research design and in depth interviews

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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

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Introduction

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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Conducting In-Depth Interviews in Qualitative Research

In-depth interviews are a cornerstone of qualitative research, providing researchers with the opportunity to explore participants' experiences, perspectives, and emotions in detail. This installment delves into the art of conducting in-depth interviews, offering insights into building rapport, creating a comfortable environment, and eliciting detailed responses.

Building Rapport and Creating Comfort

1. introduction and ice breakers:.

• Start the interview with a friendly introduction and ice breakers to put participants at ease.
• Establish a casual and conversational tone to encourage openness.

2. Active Listening:

• Demonstrate active listening by nodding, making eye contact, and providing verbal affirmations.
• Show genuine interest in participants' responses to foster a sense of trust.

Eliciting Detailed Responses

1. use of probing questions:.

• Incorporate probing questions to delve deeper into participants' responses.
• Ask follow-up questions that encourage reflection and the sharing of specific details.

2. Allowing Silence:

• Embrace moments of silence to give participants the opportunity to collect their thoughts.
• Avoid rushing to fill pauses, as participants may use this time to share more profound insights.

Handling Sensitive Topics

1. establishing ground rules:.

• Set clear ground rules for discussing sensitive topics, ensuring participants feel safe.
• Provide information on confidentiality measures to build trust.

2. Empathetic Responses:

• Respond empathetically to participants' emotions, acknowledging their feelings without judgment.
• Create a supportive environment for participants to share without fear of criticism.

Adapting to Participant Dynamics

1. cultural sensitivity:.

• Be culturally sensitive and aware of potential cultural nuances during the interview.
• Adapt communication styles to align with participants' cultural backgrounds.

2. Flexibility in Approach:

• Remain flexible in your approach, adjusting based on the participant's communication style and preferences.
• Allow participants to guide the conversation to areas they find most meaningful.

Practical Tips for Success

1. pilot interviews:.

• Conduct pilot interviews with a small sample to refine your interview approach.
• Gather feedback from pilot participants to make adjustments before the full study.

2. Transparency about Recording:

• Clearly communicate the recording process to participants and obtain consent.
• Ensure that participants feel comfortable with the recording method used.

Conducting in-depth interviews requires a combination of interpersonal skills, empathy, and methodological rigor. By building rapport, eliciting detailed responses, and adapting to participant dynamics, researchers can unlock valuable insights. In the next part of this series, we'll explore the unique dynamics of phone and video interviews, providing tips for overcoming challenges in virtual interview settings. Stay tuned for more insights into the world of qualitative research interviews!

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Qualitative research method-interviewing and observation

Shazia jamshed.

Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan Campus, Pahang, Malaysia

Buckley and Chiang define research methodology as “a strategy or architectural design by which the researcher maps out an approach to problem-finding or problem-solving.”[ 1 ] According to Crotty, research methodology is a comprehensive strategy ‘that silhouettes our choice and use of specific methods relating them to the anticipated outcomes,[ 2 ] but the choice of research methodology is based upon the type and features of the research problem.[ 3 ] According to Johnson et al . mixed method research is “a class of research where the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, theories and or language into a single study.[ 4 ] In order to have diverse opinions and views, qualitative findings need to be supplemented with quantitative results.[ 5 ] Therefore, these research methodologies are considered to be complementary to each other rather than incompatible to each other.[ 6 ]

Qualitative research methodology is considered to be suitable when the researcher or the investigator either investigates new field of study or intends to ascertain and theorize prominent issues.[ 6 , 7 ] There are many qualitative methods which are developed to have an in depth and extensive understanding of the issues by means of their textual interpretation and the most common types are interviewing and observation.[ 7 ]

Interviewing

This is the most common format of data collection in qualitative research. According to Oakley, qualitative interview is a type of framework in which the practices and standards be not only recorded, but also achieved, challenged and as well as reinforced.[ 8 ] As no research interview lacks structure[ 9 ] most of the qualitative research interviews are either semi-structured, lightly structured or in-depth.[ 9 ] Unstructured interviews are generally suggested in conducting long-term field work and allow respondents to let them express in their own ways and pace, with minimal hold on respondents’ responses.[ 10 ]

Pioneers of ethnography developed the use of unstructured interviews with local key informants that is., by collecting the data through observation and record field notes as well as to involve themselves with study participants. To be precise, unstructured interview resembles a conversation more than an interview and is always thought to be a “controlled conversation,” which is skewed towards the interests of the interviewer.[ 11 ] Non-directive interviews, form of unstructured interviews are aimed to gather in-depth information and usually do not have pre-planned set of questions.[ 11 ] Another type of the unstructured interview is the focused interview in which the interviewer is well aware of the respondent and in times of deviating away from the main issue the interviewer generally refocuses the respondent towards key subject.[ 11 ] Another type of the unstructured interview is an informal, conversational interview, based on unplanned set of questions that are generated instantaneously during the interview.[ 11 ]

In contrast, semi-structured interviews are those in-depth interviews where the respondents have to answer preset open-ended questions and thus are widely employed by different healthcare professionals in their research. Semi-structured, in-depth interviews are utilized extensively as interviewing format possibly with an individual or sometimes even with a group.[ 6 ] These types of interviews are conducted once only, with an individual or with a group and generally cover the duration of 30 min to more than an hour.[ 12 ] Semi-structured interviews are based on semi-structured interview guide, which is a schematic presentation of questions or topics and need to be explored by the interviewer.[ 12 ] To achieve optimum use of interview time, interview guides serve the useful purpose of exploring many respondents more systematically and comprehensively as well as to keep the interview focused on the desired line of action.[ 12 ] The questions in the interview guide comprise of the core question and many associated questions related to the central question, which in turn, improve further through pilot testing of the interview guide.[ 7 ] In order to have the interview data captured more effectively, recording of the interviews is considered an appropriate choice but sometimes a matter of controversy among the researcher and the respondent. Hand written notes during the interview are relatively unreliable, and the researcher might miss some key points. The recording of the interview makes it easier for the researcher to focus on the interview content and the verbal prompts and thus enables the transcriptionist to generate “verbatim transcript” of the interview.

Similarly, in focus groups, invited groups of people are interviewed in a discussion setting in the presence of the session moderator and generally these discussions last for 90 min.[ 7 ] Like every research technique having its own merits and demerits, group discussions have some intrinsic worth of expressing the opinions openly by the participants. On the contrary in these types of discussion settings, limited issues can be focused, and this may lead to the generation of fewer initiatives and suggestions about research topic.

Observation

Observation is a type of qualitative research method which not only included participant's observation, but also covered ethnography and research work in the field. In the observational research design, multiple study sites are involved. Observational data can be integrated as auxiliary or confirmatory research.[ 11 ]

Research can be visualized and perceived as painstaking methodical efforts to examine, investigate as well as restructure the realities, theories and applications. Research methods reflect the approach to tackling the research problem. Depending upon the need, research method could be either an amalgam of both qualitative and quantitative or qualitative or quantitative independently. By adopting qualitative methodology, a prospective researcher is going to fine-tune the pre-conceived notions as well as extrapolate the thought process, analyzing and estimating the issues from an in-depth perspective. This could be carried out by one-to-one interviews or as issue-directed discussions. Observational methods are, sometimes, supplemental means for corroborating research findings.

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In-depth Interviews: Definition and how to conduct them

Online surveys, user review sites and focus groups can be great methods for collecting data. However, another method of gathering data that is sometimes overlooked are the in-depth interviews.

All of these methods can be used in your comprehensive customer experience management strategy, but in-depth interviews can help you collect data that can offer rich insights into your target audience’s experience and preferences from a broad sample.

In this article you will discover the main characteristics of in-depth interviews as a great tool for your qualitative research and gather better insights from your objects of study.

LEARN ABOUT: Behavioral Research

What are in-depth interviews?

In-depth interviews are a qualitative data collection method that allows for the collection of a large amount of information about the behavior, attitude and perception of the interviewees.

LEARN ABOUT: Best Data Collection Tools

During in-depth interviews, researchers and participants have the freedom to explore additional points and change the direction of the process when necessary. It is an independent research method that can adopt multiple strategies according to the needs of the research.

Characteristics of in-depth interviews

There are many types of interviews , each with its particularities, in this case the most important characteristics of in-depth interviews are:

• Flexible structure: Although it is not very structured, it covers a few topics based on a guide, which allows the interviewer to cover areas appropriate for the interviewee.
• Interactive: The interviewer processes the material that is produced during the interview. During the interaction the interviewer poses initial questions in a positive manner, so that the respondent is encouraged to answer. The complete process is very human, and so less mundane and dull.
• Deep: Many probing techniques are used in in-depth interviews, so that results are understood through exploration and explanation. The interviewer asks follow-up questions to gain a deeper perspective and understand the participant’s viewpoint.
• Generative: Often interacting with your target audience creates new knowledge. For instance, if you are talking to your customers, you learn more about the purchase behavior. Researchers and participants present ideas for a specific topic and solutions to the problems posed.

To learn more about the characteristics of in-depth interviews, check out our blog on interview questions .

Importance of conducting in-depth interviews

As an in-depth interview is a one-on-one conversation, you get enough opportunities to get to the root causes of likes/dislikes, perceptions, or beliefs. 

Generally, questions are open-ended questions and can be customized as per the particular situation. You can use single ease questions . A single-ease question is a straightforward query that elicits a concise and uncomplicated response. The interviewer gets an opportunity to develop a rapport with the participant, thereby making them feel comfortable. Thus, they can bring out honest feedback and also note their expressions and body language. Such cues can amount to rich qualitative data.

LEARN ABOUT: Selection Bias

With surveys, there are chances that the respondents may select answers in a rush, but in case of in-depth interviews it’s hardly the worry of researchers. 

Conversations can prove to be an excellent method to collect data. In fact, people might be reluctant to answer questions in written format, but given the nature of an interview, participants might agree giving information verbally. You can also discuss with the interviewees if they want to keep their identity confidential.

In-depth interviews are aimed at uncovering the issues in order to obtain detailed results. This method allows you to gain insight into the experiences, feelings and perspectives of the interviewees.

When conducting the initial stage of a large research project, in-depth interviews prove to be useful to narrow down and focus on important research details.

When you want to have the context of a problem, in-depth interviews allow you to evaluate different solutions to manage the research process while assisting in in-depth data analysis .

LEARN ABOUT: Research Process Steps

Steps to conduct in-depth interviews

• Obtain the necessary information about the respondents and the context in which they operate.
• Make a script or a list of topics you want to cover. This will make it easy to add secondary questions.
• Schedule an interview at a time and date of the respondent’s choice.
• Ask questions confidently and let the interviewees feel comfortable, so that they too are confident and can answer difficult questions with ease.
• Set a maximum duration such that it doesn’t feel exhaustive.
• Observe and make notes on the interviewee’s body expressions and gestures.
• It is important to maintain ethics throughout the process.
• Transcribe the recordings and verify them with the interviewee.

Advantages of in-depth interviews

The benefits of conducting an in-depth interview include the following:

• They allow the researcher and participants to have a comfortable relationship to generate more in-depth responses regarding sensitive topics.
• Researchers can ask follow-up questions , obtain additional information, and return to key questions to gain a better understanding of the participants’ attitudes.
• The sampling is more accurate than other data collection methods .
• Researchers can monitor changes in tone and word choice of participants to gain a better understanding of opinions.
• Fewer participants are needed to obtain useful information. 
• In-depth interviews can be very beneficial when a detailed report on a person’s opinion and behavior is needed. In addition, it explores new ideas and contexts that give the researcher a complete picture of the phenomena that occurred.

Disadvantages 

The disadvantages of in-depth interviews are:

• They are time-consuming, as they must be transcribed, organized, analyzed in detail.
• If the interviewer is inexperienced, it affects the complete process.
• It is a costly research method compared to other methods.
• Participants must be chosen carefully to avoid bias, otherwise it can lengthen the process.
• Generally, participants decide to collaborate only when they receive an incentive in return.

LEARN ABOUT: Self-Selection Bias

What is the purpose of in-depth interviews?

The main purpose of in-depth interviews is to understand the consumer behavior and make well-informed decisions. Organizations can formulate their marketing strategies based on the information received from the respondents. They can also gain insights into the probable demand and know consumer pulse.

In the case of B2B businesses, researchers can understand the demand in more detail and can ask questions targeted for the experts. Interviews offer a chance to understand the customer’s thought process and design products that have higher chances of being accepted in the market.

LEARN ABOUT: 12 Best Tools for Researchers

Final words

An in-depth interview should follow all the steps of the process to collect meaningful data. Hope this blog helps you decide whether you should conduct a detailed interview with your target audience, keeping in mind the pros and cons of it.

If you want to get started with conducting research online, we suggest using an online survey software that offers features like designing a questionnaire , customized look and feel, distributing to your contacts and data analytics. Create an account with QuestionPro Surveys and explore the tool. If you need any help with research or data collection, feel free to connect with us.

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Design Research Methods: In-Depth Interviews

In our new three-part blog series, we introduce our favourite qualitative research methods and strategies that you can immediately start applying to your human-centered design projects.

We cover the following design research methods:

In-Depth Interviews (in this post)

Contextual Observations , and

Diary Studies

Do you want to conduct better interviews? 

We help you navigate in-depth interviews for your users and customers. We’ll explore how to plan and execute a stellar interview, and we’ll outline our Top 7 Tips for In-Depth Interviewers.

What are in-depth interviews?

In-depth interviews are one of the most common qualitative research methods used in design thinking and human-centered design processes. They allow you to gather a lot of information at once, with relative logistical ease. In-depth interviews are a form of ethnographic research, where researchers observe participants in their real-life environment. They are most effective when conducted in a one-on-one setting.

How and when can you use interviews?

In-depth interviews are best deployed during the Discovery phase of the Human-Centered Design (HCD) process . They are an opportunity to explore and a chance to uncover your user’s needs and challenges. Do you want to find out where they are struggling the most with your service? Now is the time to ask.

Logistics for In-Depth Interviews

Here are our top tips for planning out the logistics for your interviews:

Recruiting: Properly recruiting for interviews is a crucial step, and it can sometimes be the most challenging part of the process. Recruitment can either be handled by the client or in-house, and sometimes by an external recruiting firm. You’ll identify the demographics and characteristics of your different user groups as a first step (e.g. by gender, age, occupation, etc.), and then you’ll ideally find 4-6 interview participants that match your recruiting criteria.

Scheduling: Outwitly uses a scheduling tool called Calendly to schedule all of our interviews. This handy platform syncs directly with our internal calendars, and it will even hook-up to our web-conferencing tool to send call information directly to the participant.

Format: Interviews can be conducted in-person or remotely over the phone, or a combination of the two. An advantage to conducting in-person interviews is that they allow for easier rapport-building, and you’re able to more fully understand the context of how your participant may interact with the product, service, or organization, as well as a holistic picture of their lives. The advantage to remote interviews is that they are easier to schedule and recruit for, and they can really be conducted from anywhere with a cell signal or a WiFi connection. Ideally, you are able to do a mix of both interview types, or you’re able to use remote interviewing in conjunction with another research method, like observations.

Duration: The sweet spot for in-depth interview length is between 45–90 minutes. This depends on how many research themes and questions you have, and of course, your participant’s schedule. Anything over 90 minutes can be very draining for both you and the participant.

Note-Taking: When possible (and with the participant’s consent), it’s best to audio record interviews. This way you are not scrambling to keep up with your hand-written notes, and you are able to fully engage with the participant and listen closely. At Outwitly, we use manual audio recorders, but the iPhone Voice Record Pro app is also an option for in-person interviews. For remote interviewing, you might opt to use call recording software; we like to use the built-in recording feature of GoToMeeting , which is our preferred web-conference platform. Once audio recordings have been collected, we typically get the recordings transcribed using services like Rev.com . This saves a lot of time during the data analysis phase.

Interview Protocol: Before running a set of interviews, it’s important to prepare an ‘interview protocol.’ A protocol is the combination of two things:

1) An introductory script about the research and what the participant can expect from the interview. This is also the time to ask consent for recording and to assure participants that their names and everything they say will be kept confidential.

7 Tips for In-Depth Interviewers

Interviewing is an art form, and it requires a high level of emotional intelligence. You need to be in tune with how comfortable your interviewee/research participant feels, and enable them to open up to you–a complete stranger–about their challenges. Research can sometimes involve particularly sensitive subjects like weight management, divorce, personal finances, and more, so rapport-building (Tip #4) is especially crucial for successful interviewing. Here are our Top 7 best practices for interviewers.

Active Listening: The best skill an interviewer can foster is their listening ability. In a strong interview, the interviewer is not interrupting, bringing up their own anecdotes, or asking too many questions. While some of these “what-not-to-do’s” can actually be helpful to make the participant feel comfortable, too many can derail the interview and also lead the participant to certain answers (as discussed in Tip #3). The interview should flow naturally, and you should mostly allow for the participant to lead the conversation. You’ll want to be listening to them, and when appropriate, repeating key points back to them to reiterate that you are actively listening. Asking a question like “I heard you say your biggest challenges are XYZ. Is there anything else?” shows the participants that you are interested in what they are saying, and it encourages them to keep sharing.

Probing: ‘Probing’ in the context of in-depth interviews refers to diving deeper on a particular response or topic. Typically, you will have prepared your interview protocol with a list of questions and sub-questions–the latter are your probing questions. For example, you might begin with an open-ended, general question, and as your participant replies, you might ask subsequent questions that encourage them to keep digging into the subject. A good interviewer also knows when to continue probing on a subject–and when to move on.

Non-Leading: Learn not to ask leading questions. A leading question is one in which you are making an assumption in the way your question is phrased. This can influence how your participant answers the question. For example, if you ask a participant “What challenges do you have with XYZ?”, you are assuming there are challenges, which may skew the participants response. They may not have any challenges to begin with, but they might reply that there were challenges anyway to fit the question. A better way to ask that question would be: “What challenges, if any, have you had with XYZ?” When prepping the interview protocol, be careful not to draft leading questions. And in the heat of the moment if you go off-script, you’ll need to think about how you’re phrasing your questions.

Building Rapport: Learning to build rapport is one of the most important skills to cultivate as an interviewer. By ensuring your participants feel comfortable, they are much more likely to open up to you. Remember to always be friendly and courteous in your communication prior to conducting the interview (e.g. in emails you send regarding scheduling). In the interview, use a tone of voice that is soft and inquisitive, as well as understanding. Introduce yourself as the researcher and explain the research to the participant. Emphasize that you are there to learn about them, and to understand their needs and how the product, service, or organization they are interacting with could be improved to suit them. During the interview, if you hear in their tone of voice that something in their experience was very frustrating, use language to acknowledge that, by saying “It sounds like that was very frustrating” or “I understand” to let them know that you are on their side. Also, reassure them throughout the interview that their feedback is very useful and helpful by saying things like “Thank you – that’s very interesting,” or “I’ve heard that before from others, you are not the only one!”

Agility & Go-with-the-Flow Attitude: You can prepare, rehearse, and write your interview protocol, but in every interview you will have to be agile. For example, if you’ve separated your interview questions into sections, and the participant naturally starts talking about a topic that you have written down for a later portion of the interview, you should freely move down to those questions and jump back to where you were afterwards. This way, the interview will feel more organic and conversational, and less robotic. Flexibility is also critical because some participants just do not have a lot to say. In these cases, you’ll be required to think of more “off the cuff” questions, or you’ll need to reconsider whether the interview is still a valuable use of your time and theirs. Knowing when to cut an interview short is also an important skill. For the most part, let the participant lead the conversation, feel comfortable jumping around a little in your protocol, and listen to them to know what other questions you could ask that might not be in the protocol. Also, know when to skip a question if you’ve already gotten a response elsewhere in the interview.

Facilitate & Guide: Sometimes interviews will be easy and they’ll naturally follow the flow of your interview protocol. And sometimes they’ll be more challenging, especially if an interviewee is particularly passionate about one topic. In this case, you’ll need to guide your participants as much as possible, so that you can move through more of your questions. This is a delicate balance of listening, finding a time to cut in, and using transitional phrases like “That’s very helpful. I’m mindful of the time, and I would like to ask you some questions about XYZ.”

Comfort with Discomfort: It can sometimes be difficult for participants to answer a question quickly in an interview. They might need to think about their answer before responding. Or they may be able to answer quickly, but there might be things in the back of their mind related to the question that might take a minute for them to recall. It’s important to allow interviewees that space to think about the question. From a human perspective, leaving open silence can feel awkward, but it’s important to create space for the participant to remember anything else that might be important. So while you might be sitting there thinking “wow this is awkward,” they are actually just thinking about their answer. On the flip side, you also don’t want to leave too much space in case there is nothing else to add–this can in turn make participants feel insecure that they have not said enough. Perfecting this skill comes with a lot of experience, so for now, try counting to 10, or perhaps mention that you need a few seconds to catch-up on your note taking–this gives them the space to think longer without feeling too much time pressure. Of course, if nothing more comes up, just feel free to move on.

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Next in our Research Methods blog series, we walk you through best practices for conducting observations and shadowing as part of your research and design process.

Resources we like…

Calendly for Scheduling

GotoMeeting for Remote Interviewing

iPhone Voice Record Pro app for Audio Recording

Rev for Audio Transcription

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In-depth interviews.

In-depth interviews involve direct engagement with individual participants. It is a qualitative data collection method where the interviewer can ask the participants different questions based on their responses. In-depth interviews require the interviewer to be highly skilled at such data collection methods to ensure that the participants feel comfortable in sharing information authentically, that there is no data lost in the process and the quality of information collected is in-depth and thorough.

Quick details: In-depth Interviews

Structure: Unstructured, Semi-structured

Preparation: Topics, Participant recruitment

Deliverables: Transcripts, Notes, Documentation

More about In-depth interviews

The interviewer is also required to be fairly empathetic to individual participants during the one-to-one engagement. Again, the choice of location is important in the level of comfort the participants may experience. For example, a participant may feel more at ease in their own home versus at a new unfamiliar space. 

In-depth interviews prove to be highly helpful in situations where individual participants emotions, sentiments, opinions, values, etc. are an important part of the study or research being conducted. The duration of interview for individual participants may be different, the questions may vary depending on responses and therefore this method is fairly flexible in terms of its design. In-depth interviews may be conducted with a small groups as otherwise the interviews would be time-consuming. 

Advantages of In-depth Interviews

1. empathy & connection.

The researcher can give his/her undivided attention to the participants as well as connect with individual participants uniquely. This can allow the participants to feel comfortable during the interview while being authentic as well as open about the situation or issues being discussed.

2. Rich Data Collection

Many researchers use pre-existing lists of participants for methods such as focus and unfocus groups. However, in the case of in-depth interviews, because the sample size of participants is small, usually individuals are picked randomly to get a better and generalized picture of responses. Also,  as the interviewer can adapt based on participant responses, the quality of responses are high level.

3. No peer pressure

As in-depth interviews are one-on-one, there is no worry about individuals getting peer-pressured into a response that they don’t entirely agree with.

4. Simple Logistics

As individual interviews are scheduled either at a fixed location, both at the individual’s home or the research facility, and with fewer individuals being interviewed, the logistics planning and scheduling is pretty straightforward.

5. Comprehensive findings

As the participants are interviewed with the same objectives in mind, the interviewer can probe them to as much depth as desired. Again, all responses are recorded unlike email/online surveys where some individuals may not respond and focus groups where a few participants may not contribute to the discussion.

6. Deeper Insights

As the interviews are not strictly time bound, in-depth interviews allow participants to share their feelings, opinions, and attitude in greater depth as well as at length. An observant researcher can interpret the participant’s mood from their body language as well as tone of voice.

7. Quicker realization of goals

With the right participants and an experienced researcher, the path to the goals of the study can be reached quickly.

Disadvantages of In-depth interviews

1. time consuming.

In-depth interviews are quite time consuming, as interviews must be documented, analyzed and findings must be reported.

2. Experienced researcher

If the interviewer is not experienced then the entire research could get jeopardized. Again, this can sometimes drive the costs up by employing more number of researchers to one research.

3. Relatively Costly

The process can be relatively costly compared to other methods.

4. Participant recruitment

Participants must carefully chosen and this can lead to recruitment process which is time consuming. Sometimes, a background check of the participants is required to ensure authenticity but involves an additional time and cost factor.

Think Design's recommendation

Use In-depth interviews as a method when your research question needs deep probing and requires one-to-one interaction with participants. It is a qualitative research method and needs highly qualified researcher to ask relevant questions, moderate the interview and derive insights out of it.

Do not use in-depth interviews when you are seeking quantitative data or what you want is an evidence of responses. This method requires deep understanding of cultural and psychological context of the user and responses need interpretation.

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Related methods.

• Card Sorting
• Concurrent Probing
• Contextual Inquiry
• Dyads & Triads
• Extreme User Interviews
• Fly On The Wall
• Focus Groups
• Personal Inventory
• Retrospective Probing
• Unfocus Group
• User Testing/ Validation
• Word Concept Association

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Exploring the knowledge and skills for effective family caregiving in elderly home care: a qualitative study

• Open access
• Published: 15 April 2024
• Volume 24 , article number  342 , ( 2024 )

Cite this article

You have full access to this open access article

• Gebrezabher Niguse Hailu 1 ,
• Muntaha Abdelkader 1 ,
• Feven Asfaw 1 &
• Hailemariam Atsbeha Meles 2  

90 Accesses

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Family caregivers play a crucial role in providing physical, emotional, and social support to the elderly, allowing them to maintain their independence and stay in their preferred living environment. However, family caregivers face numerous challenges and require specific knowledge and skills to provide effective care. Therefore, understanding the knowledge and skills required for effective family caregiving in elderly home care is vital to support both the caregivers and the elderly recipients.

The research was carried out in Mekelle City, Ethiopia, utilizing the phenomenology study design and purposive sampling technique. A total of twenty-two in-depth interviews were conducted. Individuals with experience in providing care for elderly people in their homes were targeted. Data was gathered through the use of an open-ended guide, transcribed word-for-word, inputted into ATLAS.ti8 software, and translated. Codes and themes were then extracted from the transcribed data, and a thematic analysis was performed. To minimize personal biases, the collected data were coded independently by the data collection assistants and the PI. The analysis was carried out by authors who were not involved in the data collection process. The interviews were conducted in a quiet place.

A total of 22 in-depth interviews were conducted as part of this research. The results indicated that although the participants had knowledge about common health problems experienced by older people, they were uninformed about how to manage these conditions at home and were unaware of specialized healthcare resources for the elderly. Furthermore, they had limited knowledge about suitable exercise routines, strategies to prevent falls, and home healthcare practices for older individuals. On the other hand, they exhibited a solid comprehension and awareness of abusive behaviors specifically directed at older adults.

The results emphasized the importance of enhancing education and training for family caregivers in handling elderly health issues, raising awareness about specialized healthcare services catered to the elderly, improving understanding of activities of daily living (ADLs) and fall prevention, and offering inclusive training in healthcare tasks related to elder care.

Recommendation

Participants should receive comprehensive education and training programs to enhance their knowledge and skills in managing these conditions. Efforts should also be made to raise awareness about the availability of geriatric hospitals or specialized nurses for the elderly. Participants need to be educated about suitable exercise routines for the elderly and fall prevention strategies. Healthcare skills training is also necessary for participants, focusing on activities such as wound dressing, vital sign monitoring, and establishing a specific schedule for changing positions.

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Introduction.

Healthy aging is a constant process that improves the person’s health and quality of life [ 1 ].

According to a UN estimate on the world’s population outlook, by 2050, more than 63% of the world’s population—or approximately 22% of all people—will be 60 years of age or older and more than 63% will reside in Africa [ 2 ].

Caregiving becomes increasingly complicated and difficult as people age because of chronic illnesses and ongoing loss of mental and physical independence [ 3 ].Furthermore, research indicates that more than 70% of persons 60 and older view old age as a nightmare, a time of uncertainty about the future, and a time when they must rely on others for nearly everything [ 4 ].

The family-centered care paradigm was famously created in pediatrics and has now been applied to various fields, such as cancer, HIV, palliative care, and hospice care [ 5 ]. It is currently being modified for the care of vulnerable older individuals. Through information exchange, involvement in decision-making, and cooperation in the formulation of policies and programs, patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of treatment [ 6 ].

The older adult population suffers from poverty and social isolation especially in developing country like Ethiopia since many of them are retired and have scant or no retirement plans or benefits. For example, a study on the elderly conducted in Cameron revealed that older adults are the most vulnerable and disadvantaged people in society and are reliant on family members for their fundamental requirements [ 7 ].

Elderly family members who are unable to take care of themselves are supported by family caregivers who offer them physical, emotional, psychological, and occasionally financial support [ 8 ]. The majorities of them, however, perform this duty with little to no understanding of care, assistance, or support [ 9 ] Family caregivers who lack sufficient understanding may unintentionally injure their loved ones and sometimes even themselves [ 10 , 11 ].

In sub-Saharan Africa, it is typical for the younger spouse, (often the wife), children, or grandkids to be responsible for caring for their elderly family members [ 12 ].These family carers are required to help their elderly family members with everyday tasks and guard against elder abuse and falls [ 13 , 14 , 15 ].More broadly, they aid older family members who are unable to care for themselves by providing physical, emotional, psychological, and occasionally financial support [ 8 ].

Ethiopian traditional beliefs presuppose that younger family members will care for the elderly. Families, including children and relatives, are expected to care for the elderly, thus helping them is seen as a blessing and a good opportunity for kids. However, the majority of the family care givers in sub-Saharan Africa, including Ethiopia carry out this function with little to no knowledge of care, aid, or support [ 8 , 9 ]. Thus, exploring family care giver’s knowledge and skills for effective family caregiving in elderly home care using qualitative study to gather rich and detailed information that goes beyond numerical data is paramount important to take further action about caring of older adults at home.

Study area and period

The research took place in Mekelle, which is a city located in the Tigray region of northern Ethiopia. The study was conducted between December 2022 and October 2023. Mekelle is both the capital and largest city in the region, with a population of about 500,000 residents. The city is situated at an altitude of 2,084 m (6,837 feet) above sea level and is approximately 783 km (487 miles) away from the Ethiopian capital of Addis Ababa.

Study design

Phenomenological Study design was used to explore the personal experiences, thoughts, feelings, and perceptions of family caregivers in the context of providing care for elderly individuals at home.

Source and study populations

Source population.

All individuals who are over the age of 18 and living in Mekelle city and responsible for taking care of their elderly relatives in their homes.

Study population

All selected family care givers who were responsible for providing care for their elderly loved ones within their own homes.

Sample size determination

The sample size was determined by the level of saturation. Twenty two study participants were used for in-depth interview.

Sampling technique and procedure

We used a purposive sampling technique, which is non-probability, to select participants for our study. We specifically targeted individuals with experience in providing care for elderly people in their homes. To find these participants, we reached out to healthcare professionals like doctors, nurses, and social workers who regularly interact with elderly patients. Community events related to elderly care and family caregiving also allowed us to connect with potential participants. Additionally, we made use of online platforms, such as social media groups focused on family caregiving or elderly care, in order to reach a larger audience.

Data collection method

We developed and translated an open-ended English guide into the local language, Tigrigna, with the assistance of experts. Two experienced research assistants helped with the data collection process as data collection assistants. One assistant used a tape recorder to record interviews, while the other took notes. The PI moderated the data collection process. In-depth interviews were conducted to gather thorough information on the experiences, perspectives, and insights of family caregivers who provide care for elderly individuals in their homes.

Data quality assurance

Before starting the actual work, open-ended guiding questions were prepared and discussed with experts. Data collection assistants were trained to take notes and record using a tape recorder for one day. The use of an open-ended guiding question helped prevent dominance from participants. After each day of data collection, a debriefing session was conducted by the data collection assistants and the principal investigator (PI). The recorded data were read, re-read, and transcribed by both the researchers and data collection assistants separately to ensure data reliability. To minimize personal biases, the collected data were coded independently by the data collection assistants and the PI. The analysis was carried out by authors who were not involved in the data collection process. The interviews were conducted in a quiet place.

Data analysis and presentation

The information was gathered using a tape recorder and notes. It was later transcribed, entered into Atlas-ti8, and translated. Codes were generated and organized, eventually leading to the formation of five themes. The thematic analysis approach was employed, and the outcome was presented in both written form and as a table.

A total of twenty two individuals were participated in the study (Table 1). The results of the study were summarized in to five thematic areas: Awareness of participants on common elderly health conditions and their home based management care, Awareness of study participants on availability of elderly care resources, Awareness on practice of ADLs and fall prevention, awareness towards practices related to simple and highly skilled healthcare activities, and awareness on abuse related practices.

Awareness of participants towards common health conditions and their home based management care

Concerning the awareness of participants regarding common health conditions in elders, participants showed a good understanding. They mentioned nearly all of the common health conditions that affect elders. However, most participants lacked knowledge about how to manage these conditions properly. Caregivers, based on their opinions, have a widespread awareness of the common health conditions that affect elderly individuals. Conditions such as joint pain, forgetfulness and memory loss, visual impairment, hearing loss, and age-related muscle weakness were among those mentioned. However, what is particularly notable is the lack of knowledge regarding the management of these conditions. The participants expressed uncertainty about selecting appropriate exercises for joint pain, effectively managing forgetfulness and memory loss, providing assistance beyond clear communication for hearing loss, and measuring blood pressure.

“…….Joint pain is a common health condition among the elderly. My mother often complains about her knees and hip joints hurting, particularly during long periods of walking or standing. While I provide her with exercises, I am unsure about the most appropriate type of exercise to alleviate her pain. I know also some other common elderly health conditions like diabetes, high blood pressure and eye problems…….P 1 ” . “I have observed instances of forgetfulness and memory loss not only in my father but also in several other elderly individuals. It is quite common for him to misplace his belongings frequently or repeatedly ask the same question……… This issue poses a significant challenge for me as I am uncertain about how to effectively manage and assist him with this problem on my own. Additional support and guidance are desperately needed in order to address this situation adequately…P 7 ”. “My father is experiencing respiratory conditions, and I am also aware that high blood pressure is common among older individuals……. I have noticed several instances where it remains undetected until it causes significant health problems……….Unfortunately, we do not have a blood pressure measuring device at home and I have no any clue how to measure it, so I am unable to check my father’s blood pressure. However, when I take him to the hospital for his other health concerns, they do measure his blood pressure during the check-up….P 10 ” .

One participant demonstrated a good understanding and proactive approach towards managing his grandmother’s visual impairment caused by age-related eye problems. But nevertheless, the participant lacked knowledge and understanding on management of other common health conditions experienced by older adults such as joint pain, neck and back pain, memory loss, and chronic diseases.

“…………….My grandmother suffers from visual impairment caused by age-related eye problems. She experiences difficulty in reading or recognizing faces from a distance. To effectively manage this condition, I ensure her eyeglasses are clean and take her for regular eye check-ups. I know also many other cases which are common in older adults although, I have no clue about their management. For example: joint pain, neck and back pain, memory loss, and chronic diseases….P 6 ” .

Another one participant has also demonstrated awareness and proactive measures in managing his father’s health condition related to age-related muscle weakness. By installing handrails and providing a walker, he has significantly improved his father’s mobility and independent functioning.

“My father has difficulties walking due to age-related muscle weakness. He often requires assistance with activities like climbing stairs or getting in and out of bed. I have installed handrails around the house and provided him with a walker, significantly improving his mobility…P 15 . ”

Awareness of study participants on availability of Elderly Care resources

The participants have expressed a lack of awareness regarding the availability of geriatric hospitals or specialized nurses for the elderly. They acknowledged their limited knowledge and stated that they had not come across any specific resources or services catering to elderly care. “……………As far as my knowledge goes, I don’t think there are geriatric hospitals. I haven’t come across any information or services specifically focused on elderly care. I know there are general hospitals and nurses, but I have no idea if there are specific geriatric hospitals or specialized nurses for the elderly….P 2 ” .

However, they were aware of the presence of non-governmental organizations and social care services that offer assistance and support for the elderly population.

“Yes, I was aware of the existence of non-governmental organizations and social care services that offer assistance and care for the elderly. In fact, I have personally utilized some of these services for my aging parents………. These organizations provide various forms of support, such as in-home care, transportation assistance, and respite services. They have been a valuable resource for my family, helping us ensure that our elderly loved ones receive the necessary care and support they need…… P 4 ” .

“………….Certainly, I have knowledge about the presence of non-governmental organizations and social care services that offer assistance and care for the elderly. When my grandmother required more support than our family could provide on our own, we explored these services and found several reputable organizations that support elders. They offer services such as personal care, meal preparation, and even companionship for the elderly. The availability of these organizations has been a great relief for families like ours, as they provide professional caregivers who contribute to the overall well-being and quality of life of the elderly population……P 8 ” .

Awareness on practices of ADLs and fall prevention

Study participants were actively involved in assisting their elder family members with certain activities of daily living (ADLs) such as cooking meals, washing clothes, and bathing.

“……….As a family caregiver, I take care of my aging loved one by cooking meals, washing their clothes, and ensuring they receive proper assistance with bathing….P 16 . ”

“I have taken on the responsibility of cooking meals, washing my elderly family member’s clothes, and helping them with bathing to ensure their comfort and well-being in their home….P 1 . ”

But nevertheless, they lacked knowledge about suitable exercise routines for the elderly and, therefore, do not provide any assistance in that aspect.

“……I didn’t know that there were limits to the elderly’s exercise capacity. I just assumed they would let me know if something was too much for them. I never actively engaged them in exercise or encouraged any physical activities….P 17 . ”

“Exercise routines?…. I guess I never thought much about it. I mean, they’re old, so I didn’t think they need much physical activity. I haven’t made any specific measures to ensure their safety or meet their needs in terms of exercise….P 22 . ”

One has expressed with limited awareness of home arrangements with the elderly consideration.

“….To be honest, I never really thought about the safety aspects of the home in relation to the elderly. I didn’t make any specific changes or modifications to prevent accidents or accommodate their needs…P 13 ” .

Awareness towards practices related to simple and highly skilled healthcare activities

Participants in the study fulfilled their duty of looking after their elderly family member by complying with the doctor’s instructions and ensuring that the recommended medications were taken as instructed. Their dedication involved following the prescribed dosage and timing to ensure their family member derived the utmost advantage from the medication. Additionally, the participants showed their support by accompanying the elderly family member to medical appointments.

“I always make sure to give the prescribed medications to my elderly mother member as per the doctor’s instructions………. I try my best to follow the dosage and timing mentioned on the prescription…P 18 ” .

“……………Taking my elderly family member for doctor’s appointments is an important responsibility for me. I make sure to accompany them and ask relevant questions to the doctor regarding their health condition and medication…….P 10 ”.

However, they lacked knowledge and skills in home based healthcare activities such as wound dressing, monitoring vital signs, and establishing a specific schedule for changing positions. While they strived to meet their family members’ requests for position changes and the changing of soiled linens, they were not necessarily adhering to a specific time interval.

No, I am not aware of any specific healthcare activities related to wound dressing or changing positions frequently to prevent becoming bedridden. I only change the position when my elderly family member asks for it and change the soiled linens as soon as they get soiled.P 7 .

“I don’t have the knowledge or skills to monitor vital signs or perform wound dressing at home. I do change the positions of my elderly family member when they request it, but I am not aware of the specific time intervals when to change….P 20 ” .

Awareness on abuse related practices

The care givers had a strong awareness and understanding of abuse-related practices towards elders. They condemn any form of physical abuse, such as beating, and emphasize the importance of communication and peaceful resolution of conflicts. They also recognize the significance of providing proper nourishment and addressing dietary needs, highlighting the harm of neglecting the elderly’s access to healthy meals. Respectful and calm communication is advocated to avoid any emotional or mental harm to elders. Additionally, they stress the responsibility of providing attention and care, rejecting the notion of ignoring elders.

“I believe that abuse towards our elders is completely unacceptable……… I have never resorted to beating my elderly parents as a means of control or discipline. Instead, I try to communicate with them calmly and find peaceful solutions to any issues that may arise….P 3 . ”

“…………Refusing food to our elders is a form of neglect and abuse. I strongly believe in providing nourishment and taking care of their dietary needs. It is vital to ensure that they have access to healthy and balanced meals to maintain their well-being….P 21 ” .

“Yelling at our elders is not only disrespectful but also harmful to their mental and emotional health. I always try to maintain a calm and patient demeanor when communicating with my elders, even in challenging situations….P 9 ” .

“I believe it is our responsibility to provide proper attention and care to our elders. Ignoring them is simply not an option…………. I dedicate time every day to spend quality moments with them, listen to their stories, and address their concerns….P 11 . ”

The findings of this qualitative study highlight several important gaps in knowledge and skills among family caregivers in elderly home care. The participants demonstrated a good understanding of common health conditions affecting elders, indicating a basic foundation of knowledge in this area. However, they lacked knowledge about proper management of these conditions, suggesting a need for education and training to improve their caregiving abilities. This finding aligns with previous research, which has also identified knowledge gaps among family caregivers in areas such as medication management and symptom control [ 16 ].

One notable gap identified in this study is the lack of awareness regarding the availability of geriatric hospitals or specialized nurses for the elderly. This suggests that participants may be unaware of the resources and support services available to them, which could impact their ability to provide optimal care for their elderly relatives. Improving awareness of these resources is therefore crucial to ensure that family caregivers are accessing the necessary support to fulfill their caregiving responsibilities effectively. Previous studies have also highlighted the importance of providing information and education to family caregivers about available resources and services [ 17 ].

Another significant gap identified in this study is the lack of awareness and knowledge about suitable exercise routines for the elderly activities on daily living (ADLs) and fall prevention. ADLs are essential for maintaining independence and quality of life among elderly individuals, and family caregivers have a crucial role in assisting with these activities. Similarly, fall prevention is vital to prevent injuries and maintain the well-being of elderly individuals. Addressing this knowledge gap is essential to ensure that family caregivers are equipped with the necessary skills to promote independence and prevent accidents. Previous studies have emphasized the importance of caregiver education and training in ADLs and fall prevention [ 18 ].

Furthermore, participants in this study exhibited insufficient knowledge and skills in healthcare activities such as wound dressing, monitoring vital signs, and establishing a specific schedule for changing positions. These activities are critical for maintaining the health and well-being of elderly individuals, particularly those with chronic illnesses or physical limitations. Providing education and training on these healthcare activities is crucial to enhance the caregiving skills of family caregivers and ensure the provision of adequate medical care at home.

Despite these knowledge and skills gaps, it is encouraging to note that most participants demonstrated a strong awareness and understanding of abuse-related practices towards older adults. This highlights the importance of recognizing and addressing elder abuse, as family caregivers are in a unique position to detect and prevent such abuse. However, further research is needed to explore the specific actions and strategies that family caregivers can employ to effectively address elder abuse.

The results indicate that while participants showed a good understanding of common health conditions affecting elders, they lacked knowledge about managing these conditions properly. Participants also expressed a lack of awareness regarding the availability of geriatric hospitals or specialized nurses for the elderly. There was also a lack of awareness and knowledge about suitable exercise routines for the elderly on activities of daily living (ADLs) and fall prevention. Furthermore, participants lacked knowledge and skills in healthcare activities such as wound dressing, monitoring vital signs, and establishing a specific schedule for changing positions. However, most participants had a strong awareness and understanding of abuse-related practices towards elders. In conclusion, the study reveals that participants possess a solid understanding of common health conditions affecting the elderly but lack knowledge about proper management of these conditions. Furthermore, participants expressed a lack of awareness regarding the availability of geriatric hospitals or specialized nurses for the elderly. Moreover, there was a notable lack of awareness and knowledge regarding practices related to activities of daily living (ADLs) and fall prevention. Additionally, participants exhibited insufficient knowledge and skills in healthcare activities such as wound dressing, monitoring vital signs, and establishing a specific schedule for changing positions. Despite these gaps, most participants demonstrated a strong awareness and understanding of abuse-related practices towards older adults.

Participants should receive comprehensive education and training programs to enhance their knowledge and skills in managing these conditions. This includes learning proper management techniques, understanding available healthcare resources, and being aware of specialized care options for older adults. Efforts should also be made to raise awareness about the availability of geriatric hospitals or specialized nurses for the elderly. Participants need to be educated about suitable exercise routines for the elderly and fall prevention strategies. Healthcare skills training is also necessary for participants, focusing on activities such as wound dressing, vital sign monitoring, and establishing a specific schedule for changing positions.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. •.

Abbreviations

Activity of Daily living

Human immune virus

Institutional review board

Principal investigator

United Nation

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Acknowledgements

We sincerely appreciate Mekelle University and want to express our deep gratitude to them. Furthermore, we wish to acknowledge and express our gratitude to the data collectors and study participants for their cooperation and willingness.

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Gebrezabher Niguse Hailu, Muntaha Abdelkader & Feven Asfaw

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Gebrezabher Niguse Hailu: Supervision, Transcription and translation, inception and design; Muntaha Abdelkader: Tape recording, transcription; Feven Asfaw: Taking note, transcription, translation, design; Hailemariam Atsbeha: Transcription, translation, analysis, inception and design.

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Hailu, G.N., Abdelkader, M., Asfaw, F. et al. Exploring the knowledge and skills for effective family caregiving in elderly home care: a qualitative study. BMC Geriatr 24 , 342 (2024). https://doi.org/10.1186/s12877-024-04924-3

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Stakeholder opinions on perceived sub-standard emergency obstetric and newborn care in Ghana

• Alice Ayawine 1 ,
• Mathias J. A. Asaarik 2 &
• Roger A. Atinga 3  

BMC Health Services Research volume  24 , Article number:  461 ( 2024 ) Cite this article

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Sub-Saharan Africa is unlikely to achieve sustainable development goal (SDG) 3 on maternal and neonatal health due to perceived sub-standard maternal and newborn care in the region. This paper sought to explore the opinions of stakeholders on intricacies dictating sub-standard emergency obstetric and newborn care (EmONC) in health facilities in Northern Ghana.

Drawing from a qualitative study design, data were obtained from six focus group discussions (FGDs) among 42 health care providers and 27 in-depth interviews with management members, clients and care takers duly guided by the principle of data saturation. Participants were purposively selected from basic and comprehensive level facilities. Data analysis followed Braun and Clarke’s qualitative thematic analysis procedure.

Four themes and 13 sub-themes emerged as root drivers to sub-standard care. Specfically, the findings highlight centralisation of EmONC, inadequate funding, insufficient experiential training, delay in recruitment of newly trained essential staff and provider disinterest in profession.

Setbacks in the training and recruitment systems in Ghana, inadequate investment in rural health coupled with extent of health provider inherent disposition to practice may be partly responsible for sub-standard obstetric care in the study area. Interventions targeting the afore-mentioned areas may reduce events of sub-standard care.

Quality of emergency obstetric and newborn care is sub-standard in sub-Saharan Africa.

Sub-standard emergency obstetric and newborn care in rural Ghana may be due to hitches in placement, training and recruitment processes, centralisation of EmONC, inadequate funding, insufficient experiential training, delay in posting of newly trained essential staff and provider disinterest in profession. Adequate and timely resourcing of health facilities and standardisation of admission procedures into schools may reduce events of sub-standard care.

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In recent years, maternal and neonatal mortality rates have witnessed downward trends globally due to several maternal interventions. The rate of decline is, however, slow in sub-Saharan Africa making it unlikely to achieve SDG 3 which targets 70 deaths per 100,000 live births by 2030 and a neonatal mortality rate of less than 12 per 1,000 live births [ 1 ]. EmONC is one of the safe motherhood strategies that are aimed at improving maternal and neonatal outcomes [ 2 ]. The strategy is an attempt to addresss challenges associated with access to quality emergency obstetric care by empowering selected health facilities with essential drugs, equipment and personnel to be able to perform life saving basic and comprehensive interventions to avert preventable mortalities during childbirth [ 3 ]. EmONC operates at two levels: basic and comprehensive. Basic Emergency Obstetric and Newborn Care (BEmONC) facilities perform signal functions such as administration of parenteral antibiotics, oxytocic drugs and anticonvulsants, manual removal of placenta, removal of retained products (manual vacuum extraction, dilatation and curettage), assisted vaginal delivery such as vacuum extraction and foceps delivery and perform basic neonatal resuscitation using bag and mask. Comprehensive Emergency Obstetric and Newborn Care facilities (CEmONC) perform all these in addition to providing Cesarean section (CS) and blood transfusion. It is reckoned that the expansion of EmONC services to rural and disconnected communities will create the opportunity to provide sufficient life-saving services as well as enhance access to good quality care to parturient women.

Studies evaluating quality of EmONC have often focused on how the availability of resources influence quality maternal-neonatal outcomes [ 4 , 5 , 6 ]. The results portray inadequate resources for EmONC delivery leading to some adverse maternal and neonatal outcomes in countries across sub-Saharan Africa [ 7 ]. Similarly, studies in Ghana record concerns such as inadequate clinical knowledge and competences of health providers and lack of essential supplies as factors constraining quality EmONC provision [ 8 , 9 , 10 ]. Investigating into why these issues persist in the quality of maternal and child health care literature space, Filby and colleagues [ 11 ] in a systematic review, discovered lack of investiment in midwifery education, inadequate numbers of staff, lack of affordable transport, weak facility management and poor working conditions as main influencers. Relatedly, Geleto, Chojenta, Taddle and Loxton [ 12 ] revealed a lack of treatment protocols, poor supportive supervision and poor staff motivation as tailbacks to the provision of quality obstetric care in hospitals in Ethiopia. These studies did not only peruse the views of only health providers, they concentrated on professional factors and failed to uncover issues pertaining to other key components of EmONC notably the role of drugs and equipment. Understanding a Ghanaian situation from a stakeholder perspective may reveal additional nuances that may lead to adoption of appropriate strategies to improve upon maternal and newborn care especially in rural Ghana. The objective of the study is to explore stakeholder opinions on factors triggering sub-standard EmONC delivery in Northern Ghana.

Study design

A qualitative study design from a constructivist paradigm was used for the study [ 13 ]. The design enabled the researchers to reflect on stakeholder perspectives and opinions as staunchly as possible while admitting their own reflexive influence in the interpretation of data [ 14 ].

Study setting

Ghana is a country with a striving health care system. The health system has the onerous task of meeting the health needs of the rapidly growing population of Ghana and fighting illnesses associated with poverty and lack of education [ 15 ]. Although life expectancy has improved with declining rate of maternal and neonatal mortalities, the system is saddled with challenges such as poor coverage, poor quality of health care, corruption and weak management [ 16 ]. These challenges are very much prevalent in the Northern Region where this study was conducted. The region is largely rural, deprived and had a maternal mortality ratio of 207 per 100,000 live births, higher than the national average as at the end of 2017 [ 17 ]. At the time of the study, the region had at least one designated BEmONC facility in each rural district as a first level facility and a total of three CEmONC facilities sited in some towns [ 18 ]. Two each of BEmONC and CEmONC facilities were selected from these existing facilities for the study. The selected CEmONC facilities had an average of 250 bed capacity [ 19 ]. The study population was purposively recruited from these facilities. They comprised 42 EmONC service providers, who were mostly midwives, seven management members, 15 clients who received EmONC services and five care takers. Aside providers’ willingness to partake in the study, the sampling procedure considered years of service, role and gender. Such people were in a unique position to provide relevant information pertaining to the quality of EmONC. Clients comprised women who received EmONC and their care takers. They were selected at the facilities during care delivery and sampling progressed till data saturation.

Ethical statement

Ethical approval for the study was obtained from the Ghana Health Service (GHS-ERC004/04/19) and the University of Cape Coast [UCC] Ethical Review Board (UCCIRB/CES/2019/03). All methods were carried out in accordance with relevant guidelines and regulations stipulated by the ethics committees.

Data collection instruments

Both interview and focus group discussion guides were developed based on the study purpose and in conformity with qualitative research methodology [ 20 ]. Table s1 contains sample questions on the instruments. The questions sought to explore individual and group views on sub-standard care in the region. They explored issues pertaining to EmONC’s key components namely availability and quality of emergency obstetric drugs, equipment and essential personnel and how and why these contributed to sub-standard care. Probes and prompts were used to elicit detailed submissions from participants. Questions for both IDI and FGDs were pre-tested and corrections made before final administration.

Data collection

Interviews with management members were conducted in English and lasted an average of 62 mins. Interviews with clients took place upon discharge from facilities and at places suitable to them. A field assistant interpreted the instrument from English into the local language (Dagbani) to elicit views of clients on the subject matter. Consent of participation was obtained using a consent form which required participants to append their signatures or thumbprints as an indication of voluntary participation. Participants were assured of confidentiality and anonymity of information provided through the use of pseudonyms. Six FGDs were held with midwives and anesthetists working at the facilities to explore group views on root causes of sub-standard care. The number of focus groups was determined using Guest and colleagues recommendation on data saturation [ 21 ]. FGDs were moderated by the first author who ensured each participant had a fair chance of participation. Both interviews and FGDs were audio taped using an audio device with consent from participants. A total of 9 health providers and 6 clients declined to participate in the study for personal reasons.

Data analysis

Data were analysed using Braun and Clarke’s [ 22 ] thematic analysis procedure. The six staged iterative analysis procedure comprised transcription, reading and familiarisation, coding, searching for themes, reviewing themes, defining and naming themes and finalising the analysis. Audio files were first transcribed into texts by the first author. The transcribed documents were checked for accuracy by the second and third authors. They were then read meticulously for content familiarity and thematic coverage. It was followed by slow reading accompanied by a preliminary assignment of codes. Adhering to a pattern of occurrence process, similar codes were brought together to form sub-themes and then combined to form candidate themes across transcripts. The candidate themes were reviewed in relation to the available data by co-authors and changes made to some codes eliciting a renaming of some themes. Triangulation was performed by identifying the commonality of codes within and across transcripts. The codes were captured into a refined list of themes and sub-themes which were used in promulgating the study findings. Member checking was carried out by contacting some randomly selected participants and gaining feedback on the data interpretations and conclusions.

The findings demonstrate that sub-standard EmONC delivery is a product of systemic and personal challenges in the region.

Participant characteristics

A specialist gynaecologist, two unit heads, two hospital matrons, two hospital administrators (referred to as management members), forty midwives and two anesthetists were the health care providers who participated in the study as well as 15 clients and five care takers. These were selected out of a total of two specialist gynaecologists, 10 unit heads, two matrons, eight administrators, 69 midwives and seven anesthetists who made up the total of the provider population at the study facilities as well as a minimum of 78 women who visited the facilities monthly to receive EmONC [ 23 ]. Key management members involved in the study had acquired at least a tertiary level education in their respective fields and practised for an average of 27 years. Fourteen of the midwives possessed an earlier Post-secondary certificate indicating they were either Community or Enrolled nurses who went on to specialise in Midwifery. The rest of the midwives were either diploma or degree holders. Most of them had practised for an average of ten years. Clients who were treated of complicated deliveries were mostly of middle or advanced age, less educated hence engaged in petty trading and in polygynous marriages. Care takers possessed similar background characteristics. The most commonly reported obstetric complication was post-partum haemorrhage.

Four themes and 13 sub-themes emerged as root drivers to sub-standard care. Themes identified comprised centralisation of EmONC, inadequate commitment, training and placement issues and providers’ intrinsic factors. These are presented with corresponding sub-themes.

Theme: Centralisation of EmONC

Non-functioning bemonc facilities.

Participants disclosed that though BEmONC facilities earlier received essential equipment to perform signal functions, they were debarred by the country’s National Health Insurance Authority (NHIA), from doing so citing capacity reasons. Such facilities were rather required to conduct routine maternity care while referring all complications to the comprehensive level facilities that had the expertise to handle such cases. As such, they were denied emergency medications needed to treat basic complications. According to them, such an approach promoted needless referrals that imposed undue burden on providers at the comprehensive level facilities, increasing their workload and leading to adverse outcomes in some instances.

We have often been told by Health Insurance officers to escape risk….so I am referring all the cases and burdening my colleagues at that end while I am sitting, is it right? We can manage complications such as post-partum haemorrhage and pre-eclampsia if they give the drugs but they say no, refer. (FGD 4-midwife-BEmONC facility). So if a woman goes through normal vaginal delivery and is bleeding afterwards, I should not give any medication, I should send her to the hospital… What if she doesn’t survive, what happens and trust me, some of them truly die through that or lose their babies” (FGD 1- midwife-BEmONC facility).

Problems with referrals

Participants lamented that the poor road network system in the region served as a barrier to access health services in a timely mannner. They maintained that most settlements within the study area are hard to reach as they are cut off by rivers and streams and bumpy dusty roads. This made access to health care difficult necessitating home deliveries. Mothers who encountered complications due to home delivery and their newly born had little chance of receiving the needed intervention at the nearest EmONC health centre as it lacked the resources to intervene and to facilitate referral. A provider explained:

“...Sometimes, the midwives will want to refer the patient but no means of transport to go”.. (FGD 4-midwife-BEmONC facility).

Providers further revealed that due to problems associated with referrals, women and neonates in critical conditions did not survive.

They bring some women who deliver at home and are bleeding maybe due to retained placenta. When they arrive, we will have to refer instead of providing the needed care and the referral process may take time hence causing a delay. (FGD 1-midwife-BEmONC facility).

Clients’ reactions to referral

Evidence also showed that some clients and care takers resisted referrals to the CEmONC facilities located in the cities because it imposed transportation and associated costs on them. Hence they returned to their homes to try alternative care leading to deaths in some instances.

When we even refer, they don’t want to go. They will be begging that we should treat them at the health centre and some just take their folders and return to their homes and the next moment, we hear the client is dead together with the baby. (FGD 4 midwife-BEmONC facility).

The assertion was confirmed by a care taker:

When we came, the midwife told us to go to the hospital in the city because she didn’t have the means to treat us here. But we didn’t have money to go to the city so we returned home. (Care taker 16).

Theme: Inadequate commitment

Delayed / scant funding.

Although CEmONC facilities were mandated to provide both BEmONC and CEmONC signal functions, the facilities studied did not receive adequate financial resources to facilitate care delivery. Some management members disclosed that the hospitals sometimes lacked some basic drugs due to the NHIS inability to promptly reimburse them. Hence, they sometimes procured medicines from the open market on credit and clients had to purchase these on out-of -pocket terms at the hospital pharmacy. Some clients, however, were unable to pay for drugs used due to poverty leading to an eventual depletion of drugs in the pharmacy and a great difficulty in managing complications.

We try to buy the drugs on hire purchase to enable us provide care so when clients come, we write it for them and they send it inside the pharmacy and buy there…that is better than the open market but the people come and they can’t even afford the small token we ask them to pay, yet we have to treat them, so we end up not having drugs in the pharmacy. (1DI-Matron 1-CEmONC facility).

A client disclosed:

“...During the surgery, we had to buy some drugs from the stores in town because the pharmacy didn’t have drugs...” (Client 9).

The scarcity of emergency obstetric drugs led to administration of less effective drugs on some occasions. Participants in a focus group disclosed that some drugs bought from drug stores on the market were found to be fake. Nonetheless, these were used in managing cases. They lamented that the Northern part of the country, in general, was not well served in terms of equitable distribution of health resources.

“...Tell me how many pharmacies in the nation’s capital will you see fake drugs? It’s all over the Northern region here...”(FGD 1-CEmONC facility) “...They last supplied us with magnesium sulphate but it was expired...” (FGD 3-midwife-BEmONC).

Poor maintenance culture

Participants further ascribed the current state of care delivery to poor maintenance culture. They admitted that though essential equipment were occasionally supplied to the health facilities, they went missing the next moment while others got damaged due to malhandling. As a result, providers depended on their clinical judgement in most cases to proceed with care delivery which did not reflect best standard practice. The following quotes express the issue:

If you go to the in-charges’ offices right now, you will see the packs that contained the equipment they supplied us but you get to the wards and they are not there. So if we can’t get the BP readings, for instance, we base our judgement on strength of urine protein to guess pre-eclampsia and treat as such. It might not be the best approach but at least, we are making an effort. (FGD 3-midwife-CEmONC facility). We supply the units with the necessary equipment periodically but you go round later and they are either broken down or missing and they can’t report because they will have no justification so they struggle like that. (IDI- Matron 1-CEmONC facility)

State property mentality

The concept of “public property” reflects irresponsible posture assumed by some public sector workers in their interaction with state property. Some participants hinted that the possible feeling that staff did not own the items they worked with coupled with a weak monitoring system influenced how equipement were handled and how long they lasted leading to “no equipment” in some instances.

To be honest, some of us are reluctant taking care of these things because of the feeling that it isn’t our personal property and the in-charges are not doing much to ensure that the right number of equipment are handed over from shift to shift so we end up being left with nothing to work it. (FGD 2- midwife CEmONC facility)

Theme: Training and placement issues

Non-standardised admission procedures into health training schools.

Participants revealed that though quality of EmONC has improved over the years, it could have been better. They blamed the lapses on training and placement of health staff. They indicated that admission into health training schools in the country has become very competitive in recent years. This has led to the introduction of a “protocol list”. It is a list purported to emanate from influential persons (mostly political office holders) in the Ghanaian society whose request for admission for some persons or relatives must be granted regardless of their performance at admission interviews. The evidence suggests that such an approach interferred with the quality of trainees enlisted for training giving rise to poor work ethics and output in health facilities.

At first, when admission was on merit basis, it was better. Now the protocol midwives are too many and they don’t co-operate because when they are doing the wrong things and the other midwife complains, they fight them and as the in-charge you can’t do anything to them because they can even call the big men and report you and you may be removed from your post. (IDI- Unit head 2- CEmONC facility).

Inadequate experiential training

Participants in managerial positions further blamed the low skill level of newly trained staff on the educational system in the country. They alluded that the curriculum for instruction especially in health training schools centered more on theory than practice. They further disclosed that, the contact hours for clinical training was inadequate and a subsequent one year after school training in a health facility did not do much in improving the clinical competence of newly trained staff.

The problem is about the quality of the schools and it is at all levels across the country. They are getting inexperienced people who do not have adequate knowledge on what they teach and the teaching materials are also not there to facilitate the work… For clinical students, it was suggested at a meeting that clinical rotations should be two years instead of one. (IDI- Specialist CEmONC facility).

The assertion was corroborated in a focus group discussion:

“...We normally do not understand most things taught so we just memorise to pass…….we don’t also get enough clinical experience while in school so it is on the job that we actually learn...” (FGD 1- midwife- CEmONC facility).

Delay in recruitment of newly trained staff

The technical inadequacy especially among newly recruited staff was further traced to the delay in their recruitment. Some newly posted midwives alleged that they had to stay home for two to three years before they were employed due to the government’s inability to immediately absorb them upon completion. As such, they tend to forget most learnt procedures due to a prolonged stay at home and were unable to perform some required tasks when they were eventually employed.

Just imagine that a woman with a bleeding case was brought to the ward. The midwife should have checked her vitals before deciding on what to do but she didn’t. She transfused her with ringer’s lactate before proceeding to check for the cause of bleeding not knowing the client had high blood pressure and then she started fitting. The midwife should have given normal saline but according to her she had forgotten the right procedure. (IDI- Matron 2- CEmONC facility).

Refusal of postings to Northern Ghana

Newly posted midwives disclosed that most of their colleagues who were posted to the Northern part of the country refused postings but rather negotiated their way to practice in facilities in the Southern sector. They mentioned the lack of social life and other incentives in Northern Ghana as reasons for their refusal. This perennial attitude creates a serious shortage of midwives in Northern Ghana thereby imposing a daunting effect on the few workers and the care provided.

Some of my friends refused to come here. They said the place is not developed and the weather too is harsh; It is mostly hot, dry and windy due to its proximity to the Sahara desert. (FGD 4- midwife- CEmONC facility).

In an in-depth interview, a manager indicated:

They post newly trained midwives here but few come and they even go on transfer after a short stay. So we always have to battle with shortage of staff. (IDI- Matron 1- CEmONC facility).

Theme: Intrinsic factors

Disinterest in profession.

Evidence further suggests that aside from persons who gained admission into schools through favours, others pursued midwifery or related programmes due to persuasion from family members. A newly recruited midwife disclosed that she studied midwifery based on the advice of her father. Relatedly, some category of nurses who had earlier attained certificates to provide basic preventive care were motivated to pursue midwifery as a form of career advancement and a bid to improve the number of midwives in the country. Some other management members disclosed that the job readiness nature of the profession motivated some young girls to enroll in it and not the passion for the work and this influenced how they worked.

Actually, me, I didn’t like midwifery. My father advised me to do it. He said it is better than general nursing. (FGD 5- midwife- CEmONC facility). For some of these young midwives of today, their stay in Midwifery is but a missed call. They are here because they need a job and not for service. (IDI-Matron 2-CEmONC facility). “...They said those of us with certificate background can only be granted study leave to pursue midwifery so we had to do it for promotion sake...” (FGD 1-midwife-CEmONC facility).

Haemophobic and emetophobic health staff

It was also revealed that some practitioners abhorred contact with blood while others could not withstand a vomiting scene from labouring women. Some obstetric nurses (male midwives) doubled as teachers of the Quran (mallam) and would not taint themselves with unclean blood from labouring women. In their shift, cases had to wait for other midwives to attend to and the delays heightened client’s risk. Though management members disclosed that staff of this calibre were released from the facilities because of non-performance, such people possibly continued to pose as threat to maternal and neonatal health at their next post.

A participant shared the following in terms of males in midwifery:

You see some of these male midwives, the zeal is not in them. The females are even better. Some say they are Mallams so they won’t touch blood. If so, why did they decide to do midwifery? When they are on duty, a lot of cases go bad so I have to always pair them with the serious ones. (IDI- Unit head 1-CEmONC facility).

In a FGD, the following emerged:

As I speak with you, two of my colleague male midwives were released in the same month and they left the hospital because though they came to work every day, they never attended to clients. They either lazed about or used their phones throughout their duty period meanwhile clients will be in need of care. (FGD 4-midweife- CEmONC facility). They are some of them who run away at the sight of vomit. How can a midwife fear vomit? (Matron 1- CEmONC facility).

General apathy with associated attrition

Lack of passion, especially in midwifery, led to series of apathetic behaviours generally. Participants asserted that some colleagues deliberately refused to attend periodic in-service training aimed at skill improvement at the facilities due to apathy. This made them incapable of performing certain clinical tasks. Some others also left the field after few years of practice to persue other programmes of interest thereby creating a brain drain. Unfortunately, there was no immediate replacement in the vacancy created and this worsened the already precarious shortage of midwives in the area affecting the quality of obstetric care.

Three of my midwives left for school last year. They said they want to pursue Public Health instead. (IDI- Specialist).

Another provider lamented:

Sometimes, you can’t help but to wonder why there are so many professions and yet A or B is here, why are they here? How can someone say they cannot perform certain signal functions when they do organise such workshops here? (FGD 5- midwife- CEmONC facility).

However, staff who maintained they had passion for their career, endeavoured to give off their best at work.

I think that passion for my job is the right expression because I love what I do. No matter how tired I am if I am on duty, you see that I am filled with so much energy that I don’t know where it even comes from so I really have passion for my work. (FGD 2-midwife- CEmONC facility).

Managers affirmed that some young health workers were good and devoted but such people were rather few and had less influence on the nature of care that was provided.

“...We have just a few serious and committed ones...” (IDI- Administrator 2- CEmONC facility).

A client also indicated:

As for the young midwives, most of them don’t respect us, just a few. Maybe it is because they haven’t given birth before to experience how painful it is.(Client 12).

Good quality EmONC is crucial to reducing maternal and neonatal morbidity and mortality [ 24 ]. Regrettably, the state of EmONC in sub-Saharan Africa has often been described as sub-standard [ 25 ]. This study sought to establish the underlying nuances accountable for this situation in rural Ghana by exploring the opinions of key stakeholders. The findings highlight centralisation of EmONC, inadequate commitment, hitches in training and placement processes and provider intrinsic factors as main drivers to sub-standard care.

Centralisation of EmONC emerged as a useful factor to the course of inadequate care reported in the current study. This finding confirms many others that have cited referral-related challenges as instrumental to most adverse maternal and neonatal outcomes [ 26 , 27 ]. Evidence from this study suggests that the situation in Ghana and similar sub-Saharan African countries might be reduced through prioritisation of rural health [ 28 ]. In Ghana, health facilities are categorised into primary, secondary and tertiary to differentiate between the complexities of medical cases and to enable referral of cases to higher levels for continuous care. While this arrangement might be expedient in promoting quality, it might not be suitable for rural areas where access to care is a challenge due to geographical factors [ 9 ]. Therefore, the current emphasis on centralising EmONC in regional and some referral hospitals in urban centres, at the neglect of BEmONC facilities, may not serve the needs of rural women who need these services most [ 29 ]. It is thus crucial for governments to place priority on rural health by empowering BEmONC facilities in these areas with essential drugs, supplies and experienced staff. This, together with effective supervision and monitoring, may facilitate effective BEmONC delivery and curtail needless referrals.

Ghana’s quest to reducing its maternal mortality targetted infrastructural improvement and an increase in human resource base through added training [ 30 ]. However, this study established that the current education and training system is deficient in producing the right middle level workforce for the country’s needs. This is similar to previous studies [ 31 , 32 ]. According to the International Confederation of Midwives (ICM), midwives should be able to demonstrate competency in the provision of care during pregnancy, labour, birth and the post natal period [ 33 ]. The inadequacy of skills in these areas has partly been linked to inadequacies in education and training as well as socio-political influences. Principally, the curriculum for instruction in Ghana is generally theory driven [ 34 ] due to lack of human and material resources to adopt much more practical approaches. Although clinical staff are further expected to gain experience through in-service training, this provision seems insufficient to equip beginners with the clinical skills required to transition to practice. The situation is exacerbated by delay in posting of newly trained staff as government is unable to immediately absorb trainees after school due to fiscal policy and budgeting reasons. Ayawine and Atinga [ 35 ] reported elsewhere that delay in recruitment of staff led to harzadous care delivery as some staff adopted trial and error management procedures on clients in order to revamp lost skills. Ederer et al. [ 36 ] also attest that such service providers are a threat to patients’ safety as they are more likely to commit avoidable errors which endanger lives. To mitigate against this trend, the curriculum for health training schools may have to be rooted in emerging pedagogy that meets national and international standards in terms of knowledge acquisition and application. Students may need to spend adequate time in clinical settings where real life situations exist in order to garner the skills required for effective practice. They may also be placed under a temporary mentoring scheme or a tranisiton to practice program after training, to undergo on the job training from experienced staff as a means of improving upon their skills before they are formally employed.

Provider disinterest also emerged as a reason for sub-standard care in this study. While studies in developing countries report external factors such as poor working conditions and low opportunity for career advancement as distracts to good quality care [ 37 , 38 ], this study identified provider internal motivation as a major forerunner to sub-standard care. It is argued that health staff who are intrinsically motivated tend to give off their best at work. In a study among 12 European countries, Aiken and colleagues [ 39 ], highlighted that a substantial proportion of nursing professionals disclosed their dissatisfaction with their career and intended to vacate post the subsequent year. Nonetheless, in Turkey, albeit some seeming constraints, midwives derived inner satisfaction helping and being with women and did not wish to abandon their profession in the probable future [ 40 ]. The authors thus conceded that intrinsic motivation has a more positive impact on quality of care and general productivity. Maloney et al. [ 41 ] also revealed that motivated staff may overcome some barriers to improve quality of care while disinterest providers will exhibit reluctance to learn new things and will not be productive. Similarly, while some staff in this study disclosed they were passionate about their job, others were haemophibic or emetophobic and this affected practice. Another group maintained they were coerced by relatives to pursue certain programmes and did not have personal interest and passion for the work. It is established that these calibre of workers may not only be inefficient and irresponsible at work, they are more likely to complain of burnout, dissatisfaction, or change job thereby constantly creating a service gap for health professionals [ 41 ]. It is important to place priority on personal background of prospective candidates as part of the admission processes into health training institutions. This may be achieved by denouncing a “protocol list” and including a clinical psychologist as part of the admission team to ascertain students’ innate ability and interest through appropriate clinical simulation exercises. This approach may help identify and train personnel with the right disposition to practice.

Setbacks in the training and recruitment systems in Ghana, inadequate investment in rural health coupled with extent of health provider inherent disposition to practice may be partly responsible for sub-standard obstetric care in the study area. Providing adequate resources for BEmONC facilities, adhering to a standardised admission and screening procedure into health training schools and curriculum modification in pedagogy may motivate and enhance the competence of newly trained essential workforce and guarantee better health outcomes among rural mothers.

Implications for practice

Inadequate funding of EmONC facilities induces poor quality care that poses a threat to maternal and neonatal health especially in rural Ghana. There is the need to adequately resource rural facilities with experienced staff and essential logistics to facilitate access to critical care while enabling CEmONC facilties with similar logistics to be able to perform core signal functions. Curriculum modification may also enhance the competence of newly trained essential staff. Ghana and other developing countries may need to re-think their strategies of improving upon maternal health by not concentrating mainly on massive production of essential staff but by raising qualified and passionate workforce using objective and standardised means and absorbing them immediately after training to promote effective care delivery.

Strengths of the study

A major strength of the study lies in the use of multiple stakeholders and data collection methods to unravel the intricacies underlying the phenomenon under study. This approach enhances the trustworthiness of the findings. The study also sdopted an analytical framework in the presentation of results through the use of thick descriptions and concrete details of events in the study environment. Such a style allows for duplication in comparable settings.

Limitations

Exclusion of officials from the National Health Insurance Scheme (NHIS), being a major stakeholder in health care delivery in Ghana, might have led to loss of data that could have strengthened the findings of the study.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Basic Emergency Obstetric and Newborn Care

Comprhensive Emergency Obstetric and Newborn Care

Emergency Obstetric and Newborn Care

Focus group discussion

Ghana Health Service

International Conferedration of Midwives

In-depth Interview

National Health Insurance Authority

National Health Insurance Scheme

Sustainable development goal

Univeristy of Cape Coast

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Acknowledgements

The authors wish to thank Prof Joseph Mintah and Dr Thomas Hormenu, both of the Department of Health, Physical Education and Recreation of the University of Cape Coast, Ghana, for supervising the original project from which this paper was extracted. Appreciations also go to Dr Desmond Tutu Ayentimi of the Tasmanian School of Business and Economics, University of Tasmania, Sandy Bay, TAS, Australia, for making useful contributions in the paper and all study participants for their loyalty in participation.

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Ayawine, A., Asaarik, M.J.A. & Atinga, R.A. Stakeholder opinions on perceived sub-standard emergency obstetric and newborn care in Ghana. BMC Health Serv Res 24 , 461 (2024). https://doi.org/10.1186/s12913-024-10936-x

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Design-based Research Method in PBL/PjBL: A case in Nursing Education

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Design-based Research (DBR) focuses on real-world problems, emphasizes studying an educational intervention in its supposed context, uses a cyclical process of design, implementation, evaluation, and improvement, utilizes mixed research methods, stresses reciprocal relationships between theories and practice, and involves a close collaborative relationship between researchers and practitioners. Three iterative DBR research cycles were conducted on a project-based learning (PjBL) implementation in three population health nursing clinical PjBL blocks at a Midwest university. Data were collected at the end of each cycle through surveys, focus group interviews with students, faculty, and clinical agency contacts, as well as student work and performance. The data were analyzed, and revisions and improvements were planned for subsequent blocks and future use in the course.

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Joni Tweeten, University of North Dakota

Joni Tweeten is a Clinical Associate Professor in the Nursing Department at the University of North Dakota and is working on her Education, Health, and Behavioral Studies PhD with a specialization in Instructional Design and Technology.

Woei Hung, University of North Dakota

Woei Hung is currently a professor and graduate director of the Instructional Design and Technology Program in the College of Education and Human Development at the University of North Dakota. His research areas include problem-based learning (PBL), complex problem solving, systems thinking and modeling, concept mapping and formation, and microlearning. He has published numerous journal articles and book chapters in the areas of PBL problem and curriculum design. He is currently an executive board member and the treasurer of the PAN PBL Association of Problem-Based Learning and Active Learning Methodologies.

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Objective: To examine perceptions of obesity-related PD training needs and opportunities reported by Ohio Head Start health/nutrition program managers. Study Design, Setting, Participants: Phenomenology was utilized for this research study. Semi-structured, in-depth telephone interviews (n = 13) were conducted with HS Health and Nutrition Managers across Ohio who were recruited via emails distributed by the HS Director of Professional Development. (author abstract)

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