriers to effective collaboration. Accordingly, there is no specific protocol for admitting patients to the hospital and this had a negative impact on inter-sectorial collaboration. Bahadori et al. studied collaboration in crises and called detailed processes to achieve maximum collaboration [ 38 ]. As Bost et al. noted, clinical handover of patients is an important process that can help or prevent the safe transfer of patients to health systems [ 22 ]. Poor intragroup communication, mistrust, and lack of teamwork processes are among challenges facing collaboration [ 27 ]. Mizell et al. also assumed the standardization of handover procedures and training interdisciplinary issues as one of the important factors in enhancing collaboration between pre-hospital and emergency departments [ 39 ]. In Vitkaitis’ study, the lack of unified standards was considered as one of the negative factors regarding the performance of emergency medical services in Lithuania [ 37 ]. This finding was in line with the results of this study. Complete documentation and reporting are the major factors in the handover of traffic accident victims between the pre-hospital and emergency departments. The lack or shortage of necessary equipment and infrastructures for collecting and presenting patient information has posed challenges to inter-sectorial collaboration.

Limitations

The present study was a qualitative study with the aim of identifying the facilitators and barriers of collaboration between pre-hospital and emergency departments to handover the injured from traffic accidents in Iran. One of the limitations of this study was the qualitative feature of it; therefore, the results cannot be generalized to other emergency centers. Another limitation was the small sample size we used in this study. Moreover, the data collection was limited to a specific region, which cannot be indicative of other emergency centers in the whole country.

More quantitative and qualitative studies with a larger sample size are suggested in other emergency centers in other provinces of the country in order to better identify the facilitators and barriers to collaboration using the experiences of other staff across the country.

The current study identified the main facilitators and barriers to the traffic accidents injured delivery from pre-hospital emergency sectors to the hospitals in Iran. The results of this study indicate that individual capabilities such as knowledge and experience, development of mutual understanding through joint educational programs, sharing experiences, empathic behaviors, efficient infrastructures and processes such as the existence of specific work processes, documentation and paying attention to its prerequisites, and the availability of adequate and similar equipment are essential components in improving and facilitating collaboration between the pre-hospital and emergency departments. Ignoring the mentioned factors are barriers resulting in increased mortality rates and injuries caused by road accidents. Considering the undeniable effects of collaboration on the quality of medical services provided to traffic accident victims and the important challenges of this stage, issues related to the patient handover should be concerned as a part of the pre-hospital and emergency staff educational programs. Health managers and policy makers should take measures to develop policies and programs to strengthen facilitators and solve the challenges of establishing an appropriate collaboration framework. Empowering facilitators and removing barriers can provide positive and effective grounds for establishing collaboration in order to improve health services for road accident victims.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

This study is part of a PhD thesis approved by the Shahid Beheshti University of Medical Sciences. Our warm thanks go to the Research committee of Shahid Beheshti University of Medical Sciences, as well as for participations in the study.

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Department of Health in Disaster and Emergencies, School of Health, Safety and Environment, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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Nutrition Research Center, Department of Public Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran

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School of Health, Safety and Environment, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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Research Institute for Endocrine Sciences, Obesity Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

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HJ, RKJ, AKHJ, AA, SA and MNK assisted in conceptualization and design of the study, oversaw data collection, conducted data analysis and drafted the manuscript. HJ, RKJ and MNK conceptualized and designed the study, assisted in data analysis and reviewed the manuscript. HJ, RKJ, AKHJ, AA, SA and MNK assisted in study conceptualization and reviewed the manuscript. All authors read and approved the final manuscript.

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This study protocol was approved by the ethics committee of Shahid Beheshti University of Medical Science (Ethical Code: IR.SBMU.RETECH.REC.1396.1150). Informed consent was taken from all the participants. All methods were carried out in accordance the declarations of Helsinki. There was an emphasis on maintaining privacy in keeping and delivering the information accurately without mentioning the names of the participants. The participants were given the right to leave the interview at any time, and they were promised to have access to the study results.

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Jamshidi, H., Jazani, R.K., Khani Jeihooni, A. et al. Facilitators and barriers to collaboration between pre-hospital emergency and emergency department in traffic accidents: a qualitative study. BMC Emerg Med 23 , 58 (2023). https://doi.org/10.1186/s12873-023-00828-4

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Understanding the contexts in which female sex workers sell sex in Kampala, Uganda: a qualitative study

• Kenneth Roger Katumba 1 , 2 ,
• Mercy Haumba 1 ,
• Yunia Mayanja 1 , 2 ,
• Yvonne Wangui Machira 3 ,
• Mitzy Gafos 2 ,
• Matthew Quaife 2 ,
• Janet Seeley 2 &
• Giulia Greco 2  

BMC Women's Health volume  24 , Article number:  371 ( 2024 ) Cite this article

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Structural, interpersonal and individual level factors can present barriers for HIV prevention behaviour among people at high risk of HIV acquisition, including women who sell sex. In this paper we document the contexts in which women selling sex in Kampala meet and provide services to their clients.

We collected qualitative data using semi-structured interviews. Women were eligible to participate if they were 18 years or older, self-identified as sex workers or offered sex for money and spoke Luganda or English. Ten women who met clients in venues and outdoor locations were selected randomly from a clinic for women at high risk of HIV acquisition. Ten other women who met clients online were recruited using snowball sampling. Interviews included demographic data, and themes included reasons for joining and leaving sex work, work locations, nature of relationships with clients and peers, interaction with authorities, regulations on sex work, and reported stigma. We conducted interviews over three months. Data were analysed thematically using a framework analysis approach. The coding framework was based on structural factors identified from literature, but also modified inductively with themes arising from the interviews.

Women met clients in physical and virtual spaces. Physical spaces included venues and outdoor locations, and virtual spaces were online platforms like social media applications and websites. Of the 20 women included, 12 used online platforms to meet clients. Generally, women from the clinic sample were less educated and predominantly unmarried, while those from the snowball sample had more education, had professional jobs, or were university students. Women from both samples reported experiences of stigma, violence from clients and authorities, and challenges accessing health care services due to the illegality of sex work. Even though all participants worked in settings where sex work was illegal and consequently endured harsh treatment, those from the snowball sample faced additional threats of cybersecurity attacks, extortion from clients, and high levels of violence from clients.

Conclusions

To reduce risk of HIV acquisition among women who sell sex, researchers and implementers should consider these differences in contexts, challenges, and risks to design innovative interventions and programs that reach and include all women.

Peer Review reports

Introduction

Globally women who sell sex face a disproportionately large risk of HIV acquisition compared to the general population [ 1 , 2 , 3 ]. Among those at greatest risk are female sex workers (FSWs) in low- and middle-income countries (LMICs) who are 13.5 times more likely to acquire HIV relative to the general population [ 3 , 4 ]. Research indicates that structural, interpersonal, and individual factors influence HIV prevention behaviour [ 4 , 5 , 6 , 7 , 8 , 9 ]. Structural factors are defined as the economic, social, political, organizational or other aspects of the environment in which women sell sex, and which might act as barriers to or facilitators of women’s HIV prevention behaviour [ 7 , 10 , 11 , 12 , 13 , 14 ]. Interpersonal factors are those which relate to risks or protective factors between women and their clients, or intimate partners [ 2 , 15 ]. Individual factors are those which relate to a woman’s individual attributes such as age of initiation into sex work, alcohol and other substance use, knowledge of HIV prevention, physical, and psychological attributes [ 6 , 15 ]. Together, the structural and interpersonal factors influence the contexts in which women who sell sex work. Several structural and interpersonal factors that influence condom use among sex workers have been identified, including zoning restrictions and regulation of sex work, how women join sex work, the location where sex workers meet and provide services to clients, experiences of violent relationships with clients, and harassment by authorities and police [ 7 ]. Stigma has also been identified as an important influence on the way sex workers work and as a contributor to their risk environment. Stigma increases the risk of HIV acquisition to sex workers, yet it is experienced in several forms at the individual, interpersonal and structural levels [ 14 , 16 , 17 , 18 , 19 ].

In Uganda, sex work is illegal and criminalised. Research that investigated the contexts in which women in Kampala sell sex has however shown that women join commercial sex work because of their disadvantaged backgrounds and restricted access to economic resources [ 11 , 20 , 21 , 22 ]. Mbonye et al. [ 11 ] showed that women providing services in outdoor locations like streets, alleys and parking lots faced more challenges than women providing services in indoor locations like nightclubs, bars, and lodges. These challenges included exposure to violence, stigma from the public, and visibility to police [ 11 , 23 ]. Kawuma et al. [ 20 ]reported in a more recent study that the places in which women sell sex in Kampala are fluid in that they move from one type of venue to another. All these studies also showed that women selling sex in Kampala faced violent relationships with both the police/authorities and with their clients [ 11 , 20 , 21 ].

It is however noteworthy that women included in these studies were participants from large epidemiological cohorts that recruited participants from low socio-economic settings, with little or no education, and who typically recruited their clients in physical locations, indoor or outdoor [ 11 , 23 ]. Women outside of these cohort settings, who have higher education, belong to higher socioeconomic status, and meet clients in spaces other than those identified in these studies have not been included in important HIV research, programming, and prevention efforts in Uganda to date. Research in the United Kingdom, USA, Australia, Japan, and India has reported the experiences of women who sell sex using internet websites and social media platforms [ 24 , 25 , 26 ]. These women also face risks, violence, and crime just like their peers who meet clients in physical locations like venues and streets [ 24 , 27 ]. Understanding the contexts in which women sell sex and the strategies that they use to advertise, meet, and provide services to their clients will help us to understand HIV risk among women by highlighting how structural, interpersonal, and individual factors interact to influence HIV transmission. In Kampala, earlier studies have reported on the contexts in which women recruiting and providing services in physical locations work, but there is still a gap in knowledge about the prevalence of client recruitment using online platforms, how women who recruit this way are organised, and how this strategy affects their risk of HIV acquisition. Understanding these gaps will improve our understanding of the structural determinants framework for HIV prevention among women selling sex in Kampala. This paper presents a more comprehensive understanding of the contexts in which women sell sex in Kampala by including women who have not been included in prior research studies and emphasizes the need to reach them and target intervention efforts to them. This aligns with the UNAIDS strategy of leaving no one behind and reaching the populations at the greatest need of care [ 28 ].

Study design, participants, and process

Twenty women from Kampala and surrounding suburbs were included in the study, using two sampling strategies. The first sample – the clinic sample – included 10 women sampled from a cohort of 4500 women who had been attending a clinic dedicated to women at risk of HIV acquisition including FSWs run by the Medical Research Council/ Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit in Kampala [ 23 ]. Women who met clients in physical spaces like venues and outdoor locations had prior been recruited into the clinic through peers. The second sample – the snowball sample – included 10 women who met clients using online platforms including social media and websites such as Instagram. We identified one key informant who started the snowball recruitment as described by Heckathorn [ 29 ] and Rao et al. [ 30 ]. Women were eligible to participate if they were 18 years or older, self-identified as sex workers or offered sex for money and spoke Luganda or English. In our study, “women who meet clients” includes women actively recruiting clients, women searched out by clients, and women who are introduced to clients by peers, but meet using online spaces.

Data collection and management

An experienced female graduate social scientist (MH) made first contact with all women, planned interview appointments, administered the study information and consent process, and carried out in-depth interviews with them. For the clinic sample, we selected women from the cohort using a random number generator in Microsoft Excel to generate 10 random numbers within the range of 1 and 4,500 inclusive, which matched the women’s unique cohort identifiers. We invited women with the corresponding numbers to participate. To identify the seed for the snowball sample, the female social scientist (MH) used the Instagram search function to search through posts of women who offered mobile (in-house) massage services or sex for money. She used the keyword “massage” and the location filter set to “Kampala”. The results included both personal accounts and accounts for massage parlors. We considered the first personal account that appeared on the search results as the potential seed for our sample. The female social scientist (MH) contacted the first personal account via the Instagram chat function, providing information about the opportunity to participate in a research study. The owner of the personal account agreed to take part in the study. After her interview, the seed identified through Instagram identified other women and provided their contacts. The female social scientist (MH) then invited the potential participants to the study, and the snowball continued until 10 interviews were completed. We allocated participant numbers from A01 to A10 for those in the snowball sample, and B01 to B10 for those in the clinic sample. Interviews were carried out between September and October 2022.

We developed the interview guide from a literature review of the structural factors that influence HIV prevention for women who sell sex, and a review by Shannon et al. [ 6 ], which presented a framework for the structural drivers of HIV and the pathways through which they interact with interpersonal and individual behavioural factors. This framework expanded structural factors to include macro-structural factors such as legal, socio-political, cultural, economic, and geographic contexts in which women sell sex, sex work organisation which includes the organisational structure, community empowerment and collectivisation of sex work, and the work environment which includes the physical, social, economic and political features of the environments in which sex workers operate, such as violence, access to condoms and anti-retroviral therapy (ART), and venue policies [ 6 ]. Using this framework, we developed this guide specifically for this study, and included questions on how women joined and why they would leave sex work, how their work was organised including recruitment and where they provided services to clients, their relationships with clients and authorities, the illegality of sex work, and the stigma they experienced. A copy of this interview guide is included as an additional file (see Additional file 1). We collected basic demographics at the beginning of the interview, asking women about their age, number of children, level of education, if sex work was the main occupation, and if they used social media to meet men for sex work. These were summarised in MS Excel, and the corresponding frequencies presented as descriptive statistics. Recruitment logs with personal information were stored in a secure access-controlled cabinet separate from where interview notes, recorders and computers were kept. After obtaining informed consent from the participants, we audio-recorded interviews, then transcribed and translated them into English. The social scientist (MH) took notes to back up the recordings. We imported the transcripts, translations, and interviewer notes into NVivo 12 for data organisation and management.

Data analysis

We used framework analysis as outlined by Gale et al. [ 31 ] to analyse the qualitative data. This analytical approach involves developing a thematic structure for interpretation, under which individual codes can be grouped and compared [ 31 ].

A study team member checked five random transcripts in English for transcription accuracy, and all the 10 Luganda transcripts for translation accuracy. In the first step of the coding, both the first author and the social scientist (MH) coded four interviews independently using initial frameworks constructed both deductively using the review by Shannon et al. (2015) and inductively using themes arising from the interviews [ 3 ]. The two coders then met and consolidated their coding frameworks into a revised version, which the first author used to finalise coding of all the interviews. From the consolidated coding framework, we developed a framework matrix with the themes and subthemes as the columns, and the participants as the rows. We populated the cells of the matrix with both summaries and representative quotes from the data. We then analysed the data from each of the columns to generate analytical memos on prominent themes arising from the data. All the steps of the analysis were reviewed by two other co-authors.

Ethical considerations

This study was approved by the Uganda Virus Research Institute Research and Ethics Committee (GC/127/912), the Uganda National Council for Science and Technology (HS2386ES), and the ethics committee of the London School of Hygiene and Tropical Medicine (28,175). We obtained written informed consent from all the respondents before data collection. We compensated the participants 20,000 Uganda shillings (UGX), (USD 5.5) for their time, and 20,000 UGX (USD 5.5) for their transport. We did not offer current participants any incentive to refer seeds and informed them that they would not face any penalties whatsoever if they did not refer any seeds. To contact new participants for the snowball sample, the qualitative researcher was provided with a partial name and a contact number, or with the new participant’s Instagram handle. The identity of the referring participant was not disclosed to new participants. The referring participant was not told which of the potential participants suggested by her eventually participated in the study. A copy of the script we used is included as an additional file (see Additional file 2).

Women in our study

Twenty women participated in the study, 10 in each of the clinic and snowball samples. Of the 20 included women, 12 met clients using online platforms. Of these 12, nine were from the snowball sample and three were from the clinic sample. We reached out to 26 women for inclusion in the snowball sample, eight of whom opted not to participate, six did not come for their appointments, and two did not respond. In the clinic sample, only one of the 10 women was not reachable and was replaced. While women from the clinic sample generally had less schooling and were predominantly unmarried, women from the snowball sample generally had high levels of education, had professional jobs or were students in training for professional jobs, were able to negotiate better prices for sex, and were able to avoid outdoor confrontation with police, authorities, and the public. Table  1 below gives details of women’s individual characteristics.

The contexts in which women sold sex

The prominent themes we identified in our study included: how the women organised their work, why and how they joined or would leave sex work, the relationships that they had with clients, authorities, family, and their peers, and the stigma they experienced. We present them in Table  2 below and explain them in detail in the sections that follow.

Reasons women joined sex work, and why they would leave

Women mentioned economic need as the main reason for joining sex work, and this was driven by the loss of parents, abandonment by partners, economic hardships due to the COVID-19 pandemic, inability to continue school due to lack of school fees, and costs like rent and food.

I joined sex work because of the hardship I was going through after my husband abandoned me and the children, he was not paying their school dues, and they had nothing to eat. So, I decided to devise means of survival. (Clinic sample, 23–25 years, B04).

Women remained in sex work because of economic responsibilities and no alternative sources of comparable income. For women who met clients in public spaces, these responsibilities included costs such as rent, school fees and food for themselves and their families. For women who met clients using online spaces, responsibilities included special costs such as maintaining their lifestyle and good aesthetics both on online platforms and the social scene. They included rent for expensive apartments, hairstyles, makeup, expensive clothing and phones, trips outside Kampala and Uganda, and keeping up appearances on the Kampala party scene.

At this point as much as the money you get from sex work is little if I decide to leave, I won’t be able to sustain myself or even be able to start another business since I will not have money. The situation is bad these days, so if I leave sex work, which other job am I going to do? (Clinic sample, 23–25 years, B04). The money that it comes with is not little money. This is like salaries that people get for months, and I am doing it for just one day. So, it becomes addictive, and you must keep up with the lifestyle that you have started so you must keep going back until you are somewhere that you want to be. (Snowball sample, 25–30 years, A04).

While all participants mentioned economic need as reason for joining or staying in sex work, some women joined sex work because of trauma from being abused as children. The pain that they harboured from this trauma kept them in sex work, even if they were not proud of their work. Regardless of how they joined sex work or where they met their clients, most women would leave sex work if they had major changes in their social or financial status, for example if they got married, achieved financial stability through stable alternative and comparable sources of income, or having a home that they own.

Oh well yeah one day I want to have a family settle down and have a husband and have kids so definitely there is no way I can be married to someone when I am still doing this kind of work. (Snowball sample, 25–30 years, A04).

How female sex work in Kampala was organised

Where women met clients and provided services.

Women discussed recruiting clients in public physical spaces, in private virtual online spaces, and through go-betweens. The public spaces were both outdoor and indoor. Outdoor public spaces included streets, alleys, and markets, while indoor public spaces included venues such as bars, pubs, cafés, offices, churches, malls, casinos, hotels, restaurants, massage parlours and lodges. Women also discussed the lack of privacy and the higher risks of police prosecution and arrests, attacks by thugs, robbery, and exposure to judgement by the society, in addition to meteorological challenges like cold, windy, and rainy weather.

The person who took me on the streets [a female friend], one time we were on the street and her [the friend’s] uncle was the one haggling with her. (Laughs). Those are the things that make us leave the streets. At least you go to [the clients’] places or at our [the woman’s] place it has no problem. (Clinic sample, > 30 years, B02).

Women discussed benefiting from security offered by the management of indoor public spaces, even if in some cases they were charged a fee to be allowed to work at these places.

The street is not good but at the bar they first check clients before entering, they do not allow them to enter with keys, knives and other things which is not done on streets. That is why you see that many people who work from streets die a lot, that is why the street near [a pub nearby] many people die from there…For the places, I told you like [a specific pub], it is safe, even if a client becomes chaotic, we are protected by the guards at the bars. (Clinic sample, > 30 years, B03.

The private virtual spaces mentioned by women were online platforms that can be accessed from their homes, or other private and protected places. They included social media applications (apps) and sites such as Snapchat, Instagram, Badoo, and dating websites. Women who met clients using these spaces were able to reach many clients, had more time between the first contact with a client and accepting to offer services to the client. This time allowed them to make decisions both about their perceived safety with clients and avoid potential violent clients, but also about HIV prevention. They earned more than their peers who met clients in public spaces, and they provided services mostly in hotels, in the clients’ homes, and sometimes in their homes.

The advantage of hotels is that you can easily get help in case of any problems, which you can’t get when you are in someone’s home because its already night and some people’s homes are fenced even if you shout no one can help. (Snowball sample, 25–30 years, A07). Well, the truth is there is a lot going on, on social media. When you get offers, it is up to you to take them or not. Social media things are so easy now. You can meet people; you can easily associate with people from different parts of the world. (Snowball sample, 25–30 years, A02).

Women who met clients in virtual spaces faced some challenges particular to their strategy of recruiting clients, for example cyber threats and their online accounts being hacked into, new clients who did not want to pay being extorting money from them, and old clients who traded women’s confidentiality for money.

Because I had so many people writing to me. They wanted to meet me. So, I felt like Instagram wasn’t a safe place for me. And by then people used to hack into accounts. (Snowball sample, 25–30 years, A01).

Some women relied on pimps or peers who acted as go-betweens procuring clients for them. These women were assured of a reliable flow of clients from middle and high socio-economic status; and of more security since the go-between knew which woman was with which client, and at what location. However, they were prone to exploitation since the go-between usually took a commission off the women’s pay, while some protected violent clients.

Well, first there are what they call pimps who usually have contacts of men. Some are like delegates who come to Uganda, or who want to take girls outside for meetings outside of Uganda. These pimps are always looking for sex workers you don’t even have to look for them. (Snowball sample, 25–30 years, A04).

As much as some women used only private online spaces, others had a primary space where they usually met clients, and one ‘filler’ space they would resort to in case they didn’t have enough clients from their primary space. For example, women from the clinic sample mostly relied on online spaces during day, but used go-between or went out to clubs and bars in the night. On the other hand, women from the clinic sample relied heavily on physical spaces to recruit their clients.

During the day you can be on your phone, but you must go to clubs at night. If you are in another country, you can’t just stay in the house and chat on phone, you must go outside and look for clients if you need money. (Snowball sample, 25–30 years, A07).

Women who met clients using online platforms provided services in indoor spaces like their own and clients’ homes, and in hotels, but never mentioned offering services in public outdoor spaces. On the other hand, women who met clients in public outdoor spaces like streets provided services in indoor spaces, but also in the outdoor spaces where they met the clients.

How women competed for clients

Women who met their clients in public spaces viewed their counterparts who met clients using online platforms to be in a higher income and of a higher socio-economic status. The latter women discussed that the former operated a more versatile, more mobile, and less exposing form of sex work which was able to attract a clientele of higher socio-economic status and higher paying. Among women who met clients in physical spaces, women who met clients using online platforms were referred to as bikapu (plural for kikapu ) sex workers. A kikapu is a large travel or shopping basket that can be carried anywhere at any time, and whose contents are known only to the owner.

There are sex workers whom you will never see seated in corridors waiting for clients or even see clients entering her house. But she is also at her home doing sex work. If a client calls her, she goes, services the client, and returns to her house. They are always called ‘bikapu’ sex workers. (Clinic sample, 25–30 years, B05).

The prices women charged, and how they negotiated with clients

It was clear from the interviews that women who met clients using online spaces charged more than women who met clients in public spaces. Among women who met clients in public spaces, the highest amount received for a sexual act was 100,000 UGX (USD 27), compared to 40,000,000 UGX (USD 10,767) for those who met clients using online spaces. The latter had a minimum reserve price of 250,000 UGX (USD 67), compared to no payment or providing sex on credit among the former. Moreover, those recruiting online had more time to negotiate prices and compare offers from clients before meeting clients physically, compared to the former, who usually negotiated with one client at a time and when they had already met physically.

I can even get 8 million shillings. The lowest I get in a month is 5,000,000 shillings [USD 1,356] but it’s usually between 8 and 15 million shillings [USD 2,170–4,069]. When people who live abroad are around in large numbers, I can get up to 15,000,000 UGX [USD 4,069]. (Snowball sample, 25–30 years, A06). There are those sex workers who cannot come to my place where I work, but they meet their clients using the internet and somehow charge more expensively than me. I cannot compete with them; I am cheaper because I charge from 5,000 UGX [USD 1.40] but those sex workers charge from 100,000 [USD 28] or 200,000 UGX [USD 54]. (clinic sample, > 30 years, B03). You can get a customer who runs away after getting the service as agreed. That is what they call ‘bidding farewell with a zip’ (okusibuza zip). It depends, there is when we work tirelessly and you get 30,000–50,000 shillings [USD 8.20–13.60] monthly, and between two to three thousand (54–81 cents) daily. (Clinic sample, 25–30 years, B01).

Moreover, women who met clients using online spaces discussed being offered substantial non-financial incentives in addition to cash payment. In most cases, these incentives, which included gifts and trips within and outside Uganda, supplemented the cash payment clients offered and influenced women’s decision to reconsider some clients that had been rejected because the initial payment offer was deemed unattractive.

The relationships women had with authorities, clients, and peers

Women faced violence from clients in form of physical, verbal, and sexual abuse such as rape, clients removing or tearing condoms intentionally, and even death threats.

For me a man almost killed me. We went into a room, and I told him the amount of money I wanted. He said he did not have it. I told him to let me get out, but he started strangling me. Then I accepted that he had robbed me. (Clinic sample, > 30 years, B02). Ah God (covers her face with her palms and shakes her head) it was so hard for me. He slapped me, did everything you can think of. My dear, I gave up and had to act soft because some clients need you to be submissive. So, you must act like you are enjoying whatever he wanted. (Snowball sample, 25–30 years, A06).

However, some women met friendly and supportive clients who treated them well, got them business connections and supported them financially in their personal lives.

I will not lie to you; he was taking care of me just like any other man takes care of what he loves. (Snowball sample, 25–30 years, A01). Women’s relationships with peers were usually characterised by jealousy, mistrust, hatred, and threats. They fought with each other verbally, physically, and spiritually with witchcraft. That said, there was evidence of friendships among women who met clients in physical spaces. For example, they could demand their peers’ release if they witnessed their arrest. First, a massage parlour has a lot of girls. So, there is that hatred that comes along. Then there is a risk of being bewitched by those girls at the parlour. (Snowball sample, 23–25 years, A08). Yes, there are sex workers who compete against each other. I don’t know how to explain this but sometimes your fellow sex workers might notice that you are getting a lot of customers then they go and bewitch you. (Clinic sample, 23–25 years, B04).

Women who met using online spaces worked in isolation and were in many cases not able to get help in cases where clients turned violent. And because sex work is illegal in Uganda, women had no legal support or protection from authorities. Instead, they were exploited sexually and financially by the authorities, abused, and violated. All our participants faced some form of violence, abuse and exploitation from police and authorities.

We are treated badly. Police officers also come and arrest you and sometimes even rape you. Sometimes when they arrest you and you don’t have money to give, they force you to have sex. (Clinic sample, 23–25 years, B04. They all want sex (laughs). The truth is I don’t want to say everybody is bad among authorities but it’s like they all want to get something [sex]. Of course, I don’t give them, but I am sure there are people who do. (Snowball sample, 25–30 years, A02).

Authorities only offered protection when they got sexual favours from women, and when women paid regular fees to them. Women working in private indoor spaces like pubs discussed being protected from clients that turned violent, by private guards stationed at these indoor spaces.

Women who met clients in physical spaces were more affected by the illegality of sex work compared to their peers who met clients using online platforms. The former discussed restrictions on the areas or times when they could work, being exposed to arrest by authorities, and public shame and ridicule. The latter women discussed not knowing any laws against sex work, and their work not being hindered in by any regulations. However, majority of the women discussed not being able to report to authorities or disclose to friends and family in cases where they had been raped, for fear of prosecution, ridicule, and stigmatisation.

Women’s experiences of stigma

Our participants experienced internalised stigma where they felt like disappointments to their families, and unworthy of some things or levels of achievement in life, such as good loving relationships respect, and leadership positions in society. Some women thought they would only be able to fit in society if they left sex work. Otherwise, they had to live with persistent guilt, shame, and embarrassment from doing sex work, and consequently keeping their work secret from friends, family, and society.

Then there is also that persistent guilt of letting down your family and them expecting better. I don’t know but it’s embarrassing, how do you even start telling someone that you are getting money from having sex with multiple people not even one. (Snowball sample, 25–30 years, A07).

Women experienced stigma when they were shunned by their family and friends, health workers, local leaders, and the communities in which they live and work. They were pushed to operate in secrecy because they feared the stigma they would face if exposed. Women who met clients in public outdoor spaces like streets were most affected because they were more exposed to the public while working, and to arrests by authorities.

Banvuma [They insulted me]. I remember my mum told me I decided to go out and embarrass the family, yet they have degrees and masters. It was really bad. I never got invited to any family function. Ever since then I became a reject, and you know you can tell when you are rejected by how people look at and talk to you. (Snowball sample, 25–30 years, A01). Yes, from the neighbours one of them can see you or in a way find out that you do sex work. Then she comes and tells another person that you are a sex worker. Then they spend the whole day gossiping about you. (Clinic sample, 25–30 years, B05).

Women discussed not being able to get licences since their work is illegal, and not being able to report in cases where clients violated them. They were exposed to discrimination because they had no legal or structural backing for them to work or to be protected against violence, attacks, and exploitation.

We present the contexts in which women selling sex in Kampala met and provided services to their clients. Our participants met clients in physical spaces including venues and outdoor locations and using online spaces that included social media applications and websites. Earlier studies also found that women who sell sex in Kampala recruit clients in venues and outdoor locations like those we presented [ 11 , 17 ]. Our study goes a step further and highlights that some women met clients using virtual online spaces like social media platforms and websites. While this finding is new to literature on Uganda, it is consistent with studies carried out in other settings, where sex workers recruiting clients using online platforms like social media and websites were identified [ 24 , 25 , 27 ]. similarly to their peers who recruit clients from physical spaces, women who recruit clients using online platforms are also high-risk population, yet they have not been targeted in HIV prevention efforts. There is need for inclusion of women who recruit clients using online platforms in HIV prevention interventions.

We assert that women selling sex in Kampala work in settings where sex work is illegal and criminalised, and because of this they are forced to endure harsh treatment; they face violent and abusive clients; they are arrested, abused, and exploited by authorities; and they experience jealousy and violence from their peers, and stigma from society. It is known that sex work is illegal in Uganda, that women who sell sex have violent relationships with both clients and authorities, and that women selling sex get no legal protection [ 17 , 21 ]. Our findings are consistent with other studies in this respect. We go further and highlight the larger extent to which the illegality of sex work was felt by women who met clients in physical spaces compared to those who met clients using online platforms. This stresses the continued need for support to women who face violent relationships, and to create safe spaces for women selling sex.

We also show that women who met clients using online platforms had more time to engage and negotiate with the clients before meeting them physically, were able to generate a pool of potential clients and consequently had less pressure to find clients. These women also seemed to have better education and income compared to their peers who met clients in physical spaces. Despite these apparent individual level advantages, we show that in many ways women selling sex faced similar pressures at the structural and interpersonal levels and faced similar risks with regards to HIV acquisition.

All our participants faced challenges that are similar and consistent with those identified in earlier studies [ 11 , 17 , 20 , 21 , 23 ]. These challenges were sustained by gaps in structural, social, and interpersonal support with regards to HIV prevention. For example, all study participants were either unable or unwilling to obtain support from authorities in situations where they were abused, exploited, or violated by clients or authorities. Women who met clients using online platforms faced some challenges specific to them because of their client recruitment strategy. First, they had to deal with cybersecurity threats like their social media accounts being hacked into and being exposed on the online platforms where they met clients. The damage caused by such negative exposure would be amplified by information on these platforms being easily and affordably accessible to very many people simultaneously. Secondly, they were threatened with exposure and reputational harm by clients who did not want to pay for services. This further increased their already high costs of operation. In terms of risk, most women who met clients using online platforms were unable to get immediate help in case a client turned violent because they mostly provided services to clients in their homes (both the clients’ and women’s) and in hotels. These women were exposed to high levels of violence that was potentially fatal from clients, and yet they did not readily access the needed services because they were pushed to operate in secrecy due to fear of stigma, judgement, and prosecution. This was exacerbated by the fact that they were mostly university graduates with professional jobs and were therefore very secretive and protective of their involvement in selling sex. Women’s experiences of stigma were consistent with what has been found in the literature (Beattie et al., 2023; Cruz, 2015; Fitzgerald-Husek et al., 2017; Ruegsegger et al., 2021; Seeley et al., 2012). It is still interesting to note that our participants across the samples faced stigma in similar ways and that most were ashamed of their work. Even women who met clients using online platforms were unable to report clients because they feared the prosecution by authorities or judgement by society that would come with being exposed. Provision of safe structural and social environments that support and protect women who sell sex as they carry out their work is necessary. Additionally, interventions to reduce stigma for women who sell sex are still very important but should target the more secretive and protective women who recruit clients using online platforms.

While access to health care for women who sell sex has improved over the years, these improvements in access have been identified among women who sell sex and have been included in research studies. This includes women in the clinic sample of our study, who mostly meet clients in physical spaces. Access to health care and HIV prevention services for women who meet clients using online platforms has not been systematically recorded. Yet, our results show that women who meet clients using online platforms face similar and even more challenges than their peers who meet clients in physical spaces. While the common challenges that all women face, including stigma and violence are barriers to health care access [ 32 , 33 , 34 ], the additional challenges that women who meet clients using online platforms face could be additional barriers for access to health care. This calls for continued efforts to address the common challenges but also highlights the need for specific interventions to improve access to health care among women who meet clients using online platforms. Our findings on how women joined sex work or would leave are consistent with published literature. Earlier research showed that women joined due to economic need, or because of earlier traumatic experiences of sexual abuse, and they would leave if they achieved economic stability [ 16 , 21 , 35 ]. This further highlights the importance of continued efforts to empower all women, and protect them from sexual violence, regardless of their level of education, status of work, and where they recruit or provide services to their clients.

Women who met clients using online platforms were hard to reach for us as a research team, and we assume that it will be hard for other researchers, health service providers and policy to reach them effectively. In fact, most women who we contacted to be part of the snowball sample (16 of 26) did not participate in the study, and those who accepted did so with caution. The spaces in which our participants provided services were identical to those reported in the literature, i.e., in indoor venues and outdoor locations [ 11 , 17 , 20 ]. We however highlight the fact that women who met clients using online spaces always provided services in indoor spaces and never in public outdoor spaces. Intervention efforts that target women recruiting clients in venues and in outdoor spaces will therefore miss women who recruit using online platforms. To increase their access to health care, to support services, and to the HIV prevention services they need, research and policy makers need to generate innovative strategies that will reach and engage women recruiting clients using online platforms.

Strengths and limitations

We used the framework analysis method. This method can neither handle highly heterogeneous data nor pay attention to the language of the respondents and how it is used [ 31 ]. We could therefore have missed some heterogeneity in women’s individual, interpersonal, or structural factors because of our choice of data analysis method. Moreover, we based our initial interview guide and coding framework on structural factors identified in the literature. Even though we used some inductive coding to complement the initial deductive framework, results from a similar study using a fully inductive approach would make an interesting comparison. We neither used complex theories nor sought to develop theory derived from the data but used robust framework analysis techniques to generate the major themes related to the structural factors that affect the sexual and reproductive health of women selling sex in Uganda. Despite these limitations, we present important results that could be applicable to women selling sex in Uganda, and other similar settings.

Over half of women in our study met their clients using online platforms and faced additional specific challenges and risks by recruiting their clients using online platforms. Regardless of where they met their clients, our participants worked in environments that exposed them to high risk of acquiring HIV. To reduce risk of HIV acquisition among women who sell sex, researchers and implementers should consider these differences in contexts, challenges, and risks, and design innovative interventions and programs that reach and include all women selling sex in Kampala.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Female Sex Worker

Low and Middle Income Country

Human Immunodeficiency Virus

Anti-Retroviral Therapy

Uganda Shillings

United States Dollars

COrona VIrus Disease of 2019

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Acknowledgements

We are grateful to all the participants for their time and information, the entire UPTAKE consortium from which this work drew, Rachel Kawuma and Andrew Ssemata for the support on qualitative data analysis, and the MUL study site team for the invaluable support, thank you.

This work was supported by the European and Developing Countries Clinical Trials Partnership (EDCTP) [grant number CSA2018HS-2525]. This work was conducted at the MRC/UVRI and LSHTM Uganda Research Unit which is jointly funded by the UK Medical Research Council (MRC) part of UK Research and Innovation (UKRI) and the UK Foreign, Commonwealth and Development Office (FCDO) under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union.

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Kenneth Roger Katumba, Mercy Haumba & Yunia Mayanja

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Kenneth Roger Katumba, Yunia Mayanja, Mitzy Gafos, Matthew Quaife, Janet Seeley & Giulia Greco

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KRK: Conceptualization, formal analysis, investigation, methodology, project administration, writing - original draft, writing - review & editing. MH: Investigation, writing - review & editing. YM: Funding acquisition, project administration, writing - review & editing. MG: Funding acquisition, supervision, validation, writing - review & editing. YWM: Funding acquisition, writing - review & editing. MQ: Conceptualization, funding acquisition, methodology, supervision, validation, writing - review & editing. JS: Methodology, supervision, validation, writing - review & editing. GG: Conceptualization, methodology, supervision, validation, writing - review & editing. All authors read and approved the final version.

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Correspondence to Kenneth Roger Katumba .

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The study received ethical approvals from the Uganda Virus Research Institute Research Ethics Committee (Ref: GC/127/912), the Uganda National Council for Science and Technology (Ref: HS2386ES), and from the London School of Hygiene and Tropical Medicine Research and Ethics Committee (28175). All women provided written informed consent to participate in this qualitative methods study.

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Katumba, K.R., Haumba, M., Mayanja, Y. et al. Understanding the contexts in which female sex workers sell sex in Kampala, Uganda: a qualitative study. BMC Women's Health 24 , 371 (2024). https://doi.org/10.1186/s12905-024-03216-7

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Received : 26 March 2024

Accepted : 19 June 2024

Published : 26 June 2024

DOI : https://doi.org/10.1186/s12905-024-03216-7

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